Linwood Meadows Care Center

Based on interview and record review, the facility failed to provide in-service education on Covid-19 (severe respiratory illness) for 143 of 186 total staff. This failure had the potential for staff not knowing how to prevent the spread of Covid-19 in the event of a pandemic (widespread outbreak of an infectious disease) affecting all residents, staff, and visitors. Findings: During a review of the facility's in-service education on Covid-19 titled, Prevention of Covid-19 (PC), dated 1/22/25 until 4/11/25, the PC indicated there were only 43 staff who attended the in-service education on Covid-19 in the last 12 months. During an interview on 5/22/25 at 3:21 p.m. with Assistant Director of Nursing (ADON), ADON stated, I did not review that [in-service education on Covid-19]. I was not here when the in-service education [on Covid-19] was conducted. During an interview on 5/22/25 at 4:28 p.m. with Director of Nursing (DON), DON stated the facility has a total of 186 staff. DON stated the facility had no policy on providing in-service education to staff and residents on Covid-19.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an ambient (surrounding air) temperature for three of six sampled resident rooms (room [ROOM NUMBER] A/B, room [ROOM NUMBER] A/B, room [ROOM NUMBER] A/B). This failure resulted in the residents feeling warm and uncomfortable in their respective rooms. Findings: During a concurrent observation and interview on 5/19/25 at 9:59 a.m. with Resident 75, in room [ROOM NUMBER] A, Resident 75 was not wearing a gown or shirt and had a portable electric fan blowing by the left side of his bed. Resident 75 stated his room was hot. During an interview on 5/19/25 at 10:02 a.m. with Resident 5 in room [ROOM NUMBER] B, Resident 5 stated the room was hot. During a concurrent observation and interview on 5/19/25 at 10:05 a.m. with Assistant Maintenance Supervisor (AMS) in room [ROOM NUMBER], AMS stated the temperature was 82 degrees (°) Fahrenheit (F) and felt warm. During an observation on 5/19/25 at 10:20 a.m. in Hallway B, AMS took the ambient…

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 : 1. Six of Six sampled Certified Nursing Assistants (CNA 3, CNA 1, CNA 2, CNA 5, CNA 6 and CNA 4) attended a minimum of five hours of annual dementia (a general term for the loss of memory, language, and reasoning skills) care training. This failure had the potential for CNAs to not have the knowledge and skills on how to meet the care needs of residents with dementia. 2. One of five sampled CNA's (CNA 3) received annual abuse prevention training. This failure had the potential for CNA 3 to not have the knowledge and skills on how to recognize and report abuse. Findings: 1. During a concurrent interview and record review on 5/22/25 at 11:11 a.m. with Assistant Director of Nursing (ADON), CNA 3's Individual Inservice Attendance Record (IIAR), dated 2024 was reviewed. The IIAR indicated, CNA 3 had dementia training on 1/5/24 for one hour, 2/16/24 for one hour, 10/1/24 for one hour, and 11/18/24 for one hour. ADON stated CNA 3 had a total of four hours of dementia training in 2024 and should have had an additional…

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. Ensure Informed Consent (IC, a process in which a healthcare professional educates a patient about the risks, benefits, and alternatives of a given procedure or medication) for one of seven sampled resident (Resident 5's) Mirtazapine (Remeron-antidepressant medication) 15 milligrams (mg) was signed by the physician prior to medication administration. This failure had the potential to result in adverse consequence when the physician had not given the resident sufficient information about the drug, which may have negative effect on the resident. 2. Have accurate informed consent for a psychotropic (medication to treat mental disorders) medication for one of seven sampled residents (Resident 27). This failure had the potential for Resident 27 to not be aware of the risks and benefits of taking psychotropic medications. Findings: 1. During a review of Resident 5's admission Record, (AR), dated 11/3/22, the AR indicated, Resident 5 was admitted on…

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 assess the effectiveness of the plan of care for the use of a communication board (a visual aid that facilitates communication between patients and their care team) for one of one sampled resident (Resident 29). This failure resulted in the facility not understanding, identifying, and determining Resident 29's needs and the potential to deprive her of maintaining the highest practicable physical, mental, and psychosocial well-being. Findings: During a review of Resident 29's admission Record, (AR), the AR indicated, Resident 29 was admitted on [DATE] with a diagnosis including unspecified Dementia (a group of symptoms affecting memory, thinking and social abilities) and unspecified hearing loss. During a concurrent observation and interview on 5/19/25 at 11:12 a.m. with Infection Preventionist (IP) and Resident 29, in Resident 29's room, Resident 29 was lying in bed on her left side. Resident 29 did not respond verbally when greeted but…

