Tampico Healthcare Center

Based on interview and record review, the skilled nursing facility's licensed nursing staff did not provide care according to professional standards for 2 of 26 sampled residents (Residents 90 and 111). Residents 90 and 111 had elevated blood pressures that were not treated with available medication or reported to the doctor. This resulted in the potential for a stroke. (bleed or clot in the brain) Findings: Record review of the document admission Record showed the facility admitted Resident 90 on 1/24/2025. Diagnoses included End Stage Renal Disease. During an interview on 3/25/2025 at 2:55 p.m. the Director of Nursing (DON) stated the dialysis center had called on 3/15/2025 to ask that Resident 90's blood pressure medication be adjusted as his blood pressure became too low at dialysis. The DON stated the medication was changed to prn (as needed) as opposed to regularly scheduled. Record review of the document Order Summary Report dated 3/25/2025 showed Hydralazine (blood pressure medication) was to be given by mouth every 8 hours as needed for SBP greater than 170. (SBP: systolic…

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 skilled nursing facility did not make an appointment to assess poor vision for one of 26 sampled residents (Resident 51). Resident 51 had broken his glasses and could not adequately see. This resulted in Resident 51 feeling Frustrated. Findings: Record review of the document admission Record showed the facility admitted Resident 51 on 2/27/2025. Diagnoses included epilepsy (seizure disorder). Review of the document Nursing admission Assessment 5.4 dated 3/6/2025, showed Resident 51 had Adequate vision without the use of corrective lenses. Review of the document MDS 3.0 Nursing Home Comprehensive (NC) Version 1.19.1 dated 3/6/2025, (resident assessment) showed Resident 51 was alert and oriented. Review of the section Hearing, Speech, and Vision showed Resident 51 used Corrective Lenses. During an interview on 3/24/25 at 10:15 a.m. Resident 51 stated he had seizures and broke his glasses in October. He stated he could not see this surveyor as his vision was Blurry and he…

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 for one out of 26 sampled residents (Resident 99), Resident 99's head of the bed (HOB) was elevated at a minimum of 30 degrees during tube feeding administration. This failure had a potential to affect Resident 99's health due to accidental inhalation of stomach contents to lungs. Findings: A review of facility's admission Record indicated Resident 99 was admitted on [DATE], with diagnoses that included protein-calorie malnutrition and cancer of upper opening of the stomach. Resident 99's Minimum Data Set (MDS - resident assessment tool) dated 12/18/2024, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 00, (BIMS score of 00 - 07, severe impairment). During a review of Resident 99's physician's Order Summary Report (OSR) for the month of 3/2025 indicated Enteral…

