Extended Care Hospital Of Westminster

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two final sampled residents (Resident 7) reviewed for weight loss received the necessary services to maintain acceptable nutritional status. * The facility failed to notify Resident 7's physician and resident's responsible party, when Resident 7 experienced significant weight loss upon readmission to the facility. This failure had the potential to delay needed medical intervention, contribute to further nutritional decline, and increase the resident's risk for adverse health outcomes related to unaddressed significant weight loss.Findings: Review of the facility P&P titled Nutrition (Impaired) unplanned weight Loss- Clinical Protocol dated September 2012 showed the staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. The physician will review for medical causes of weight gain, anorexia and weight loss before ordering…

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, medical record review, and facility P&P review, the facility failed to ensure appropriate care and services were provided for the residents with GT for two of three final sampled residents (Residents 3 and 87) reviewed for the tube feeding management. * The facility failed to ensure LVN 3 administered diluted medications via GT by gravity flow as required, for Resident 3. * The facility failed to ensure Resident 87's enteral feeding formula and water feeding bag were changed within 24 hours per facility P&P and accepted standards. These failures placed the residents at risk for complications related to GT use, including tube dislodgement, gastrointestinal injury, contamination, or infection. Findings: 1. Review of the facility's P&P titled Administering Medications Through an Enteral Tube revised 11/2018 showed under the Steps in the Procedure section, to administer medication by gravity flow: pour diluted medication into the barrel of the syringe while holding the tubing…

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 medical record review, the facility failed to provide the necessary care for one of one resident reviewed for respiratory care (Resident 7). * The facility failed to ensure Resident 7's suction canister, tubing, and opened Yankauer suction was labeled. This failure had the potential for Resident 7 to not receive appropriate respiratory care and increase risk of infection.Findings: On 5/19/26 at 1007 hours, during an observation in Resident 7's room, the suction canister connected to the suction tubing was observed on top of the drawer located on the right side of the resident's bed. The suction tubing contained yellowish fluid. The suction tubing was connected to a Yankauer, which was stored inside the top shelf of the drawer. The Yankauer was stored in an opened original package. The suction canister, suction tubing, and Yankauer were not labeled to indicate the date they were last changed. Resident 7 was not present in the room at the time of the observation. On 5/19/26 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, facility document review, and facility P&P review, the facility failed to ensure one licensed nurse reviewed for competency had specific competencies and standard of practice skill sets needed to provide safe and efficient nursing care. * The facility failed to ensure LVN 3 was able to competently administer the medications via GT (gastrostomy tube, a small tube placed through the abdominal wall into the stomach, used to provide enteral feedings and/or administer medications) to Resident 3. This failure had the potential to put the resident at risks for the care not provided in a safe and competent manner. Findings: Review of the facility's document titled Charge Nurse Job Description - Nursing Services dated 2003, showed the Charge Nurse must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities, must implement and maintain established nursing objectives and standards, and must be able to administer professional services such as: catheterization, tube…

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 provide the necessary pharmacy services to ensure proper storage of the medications in one of one medication storage room inspected. * The facility failed to ensure over the counter medications were stored in a locked compartment. This failure resulted in unauthorized staff having access to the medications.Findings: On 5/20/26 at 0900 hours, an observation and concurrent interview was conducted with the Central Supply Staff. When asked about the medication storage areas, the Central Supply Staff showed an unlocked, and easily accessible storage room located within the facility's administrative office building. Inside the unlocked storage area, multiple bottles of over-the-counter medications including bottles of aspirin, loratadine (antihistamine), artificial tears (eye drops), and arthritis pain medications were observed stored openly on a counter and inside an open box. When asked who had keys to the office building, the Central Supply Staff stated the Business Office Manager, Chief Financial Officer, Administrator, and…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed for 87 of 93 residents who received meals from the facility's kitchen. * The facility failed to ensure facial hair was covered in the food preparation area. * The facility failed to ensure the ice machine was not dirty. * The facility failed to ensure open food items were dated. These failures increased the risk of foodborne illness for the highly susceptible resident population of 87 residents who received meals prepared in the facility's kitchen.Findings: Review of the facility's Resident Matrix dated 5/19/26, showed 87 of 93 residents received meals prepared in the facility's kitchen. 1. Review of the facility's P&P titled Dress Code (undated) showed beards and mustaches (any facial hair) must wear beard restraint. On 5/19/26 at 0815 hours, during the initial tour of kitchen, an observation was conducted with Diet Aide 1. Diet Aide 1 was observed working in the food preparation area with uncovered facial hair. On…

