Coastal View Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy and procedure, the facility failed to ensure pain medication orders were followed to ensure adequate pain management for one of two sampled residents (Resident 1). This failure resulted in Resident 1 experiencing unnecessary pain. Findings: During a review of Resident 1's Clinical Record, the Clinical Record indicated, Resident 1 was admitted to the facility on [DATE] from a hospital with a diagnosis of rectal abscess (a collection of pus in the tissues around the rectum) and a newly placed colostomy (surgical opening through the abdomen) general muscle weakness, difficulty walking, legally blind and major depressive disorder (a common and serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities). During an interview 2/26/25 at 1:30 p.m. with Resident 1, Resident 1 stated his pain medication takes a long time to work, and he feels his pain is not well managed in the facility…

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 resident (Resident 1) received hygiene care when the resident continually refused care and this was not reported to the doctor or resonsible party. This failure had the potential to result in Resident 1's hygiene needs not being met and sustaining skin complications. Findings: During a review Resident 1's documents, the documents indicated, Resident 1 was admitted on [DATE] with diagnoses that included, Dementia (condition characterized by impairment such as memory loss and judgment) and Other Behavioral Disturbance (manifestation of dementia categorized by mood disorders, sleep disorders, psychotic disorders and agitation). During a concurrent observation, interview, and record review on 12/30/24 at 1:45 p.m. with Resident 1, Resident 1 was in bed and was not interviewable in English due to Resident 1 only spoke Cantonese. Review of Resident 1's Brief Interview for Mental Status ([BIMS] - test, which is used to evaluate a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain a physician order for siderails for one of 21 sampled residents (Resident 25). This failure had the potential for Resident 25 to experience negative outcomes, while receiving care in the facility. Findings: During a review of Resident 24's, Face Sheet (FS), dated 10/15/22, the FS indicated, Resident 25 was a [AGE] year-old, who was admitted to the facility on [DATE], with admitting diagnoses including dementia (the loss of cognitive functioning, thinking, remembering, and reasoning), and chronic kidney disease (kidneys are damaged and can't filter blood properly). During an observation on 10/14/24, at 12:05 p.m., Resident 25 was observed in bed, alert and awake with bilateral quarter side rails were raised in the middle section of the bed. During a review of Resident 25's Care Plan (CP), dated 12/30/23, the CP indicated, staff were to Obtain Physician's order for the use of anything attached to a normal bed. 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.

Based on observation, interview and record review, the facility failed to ensure to provide daily nutritional needs were met for 72 of 92 residents when they failed to follow the recipe card for making meatballs for the meatball sub sandwiches being served to the residents on regular diets. This failure resulted in food with inadequate nutritional value and had the potential to result in weight loss of residents. Findings: On 10/14/24, at 9:05 a.m. during an interview with a facility cook (Cook 1) and the Dietary Supervisor (DS) and a concurrent observation in the kitchen, [NAME] 1 was observed preparing food for lunch. A review of the menu for October 14-20, 2024, revealed a meatball sandwich was to be served for part of the lunch meal on 10/14/24. When asked for how many residents he was preparing for, [NAME] 1 stated, for 72 residents. A review of the recipe revealed, Recipe: Meatball Sandwich, indicating the following ingredients and their measurements for 72 residents. Ground beef 11 lbs. (pounds) 4 oz. (ounces) and Italian seasoning 3/8 cup. Cook 1 was asked how he prepared…

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 that a current copy of an advanced directive was in one out of 21 sampled residents (Resident 71) medical record. This failure had the potential to result in inaccurate treatment or intervention during an emergency medical situation. Findings: During a concurrent interview and record review on 10/16/24 at 8:52 a.m. with Licensed Nurse (LN 1), Resident 71's medical record was reviewed. Resident 71's advanced health care directive (a legal document stating a person's wishes for medical care if the person is unable to communicate his/her wishes), dated 10/12/2017, indicated choice not to prolong life. Resident 71's Physician Orders for Life-Sustaining Treatment (POLST) dated 6/27/24, indicated primary goal of prolonging life by all medically effective means. LN 1 verbalized Resident 71's advanced health care directive did not match Resident 71's POLST and it should match. During a concurrent interview and record review on 10/16/24 at 11:10 a.m., with the Director of Nursing (DON), Resident 71's medical record was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation (a process in which a healthcare provider educates a patient about the risks, benefits, and alternatives of a given procedure or treatment) was obtained prior to the use of bed rails for one of 21 sampled residents (Resident 25). This failure had the potential for Resident 25 to experience negative outcomes. Finding: During a review of Resident 24's, Face Sheet (FS), dated 10/15/22, the FS indicated, Resident 25 was a [AGE] year-old, who was admitted to the facility on [DATE], with admitting diagnoses including dementia (the loss of cognitive functioning, thinking, remembering, and reasoning), and chronic kidney disease (kidneys are damaged and can't filter blood properly). During an observation on 10/14/24, at 12:05 p.m., Resident 25 was observed in bed, alert and awake with bilateral quarter side…