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 act on a recommendation from the pharmacy consultant (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) for one of 10 sampled residents (Resident 71). This failure had the potential to result in Resident 71 not receiving a needed medication and possibly leading to medical complications that could diminish quality of life. Findings: During a review of Resident 71's Medication Regimen Review (MRR), dated 3/27/25, the MRR indicated, Please clarify the findings below with the MD 1 [medical doctor] and update orders accordingly: 1. Hospitalist recommended to continue with allopurinol [medication used to treat joint inflamation and prevent kidney stones] 100 mg [milligrams] PO [by mouth] daily. Pharmacy does not have this order. Please have MD 1 evaluate need for medication. During a concurrent interview and record review on 5/22/25 at 3:44 p.m. with Regional Director of Clinical Services…

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 maintain accurate medical records for two of 38 sampled residents (Resident 3 and Resident 142) when the Nursing Weekly Summary (NWS) did not reflect the residents' skin condition, including toes and toenails. This failure resulted in Resident 3 and Resident 142's medical records to be incomplete and inaccurate, which could lead to misdiagnosis, inappropriate treatment, and delay in care. Findings: During a concurrent observation and interview on 5/19/25 at 12:23 p.m. with Resident 3 in Resident 3's room, Resident 3 was in her bed with her feet uncovered. Resident 3 was awake and alert and stated her right side was paralyzed (unable to move due to a loss of muscle function) and had no sensation on the right side. Resident 3's right great toe was red, swollen, and the toenail was yellowish in color, thick, and hard. Resident 3's left toenails were also yellowish in color and long. Resident 3 denied pain in her right foot due to her right sided paralysis. During a concurrent observation and interview on 5/19/25 at 12:30 p.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 ensure maintenance staff conducted bed rail risk assessments to include evaluation of the bed and measurements of siderails and potential bed entrapment zones for two of two newly admitted sampled residents (Resident 32 and Resident 142). This failure had the potential to place Resident 32 and Resident 142 at risk for harm. Findings: 1. During a review of Resident 32's admission Record (AR), dated 4/7/25, the AR indicated, Resident 32 was admitted on [DATE] with a diagnosis including muscle wasting (decrease in the size of muscle tissue) and atrophy (tissue loss), and morbid obesity (weight is more than 80 to 100 pounds above their ideal body weight, and a body mass index [BMI- measure of body fat based on height and weight] of 40 and greater). During a review of Resident 32's Brief Interview for Mental Status (BIMS- assessment for cognitive impairment, 0-7 means severe cognitive impairment, 8-12 means moderate impairment, and 13-15, intact cognitive…

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 a fall assessment was accurate for one of two sampled residents (Resident 1). This failure had the potential for staff to be unaware of Resident 1's risk for falls. Findings: During a review of Resident 1's S (Situation) B (Background) A (Appearance) R (Review and Notify) (SBAR), dated 12/31/24, the SBAR indicated, Resident was heard yelling from room, upon arrival resident was found on the floor. During a review of Resident 1's Nursing Post Fall Review (NPFR), dated 12/31/24, the NPFR indicated, History of Falls within last six months.no history. The NPFR indicated Resident 1 was a low fall risk. During a review of Resident 1's SBAR, dated 10/6/24 (approximately 2 ½ months prior to 12/31), the SBAR indicated, Resident had a unwitnessed fall. During a review of Resident 1's SBAR, dated 11/21/24 (approximately 1 month prior to 12/31), the SBAR indicated, Resident had a fall while LOA (leave of absence). During an interview on 1/10/25 at 1:09 p.m. with Director of Nursing (DON), DON stated the NPFR was used 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 follow its policy and procedure when staff in-service training records were incomplete. This failure resulted in incomplete training records and the potential for staff to be inadequately trained to care for residents. Findings: During a concurrent interview and record review on 12/13/24 at 12:44 p.m. with Director of Staff Development (DSD), three in-service training logs were reviewed. In-service training log one had three staff signatures and in-service training log two had one staff signature, both training logs did not contain a date, start time, end time, in-service course title, instructor name and instructor signature. In-service training log three contained the signature of five staff but did not contain the start time, end time, instructor name and instructor signature. DSD stated the in-service training logs must contain the date, the time the in-service started and ended, the topic and name and signature of the person giving the lesson to be complete. During a concurrent interview and record review on 12/13/24…

