Cottonwood Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal the need for help) was accessible for 1 of 8 sampled residents (Resident 2) when Resident 2 was not physically able to use the call light provided when it was out of reach. This failure had the potential to result in unmet resident needs and delayed staff response. Findings: A review of the admission record indicated Resident 2 was admitted [DATE] with multiple diagnoses including encounter for orthopedic aftercare following surgical amputation (a procedure to remove a body part) and acquired absence of left foot (loss due to surgery). A review of Resident 2's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 9 out of 15 indicated Resident 2 had moderate cognitive impairment. Resident 2's functional abilities dated 1/7/25 indicated he required both…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse for one of three sampled residents (Resident 1) when Resident 2 hit the leg and grabbed the arm of Resident 1. This failure resulted in an injury to Resident 1 ' s left arm. Findings: Resident 1 was admitted to the facility late 2023 with diagnoses which included heart failure and anxiety disorder. During a review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool) dated 11/27/24, the MDS indicated a Brief Interview for Mental Status (BIMS, a standardized test that screens for cognitive impairment) score of 14/15, which showed intact cognition. Resident 2 was admitted to the facility late 2024 with diagnoses which included stroke, depression, and communication difficulty caused by a cognitive impairment . During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated a BIMS score of 6/15, which showed severe cognitive impairment. During a review of Resident 1 ' s SBAR…

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 interviews, clinical record review, and facility documents review, the facility failed to ensure one of three Residents (Resident 1) was treated with dignity and respect when Certified Nursing Assistant (CNA) 1 raised her voice and cussed at Resident 1. This failure resulted in Resident 1 feeling scared. Findings: Resident 1 was admitted to the facility on [DATE]. During a review Resident 1 ' s Quarterly Minimum Data Set (MDS-an assessment tool), dated 10/20/24, described Resident 1 as having clear speech, able to make herself understood and as able to understand others. Resident 1 ' s BIMS (a brief screening that aids in detecting cognitive impairment) score was 15 which indicated she was cognitively intact. The MDS described Resident 1 as having no signs or symptoms of delirium or behavioral symptoms. During a review of Resident 1 ' s Progress Notes, dated 11/18/24 at 10:39 a.m., it Was reported to the DON [Director of Nursing] at 0815 11/18/24, by the resident that on 11/16/24 during lunchtime when…

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

Based on observation, interview, and record review, the facility failed to ensure medications were stored correctly for census of 87 when: 1. Two bottles of sodium chloride (a solution used to dilute medications) were found expired in the automatic dispensing system inside the medication room of station 1 and 2; and, 2. Multiple medications were found at the bottom of medication carts behind the medication drawers in medication carts 3 and 5. These failures had the potential for medication misuse, ineffectiveness, diversion, and missed dosages. Findings: 1. During a concurrent observation and interview on 8/14/24 at 12:05 p.m. with Licensed Nurse (LN) 4 in the medication room of station 1 and 2, an automatic dispensing system unit was inspected. Two bottles of sodium chloride each of 10 milliliters (a unit of measure) were expired on 8/1/2024. The LN 4 verified the expiration date. 2. During a concurrent observation and interview on 8/15/24 at 11:03 a.m. with LN 3 on station 1 and 2, medication cart 3 was inspected. One bubble pack of medications and a vial full of liquid medication…

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 policy review, the facility failed to ensure the competency of food and nutrition services for a census of 87 when: 1. Dietary Staff 2 (DS 2) did not know the chlorine sanitizing concentration when performing the three compartments of manual dish washing; 2. Dietary [NAME] 1 (DC 1) did not follow standardized recipes when cooking green beans; and, 3. DC 2 did not follow the recipes when making pureed bread. These failures had the potential to cause contamination of food resulting in food borne illness and provide food for residents which did not meet the nutrients according to the planned recipes resulting related medical issues. Findings: 1. During an interview on 8/14/24 at 8:26 a.m. with DS 2, DS 2 confirmed he did not know the chemical concentration for sanitizing dishes when manual dish washing. A review of the facility's policy titled, 3 Compartment Procedure for Manual Dish Washing, stipulated, The third compartment is for sanitizing. Test the concentration with appropriate test drip, which is dipped in the sanitizer solution 10…

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

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner for a census of 87 when: 1. Seven snack cookie bags and seasoning bottles were stored past their expiration date and several food items were opened and not dated with their open date in the dry storage; and, 2. Staff did not check and document the ammonia log when performing test strips for one shift on 8/11/24. These failures had the potential to result in foodborne illnesses. Findings: 1. During a concurrent observation and interview on 8/12/24 at 8:21 a.m. in the kitchen with Dietary Manager 1 (DM 1), there were: -Seven bags of cookies with expiration date 8/11/24; -One pound (lb., a unit of measurement) seasoning bottle with expiration date 8/4/24; -An opened salad oil with no labeling; -An opened one lb and 12 ounces (oz., a unit of measurement) quick creamy wheat without its use-by-date; and, -An opened one lb corn starch without an open date and labeling. The DM 1 confirmed food items should have labeling with open date, use-by-date, and expiration date. The DM 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.