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 label/date a multidose vial once opened. This failure had the potential for an expired product to be administered to a resident. Findings: During an observation and concurrent interview, on [DATE], starting at 10:00 a.m., with licensed nurse (LN 2) the west side medication storage room's medication refrigerator was inspected. Inside the refrigerator was one vial of tuberculin purified protein derivative (PPD) (used in a skin test to diagnose tuberculosis). The box containing the vial was open, and the vial's cap had been removed indicating use. The LN 2 verbalized the vial should have had a yellow sticker on it, indicating the date opened, but it did not. The product box indicated Discard opened product after 30 days. During a review of facility's policy and procedure titled Preparation and General Guidelines dated 4/08, indicated in part The date opened and the initials of the first person to use the vial are recorded on multi-dose vials…

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 proper sanitary and food handling practices were observed while preparing food when: 1. A male employee, Dietary 1, with facial hair and without a beard net working in the kitchen. 2.Observed cook 1 preparing meatballs using an ice cream scoop while the container of seasoned ground beef was in a rectangular metal tray, observed inside the kitchen sink. 3. Observed Dietary 1 pushing trash can on wheels where food scraps were disposed around the kitchen without a cover/lid. This failure had the potential to result in the outbreak of foodborne illnesses (caused by eating food that has been contaminated with bacteria, viruses, or parasites). Findings: 1. On 10/14/24, @ 8:40 a.m., observed a male employee, Dietary 1, with facial hair and without a beard net working in the kitchen. Dietary supervisor (DS) said they did not have beard nets available. On 10/15/24, at 10 a.m., observed Dietary 1 without a beard net working in the kitchen. On 10/16/24, at 1 p.m., observed Dietary 1 without a beard net working in the kitchen. In…

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

Based on observation, interview, and record review, the facility failed to clean and disinfect a glucometer (an instrument that measures the concentration of glucose in the blood). This failure had the potential to spread disease to residents. Findings: During a concurrent observation and interview, on 10/14/24, at 3:28 p.m., with licensed nurse (LN 3), and licensed nurse (LN 4), a medication cart was inspected. Inside the medication cart a glucometer was observed having red stains on it. The LN 3 and the LN 4 confirmed the red substance on the glucometer and verbalized the glucometer was stored into the medication cart dirty and needed to be cleaned and disinfected. During a review of the facility's policy and procedure titled Cleaning and Disinfecting Glucometers dated 1/17, indicated in part It is the policy of this facility to properly clean and disinfect glucometers between resident use.

Based on and interview and record review for one of three sampled resident (Resident 1)'s MDS (Minimum Data Set ((MDS) - an assessment tool for residents in a nursing homes) the facility failed to assessment that must accurately reflect the resident's status for wandering (to move from place to place without a set path) behavior and wander alarm used for one of two sampled residents (Resident 1) was not accuratey document upon assessment when MDS indicated: 1. Resident 1 ' s MDS assessment for wandering behavior indicated that resdient had no behavior exhibited. 2. Resident 1 ' s MDS assessment for an alarm indicated that Resident 1 used the alarm daily from the 7-day look-back period requirement. These failures creates a situation whereby Resident 1 ' assessment did not reflect current satus which can delay and affect tratment. Findings: 1. During a review of the facility ' s policy and procedure (P&P) on MDS titled, Resident Assessment Instrument (RAI), dated 10/2019, the P&P indicated, Coding instruction for E0900 (Wandering - Presence & Frequency) Code 0, behavior not exhibited…

