Foothill Regional Medical Center D/P SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for two of nine final sampled residents (Residents 7 and 18). * The facility failed to develop a comprehensive person-centered care plan to address Resident 18's nutritional oral gratification and GT feeding. In addition, the facility failed to develop a comprehensive care plan for the use of the abdominal binder. * The facility failed to develop a comprehensive person-centered care plan to address Resident 7's GT feeding. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Resident Care Plan revised 7/2024 showed all the residents will have an individualized comprehensive person-centered care plan developed and implemented based on residents individual care needs and includes all problems, goals, and interventions…

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, medical record review, and facility P&P review, the facility failed to ensure the treatment was provided to two of nine final sampled residents (Residents 4 and 12). * The facility failed to assess and check the skin of Residents 4 and 12 every two hours when the splint device was applied as ordered by the physician. In addition, the plans of care to address the function and mobility of Residents 4 and 12 were not included in the interventions for skin assessments every two hours when the splint device was applied. These failures had the potential to affect the residents well being while wearing the splint device. Findings: Review of the facility's P&P titled Splint Application revised 7/2024 showed the supportive devices will be applied to the resident as per physician's order. Prior and after application of the splint device, skin and site will be visually viewed for any changes. Document the application and removal of the splint device on the residents record. a. On 1/29/25 at…

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, medical record review, and facility P&P review, the facility failed to ensure appropriate care and services for the use of a GT for two of nine final sampled residents (Residents 7 and 12) and two nonsampled residents (Residents 1 and 9). * The facility failed to ensure LVN 1 elevated Resident 9's HOB at a 30 degree angle or above prior to the administration of medication via the GT, to reduce the risk of aspiration. * The facility failed to ensure LVN 3 elevated Resident 12's HOB at a 30 degree angle or above prior to the administration of the medication via the GT, to reduce the risk of aspiration. * The facility failed to ensure Resident 1's HOB was elevated at a 30 degree angle or above during the enteral feeding via the GT. * The facility failed to ensure Resident 7's HOB was elevated at a 30 degree angle or above when Resident 7 was receiving the enteral feeding via the GT. These failures posed the risk for complications related to use of the GT for Residents 1, 7, 9, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to obtain the informed consent for the use of side rails for one of three final sampled residents (Resident 11) reviewed for side rails. This failure posed the risk for Resident 11 and/or his representative to not be informed of his care and the risks for the padded bilateral upper and lower siderails. Findings: Review of the facility's P&P titled Side Rails revised 9/2023 showed all the residents shall have side rails in the full up position while in bed or crib. If the four siderails are required for the patient safety, a consent is required. Review of the Foundations and Adult Health Nursing published 2023 showed under Informed Consent, the Patient Care Partnership establishes the patient's right to make decisions regarding his or her health care. On 1/29/25 at 0823 hours, during the initial facility tour, Resident 11 was observed lying in bed with padded bilateral upper and lower siderails elevated. Medical record review…

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, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration and storage of the medications as evidenced by: * The facility's medication error rate was 3.85%. One of four licensed nurses (LVN 4) who were observed during the medication administration was found to have an error. LVN 4 failed to administer the complete dose of one of Resident 3's medications when significant residual of the medication was observed in the medication cup after administering the multivitamin (supplement) via GT to Resident 3. * The facility failed to ensure the electronic MAR for Resident 3 was not signed prior to the medication administration. These failures had the potential to negatively affect the resident's health conditions and posed the risk for possible complications or delay in interventions. Findings: Review of the facility's P&P titled Medication Administration, General Guidelines revised 3/2024 showed all medication orders must be ordered for a specific patient and include 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 medical record review, the facility failed to ensure one of nine final sampled residents (Resident 4) were free from the unnecessary medications. * The facility failed to ensure to document the monitoring of seizure activities and side effects related to Resident 4's use of clobazam, clonazepam, diazepam, lacosamide, lamotrigine, and levetiracetam (anticonvulsant medications to prevent seizure). This failure had the potential for Resident 4 to receive unnecessary medications and develop significant adverse effects, and risk for adverse effects from prolonged used of medications. Findings: Medical record review for Resident 4 was initiated on 1/30/24. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's physician's order showed the following orders: - dated 2/23/24, to administer clobazam 10 mg via GT every day for seizure. - dated 3/23/24, to administer clonazepam 0.5 mg via GT every eight hours for seizure. - dated 4/15/24, to administer diazepam 7.5 mg…