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee met at least quarterly with the required members for a census of 87, when the QAA committee did not meet in the first quarter of 2024, and the Medical Director (MD) and Director of Nursing (DON) did not attend two meetings. This failure had the potential to negatively impact the quality of resident care. Findings: A record review of the document titled, Class Attendance Roster, dated 11/16/23, indicated a Quality Assurance and Performance Improvement (QAPI) meeting was held on 10/2023. The document further indicated that the DON and MD did not attend this meeting. A record review of a document titled, Quality Assurance [QA] Meeting, dated 4/2024, indicated a QAA meeting was held 4/2024. A review of a document titled, QA Meeting, dated 8/13/24, indicated a QAA meeting was held 8/13/24. The document further indicated that the MD did not attend this meeting. During an interview with the Administrator (ADM) on 8/15/24 at 12:35 p.m., ADM confirmed the QAA committee 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 2. A review of admission Record indicated Resident 79 was admitted in May 2024 with diagnoses including End Stage Renal Disease (Kidneys stopped working) and Dependence on Hemodialysis (life sustained through hemodialysis). During an observation on 8/13/24 at 09:44 a.m. with LN 6, Resident 79 was observed with a hemodialysis catheter at right chest with two lumens (channels) and covered with clean dressing. During a review of Resident 79's Physician's Orders, dated 5/21/2024 indicated, an order of hemodialysis three times a week on Tuesday, Thursday, and Saturday, and orders changed on 6/6/2024 to hemodialysis on Monday, Wednesday, and Friday. During a review of Resident 79's MDS, dated [DATE], the MDS indicated, Resident 79 was not receiving hemodialysis. During a concurrent interview and record review on 8/14/2024 at 2:45 p.m. with MDSC, Resident 79's MDS, dated [DATE], was reviewed. The MDS indicated Resident 79 was not receiving hemodialysis. The MDSC agreed for inaccurate assessment and stated Resident 79…

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 According to an admission Record for Resident 82 he was admitted to the facility in late June 2024 with diagnoses including dementia (loss of cognitive functioning to an extent that it interferes with a person's daily life and activities) with agitation. During observation rounds on 8/13/24 at 9:28 a.m., Resident 82 was observed inside his room able to get up on his own, ambulate without using equipment and was wearing a wander guard bracelet to his right ankle. A review of Resident 82's Order Summary Report, dated 6/21/24, indicated an order for a wander guard to be worn due to elopement risk. Review of Resident 82's Care Plans revealed there was no care plan in place that addressed Resident 82's use of a wander guard. In a concurrent interview and record review on 8/14/24 at 1:47 p.m. with the Director of Nursing (DON) Resident 82's care plan was reviewed, and the DON confirmed that there was no care plan developed for the use of a wander guard. DON stated it should have been added to Resident 82's care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise care plan interventions in a timely manner following a change in condition for one of 19 sampled residents (Resident 14), when Resident 14 developed moisture associated skin damage (MASD) and a right hip pressure ulcer (skin and tissue injury). This failure decreased the facility's potential to provide Resident 14 with a person-centered care plan and evaluate its effectiveness. Findings: A review of an admission record indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including joint contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and muscle wasting and atrophy (loss of muscle tissue). A review of Resident 14's Nurses Weekly Progress Notes, dated 2/2/24 and 2/9/24, indicated Resident 14 developed MASD. A review of Resident 14's Situation, Background, Assessment, and Recommendation [SBAR] Communication Form, dated 2/28/24, indicated a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify and assess the skin condition for one of 19 sampled residents (Resident 14), when the licensed nurses did not assess or inaccurately assessed Resident 14's skin condition before she developed a right hip pressure ulcer (skin and tissue injury). This failure decreased the facility's potential to prevent Resident 14's development of pressure ulcer. Findings: A review of an admission record indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including joint contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and muscle wasting and atrophy (loss of muscle tissue). A review of Resident 14's Minimum Data Set (MDS; an assessment tool), dated 1/24/24, indicated Resident 14 had no pressure ulcers/injuries. MDS further indicated Resident 14 had a skin tear and moisture associated skin damage (MASD). A review of Resident 14's Shower Sheet, dated 2/2/24,…