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 record review, interview and facility policy and procedure (P/P), the facility failed to ensure one of three sampled residents (Resident 1) health record was current and accurate with good medical and professional practice based on the service provided when: 1. Resident 1 ' s medical record fall history assessments documentation remained inconsistent. 2. Resident 1 ' s bowel and bladder (B&B) training assessment documentation remained inconsistent. This facility failure resulted Resident 1 ' s medical record not reflecting accurate fall assessments and bowel and bladder (B&B) assessments and had the potential for Resident 1 to not receive adequate care to meet Resident 1 ' s needs. Findings: During a review of Resident 1 ' s Face Sheet ( A face sheet is a document that gives a patient's information at a quick glance) indicated, resident was admitted to the facility on [DATE], with a diagnosis that included Chronic obstructive pulmonary disease (COPD - a disease that causes airflow blockage 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 and record review, the facility failed to ensure staff has completed their annual skill competencies on the following topics: Mechanical Ventilation (a machine that assists a patient to breathe), Oral and Dental Assessments, Licensed Nurse Checklist, Neurological Care (care to patients with brain or neurological problems), Enteral Feeding (nutritional support through a feeding tube) and Skills Check List. This facility failure had the potential for residents to receive sub-standard quality of care. Findings: During a concurrent interview and record review on 10/18/23 at 2:15 pm with the administrator (ADM), the Oral/Dental Assessment Competency, Neurological Care Competency, Licensed Nurse Checklist, Enteral Feeding Competency, and Skill Check List, competencies indicated, no signature or date of the instructor. The ADM acknowledged the competencies were not complete and ADM stated my expectation is competencies should be complete. According to Fundamentals of Nursing ([NAME] et al.; Elsevier:…

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

Based on record review, and interview, the facility failed to ensure staff received annual mechanical ventilation (a machine that helps a patient breathe when he or she cannot breathe on his or her own) competencies according to policy and procedure. This facility failure had the potential for residents on ventilators to receive sub-standard quality of care. Findings: During a concurrent interview and record review on 10/18/23 at 2:15 pm with the administrator (ADM), the Respiratory Care Key Competency Checklist Ventilator (Competency), dated 11/2/22 was reviewed. The Competency did not indicate if the performance criteria was simulated by encircling a yes or no. The ADM acknowledged the competencies were not complete and ADM stated my expectation is competencies should be complete. During a concurrent interview and record review on 10/18/23 at 2:22 pm with the sub-acute consultant (SAC), the Respiratory Care Key Competency Checklist Ventilator (Competency), dated 11/2/22 was reviewed. The Competency did not indicate if the performance criteria was simulated by encircling a yes or…

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 safe food handling when: 1. TCS foods (Time-Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria) were not consistently and accurately cooled down. 2. Raw poultry was not thawed safely. 3. Food items were unlabeled and/or undated in the refrigerator in the kitchen, and in the refrigerator adjacent to the nursing station that stored resident food brought in from the outside. These failures had the potential to place the residents at risk for developing a foodborne illness. Findings: 1. During a concurrent observation and interview on 05/17/22, at 09:20 AM, with a [NAME] (Cook) 1, in the walk-in refrigerator in the kitchen, [NAME] 1 observed a large container of potato salad, undated. [NAME] 1 stated, the potato salad was for the resident's lunch that day. [NAME] 1 stated he cooked the potatoes yesterday, and forgot to label with a date. [NAME] 1 stated after boiling the potatoes yesterday, he placed them on ice and took the temperature which was…

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

Based on observation, interview, and record review, the facility failed to ensure: 1.Resident 46 received the Restorative Nursing Assistant (RNA) treatments per physician orders. 2. Resident 58 received the RNA treatments as ordered by the physician. 3. Resident 31 Occupational Therapy recommendation for RNA exercises was relayed to the attending physician for orders. 4. Resident 42 received proper Gastrostomy Feeding (GT- nutritional tubing inserted in the abdomen) care per facility's policy and procedure. These failures placed Residents 46, 58, and 31 at increased risk for decreased muscle strength, decreased range of motion, contractures and possible decline in function, and Resident 42 at risk for aspiration (feeding formula to lungs). Findings: 1.During a concurrent observation and interview on 5/17/22, at 10:46 a.m., Resident 46 was observed sitting in a wheelchair wearing a right arm brace. The resident indicated having a stroke , with weakness to the right body, able to use the left sided arm, leg, and hand, had physical therapy before and now on RNA treatments. Resident 46…

