Ukiah Post Acute

Based on interviews and record reviews, the facility failed to ensure medications were administered timely for three out of three sampled residents (Residents 11, 32 and 45). This failure put Residents 11, 32 and 45 at significantly increased risk of worsened health condition, untreated symptom, and complications from untreated symptoms. Findings: A review of Resident 11s face sheet indicated an admission date of 10/25/24 with a diagnoses of Weakness, Hypertension (HTN, high blood pressure) and Hyperlipidemia (HLP, high levels of fat particles (lipids) in the blood. Resident 11s BIMS dated 11/19/24 score was 15 indicating intact cognition. A review of Resident 11s MAAR indicated 2 medications were administered late on 1/19/25: Insulin injection scheduled time was 6:30 a.m. and was not administered until 8:15 a.m. and Insulin injection scheduled time was 4:30 p.m. and was not administered until 5:41 p.m., A review of Resident 11s MAAR indicated at least 2 medications were administered late on 1/21/24: Vasoconstrictor scheduled time was 6:30 a.m. and was not administered until 08:25…

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 sufficient and competent staff were scheduled to carry out the functions of the food and nutrition service safely when: 1. Two staff members worked tray line affecting timeliness of meal delivery. 2. One dietary aide (DA B) could not verbalize or demonstrate proper method to check sanitizing solution. 3. Presentation of pureed food was not appetizing. Findings: 1. During an observation on 1/21/25 at 10:00 a.m., a posted sign at the nursing station 2 read: breakfast served at 7:30 a.m., lunch at 11:30 a.m. and dinner at 5:30 p.m. daily. During an observation on 1/21/25 at 11:49 a.m., a food cart arrived in the dining room. Five residents seated at different tables were served and started eating. The second cart arrived at 12:07 p.m. During an observation on 1/22/25 at 12:11 p.m., the lunch food cart was delivered to nursing station 2. During an observation on 1/22/25 at 7:15 a.m., breakfast trayline was in progress. [NAME] (CK) C plated entrees and sides while Dietary Aide (DA) B placed drinks,…

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 accommodate resident food preferences or offer snacks to seven of 46 residents (Resident 154, Resident 36, Resident 1, Resident 3, Resident 27, Resident 11, Resident 29), when alternate menu items were continuously repeated, and snacks were not offered to all residents in the facility. This failure had the potential for residents in the facility to experience weight loss and become malnourished. Findings: During an interview with Resident 154, on 1/21/25 at 3:54 p.m., Resident 154 stated the food at the facility was not very good. She stated substitutions were limited to cheese based options that did not taste good and was served cold. She stated too much cheese created a constipation problem. She stated she was not offered snacks ever. During an interview on 1/22/25 at 8:21 a.m., Resident 154 and Resident 36 stated they were not offered snacks last night. Resident 36 stated the facility had never offered bedtime snacks. During an observation and interview on 1/22/25 at 8:24 a.m., Certified Nurses Aid (CNA) N…

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 observations, interviews and record reviews, the facility failed to ensure: 1. Staff were following the Enhanced Barrier Precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) when administering medications via feeding tube (tube inserted into the stomach to provide a patient with enteral nutrition, used when someone is unable to eat or drink safely by mouth). This failure could lead to spread of infection, increased complications and adverse events. 2. Staff were performing hand hygiene (HH, cleansing of your hands with soap and water, antiseptic hand washes, antiseptic hand rubs such as alcohol-based hand sanitizers) prior to donning gloves. These failures could lead to spread of infection, increased complications and other adverse events. Findings: A review of Resident face sheet (demographics) indicated an admission date of 12/23/24 with a diagnoses of Dysphagia (difficulty swallowing) and Esophagitis (an inflammation of 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, interviews and record reviews, the facility allowed one out of two sampled residents (Resident 11) to self-administer medications without the Interdisciplinary Team (IDT, a collaborative approach that combines data, techniques, and perspectives from multiple disciplines) determining if self-administration was clinically appropriate for Resident 11. This failure was a safety issue which could lead to dosing errors and ineffective symptom management. Findings: A review of Resident 11s face sheet (demographics) indicated an admission date of 10/25/24 with a diagnoses of Weakness, Hypertension (HTN, high blood pressure) and Hyperlipidemia (HLP, high levels of fat particles (lipids) in the blood. During a concurrent observation and interview on 1/22/25 at 10:36 a.m., there was a medicine cup with 4 ½ tablets noted on top of Resident 11's overbed table. Resident 11 stated the morning nurse left it there. Resident 11 could not recall the name of the pills but knew one of them was tramadol (opioid analgesic and had high potential for misuse and abuse). Resident 11…