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 medical record review, the facility failed to ensure one of five final sampled residents (Resident 2) reviewed for unnecessary medications was free from the unnecessary psychotropic medication when: * The facility failed to monitor the behaviors specific to the use of clonidine (antihypertensive and sedative medication) for Resident 2. * The facility failed to ensure the informed consent was obtained from the resident representative for the use of the psychotropic medication (clonidine) when the route of administration, dose, and targeted behaviors were changed for Resident 2. These failures had the potential for the residents to receive unnecessary medications and not effectively evaluate the effectiveness of the psychotropic medications, and had the potential for Resident 2's representative not being informed of his clonidine medication and potential effects from the changed routes of administration, doses and targeted behavior. Findings: Review of the article published in National…

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 facility P&P review, the facility failed to ensure the residents' medications were stored and labeled properly. * The facility failed to ensure the medications were stored inside a locked medication cart and were not left unattended by the licensed nurse. * Resident 12's simethicone (antiflatulence) medication was not labeled with the opened date. These failures had the potential for medication diversion and resident exposure to the expired medications with questionable potency and efficacy. Findings: 1. Review of the facility's P&P titled Medication Storage revised 9/2024 showed the drugs are stored in an orderly manner in cabinets, drawers, or carts of sufficient size to prevent crowding. All the medications and other drugs, including treatment items, are stored in a locked cabinet or room inaccessible to patients and visitors. Drugs are accessible only to the licensed personnel. The drugs of each resident are kept and stored in secure containers. On 1/30/25 at 0931 hours, during a medication administration observation with LVN 4, LVN 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 observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The facility failed to ensure the kitchen equipment was maintained in a sanitary condition. * The facility failed to ensure the food items was properly stored and maintained. These failures had the potential to result in foodborne illnesses for the residents receiving kitchen services in the facility. Findings: Review of the facility's untitled document for diet orders for the residents dated 1/29/25, showed one of 18 residents was receiving food prepared from the kitchen. 1. According to the USDA Food Code 2022, Section 4-601.11 Equipment, Food- Contact Surfaces, Nonfood Contact Surface, and Utensils. Equipment food - contact surfaces and utensils shall be clean to sight and touch. According to FDA Food Code 2022, Section 4-501.12, Cutting Surfaces, surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms…

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, medical record review, and facility P&P review, the facility failed to ensure the COVID-19 immunization was offered and administered to three of five sampled residents (two final sampled residents, Residents 17 and 6; and one nonsampled resident (Resident 1) reviewed for COVID-19 immunization. This failure placed the residents at risk to acquire COVID-19 infection. Findings: Review of the facility's P&P titled Coronavirus Disease (COVID-19) Mitigation Plan: 2019, 2020, 2021, 2022,2023 dated 9/2023 showed the Infection Prevention will maintain a listing of the residents eligible for vaccination. Consent will be obtained from resident or responsible person after education is provided. Consent will be maintained in the medical record. The resident or responsible party has the right to refuse vaccination and refusal will be documented and placed in the medical record. Review of the COVID-19 Vaccine information sheet dated 10/17/24, showed COVID-19 vaccine can prevent COVID-19 disease. The vaccine…

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, facility document review, and facility P&P review, the facility failed to ensure the dish machine was repaired in a timely manner to ensure the dish machine final water temperature reached a minimum of 180 degrees Fahrenheit (F) as per manufacturer instruction. This failure had the potential to cause foodborne illness for residents using dishes that were not properly sanitized. Findings: Review of the facility's untitled document for diet orders for the residents dated 1/29/25, showed one of 18 residents was receiving food prepared from the kitchen. According to the USFDA Food Code 2022 Annex 3, Equipment 4-501.11 Good Repair and Proper Adjustment, proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. Review of the facility's P&P titled Dishmachine Temperature revised 1/2024, under the section High Temperature Machine showed multi…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of two sampled residents (Resident 1). * The facility failed to implement their P&P to conduct an hourly rounding, neurological, skin, and body assessments for Resident 1 after she had sustained a fall on 11/2/24. * The facility failed to thoroughly investigate the fall incident for Resident 1. These failures had the potential to negatively affect the resident's health condition and well-being. Findings: Review of the facility's P&P titled Change of Condition: Reporting revised 9/2023 showed when a licensed staff member identifies a change of condition or becomes aware of any incident involving the care of a resident, a change of condition report is to be filled out on the shift report. This entry is in addition to the usual and customary documentation of the resident medical record which includes injuries, even minor to a resident. The director will…

