Watsonville Post Acute Center

Based on interview and record review, the facility failed to monitor the side effects related to the use of Apixaban (an anticoagulant [blood thinner] medication that interrupts the formation of blood clots) for one of 19 sampled residents (Residents 38). This failure had the potential to affect the residents' physical well-being while in the facility. Findings: During a review of Resident 38's Medical Record (MR), the MR indicated Resident 38 was admitted to the facility for multiple diagnoses that included hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side, and chronic atrial fabulation (an irregular and often very rapid heart rhythm). During a review of Resident 38's medical record, the physician orders, dated 1/6/23, indicated, Apixaban Tablet 5 milligrams (mg, a unit of measurement) via G-tube (a gastrostomy tube is a tube inserted through the belly that brings nutrition…

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 food items were not stored in the residents' refrigerator readily available for use when two boxes of Jevity (a calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition) was found unlabeled and expired in the residents' refrigerator. This failure had the potential to result in contaminated food and foodborne illnesses to an already vulnerable facility population. Findings: During a concurrent observation in the nurses' station and interview with the Director of Staff Development (DSD) on 3/6/24 at 9:31 a.m., two boxes of Jevity were observed in the residents' refrigerator. Both boxes had an expiration date of 12/1/2023 printed on the box. The DSD stated she did not think they were for anyone; the expiration dates should be checked. Review of the facility's policy and procedure titled, Resident Food Refrigerator, dated November 2023, indicated, Foods that are in their original containers and have not been opened will be kept per the manufacturer'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.

Based on observation, interview, and facility record review, the facility failed to ensure infection control practices were followed for one of three residents (Resident 293) when licensed vocational nurse A (LVN A) did not perform hand hygiene during medication administration. This failure had the potential for transmition of infectious agents to residents. Findings: During a medication pass observation with LVN A on 3/5/24 at 8:22 a.m., LVN A took the blood pressure of Resident 293 and sanitized the blood pressure cuff. LVN A proceeded to prepare Resident 293's medications. LVN A administered the medications to Resident 293 without performing hand hygiene. During an interview with LVN A on 3/5/24 at 8:37 a.m., she stated she should have sanitized her hands after taking the resident's blood pressure and before popping out the medicine. LVN A confirmed she did not perform hand hygiene. During an interview with the Nurse Supervisor (NS) on 3/7/24 at 9:43 a.m., the NS stated when a nurse is giving medication, they need to do hand hygiene between each task. Review of facility's policy…

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 competency of the two of two staff, the Registered Dietitian (RD) and the Dietary Services Supervisor (DSS), responsible for oversight of Food and Nutrition Services, when: 1. The RD did not provide consultation to the DSS regarding multiple kitchen sanitation issues (cross-reference F812); 2. The RD did not provide consultation regarding the palatability and consistency of food texture; 3. The DSS did not report multiple maintenance issues she was aware of including: a. a leaking reach-in refrigerator; and b. a reach-in freezer with significant ice build-up, 4. The DSS did not have a reliable system for ensuring staff cleaned according to the cleaning schedule; 5. The DSS and the RD did not ensure the juice machine was maintained in a clean and sanitary manner. 6. The DSS and the RD did not ensure sanitary handling of drinking ware, utensils, and ready to eat food. These failure had the potential for the functions of the Food and Nutrition Service not to be carried out in a safe and sanitary…

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 palatability and nutritive value of cooked foods were maintained when vegetables were cooked for an extended time. In addition, one resident (Resident 78) complained about food being overcooked. This failure had the potential to result in decreased palatability; leading to a decrease in food consumed by residents, and food cooked for extended time periods could lose nutritive value leading to a decreased nutrient intake for 90 residents who received food from the kitchen. Findings On 12/6/2021 at 9:21 a.m., during an observation and interview with [NAME] 1 and Dietary Services Supervisor (DSS), indicated pans in a hot oven covered with foil. [NAME] 1 stated the items in the oven were pureed meat and pureed vegetables cooking in the oven for lunch time. DSS stated the meat and vegetables were already cooked and fully heated and ready to place on the tray line that started at 11:45 a.m. [NAME] 1 and the DSS stated the vegetables were in the oven since 9:00 a.m. The DSS stated this is their kitchen'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.

