Watsonville Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement care plans for five of five residents (Residents 19, 66, 78, 238, and 59): 1. For Resident 19, the facility did not develop care plan for activities of daily living (ADLs, a term used to describe the basic skills needed to independently care for oneself) to address hygiene and did not implement the anticoagulant therapy (sometimes called blood thinning medicines that reduces blood clots and can cause bleeding) care plan; 2. For Resident 66, the facility did not develop care plan for Urinary Tract Infection (UTI- an illness that often start when bacteria get into the tube through which urine leaves), and the physician order of Ciprofloxacin Hydrochloride (medication for bacterial infections). 3. For Resident 78, the facility did not develop care plan for UTI and the physician order of Cephalexin Oral Capsule (medication for bacterial infections). 4. For Resident 238, the facility did not develop care plan for the use…

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 expired medications were removed, and medications were labeled and stored according to manufacturer's instructions for two out of three medication rooms and two out of three medication carts when: 1. There was an outdated vial (cylindrical container) of tuberculin (liquid used to test for tuberculosis) in the medication refrigerator in med storage CC; 2. There was an open, unlabeled Ozempic (medication used to lower blood sugar) injection pen in the medication refrigerator in med storage CC; 3. There were three medications in med cart BB that were not refrigerated as ordered; 4. There were two outdated antiperspirants and one outdated biohazard spill kit (a collection of materials used to clean up blood, vomit, mucus, saliva, and other bodily fluids) in med storage CC; 5 Two over the counter (OTC) eye medication bottles, for two residents were identified in the medication cart; and 6. A medication Eplerenone 25 mg tablet on the blister pack label was not the same order as the physician order. These…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the food was prepared by methods that conserved nutritive value and appearance when eight out of 18 resident sample (Residents 51, 6, 26, 20, 17, 192, 59, and 41) stated facility food was served cold without flavor and not at the appropriate texture. These deficient practices had the potential to decrease the food intake of residents and negatively impact their nutritional status. Cross Reference F803 Findings: During an interview on 8/12/24 at 10:12 a.m. with Resident 51, Resident 51 stated food is not very good and had no taste. During an interview on 8/12/24 at 10:15 a.m., with Resident 6, Resident 6 stated that food was absolutely horrible. During an interview on 8/12/24 at 10:23 a.m. with Resident 26, Resident 26 stated food was inedible, and meat was tough. During an interview on 8/12/24 at 10:34 a.m., with Resident 20 and Resident 17, Resident 20 stated that meatloaf was bland and had no seasoning. Resident 17 stated she…

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

Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. Certified nursing assistant N (CNA N) and certified nursing assistant O (CNA O) did not perform hand hygiene when serving lunch trays; 2. Resident 187's nebulizer mask (a device used to convert a drug from liquid form into a mist, inhaled through the mask) was not properly stored when not in used and undated; 3. Licensed Vocational Nurse C (LVN C) did not disinfect the blood pressure (BP) apparatus (BP apparatus, a cuff that is wrapped around the arm to measure BP) in between residents; 4. Resident 238's nebulizer tubing was outdated and left on top of the resident's bedside table; 5. Resident 50's humidifier bottle was on the floor; 6. Registered nurse I (RN I) did not follow manufacturer's instructions for disinfecting the glucometer (device used to check blood sugar levels); and 7. Nursing Assistant (NA) P did not do hand hygiene in between residents' assistance during lunch. These failures had the potential to compromise resident's health and safety in 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 dignity and privacy was upheld for 1 of 2 sampled Residents (Resident 12) when Resident 12's Suprapubic catheter [SP Catheter, a device inserted into your bladder (organ that collects urine) to drain urine if you cannot urinate on your own made of a semi-flexible plastic tube, one end inserted into the bladder and the other end attached to a bag that collects urine] drain bag was left uncovered. This failure had the potential for adverse effects on the psychosocial well-being and health of Resident 12. Findings: During a review of Resident 12's Facesheet (FS, a document that gives a resident's information at a quick glance), undated, the FS indicated, admission diagnoses include End Stage Renal Disease (ESRD, condition in which the kidneys lose the ability to remove waste and balance fluids). During a review of Resident 12's physician order dated, 7/8/2024 indicated, an order for a Suprapubic Catheter due to diagnosis of obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed…