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 staffing for restorative nursing assistants (RNA- personnels trained to render range of motion exercises to residents as ordered by the physician) was adequate to render the treatments as ordered by the physician for the residents. This failure had resulted to residents missing RNA treatments placing them at risk for contratures, and decreased mobility. Findings: Cross reference with Tag F658. 1. Residents 46's RNA Treatment Orders ambulation practice with platform walker wearing right AFO (ankle foot orthodic) brace each day three times a week as tolerated. Resident 46 to receive AAROM (active assisted range of motion) exercises to LUE (left upper extremity) and PROM (passive range of motion) exercises to RUE (right upper extremity) five times a week as tolerated. During a review of Resident 46's RNA Treatment Record dated 4/2022 indicated for the week of : 4/1-4/7 Resident 46 received ambulation practice one time that week and AAROM to LUE and PROM to RUE one time that week. 4/8-4/14 Resident 46 received ambulation…

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 meals were palatable to ensure resident's satisfaction for one of 24 sampled residents (Resident 63), and for approximately five to six residents who attend a dining committee as reported by the Dietary Services Supervisor (DSS). Findings: During a concurrent observation and interview on 05/17/22, at 11:15 AM., with a cook (Cook 1), in the kitchen, [NAME] 1 was observed to prepare mashed potatoes for an alternative choice for the lunch meal for puree diet. [NAME] 1 added an unmeasured amount of powdered potatoes to boiling water. [NAME] 1 then placed the mashed potatoes in a container and put on the steam table for hot holding until trayline began at 11:45 PM. [NAME] 1 was asked if there was a recipe to guide [NAME] 1 on how to prepare the puree mashed potatoes. [NAME] 1 stated he follows the directions on the container of mashed potatoes. The dietary services supervisor (DSS) was present and agreed. During a concurrent interview and review of the directions located on the carton of Complete Instant…

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 evidence was in place that informed consents (authorization from residents or responsible party) were obtained and completed prior to the administration of psychotropic medication ( medications that affects behavior, mood, thoughts,or perception) in one resident (Resident 190). This failure had the potential to deny the resident the opportunity to know the risks and benefits of taking the medications which is part of the resident's right to know. Findings: During a review of the clinical record for Resident 190, the physician orders indicated the following orders: 5/4/22- Trazodone Hcl Tablet 150mg 1 tablet by mouth at bedtime for depression for verbalization of sadness. 5/11/22 -Lorazepam (for anxiety) 1mg to give 1 tablet give by mouth every 6 hours as needed for nausea and vomitting. Further review of the clinical record indicated, the Facility Verification of Informed Consent of Resident 190 for the medications Trazadone and Lorazepam, were with missing signature, name, date of the physician who obtained 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 interview and record review, the facility failed to ensure: 1. Representatives of the office of the state long-term care Ombudsman were informed or notified of the residents ongoing and recurring resident council meetings (RCM). This failure has the potential for residents to have no patient advocate present when conducting their council meetings especially when airing their concerns regarding care in the facility. 2. The Resident council meeting minutes (RCMM) presented by the facility to the resident council (RC) president to be signed and dated should be on the month and date the RCM was conducted to prevent back dating. This failure has the potential for the RC president to not know exactly what RCMM dates the signature requested is for with risk for fraudulent recordings of the RCMM. 3. Residents issues, and concerns are reflected consistently on the RCM, and relayed to proper management personnel for resolution, with outcomes, and follow ups documented in the RCM document. This failure has 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 interview and record review the facility failed to ensure a completed Minimum Data Set (MDS, an assessment tool) was transmitted in a timely manner for three residents (Residents 12,3 and 2). This facility failure resulted in non-compliance with the regulatory requirements for MDS transmission.and with the potential for records unaccountablility of resident ' s whereabouts and current conditions. Findings: Review of the facility ' s MDS transmittal records on 5/19/22 at 9:10 AM, indicated Resident 12 ' s MDS assessment target date was 4/11/22, MDS assessment was transmitted on 5/16/22. Resident 3 ' s MDS assessment target date was 4/7/22, MDS assessment was transmitted on 5/16/22. Resident 2 ' s MDS assessment target date was 2/21/22, MDS assessment was transmitted on 5/15/22. All transmission dates are over the 14 day submission window. During an interview on 5/19/22 at 10:09, the MDS nurse acknowledged transmission dates for the three residents were over the 14 day submission window. Center 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 interview and record review, the facility failed to accurately assess and code the Minimum Data Set (MDS-resident care assessment tool) for three out of 24 sampled residents when: 1. Resident 46's Section I (Active diagnoses) was not documented accurately 2. Resident 58's Section I (Active diagnoses) was not documented accurately 3. Resident 25's Section O (Special treatments, procedures, and programs) were not documented accurately This failure resulted in the documentation of inaccurate assessments and had potential of unmet care needs for Resident 46, Resident 58, and Resident 25. Findings: 1. During a concurrent observation and interview on 5/17/22, at 10:46 a.m., with Resident 46, Resident 46 was observed sitting in his wheelchair wearing a right arm brace. Resident 46 verbalized he had a stroke and has right sided paralysis but had use of his left side. During a review of Resident 46's admission Record dated 2/7/2020, indicated Resident 46 had diagnosis of cerebral infarction (stroke) due 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.