Based on observation, interview, and record review the facility failed to ensure food was stored, prepared, and served in a sanitary manner when: a. The wood shelving under a preparation table was dirty and in poor condition; b. Cooking pans ready for use had a significant amount of residue build-up, were significantly scratched on the cooking surface, and had non-stick coating peeling off; c. The floor area around a reach-in refrigerator and under a preparation table had a significant amount of residue build-up and cobwebs; d. Knives for food preparation had residue on the blades, the blades came into contact with dirty wire covers, and were stored directly under an insect killer machine which had a fly on the surface; e. A significant amount of grime was in the grooves of the rubber gaskets (a rubbers seal that on the door of the refrigerator to prevent leakage of cold from inside the refrigerator when the door is closed) of two refrigerator doors; f. The light switch into the dry food storage had residue build-up and had dirty tape on the surface; g. The wall in the dish washer…

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 proper upkeep, maintenance, and safe operating conditions of the kitchen appliances: 1. dairy reach-in refrigerator 2. multi-door reach-in freezer These failures had the potential to attract pests (cross-reference F-925) and impact the ability of the equipment to operate as intended leading to improper storage of food resulting in food that is not safe and/or poor quality for 90 residents who received food from the kitchen. Findings: 1. During an observation on 10/6/2021 at 9:48 a.m., the reach-in refrigerator that held dairy products, located next to the food preparation sink and the entry to the dry food storage, was observed to have a moist grime build up around the front of the refrigerator that would wipe off with paper towel. The DSS stated the grime was rust because the refrigerator leaked. During an observation and concurrent interview with the Dietary Services Supervisor (DSS), on 12/10/2021 at 9:54 a.m., the DSS stated the dairy refrigerator leaked .on and off since October 2021. She said…

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 an effective pest control program to ensure a pest free environment when the facility had flying black bugs in the kitchen. This failure had the potential to cross-contaminate food and utensils leading to illness for 90 residents who received food from the kitchen. Findings During observation on 12/6/2021 at 9:39 a.m., a small black fly was observed on the underside of the bug extermination machine, which was mounted above the clean, ready for use, knives. During an observation and concurrent interview on 12/6/2021 at 9:45 a.m., with the Dietary Services Supervisor (DSS), she showed a reach-in refrigerator holding dairy products had a significant amount of thick residue at the base of the front, near the floor. The thick residue was orange, brown, and black in color. It was sticky and moist and was removable with a paper towel. The DSS stated it was rust because the refrigerator was leaky. During observation on 12/7/2021 at 10:08 a.m., five small flies were observed on water pitchers. During…

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 an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care when the individual is incapacitated) or Physician Orders for Life-Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) was available and completed for five of five residents (8, 33, 54, 282, and 283) reviewed under the advance directive care area. These failures had the potential to result with inability to make medical decisions when residents cannot make for themselves and could lead to the delivery of unnecessary or inappropriate medical services, which are against the resident's goals and wishes. Findings: Review of Resident 8's admission record indicated he was admitted on [DATE] with a diagnosis including diabetes mellitus (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the State Long-Term Care Ombudsman (Ombudsman) when six of six sampled residents (Residents 46, 30, 68, 33, 10, 52 and 33) were transferred to the hospital without notifying the Ombudsman. This failure had the potential to compromise the residents' admission, transfer, and discharge rights. Findings: 1. Review of Resident 46's electronic record indicated, Resident 46 had right shoulder pain after he had an unwitnessed fall on 11/2/2021. Resident 46 was transferred to the hospital for evaluation. 2. Review of Resident 30's electronic record indicated, Resident 30 had an unwitnessed fall on 9/29/2021 and was sent to the hospital because she had a left forearm bruise and her nose was swollen/bleeding. The diagnoses from the hospital included a diagnosis of forehead contusion (bruise), fractured (broken) nasal bone, right knee swollen, and skin abrasion (scrape) under right knee. 3. Review of Resident 68's electronic record indicated Resident 68 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for 10 of 18 sampled residents (Resident 33, 54, 282, 21, 48, 9, 70, 71, 76 and 14) when: 1. Resident 33, facility staff failed to address nail care, ensure oxygen (a colorless and odorless gas that people need to breathe) and diet order was administered as specified in the physician's order; and his indwelling catheter care plan was initiated timely; 2. Resident 54 did not receive his restorative nursing assistant treatment (RNA) as specified in the physician's order; 3. Resident 282 did not have a care plan for the use of oxygen; 4. A licensed staff crushed a medication without a physician's order for Resident 21; 5. Resident 48 did not have an initial care plan within 48 hrs from admission; 6. An extended release medication for Resident 9 was crushed; 7. Resident 70's call light was not within reach; 8. Resident 71's care plan was not…

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 fall management and interventions were evaluated and implemented to prevent further falls for four out of 18 sampled residents (Residents 36, 52, 54 and 283) when: 1. For Resident 36, neuro-checks (an evaluation to sensory and motor responses, reflexes to determine if the nervous system is impaired) were incomplete, interdisciplinary team (IDT, staff from different disciplines who work together to plan and provide care) did not discussed falls, OT evaluation was not implemented, no new interventions were implemented after a fall, there was no physician order for the use of soft padded helmet, postural hypotension was not monitored. 2. For Resident 52, medication regimen review (MRR, process of comparing medication), no fall risk assessment, and no evidence an IDT was done after a fall. 3. For Resident 54, failed to follow care plan and physician order for the use of floor mat. 4. Resident 283, failed to provide assistance to two…