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, medical record review, and facility P&P review, the facility failed to ensure the resident's Physician Orders for Life-Sustaining Treatment (POLST) was obtained and maintained in the medical record for one of 12 final sampled residents (Resident 22). This failure had the potential for the resident's decisions regarding his healthcare and treatment options to not be honored. Findings: Review of the facility's P&P titled Life Sustaining Treatment Physician Orders (POLST) revised 8/2023 showed all departments licensed by the facility will honor the POLST, a statewide mechanism for an individual to communicate his or her wishes about a range of life sustaining and resuscitative measures. Medical record review for Resident 22 was initiated on 2/26/24. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's Patient Orders showed a physician's order dated 10/19/22, for a Full Code, and to obtain POLST. Review of Resident 22's medical record failed to show a copy of Resident 22'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, medical record review, and facility P&P review, the facility failed to ensure two of 12 final sampled residents (Residents 8 and 24) were free from the physical restraints. * The facility failed to conduct an assessment, obtain an informed consent and a physician's order, and implement the least restrictive interventions prior to applying the seat belt and chest strap restraints for Residents 8 and 24 when the residents were up in the wheelchair. In addition, the facility failed to monitor and document the use of seat belt and chest straps restraints in the wheelchair. These failures posed the risk of compromising the residents' independence and psychosocial well-being. Findings: Review of the facility's P&P titled Restraints-Physical/Postural support, Safety revised 9/2021 showed the facility would complete the form Physical Restraint Assessment by the DON/Charge Nurse. The use of restraints should have been discussed with the resident and/or the responsible party. The nurse…

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, medical record review, and facility P&P review, the facility failed to notify the Office of the State Long-Term Care Ombudsman (a person who routinely visits the facility and advocated for the residents) of Resident 25's discharge to another SNF. This failure had the potential for the Ombudsman not knowing about the resident's discharge to another SNF. Findings: Closed medical record review for Resident 25 was initiated on 2/29/24. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's closed medical record showed the resident was discharged to another SNF on 12/19/23. Review Resident 25's Physician's Discharge summary failed to show documented evidence the Office of the State Long-Term Care Ombudsman was notified of the resident's discharge from the facility. On 2/29/24 at 1610 hours, an interview and concurrent closed medical record review was conducted with the facility's assigned Ombudsman. When asked if Ombudsman 1 was notified of Resident 25's discharge, Ombudsman 1…

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 facility document review, the facility failed to ensure the environment was free from accident hazards for two of 12 final sampled residents (Residents 3 and 16). This failure had the potential to negatively affect the residents' well-being and increased the risk of accidents or injuries to the residents. Findings: 1. On 2/26/24 at 0927 hours, an observation of Resident 3 was conducted. Resident 3 was in bed with billateral upper and lower siderails elevated without padding. On 2/28/24 at 1114 hours, an observation of Resident 3 was conducted. Resident 3 was in bed with bilateral upper and lower siderails elevated without padding. Medical record review for Resident 3 was initiated on 2/27/24. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Patient Orders showed a physician's order dated 9/8/23, to apply the seizure pads to all four side rails for safety/injury protection. Review of Resident 3's H&P examination dated 9/8/23, showed the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure three of 12 final sampled residents (Residents 13, 14, and 24) remained free from accident hazards associated with the use of elevated side rails. * The facility failed to assess Residents 13, 14, and 24 for the risk of entrapment from elevated side rails. This failure had the potential to place the residents at risk for entrapment and serious injury. Findings: Review of the FDA issued Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails showed the residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related…