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 medications and properly dispose of expired medications for two of 26 sampled residents (Residents 24 and 28): 1. Resident 24's one open inhaler (inhaler: a devise used for delivering medicines into the lungs through breathing) was used beyond the use by date. 2. Resident 28's one discontinued inhaler was found in the medication cart. This failure exposed Resident 24 in receiving an inhaler with questionable potency and efficacy. This failure also resulted in a lack of oversight for Resident 28's discontinued inhaler. Findings: 1. During a review of Resident 24's admission Record (information containing contact details, brief medical history at-a-glance) indicated, Resident 24 was admitted to the facility on [DATE]. During a concurrent observation and interview on 3/25/25, at 1:05 p.m., with Licensed Vocational Nurse (LVN) 2, while inspecting medication cart one, Resident 24 had one opened medication box which contained Wixela 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 skilled nursing facility's staff did not set up a dental appointment for one of 26 sampled residents (Resident 51). Resident 51 had no natural teeth and had poor fitting dentures. This resulted in Resident 51 feeling Frustrated. Findings: Record review of the document admission Record showed the facility admitted Resident 51 on 2/27/2025. Diagnoses included epilepsy (seizure disorder). Review of the document Nursing admission Assessment, dated 2/27/2025 showed, under the section Natural Teeth and Dentures, nothing had been checked off to indicate he had no teeth or dentures. Review of the document MDS 3.0 Nursing Home Comprehensive (NC) Version 1.19.1 dated 3/6/2025, (resident assessment) showed Resident 51 was alert and oriented. Review of the section Oral/Dental Status showed he had No natural teeth or tooth fragment(s) and had Mouth or facial pain, discomfort or difficulty with chewing. Review of the document Inventory of Personal Effects dated 2/27/2025, showed Resident 51 entered the facility at that time with upper 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 The facility failed to assist one out of three sampled residents (Resident 73) obtain Medi-Cal authorization for dental services in a timely manner.This failure had the potential to cause Resident 73 to be without dentures longer than necessary, which could result in weight loss, unhappiness, and stress. Findings: During a review of Resident 73's admission Record, dated 3/27/25, Resident 73 was admitted to the facility on [DATE] with multiple diagnoses including homelessness, depression, and hypertension (high blood pressure). During an interview on March 24, 2025 at 11:55 a.m. with Resident 73, Resident 73 stated his teeth were removed several months ago, he wanted dentures, and he did not understand what was happening with his dental insurance. Resident 73 stated he was feeling very stressed about dental insurance and that if he understood about the share of cost, he would not have consented to have his teeth removed. Resident 73 stated not having teeth or dentures makes him feel like crap. During an 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 (Resident 1 and 3) of three sampled residents were free from verbal and physical abuse when, 1. Resident 2 screamed, hit and made verbal threats to harm Resident 1 during an altercation in the hallway; and 2. Resident 2 threw an object at Resident 3 who reacted by pushing the table, lost his balance and fell at a bingo game in the dining room. This failure caused repeated resident-to-resident altercations, emotional distress and potential to result in injuries for residents in the facility. Findings 1. Review of Resident 2 ' s progress notes dated 3/12/24 indicated Resident 2 screamed, hit and made verbal threats to harm Resident 1. Resident 2 was angry that Resident 1 was in the room next to Resident 2. Resident 2 demanded that Resident 1 leave her side of the hallway. During an interview with Resident 1, on 4/3/24, at 11:26 a.m., Resident 1 stated he went to visit one resident in the room next to Resident 2 ' s room, when Resident 2 came…

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 resident was free from physical abuse when Resident 2 punched her roommate (Resident 1) on the left arm with her right hand. This failure had the potential for physical injury from retaliation in response to the roommates's aggressive behavior. Findings: Review of Resident 1's admission Record, dated 10/19/23, indicated Resident 1 had a diagnosis of Dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbances and schizophrenia (a mental disorder in which a person loses touch with reality). Review of the clinical record for Resident 1, the Minimum Data Set (MDS-a comprehensive assessment tool) dated 8/10/23, indicated Resident 1 had severe memory and judgement impairments. Review of Resident 1 ' s Care Plan, indicated Resident 1 had behavior problems of saying profanities and throwing things on the floor. Review of Resident 1's interdisciplinary team (IDT,…

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 nursing staff followed policies and procedures for safe medication administration when: 1. For one (Resident 5) of five sampled residents, Registered Nurse 1 (RN 1) left six prescription medications on Resident 5 ' s bedside table unmonitored. 2. For three of five sampled residents (Resident 5, Resident 2, and Resident 4), nursing staff did not use two resident identifiers (Information directly associated with a person that reliably identifies the individual as the person for whom the service or treatment is intended) before administration of medications. The failure to monitor the medications left on Resident 5 ' s bedside table resulted in Resident 5 taking medications prescribed for another resident and required two days in an acute care hospital to monitor Resident 5 for adverse side effects from the medications. The failure to use two resident identifiers resulted in Resident 5 receiving medications not prescribed for Resident 5 and had the potential to result in administration of the wrong medications 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 observation, interview, and record review, for one of four sampled residents (Resident 5), the facility failed to ensure nursing staff followed policy and procedures to prevent significant medication errors when nursing staff failed to use resident identifiers (Information directly associated with a person that reliably identifies the individual as the person for whom the service or treatment is intended) to check Resident 5 ' s identity before leaving six medications not prescribed for Resident 5, on Resident 5 ' s bedside table. These failures resulted in Resident 5 taking the six unprescribed prescription medications (quetiapine as a mood stabilizer/depression treatment, empagliflozin for high blood sugar/heart failure, enalapril for high pressure/heart failure, divalproex for seizures/mood stabilizer, duloxetine for depression, and alogliptin for high blood sugar) left at her bedside. The unprescribed medications caused Resident 5 to have dizziness, drowsiness, and required two days in acute care hospital to monitor for potentially life-threatening adverse consequences…

