Redwood Cove Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and document reviews, the facility failed to ensure Certified Nursing Assistants (CNA) possessed a current and active certificate in accordance with applicable State laws when one CNA (CNA A) of a sample of nine CNAs had an expired certificate. This failure decreased the facility's potential to provide safe resident care within CNA A's scope of practice. Findings: A review of nine CNA certificate verifications which were provided by the Director of Staff Development (DSD) was conducted on [DATE] and indicated CNA A's certificate expired on [DATE]. A review of the daily nursing schedule dated [DATE] indicated CNA A was scheduled to work that afternoon from 3 p.m. until 7 a.m. on [DATE]. During an interview on [DATE] at 11:10 a.m., the DSD acknowledged CNA A had been working with an expired certification. A review of the daily CNA schedule between [DATE] and [DATE] indicated CNA A worked with an expired certificate from [DATE] to [DATE], [DATE] to [DATE], and [DATE] to [DATE]. During an…

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 carry out a physician ' s order for one resident (Resident 1) of two sampled residents when nursing staff did not document they were monitoring Resident 1 ' s Peripherally Inserted Central Catheter (PICC line, a long, thin, flexible tube inserted into a vein in the upper arm and guided to a large vein near the heart used to deliver medication) insertion site every shift from 3/28/25 to 4/11/25. This failure increased the potential for a delay in identification of infection and negatively affect the health of Resident 1. Findings: A review of Resident 1 ' s admission record indicated she was admitted on [DATE], and her medical diagnoses included acute osteomyelitis (infection of the bones), right tibia and fibula (two long bones of the lower leg) and Methicillin Resistant Staphylococcus Aureus (MRSA, a bacterium resistant to many antibiotics) infection. A review of Resident 1 ' s order summary report dated April 2025 indicated an active order for a PICC…

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 resident (Resident 1) of two sampled residents was free from a significant medication error when a dose of intravenous (IV- administered into a vein) antibiotic was not documented as administered on 4/5/25 per the physician's order. This failure had the potential to result in incomplete treatment and increase the risk of antibiotic resistance, making further infections harder to treat. Findings: A review of Resident 1's admission record indicated she was admitted on [DATE], and her medical diagnoses included acute osteomyelitis (infection of the bones), right tibia and fibula (two long bones of the lower leg) and Methicillin Resistant Staphylococcus Aureus (MRSA, a bacterium resistant to many antibiotics) infection. A review of Resident 1's order summary report indicated an order for daptomycin-sodium chloride (an antibiotic used to treat complicated skin infections) IV solution 700-0.9 milligrams (mg)/100 milliliters (ml) every evening…

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 it designated a person to serve as the Director of Food and Nutrition Services who was certified, when the Registered Dietician (RD) was not employed full-time. This failure indicated the facility did not meet the Federal guidelines and did not follow the job description, when hiring a Dietary Manager (DM). During an interview on 4/29/24 at 10:01 a.m., the Dietary Manager (DM) stated she was not a Certified Dietary Manager. The DM stated the Registered Dietician (RD) only came in once every week on Wednesdays. The DM stated she did not receive consistent in-services and training's from the RD. During an interview on 4/30/24 at 3 p.m., the DM stated she was not a Certified DM. The DM also stated she was not a graduate of a Dietetic Technician Training Program approved by Academy of Nutrition and Dietetics (AND, an organization of dietetic professionals committed to improving the nation's health). The DM stated she also did not receive six hours of Title 22 (State regulations on health and safety standards for…

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 the Resident Rights of 13 Sampled Residents (Resident 200, Resident 16, Resident 28, Resident 164, Resident 264, Resident 22, Resident 5, Resident 42, Resident 14, Resident 53, Resident 38, Resident 30 and Resident 31) were honored, when: 1. Ten Sampled Residents (Resident 200, Resident 16, Resident 28, Resident 164, Resident 264, Resident 22, Resident 5, Resident 42, Resident 14, and Resident 53) reported call light response times of up to two hours. This failure resulted in delay in care and a loss of dignity, when residents were not assisted with timely brief changes when soiled and had the potential to result in incontinent accidents, falls resulting in broken bones, soft tissue injuries, pressure ulcers, psychosocial harm, feelings of despair and depression. 2. The facility did not ensure two sampled Residents (Resident 200, Resident 16) had useable prescription glasses. This failure resulted in the inability of Residents to…