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

Based on observation, interview, and record review the facility failed to provide respiratory care services according to professional standards of quality for one of 19 sampled residents (Resident 244) when Resident 244's administered oxygen was not consistent with physician's order. This failure decreased the facility's potential to safely follow the physician's order when providing respiratory services and increased the resident's risk of developing lung problems. Findings: A review of Resident 244's admission Record indicated she was admitted in late July 2024 with diagnoses including heart failure. During the initial screen and interview on 8/12/24 at 9:33 a.m., Resident 244 was observed in bed breathing oxygen via nasal cannula (a device that delivers oxygen through a tube into your nose). The oxygen was connected to a concentrator which was set at 5L/min (liters per minute, unit of measurement). Resident 244 verbalized that it felt like the oxygen she was getting from the concentrator was too much. A review of Resident 244's Order Summary Report, dated 7/31/24, indicated…

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

Based on interview and record review, the facility failed to complete the annual performance evaluations for three of seven sampled certified nursing assistants (CNAs; CNA 1, CNA 2, and CNA 3). This failure increased the residents' potential to receive poor quality of care from CNAs. Findings: A review of an undated document titled, Employee Data Base-Certified Nurse Assistant, indicated the following: 1. CNA 1's date of hire (DOH) was 5/15/07, and last performance evaluation (PE) was completed on 7/13/22; 2. CNA 2's DOH was 5/9/23, and had no PE; and, 3. CNA 3's DOH was 4/24/17, and last PE was completed on 5/28/23. During an interview on 8/14/24 at 12:25 p.m. with Director of Staff Development (DSD), DSD confirmed CNA 1, CNA 2, and CNA 3's PEs were due and stated it should have been completed annually. During an interview on 8/14/24 at 12:59 p.m. with Director of Nursing (DON), DON stated the CNAs' PEs should have been completed annually to receive positive and negative feedback about the care provided by staff. DON further stated PEs are used to identify areas for improvement 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.

Based on interview and record review, the facility failed to act on the Consultant Pharmacist's Medication Regimen Review (MRR) recommendation for one of 19 sampled residents (Resident 24) when the physician did not address Resident 24's MRR recommendation related to the use of risperidone tablet (an antipsychotic medication, that affects brain activities associated with mental processes and behavior). This failure had the potential to increase Resident 24's risk for the continued use of an antipsychotic medication without adequate indication that could cause adverse consequences. Findings: A review of Resident 24's admission Record indicated she was originally admitted in October 2022 with diagnoses including schizophrenia. Resident 24 receives psychological services through the Yolo County Mental Health. A review of an Order Summary Report of Resident 24 revealed an order, dated 8/8/24, for an antipsychotic medication risperidone tablet 1 milligram (mg, unit of measurement) given at bedtime for adjustment disorder (excessive reactions to stress that involves negative thoughts,…

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

Based on interview, and record review the facility failed to ensure one of 19 sampled residents (Resident 24) was free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processes and behavior) when Resident 24 was ordered an anti-psychotic medication without an adequate indication. This failure placed the resident at risk for unnecessary psychotropic medication use. Findings: A review of Resident 24's admission Record indicated she was originally admitted in October 2022 with diagnoses including schizophrenia. A review of an Order Summary Report of Resident 24 revealed an order dated 8/8/24 for an antipsychotic medication risperidone tablet 1 milligram (mg, unit of measurement) given at bedtime indicated for adjustment disorder (excessive reaction to stress that involves negative thoughts, strong emotions, and changes in behavior) with mixed anxiety and depressed mood. A review of the facility's Consultant Pharmacist's (CP) Medication Regimen Review, dated 6/25/24, indicated that the CP reviewed Resident 24's medication orders 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, and record review, the facility failed to follow infection control practices for a census of 87 when Dietary Staff 1 (DS 1) did not change gloves and perform hand hygiene after cleaning and disinfecting the kitchen cart and touched clean kitchen items. This failure had the potential to spread infection in the facility. Findings: During an observation on 8/13/24 at 8:36 a.m. with DS 1, DS 1 had gloved hands and was on the clean side (the side that handles only cleaned kitchen items) of the dishwasher machine. DS 1 then used the same gloved hands, got a rag from the red bucket (the disinfecting water mixture), and wiped down the soiled kitchen cart. With the same gloves, DS 1 took the clean cooler and went to the ice machine to fill it up with some ice. DS 1 continued with dishwashing on the clean side of the dishwasher. There was no change of gloves or hand hygiene performed between these kitchen tasks. During an interview on 8/13/24 at 8:46 a.m. with Dietary Manager 1 (DM 1), DM 1 confirmed staff should have removed their gloves and washed their…