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

Based on interview, facility document review, and facility P&P review, the facility failed to ensure residents in the TRC were offered suitable alternate meal choices in accordance with their food when refusing a planned meal. * The residents in the TRC were offered only nutritional supplement drinks when planned meals were refused. This failure had the potential to prevent the 45 TRC residents receiving meals from the facility's kitchen from meeting the residents' nutritional needs.Findings: Review of the facility's Census (undated) showed 45 residents resided in the TRC. Review of the facility's P&P titled Food Substitutions for Residents Who Refuse the Meal (undated) showed the residents will be provided a suitable nourishing alternate meal after the planned, served meal has been refused. Nursing personnel will ask any resident who does not eat his meal of food item as to why he is not eating and offers a food substitution in accordance with the resident's diet order. On 5/19/26 at 1115 hours, an interview was conducted with LPT 1 in the main dining room. LPT 1 stated if 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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medical record was complete and accurate for one of 19 final sampled residents (Resident 8). * The facility failed to ensure Section D of the POLST, and the Advance Directive Acknowledgement form were completed accurately for Resident 8. This failure had the potential to result in unmet care needs for the resident due to inaccurate medical information.Findings: Review of the facility's P&P titled Charting and Documentation dated 7/2017 showed documentation in the medical record will be objective (not opiniated or speculative), complete and accurate. Medical record review for Resident 8 was initiated on 5/20/26. Resident 8 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 8's H&P examination dated 12/18/25, showed the resident had no capacity to understand and make decisions. Review of Resident 8's POLST dated 3/15/22, shown under Section D -…

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, medical record review, and facility P&P review, the facility failed to properly obtain the informed consents for the use of bed exit alarms from the resident or responsible party for three of three sampled residents (Residents 1, 2, 3). * The facility failed to ensure Residents 1, 2, 3 had informed consent for the use of the bed alarm. This failure posed the risk for the residents and their responsible parties to not be informed of their treatment plan and the potential risks.Findings: Review of the facility's P&P titled Informed Consents revised 04/2024 showed each resident will receive in advance all information that is material to a decision to accept or refuse treatment and the resident has the right or accept or refuse any treatment or procedure. If a resident has a responsible person, that individual is informed and consent will be obtained from them. 1. Medical record review for Resident 1 was initiated on 11/3/25. Resident 1 was admitted to the facility on [DATE] and readmitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the staff provided care and promoted dignity and respect for two of 21 final sampled residents (Residents 31 and 45) and five nonsampled residents (Residents 17, 27, 28, 33, and 84). * CNA 1 was observed assisting Residents 31 and 84 with meals at the same time. In addition, CNA 1 was observed assisting Resident 31 and 17 with meals at the same time. * CNA 2 was observed assisting 27 and 28 with meals at the same time. * CNA 3 was observed assisting Residents 33 and 45 with meals at the same time. These failures had the potential to negatively impact the residents' feelings of self-worth and well-being. Findings: Review of the facility's P&P titled Assistance with Meals revised 3/2022 showed the residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, by keeping interactions with other staff to a minimum while assisting residents with meals. 1. On 6/24/25 at 1230 hours, 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 4. Medical record review for Resident 397 was initiated on 6/24/25. Resident 397 was admitted to the facility on [DATE]. Review of Resident 397's admission Summary note dated 6/26/25 showed Resident 397 was admitted to the facility with diagnoses including bipolar disorder, anxiety disorder, and substance use disorder. Resident 397 had conservators to make medical decisions for him. Review of Resident 397's June 2025 Order Summary Report showed Resident 397 had the following orders dated 6/20/25: - buspirone (antianxiety medication) 10 mg by mouth twice daily for anxiety related to anxiety disorder - Haldol (antipsychotic) 10 mg inject intramuscularly as needed for any refusal of by mouth psychotropic medications for 14 days - Latuda (antidepressant) 80 mg by mouth in the evening for labile moods related to depression - Remeron (antidepressant) 30 mg by mouth at bedtime related to depression - Seroquel (antipsychotic) 100 mg every six hours as needed for increase psychosis related to bipolar disorder - Seroquel…