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 three of three sampled staff Restorative Nursing Assistant (RNA 1), Registered Nurse (RN 1), and Certified Nursing Assistant (CNA 1), were aware of the facility's Enhanced Barrier Precaution (EBP-infection control measures used to reduce the spread of infection) protocol (blue heart placed above the bed of the affected resident) used to identify the residents requiring staff to wear PPE while providing care. This failure resulted in staff being unaware of which resident required EBP. Findings: During a concurrent observation and interview on 12/13/24 at 11:32 a.m. with RNA 1, RNA 1 entered a two-bed resident room with a blue PPE (personal protective equipment) caddy on the door. RNA 1 stated she was unaware of which resident required EPB. During an interview on 12/13/24 at 11:51 a.m. with RN 1, RN 1 stated when the blue caddy was on the resident's door staff were required to use EBP's while providing care to the residents in the room. RN 1 was unaware of how to identify the resident requiring the EBP. 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 ensure two of three sampled residents (Resident 1 and Resident 2) Responsible Representative (RR 2 and RR 3) were notified and informed of changes made with the existing Physician Orders for Life-Sustaining Treatment (POLST-a focused type of advance directive used in critical situations where immediate medical decisions are needed). This failure resulted in Resident 1 being intubated (involves inserting a plastic tube into the airway to help breath) without consent. Findings: During an interview on [DATE] at 8:45 a.m. with RR 1, RR 1 stated on [DATE], Resident 1 signed an Advance Health Care Directive (AHCD-legal document outlining a person's healthcare wishes) and appointed RR 2 to be her POA (Power of Attorney) to make healthcare decisions. RR 1 stated Resident 1 had always wished for her code status to remain a DNR (Do Not Resuscitate-allow natural death). RR 1 stated on [DATE], Resident 1 became unresponsive and was transferred to the emergency…

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 implement a care plan for two of two sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2 to have unmet care needs. Findings: a. During a review of Resident 1 ' s S (Situation) B (Background) A (Appearance) R (Review and Notify) (SBAR), dated 8/9/24, the SBAR indicated, Writer was called to residents room by CNA (Certified Nursing Assistant), writer walked in and found resident sitting on the floor back up against the bed on the right side of bed, legs crossed. During a review of Resident 1 ' s Care Plan (CP), dated 8/9/24, the CP indicated, Resident had an unwitnessed fall and is at risk for change in neurological status, fear or falls.Interventions.Medication regiment review as indicated.Evaluation of medications for side effects that may increase fall risk. During a concurrent interview and record review on 8/20/24 at 10:47 a.m. with Director of Nursing (DON), Resident 1 ' s clinical record was reviewed. DON was unable to provide evidence the medication…

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

Based on interview and record review, the facility failed to follow its policy and procedure on: 1. Surveillance for Infections when the monthly reports did not contain the complete information required. 2. Monitoring Compliance with Infection Control when the facility did not complete the hand hygiene monitoring. These failures had the potential to result in a facility-wide infection outbreak affecting all residents, staff, and visitors. Findings: 1. During a concurrent interview and record review on 10/24/23 at 9:28 a.m. with Infection Preventionist (IP) 1 and IP 2. The facility's Infection Surveillance Monthly Report (ISMR) dated August and September 2023, were reviewed. IP 1 stated the infection surveillance were incomplete. The ISMR indicated there were no records of interpretation of data and laboratory results. IP 2 verified the finding. During a concurrent interview and record review on 10/26/23 at 9:08 a.m. with IP 1, IP 1 stated she lacks documentation and she was not performing and documenting laboratory records she was reviewing, skin care sheets. IP 1 stated she lacks…

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 for three of eight sampled residents (Resident 14, Resident 62, Resident 55) a home-like environment when: 1. Resident 14's bathroom wall paint was peeled off. 2. Water temperature in the shower rooms were turning cold during showers. These failures had the potential to negatively affect residents' quality of life. Findings: 1. During an observation on 10/23/23 at 10:20 a.m. in Resident 14's bathroom, there was paint peeled off around the wall of the hand soap dispenser. During a concurrent observation and interview on 10/23/23 at 3:11 p.m. with Maintenance Assistant (MA), in Resident 14's bathroom, the bathroom wall paint was peeled off around the soap dispenser. MA stated there was an old hand soap dispenser that was removed and when it was removed, it pulled off the wall paint. MA stated they did not fix it (wall paint) and had no record of a repair in the maintenance log. During a review of the facility's policy and procedure (P&P) titled, Interior General Maintenance, dated 12/31/15, the P&P…

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 prompt efforts to act on and resolve grievances for two of seven sampled residents (Resident 54 and Resident 70). This failure resulted in residents experiencing frustrations and had the potential to affect their quality of life. Findings: During an interview on 10/24/23 at 10 am in the Resident Council Meeting (RCM, organized group of residents who meet regularly to discuss concerns about their rights, qality of care and quality of life), Resident 54 stated, I attend the meeting, and issues are not resolved. They [the facility] do not resolve anything, they blame the state (California Department of Public Health) for everything. Resident 54 stated, the rose garden is important and the ramp to get out there needs to be fixed, I have to lift my walker to get in and out of the rose garden, the facility does not fix things correctly.Resident 54 stated she loved the rose garden and is the only nice place she can go but she required assistance to go in and out due to the steep ramps. During an interview on…

