Turlock Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure respect and dignity for two of 13 sampled residents (Resident 147 and Resident 40) when:1. Resident 147's lunch tray on 3/3/26 was delivered 24 minutes after all other residents received their meals in the Tuolumne dining room due to his dining location on his meal ticket not being updated for 4 days. 2. Resident 40 gave his lunch tray to Resident 58 and staff did not check residents' lunch trays to ensure all residents received their correct lunch tray at the same timeThis failure resulted in Resident 147 and Resident 40 having to observe other residents eating without being able to participate which led to Resident 147 eating his meal alone and could result in a non-dignified social dining experience with the potential to cause feelings of exclusions or isolation. 1.During a review of Resident 147's admission Record (AR -a summary of information regarding a patient which includes patient identification, past medical history,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement a comprehensive person-centered care plan for one of seven sampled residents (Resident 149) when Resident 149's care plan for Stage 3 pressure ulcers ( a deep, full-thickness skin loss injury where subcutaneous fat is visible, but muscle, tendon, or bone are not exposed) to coccyx ( the last bone at the bottom [base] of your spine) was not implemented.This failure resulted in Resident 149 not receiving necessary care and treatment in promoting wound healing and placed Resident 149 at increased risk of an avoidable worsening of pressure ulcers (areas of damaged skin caused by staying in one position for too long), developing new pressure ulcers and wound infection (an invasion of the body by bacteria or viruses that cause disease).During a concurrent observation and interview on 3/3/26 at 10:47 a.m. with Resident 149, in Resident 149's room, Resident 149 was sitting in a wheelchair watching a program on television. Resident 20 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure necessary care and treatment in promoting wound healing, preventing infection (an invasion of the body by bacteria or viruses that cause disease), developing new pressure ulcers (areas of damaged skin caused by staying in one position for too long) and preventing worsening of existing pressure ulcers were implemented for one of seven sampled residents (Resident 149) when Resident 149 had no pressure relieving device when sitting in a wheelchair and was not repositioned by the nursing staff while sitting in a wheelchair for more than two hours. Resident 149 had a Stage 3 pressure ulcers (is a deep, full-thickness skin loss injury where subcutaneous fat is visible, but muscle, tendon, or bone are not exposed) to coccyx (is the last bone at the bottom [base] of your spine).These failures had placed Resident at increased risk of an avoidable worsening of pressure ulcers, developing new pressure ulcers and wound infection.During a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents receive appropriate services to maintain or improve mobility with the maximum practicable independence for one of seven sampled residents (Resident 35) when Resident 35's Restorative Nursing Program (RNP- a formal, planned and organized program of care which is intended to restore a lost ability or maintain a potentially deteriorating function for a particular resident. RNP is initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy services) was not developed and implemented after completion and discharge from skilled Occupational Therapy services on 1/30/26.This failure resulted in Resident 35 not receiving RNP to maintain or improve her mobility and placed Resident 3 at an increased risk of decline in range of motion and functional mobility such as transfers and ambulation.Based on concurrent observation and interview on 3/3/26 at 12:03 p.m. with Resident 35, in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to ensure the daily nurse staffing information posted for public viewing accurately identified the actual number of Registered Nurses (RNs), Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs) providing direct care for each shift. Review of the facility's posted staffing sheets indicated staffing was reported under the categories of Licensed and Unlicensed staff, which combined RN and LVN hours under licensed staff and combined CNA and Restorative Nursing Assistant (RNA) hours under unlicensed staff.This failure had the potential to affect 136 of 136 residents residing in the facility, as the inaccurate posting of daily nurse staffing information had the potential to prevent residents, visitors and the public from clearly determining the number and type of nursing staff providing direct care in the facility.Findings:During an observation on 3/6/26 at 10:51 a.m. the facility's posted nurse staffing information was observed in a common area accessible to residents and visitors. The posting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors, when one of one resident (Resident 69) was administered the incorrect dose of Dulaglutide (an injectable medication used to improve blood sugar levels in the blood) that was prescribed by the physician from January 27 2026 to March 3 2026, which resulted in continued high blood sugar