Bayshire Yorba Linda Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the person-centered care plan for the use of the psychotropic medications were complete for one of 12 final sampled residents (Resident 15). * The facility failed to ensure the care plan included the specific targeted behavior monitoring for Resident 15's use of zolpidem tartrate (a psychotropic sedative used to treat insomnia) and buspirone HCl (antianxiety) medications. This failure posed the risk of not providing appropriate, consistent, and individualized care to the resident.Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised December 2016 showed a comprehensive person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs will be developed for each resident. The care plan will incorporate identified problem areas and reflect treatment goals, timetables and objectives in measurable outcomes.…

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, interviews, medical record review, and facility P&P review, the facility failed to ensure the proper IV care was provided for one of one final sampled residents (Resident 19) receiving IV infusions. * The facility failed to ensure Resident 19's PICC line dressing was changed every seven days and Resident 19's IV infusion tubing was labeled. These failures posed the risk for Resident 19 developing complications related to IV infusions.Findings: Review of the facility's P&P titled Central Venous Catheter Dressing Changes revised 4/2016 showed the following:- The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings; and- Change transparent semi-permeable membrane dressings at least every 5-7 (five to seven) days and PRN (when wet, soiled, or not intact). Review of the facility's P&P titled Administration Set/Tubing Changes revised 10/2024 showed the purpose of this procedure is to provide guidelines 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 provide the necessary respiratory care and services for two nonsampled residents (Residents 17 and 52) reviewed for respiratory care. * The facility failed to ensure Residents 17 and 52 were provided the humidifier attached to the concentrator for the use of continuous oxygen therapy. This failure posed the risk for the residents to have nasal dryness and throat irritation. Findings: Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed in part, the purpose of this procedure is to provide guidelines for safe oxygen administration. Under the section for Steps and Procedure, showed check the mask, tank, humidifying jar, etc to be sure they are in good working order and are secularly fastened. Periodically re-check water level in humidifying jar. 1. On 4/12/26 at 0918 hours, during the initial tour of facility, an observation was conducted for Resident 52. Resident 52 was observed on her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care of the dialysis access site was provided for one of 12 final sampled residents (Resident 4). * The facility failed to ensure Resident 4's dialysis access site was consistently and accurately assessed pre and post hemodialysis treatments. This failure had the potential for delay in identifying complications related to the resident's dialysis access site.Findings: Review of the facility's P&P titled Care of a Resident with End-Stage Renal Disease date revised 9/2010 showed the residents with End-Stage Renal Disease (ESRD) will be cared for according to currently recognized standards of care. Further review of the facility's P&P titled Access and Care of Hemodialysis Catheters revised 2/2023 showed to check for signs of infection (warmth, redness, tenderness or edema) at the access site when performing routine care and at regular intervals. Check the color and temperature of the fingers, and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the pharmaceutical services to ensure for accurate reconciliation and administration of the medications for one of 12 final sampled residents (Resident 55). * The facility failed to ensure the Lasix (a diuretic medication) order for Resident 55 listed the appropriate indication for use. This failure had the potential for the resident's needs not being met as the indication of the medication use was incorrect.Findings: Medical record review for Resident 55 was initiated on 4/12/26. Resident 55 was admitted to the facility on [DATE]. Review of Resident 55's H&P examination dated 4/9/26, showed Resident 55 had the capacity to understand and make decisions. On 4/12/26 at 1119 hours, an observation and concurrent interview was conducted with Resident 55. Resident 55 stated she was having trouble sleeping due to the edema in her legs. Resident 55's lower legs were observed with edema was present. Review of Resident 55's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 20%. Two of four licensed nurses (LVNs 1 and 5) who were observed during medication administration were found to have errors. * LVN 5 failed to ensure medications levothyroxine (medication to treat underactive thyroid) and pantoprazole/lansoprazole (medication to relieve stomach acids) were administered a minimum of four hours apart for Residents 17 and 19 * LVN 5 crushed a delayed release medication (pantoprazole) for Residents 2 and 46 * LVN 1 failed to ensure Resident 30's levothyroxine sodium and pantoprazole sodium medications were not administered together. These failures created the risk for the residents to have potential side effects or complications related to the medications.Findings: 1.a. Review of Mayo Clinic's online recommendations dated 3/31/26, for proper use of the levothyroxine medication showed: - If you are using stomach…