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 obtain an informed consent for one of two sampled residents (Resident 44), for the medication lorazepam (medication used for anxiety). This deficient practice had the potential for the resident or the representative not to be informed of the risks, benefits, and alternatives of the given treatment (medication) and may lead to the inability to exercise the rights to a preferred choice or alternative treatment. Findings: A record review of Resident 44's clinical record, indicated medical diagnoses including Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Catatonic Schizophrenia (a rare and severe mental disorder that's characterized by extreme changes in movement, behavior, and communication). A record review of Resident 44's Physician Orders indicated an order dated 7/4/2023 for Lorazepam, give 1 milligram (mg, unit of measurement) by mouth three times a day for Catatonic Schizophrenia, started on 7/4/2023. A review of Resident 44's Informed Consent form for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report a suspected allegation of resident abuse in a timely manner for two of two residents (Residents 196 and 24) when: 1. The alleged missing money of Resident 196 was not reported to the California Department of Public Health (CDPH, a state department responsible for public health in California), Adult Protective Services (APS) and Office of the Long Term Care Ombudsman ( LTCO, an advocate for residents of nursing homes, assisted living facilities, and other residential care communities) when it was first reported to the Social Services Director (SSD) on 11/18/2022; and 2. The alleged Resident/Patient/Client Abuse (Resident to Resident) incident on 12/31/22 was not reported to CDPH , Ombudsman , and Law Enforcement when the incident was first reported on 12/31/22 not until 1/3/23. When Resident 24 randomly struck another Resident on the face at the hallway while alleged victim was self-propelling in wheelchair. These failures had the potential to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a baseline care plan to include instructions on care of oxygen use for one of three residents (Resident 190). This failure resulted in improper level of oxygen administration for Resident 190 and had the potential to result in oxygen toxicity such as lung damage. Findings: Review of Resident 190's admission Record indicated, Resident 190 was admitted to the facility on [DATE] with diagnoses including displaced (the pieces of the bone moved so much that a gap formed around the broken bone) supracondylar fracture of left femur (when the thigh bone is broken at the knee), morbid obesity (a person weighing more than 100 pounds over the ideal weight for men and 80 pounds for women) and obstructive sleep apnea (a common sleep disorder that causes breathing to pause during sleep due to a blocked or narrowed airway). Review of Resident 190's physician's order dated 8/2/2024, indicated, Oxygen @ [at] 0.5 liter/min [liter per minute] via…