levels requiring the increase and addition of medications to help regulate Resident 69's blood sugar levels.This failure put Resident 69 at risk of developing hypoglycemia (when the level of glucose [sugar] in the blood drops below the range that is healthy) which had the potential to cause, seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), confusion (a situation in which people do not understand what is happening, what they should do or who someone or something…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure and maintain complete medical records for one of seven sampled residents (Resident 4) when Resident 4's Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) was not signed by the physician. Resident 4's POLST was prepared by qualified staff and signed by Resident 4 on 1/27/26.This failure had the potential for Resident 4 not to receive necessary care and treatment according to her wishes as stated in her POLST during emergency or significant change of conditions.During a concurrent observation and interview on 3/3/26 at 11:50 a.m. with Resident 4, in Resident 4's room, Resident 4 was laying in bed with oxygen on at two liters per minute via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). Resident 4 was awake,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1's) family member (FM 1) was notified of a significant change of condition when Resident 1 returned to the facility after a seven-day stay in a nearby hospital, and facility staff noted Resident 1 had new areas of skin breakdown, was refusing further skin assessment of this new breakdown, was refusing antibiotics (medication used to treat infections), and refusing to have a blood test as ordered by her physician. This failure resulted in Resident 1's family being unaware of Resident 1's changes in condition upon her return to the facility from the hospital. Findings: During a review of Resident 1's admission Record (AR) , dated 6/16/25, the AR indicated she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included Congestive Heart Failure (chronic condition where the heart doesn't pump blood as efficiently as it should, leading to a buildup of fluid in the body), Chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy on resident possessions when it failed to return belongings to the family of one of five sampled residents (Resident 1) when a 42-inch television belonging the Resident 1 was not returned to her family when Resident 1 was discharged from the facility. This failure resulted in Resident 1's family not receiving Resident 1's 42-inch television upon Resident 1's discharge. Findings: During a review of Resident 1's admission Record (AR) , dated 6/16/25, the AR indicated she was a [AGE] year-old female admitted to the facility on [DATE]. The AR indicated Resident 1 was discharged on 5/2/24. During an interview on 6/17/25, at 3:22 p.m., with Family Member (FM) 1, FM 1 stated Resident 1's family had purchased her a 42-inch television to use while in the facility. FM 1 stated that when Resident 1 was discharged from the facility in May 2025, the 42-inch television was never returned. During an interview on 6/18/25, at 12:35 p.m., with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 2) had bed rails installed as determined by the facility's Bed Rails – Safety Assessment (BRSA) . (The United States Food and Drug Administration's website page, titled, Adult Portable Bed Rail Safety, dated 2/27/23, indicated, Adult portable bed rails are used by many people to help create a supportive and assistive sleeping environment in homes, assisted living facilities and residential care facilities. This type of equipment has many commonly used names, including side rails, bed side rails, half rails, safety rails, bed handles, bed canes, assist bars, grab bars, and adult portable bed rails. [These devices are] intended to assist individuals who are disabled, injured, or recovering from surgery or hospitalized with transfer in and out of bed or repositioning, intended to reduce risk of falling or fracture or mitigate the risk of falling due to the effects of balance disorders or other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to: 1. Ensure the rights of 1 of 3 sampled residents (Resident 11) were respected and honored when one Certified Nursing Assistant (CNA 9) displayed an obscene finger gesture toward Resident 11. This failure had the potential for Resident 11 to experience a negative effect to his psychosocial well-being, and, 2. Honor the rights of an unknown number of resident rights by ensuring staff followed their policy and procedure and spoke only English in the facility. This failure had the potential for resident rights to not be honored when an unknown number of residents heard staff speaking a non-English language, and possibly thinking staff were speaking about them. Findings: 1. During a review of the facility document titled, Verification of Incident Investigation / Administrative Summary (VIIAS) , dated 11/25/24, the VIIAS indicated, On 11/21/24 at approximately 4 pm an Admissions staff member reported that she witnessed male CNA flip off [Resident 11] with his middle finger. [Director of Staff Development, or DSD] was notified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure timely responses to 2 of 5 residents (Resident 