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, for two of two sampled residents (Resident 1 and Resident 2), the facility failed to ensure a homelike environment with clean bed and bath linens that are in good condition when facility did not have enough towels and bed linens and used washcloths that had frayed edges. This failure resulted in an unfamiliar and uncomfortable environment for residents. Findings: During a review of Resident 1's admission Record, printed 9/15/23, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included pain in the right leg and the thoracic spine (upper and middle part of the back). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 6/10/23, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention,…

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, for three of three sampled residents (Resident 1, Resident 2, and Resident 3), the facility failed to ensure restorative nursing program was provided to prevent decrease in range of motion and improve mobility. This failure had the potential to result in decline in range of motion and mobility. Findings: 1. During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility in June 2020 with diagnoses that included right side sciatica (pain, weakness, numbness, tingling in the leg), muscle weakness, pain in the right leg, unsteadiness on feet, history of falling, osteoarthritis (the ends of the bones/joints wear down causing pain), and lumbar region spinal stenosis (narrowing of the spinal canal, compressing the nerves that travel through the lower back down to the legs). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 6/2/23, under Section G, the document 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 ensure there was sufficient staff to provide nursing services to maintain residents' practicable physical and psychosocial well-being. This failure had the potential to result in poor care and increased risk for safety like falls. Findings: During a review of the Facility Assessment, last updated 8/14/23, the document indicated a total average daily census of 98 to 100 residents. The assessment indicated services the facility offers included activities of daily living (ADLs) like bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment. The facility assessment also indicated resident acuity ranged from residents needing assistance from 1-2 staff to residents who are totally dependent on staff assistance for all ADLs. The general staffing plan to meet residents' needs are as follows; for the morning shift, 11 Certified Nursing Assistants (CNA), for the afternoon/evening shift, ten CNAs and six CNAs for the night shift for a total of 27 CNAs over a 24-hour period.…

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, for one of three sampled residents (Resident 2), who was dependent on staff for Activities of Daily Living (ADLs, such as transfers from bed to chair, bathing/showers, eating, personal hygiene), the facility failed to ensure showers were provided to maintain grooming and personal hygiene. This failure had the potential to result in diminished self-esteem and poor grooming and personal hygiene. Findings: During a review of Resident 2's admission Record, the record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included muscle spasms, chronic pain, multiple sclerosis (chronic disease of the central nervous system, symptoms include trouble walking) and epilepsy (nerve cell activity in the brain is disturbed causing seizures). During a review of Resident 2's MDS (Minimum Data Set, a standardized assessment tool used for nursing home residents), dated 4/14/23, the MDS indicated Resident 2 had a Brief Interview for Mental Status (BIMS,…

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 store and procure food in a sanitary manner when eggs were not pasteurized, dented cans were stored in the dry storage area, and a scoop used for a thickening agent was not stored in its holder. These deficient practices had the potential to cause food borne illness that can affect all residents. The facility census was 79. Findings: During a concurrent observation of the kitchen and interview on 12/5/22 at 9:30 a.m., with the Dietary Manager (DM) 1, eggs stored in the refrigerator were not pasteurized, a dented can of marinara sauce was stored with the undented cans and a scoop for a thickening agent was placed on top of a nearby shelf. DM 1 confirmed the eggs in the refrigerator were not pasteurized. DM 1 further stated when unpasteurized eggs are not fully cooked and served, it can make residents sick. DM 1 acknowledged the dented can of marinara sauce stored with the rest of the ready-to-use cans and should be placed in a designated area for dented cans. DM 1 further stated the scoop for the thickening…