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: 1. the opthalmic (eye) suspension medication of one out of two sampled residents (Resident 4) was labeled properly when the physician's order had changed. 2. the discontinued level II-V medications (drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) were stored in a permanently affixed compartment prior to destruction. These failures had the potential to cause medication errors and/or lead to drug diversion. 1. Findings: A review of Resident 4s face sheet (demographics) indicated an admission date of 3/17/23 with a diagnoses of Low Back Pain and Weakness. A review of Resident 4s Physician Order Summary (POS, a written physician order/instruction for staff to follow) indicated an order of ophthalmic (eye) suspension 1 percent (%, one part in every hundred) instill 1 drop (gtt) in left eye two times a day dated 1/20/25 for herpes viral keratitis (infection of the eye caused by the herpes simplex virus (HSV). During a concurrent…

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.there were adequate staff to care for the residents at the facility when three out of three sampled residents (Residents 1, 2 and Anonymous 1) complained the facility was short staffed and staff would take a long time to answer their call lights. 2.the Abuse Policy and Procedure (P&P) were updated to reflect correct reporting guidelines and staff were aware on which agencies to report abuse allegations and the reporting time frame for abuse allegations. These failures: 1a. resulted in residents feeling frustrated, upset and worried nobody will answer their call light on time in case of emergency. This also had the potential for neglect, late provision of care or care not being provided at all. 2a. had the potential for abuse to not be reported to the appropriate agency timely and could result in ongoing abuse and safety risk for the resident. Findings: A review of Resident 1's face sheet (demographics) indicated she was initially admitted…

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 dietetic services observations, dietetic staff and Registered Dietitian interview and departmental document review the facility failed to ensure meals were prepared in a sanitary manner, in accordance with standards of practice and departmental procedures as evidenced by 1) holding of foods for extended periods of time at a temperature which may promote bacterial growth; 2) vegetable preparation without prior washing; 3) use of wiping cloths that were not immersed in a chemical sanitizer; 4) undated, thawed nutrition supplements; 5) multiple kitchen areas and equipment that were not clean and 5) storage of scoops in shelf stable foods. Failure to follow standardized sanitation practice may result in bacterial growth associated with foodborne illness, cross contamination of foods, retention of expired items and create an environment that supports a vermin infestation. Findings: 1. Foods which require time/temperature control for food safety include protein-based products such as meat as well as…

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 dietetic services observations and administrative and dietetic staff interview the facility failed to ensure frequent and comprehensive consultative departmental oversight by a Registered Dietitian and to employ a qualified Director of Food Services for day-to-day management duties. Failure to provide an organizational structure led by qualified staff, in a consistent manner, resulted in lapses related to staff competency, safe food handling practices, ineffective meal distribution and poor sanitation practices in dietetic services. Failure to develop staff and systems in accordance with regulatory requirements and professional standards may result in practices that put residents at risk for foodborne illness, decreased meal intake further compromising the medical status of 44 residents receiving meals from the facility dietetic services. Findings: During the abbreviated survey on 9/11/23 between the hours of 12:30 p.m. and 6:30 p.m., and on 9/12/23 between the hours of 9:30 a.m., and 12:30 p.m., there…

