Mission Palms Healthcare Center

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 revise the comprehensive, person-centered care plan for three of 19 final sampled residents (Residents 5, 11, and 87). * The facility failed to revise Resident 5's care plan when the order for Foley Catheter (a thin, flexible, indwelling tube inserted through the urethra - a tube that transports urine from the bladder to the opening of penis in male and vulva in female, into the bladder to drain urine into a bag, held in place by a small balloon) was discontinued. This posed the risk of not providing the resident with individualized and person-centered care. * The facility failed to revise the plan of care for Residents 11 and 87 to address the adjustments to the APP mattress settings made for the residents' comfort. This failure had the potential to result in inconsistent interventions and place the residents at risk for inadequate pressure redistribution and skin breakdown.Findings: 1. Review of the facility's P&P titled…

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 care and services for one of 19 final sampled residents (Resident 5). * The facility failed to identify and notify the physician and the resident's representative of Resident 5's eye redness with discharge. In addition, the facility failed to ensure the dark purplish discoloration on the resident's right dorsal (back side) hand and the light purplish discoloration on the left posterior lower arm were monitored and reported to the physician and responsible party. This failure had the potential for Resident 5 not to receive appropriate care and treatment.Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised May 2017 showed the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical / mental condition and or/status. The nurse will notify the resident's attending physician…

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 document review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for one of three final sampled residents (Resident 9) reviewed for pressure injuries. * The facility failed to ensure Resident 9's LAL mattress was used correctly and was not covered by an additional foam mattress topper. This failure had the potential to contribute to the development of new pressure injuries or worsening of existing pressure injuries for Resident 9.Findings: Review of the facility document titled Adapt Pro Elite Model 9200 User Manual showed the Adapt Pro Elite (type of LAL mattress) is intended to help and reduce the incidence of pressure sores while optimizing patient's comfort. Medical record review for Resident 9 was initiated on 4/21/26. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's H&P examination dated 3/11/26, showed the resident had the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure an appropriate pain management were provided for one of one final sampled resident (Resident 4) reviewed for pain management. * The facility failed to ensure the nonpharmacological interventions for pain management were provided before the administration of the pain medication for Resident 4. This failure had the potential to result in Resident 4 not receiving appropriate and comprehensive pain management.Findings: Review of the facility's P&P titled Pain Assessment and Management dated 3/2015 showed the purpose of the procedure was to help facility staff to identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address underlying causes of pain. Further review of the P&P showed nonpharmacological interventions may be appropriate alone or in conjunction with medications. Some non-pharmacological interventions include:- Environmental - adjusting…

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 the nursing staff demonstrated competency in providing care and identifying changes in condition for Residents 5 and 87. * The facility failed to ensure LVN 1 was competent in identifying eye redness with discharge in Resident 5 and notifying the physician and responsible party. * The facility failed to ensure LVN 2 was adequately trained and competent in the use of the APP machine for Resident 87. These failures had the potential to result in Residents 5 and 87 not receiving care and treatment in a safe and competent manner.Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised May 2017 showed the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical / mental condition and or/status. The nurse will notify the resident's attending physician or physician on call when there has been…

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 provide the necessary pharmacy services were provided to maintain proper medication storage for one of three medication carts (Medication Cart A) inspected. * The facility failed to ensure the orally administered medications were stored separately from the externally used medications. This failure had the potential to have negative impact the residents' well-being, and the potential for the medications to be contaminated, lose stability, and effectiveness.Findings: Review of the facility's P&P title Storage of Medications revised 4/2007 showed drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications. On 4/22/26 at 1400 hours, a medication cart inspection for Medication Cart A was conducted with LVN 3. The following was observed: - one box of alendronate sodium (medication use to treat or prevent thinning of the bone) 7 mg tablets and 11 individually packaged pantoprazole DR (medication use to treat acid reflux) 40 mg suspensions…