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 manufacturers guidelines were followed for use of low air loss (LAL) mattresses (mattress used for prevention of pressure injuries) for five of 14 sampled residents (Resident 84, Resident 51, Resident 347, Resident 11, and Resident 246). This failure had the potential to result in developing new or worsening of pressure injuries. Findings: During a concurrent observation and interview on 10/23/23 at 10 a.m. with Resident 84 in Resident 84's room, resident was laying on a LAL mattress with no sheet. Resident 84 stated they normally only put a draw sheet (1/2 sheet used to turn resident). During an observation on 10/23/23 at 10:06 a.m. in Resident 51's room, Resident 51 was laying on a LAL mattress with no sheet. During an observation on 10/23/23 at 10:14 a.m. in Resident 347's room, Resident 347 was laying on a LAL mattress with no sheet. During an observation on 10/23/23 at 10:56 a.m. in Resident 11's room, Resident 11 was laying on a LAL mattress with no sheet. During a concurrent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assist three of three sampled residents (Resident 19, Resident 44 and Resident 55) to receive dental services. This failure had the potential for these residents to have difficulty chewing food and maintaining nutritional needs. Findings: During a concurrent observation and interview on 10/23/23 at 10:43 a.m. with Resident 44, Resident 44 had many missing front teeth. Resident 44 stated the facility had not sent her to a dentist to get dentures or partials. During a concurrent interview and record review on 10/25/23 at 11:56 a.m. with Social Services Director (SSD), Resident 44's DENTAL NOTES (DN), dated 8/5/20 was reviewed. DN indicated Resident 44 was seen on 8/5/20. SSD confirmed 8/5/20 was the last time Resident 44 received dental care. SSD stated Resident 44 should have been seen at least annually. During an observation on 10/23/23 at 10:29 a.m. in Resident 19's room, Resident 19 wearing loose fitting dentures. During an interview on…

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 storage area were labeled and dated. This failure had the potential to result in foodborne illnesses. Findings: During a concurrent observation and interview on 9/24/23 at 9:50 a.m. with Kitchen Manager (KM), in the kitchen refrigerator room, there were chicken nuggets without a label and date. KM verified the findings and stated the chicken nuggets should be labeled and dated. During a concurrent observation and interview on 9/24/23 at 9:51 AM with KM, in the kitchen dry store room. A box of crackers had no label indicating when they were opened. KM stated the crackers in the box should have a label on them. During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods, dated 2023, the P&P indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated.Food delivered to facility needs to be marked with a received date. Note that the delivery sticker is dated, and it can serve as the delivery date for the product.…

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 a handrail was firmly secured and in good repair. This failure had the potential to expose residents and visitors to injuries or accidents as a result of a broken handrail. Findings: During an observation on 10/23/23 at 10:26 a.m. in the hallway, the right corner of the handrail was loose and detaching from the center handrail. During a concurrent observation and interview on 10/23/23 at 10:26 a.m. with Maintenance Assistant (MA) in the hallway, MA verified the handrail was loose. MA stated he was not aware of it (handrail being loose). MA stated there was no documentation of maintenance was completed. During a review of the facility's policy and procedure (P&P) titled, Maintenance Policies & Procedures dated December 2015, the P&P indicated, Test handrails daily as you go through the Center to make sure they are securely fastened. Repair immediately any loose handrails. Replace damaged handrails immediately.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure titled, Dignity, for one of two sampled residents (Resident 299), when a urine collection bag (a bag used to collect urine that is drained from the bladder) was not covered with a dignity bag. This failure had the potential to cause Resident 299 embarrassment. Findings: During an observation on 10/23/23 at 10:50 a.m. in Resident 299's room, an uncovered urinary bag, visible to other residents, staff, and visitors was hanging from the right side of Resident 299's wheelchair. During an interview on 10/23/23 11 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 299's urinary bag was not covered by a dignity bag but Resident 299 should have a dignity bag. During an interview on 10/26/23 at 2:03 p.m. with Director of Nursing (DON), DON stated there should always be a dignity bag on foley catheters (bag used to collect urine from bladder), that is a standard of practice. During a review of the facility's P&P titled, Dignity, dated Feburary 2021, the P&P indicated,…