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 observations, interview and record review, the facility failed to ensure a safe and sanitary environment for residents, when hand hygiene was not offered to residents before meals, when the hand hygiene P&P was not followed during medication administration, and cross-contamination risks were observed in linen storage and laundry processing areas. Findings: (Reference F 880) During an observation on 4/29/24, at 11:33 a.m., in the housekeeping closet next to Resident room [ROOM NUMBER], the floor, walls, sink and equipment, door and door jamb appeared to have a black, gray residue on all surfaces. The black, gray substance felt greasy to the touch. Under the sink was what appeared to be a calcified, wet, plumbing leak originating from the hopper sink. (See Photos) During an observation on 4/29/24, at 11:34 a.m., the resident Shower Room, located in the hallway across from staffing, had multiple unlabeled razors, lotions, and shampoo sitting on a shower shelf. An insect was on a resident shower seat. 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 interviews and record reviews, the facility failed to ensure: 1. Staff were aware of what a Basic Care Plan (BCP, a plan that promotes continuity of care and communication among nursing home staff which should be completed within 48 hours of resident admission and contain the minimum healthcare information necessary to care for resident safely) was and its completion time frame. 2. The BCP was completed for one out of one sampled resident (Resident 216) and completed timely for seven out of eight sampled residents (Residents 10, 14, 20, 30, 31, 216, and 265). These failures had the potential to put residents' safety at risk and for residents not receiving the care they need. Findings: A review of Resident 10's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Hyperlipidemia (HLP, high cholesterol is an excess of lipids or fats in your blood), Essential Hypertension (HTN, high blood pressure) and Type 2 Diabetes Mellitus (DM, disease caused by…

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 observations, interviews and record reviews, for a resident who had a tube feeding (method of feeding that uses the gastrointestinal (GI) tract to deliver nutrition and calories when you cannot eat or drink safely by mouth), the facility failed to: 1. periodically evaluate the amount of feeding being administered for one out one sampled resident (Resident 265), when staff did not know to calculate how much formula was given and how much formula should be left in the feeding bag in a period of time. 2. monitor Resident 265's input and output (I &O, important to help evaluate a person's fluid and electrolyte balance, to suggest various diagnosis, and allows for prompt intervention to correct the imbalance) to ensure she was receiving the calculated amount of tube feeding consistent with practitioner's orders. These failures could put Resident 265 at risk for fluid and electrolyte imbalance (occurs if the body has too much or too little water), dehydration (a condition that results when the body loses more…

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: 1. Follow its Policy and Procedure for Medication Regimen Review. 2. Ensure staff knew what a glycoprotein-colony stimulating factor (G-CSF, used to increase the number of white blood cells in the blood, which helps your immune system fight infections and heal injuries, in patients receiving anticancer drugs) injection was. 3. Ensure the monthly Medication Regimen Review by the Pharmacist for Resident 14 was thorough and accurate, when the medication G-CSF injection was not listed on Resident 14's current medications, and staff did not notify the pharmacist Resident 14 was receiving G-CSF injection weekly. These failures had the potential to: 1. Cause serious physical and/or psychosocial harm when the facility did not forward pharmacy recommendations to any facility physician for five months, September 2023 through March 2024. 2. Prevent the Pharmacist from identifying an irregularity that might require an urgent action to protect Resident 14.…

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 observations, interviews and record reviews, the facility failed to ensure food was palatable, and served at temperatures in accordance with resident preferences, for four out of five sampled residents (Residents 5, 14, 42 and 53), and the food temperature was not taken prior to serving to one out of 5 sampled residents (Resident 47). These failures could result in residents not eating the food served, which could result in weight loss and further compromise their medical status. Not taking the food temperature prior to serving to the resident could result in accidents such as burns. Findings: A review of Resident 14's face sheet (demographics) indicated she was admitted to the facility on [DATE], with a diagnoses of Dysphagia (swallowing difficulties), Hyperlipidemia (HLP, abnormally high levels of fats (lipids) in the blood) and Essential Hypertension (HTN, high blood pressure). Resident 14 reported she had Breast Cancer (Cancer that forms in tissues of the breast) which was being treated outside 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 and interviews, the facility failed to ensure food items in the refrigerator, freezer and dry pantry area were opened- and discard-dated and expired food items were discarded. These failures led to unsafe and unsanitary storage of food. These failures were also a safety risk that could lead to accidental ingestion of expired food items that could result in food-borne illness (an illness that comes from eating contaminated food). Findings: During a concurrent observation and interview on 4/29/24 at 9:49 a.m., the dry pantry was noted with cooking oil that was halfway used and an opened two-way chocolate mix that did not have a discard date. Refrigerator 1 had an opened bottle of 100% lemon juice and teriyaki sauce that had no open and discard-by date. The Dietary Manager (DM) stated these items should be opened- and discard-dated. The DM stated all food items in the kitchen should be opened- and discard-dated. During an interview on 4/29/24 at 10:01 a.m., the DM stated food items in the kitchen should have an open- and discard-by date so staff knew when food…