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 6. Review of the facility's P&P titled Psychiatric Pharmacy Policy dated 7/2/20, showed a standing order for Haldol (antipsychotic medication) 10 mg IM when residents refused to take any PO psychotropic medications. However, the policy did not mention nonpharmacological interventions that would be attempted prior to this standing order of residents refusing to take any PO psychotropic medications. Medical record review for Resident 397 was initiated on 6/24/25. Resident 397 was admitted to the facility on [DATE]. Review of Resident 397's admission Summary note dated 6/26/25, showed Resident 397 was admitted to the facility with diagnoses including bipolar disorder, anxiety disorder, and substance use disorder. Resident 397 had conservators to make medical decisions for him. Review of Resident 397's 6/2025 Order Summary Report showed Resident 397 had an order dated 6/20/25, for Haldol 10 mg, inject intramuscularly as needed for any refusal of by mouth psychotropic medications for 14 days. Further review 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 observation, interview, medical record review, and facility P&P review, the facility failed to develop the care plan problems for the residents' plans of care as evidenced by: * The care plans were not developed for 23 of 23 residents in the TRC unit who smoked. * The facility failed to develop the comprehensive person-centered care plans for two of 21 final sampled residents (Residents 1 and 67) addressing the disputes on closing and leaving their door open. These failures had the potential risk of not providing the appropriate, consistent, and individualized care to the residents Findings: Review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered revised 12/2016 showed a comprehensive person-centered care plan will incorporate identified problem areas. 1. Medical record review for the list of smokers in the facility was initiated on 06/24/25. Review of the facility's document titled List of Smokers dated 6/24/25, showed the facility had 23 smokers. Review of the plans of care 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 observation, interview, facility document review, and facility P&P review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests of one of 21 final sampled resident reviewed for activities (Resident 49). * The facility failed to provide Vietnamese cultural music and TV program in the room for Resident 49 as per activities assessment. This failure had the potential for the resident to experience feelings of social isolation and frustration. Findings: Review for facility's P&P titled Activity Programs revised 6/2018 showed the following: - Activity programs are designed to meet the interest of and support the physical, mental and psychosocial well-being of each adult; - Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident; and - Individualized and group activities are provided that reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 21 final sampled residents (Resident 49) remained free of accident hazards and four smokers were provided adequate supervision as evidenced by: * The facility failed to ensure the safety and supervision were provided during smoking times for four residents who were smoking. * The facility failed to ensure Resident 49's right floor mat was placed near the resident's bed. In addition, the facility failed to monitor resident's BP while lying, sitting and standing as per the care plan to address the fall that occurred on 5/21/25. Furthermore, Resident 49 was assessed to have changes from clear to rambling speech as per the neurocheck for the fall on 5/27/25; however, the facility failed to notify the physician for the changes in the resident's neurological status. These failures put the residents at risk for injuries. Findings: Review of the facility's P&P titled Designation of Smoking Areas and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for two of three final sampled residents (Residents 16 and 42) reviewed for GT feeding. * The facility failed to ensure the GT feeding formulas were not stored at bedside and the GT formula labels were accurate and matched the physician's orders for Residents 16 and 42. These failures posed the risk of misleading information on the residents' GT feeding rate and could lead to overfeeding or underfeeding, and storing a feeding formula at bedside posed a risk of contamination and spoilage, and increased risk of unauthorized access of the feeding formula. Findings: 1. Review of the facility's P&P titled Enteral Feedings - Safety Precautions revised 5/2014 showed to store unopened liquid enteral formulas in temperature and light-controlled conditions (cool, [NAME] from direct sunlight). The Preventing Errors in Administration section showed the following: - To check the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the adequate and appropriate pain management for two of three final sampled residents (Resident 20 and 67) reviewed for pain management. * The facility failed to ensure the pain medication was administered as per the physician's orders for Resident 20. * The facility failed to ensure the non-pharmacological pain interventions were implemented and documented before the administration of the PRN pain medication for Resident 67. These failures had the potential for residents not to receive the appropriate treatment for pain. Findings: Review of the facility's P&P titled Pain Assessment and Management revised 3/2015 showed pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Some…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the competency of the licensed nurses on obtaining and evaluating the orthostatic hypotension as evidence by: * The facility failed to provide in-services and conduct the competency evaluations for the orthostatic hypotension monitoring as verified by the DON. * The facility failed to ensure the competency of the licensed nurses (LVNs 1 and 3, and LPTs 1 and 2) in obtaining and evaluating for orthostatic hypotension. These failures had the potential to put the residents at risk for the care not provided in a safe and competent manner. Findings: Review of the facility's P&P titled Blood Pressure, Measuring revised 9/2010 showed orthostatic (postural) hypotension is defined as a 20 mm/Hg (or greater) decline in systolic blood pressure or a 10 mm/Hg (or greater) decline in diastolic blood pressure upon standing. Hypotension should be reported to the physician. 1. Review of the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration of the medications as evidenced by: * The facility's medication error rate was 3.85%. One of two licensed nurses (RN 1) who was observed during the medication administration was found to have an error. RN 1 failed to administer the complete dose of one of Resident 53's medications when significant residual of the medication was observed in the medication cup after RN 1 administered the docusate sodium (stool softener) to Resident 53. This failure had the potential to negatively impact the residents' health outcomes. * The facility failed to ensure the accurate reconciliation and documentation of the controlled medications for one nonsampled resident (Resident 748). This failure posed the risk of diversion of controlled medications and medication administration errors. Findings: 1. On 6/25/25 at 0905 hours, a medication administration…