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 follow their policy and procedure (P&P) titled, Transfer or Discharge Notice, when the facility did not send a notice of transfer to the Ombudsman (representatives who assist resident in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) for two of five sampled residents (Resident 59 and Resident 17). This failure had the potential to result in residents being discharged inappropriately and not having an advocate who could inform them of their admission, transfer, and discharge rights and options. Findings: During a concurrent interview and record review on 10/25/23 at 2:40 p.m. with Social Services Director (SSD), Resident 59's SSD Clinical Record (CR), dated 7/22/23 reviewed. The CR indicated Resident 59 was transfered to the hospital. There was no documentation in the CR that Ombudsman was notified about the transfer. SSD stated she was unable to provide documentation of notification to Ombudsman. During a concurrent interview and record review on 10/25/23 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 develop a plan of care for two of two sampled residents (Resident 29, Resident 19) when: 1. Resident 29's plan of care did not include nail care. 2. Ensure an accurate assessment to reflect Resident 19's loose fitting dentures. These failures resulted in residents not receiving the services they needed which had the potential for negative health outcomes. Findings: 1. During an interview on 10/24/23 at 12:00 p.m. with Family Member (FM) 1, FM 1 stated Resident 29 was in the hospital in July or August for surgery. A hospital nurse showed FM 1 Resident 29's long nails on his right hand, which had a contracture (a fixed tightening of muscles, tendons, ligaments, or skin, preventing normal movement of the body part). FM 1 stated the hospital nurse was concerned the long nails could cause Resident 29's skin to be pierced by them. During a concurrent observation and interview on 10/24/23 at 12:14 p.m. with CNA 11 in Resident 29's room, CNA 11 carefully opened Resident 29's smallest finger, and the nail 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.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure titled, Administering Medications when: 1. The Director of Nursing of Nursing (DON) did not check the intravenous (IV-given inside of a vein) antibiotic (medication used to treat bacterial infection) for one of one sampled resident (Resident 92). 2. Resident 92' IV antibiotic were not administered at the right time according to physician's order. These failures had the potential for Resident 92 to recieve the wrong medication with potential to result in adverse health outcomes Findings: 1. During a concurrent observation and interview on 10/23/23 at 10:20 a.m. with Resident 92, in Resident 92's room, a Peripherally Inserted Central Catheter (PICC-used to deliver medications and other treatments directly to the large central vein near the heart) was on Resident 92's right upper arm. Resident stated he had IV antibiotics being hung once a day at different times, but not at the same time every day. During a concurrent observation and interview on 10/24/23 at 11:11 a.m. with DON,…

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 one of 19 sampled residents (Resident 29) received nail care. This failure had the potential to cause injury to Resident 29. Findings: During an interview on 10/24/23 at 12:00 p.m. with Family Member (FM) 1, FM 1 stated Resident 29 was in the hospital in July or August for a surgery. A hospital nurse showed FM 1 Resident 29's long nails on his right hand, which had a contracture (a fixed tightening of muscles, tendons, ligaments, or skin, preventing normal movement of the body part). FM 1 stated the hospital nurse was concerned the long nails could cause Resident 29's skin to be pierced by them. During a concurrent observation and interview on 10/24/23 at 12:14 p.m. with Ceritifed Nursing Assistant (CNA) 11 in Resident 29's room, Resident 29's right hand was observed. Resident 29's right hand was observed to have a contracture and it was tightened into a fist. CNA 11 carefully opened Resident 29's smallest finger, and the nail was observed to be approximately ¼ to ½ inch beyond the fingertip. CNA 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, interview, record review, the facility failed to ensure one of eight sampled residents (Resident 14) physician's order for treatment was followed. This failure had the potential for delaying Resident 14's wound healing and result in infection. Findings: During an observation on 10/23/23 at 10:20 a.m. in Resident 14's room, Resident 14's right side of nose by cheek had a wound about the size of a dime, red in color, with a glossy appearance, and opened to air. During a review of Resident 14's Order Summary Report (OSR), dated 10/18/23, the OSR indicated, Cleanse surgical site to right side of face with NS [normal saline-mixture of salt and water], pat dry, apply bacitracin [antibiotic-medication to treat bacterial infection] ointment, apply medi-honey [ointment used to treat certain wounds], cover with super absorbent dressing, daily, X [for] 30 days, everyday shift for s/p [status post-after] surgical incision [wound] removal of abnormal growth to face, for 30 Days. During a concurrent observation and interview on 10/23/23 at 2:57 p.m. with Licensed Vocational…