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 an effective Infection Control Program when: 1. Dirty and stained carpeting, broken floor surfaces, cracked wheelchair arm rests, exposed wall plaster, rust, and chipped paint were observed in patient care areas. 2. Cross-contamination risks were observed in Laundry Processing and storage areas, Clean Utility Room, and resident Ice Storage Room. 3. Vaccination rates of staff and Residents and Hand Hygiene compliance was not monitored. These failures had the potential for resident infection, potential death from cross-contamination and infection, and psychosocial harm Findings: (Reference F 584) 1. During an observation on 4/29/24, at 11:33 a.m. the Housekeeping Closet, next to Resident room [ROOM NUMBER], revealed the floor, walls, sink and equipment, door and door jamb had black, gray residue on all surfaces. The black, gray substance felt greasy to the touch. Under the sink there appeared to be a calcified, wet, plumbing leak…

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 kitchen walls were in good repair, when cracks and holes in the walls were noted during rounds, and the dish washing sink counter was rusty. These failures could result in rodents and pests accessing the kitchen area through these cracks and holes, which could put residents at risk for harmful diseases. The rusty kitchen sink counter created a breeding ground for bacteria as it could not be disinfected and cleaned thoroughly, which could be a safety risk. Findings: During an observation on 4/29/24 at 9:58 a.m., the wall underneath the dish washing sink, near the dish sanitizing machine, was cracked and had a hole, the floor was dirty with whitish material build up, the area under the sink was noted with cobwebs. The metal sheet wall by the dish washing area had holes. The wall by the door leading towards the hallway had a hole, and the dishwashing sink counter was rusty. During a concurrent observation and interview on 5/1/24 at 7:23 a.m., the Dietary Manager verified the sheet metal wall by 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 and interviews, the facility failed to maintain an effective pest control program to ensure the facility was free of pests or cockroaches, when a cockroach was seen crawling underneath the dish washing sink. This failure could lead to transfer of harmful bacteria to humans and could cause Salmonella (a group of bacteria that can cause diarrhea-3 or more loose, watery stool in a day, in humans), Leptospirosis (an infectious disease that damages the liver and kidneys), Typhoid Fever (a life-threatening infection that causes diarrhea and fever) and Cholera (an infectious disease that causes severe watery diarrhea). During a concurrent observation and interview on 5/1/24 at 7:23 a.m., a brownish-colored pest was crawling underneath the dishwashing sink area, which the Dietary Manager (DM) identified as a small cockroach. The DM stated this was not the first time they saw a cockroach in the kitchen area. The DM stated this was an ongoing issue. The DM stated pests and cockroaches could bring illness, and residents could get sick, such as Nausea (the condition of…

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 residents were aware of and had access to, State Survey Agency contact information. This failure had the potential to interfere with residents' ability to file a complaint with the State Agency and possibly delay an investigation. Findings: During an interview on 4/30/24 at 2:05 PM, during the Resident Council Meeting, Residents 5, 42, 14, 53, and 4 stated they did not know how to file a complaint with the State Agency or where to find contact information. During an interview and observation on 5/2/24 at 4:35 PM, with Licensed Nurse F (LN F), when asked about the posting for residents to file a complaint with the State Agency, LN F pointed to the posting for the Ombudsman. During an interview and observation on 5/2/24 at 4:36 PM, with LN F, the surveyor was escorted to a bulletin board which did not contain State Agency contact information. The LN F stated, Let me ask my supervisor where to find the posting. During an interview and observation on 5/2/24 at 4:38 PM, with LN F, the surveyor was escorted…