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 pharmaceutical services to meet the needs of each resident when: 1. Failed to obtain and administer warfarin (Coumadin, a medication that can treat and prevent blood clots) for atrial fibrillation (a-fib, an irregular heartbeat that can cause poor blood flow) for one of 18 sampled residents (Resident 71). 2. An opened refrigerated emergency kit was not replaced timely. The deficient practice resulted in Resident 71 not receiving seven scheduled doses of the medication in October, 14 doses in November and seven doses in December 2021. An e-kit not being replaced in timely manner could put residents needs not being met. Findings: 1. Review of Resident 71's clinical record indicated he was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including a-fib, dementia (memory loss) and unspecified psychosis (abnormal thinking and perceptions). Review of Resident 71's physician order dated 12/24/20, 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 palatability and safety of cooked foods was maintained when pureed food was runny. These failures had the potential to impact all 19 residents on pureed diets in that it could result in a choking hazard (airway blocked by food), aspiration risk (when food or drink goes into the airway), and decreased palatability which could result in decreased intake and weight loss out of a facility census of 90. Findings: In an observation and interview on 12/6/2021 at 11:57 a.m., indicated [NAME] 1 plated food for resident lunches. He placed pureed food on the plates which went on the cart to serve then he added a powder to the pureed meat and mixed it up. He stated he added thickener because the meat was runny. After [NAME] 1 added the thickener to the pureed meat, the consistency was still very thin. It was noted that all the pureed diet tickets read Puree level 4. During observation and interview with the Registered Dietitian (RD), of the plating of the pureed food for lunch on 12/6/2021 at 12:02 p.m., it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff implemented the infection control practices when: 1. Licensed vocational nurse G (LVN G) brought a medication to Resident 132's bedside and handled the medication bottle with used gloves; 2. There were used gloves near the clean linen in room CC; 3. The curtain in room DD had a whitish discoloration; and 4. Oxygen tubing for Resident 282 was left uncovered . These failures had the potential to result in transmission of infection in the facility. Findings: 1. Review of Resident 132's clinical record indicated he had a jejunostomy tube (J-tube, tube placed through the skin into the small intestine for medication or nutrition). Resident 132 had an order for omeprazole (medication used to treat heartburn) suspension 20 milligrams (mg)/10 milliliters (ml) two times a day via J-tube. During an observation on 12/7/21 at 4:01 p.m., LVN G took Resident 132's bottle of omeprazole from the medication cart and placed it on Resident 132'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 the Minimum Data Set (MDS, a standardized assessment and screening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one resident (Resident 1). This deficient practice had the potential to result in the delay of resident assessments. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including cellulitis (inflammation of the skin) of right lower limb. A review of Resident 1's Discharge Assessment with Assessment Reference Date (ARD) dated 7/21/21, indicated Resident 1 was discharged to the community . During a concurrent interview and record review with the minimum data set nurse (MDSN) on 12/13/21 at 8:52 a.m., the MDSN confirmed Resident 1 was discharged on 7/21/21 and the MDS was exported. The MDSN stated she finished the Discharge Assessment on 9/21/21 and did not follow-up if Resident 1's MDS was accepted or not. Review of facility'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 accurately code the Minimum Data Set (MDS, an assessment tool) for two of 18 sampled residents (Residents 7 and 78) when the MDS did not reflect the current status of the residents. This failure had the potential to affect inappropriate care planning and intervention. Findings: 1. Review of Resident 7's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including encounter with palliative care (care aimed to optimized quality of life), secondary malignant neoplasm of bone (unusual cells growing in the bone), squamous cell carcinoma (skin cancer) Review of Resident 7's physician order dated 6/23/21 indicated to admit to [name of hospice]. During a concurrent interview and record review with the minimum data set nurse (MDSN) on 12/9/21 at 9:21 a.m., the MDSN confirmed Resident 7 was admitted to hospice on 8/10/2020. The MDSN reviewed the MDS and stated there was no significant changed done to the MDS. 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 accurately assess the preadmission screening and resident review report (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI) requires specialized services such as referral to a mental health authority) for two of 18 sampled residents (Residents 71 and 49). This failure had the potential to put the residents at risk for not receiving appropriate care and services. Findings: 1. Review of Resident 71's clinical record indicated he was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including major depressive disorder (persistent feeling of sadness and loss of interest) unspecified psychosis (abnormal thinking and perceptions). Review of Resident 71's PASSR dated 10/1/19, did not indicate a diagnosis of psychotic or psychosis disorder. During a concurrent interview and record review with the nursing supervisor (NS) on 12/7/21 at 4:21 p.m., the NS reviewed Resident 71's PASSR 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 and interview, the facility failed to post the daily nurse staffing number of hours ratios (PHPPD) in a prominent place, which was easily visible to all. This failure had potential to affect residents' care due to the lack of nursing working hours information. Findings: During an interview on 12/13/2021 at 9:28 a.m. with the staffing and central supply staff (CSS), CSS stated the PHPPD is posted in the back of the building. During an observation on 12/13/2021 at 10:21 a.m., accompanied by CSS, CSS pointed out where the PHPPD was posted, which was near the back entrance, which leads to the parking lot, near room [ROOM NUMBER]. During an interview on 12/13/2021 at 11:02 a.m. with the administrator (ADM), the ADM stated the PHPPD has always been posted by the back door, where the parking lot is located. Before COVID, that was where people entered the facility. Now the only entrance was the front door.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 18 sampled residents (Residents 10 and 52) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. For Resident 10, the facility failed to address the continued use of a PRN (as needed) psychotropic medication in a timely manner. The facility failed to ensure there was a specific duration of use for a PRN psychotropic medication that exceeded 14 days. 2. For Resident 52, Seroquel (medication used to treat mental/mood conditions) did not have specific manifestation and orthostatic hypotension was not monitored. These failures could result in lack of adequate monitoring and had the potential for the residents to receive unnecessary medications. Findings: 1. Review of Resident 10's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including encounter with palliative care (comfort care) anxiety disorder…