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 proper care and treatment services for oxygen (O2) was provided for three of three sampled residents (Residents 190, 18 and 36) when: 1.Resident 190's physician'a order for oxygen administration was not followed and the Oxygen in Use sign was not visible to all passersby (staff, residents and visitors); 2.Resident 18's physician's order for oxygen administration was not followed; and 3.Resident 36's physician's order for oxygen administration was not followed. These failures had the potential to result in complications related to improper treatment while receiving O2 therapy. Findings: 1a. Review of Resident 190's admission Record indicated, Resident 190 was admitted to the facility on [DATE] with diagnoses including displaced (the pieces of the bone moved so much that a gap formed around the broken bone) supracondylar fracture of left femur (when the thigh bone is broken at the knee), morbid obesity (a person weighing more…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of the bed) for 2 of 24 sampled residents (residents who used bed or side rails), (Residents 39, and 78) when: 1. There was no physician orders obtained prior to the use of bed rails for Residents 39 and 78; 2. There was no side rail assessment completed prior to the use of side rails for residents 39 and 78; and 3. There were no side rail care plans for Residents 39 and 78. These failures had the potential to place the residents at risk of entrapment and serious injury. Findings: 1. During an observation on 8/12/24 at 10:15 a.m., inside Resident 78's room, Resident 78 was seated on a wheelchair and her bed was observed with 1/4 bilateral siderails. Review of Resident 78's Side Rails Utilization Assessment, dated 7/18/24, indicated there was no documentation and was blank. There was no physician's order for side rails, and care plan regarding the use of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide sufficient social services for one out of three sampled residents (Resident 44) when follow up psychological evaluation was not arranged. This failure had the potential to result in unmet psychosocial care needs. Findings: A review of Resident 44's face sheet (a document that includes pertinent resident information and medical diagnoses) indicated, Resident 44 was admitted on [DATE] with diagnoses including Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and catatonic schizophrenia (a rare and severe mental disorder that's characterized by extreme changes in movement, behavior, and communication). During a concurrent interview and record review on 8/14/24 at 11:42 a.m. with the Interim Director of Nursing (IDON), IDON confirmed there was only one psychological evaluation done for Resident 44 since admission. IDON confirmed the only psychological evaluation recorded on Resident 44'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 interview and record review the facility failed to ensure one of two sampled residents (Resident 46) was free from unnecessary medication when the facility failed to provide sufficient documentation to support a diagnosis of Dementia (decline in mental capacity affecting daily function) with psychotic (A mental disorder characterized by a disconnection from reality) disturbance m/b (manifested by) paranoia (An unrealistic distrust of others or a feeling of being persecuted) in one of two sampled residents for unnecessary medication (Resident 46.) This deficient practice increased the risk of Resident 46 to receive unnecessary medication. Findings: During a review of Resident 46's admission Record on 08/14/24 at 02:11 p.m., indicated, Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses includes Hemiplegia (one-sided weakness) and Hemiparesis (one-sided paralysis), Depression unspecified (constant feeling of sadness and loss of interest, which stops you doing normal…

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 had a medication error rate of 5.88% when two medication errors occurred out of 34 opportunities during the medication administration for one of four residents (Residents 58). Residents 58 did not receive the medications as ordered. These failures resulted in medications not given according to the physician's orders and had the potential for Resident 58 not receiving the full therapeutic effects of the medications. Finding: 1. During a medication administration observation and interview on 8/13/24 at 9:35 a.m., with Licensed Vocational Nurse (LVN) C, she was observed giving several medications to Resident 58 including a bottle of Zaditor Ophthalmic Solution (Ketotifen Fumarate (Ophth) Eye drops. Upon checking the medication, she verified there was no open date on the Zaditor eye drop. She confirmed the eye drop should have an open date on the bottle of the eye drop. LVN C further stated she will inform and ask the physician to give a new order for Zaditor. During a review of Resident 58's physician's order dated…

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

Based on observation and interview, the facility failed to ensure the dietary staff had the appropriate competencies and skills set to carry out the functions of the food and nutrition services when: 1. A pair of tongs with visual residues was found in the kitchen drawer; 2. Dietary cook E (DC E) was not able to state the cool down process; and 3. Dietary aide G (DA G) did not demonstrate the correct process of checking the chemical sanitation concentration of the dish machine. These failures had the potential to negatively impact the facility's ability to ensure foods were prepared in competent and efficient manners that prevent food borne illnesses. Findings: 1. During the initial kitchen tour on 8/12/24 at 9:32 a.m. with Registered Dietician (RD) and Dietary Supervisor (DS), a pair of tongs with residual substance was found inside a kitchen drawer. DS stated it should not be stored in the drawer if there were visible residual substance. DS then took the pair of tongs and asked another staff to have it washed. A review of facility's policy and procedure (P&P) titled Sanitization…