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 post the results of the most recent State Survey in a location readily accessible (a place where individuals wishing to examine survey results did not have to ask to see them) to residents, family members, and/or legal representatives of residents. This failure had the potential to prevent access to relevant information that could affect a resident's decision making, quality of care and/or quality of life. Findings: During an interview on 4/30/24 at 2:05 PM, in the Resident Council Meeting, Residents 5, 42, 14, 53, and 4 stated they did not know where to access the results of the State Survey. Residents 5, 42, 14, 53, and 4 stated they wanted to know where the information was located. During an observation on 5/2/24 at 4:30 PM, in the hallway across from the nurse's station, a large white binder with a label, Survey Results, and with a small piece of paper stuck to the binder indicating, 2012 - 2016, was in a binder holder on the wall. During an interview on 5/2/24 at 4:40 PM, the Administrator stated he 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 interviews and record reviews, the facility failed to ensure the physician was notified for a significant weight loss (5% in 1 month, 10% in 3 months and 7.5 % in 6 months) for one out of one sampled resident (Resident 25). This failure had the potential to further aggravate and compromise her medical status. Findings: A review of Resident 25's face sheet (demographics) indicated she was initially admitted to the facility on [DATE]. Her diagnoses included Essential Hypertension (occurs when you have abnormally high blood pressure that is not the result of a medical condition), Dysphagia (difficulty swallowing) and Anxiety (a feeling of fear, dread, and uneasiness). Her Minimum Data Sheet Assessment (MDS, a federally-mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 2/12/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 13, indicating intact cognition…

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 The facility did not ensure two sampled Residents (Resident 200, Resident 16) had useable prescription glasses. This failure resulted in the inability of Residents to read, be able to watch television, see what they were eating, or engage in activities that provided them joy. This failure made the Residents feel like they did not matter and were unimportant to the facility. Findings: (Cross Reference F550) During an observation and interview on 4/29/24, at 11:19 a.m., Resident 16 was laying in her bed, with the curtains pulled shut and no lights on. She was on her back, in a patient gown, not wearing glasses. A bedside table with a paperback book, an embroidery project and an eyeglass case were on her right side. She stated she wore glasses and pointed to her eyeglass case, which contained a pair of yellow metal eyeglass frames missing the right lens. Resident 16 stated she did not know if anyone ordered her a new pair of glasses. She stated she told staff about it, and no body had followed up with her for 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 observation and interview, the facility failed to properly label insulin pens (insulin delivery device that comes preloaded with insulin, including premixed insulin's) with resident information, when insulin pens were labeled on the outer plastic storage bag or on the cap of the pen instead of the shaft (the section of the pen that contains the insulin storage container). This failure had the potential to: 1. Expose residents to infectious agents if the insulin pens were used by more than one resident. 2. Cause serious adverse effects if a resident was given a dose and/or type of insulin prescribed for another resident. Findings: During an observation and interview on 5/1/24 at 8 AM, Licensed Nurse G (LN G) prepared and administered insulin to Resident 1 using an insulin pen. LN G stated the insulin pen was obtained from the E Kit (Emergency Medication Supply for use when resident medications were not available) and did not come labeled with resident identifying information. LN G filled in the label with Resident 1's identifying information. During an observation 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 development of a plant-based menu. This failure had the potential for residents to not meet the Recommended Daily Intake (RDI, the average daily dietary intake level that is sufficient to meet the nutrient requirements of nearly all (97-98 per cent) healthy individuals in a particular life stage and gender group) for certain nutrients like protein or vitamins,which could further compromise their medical status. During a concurrent observation and interview 5/1/24 at 7:23 a.m., the Dietary Manager (DM) stated the facility did not have a plant-based menu. The DM stated she asked their vendor and was told they did not have any plant-based menu being offered at this time, but they would be releasing a plant-based menu soon. The DM stated, if the facility had a resident on a vegan diet, they would just use the food items they currently had in the building to substitute. The DM checked the freezer and found a Ziploc labeled Veggie burger which had no information on the dietary content, such as calories…

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 observations, interviews, and record reviews, the facility failed to implement its policies and procedures on infection prevention and control practices when: 1. An unlicensed staff did not perform hand hygiene and change her gloves between residents did not clean and disinfect the vital signs equipment between residents and after using the equipment. 2. Two staff did not wear proper PPE (Personal Protective Equipment) upon entering two resident rooms that were on transmission-based precautions. 3. Two licensed staff did not cleanse and disinfect vital sign equipment in-between residents and after using equipment. These failures did not ensure a clean physical environment for patient care and services, and had the potential to result in an outbreak of infections and illnesses to all residents of the facility. Findings: 1. During an observation on 3/9/22, at 9:54 a.m., in room [ROOM NUMBER] with Unlicensed Staff L, she was observed taking the vital signs equipment to the room. Unlicensed Staff L…