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 interviews, clinical record review, and facility documents review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect when Certified Nursing Assistant (CNA) 1 refused to assist Resident 1 with cleaning, pulling up his brief, and sat him in his wheelchair with his pants down while still soiled with feces. This failure resulted in Resident 1 to feel sad and left soiled. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), hemiplegia (paralysis of one side of body) and hemiparesis (weakness on one side of the body) following cerebral infarction affecting left non-dominant side, repeated falls, muscle weakness. During a review of Resident 1's Quarterly Minimum Data Set (MDS-an assessment tool), dated 2/1/24, described him as having clear speech, able to make himself understood and as able to understand others. Resident 1's Brief Interview for Mental Status (BIMS-a brief screening…

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

Based on observation, interview, and record review, the facility failed to ensure that all drugs were labeled and disposed of in accordance with professional standards when 2 of 4 medication carts had expired medications, unlabeled medications, inappropriate handling of hazardous drugs, unrefrigerated medications, personal resident belongings and 1 controlled medication destruction container not disposed of for a census of 80 when: 1. Four unopened insulins (lowers sugar) (1 vial and 3 pens) were labeled Refrigerate; 2. One Capsaicin Cream (relieves muscle pain) 0.025% was not labeled; 3. Four loose pills, (1 small round pink with #5 inscribed; 2 small white pills (G +32?; ZG40?); and a small blue pill [F 5]) were underneath residents medication packs; 4. Three Ophthalmic (eye) medications were expired; 5. One bottle of Assure Platinum blood glucose strip (measure blood sugar level) was opened and not dated; 6. One bottle of Megestrol Acetate (increase appetite) suspension with yellow hazardous warning label; 7. One resident's bracelet was stored with the over-the-counter…

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 documentation review, the facility failed to resolve grievances according to the facility's policies and procedures when two residents (Resident 40 and Resident 49) reported missing personal belongings for a census of 80. This failure resulted in Resident 40 feeling frustrated and angry, and Resident 49 being emotional. Findings: During the Residents Council interview on 7/13/21 starting at 10:01 a.m., Resident 40 complained multiple items were lost when room changes were made during the pandemic. The resident stated he reported his missing items to staff about 6 months ago but they had not been returned or refunded. Resident 40 stated his missing items were a brand new DVD player, 3 DVD movies, 4 fly swatters, and described his missing gold ring in detail that his father gave him that had his birth stone in the middle with two cubic diamonds, one on each side of the stone. The resident showed another ring he wore on his finger. The resident reported his electric scooter…

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 documentation review, the facility failed to ensure staff were competent in providing safe resident care for a census of 80 when: 1. Certified Nurse Assistants (CNA) were unknowledgeable to turn on the mechanical assistive devices or to check the battery level of the devices; and, 2. Dietary Aide was unaware of Nepro (a nutrient supplement for dialysis resident) stored in the kitchen. These failures decreased the potential for residents to receive needed care in a timely manner and resulted in Resident 45 not receiving her daily nutritional supplement. Findings: 1. During the Resident Council interview on 7/13/21 starting at 10:01 a.m., Resident 6 voiced that electrical lifts (assistive devices to transfer residents who were no longer able to bear weight) were not working when staff needed to transfer him. Resident 6 stated the electrical lifts were not working because they were not charged. Resident 6 stated he often had to wait or was not being transferred at all because the lifts were not charged. During the Resident Council interview 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 observation, interview, and record review the facility failed to ensure there was sufficient staff with appropriate competencies and skills sets to carry out food and nutrition services for a census of 80 residents when: 1. Dietary staff did not label milk beverages in a way that allowed nursing staff to differentiate between the various types of milk found on resident trays; 2. Dietary staff were uncertain regarding cleaning protocol in the kitchen; 3. Dietary staff were unable to describe appropriate thawing of meat. These failures had the potential to lead to food intolerances and food borne illnesses. Findings: 1. During an observation of the kitchen and concurrent interview with the Director of Food Services (DFS) on 7/12/21 at 8:44 a.m., there were three bins of milk in the walk-in refrigerator. The cups were labeled with the identifiers either a N, H, A, or a straight line. The DFS stated the letter N was for nectar consistency, the letter H was for honey consistency, the letter A was for almond milk, and the straight line was for skim milk. There were 29 milk…