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 dietetic services observations, dietary and administrative staff interview and departmental document review the facility failed to ensure staff competency as evidenced by lack of training and orientation of 2 of 2 dietary staff (Dietary Staff 1 and 2) members present during the abbreviated survey. Findings: 1. During meal distribution observation on 9/11/23 beginning at 5:15 p.m., the evening meal consisted of soy glazed pork, pineapple fried rice, spinach salad and fresh fruit. It was noted except for the texture altered diets all residents received the same meal tray. In a concurrent interview the surveyor asked DS 2 the meaning of fortified on the tray tickets. DS 2 stated the terminology indicated residents were losing weight and needed to gain fat. In an interview on 9/11/23 at 4:30 p.m., DS 2 indicated she has been working at the facility for approximately 2 months. She also stated her work experience was primarily in the retail sector and except for working with another cook for several days she…

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 dietetic services observations, resident interview and departmental document review the facility failed to consistently follow the menu and when menus were altered did not have a method to advise residents of the changes. Failure to follow menus as outlined may result in decreased resident meal satisfaction, nutritional value of meals which in turn may result in decreased meal intake leading to weight loss, further compromising medical status. Findings: 1. During initial kitchen tour on 9/11/23 beginning at 12:30 p.m., dietary staff had just completed the noon meal service and were cleaning up. In a concurrent interview Dietary Staff 3 stated they switched the noon meal and are serving the meals intended for Thursday (9/14) today and would serve Monday ' s (9/11) meal on Thursday. The surveyor inquired the process for informing residents and the Registered Dietitian when meals were altered. DS 3 stated he was not aware of any process. Concurrent review of the menu posted in the kitchen revealed the served lunch meal should have been zesty lasagna, Italian green beans,…

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 meal plating observation, dietary staff interview and departmental document review the facility failed to ensure the standardized menu, approved by the Registered Dietitian, was followed resulting in physician ' s orders not followed for six Residents (Residents 5,6,7,8,9 and 10) with fortified diet orders. Findings: During meal distribution observation on 9/11/23 beginning at 5:15 p.m., the evening meal consisted of soy glazed pork, pineapple fried rice, spinach salad and fresh fruit. It was noted except for the texture altered diets all residents received the same meal tray. In a concurrent interview the surveyor asked DS 2 the meaning of fortified on the tray tickets. DS 2 stated the terminology indicated residents were losing weight and needed to gain fat. In an interview on 9/11/23 at 4:30 p.m., DS 2 indicated she has been working at the facility for approximately 2 months. She also stated her work experience was primarily in the retail sector and except for working with another cook for several days she has not received any additional training, was not given guidance…