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 ensure safe food handling of food brought for the residents from outside sources. * The facility failed to ensure two staff (CNA 3 and LVN 5) were knowledgeable regarding the facility's P&P for food brought in by families or visitors. In addition, the facility failed to follow its P&P requiring outside food be stored in a designated unit to ensure safety. These failures posed the risk of the residents not being able to enjoy foods brought from outside in a safe and accessible manner.Findings: Review of the facility's P&P titled Use and Storage of Food Brought in by Family or Visitors revised 10/25 showed food was to be stored in a way to facilitate safety. Facility could store the food in a designated unit, and it was recommended the food was consumed within three days of preparation. On 4/22/26 at 1550 hours, an observation and concurrent interview was conducted with the DSS. When asked about the refrigerator used to store food for the residents brought in from outside, the DSS showed the walk-in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure coordination and consistency between the facility and hospice provider for one of one final sampled resident (Resident 13) reviewed on hospice services. * The facility failed to ensure the current frequencies of hospice staff visits as shown in the hospice plan of care were transcribed into Resident 13's physician's orders. In addition, the facility failed to ensure the hospice aide visit notes were maintained in the resident's medical record. These failures placed Resident 13 at risk for a breakdown in hospice care coordination and recordkeeping and could potentially result in delays in providing hospice care and services to Resident 13.Findings: Review of the facility's P&P titled Hospice Program revised 7/2017 showed the following:- In general, it is the responsibility of the facility to [NAME] the resident's personal care and nursing needs in coordination with the hospice…

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 the facility P&P review, the facility failed to ensure the essential equipment was maintained in safe and operating condition for one of three glucometers (a device which measures the amount of sugar in the blood) inspected. * The facility failed to ensure the glucometer in Medication Cart A was calibrated and had quality control testing performed on 4/21/26. This failure had to result in inaccurate blood glucose readings for the residents of the facility requiring blood glucose monitoring.Findings: Review of the facility's P&P titled Quality Control Testing on Assure Glucometer dated 10/1/23, showed quality control testing using the Assure Dose Control Solution will be performed to examine the performance of the Assure Blood Glucose Monitoring System. The Assure Dose Control Solution checks if the meter and test strips are working correctly as a system and if you are testing correctly. A control solution test should be performed every night. Review of the facility document titled Quality Control Record dated 4/2026 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.

Based on observation and interview, the facility failed to ensure for a safe and comfortable environment for the staff, vendors, and visitors as evidenced by: * The facility failed to ensure hot water temperatures at one kitchen handwash sink and the two compartment manual dishwashing sink were maintained at a safe and comfortable temperature level. This failure posed the risk of burn injuries to the staff, vendors, and visitors.Findings: Review of the State Operations Manual, Appendix PP Table 1, titled Time and Temperature Relationship to Serious Burns showed for a water temperature of 148 degrees Fahrenheit, the time required for a third degree burn to occur was two seconds. Further review of this table showed that for a water temperature of 150 degrees Fahrenheit, the time required for a third degree burn to occur was one second. On 04/21/26 at 1038 hours, the hot water from the kitchen handwash sink located near the DSS's office felt abnormally hot to the touch. Dietary Aide 1 verbalized the water was often very hot. The sinks inside the kitchen were observed with Caution - Hot…

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 two sampled residents (Resident 1) remain free from the accident hazards. * The facility failed to ensure Resident 1 was provided with two-person assistance for transfers. This failure had the potential to place the resident at risk for serious injuries. Findings: Medical record review for Resident 1 was initiated on 3/18/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Fall Risk Screen dated 3/7/25, showed Resident 1 was at high risk for falls and had a history of falls. Review of Resident 1's plan of care showed a care plan problem dated 3/8/25, addressing the resident's altered skin integrity. The interventions included to provide two-person assistance with transfers and positioning. Review of Resident 1's Nurse Weekly Progress Note dated 3/12/25, showed Resident 1 was dependent on the facility's staff for ADL care and required extensive assistance for transfers. On 3/17/25 at 0919 hours, CDPH, L&C…