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 recipe was followed for puree diet. This failure had the potential to not meet adequate nutritional value and nutritional requirements for the residents. Findings: During a concurrent observation and interview on 8/13/24 at 11:42 a.m. in the facility kitchen with Dietary Aide (DA) F and Registered Dietician (RD), DA F was preparing pureed bread. DA F put a cut whole loaf of bread in the food processor machine. DA F then transferred the processed bread in a rectangular steel container. DA F brought the metal container under the hot water machine and let the water run onto the container. When DA F was asked how much water must be added onto the mixture, DA F stated, I don't measure water. RD stated Typically, we have a recipe, but we are also watching for consistency. A review of facility provided menu for Pureed Bread indicated, Scratch method: Place portions of bread/margarine into a food processor, process to fine crumbs. For every 5 portions needed, add 1 cup of warm milk or water .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to store, prepare, and distribute food safely when: 1. Ground beef was not submerged in water during the thawing process; 2. Cooked potatoes (a potentially hazardous food capable of supporting bacterial growth associated with foodborne illness) were not logged for proper cool down; 3. Resident refrigerator contained multiple food items beyond the discard date; and 4. Cups and mugs used to serve resident drinks were stored stacked and wet; These failures had the potential to cause food Borne illness to a highly susceptible population of 76 residents who received food from the kitchen. The facility census was 80. Findings: 1. During concurrent observation and interview on 5/2/22 at 12:36 p.m. in the kitchen with food service worker (FSW) K, three, five-pound chubs of ground beef were observed in a plastic container in the sink with cold water running over them. The chubs were not fully submerged in the water. FSW K stated she was defrosting 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 interview and record review, the facility failed to ensure proper communication with the dialysis (a treatment that does some of the things done by healthy kidneys) Center for two of seven residents (Residents 46 and 41) who get dialysis treatments, when the dialysis communication forms were not completely filled out. This failure had the potential to result in a lack of knowledge of the residents' health status. Findings: Resident 46 was admitted with diagnoses which included end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis), chronic kidney disease (a gradual loss of kidney function) type 1 diabetes (increase blood sugar), and resident's non-compliance with renal dialysis. 1. During a review of Resident 46's dialysis communication forms, the forms indicated: a. the form dated 5/2/22 did not have a post-dialysis assessment; b. the form dated 4/20/22 did not have vital signs post-dialysis and no post-dialysis assessment; c. the form dated 4/29/22 had…

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

Based on observation, interview and record review the facility failed to ensure the planned menu was followed when: 1. Seven of seven residents (Residents 19, 20, 30, 46, 54, 56, and 63) on a renal diet (renal diet is one that is low in sodium, phosphorous, and protein, limit potassium and calcium) did not receive rice and one received potatoes; 2. One of one resident (Resident 72) on a vegan diet did not receive planned menu items and received foods that were not on the menu including foods with milk and chicken, 3. [NAME] beans were served instead of seasoned beans as indicated on the menu during the lunch meal on 5/2/22, and, 4. Portion size was not followed for seasoned greens during the lunch meal on 5/2/22. Theses failures had the potential to result in the facility not meeting the nutritional needs of the residents and compromising their nutritional status. Seventy-six residents received meals from the kitchen. The resident census was 82. Findings: 1.a. During a review of the facility's menu titled, Therapeutic Spreadsheet dated 5/2/22, the lunch menu indicated for Liberal…