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, facility P&P review, and facility document review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the orally administered medications were kept separate from externally used medications, e.g., suppositories, eye drops. This failure posed the risk for the occurrence of error in the medication administration. * The facility failed to ensure the refrigerator containing insulins, vaccines, and other medications requiring refrigeration was monitored daily to ensure the temperature was within the required range. This failure had the potential for the medication to lose the stability and effectiveness of the medication. * The facility failed to ensure the enteral formula (specialized liquid products that deliver nutrients directly to the gastrointestinal tract administered via tube feeding) and other oral nutritional supplements were stored in the room not exposed to excessive heat and freezing. This failure posed the risk of not providing 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, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure proper labeling and dating of food in the walk-refrigerator. * The facility failed to ensure the plate lowerator was clean. * The facility failed to ensure the walk-in freezer was free from ice build-up. * The facility failed to ensure proper backflow prevention under the dishwasher. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen. Findings: Review of the facility's document titled Order Listing Report showed 91 of 98 residents residing in the facility who received food prepared in the kitchen. 1. Review of the facility's P&P titled Labeling and Dating of Foods dated 2023 showed all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Newly opened food items will need to be closed and labeled with an open date and used by the date that follows the various…

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 P&P review, the facility failed to follow the facility's P&P regarding the use and storage of food brought to the residents by the family or visitors. In addition, the facility failed to ensure the staff were aware of the facility's P&P on safe food handling of outside food. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consume food brought from outside sources. Findings: Review of the CMS S&C-09-39 Food Procurement, and Self-Determination and Participation dated 5/29/09, showed the following: - The residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices; and - The facility has the responsibility under the food safety regulation to help visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees F. Review of the facility's P&P titled Foods Brought by Family/ Visitors revised 3/2022 showed…