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 medical record review, the facility failed to ensure one of 12 final sampled residents (Resident 24) was free from the unnecessary psychotropic medications. * The facility failed to ensure the physician's order for the quetiapine medication (a medication use to treat symptoms of schizophrenia or bipolar disorder) had a behavior indication for it's use, and the behavior and side effects were monitored related to the use of quetiapine. In addition, Resident 24's medical record failed to show monthly psychotropic summaries related to the use of quetiapine were completed and a plan of care was formulated for the use of the medication. These failures had the potential for the resident to have adverse complications from the medications and the potential of not providing the correct data to the prescriber to adjust the dose of the psychotropic medications for the resident. Findings: Medical record review for Resident 24 was initiated on 2/27/24. Resident 24 was admitted 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, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 8%. One licensed nurse (LVN 3) was found to have made errors during the medication administration observation. * Resident 3 had a physician's order for ocular lubricant ophthalmic solution and chlorhexidine (antiseptic) mouthwash which were scheduled at 0800 hour; however, LVN 3 failed to administer the medications as scheduled. This failure had the potential to negatively effect the resident's health. Findings: Review of the facility's P&P titled Medication Orders and Management revised 9/2021 showed the medications shall be administered within one hour before the prescribed time and within one hour after the prescribed time for a total of a two hour window. On 2/28/24 at 0834 hours, a medication administration observation for Resident 3 was conducted with LVN 3. LVN 3 prepared and administered Resident 3's medications. On 2/28/24 at 1129 hours, LVN 3 was observed administering two medications…

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 facility P&P review, the facility failed to ensure the medications were properly stored and labeled. * The facility failed to ensure the safe storage and dispose of Resident 16's expired medication found on his bedside table. * Resident 1 had a physician's order for vitamin D. Resident 1's vitamin D liquid bottle was observed with an unknown substance accumulated on the outside of the bottle. These failures had the potential to negatively impact the residents' well being. Findings: 1. Review of the facility's P&P titled Medication Storage date revised 9/21 showed all medications should be stored in a locked cabinet or room inaccessible to the residents and visitors. Drugs should not be kept on hand after the expiration date on the label. Medical record review for Resident 16 was initiated on 2/26/24 at 1004 hours. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's physician's order dated 4/3/23, showed an order for fluticasone (steroid medication)…

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, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were not worn out. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the microwave utilized to warm up the residents' food was in sanitary condition and free of food residue. * The facility failed to ensure the plumbing for the ice machine in the kitchen had an air gap. * The facility failed to ensure the test strip to measure the pH of the chemical sanitizing solution used to wash raw fruits and vegetables were not expired. * The facility failed to ensure the pH value of the chemical sanitizing solution used to wash raw fruits…

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 facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide the safe and sanitary environment were implemented. * The facility failed to record all the residents with infection on the facility's Infection Surveillance Tool. The facility's Infection Surveillance Tool did not include all the residents identified with infections. Only the residents with positive culture results were identified as having infection and were listed on the surveillance list. * The facility failed to ensure the laundry room's soap bucket was kept clean and failed to keep the soap bucket off the floor surface. * The facility failed to remove the isolation signage after the neutropenic precaution order was discontinued for Resident 5. These failures posed a risk for transmission of disease causing microorganisms and infections and incorrect notification of infection control practices. Findings: Review of the facility's P&P titled Pediatric…

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, medical record review, and facility P&P review, the facility failed to implement their Antibiotic Stewardship Program when: * The facility failed to conduct an assessment for the McGeer's criteria for one of 12 final sampled residents (Resident 15), and two nonsampled residents (Residents 17 and 676) * The facility failed to notify the physicians regarding the McGeer's criteria were not met for true infection for two of 12 final sampled residents (Residents 3 and 19) and one nonsampled residents (Resident 12) These failures had the potential for inaccurately identifying for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antibiotics. Findings: According to the Centers for Disease Control and Infection, an estimated 70% of nursing home residents receive one or more courses of antibiotics during a year. Studies have shown that 40% to 75% of the antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Frail and older…

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 medical record review, the facility failed to ensure the COVID-19 vaccinations were administered to one of 12 final sampled residents (Resident 9) after receiving the consent from Resident 9's responsible party. This failure placed the resident at risk to acquire COVID-19 infection. Findings: Medical record review for Resident 9 was initiated on 2/29/24. Resident 9 was admitted to the facility on [DATE]. Review of Resident 19's COVID-19 VACCINE CONSENT form showed on 1/6/23, Resident 19's responsible party consented for Resident 19 to receive the COVID-19 vaccination. Review of Resident 19's Immunization Record failed to show documented evidence of the administration of COVID-19 vaccination. On 2/29/24 at 1323 hours, an interview and concurrent medical record review was conducted with the Infection Control Coordinator. The Infection Control Coordinator verified Resident 9's responsible party had signed the consent form on 1/6/23. However, the Infection Control Coordinator stated the charge…