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 six of six final sampled residents (Residents 11, 28, 32, 37, 44, and 685) reviewed for respiratory care were provided with the appropriate respiratory care and services when: * The facility failed to ensure Residents 11, 32, 37, 44, and 685 were receiving the correct rate of oxygen as per the physician's order. * The facility failed to ensure Resident 28's nebulizer set-up was changed weekly as per the facility's P&P. These failures had the potential to affect the respiratory health and well-being of the residents in the facility. Findings: Review of the facility's P&P titled Oxygen Administration revised October 2010 showed the staff member should verify that there is a physician's order for the oxygen administration and to review the physician's orders or facility protocol for oxygen administration. 1. On 2/4/25 at 1425 hours, during the initial tour of the facility, Resident 44 was observed awake…

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 ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure Dietary Aide 1 performed handwashing in between glove changes and performed proper hand hygiene and glove changes between dirty and clean areas during dishwashing. * The facility failed to ensure the rusty cooling steel racks were not stored with clean kitchen utensils. * The facility failed to ensure a spatula stored in a drawer had a smooth, easily cleanable surface. * The facility failed to ensure the plate lowerator and microwave were clean. * The facility failed to ensure kitchen employee belongings were not stored on a shelf used to store paper cups. * The facility failed to ensure the kitchen thermometers were calibrated properly. * The facility failed to ensure the sanitizing solutions in the sanitizer buckets were checked and documented. * The facility failed to ensure the food preparation area was clean 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 document review, the facility failed to maintain the infection control program and practices as evidenced by: * Room A did not have a receptacle to dispose of used or soiled gowns. * The infection surveillance logs failed to accurately document the infections in the facility. * Mapping for infections did not accurately reflect all the HAIs. * The facility failed to ensure Resident 44's nasal cannula was stored in a sanitary manner. * The facility failed to ensure the medication carts were kept clean. * The facility failed to ensure the facility staff followed the EBP for Resident 688 as per the physician's order. These failures posed the risk for transmission and development of disease-causing microorganisms. Findings: 1. On 02/4/25 at 1400 hours, during the initial tour of the facility, Room A was observed to be an Enhanced Barrier Precautions isolation room. Room A was observed without a receptacle to dispose of used gowns. On 02/4/25 at 1510…

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 medical record review, the facility failed to ensure the McGeer's Criteria for Infection Surveillance Checklist were completed for one of 20 final sampled residents (Resident 685) reviewed for antibiotic medication use. This failure posed the risk of the continued use of unnecessary antibiotics, potentially resulting in adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria. Findings: 1. On 2/7/25 at 1132 hours, an interview and concurrent medical record review for Resident 685 was conducted with the IP. The IP verified Resident 685 was administered two different antibiotics (azithromycin and cefepime) on 1/28/25 and one of the antibiotic (cefepime) dose was increased on 1/29/25. The IP verified she failed to complete the McGeer Criteria for Infection Surveillance Checklist to follow up on the use of the antibiotics. 2. On 2/6/25 at 1104 hours, an interview about the facility's infection control program was conducted with the IP. When asked how she was made aware of the infections in the facility, the IP stated she…

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

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 20 final sampled residents (Resident 389) was safe to self-administer the medications found at the bedside. * The facility failed to ensure the bottles of ibuprofen (NSAIDs), and Advil (NSAIDs), several tablets of alpha-chymotrypsin (a digestive enzyme supplement), a tube of arthritis relief pain ointment (NSAIDs), and a bottle of dry relief eye drops (used to relieve irritation and discomfort caused by dry eyes) were not at Resident 389's bedside table. Resident 389 stated she administered the medications herself, however, Resident 389 was not assessed for safe self-administration of medications per her admission assessment. This failure had the potential for Resident 389 to administer the medications inaccurately, the risk of adverse reactions from the medications, and negatively affect Resident 389's well-being. Findings: Review of the facility's P&P titled Medication - Self-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.