6, Resident 7) requests for pain relief when they had to wait over 30 minutes for a nurse to bring them their prescribed pain medication. This failure had the potential for Resident 6 and Resident 7 to have their pain poorly managed, potentially resulting in prolonged pain and discomfort. Findings: 1. During a concurrent observation and interview on 12/10/24, at 12:42 p.m., with Resident 6, in his room, Resident 6 stated he takes Norco (a strong narcotic pain reliever) for his painful right elbow. Resident 6's right elbow was observed, it was noted to be swollen and red. Resident 6 stated, Sometimes it takes two to three hours to answer my call light. I laid awake all night last night from the pain in my elbow. Last night I was hurting so bad. I got my Norco at 7:30 a.m. this morning. Resident 6 then produced his personal notebook that indicated his handwritten note, indicating he received Norco at 7:30 a.m. that day. During a review of Resident 6's admission Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the Interdisciplinary Team (IDT- a group of professional individuals involved in the care of the resident) assessed one of 14 sampled resident (Resident 4) on the resident ' s ability to self-administer medications safely and accurately when Resident 4 did not take her six oral medications left by License Vocational Nurse (LVN) 3 at the bedside table. This failure had the potential to result of Resident 4 not receiving the correct dose of medications necessary to treat her condition or illness. Findings: During a review of Resident 4 ' s admission Record (AR-documents that contained the resident ' s demographics and medical diagnosis), dated 9/6/24, the AR indicated Resident 4 was admitted to the facility in 2020, with diagnoses which included Alzheimer ' s Disease (a progressive disease affecting the brain, altering mood, judgement, and memory); and schizophrenia (mental disorder affecting perceptions of reality). During an observation on 9/5/24, at 12:02 p.m., in Resident 4 ' s room, Resident 4 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to notify the Responsible Party (RP- the person who is responsible for paying the patient ' s account bills) of a change of condition for one of 14 sampled resident (Resident 3) when Resident 3 was diagnosed with Urinary Tract Infection (UTI- a bacterial infection that occurs when bacteria enter the urinary tract) and was started on antibiotics (a medication that kills bacteria). This failure resulted for the RP not aware of Resident 3 ' s UTI diagnosis and was not able to make informed decisions and participate with Resident 3 ' s care and treatment. Findings: During a review of review of Resident 3 ' s admission Record (AR-documents that contained the resident ' s demographics and medical diagnosis), dated 9/6/24, the AR indicated, Resident 3 was admitted to the facility with diagnoses which included dementia (a progressive disease affecting the brain, memory, mood, and judgement) and Resident 3 ' s RP for Power of Attorney – Care (a legal document that allows someone to act on another person ' s behalf) was Family Member…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, interview, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately code a Minimum Data Set (MDS) assessment for 1 (Resident #277) of 33 residents for whom MDS assessments were reviewed. Specifically, the facility failed to ensure Resident #277's 08/02/2024 admission MDS assessment reflected the presence of a nephrostomy tube. Findings included: The CMS Long-Term Care Facility RAI 3.0 User's Manual, revised in 10/2023, revealed, H0100: Appliances, Steps for Assessment: 1. Examine the resident to note the presence of any urinary or bowel appliances. 2. Review the medical record, including bladder and bowel records, for documentation of current or past use of urinary or bowel appliances. Coding Instructions Check next to each appliance that was used at any time in the past 7 days. Select none of the above if none of the appliances A-D were used in the past 7 days. -H0100A, indwelling catheter (including suprapubic catheter and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview, and facility policy review, the facility failed to complete Abnormal Involuntary Movement Scale (AIMS) assessments every six months in accordance with a care planned intervention for 1 (Resident #81) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Care Plan, Comprehensive, dated 12/2017, indicated the purpose was To support and guide resident and IDT [interdisciplinary team] collaboration to achieve and maintain optimal resident health, function and quality of life. The Procedure specified, 1. Care Plans are individualized through the identification of resident concerns, unique characteristics, strengths, and individual needs. 2. Care Plans are based on fundamental information gathered by the MDS [Minimum Data Set], CAA's [Care Area Assessments] and information gathered through observation and evaluation. 3. Care Plans become a comprehensive tool for the IDT to utilize as a reference for identified concerns and approaches to establish guidance for meeting resident individual needs. 4, Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview, and facility policy review, the facility failed to follow physician's orders requesting psychiatric evaluations for 2 (Residents #81 and Resident #9) of 5 residents reviewed for unnecessary medications. Findings included: 1. An admission Record indicated the facility admitted Resident #81 on 12/07/2021. According to the admission Record, the resident had a medical history that included diagnoses of unspecified psychosis, schizophrenia, and other specified persistent mood disorders. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/30/2024, revealed Resident #81 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. According to the MDS, the resident had verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others during one to three days of the assessment look-back period and received antipsychotic, antidepressant, and antianxiety medications in the seven days prior to the assessment. Resident #81's care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and review of the National Pressure Ulcer Advisory Panel (NPUAP) document titled Pressure Injury Stages, the facility failed to ensure Nurse Practitioner (NP) #37 followed professional standards of practice for wound staging for 1 (Resident #278) of 5 residents reviewed for pressure ulcers/injury. Specifically, NP #37 reverse staged Resident #278's Stage 4 right heel pressure injury to a Stage 3. Findings included: An NPUAP document titled, Pressure Injury Stages, dated 2018, revealed, Do not Reverse Stage: NPUAP pressure injury staging describes the depth of tissue damage due to pressure. It does not describe healing tissue. Do not reverse stage using NPUAP pressure injury staging. (i.e. [id est; that is]- a Stage 4 pressure injury cannot become a Stage 3, Stage 2, and/or subsequently Stage 1. When a Stage 4 injury has healed it should be classified as a healed Stage 4 pressure injury. An admission Record indicated the facility admitted Resident #278 on 04/26/2024. According to the admission Record, the resident had a medical history that included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure proper incontinence care was provided for 1 (Resident #58) of 3 residents observed during incontinence care. Findings included: A facility policy titled, Perineal Care, dated 2006, revealed the section titled Procedure indicated 11. Female perineal care f. Use one gloved hand to stabilize and separate the labia, with other hand wash from front to back. Rinse and pat dry with towel. An admission Record revealed the facility admitted Resident #58 on 06/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of peripheral vascular disease (PVD) and palliative care. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/19/2024, revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #58 was dependent on staff for toileting and bed mobility and was always incontinent of bowel and bladder.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, interview, and facility policy review, the facility failed to reevaluate the appropriateness of continued use of bed rails after a resident attempted to climb over their bed rails and sustained a fall. This deficient practice affected 1 (Resident #23) of 8 residents reviewed for accidents. Findings included: A facility policy titled, Proper Use of Bed Rails, dated 10/2022, revealed, Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. The policy further indicated, 3. Assess Resident's risk from using bed rails. Examples of the potential risks with the use of bed rails include: a. Accident hazards (e.g. [exempli gratia, for example], falls, entrapment, and other injuries sustained from attempts to climb over, around, between, or through the rails, or over the footboard) and 15. Responsibilities of ongoing monitoring and supervision are specified as follows: a. Direct care staff will be responsible for care and treatment in accordance with the plan of care b. A nurse assigned to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were followed while providing direct care for 1 (Resident #91) of 6 residents reviewed for pressure ulcers and 1 (Resident #54) of 1 resident reviewed for dialysis. The facility also failed to ensure staff washed their hands and changed soiled gloves when providing incontinence care, which affected 1 (Resident #58) of 3 residents observed during incontinence care. Findings included: 1. A facility policy titled, Infection Prevention Manual for Long Term Care, revised 10/2022, indicated, Enhanced Standard Precautions, It is facility policy to adopt a comprehensive strategy to prevent, contain, and mitigate multidrug-resistant organisms (MDRO) in the facility. Enhanced Standard Precautions (ESP) is a core component of this strategy, both during the prevention and mitigation phases. The policy revealed, Identify residents at high risk for MDRO colonization and transmission: the use of ESP, primarily the use of gowns and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and record reviews, the facility failed to ensure the menu approved by the Registered Dietitian (RD) was followed for 131 of 131 residents when the meatloaf portion served to residents was less than 4 ounces (oz-unit of measurements). This failure had the potential for residents to receive the wrong caloric intake and not meet the nutritional needs of the residents which could compromise their medical status. Findings: During a review of the Detailed