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 follow their policy and procedure (P&P) titled, Medication Storage, when: 1. Expired medication was not removed from one of three sampled medication refrigerators (Refrigerator C). 2. Diabetic testing strips (strips used to test blood sugar) were not labeled with the date they were opened on one of two sampled medication carts (D Hall Cart). 3. Medication refrigerator temperature was not monitored every shift for three of three sampled medication refrigerators (Refrigerator A, Refrigerator B, and Refrigerator C). These failures had the potential to result in unintended, harmful, or undesirable health outcomes to the residents. Findings: 1. During a concurrent observation and interview on [DATE] at 9:16 a.m. with Director of Staff Development (DSD), in the medication storage room. Refrigerator C had a package containing lidocaine (numbing medication) 2% suppositories (medication inserted in body through rectum or vagina) that had a best 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.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 36)'s diet texture was followed according to the physician's order. This failure had the potential for Resident 36 to experience choking due to incorrect food texture. Findings: During an observation on 10/23/23 at 12:22 p.m. in the dining room, Resident 36 was eating and Resident 36's tray contained a piece of bread with crust on, the area of the crust was darker in color. During a concurrent interview and record on 10/23/23 at 12:26 p.m. with Director of Staff Development (DSD) Resident 36's Meal Ticket was reviewed. The Meal Ticket indicated, mechanical soft (food that is broken down for easy swallowing without biting or chewing). DSD stated Resident 36 is on mechanical soft diet. During a concurrent observation and interview on 10/23/23 at 12:37 p.m. with DSD, in the dining room, the bread crust was darker in color was noted on Resident 36's tray. DSD stated she did not verify if the piece of bread crust was a mechanical soft before serving the tray 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 implement an effective antibiotic stewardship program when one of six sampled residents (Resident 86) was reviewed and monitored for the use of an antibiotic. This failure had the potential for Resident 86 to continually take inappropriate or unnecessary antibiotic and may result in infections not treated appropriately. Findings: During an interview on 10/24/23 at 9:28 a.m. with Infection Preventionist (IP) 1 and IP 2, IP 1 stated the antibiotic use was not monitored. IP 2 stated there was no justification documented if the antibiotic was appropriate for Resident 86. During a review of facility's Infection Surveillance Monthly Report dated September 2023, the ISMR indicated Resident 86 was on Cephalexin (medication to treat bacteria) Tablet 500 MG (milligrams-unit of measurements). During a concurrent interview and record review on 10/24/23 at 9:32 a.m. with IP 2, Resident 86's Urinalysis (UA-test of the urine for bacteria), dated August 2023 was reviewed, the Urinalysis indicated, UA Culture [identifies the bacteria]…

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 dietary staff failed to follow proper sanitation and safe food handling practices when: 1. Ensuring the inside of two clean plate covers were not touching DS uniform while waiting to cover the lunch plates. 2. Performing handwashing and changing gloves prior to preparing a grilled cheese sandwich during tray line. These failures had the potential to result in foodborne illnesses for residents in the facility. Findings: 1. During a concurrent observation and interview on 7/20/21, at 12:16 PM, with Registered Dietitian (RD), Dietary Aide (DA) was observed holding the inside of two clean plate covers against his uniform while waiting to cover lunch plates with food prepared in the tray line. RD validated the findings. 2. During an observation on 7/20/21, at 12:30 PM, DA was observed touching two slices of bread to make a grilled cheese sandwich without handwashing and changing his gloves. During an interview on 7/23/21, at 10:00 AM, with the Dietary Supervisor (DS), DS stated she is responsible to provide annual competencies 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, interview, and record review, the facility failed to ensure garbage and refuse were properly collected and disposed in a safe and efficient manner. This failure had the potential to result in harboring, feeding, and attracting pests and vermin. Findings: During an observation on 7/19/21, at 12:32 PM, in the area just outside of the kitchen, with Dietary Supervisor (DS) and Registered Dietitian (RD), one of two garbage dumpster's had the cover left opened . During an interview on 7/23/21, at 11:00 AM, with RD, RD stated, the two garbage dumpster's should always be closed to prevent harborage and feeding of pests, and pest infestation.

Based on observation, interview, and record review, the facility failed to: 1. Handle, store, process linens in a safe and sanitary method to prevent the spread of infection. 2. Store clean briefs appropriately. 3. Maintain a safe and sanitary environment in resident bathroom. 4. Two housekeeping staff failed to follow manufactures contact times for disinfectant. These failures had the potential to spread communicable diseases and infection to the facility's residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 7/20/21, at 8:56 AM, with the Laundry Aide (LA), in the Laundry Dirty Area, seven yellow barrels with soiled linens inside and three big gray barrels with clean pillows inside were observed stored side by side. A gray uncovered trash bin was observed between the washer and the employees' bathroom. LA stated, that she was not trained to sort dirty linens inside the dirty area, LA stated, two other LAs trained her to sort all of the soiled linens right in front of the two big washers. LA stated, if she finds dirty briefs, used gloves,…