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 necessary care and services to attain or maintain the highest practicable well-being for two of three final sampled residents (Residents 7 and 685) reviewed for falls. * The facility failed to ensure Resident 685's post fall neurological assessment was accurately completed after the resident had an unwitnessed fall on 2/4/25. * The facility failed to ensure Resident 7's post fall neurological assessment was accurately completed after the resident had a fall on 1/23/25. These failures had the potential for a delay in providing care to these residents. Findings: 1. Review of the facility's P&P titled Neurological Assessment revised October 2010 showed under Documentation Information, the assessment data obtained during the procedure, should be recorded in the resident's medical record. Review of the facility's P&P titled Charting and Documentation revised July 2017 showed: - The medical record should facilitate…

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 necessary care and services were provided to prevent further falls and/or injuries for one two of three final sampled residents (Resident 7) reviewed for falls. * The facility failed to implement Resident 7's care plan interventions to address the resident's risk for falls, including the resident fall risk monitoring, star sticker to the resident's room, and colored arm band. This failure post the risk for the resident to sustain further falls and/or injuries. Findings: Review of facility's P&P titled Managing Falls and Fall Risk revised on 3/2018 showed the staff member will monitor and document each of the resident's response to interventions intended to reduce falling or the risks of falling. Medical record review for Resident 7 was initiated on 2/5/25. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's H&P examination dated 10/31/24, showed Resident 7 could make her needs known but could 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 interview, medical record review, and the facility P&P review, the facility failed to maintain the acceptable parameters for fluid intake for one of one final sampled resident (Resident 9) reviewed for hydration status. * The facility failed to ensure Resident 9 was monitored when her fluid intake was above the parameter as documented by the CNAs. In addition, the facility failed to ensure the I&O Record documentation was accurate. This failure had the potential for Resident 9 to have fluid overload and negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Intake and Output revised date 10/12/20, under the Procedures for Measuring Intake section, showed the following: - The CNA shall measure and record oral fluids taken by the resident during meals and during care; - The CNA shall inquire from the resident, family members, and/or visitors if the resident has consumed additional fluids and record the volume; - The licensed nurse shall measure oral fluids taken by 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 adequate monitoring for the signs and symptoms of bleeding to ensure two of four final sampled residents (Residents 39 and 84) reviewed for anticoagulant (prevents blood clots) medication use were free from unnecessary drugs. * Residents 39 and 44 were administered with apixaban (Eliquis, blood thinner medication) without monitoring for the signs and symptoms of bleeding. These failures had the potential for the residents to develop significant side effects of bleeding and negatively affect the residents' health condition and well-being. Findings: According to DailyMed, the most common clinically adverse effect of the Eliquis medication was the risk of serious and potentially fatal bleeding. Review of the facility's P&P titled Anticoagulation - Clinical Protocol revised November 2018 showed the facility staff member should assess for any signs or symptoms related to adverse drug reactions due to the medications…

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 (Resident 9) reviewed for unnecessary medications was free from the unnecessary psychotropic medication. * The facility failed to ensure the monitoring of Resident 9's meal intake related to the use of mirtazapine (antidepressant medication) medication was accurate. In addition, the facility failed to ensure the monthly behavior summary related to the use of mirtazapine medication was completed. These failures had to potential to result in unnecessary use and ineffective monitoring for the use of psychotropic medication that could negatively affect Resident 9's well-being. Findings: Medical record review for Resident 28 was initiated on 2/4/25. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's H&P examination dated 10/15/24, showed Resident 9 had the capacity to understand and make decisions. Review of Resident 9's Order Summary Report showed the following physician's orders: -…

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 for the safe storage of the medications and supplies. * The facility failed to ensure Medication Cart F was not left unlocked and unattended. In addition, the facility failed to ensure the containers of the bleach wipes were not stored with a box of tuberculin syringe. * The facility failed to ensure the vitamin A&D ointment (barrier cream/ointment) was not kept at Resident 9's bedside. * The facility failed to ensure the eye and rectal medications were not stored together. These failures had the potential to result in the unsafe administration of medications, and cross-contamination of the medications. Findings: 1. Review of the facility's P&P titled Storage of Medications revised 4/2007 showed the following: - Antiseptics, disinfectants, and germicides used in any aspect of resident care must have legible, distinctive labels that identify the contents and the directions for use, and shall be stored separately from regular…