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 administer warfarin (Coumadin, a medication that can treat and prevent blood clots) for atrial fibrillation (a-fib an irregular heartbeat that can cause poor blood flow) for one of 18 sampled residents (Resident 71). This deficient practice resulted in Resident 71 not receiving seven scheduled doses of the medication in October, 14 doses in November, seven doses in December 2021 a period of 28 days and put the resident at risk for developing a stroke (damage to the brain from interruption of its blood supply). Findings: Review of Resident 71's clinical record indicated he was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including a-fib, dementia (memory loss) and unspecified psychosis (abnormal thinking and perceptions). Review of Resident 71's physician order dated 12/24/20 indicated, warfarin 5 milligrams (mg, unit of measurement) one tablet by mouth in the evening every Monday, Tuesday, Wednesday, Thursday, Saturday…

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 medications and biologicals were stored appropriately when a medication was left on Resident 34's bedside table and an unopened bottle of Latanoprost was not refrigerated. These failures had the potential to result in the access of medications by unauthorized personnel or residents and use of medications being used past the expiration date. Findings: 1. During an observation on 12/6/21 at 10:20 a.m., there was one tablet in a medication cup on Resident 34's bedside table. During a concurrent interview, Resident 34 stated she was going to take it last night but she fell asleep. During a concurrent interview, certified nursing assistant M (CNA M) confirmed there was a medication on Resident 34's bedside table and stated there should not be medication there. During an interview on 12/6/21 at 10:22 a.m., the director of nursing (DON) took the medication from Resident 34's bedside table and stated medication should not be left…

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 facility document review, the facility failed to ensure staff competency when one of four cooks (Cook 2) did not follow a recipe for the preparation of vegetables which were bland and not palatable. This failure had the potential a decreased intake of food for residents who ate food from the kitchen. Findings: On 12/7/21 at 12:30 p.m., due to resident food complaints (Cross-reference F804), a test tray to sample resident food was conducted in the presence of the Registered Dietitian (RD) and the Dietary Services Supervisor (DSS). The observation showed the regular mixed vegetables were mushy and bland, and the pureed vegetables were bland. The RD stated the vegetables could use more salt. In an interview on 12/7/21 at 12:50 p.m., [NAME] 2 stated she cooked the regular and pureed vegetables that day. She stated she took the frozen vegetables out of the box and placed them in the oven in a covered pan. She stated the only ingredient she added to the vegetables was butter. She said she placed the vegetables in the oven about 10 a.m., and they took…

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 one of five residents (Resident 48) were offered and/or received pneumococcal vaccinations. This failure had the potential to expose residents to pneumococcal infections (caused by common bacteria (streptococcus pneumonia) that can affect different parts of the body). Findings: Review of Pneumococcal Vaccination Consent Form dated 1/9/21 indicated, responsible party (RP, person who is accountable in making decision in behalf of the resident) consented for the PNA vaccine to be given. Review of the immunization list provided by the facility, indicated Resident 48 did not have the PNA immunization. During an interview with the infection preventionist (IP) on 12/13/21 at 12:11 p.m., the IP confirmed the PNA vaccine was not followed up. Review of the facility's policy, Pneumococcal Vaccine dated August 2016 indicated, All residents will be offered pneumoccoal vaccines to aid in preventing pneumonia/penumoccoccal infections.