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, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment; and prevent the transmission of diseases and infections for two of 21 final sampled residents (Residents 31 and 45) and six nonsampled residents (Residents 17, 27, 28, 33, 40, and 84). * The facility failed to ensure CNA 1 performed hand hygiene between assisting Residents 31 and 84 with meals. In addition, the facility failed to ensure CNA 1 performed hand hygiene between assisting Residents 31 and 17 with meals. * The facility failed to ensure CNA 2 performed hand hygiene between assisting Residents 27 and 28 with meals. * The facility failed to ensure CNA 3 performed hand hygiene between assisting Residents 33 and 45 with meals. * The facility failed to ensure LVN 2 performed hand hygiene before administering a nebulizer treatment for Resident 40. These failures posed the risk for transmission of disease-causing…

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 medical record review, the facility failed to provide the necessary services as ordered by the physician for one of eight sampled residents (Resident 6). * The facility failed to ensure the psychiatric evaluation and treatment were provided to Resident 6 as ordered. This failure had the potential for the resident not to receive the necessary care and services. Findings: Medical record review for Resident 6 was initiated on 7/5/24. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P Examination dated 5/13/24, showed Resident 6 did not have a capacity to understand and make decisions. Resident 6's diagnosis included senile dementia with psychosis. The H&P examination further showed Resident 6 needed a psychiatry follow up. Review of Resident 6's MDS dated [DATE], showed Resident 6's cognition was moderately impaired. Review of Resident 6's Order Summary Report showed a physician's order dated 5/10/24, for psychiatric evaluation and treatment with Physician 1.…

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, medical record review, and facility P&P review, the facility failed to ensure the post fall assessments were completed for two of two residents (Residents 4 and 5) reviewed for falls. * Resident 4's post fall neuro check assessment was not done. * Resident 5's post fall neuro check assessment was incomplete. These failures had the potential to delay the identification and response to post fall neurological changes. Findings: Review of the facility's P&P titled Assessing Falls and Their Causes revised March 2018 showed the After a Fall section includes the following: - If a resident had just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities; - Obtain record of vital signs as soon as it is safe to do so; - Observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall, and would document findings in the medical record; and - Document any observed signs or symptoms…

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, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the heavy-duty blender used for the puree preparation was air dried prior to use. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the ice machine utilized for the residents and staff was maintained in a sanitary condition. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were in good conditions. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. These failures had the potential to cause foodborne illnesses for the residents in the facility. Findings: Review of the facility's Resident Assessment Report (CMS-802) dated 5/20/24, showed 90 of 95 residents residing in the facility received food…