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 menus were followed. * The pureed mixed vegetable was not the same as the regular mixed vegetable with tofu. * The pureed beef was not served with a ladle of sauce per the recipe. These failures had the potential for residents on pureed diet not receiving adequate nutrition, and negatively affect their well-being. Findings: 1. Review of the facility's Order Listing Report dated 2/4/25, showed 17 of 89 residents receiving foods prepared in the kitchen were on pureed diet. Review of the facility's P&P titled Menus revised 10/2017 showed deviations from posted menus are recorded (including the reason for the substitution and/or deviation) and archived. On 2/6/25 at 1018 hours, a pureed food preparation was observed with [NAME] 1, with the DSS present. [NAME] 1 was observed preparing the pureed mixed vegetables from a pan containing cooked broccoli, zucchini and carrots. There were cauliflowers nor tofu observed in the pan of cooked mixed vegetables. On 2/6/25 at 1145…

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 facility staff assisted the residents regarding the use and storage of food brought in by the family member or visitors for the residents. * The facility failed to ensure the safe handling and storage of food from outside sources to be included in the facility's P&P. This failure 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 Fahrenheit. Review 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 observations, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was promptly assessed and notified to the physician and responsible party after a COC was identified as per the facility's P&P. This failure had the potential for the resident to not receive adequate care and risk for adverse complications. Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised on 5/2017 showed the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The P&P also showed prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. The P&P further showed the nurse will notify the resident's Attending Physician or physician on call when there has been a(an):…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the proper administration, storage, and disposal of the medications in a safe manner as evidenced by the following: * The facility failed to ensure the medications were not left unattended. * The facility failed to ensure the discontinued medications were properly stored and disposed. * The facility failed to ensure the expired lemon glycerin swab sticks and used sterile wound dressing supplies were disposed from the treatment cart. These failures had the potential to cause unsafe handling and storage of the residents' medications. Findings: 1. Review of the facility's P&P titled Storage of Medications revised April 2007 showed the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. During an observation of Resident 58's room on 3/20/23 at 0845 hours, one medication cup containing seven medications observed unattended at Resident 58's bedside. During a concurrent interview with Resident 58, the resident was unable to…

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

Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the puree recipes were followed during the puree food preparation for 18 of 96 residents who received puree diets. This failure posed the risk for the inconsistent puree product which could alter the quality and nutrient content of the puree food for the residents receiving puree diets. Findings: Review of the facility's P&P titled Food Preparation dated 2018 showed the facility should prepared food by methods that conserve nutritive values, flavor and appearance. The facility will use approved recipes, standardized to meet the residents needs. The recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. 1. Review of the Stir Fry Vegetables, Puree dated 5/29/19, showed the ingredients for puree vegetables were as follows: five slices of wheat bread and four tablespoons of Margarine for ten portions. Instructions for puree vegetables included to add the margarine and bread while processing and process until…

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's P&P review, and facility document review, the facility failed to ensure the food preparation, storage, and sanitary requirements were met in the kitchen. * The facility failed to ensure the cutting boards were in the sanitary conditions. * The facility failed to ensure the meat slicer was in the sanitary conditions. * The facility failed to ensure that cooked items were properly stored, labeled, and dated. * The facility failed to ensure the temperature of beverages were checked prior distributing to the residents. * The facility failed to ensure the dietary staff maintained proper handling of dirty to clean plates and utensils. * The facility failed to ensure the dietary staff maintained proper hand hygiene. These failures had the potential to cause foodborne illness to a medically vulnerable resident population who consumed food prepared in the kitchen Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 3/20/23, showed 85 of 96 residents in the facility received food prepared in the…