Based on interview and record review the facility failed to 1. Develop an appropriate person-centered care plan when Resident 60 was NPO (nothing by mouth), on G-tube (gastrostomy tube-a tube inserted through the belly that brings nutrition directly to the stomach) feedings, and had weight loss. 2. Ensure an intervention of high calorie snacks, on Resident 187's IDT nutritional care plan, was implemented. These failures had the potential for unmet nutritional needs and weight loss for Resident 60 and Resident 187, and risk of aspiration for Resident 60. Findings: 1. During a review of Resident 60's monthly weights indicated on 1/29/22 Resident 60's weight was 144 pounds, on 2/1/22 weight was 144 pounds, on 3/8/22 weight was 141 pounds, on 4/5/22 weight was 139 pounds, on 5/3/22 weight was 137 pounds, which was a 4.86% weight loss in 5 months. During a review of Residents 60's Order Summary Report indicated Resident 60 was NPO, on Enteral (nutrition administered through a feeding tube) feed order three times a day for enteral nutrition bolus two cans of Jevity 1.5 (liquid…

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

Based on observation, interview and record review, the facility failed to ensure the planned menu and/or meal tray card (guidance to staff on what to serve for a meal to a resident) was accurate and followed for two of 24 sampled residents pertaining to: 1. A health shake order for Resident 187. 2. A low-potassium diet for Resident 7. This facility failure had the potential to not meet the resident's nutritional needs per the planned menu and/or planned meal tray card. Findings: 1. During a concurrent observation and interview on 05/18/22, at 12:33 PM., with Dietary Aide (DA) 1, in the kitchen, DA 1 was observed to place Resident 187's meal tray onto the meal delivery cart. DA 1 was asked to remove Resident 187's meal tray from the meal delivery cart and check it for accuracy. DA 1 reviewed Resident 187's meal tray card that included directions to provide a H. Shake Chocolate (a health shake to provide increased calories and protein), and compared the meal tray card to items on Resident 187's meal tray. DA 1 then proceeded to inform Dietary Aide (DA) 2 that the chocolate health…

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

Based on record review and interview the facility failed to ensure resident's care of being turned every 2 hours was accurately documented as care planned in the medical record of one resident of 24 sampled residents (resident 42). This failure had the potential for the resident's condition and care to be misrepresented. Findings: During a review of the clinical record for Resident 42 indicated a care plan (approaches, interventions for implementation) for limited mobility. The clinical record further indicated turning and repositioning should be done every 2 hours. During a review of the facility's turning and repositioning documentation for Resident 42 indicated: 5/13/22 -turning and repositioning done at 6:47 AM. 5/14/22 - turning and repositioning at 6 AM. 5/15/22 -turning and repostioning done up to 2 PM. 5/16/22 -last documentation was at 6:53 AM. 5/17/22 - the resident was turned and repositioned every 2 hours up 8:21 PM. No other documentation for that day. The facility policy and procedure titled Certified Nursing Assistant Documentation dated 10/2015 indicated in part 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 maintain infection control practices when: 1. A nasal cannula and tubing for oxygen administration for one resident (Resident 188) was found on the floor and there was no date on the tubing. 2. A shower chair that is shared between residents had red smear marks on it. These facility failures had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact residents' health and safety and cause preventable HAIs (Healthcare Associated Infections) for residents in an already compromised condition. Findings: 1. During an observation and concurrent interview on 5/17/22, at 10:57 am, licensed nurse (LN 1) confirmed Resident 188's nasal cannula and oxygen tubing was on the floor. LN 1 also confirmed tubing was not dated. During an interview on 05/19/22, at 11:33 am, LN 2 confirmed oxygen tubing should be changed every 7 days as needed - there should be a label that has the date. During a review of the facility policy titled, Oxygen Concentrators revised 6/2017, indicated in part…

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.