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 essential kitchen equipment was maintained in a safe operating condition when: 1.The produce refrigerator was not maintaining temperatures below 41 Fahrenheit (F); the oven temperature dial did not contain numbers or markings for the temperature setting; and the plate warmer handle was detached from the lid on one side. These failures had the potential to cause equipment to not be functionally safe and impact the ability of the equipment to operate as intended or cause contamination of food, leading to foodborne illnesses. Findings: 1.a. During an observation on 5/2/22 at 9:17 a.m. in the kitchen during the initial tour, the plate warmer cover handle was broken. One side of the handle was not attached making it difficult to lift the lid. 1.b. During an observation on 5/2/22 at 9:38 a.m. in the kitchen during the initial tour, the left oven temperature dial had no numbers or markings to indicate the temperature setting. During a concurrent interview with food service worker (FSW) B, FSW B confirmed there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement their policies on medication self-administration (resident takes medication without staff assistance) and bedside medication storage for one of 18 sampled residents (Resident 15) when: 1. The facility did not determine that the resident was clinically appropriate and safe to self-administer medications; 2. The facility did not ensure self-administered medications were stored in a safe and secure place; 3. The facility did not remove an expired medication from the resident's bedside; 4. The facility did not obtain a physician's order to store medications at bedside; and 5. The facility did not develop care plans to address self-administration of medications or bedside storage of medications. These failures had the potential to result in unsafe medication self-administration. These failures also had the potential to result in other residents gaining unapproved access to the medications. Findings: Review of Resident 15's medical…

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 three of 18 sampled residents (Residents 227, 20 and 226) received necessary and proper care and services when: 1. For Resident 227, licensed vocational nurse D (LVN D) did not give the medication per physician's order; 2. For Resident 20, LVN did not wear gloves during administration of insulin (used to treat high blood sugar) by subcutaneous (SC, under the skin) injection; and 3. For Resident 226, the facility failed to develop a care plan (a document which communicates and directs the care and services, including goals and interventions, required to meet residents' needs and recognizes potential needs or risks) related to resident's pain and change of condition on 1/14/2022. These failures could affect the residents' health and individualized care and services provided while in the facility. Findings: 1. Review of Resident 227's clinical record with diagnoses of Diverticulitis of intestine (infection or inflammation of pouches…

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 arrange podiatry (medical specialty concerned with the care and treatment of the foot) services for two of 18 sampled residents (Residents 43 and 64). This had the potential to affect the residents' physical and psychosocial health and well-being. Findings: 1. During a concurrent observation and interview on 5/5/2022 at 10:52 a.m., while in the resident's room. Resident 43 was alert and oriented and was sitting on the edge of the bed. Resident 43 stated his toenails on both feet were so long and thick that it is hard to walk comfortably. Resident 43's had long, thick and discolored toenails on both feet. Resident 43 stated he reported it to the staff (could not remember their names) about his long, thick toenails. During an interview with the director of nursing (DON) on 5/6/2022 at 09:16 a.m., the DON stated if the resident requested podiatry services, facility staff should notify the social worker or the DON via email, then the resident…

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 provide the appropriate services for two of 18 sampled residents (Residents 29 and 72) who had a gastrostomy tube (GT, tube surgically placed through the abdomen and into the stomach to administer nutrition, hydration and medications) when: 1. For Resident 29, licensed vocational nurse J (LVN J) did not check the GT placement and did not raise the head of the bed during feeding, and 2. For Resident 72, staff did not label and date the GT feeding formula bag. Findings: 1. Review of Resident 29's medical record indicated with diagnoses of nontraumatic intracerebral hemorrhage (refers to bleeding into the substance of the brain in the absence of trauma or surgery), diabetes mellitus (high blood sugar), and gastro-esophageal reflux without esophagitis (when stomach contents and acids back up into the esophagus). During an observation and interview with LVN J on 5/4/2022 at 2:07 p.m., while in the resident's room. Resident 29 was lying in bed,…

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.

2. Review of Resident 62's Order Summary Report indicated, Oxygen at 3 LPM via NC continuously. During an observation on 5/2/2022 at 9:10 a.m., Resident 62 was lying in bed and was receiving oxygen at 3 LPM via NC connected to an oxygen concentrator machine (a type of medical device used for delivering oxygen to individuals with breathing-related disorders). There was no Oxygen in Use sign posted at the door or in the resident's room. Review of the facility's policy titled Oxygen Administration, revised 10/2010 indicated, Place an 'Oxygen in Use' sign on the outside of the room entrance door. Based on observation, interview and record review, the facility failed to follow their oxygen administration policy for one of 18 sampled residents (Resident 54) and one non-sampled resident (Resident 62) when staff did not place an Oxygen in Use sign outside the entrance to the residents' rooms. This failure had the potential to compromise the residents' safety. Findings: 1. Review of Resident 54's medical record indicated he had a physician order, dated 3/30/22, for oxygen at 3 liters per…