Census Report, (census), dated 5/21/24, the census indicated there were 134 residents in the facility. During an observation on 5/21/24, at 11:40 AM, in the facility kitchen, [NAME] 1 was cutting a cooked meatloaf into slices for lunch. During a concurrent interview and record review on 5/21/24, at 11:42 AM, with the Dietary Manager (DM), the recipe for the meatloaf titled Meatloaf 3 OZ SCR - Recipe #138 (recipe) was reviewed. The DM stated the recipe calls for the portions served to weigh 3 ounces (OZ). During a concurrent observation and interview on 5/21/24, at 11:44 AM, in the facility kitchen, with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) when Resident 1 was admitted in the facility on 10/3/24 for status post left hemiarthroplasty (a surgical procedure where half of the hip is relaced) and scheduled to have a follow-up appointment with Orthopedic Surgeon (OS- a physician who specialized in treating injuries and diseases of the bones) on 10/26/23. The Facility did not know of the appointment and did not perform a hip xray (a test used to create pictures inside of the body) for Resident 1 to bring for the appointment. This failure resulted for Resident 1 to arrive on his OS appointment without a hip x-ray result and was not assessed by the OS to ensure recovery was proceeding as expected and early detection of potential complications such as hip dislocation, infection, blood clots, and loosening of the joint. Findings: During an interview on 3/19/24, at 8:06 a.m. with the Family Member (FM), the FM stated Resident 1 recently had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to assist in making transportation arrangements for one of three sampled residents (Resident 1), when Resident 1 was scheduled to have an orthopedic surgeon (OS- a physician who specialized in treating injuries and diseases of the bones) appointment on 10/26/23 and the facility did not know of the appointment and did not make prior transportation arrangements from the facility to the OS appointment. This failure resulted in Resident 1's family member (FM) to transport Resident 1 in her private vehicle at the last minute to the OS appointment. Findings: During an interview on 3/19/24, at 8:06 a.m. with the Family Member (FM), the FM stated Resident 1 recently had a surgery on his hip performed by OS and scheduled to have his first follow-up appointment with OS on 10/26/23. The FM stated she arrived at the facility on 10/26/23 to accompany Resident 1 to his orthopedic appointment. The FM stated the facility did not know of the OS appointment and only knew when she arrived and told them. The FM stated the facility did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to store, and prepare food in accordance with professional standards for food service safety and proper sanitary conditions when: 1. The walk-in refrigerator stored expired (past the storage guidelines) vegetables. 2. The ice machine contained yellow substance on the evaporator (part where the ice cubes were formed). 3. The commercial can opener had black particles on the blade. These failures resulted in unsafe food storage that could potentially lead to contamination and foodborne illnesses for residents. Findings: 1. During a concurrent observation and interview with the Dietary Manager (DM) on 9/24/19, at 9:23 a.m., in the kitchen walk-in refrigerator, the walk in refrigerator shelves had several vegetable items that were past their use-by date. There was an unopened bag of shredded cabbage. The DM stated, I think, it is 5 lb. [pound - unit of measure] bag [cabbage]. The DM stated the received date (date received) of the cabbage was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice when: 1. One of two sampled Licensed Vocational Nurse (LVN )1 signed Resident 36's electronic medication administration record (e-mar) before administering her medications. This failure had the potential to result in medication errors. 2. The physician order for one of three sampled residents (Resident 8's) insulin (medication to treat high blood sugar) medication was incomplete and did not include the indicated time for the insulin medication administration. This failure had the potential to place Resident 8 at risk for a hypoglycemic (low blood sugar) episodes. Findings: 1. During a medication pass observation on 9/26/19, at 7:34 a.m., LVN 1 prepared Resident 36's medications which included escitalopram (a medication used to treat depression [feelings of persistent sadness over a prolonged period of time]), 5 milligrams (mg- a unit of dry measurement), lisinopril (a medication used to treat high blood pressure) 20 mg and polyethylene glycol (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to accommodate the needs for one of 30 sampled residents (Resident 455) when the call light was not within Resident 455's reach. This failure resulted in Resident 455's needs not being met and being unable to reach her call light to ask for help. Findings: During a concurrent observation and interview with Resident 455, on 9/24/19, at 11 a.m., in Resident 455's room, she was seated in her wheelchair a foot away from her bed, in front of the side table. Resident 455 stated, I am sleepy . I want to lay down in bed . I can't reach it (call light). Resident 455 was trying to reach her call light and could not reach her call light. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 2, on 9/24/19, at 11:05 a.m., in Resident 455's room, Resident 455's call light was in the middle of the head of the bed. CNA 2 stated it was not the best place for [Resident 455's] call light. CNA 2 stated, The call light should be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to protect the privacy of personal information for one of three sampled residents (Resident 36) when Licensed Vocational Nurse (LVN) 1 left the protected health information (PHI) exposed for public view. This failure resulted in the potential for unauthorized access to personal resident information and violated Resident 36's rights to confidentiality. Findings: During an observation on 9/26/19, at 7:27 a.m., in the facility's hallway, the computer on the medication cart was left open and unattended by LVN 1. The computer screen displayed Resident 36's name, photo, room number, allergies and a list of residents prescribed medications visible to everyone who passed by the medication cart out in the hallway. During an interview with LVN 1, on 9/26/19 at 7:39 a.m., LVN 1 stated the computer screen displayed Resident 36's name, photo, room number, allergies and a list of residents prescribed medications visible to everyone who passed by the medication cart out in the hallway. LVN 1 stated the computer screen with Resident 36's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a plan of care to reflect the care needs for one of two sampled residents (Residents 106) with clostridium difficile (c. diff - a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon) when Resident 106 did not have a care plan to direct the care required to address a C-Diff infection of Resident 106. This failure placed Resident 106 at risk of not receiving appropriate, consistent and individualized care to ensure his needs were being met. Findings: During a concurrent observation and interview with Certified Nursing Assistant (CNA) 3, on 9/24/19, at 10:18 a.m., in the hallway by Resident 106's room, there was a plastic cart with drawers containing personal protective equipment (PPE) by the door. CNA 3 was in the room wearing a gown, mask and gloves. CNA 3 stated Resident 106 had C- diff and was on contact precautions (used to help reduce and/or stop the spread of germs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide services for one of three sampled residents in the dining table (Resident 131) when Resident 131 did not receive the needed feeding assistance during her lunch meal. This failure had the potential to result in Resident 131 not meeting her daily nutritional needs, and the potential to result in unplanned weight loss. Findings: During a dining observation on 9/24/19, at 12:15 p.m., Resident 131 sat on her wheelchair around a dining table with her meal placed in front of her. Resident 131 sat at the same dining table where two other residents were eating their meal as Resident 131 watched the other two residents eat. Resident 131 did not make an attempt to pick up utensils and did not begin to eat. Resident 131 sat around the dining table waiting for staff to provide physical assistance with her meal. During an observation on 9/24/19, at 12:30 p.m., Resident 131 sat on her wheelchair and began to fall asleep while the other two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to administer pain medication at the prescribed time for one of three sampled residents (Resident 37) when Resident 37's pain medication was administered an hour and a half after the scheduled prescribed time. This failure resulted in Resident 37 stating she was crying due to being in pain for over one hour. Findings: During an interview with Resident 37 at the Resident Council meeting, on 9/25/19, at 11:24 a.m., she stated her pain medication was prescribed to be given to her this morning at 7:30 a.m. but it was not administered to her until 10:30 a.m. Resident 37 stated she was in so much pain and she was jerking all over her bed this morning. Resident 37 stated her pain level was an eight out of ten (on numerical pain scale from 0 to 10: 0 means no pain; one to three means mild pain; four to seven moderate pain; eight and above is severe pain) when she finally received her pain medication at 10:30 a.m. Resident 37 stated her pain level was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain and implement an effective infection prevention and control program designed to prevent spread of infectious organisms for one of two sampled residents (Resident 509) with known diagnoses of clostridium difficile (C- diff - a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon), when Resident 509 sat in the social dining area, ate next to other residents in the facility and the facility did not implement their infection prevention practices to prevent the potential spread of C-diff infection to other residents in the dining area as indicated on the facility's protocol criteria. This failure had the potential to place other residents at unnecessary risk of exposure to an infectious bacterium (germ). Findings: During a concurrent observation and interview with the Director of Nursing (DON) on, 9/24/19, at 11:13 a.m., a sign was posted outside Resident 509's room indicating,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.