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, record review, the facility failed to provide an effective pest control program. This failure had the potential to spread disease to residents, staff, and visitors. Findings: During an interview on 7/19/21, at 12:25 PM, with Resident 27, Resident 27 stated, she has seen a few roaches in the facility but it (the roaches) has gotten better. During an interview on 7/19/21, at 3:06 PM, with Resident 217, Resident 217 stated, he has seen roaches in the facility. He stated, he has let the facility staff know about the roaches. Resident 217 stated, he still see them (roaches). During an observation on 7/20/21, at 8:10 AM, in the conference room a black bug approximately one inch long ran from under (Surveyors) feet. Surveyor killed the black bug. During a concurrent observation and interview on 7/20/21, at 8:11 AM, inside the conference room, with Laundry Staff (LA), LA confirmed the smashed black bug. LA stated, she sees them (roaches) often. LA stated, the roaches somehow sneak 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS- standardized screening assessment tool) were completed and transmitted within the required time frame for three of 24 sampled residents (Resident 1, Resident 3, and Resident 16). This failure had the potential to negatively affect the provision of necessary care and services for the residents. Findings: During a review of Resident 1's Comprehensive MDS Annual Assessment (AA ), dated 4/20/21, Resident 1 was admitted to the facility on [DATE] (Section A1900). Resident 1's AA indicated it was signed by a Licensed Vocational Nurse (LVN) on 7/23//21 (Section V0200C- Signature of Person Completing Care Plan Decision and Date Signed). Resident 1's AA indicated it was signed by a Registered Nurse (RN) on 7/23/21 (Section Z0500B- Date RN Coordinator Signed Assessment as Complete). During a review of Resident 3's Comprehensive MDS Significant Change in Status Assessment (SCSA), dated 7/10/20, Resident 3 was admitted to 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.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for the reconciliation of controlled substances (a drug subject to special handling, storage, and disposal because of its potential for abuse or addiction) for one of 24 residents (Resident 321). This failure had the potential for the potential for loss or diversion of controlled substances. Findings: During an interview on 7/23/21, at 11:33 AM, with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, narcotics (controlled substances) are counted when I come on and when I go off and if the count is off we would let the ADON (Assistant Director of Nursing) or DON (Director of Nursing) know and the person who is there with me doesn't go home until it is resolved. During a concurrent interview and record review on 7/23/21, at 9:43 AM, with LVN 4, Resident 321's Controlled Drug Record (CDR) for Oxycodone (a controlled medication used for severe pain) 5 mg (milligram - a unit of measurement), dated 7/16/21, was reviewed. The CDR indicated the following: 7/17/21; 11 PM; one tablet; 21…

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: 1. Lock controlled substances in one of five medication carts. This failure had the potential to result in medication loss. 2. Have the correct label on a bag that corresponded to the medication inside for one of 24 sampled residents (Resident 63). This failure had the potential for medication administration errors resulting in significant harm to the resident. Findings: 1. During a concurrent observation and interview on 7/20/21, at 3:52 PM, in the medication room at Medication Cart Station 1, with Licensed Vocational Nurse (LVN) 1, the medication cart and internal controlled substances bin were not locked. LVN 1 stated, internal medication bins are supposed to lock automatically. LVN 1 stated, I'll be sure it's locked at all times and validated the findings. During a review of the facility's policy and procedure (P&P) titled, Controlled Medication Storage, dated 2007, the P&P indicated, Schedule II medications are stored in a separate area under double lock. 2. During a concurrent observation and interview…

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 two of five sampled residents (Resident 24 and Resident 50) were offered and administered the pneumococcal vaccine (vaccines to prevent severe pneumococcal disease) in a manner consistent with professional standards and guidance from Centers for Disease Control and Prevention (CDC) recommendation. This failure had the potential to increase potential transmission of pneumonia for Resident 24 and Resident 50. Findings: During an interview on 7/21/21, at 11:09 AM, with Infection Preventionist (IP), IP stated, we audit all new admissions; medical records also does audits to ensure residents are offered vaccine. IP stated, we reach out to the families to find out the residents' vaccine history. IP stated, vaccines are also discussed in stand up (daily meetings) and Interdisciplinary Team (IDT- group of health care professional from diverse fields that work together to ensure residents health and safety) meetings to ensure residents are given 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 accurately code the Minimum Data Set (MDS- a standardized screening assessment tool) for one of three sampled residents (Resident 68). This failure had the potential to negatively affect the provision of necessary care and services. Findings: During a review of Resident 68's MDS, dated [DATE], the MDS indicated, Resident 68 was discharged to an acute hospital (Section A2100). During a review of Resident 68's Face Sheet (FS), dated 6/11/21, the FS indicated Resident 68 was discharged to home. During an interview on 7/22/21, at 4:16 PM, with the Minimum Data Set Nurse (MDSN), the MDSN stated, It was a coding error.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for three of 24 sampled residents (Resident 317, Resident 28, and Resident 59) This failure had the potential for Resident 317's and Resident 28's grooming and personal hygiene needs to go unmet and placed Resident 59 at risk for injury. Findings: 1. During a concurrent observation and interview on 7/21/21, at 11:08 AM, with Resident 317, in room [ROOM NUMBER], Resident 317 was observed unkempt, not shaved, and with greasy, uncombed hair. Resident 317 stated, I haven't had a shower for over two weeks. During a concurrent interview and record review on 7/23/21, at 9:04 AM, with Infection Preventionist (IP), the facility's AM Shower List (SL) and PM Shower List (SL), dated 7/1/21 to 7/23/21, was reviewed. The SL indicated, Resident 317's shower days were Monday and Thursday each week. Resident 317 refused showers on 7/1, 7/8, 7/19, and 7/22. IP validated the findings. 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 Surveyor: [NAME], [NAME] Based on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Resident 63 and Resident 28), received necessary services to maintain grooming and personal hygiene. This failure had the potential to result in a negative impact tot he resident's quality of life and self-esteem. Findings: During an observation of Resident 63, on 7/19/21, at 3:20 PM, in the hallway outside Resident 63's room, the Resident 63 was observed sitting up on her wheelchair with no socks or shoes, with unkempt (untidy and not combed) long hair, and with long fingernails on her right hand. During a review of Resident 63's admission Record, (undated), the admission Record indicated, the Resident 63 was admitted to the facility on [DATE], with diagnoses that included Hemiplegia (paralysis or weakness on one side of the body) affecting the right side and Diabetes Mellitus (DM - abnormal blood sugar level). During a review of Resident 63's Minimum Data Set (MDS -…