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, record review, and interview, the facility failed to follow the lunch menu planned for 12/6/22 when fruit cups was served as dessert instead of triple fruit crisp. This deficient practice resulted in Resident 26 feeling disappointed. Findings: During an interview on 12/6/22 at 12:25 p.m. with Dietary Aide (DA) 1, DA 1 stated the triple fruit crisp dessert ran out during tray line and substituted the desert with fruit cups. During an interview on 12/6/22 at 12:45 p.m., with Resident 26, Resident 26 stated she was disappointed because she was given a fruit cup instead of the triple fruit crisp as a dessert for lunch. Resident 26 further stated she was not informed of the menu change. A review of the facility document titled, Food Menus, dated April 2020 indicated Menus must: be prepared in advance and be followed. A review of the document titled, Menu Changes dated April 2020 indicated, Procedure 1. Modify posted menus to reflect menu changes . Documentation- Record changes directly on the printed menu. Retain all menus according to state requirements.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to follow infection control policies and procedures when two residents (Resident 189 and 28) of four sampled residents receiving oxygen therapy aerosol set-ups were not labeled and put away in a manner to prevent infection. This deficient practice has the potential to spread infection. Findings: 1. A review of Resident 189's admission Record, dated 12/7/22 indicated Resident 189 was admitted to the facility on [DATE] with a diagnosis of COVID-19 (respiratory disease caused by SARS-CoV-2). Resident 189 also has a diagnosis of chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). A review of Resident 189's Minimum Data Set (MDS- an assessment tool to guide care) dated 11/28/22 indicated Resident 189 receives oxygen while a resident. A review of Resident 189's doctor's orders on 11/23/22 indicated for oxygen by nasal cannula as needed 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 observation, interview, and record review, the facility failed to identify, assess, and intervene for multiple purplish discolorations on the right and left arms of one of 23 sampled Residents (Resident 28). This failure placed Resident 28 at risk for further skin injury and delayed care. Findings: During an observation on 12/05/22, at 10:35 a.m., Resident 28 was observed with multiple purplish discolorations on her right and left arms. During a concurrent observation and interview on 12/05/22, at 10:40 a.m., with the Licensed Vocational Nurse (LVN) 2, Resident 28's arms were visible. LVN 2 stated Resident 28 had multiple discolorations on both arms. During a concurrent interview and record review on 12/06/22, at 9:50 a.m., with the Director of Nursing (DON), of Resident 28's Weekly Nursing Summary, dated 11/30/22 was reviewed. DON stated the multiple discolorations on both arms were not documented on the Weekly Nursing Summary, and no other skin assessments were evident from 11/30/22 through 12/6/22. DON further stated nurses should have checked Resident 28's skin daily…

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 a homelike environment for one of 23 sampled residents (Resident 59). This failure resulted in Resident 59 feeling upset that her room was not homelike. Findings: During a concurrent observation and interview on 12/05/22, at 12:52 p.m., in Resident 59's room, Resident 59 stated her room walls were in disrepair and was not homelike. The wall above Resident 59's bed had multiple areas with paint peeling and wall scratches. Resident 59 stated it made her feel so upset that her walls had always been in disrepair and had told staff about it. During a concurrent observation and interview on 12/06/22, at 12:15 p.m. with the Maintenance Director (MD), Resident 59's room walls had scratches. MD stated the room walls had a lot of scratches that needed to be repaired. MD stated he didn't keep a log of wall repairs and did know when the wall was last repaired. MD further stated it was not homelike. During a concurrent observation and interview on 12/07/22, at 11:18 p.m., with Licensed Vocational Nurse (LVN) 2,…

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 that one (Resident 46) of five sampled residents with mobility issues received treatment and care to prevent a worsening of contractures (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) when Resident 46 did not receive Restorative Nursing Program (RNA) services. This deficient practice has the potential for Resident 46 contractures to worsen. Findings: A review of Resident 46's admission Record, dated 12/7/22 indicated Resident 46 was admitted to the facility on [DATE] with a primary diagnosis of urinary (bladder) tract infection. Resident 46 also had a diagnosis of generalized muscle weakness. A review of Resident 46's Minimum Data Set (MDS) an assessment tool to guide care, dated 11/27/22 indicated, Resident 46 requires extensive assistance from one staff person to dress, eat, use the toilet and for personal hygiene. During a review of Resident 46's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy and procedures for oxygen administration for one (Resident 23) of four sampled residents receiving oxygen therapy when two portable oxygen tanks were not safely stored. This deficient practice may result in placing individuals in the facility at risk of potential harm in the event that a portable oxygen tank is dropped. Findings: A review of Resident 23's admission Record, dated 12/7/22 indicated Resident 23 was admitted to the facility on [DATE] with the primary diagnosis of spinal stenosis (narrowing of the spaces in your spine and creating pressure of the spinal cord and nerve roots). Resident 23 also had chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). A review of Resident 23's Minimum Data Set (MDS- an assessment tool to guide care dated 11/10/22 indicated, Resident 39 is cognitively intact and receives…