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 food storage observations and resident interview the facility failed to store food in accordance with manufacturer ' s recommendations. Failure to follow manufacturer ' s recommendations may affect meal palatability resulting in decreased resident meal satisfaction. Findings: Scientific evidence has shown that storage of bakery products such as bread and muffins change the structure of the starches, causing it to crystalize which in turn makes the bread hard and stale (Food Science, 2023). During initial tour of the kitchen on 9/11/23 beginning at 12:30 p.m., there were greater than 6 cases of baked goods including bread and desserts in the walk-in refrigerator. The manufacturer ' s guidance on each of the cases was listed as Keep Frozen at 0°F (degrees Fahrenheit) or below. During food production observation on 9/11/23 beginning at 3:30 p.m., noted DS was preparing the soy glazed pork for the evening meal. DS 2 was observed sautéing onions in oil. After a few minutes she added pre-cooked diced pork cubes. In a concurrent interview DS 2 stated she has not been trained 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 facility observations and administrative staff interview the facility failed to provide a functional space for the Director of Food Services to effectively provide supervision, guidance and oversight to the day-to-day operations of dietetic services. Findings: During an interview on 9/12/23 beginning at 11:55 p.m., the Administrator indicated the workspace for the Director of Food Services (DFS) was not within the Skilled Nursing Facility, rather was in a house adjacent to the facility. In a concurrent interview Regional Dietary Staff (RDS) indicated she had worked in the facility in the past and at that time the workspace was in the Dry Food Storage area within the kitchen. The DTR also indicated at some point the facility closed off one of the exit doors in the kitchen and placed a 2-door freezer unit in front of the opening. The purpose of the DFS is to provide day to day guidance and oversight in all aspects of food storage, production, and distribution. Relocation of a workstation for the DFS, to an offsite location, would not support effective oversight 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 observation, interview, and record review, the facility failed to ensure the call light system, installed in 16 of 16 resident bathrooms, were accessible to residents from the bathroom floor. This failure had the potential for residents to not be able to alert staff and call for assistance, should they sustain a fall in the bathroom. Findings: During an observation of room [ROOM NUMBER]'s bathroom on 3/14/23 at 10:36 a.m., a call light button was located on the wall next to the toilet. The button was around elbow-height of a resident sitting on the toilet, easily accessible in said position. The bathroom size was approximately six feet by five feet. An observation of room [ROOM NUMBER]'s bathroom on 3/14/23 at 3:52 p.m. revealed a similarly sized bathroom, call light system, and call button location. During an observation on 3/14/23 at 3:59 p.m., the bathroom between rooms [ROOM NUMBERS] was noticeably bigger, approximately eight feet by 10 feet in size, with a partial wall in the middle separating 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, and record review, the facility failed to protect two (Residents 149 and 42) of three sampled residents' rights to be free from verbal abuse by a staff member (Unlicensed Staff D). This failure resulted in Residents 149 and 42 to experience fear and verbalize feelings of being unsafe, which could lead to negative effects to the residents' emotional and psychosocial well-being. Findings: Record review of the Grievance Binder on 3/16/23 2:42 p.m. revealed the facility received two verbal abuse allegations against Unlicensed Staff D, from Residents 149 and 42, on 2/27/23. During a concurrent interview, Social Services Director (SSD) stated she verbally reported the incidents to the Administrator immediately on 2/27/23. A review of Resident 149's admission Record indicated diagnoses including need for weakness, assistance with personal care, and anxiety disorder (a mental health disorder characterized by intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 149's Grievance Resolution Form, dated Date Received:…

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 develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act, when two of three resident abuse allegations (by Residents 149 and 42) were not reported to other officials, including to the Department, in accordance with State law. This failure decreased the Department's ability to ensure a complete investigation and appropriate interventions were started and implemented timely to protect Residents 149 and 42, and the 40 other vulnerable residents, from further potential abuse reoccurrence. (Cross Reference F600) Findings: Record review of the Grievance Binder on 3/16/23 2:42 p.m. revealed the facility received two verbal abuse allegations against Unlicensed Staff D, from Residents 149 and 42, on 2/27/23. During a concurrent interview, Social Services Director (SSD) stated she verbally reported the incidents to the Administrator immediately on 2/27/23. During an interview on 3/17/23 at 8:35 a.m., the Administrator stated he 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: a. Provide sufficient evidence to demonstrate thorough investigations of two of three abuse allegations (by Residents 149 and 42), and b. Prevent potential for further abuse when Unlicensed Staff D continued to work at the facility for two more shifts after the facility was notified of Resident 42's verbal abuse allegations against said staff, with one shift schedule even including Resident 42 under Unlicensed Staff D's assignment. These failures subjected the 44 vulnerable resident population to potential reoccurrence of abuse, and continued placement of Resident 42's care under her aggressor resulted in feelings of fear and anxiety. Findings: Record review of the Grievance Binder on 3/16/23 2:42 p.m. revealed the facility received two verbal abuse allegations against Unlicensed Staff D, from Residents 149 and 42, on 2/27/23. During a concurrent interview, Social Services Director (SSD) stated she verbally reported the incidents to the Administrator immediately on 2/27/23. During an interview on 3/17/23 at 8:35 a.m.,…