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, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control program designed to help prevent the development and transmission of diseases and infections. * The facility failed to implement their infection control surveillance program for the months of January through March 2024. The facility failed to conduct an accurate infection surveillance as per the McGeer's Criteria (a set of criteria used in long term care facilities to identify if residents' symptoms meet the criteria of a true infection). This failure posed the risk for not identifying infections and controlling the transmission of communicable disease to other residents throughout the facility. * The facility failed to ensure the infection control practices were maintained in the facility's laundry room area. This failure had the potential for cross-contamination. * The facility failed to ensure the staff (LVNs 3 and 4) performed hand hygiene during the medication administration per facility's P&P. This failure had 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, medical record review, and facility P&P review, the facility failed to offer PCV 15/PCV 20 (PCV 15 protects against two additional serotypes and PCV 20 protects against seven additional serotypes involved in cases of invasive pneumococcal disease (IPD) and pneumonia) immunizations for 11 of 19 final sampled residents (Residents 10, 16, 27, 29, 32, 37, 39, 40, 51, 52, and 54) and 47 nonsampled residents (Residents 1, 2, 3, 4, 6, 7, 8, 9, 13, 19, 21, 24, 25, 30, 33, 34, 36, 38, 41, 42, 43, 44, 45, 49, 50, 53, 56, 57, 58, 59, 60, 61, 62, 64, 65, 66, 67, 68, 70, 71, 73, 79, 83, 89, 448, and 449) reviewed for pneumococcal vaccination (a vaccine given to protect the resident from pneumococcal disease) in accordance with the CDC's recommendations. This failure increased the residents' risk for being inadequately vaccinated for the pneumococcal disease and its associated complications. Findings: According to https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, there are two types 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 medical record review, the facility failed to ensure one of 19 final sampled residents (Resident 20) received a timely Level II Mental Health Evaluation for suspected mental illness. * Resident 20's initial Level 1 PASRR screening conducted on 3/20/23, was positive for mental illness and required a Level II mental health evaluation. However, Resident 20 was not available for her Level II mental health evaluation, as Resident 20 was on isolation as a health/safety precaution. When Resident 20 was no longer isolated, the facility failed to submit another Level 1 PASRR screening (as indicated on Resident 20's Unable to Complete Level II Evaluation report dated 4/10/23). Approximately one year after Resident 20's initial Level 1 PASRR screening was conducted (3/20/23), the facility then conducted another Level 1 PASRR screening (on 3/29/24) which again required Resident 20 to receive a Level II mental health evaluation, which Resident 20 received on 4/2/24. After Resident 20 received her Level…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure three of 19 final sampled residents (Residents 37, 16, and 51) attained and maintained their highest practicable well-being. * The facility failed to coordinate the care of Resident 37 with the contracted hospice. The hospice calendar and the sign-in/out forms did not show complete skilled nursing and CHHA visits were provided as per the physician's orders. In addition, the nursing clinical notes, and hospice aide notes were not updated. These failures had the potential for the residents to not receive appropriate hospice care and services. * The facility failed to ensure Resident 16's medication order for Lantus solution (Insulin glargine, a long-acting, synthetic insulin, work by replacing the insulin that is normally produced by the body and by helping move sugar from the blood into other body tissues where it is used for energy) 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, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled residents reviewed for the use of side rails (Resident 20) remained free from accident hazards due to the use of elevated side rails. * The facility failed to attempt alternatives prior to the use of elevate side rails for Resident 20. This failure had the potential to place the resident at risk for entrapment and serious injury. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related…