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, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to meet the care needs related to the tracheostomy care for one of the three sampled residents (Resident 2). * The facility failed to ensure the tracheostomy care was provided to Resident 2 as per the facility's P&P. This failure posed the risk for not keeping the stoma area clean and being susceptible to infection. Findings: Review of the facility's P&P titled Trach Care dated 5/2014 showed the respiratory care staff along with nursing staff will provide proper and correct tracheostomy/stoma care in order to keep stoma area clean, free of secretions, and less susceptible to infection. The procedure showed the following: - to dampen the applicators and gauze with hydrogen peroxide (mild antiseptic) and swab the secretions from stoma/trach area until clean. Rinse with sterile water. On 2/1/24 at 1200 hours, a tracheostomy care observation of Resident 2 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the pharmaceutical services to ensure the accurate medication dispensing and administration as evidenced by: * The facility failed to ensure the crushed medications administered via GT were administered separately and not combined as per the facility's policy and standards of nursing practice. This failure had the potential to alter the composition of the medications. * The facility failed to ensure Resident 4's supply of Vitamin D was available. LVN 5 took another resident's medication supply of Vitamin D due to the lack of Resident 4's medication supply. This failure posed the risk of residents not receiving their ordered dose of medication and has the potential for medication errors. * The facility failed to ensure Medication Administration Records for seven of 17 sampled residents (Residents 1, 5, 6, 7, 9, 13, and 14) were immediately signed as administered after the medications were administered to the residents. This…

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, medical record review, and facility document review, the facility failed to allow visitation from a family member for one of 17 sampled residents (Resident 3). This failure had the potential to negatively affect the resident's psychosocial well-being. Findings: Review of the Centers for Medicare & Medicaid Services (CMS), QSO-20-39-NH (Quality, Safety, and Oversite), memorandum, revised 05/08/2023, showed facilities must allow visitation at all times and for all residents as permitted under the regulations. Facilities cannot limit the frequency and length of visits for residents, the number of visitors, or require advance scheduling of visits. Review of the facility's Notice titled Your Information, Your Rights, Our Responsibilities, revised 3/2019 showed the residents have the right to designate a support person as well as visitors of their choosing. However, the facility may establish reasonable restrictions upon visitation and must inform the resident or their support person of any…

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, medical record review, and facility P&P review, the facility failed to allow one of 17 sampled residents (Resident 3) to return and resume residence in the facility after the acute care hospital determined Resident 3 was ready for discharge. This failure caused Resident 3 to remain in the acute care hospital for an additional three days, which had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Transfer/Discharge of Resident-Pediatric revised on 9/2021 showed discharge planning meetings will begin 3 months before discharge for planned transfers or as soon as possible for unplanned transfers. Meetings will be coordinated by the social worker and will be attended by members of the resident's family and interdisciplinary team. Medical record review for Resident 3 was initiated on 8/14/23. Resident 3 was originally admitted to the facility on [DATE], and transferred to the acute care hospital on 3/5/23. Resident 3 was readmitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the proper GT care for two of 17 sampled residents (Residents 4 and 16) as evidenced by: * Residents 4 and 16's GTs were not flushed with water before being administered their first medications and in between each of their medications per the facility's P&P. This failure posed the risk for Residents 4 and 16 to develop complications related to their GT. Findings: According to the Journal of Parenteral and Enteral Nutrition, Volume 41, Issue 1 dated 01/17, showed feeding tubes are prone to clogging for a variety of reasons that include insufficient water flushes and incorrect medication preparation and administration. The document further showed to flush feeding tubes before and after each medication administration. Review of the facility's P&P titled Enteral Nutrition and Medication Administration revised 2/2020 showed when medications are administered via enteral routs, the tubes should be flushed 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 observation and interview, the facility failed to ensure the safe storage and labeling of medications as evidenced by: * A medication cart (Medication Cart A) was left unlocked and unattended when LVN 6 walked away from the medication cart and into a resident's room to administer medications. Medication Cart A was accessible to unlicensed staff and visitors. This failure had the potential to allow unauthorized access to medications and residents' medication records. * Two opened bottles of medications were not labeled with open and expiration dates. This failure posed the risk for the residents receiving expired medications. Findings: 1. On 8/4/23 at 1032 hours, an observation of medication preparation and administration was conducted with LVN 6. LVN 6 was observed to leave Medication Cart A unlocked and unattended in the hallway when LVN 6 went into a resident's room to administer medications. On 8/4/23 at 1055 hours, an interview was conducted with LVN 6. LVN 6 stated he should have locked the medication cart before going into the resident's room to administer…

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.