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 interviews, and record reviews, the facility failed to offer and document advance directives for 8 of 17 sampled residents (Resident 9, Resident 11, Resident 13, Resident 15, Resident 17, Resident 40, Resident 57, and Resident 163). This failure had the potential to result in facility performing care and services at residents' end-of-life that is inconsistent with the residents' best interests or preferences. Findings: During a review of medical records for Advance Directives, the following residents (Resident 13, Resident 15, Resident 17, Resident 40, and Resident 57) had no indication in their medical records that an advanced directive was listed or offered to these residents upon admission. During an interview on 3/9/22 at 11:30 a.m., the Social Service Director (SSD) stated she was not responsible for obtaining the Advance Directives. When asked who the responsible party for Advance Directives was SSD stated to check with the facility's Admissions Coordinator. During an interview on 3/9/22 at 12:00 p.m., the Admissions Coordinator stated he was the responsible person…

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 access to telephone communication for residents, family members, staff, and outside affiliates was easily available. This failure denied residents, family members and medical staff consistent communication regarding the medical care for residents and had the potential to result in a delayed or non-delivery of care and services to its residents. Findings: During an observation on 3/8/21 at 8:30 a.m., the screener (e.g., facility staff assigned to screen staff and visitors for COVID-19 signs and symptoms as they come into the facility) was observed answering the telephone and walking to individual staff to let them know they have a phone call. During an interview on 3/11/2022 at 12:15 p.m., the Director of Staff Development (DSD) stated the facility utilized a new telephone system, and she was trying to learn how it worked. When phone calls for a resident come into the facility, the calls are forwaded to a satellite phone that was brought to the Resident. Not all resident rooms had their own telephones. During an…

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 one of the three sampled residents (Resident 50) was provided support with activities of daily living (ADL). This failure resulted in Resident 50 staying in bed throughout the survey, which had the potential to cause development of a pressure injury. Findings: A review of Resident 50's current medical diagnoses indicated the following: dementia (loss of cognitive functioning-thinking, remembering, and reasoning), muscle weakness, and difficulty walking. During an observation on 3/7/22, at 11:30 a.m., Resident 50 was observed laying on bed, doing nothing. During an observation on 3/7/22, at 3:46 p.m., Resident 50 was observed laying on bed sleeping. During an observation on 3/8/22, at 10:29 a.m., Resident 50 was observed laying on bed, looking around the room and playing with her blanket. At 11:35 a.m. Resident 50 was observed still in bed. During an interview on 3/9/22, at 3:16 p.m., Management Staff S stated that Resident 50 did…

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 food items in the refrigerator were labeled and dated. This failure had the potential to result in residents eating or drinking expired or contaminated food items, which could cause gastrointestinal illness for the vulnerable residents. Findings: During a concurrent observation and interview on 3/7/22, at 10:28 a.m., the kitchen was observed with Management Staff E. One carton of opened orange juice that was not dated was observed inside the drink refrigerator. Management Staff E stated they can keep the opened orange juice for five days and it should be dated. Four small disposable white cups/bowls with lids with food inside were observed in refrigerator #1. Management Staff E was about to throw them away and Dietary Staff F stated those were Rocky Road pudding and will be used for later. During a concurrent observation and interview on 3/9/22, at 9:36 a.m., the nursing station refrigerator for residents' snacks and supplement was observed with Licensed Staff D. One carton of half-filled Med-Pass 2.0…

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 all areas of the facility were safe, sanitary, of comfortable, when facility staff allowed one resident's (Resident 61) room to become cluttered and odiferous. This failure resulted in added safety risk to Resident 61 related to obstacles in the physical environment that posed a risk to timely evacuation in time of emergency, as well as a strong, foul-smelling odor emitting into the adjacent hallway through the doorway of the resident's room. Findings: During an observation on 3/7/22, at 11:35 a.m., Resident 61's door was observed closed. When opened, there was a distinct foul odor that appeared to be coming from a wound. Resident 61's room was observed full of stock boxes and cluttered personal items. During an interview on 3/7/22, at 11:35 a.m., Management Staff Q stated that Resident 61 had several wounds and last assessment was December 2021, because Resident 61 would not let staff assess the wounds. During a concurrent observation and interview on 3/7/22, at 11:50 a.m., Resident 61 was observed…

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.