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 24 sampled residents (Resident 32) received audiology (hearing) services. This failure had the potential for Resident 32 to have unmet care needs. Findings: During an observation and interview on 7/19/21, at 11:16 AM, outside of Resident 32's room, Resident 32 did not respond to surveyor's voice or knocking. Certified Nursing Assistant (CNA) 1 passed by and stated, both residents in that room are very hard of hearing. During an interview on 7/19/21, at 6:47 PM, with Family Member (FM) 1, FM 1 stated, Resident 32 is very hard of hearing. FM 1 stated, Resident 32 had hearing aids in the past. FM 1 stated, during the 30 days he had the hearing aids he went out and got his driver's license and was very active. FM 1 stated, Resident 32 returned the hearing aids after a month, stating they were too expensive. During a review of Resident 32's, Face Sheet (FS), the FS indicated, Resident 32 was admitted to the facility on [DATE],…

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 consultant pharmacist failed to identify and make recommendations to attempt a gradual dose reduction of an antipsychotic drug (classification of drugs used to treat mental disorders) for one of 24 sampled residents (Resident 32).This failure had the potential to result in decreased quality of life, adverse consequences, and significant, irreversible side effects. Findings: During a concurrent interview and record review on 7/22/21, at 10:55 AM, with the Assistant Director of Nursing (ADON), Resident 32's Medication Regimen Review (MRR), dated 3/13/20 to 7/22/21, were reviewed. The MRR indicated no recommendations were made by the consultant pharmacist to reduce Resident 32's Seroquel (an antipsychotic medication) dose. ADON validated the findings. During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, dated 12/16, the P&P indicated, Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to attempt a gradual dose reduction of an antipsychotic drug (classification of drugs used to mental disorders) for one of 24 sampled residents (Resident 32).This failure had the potential to result in decreased quality of life, adverse consequences, and significant, irreversible side effects. Findings: During a concurrent interview and record review on 7/22/21, at 10:55 AM, with the Assistant Director of Nursing (ADON), Resident 32's Medication Regimen Review (MRR), dated 3/13/20 to 7/22/21, were reviewed. MRR indicated Resident 32's Seroquel(medication used to treat mental disorders) dose had been gradually increased from 25 mg (Milligrams=unit of measure) at bedtime to 25 mg twice a day (50 mg daily), then increased to 25 mg three times a day (75 mg daily), and then increased to 25 mg twice a day and 50 mg at bedtime (100 mg daily). ADON validated the findings. During a review of Resident 32's Physician Orders (PO), dated 12/1/20, the PO indicated,…

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 medication error rate was five percent or less when four medication errors were observed out of 42 medication administration opportunities, which yielded a medication error rate of 9.52 percent. These failures had the potential for residents not to receive the therapeutic effects of the medications. Findings: During a concurrent medication pass observation and interview on 7/20/21, at 8:45 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed administering five tablets to Resident 61. LVN 1 stated, this completed Resident 61's 9 AM medication pass. During a review of Resident 61's Physician Order Report (POR), dated 7/18/21, the POR indicated, Ventolin HFA (albuterol sulfate).1 puff; inhalation. Twice a day; 09:00, 21:00. During an interview on 7/20/21, at 11:59 AM, LVN 1 stated, the albuterol inhaler was not given at 9 AM as ordered and validated the omission. During a concurrent medication pass observation and interview on 7/20/21, at 8:55 AM, with LVN 1, LVN 1 was observed administering…

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.