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 develop and implement resident-centered care plans for three of twelve sampled residents (Resident 23, 32 & 38) when: 1. Resident 23 and Resident 38 were identified to be at risk for pressure ulcer and no resident centered care plan was developed to prevent facility-acquired pressure ulcers. This failure resulted in the development of a blister (a painful skin condition where fluid fills a space between layers of skin) to Resident 38's left heel and Suspected Deep Tissue Injury (SDTI - Intact or non-intact skin with localized area of persistent non-blanchable [when the skin is pushed and the area stays red, that means that there is little or no blood flow going to that area] deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister) to Resident 23's left heel. (Reference F686) 2. Resident 32 did not have a respiratory assessment or medical orders for oxygen therapy (Reference F 695). Findings:…

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, interviews, and records review, the facility failed to ensure showers and oral hygiene were provided to three of twelve sampled residents (Resident 23, 40 and 38). This failure resulted to an untimely identification of a facility acquired pressure ulcer for Resident 23 and 38 and a potential oral infection for Resident 40. (Reference F686) Findings: Resident 23 During a record review for Resident 23, the Face Sheet (A one-page summary of important information about a resident) indicated Resident 23 was admitted on [DATE] with diagnoses including but not limited to Fracture of Shaft of Left Fibula (a break in the small bone that runs along the outside of the lower leg); Diabetes Mellitus (disease that result in too much sugar in the blood); Protein Calorie Malnutrition (when a person is not consuming enough protein and calories) and COVID (Corona Virus Disease - an infectious respiratory disease). During a record review for Resident 23, the Minimum Data Set (MDS -health status screening 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 observations and interviews, and record review, the facility failed to ensure sufficient nursing staff to provide care for 2 of twelve sampled residents (Residents10 and 248) and 5 unsampled residents (Residents 27, 20, 33, 37 and 250). This failure resulted in untimely call light response placing them at risk for neglect and harm. Findings: During an interview with Resident 27 on 3/13/23 at 10:54 a.m. when asked how long she had to wait for her call light to be answered, Resident 27 stated it took 10 to 15 mins before staff gets to her. During an interview with Resident 10 on 3/13/23 at 11:03 a.m., when asked how long she had to wait for her call light to be answered, Resident 10 stated, would not say quickly. Resident 10 stated the facility was short staffed mostly evening shift. During an interview with Resident 248 on 3/13/23 at 11:25 a.m. Resident 248 stated it could take an hour for staff to answer her call light. Resident 248 stated this happened during AM (day) and night shifts. Resident 248 stated she had peed on her pants and her bed was all wet because she could…

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 dietetic service observations, dietary staff interviews, and administrative document review, the facility failed to ensure dietary staff had competencies and skills to carry out the functions of the food and nutritional services safely and effectively, when Dietary Staff did not: 1. Test dishwasher chlorine following manufactures instructions 2. Ensure freezer thermometers were functioning and accurate freezer temperatures were recorded on logs 3. Monitor Potentially hazardous foods (food that could cause food borne illness if not prepared and stored properly) for safe cool down. These deficient practices resulted in creating a false sense of security as to the safety of food preparation, and potentially expose Residents to food-borne illness. Findings: During an initial observation of the kitchen on 3/13/23 at 11:15 a.m., Dietary Staff L was asked what type of dishwasher she used. Dietary Staff L stated a low-pressure dishwasher. Dietary Staff L was asked to check the chlorine of the dishwater. Dietary Staff L took an ECO lab (brand name) chloride test strip and held 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, and record review, the facility failed to provide food that was palatable, attractive, and flavorful to 3 sampled residents (Resident 32, Resident 148, Resident 248) and 5 unsampled residents (Resident 20, Resident 34, Resident 35, Resident 37, and Resident 251). These failures had the potential to lead to decreased nutritional intake and weight loss in a vulnerable population. Findings: Dining observations and interviews from 3/13/23 to 3/16/23 included: On 03/13/23 at 2:44p.m., Resident 34 stated the food was terrible, had lost 65 lbs, couldn't get real food, and the pancake were hard. On 03/13/23 at 3:41 p.m., Resident 20 stated the was food terrible, the toast was burnt, and a little bit of egg for breakfast. On 03/13/23 at 5:01 p.m., Resident 37 didn't like the food. Stated it doesn't have any flavor, had lost weight about 40 pounds since admission. On 03/14/23 at 10:30 a.m., Resident 35 stated the food was icky it did not have any flavor, was not cooked well, and was sometimes cold. On 3/14/23 at 11:00 a.m., Resident 32 stated the food 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 dietetic service observations, dietary staff interviews, and administrative document review, the facility failed to ensure dietary staff carried out the functions of the food and nutritional services safely and effectively, when Dietary Staff did not: 1. Test dishwasher chlorine following manufactures instructions 2. Ensure freezer thermometers were functioning and accurate freezer temperatures were recorded on logs 3. Monitor Potentially hazardous foods (food that could cause food borne illness if not prepared and stored properly) for safe cool down These deficient practices resulted in creating a false sense of security as to the safety of food preparation, and potentially expose Residents to food-borne illness. Findings: During an initial observation of the kitchen on 3/13/23 at 11:15 a.m., Dietary Staff-L was asked what type of dishwasher she used. Dietary Staff-L stated a low-pressure dishwasher. Dietary Staff-L was asked to check the chlorine of the dishwater. Dietary Staff-L took an ECO lab chloride test strip and held the strip in the water for approximately 30…