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 prepare food that was palatable and attractive when Resident 26 was served a burnt quesadilla for lunch. This deficient practice resulted in Resident 26 not enjoying her lunch and feeling disappointed. Findings: During an observation on 12/6/22 at 12:20 p.m. the tortilla on one side of a quesadilla had burned spots and was placed on a serving platter by [NAME] 1 to serve. During a concurrent observation and interview on 12/6/22 at 12:45 p.m., Resident 26 had leftover burnt tortilla left on her plate. Resident 26 stated she had to eat around the burnt parts and she did not enjoy her lunch and felt disappointed. During an interview with Dietary Manager (DM) 1 on 12/6/22 at 1:45 p.m., DM 1 stated he was not aware a burnt quesadilla was served to Resident 26. DM 1 stated burnt foods should not be served. DM 1 further stated food that is served should have a good appearance and should be palatable to the residents.

Based on observation, interview and record review, the facility had a 7.14 % medication error rate when two medication errors of 28 opportunities were observed during medication passes observation: 1. Reglan 5 mg (metoclopramide- use to treat nausea, vomiting) was given with meals. 2. Staff did not follow physician order to mix Prostat (a liquid protein for pressure ulcers, wounds, critical illnesses and other conditions requiring increased protein) 30 milliliters with 100 milliliters. These failures had the potential of ineffective medication treatment for Residents 19 and 69. Findings: 1. Review of the admission Record (a medical record that documents the patient's status) indicated Resident 19 was admitted to the facility with diagnosis that included nausea. During the morning medication pass observation on 2/5/2020 at 8:10 a.m., Resident 19 was eating breakfast. Licensed Vocational Nurse (LVN) 1 pulled the over-bed table where the breakfast tray was and gave all his medications that were due at 9:00 am., including his dose of Reglan. During an interview on 2/5/2020 at 9:05 a.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: 1. a male kitchen staff did not wear facial hair protection while in the kitchen food preparation areas; 2. several food items were expired; 3. canned emergency food supplies were dented; 4. expired nutritional supplements were stored with currently used enteral (food fed via a tube) products. These failures had the potential to cause food contamination or food borne illness. Findings: 1. During a brief tour of the Kitchen on 2/3/20 at 9:07 a.m., the Dietary Manager (DM) was observed to have facial hair that was not covered while in the food preparation areas of the Kitchen. In an interview with the DM on 2/3/20 at 9:07 a.m., the DM stated the facility's policy was to cover facial hair with a hair net while inside the Kitchen. Review of the Food and Drug Administration (FDA) Food Code 2017, Chapter 2-4, paragraph 402, Hair Restraints, indicated, Food employees shall wear hair…

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 infection control practices when: 1. The staff did not change gloves during treatment for Resident 40. 2. The staff did not wash hands before and between glove changes during treatment for Resident 19. 3. The staff did not wash hands before and after delivering meal tray to Residents. 4. The staff did not wash hands between residents during medication pass for Resident 69 and 84. These failures increased the potential for cross contamination. Findings: 1. During an observation of a gastrostomy tube (G-Tube, a tube inserted through the belly that brings nutrition directly to the stomach) dressing change with Licensed Vocational Nurse (LVN) 6 on 2/3/2020 at 2:10 p.m., for Resident 40, LVN 6 used the gloves from the dispensing box and started cleaning the GT site with normal saline, patted dry, she then applied skin prep surrounding the skin, and she covered the site with a drain sponge, leaving the gloves on from the beginning to the…