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

Based on observation, interview, and record review, the facility failed to ensure food was procured, stored, and served under sanitary conditions for 80 residents to prevent food borne illness when: 1. Food was not labeled and dated per policy; 2. Expired and spoiled food was not discarded from the refrigerator; 3. Service items (7 measuring spoons in a plastic bag, a spatula, a knife, a ladle, 3 serving spoons, a rusted pizza cutter, and a rusted peeler) were dirty; 4. Service items were stacked wet in the ready-to-use area; 5. Floors were dirty; 6. Food carts were not cleaned per policy; and, 7. The ice machine pipe fitting inside of the air gap was without needed clearance. These failures increased the potential for foodborne illness. Findings: 1. During a concurrent observation and interview, on 7/12/21 at 8:15 a.m., 1-8 oz. (ounce, a unit of measurement), 2- 8 oz. glasses of milk, and 29 cups of milk on a dinner tray were undated. The Director of Food Services (DFS) and Dietary Aid 3 (DA 3) acknowledged the milk should have been dated and labeled. During a concurrent…

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, interviews and documentation review, the facility failed to ensure electrical assistive devices were maintained in operational condition for a census of 80. This failure resulted in residents a long wait to be transferred or not being transferred when needed and had the potential for residents being unable to transform from a sitting position to a standing position of their own. Findings: During the Resident Council interview on 7/13/21 starting at 10:01 a.m., Resident 6 voiced electrical lifts ( assistive device to transfer residents who no longer bear weight) was not working when CNAs (Certified Nurse Assistant) attempted to use the lifts to transfer him. Resident 6 stated they did not work because they were not charged. Resident 6 complained he had to wait long or was not being transferred when needed. Resident 6 stated it happened often. During the Resident Council interview on 7/13/21 starting at 10:01 a.m., Resident 40 complained the same issue that the electrical lifts not working when he needed to be transferred. Resident 40 stated, for a person like…

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 documentation review, the facility failed to promote one of 18 sampled residents' (Resident 41) dignity when the indwelling catheter (a tube inserted into the bladder and remained to drain urine) urinary bag was exposed and visible from the hallway with the urine drainage tubing touching the floor. This failure had the potential for Resident 41 feeling devalued, embarrassed, and disrespected, and placed the resident at risk for infection. Findings: Resident 41 was a long term resident in the facility with diagnoses including memory problems. Resident 41 shared a bedroom with two other residents. In an observation on 7/12/21 at 12:05 p.m., Resident 41's room door was wide open. The resident's urinary bag was exposed and visible from the hallway. The urinary tubing was connected to the urinary bag and touched the floor. The tubing was cloudy with sediment. One of Resident 41's roommates suddenly voiced that she had a right to see outside the window and insisted drawing Resident 41's privacy curtain. The roommate abruptly pulled the privacy curtain…

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

Based on observation, interview, and record review, the facility failed to provide meaningful individualized activities for one of 18 sampled residents (Resident 41). This failure placed the resident at risk for physical and psychosocial deterioration. Findings: Resident 41 was a long term resident in the facility with diagnoses including memory problems with behavioral disturbance, and inability to express spoken language. During the recertification survey period between 7/12/21 and 7/15/21, Resident 41 was not observed out of bed or engaged in any activities. Review of Resident 41's activity care plan, undated, indicated, the resident had activity goals to have room visits, 3x per week .will have active responses during room visit 3 times per week .will attend at least 1 activities per month . The care plan included interventions, Provide activity that is meaningful to the resident Room visits to offer music, word games, include family life and history, show pictures for conversation starters .video chats with family set up . Review of the resident's Monthly Resident Activity…

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

Based on observation, interview, and record review, the facility failed to ensure the physician's treatment order to float/offload (removing weight placed on the foot to help prevent and heal ulcers [injury to the skin and underlying tissue]) both heels for one of 18 sampled residents (Resident 34) was implemented. This failure increased the risk for additional pressure ulcers. Findings: A review of Resident 34's clinical record indicated he was admitted to the facility in early February 2017 with diagnoses which included diabetes mellitus with diabetic neuropathy (nerve damage), pressure-induced DTI damage of left heel, and peripheral vascular disease (PVD, narrowed blood vessels reduce blood flow to the limbs). A review of Resident 34's Treatment Administration Record (TAR) for the month of July 2021 indicated, ENSURE BOTH HEELS FLOATED ON 2 PILLOWS EVERY SHIFT FOR OFFLOADING. A review of Resident 34's care plan, Impaired skin integrity related to diabetes, dated 7/3/21, indicated, Keep heels off pressure. During an observation on 7/12/21 at 11:38 a.m., Resident 34 was lying 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.