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 facility document review, the facility failed to have an RN on duty for at least eight consecutive hours a day. This failure has the potential for the residents' clinical needs not being met either directly by the RN or indirectly by the licensed nurses for whom the RN was responsible for overseeing resident care. Findings: On 5/22/24 at 1524 hours, an interview and concurrent facility document review was conducted with the IP. When asked about the facility direct care staffing, the IP stated the DSD who was responsible for the nursing staffing was on leave, so she had to take over. On 5/22/24 at 1549 hours, an interview and concurrent facility document review was conducted with the Social Worker. The Social Worker for the SNF stated she was responsible for reporting and submitting the staffing report. The Social Worker for the SNF stated she keeps the CMS PBJ Staffing Report and the Nursing Sign-in sheets. Review of the facility's document titled Nursing Sign-in sheets for October through December 2023 for the SNF showed the following: - On 10/14/23, did 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.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to meet the need of the residents. * The facility failed to ensure the quantities documented for the discontinued controlled medications matched the quantities of the medication bubble pack and/or bottle. In addition, the facility failed to document one discontinued controlled medication on the Discontinued Controlled Drug Log sheet. * The facility failed to ensure the two discontinued controlled medications were documented on the Discontinued Controlled Drug Log sheet for the TRC. These failures had the potential for drug diversion (illegal distribution or abuse of prescription drugs). Findings: Review of the facility's P&P titled Discarding and Destroying of Medications revised 10/2014 showed the medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances. The medication disposition record will contain the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure one of five final sampled residents reviewed for unnecessary medications (Resident 18) were properly monitored for the medications. * Resident 18 was administered Norvasc (amlodipine besylate, a medication used to treat high blood pressure) when Resident 18's pulse was below the parameter prescribed by the physician. This failure had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 18 was initiated on 5/21/24. Resident 18 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of Resident 18's H&P examination dated 1/18/24, showed Resident 18 had no capacity to understand and make decision. Review of Resident 18's Physician Order Summary Report dated 5/22/24, showed a physician's order dated 2/8/24, to administer Norvasc 5 mg by mouth in the morning and hold for the systolic blood pressure below 90 mmHg, diastolic pressure less than 60 mmHg, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure three of six final sampled residents reviewed for the use of psychotropic medications (Residents 3, 18, and 54) were free from the unnecessary psychotropic medications. * The facility failed to ensure Residents 3 and 54 were properly monitored for orthostatic blood pressures (measure the blood pressure while laying down or sitting and again upon standing up) as ordered by the physician for the use of the Seroquel (antipsychotic medications). * The facility failed to ensure Resident 18's episodes of behavior for the use of Abilify (antipsychotic medication), Seroquel (antipsychotic medication), Zyprexa (antipsychotic medication), Lithium carbonate (antipsychotic medication), Buspar (antianxiety medication), and Prozac (antidepressant medication) were summarized on the monthly basis to serve as reference for the gradual dose reduction. The monthly behavior summary was not completed related to Resident 18's use of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were safely and securely stored. * The facility failed to ensure Resident 32's insulin pen was properly labeled. * The facility failed to ensure the safe storage of the insulin pen for Resident 32. * The facility failed to ensure the staff reported to the licensed nurse when Resident 53's medicated patch came off. * The facility failed to ensure Medication room [ROOM NUMBER] did not have expired containers of Sani-Hands sanitizing wipes. * The facility failed to ensure the SNF Medication Cart 2 was secured and locked. These failures had the potential to result in unsafe medication administration, and posed the risk of unauthorized access to the medications and undermining the efficacy of the sanitizing wipes. Findings: Review of the facility's P&P titled Storage of Medications revised 4/2007 showed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall…

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, medical record review, and facility P&P review, the facility failed to ensure the laboratory test for one of the 19 final sampled residents (Resident 18) was completed as ordered by the physician. * The facility failed to ensure TSH blood test was completed for Resident 18 as ordered by the physician. This failure posed the risk for undetected blood test abnormality which could significantly impact the resident's well-being. Findings: Review of the facility's P&P titled Lab and Diagnostic Test Results - Clinical Protocol revised September 2012 showed the physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. Medical record review for Resident 18 was initiated on 5/21/24. Resident 18 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of Resident 18's H&P examination dated 1/18/24, showed Resident 18 had no capacity to understand and make…

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, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurately maintained for two of 19 final sampled residents (Residents 20 and 40). * Resident 40 was transferred to the acute care hospital. Resident 40's medical record failed to show documentation for Resident 40's change of condition which required a transfer to the acute care hospital. * Resident 20's POLST failed to show documentation as to whether Resident 20 had formulated an advance directive. These failures had the potential for the residents' care needs not being met as the medical record was incomplete. Findings: 1. Medical record review for Resident 40 was initiated on 5/20/24. Resident 40 was admitted to the facility on [DATE]. Review of Resident 40's physician's order dated 5/22/24 1918 hours, showed an order to send Resident 40 out to Acute Care Hospital 1. Further review of Resident 40's medical record failed to show documentation specific to Resident 40's change of condition…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure a designated IDT member was appointed to coordinate care between the facility and hospice agency for one of one final sampled resident reviewed for hospice services (Resident 37). This failure had the potential to put the resident on hospice services at risk of uncoordinated medical care between the facility and the hospice agency. Findings: Medical record review for Resident 37 was initiated on 5/21/24. Resident 37 was admitted to the facility on [DATE], with a physician's order to be admitted to Hospice A's services. Review of the facility's P&P titled Hospice Program dated 7/2017 showed the facility has a designated hospice coordinator to collaborate with hospice representatives and coordinating facility staff participation in the hospice care planning process. However, the designated hospice coordinator information was blank. Review of Resident 37's Hospice Service Agreement between 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.