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

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 20 final sampled residents (Resident 5) was informed and provided education on mirtazapine (an antidepressant that affects a person's mental state) and quetiapine (an antipsychotic that affects a person's mental state) use prior to signing the informed consent. This failure had the potential to violate the resident's rights to be fully inform of the psychotropic medications use for Resident 5. Findings: Review of the facility's P&P titled Informed Consent (undated) showed the facility must provide the information and obtain the consent for the use of psychotropic drugs (drugs that affect a person's mental state). Medical record review for Resident 5 was initiated on 3/20/23. Resident 5 was admitted to the facility on [DATE] with the diagnosis of chronic kidney disease and dementia. Review of Resident 5's Order Summary Report for the month of March 2023 showed the following: - An order dated 2/13/23, 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, medical record review, and facility P&P review, the facility failed to accommodate the individual needs and preferences for two of 20 final sampled residents (Residents 36 and 72) when the call lights button were placed out of the residents' reach. This failure could delay in providing the residents assistance to meet their needs. Findings: Review of the facility's P&P titled Call Light Answering dated 3/2010 showed to place the call device within the resident's reach before leaving the room and if the call light/bell is defective, immediately report this information to the unit supervisor. 1. Resident 72 was admitted to the facility on [DATE], with diagnoses including S/P right leg below knee amputation, DM, PVD, and general weakness. Review of Resident 72's MDS dated [DATE], showed Resident 72 had a BIMS Score of 14 (cognitively intact), needed extensive assistance from staff for bed mobility and transfers, and had ROM impairment on one side of lower extremity. On 03/20/23 at…

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

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 20 final sampled residents (Resident 5)'s care plan was developed to be comprehensive and person-centered to address Resident 5's psychotropic medication use. This failure had the potential to cause unnecessary use of mirtazapine and quetiapine for Resident 5. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Center revised December 2016 showed a comprehensive, person-centered care plan should be developed and implemented for each resident. Medical record review for Resident 5 was initiated on 3/20/23. Resident 5 was admitted to the facility on [DATE], with diagnosis of dementia. Review of Resident 5's Order Summary Report for the month of March 2023 showed the following: - an order started on 2/13/23, for mirtazapine tablet 7.5 mg at bedtime for depression manifested by poor food intake. - an order started on 2/13/23 for quetiapine tablet 25 mg at bedtime for psychosis manifested…

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 six nonsampled residents (Resident 4) was provided accurate doses of prescribed vitamin C (supplement). This failure had the potential to cause harm to Resident 4. Findings: Review of the facility's P&P titled Administering Medications revised December 2012 showed the dosage of a medication must be recorded in the resident's medical record. Medical record review for Resident 4 was initiated on 3/20/22. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis including pressure induced deep tissue damage to the left and right heels. On 3/21/23 at 0753 hours, during the medication observation, LVN 2 prepared one tablet of vitamin C 500 mg tablet to Resident 4. Review of Resident 4's Order Summary Report for the month of March 2023 showed an order started on 3/10/23, for vitamin C oral tablet (Ascorbic Acid) one tablet by mouth two times a day for supplement.…

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 one of 20 final sampled residents (Resident 5) was provided the comprehensive assessment and management for the use of psychotropic medications. * The facility failed to ensure the physician's assessment and diagnose of Resident 5 were completed and documented for the use of mirtazapine and quetiapine. * The facility failed to document the non-pharmacological interventions attempted prior to the administration of mirtazapine and quetiapine for Resident 5. These failures had the potential to cause harm to Resident 5. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated October 2017 showed the facility should ensure that a physician/prescriber has conducted a comprehensive assessment of the resident and has documented in the clinical record that the psychopharmacological medication is necessary. Medical record review for Resident 5 was initiated on 3/20/23. Resident 5 was admitted to the…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the hand hygiene practices were performed before patient contact and after glove use. This failure posed the risk of spreading infectious organism to residents in the facility. Findings: Review of the facility's P&P titled Infection Control Guidelines for All Nursing Procedures revised August 2012 showed the conditions for performing hand hygiene include before and after patient contact, before preparing and handling medications, and after removing gloves. - On 3/20/23 at 1135 hours, during the medication administration observation for Resident 29, LVN 1 was observed wearing gloves while cleaning a glucometer (a machine to measure blood sugar) and medication tray. After cleaning the glucometer and medication tray, LVN 1 removed the old gloves and immediately put on new gloves. Hand hygiene was not observed before and after removing the contaminated gloves. LVN 1 proceeded to obtain Resident 29's blood sugar finger prick. - On 3/20/23 at 1155 hours, during the medication administration observation…

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.