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 obtain and implement physician's order for one of 12 sampled residents (Resident 32) when: 1. The facility did not obtain a physician's order for oxygen (O2 - life-supporting component of the air) when Resident 32 was observed on oxygen inhalation for three days. This deficient practice placed Resident 32 at risk for unnecessary respiratory care. Findings: Review of Resident 32's admission record indicated Resident 32 was admitted to the facility on [DATE] with multiple diagnosis that included: Chronic Obstructive Pulmonary Disease, Unspecified (A group of lung diseases that block airflow and make it difficult to breathe). During an initital observation of the facility on 3/13/23 at 2:00 p.m., the resident was observed in bed sleeping, a nasal cannula attached to an oxygen concentrator was running at 2/liters of oxygen, the nasal cannula was on the floor and there was no date on the oxygen tubing. During an observation on 3/16/23 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.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services that meet the needs of their residents as evidence by: 1. Licensed Nurse A, Licensed Nurse B, and Licensed Nurse C did not rotate the site for injection for one of one sampled resident (Resident 148) on subcutaneous (SC-injection given under the skin) Insulin Lispro (medication to reduce blood sugar) in accordance with manufacturer specifications. This failure increases the risk for an adverse reaction to Insulin. 2. Two oral emergency medications kits were not replaced, when medications were taken out of the kit, within 72 hours as required by facility policy. This failure increases the risk for not having the necessary medications to treat residents. Findings: 1. A review on 3/14/23 of the Insulin Lispro manufacturer's insert indicated Administer the dose of insulin lispro .by injection into the subcutaneous tissue of the abdominal wall, thigh, upper arm, or buttocks. To reduce the risk of lipodystrophy, rotate the injection site within the same region from one injection 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 The facility failed to maintain an effective infection prevention and control program, designed to prevent the development and transmission of disease and infection for the residents in the facility when: a. A staff member brought in a bag of resident's soiled items directly to the clean area of the laundry room, and b. One of two sampled residents (Resident 248) who was on oxygen (O2 - life-supporting component of the air) therapy was using an undated nasal cannula (tube which on one end splits into two prongs which are placed in the nostrils) tubing and humidifier (add moisture to the air to prevent dryness that can cause irritation in many parts of the body). Unsanitary transport and processing of residents' washables increased the potential of cross-contamination, and the use of undated oxygen equipment, unverifiable of its replacement date, had the potential for buildup of harmful bacteria which may then be inhaled by Resident 248. Findings: a. During an observation of the laundry room with Unlicensed Staff…

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.