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

Based on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 40) was treated with respect and dignity when staff failed to close the privacy curtain during treatment procedure. This failure had the potential to result in Resident 40's unnecessary body exposure, and embarrassment that could lower her self-stem and self-worth. Findings: A review of Resident 40's physician's order dated 9/18/2019, indicated gastrostomy tube (GT- a tube inserted through the belly that brings nutrition directly to the stomach) site cleanse with normal saline, pat dry, skin prep (the) surrounding skin, cover with drain sponge, secure with tape and change every day and PRN spoilage. During treatment observation on 2/3/2020 at 2:10 p.m., Licensed Vocational Nurse (LVN) 6 approached Resident 40 (who was in bed) and explained the procedure to Resident 40 of what she was going to do. The privacy curtain surrounding Resident 40's bed on her right side was left open. LVN 6 pulled Resident 40's gown up above her abdomen, exposing the resident's abdomen…

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 provide notice to the Office of the Long-Term Care Ombudsman of transfers to the hospital for two of 22 sampled residents (Residents 66 and 76). This failure had the potential to result in the residents not having access to an advocate. Findings: Review of Resident 66's clinical record indicated Resident 66 was transferred to the acute care hospital on [DATE]. A notice to the Office of the Long-Term Care Ombudsman was unable to be found in Resident 66's clinical record. During an interview on 2/6/20, at 11:09 a.m., with the Assistant Administrator (AA.), the AA stated there was no notice sent to the Office of the Long-Term Care Ombudsman for Resident 66's transfer to the hospital. The AA stated she did not know the facility was supposed to do that, but the facility will now start sending a notice to the ombudsman for resident transfers to the hospital. Review of the admission Record indicated Resident 76 was admitted to the facility with multiple…

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 to provide pain management for one (Resident 25) of 22 sampled residents when: 1. a pain assessment was not conducted routinely. 2. pain medication or non-drug intervention was not given for complaints of pain. These failures resulted in unnecessary pain and suffering which affected Resident 25's ability to maintain his highest practicable physical, mental, and psychosocial well-being. Findings: 1. Review of the Face Sheet indicated that Resident 25 was admitted on [DATE] with multiple diagnosis including, Muscle Spasms, Chronic Pain Syndrome and Anxiety. During an observation on 2/3/20 at 9:30 a.m., Resident 25 was awake in bed. Both arms and feet were flexed as if he was in a fetal position. The Minimum Data Set (MDS - a resident assessment tool) Coordinator at bedside attempted to take Resident 25's hand away from the center of his body but Resident 25 yelled and screamed was if he was in a lot of pain. Review of clinical records…

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, for one (Resident 25) of 22 sampled residents, the facility failed to ensure that Resident 25 was free of a significant medication error when a scheduled antibiotic medication was not given. This failure had the potential for Resident 25 not getting the full effect of the antibiotic and compromise the healing process. Findings: A review of Resident 25's face sheet (a document that gives resident information at a quick glance), indicated that Resident 25 was admitted on [DATE] with multiple diagnoses which included Urinary Tract Infection (UTI). In an observation of Resident 25 on 2/3/20 at 9:30 a.m, Resident 25 was in bed eating his breakfast. Resident 25 stated the nurses did not wake him up to give his medications. Review of the Physician's order dated 2/1/20, indicated, Cipro (medication given for infection) 500 mg tablet, give 1 tab by mouth twice daily x (for) 7 days. Review of the Medication Administration Record, dated February 2020, indicated that staff…

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

Based on observation, interview and record review, the facility failed to ensure safe medication storage when: 1. in the North Wing Station medication room, the refrigerator had a yellowish sticky liquid at the bottom and the container for the medications to be destroyed was overflowing. 2. in the South Wing Station medication room, the refrigerator had a yellowish sticky liquid at the bottom. 3. the South Wing Station Medication Cart 3 was dirty with small pieces of aluminum paper and multiple loose tablets in the bottom of the cart; the pill crusher was with brownish substance around the rim. Discontinued medication for Resident 83 was still stored it the Medication Cart 3. 4. in the South Wing Station, Medication cart 1 was dirty with small pieces of aluminum paper and multiple loose tablets in the bottom of the cart and pill crusher had brownish substance around the rim. These failures had the potential for residents to receive unintended medications. Findings: 1. During a concurrent observation and interview on 2/4/2020 at 9:20 a.m., with Registered Nurse (RN) 1, the North Wing…

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.