Based on interview and record review, the facility failed to provide behavioral health care and services for one of 18 sampled residents (Resident 34) when Resident 34 exhibited patterns of refusals and non-compliant behavior with nursing care for a census of 80. This failure increased Resident 34's risk for mental, physical and psychosocial well-being deterioration. Findings: A review of Resident 34's clinical record indicated he was admitted in early February 2017 with diagnoses which included personality disorder, mild cognitive impairment, and noncompliance with other medical treatment and regimen. A review of Resident 34's Minimum Data Set (MDS, an assessment tool), dated 11/17/20, indicated, his cognition score was 9 (moderately impaired). On 2/5/21, his cognition assessment scored 6 (severely impaired), and on 5/5/21, his cognition assessment scored 5 (severely impaired). A review of Resident 34's care plan, non-compliant with nursing care dated 7/6/21 indicated, Resident 34 refused showers, pericare, oral hygiene, dressing, grooming, treatments, repositioning, refused to ask…

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

Based on observation, interview, and record review, the facility failed to ensure safe medication administration, proper labeling of medications, and removal of expired medications for a census of 80 when: 1. One dolutegravir (treatment medication for human immunodeficiency virus (HIV) infection) and multivitamin (MVI) prescribed for one resident were administered concurrently; and, 2. Three ophthalmic (eye) (ointment, lubricant, suspensions) medications with expired dates were prescribed to different residents . These failures increased the risk for reduced medication effectiveness, residents receiving expired medications, and increased eye infections. Findings: 1. During a medication pass observation on 7/12/21, at 10:04 a.m., Licensed Nurse 1 (LN 1) administered one Dolutegravir 50 mg (unit of measure) tablet and one MVI tablet concurrently. Dolutegravir bottle label instructions included .take 2 hours before or 6 hours after multivitamins. During an interview on 7/12/21, at 10:15 a.m., LN 1, read the medication label instructions and acknowledged she administered 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.

Based on observation, interview and record review the facility failed to ensure a medication error rate of less than 5 percent with 32 observed opportunities for 2 of 5 sampled residents (Resident 45 and Resident 137), when: 1. Resident 45 was administered calcium acetate 667 (phosphorus [mineral] binding medication for people with kidney disease) mg (unit of measurement) approximately one hour and fifty minutes later than the scheduled dose and combined with the next dose; and, 2. Resident 137 was administered dolutegravir (treatment medication for human immunodeficiency virus [HIV] infection) 50 mg (unit of measurement) tablet and 1 multivitamin (MVI) pill concurrently. These failures resulted in 2 medication errors identified out of 32 opportunities during an observation of medication administration. This resulted in the facility having a medication error rate of 6.25%. Findings: 1. According to the Facesheet Resident 45 was admitted in 2018 with diagnoses including chronic kidney disease Stage 5 (unable to filter waste and excess water) and renal dialysis (removal of excess…

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

Based on observation, interview and record review, the facility failed to maintain infection control standards for one of 18 sampled residents (Resident 80) when the resident's indwelling urinary catheter drainage bag was observed sitting on the floor. This failure put the resident at increased risk for acquiring a urinary tract infection. Findings: According to the Resident Face Sheet, Resident 80 was admitted in late 2020 with diagnoses including acute kidney failure, urinary tract infection, and retention of urine. In an observation, on 7/12/21 at 11:00 a.m., Resident 80 was seen lying asleep in bed, and his urinary catheter bag was sitting on the floor. In an interview, on 7/12/21 at 11:13 a.m., Certified Nursing Assistant 4 (CNA 4) stated residents' urinary catheter bags should be off the floor. CNA 4 confirmed Resident 80's catheter bag was on the floor. In an interview, on 7/15/21 at 10:04 a.m., the Director of Nursing (DON) stated she expected urinary catheter bags to be kept off the floor because it increased the risk for infection if they were not. A 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.