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 upon consultant pharmacist reports for two of 18 sampled residents (Residents 39 and 27). This failure had the potential to negatively affect the residents' health and well-being. Findings: 1. Review of Resident 39's medical record indicated he was admitted on [DATE] and had the diagnosis of major depressive disorder (a mood disorder that causes persistent feelings of sadness or loss of interest). Further review of the record indicated Resident 39 had a physician's order dated 12/15/19, for Duloxetine (medication used to treat depression) 60 milligrams (mg, unit of dose measurement) one capsule by mouth two times a day. Review of Resident 39's Note to Attending Physician/Prescriber, dated 2/12/22, indicated for Duloxetine 60 mg BID (two times a day), Per Federal CMS guidelines, gradual psychotropic [medications that affect the mind, emotions and behavior] dose reductions should be attempted in two separate quarters within the first year (with 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 ensure that medications were stored safely and properly when: 1. Two of two medication room refrigerators in Stations A and B were not kept locked; 2. Two of two Xalatan (Latanoprost, to treat high pressure inside the eye due to glaucoma) eye drops for Resident 23, and Resident 69 did not have an open date; and 3. One opened Humalog insulin (fast acting insulin) vial for Resident 228 did not have an open date. Findings: 1.a. During an initial observation of the medication room in Station A with the infection preventionist (IP) on 5/2/2022 at 9:03 a.m., the medication room refrigerator was not locked. The medication room refrigerator had controlled medications (drug or other substance that is tightly controlled by the government because it may be abused or cause addiction). IP stated the medication refrigerator should be locked. 1b. During another observation of the medication room in Station B, with the director of nursing (DON) on 5/2/2022 at 10:00 a.m., the medication refrigerator was not locked. There were…

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, staff interview, and facility document review, the facility failed to provide food in a form that meets the needs of two residents (Residents 31 and 45) on either mechanical soft (texture modified diet for people with difficulty chewing or swallowing) or ground meat diets when: a. Residents 31 and 45 received whole pork chops, and b. Resident 45 received two whole bean burritos. This failure had the potential to place residents on a mechanical soft or ground meat diet at an increased risk for choking. Findings: 1. During an observation of the lunch meal service starting on 5/2/22 at 11:38 am in the presence of dietary services supervisor N (DSS N), food service worker B (FSW B) placed a whole pork chop on Resident 45's plate. food service worker C (FSW C) placed the plate on a tray and put the tray in the meal delivery cart for delivery. Once the cart was full, FSW C rolled the cart out to the hall for delivery to residents. During a concurrent observation of Resident 45's plate and tray ticket (a form placed on each resident's meal tray with diet order, foods…

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 their antibiotic stewardship program (program intended to prevent the overuse of antibiotics) for one of 18 sample residents (Resident 54). Resident 54 received a course of antibiotics for pneumonia (a lung infection), but did not meet all the criteria that needed to be present for antibiotic use. This failure had the potential to increase the prevalence of multi-drug resistant organisms in the facility. Findings: Review of Resident 54's Progress Notes, dated 4/23/22, indicated he had intermittent (no continuous or steady) coughing and the doctor ordered a chest x-ray (procedure that produces images of the internal components of the chest). Review of Resident 54's Progress Notes, dated 4/24/22 indicated, Received xray result date of service 4/22/22, with impression of left lung base infiltrate (a substance in the left lung). Review of Resident 54's medication administration record (MAR) indicated he had a physician's order dated 4/24/22, for Amoxicillin-Pot Clavulanate (an antibiotic used to treat a variety of…

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