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

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were store in a safe manner for one of 12 final sampled residents (Resident 55), one nonsampled resident (Resident 56) and in one of two medication carts (Medication Cart B). * LVN 5 failed to ensure Residents 55 and 56's medications were safely stored during the medication administration. This failure posed the risk for unauthorized individuals to have access to the medication. * An open foil packet of Sorbalgon Ag (Ca Alginate Ag) wound dressing was stored in Medication Cart B. This failure had the potential for residents to receive medications that was contaminated and/or losing stability and effectiveness.Findings: 1. Review of the facility's P&P titled Administering Medications revised 4/2019 showed during administration of the medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. a. On 4/13/26 at 0540 hours, a medication administration observation 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, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed for three of 41 residents that consumed the foods prepared in the kitchen. * The facility failed to provide bread or roll with margarine to Resident 30 as per her meal ticket. * The facility failed to provide bread or roll with margarine to Resident 36 as per his meal ticket. * The facility failed to provide mashed potatoes to Resident 33 as per her meal ticket. These failures had the potential for the residents to not receive adequate nutrition and appropriate servings to meet their individual needs.Findings: Review of the facility's Diet Type Report dated 4/12/26, showed 41 of 41 residents consumed the foods prepared in the kitchen. Review of the facility's menu titled Week at a Glance dated 4/7/26, showed the lunch menu for 4/12/26, included mixed green salad with dressing, bacon meatloaf, scalloped potatoes, sauteed broccoli florets, bread or roll with margarine, cherry cheesecake, and choice of beverage. 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.

Based on observation, interview, and facility P&P review, the facility failed to ensure the facility's garbage and refuse was properly disposed of in three of seven garbage dumpsters. * Three garbage dumpsters were observed with the lids partially propped open by the cardboard boxes and black trash bags, preventing the lids from closing. This failure had the potential to harbor pests and rodents and cause unsafe sanitary conditions.Findings: Review of the facility's P&P titled Garbage and Rubbish Disposal dated 2020 showed garbage and rubbish will be disposed of to ensure a clean and sanitary kitchen that does not encourage insects or rodents. All outside dumpsters will be maintained in clean and sanitary condition. All garbage or rubbish is to be put into waste containers which are emptied as often as necessary to prevent overfilling. This will assist in the prevention of odors, pests, and possible contamination. All containers will be provided with tight-fitting lids or covers and will be leak proof and waterproof. All garbage and rubbish containing food waste are covered when 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 and medical record review, the facility failed to ensure the necessary care and services were provided to one of four sampled residents (Resident 4). * The facility failed to ensure Resident 4's orthostatic blood pressure was obtained per the physician's order. This failure had the potential to negatively impact the resident's health and safety.Findings: Medical record review for Resident 4 was initiated on 11/25/25. Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnosis included orthostatic hypotension. Review of Resident 4's Order Listing Report showed a completed order status dated 11/18/25, to check the orthostatic blood pressure and pulse rate daily (lying, sitting and standing positions) for three days. Review of Resident's 4 MAR for November 2025 showed the following:- dated 11/18/25, blood pressure of 116/68 mmHg and pulse rate of 81 beats per minute;- dated 11/19/25, blood pressure of 112/72 mmHg and pulse rate of 80 beats per minute; and- dated 11/20/25, blood…

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 sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the proper labeling and dating of the food items and expired food items were discarded in the satellite kitchen. * The facility failed to ensure the proper labeling and dating of the foods in the refrigerator was in place for the residents' food brought in by the visitors. * The facility failed to ensure the bins, scoops, spoons, peeler, can opener, and microwave were clean. * The facility failed to air dry the scoops before storing in the storage bin. * The facility failed to ensure the cutting boards were kept in a sanitary condition. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen. Findings: Review of the facility's Diet Type Report dated 4/4/25, showed 42 of 43 residents residing in the facility received foods prepared in the kitchen. 1. Review of the facility's P&P titled Labeling and Dating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to develop the plan of care to reflect the individual care needs for one of 13 final sampled residents (Resident 25). * The facility failed to develop a care plan problem to address Resident 25's spinal precautions and use of LSO brace while out of bed. This failure posed the risk of not providing appropriate, consistent, or individualized care to the resident. Findings: Medical record review of Resident 25 was initiated on 4/2/25. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's H&P examination dated 3/31/25, showed one of Resident 25's diagnosis was S/P lumbar fusion. Review of Resident 25's PT and OT Evaluation and Treatment notes dated 4/1/25, showed the section for Precaution/Contraindication showing to provide spinal precautions and LSO brace when out of bed. Review of Resident 25's Order Summary Report showed a physician's order dated 4/1/25, for the LSO brace when out of bed. Review of Resident 25's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to revise the residents' comprehensive care plans to address the use of side rails for three of four final sampled residents (Residents 16, 17, and 339) reviewed for the side rail use. * The facility failed to ensure the plan of care for Residents 16, 17, and 339 addressing the use of the side rails were revised to show the accurate least restrictive interventions prior to the use of side rails. The residents' plan of care showed the grab rails and quarter-sized rails were used as the least restrictive interventions prior to the use of the side rails. These failures posed the risk of not providing an individualized care for Residents 16, 17, and 339 related to the use of the side rails. Findings: 1. Medical record review for Resident 16 was initiated on 4/1/25. Resident 16 was readmitted to the facility on [DATE]. Review of Resident 13's Order Summary Report showed a physician's order dated 3/13/25, for the bilateral deluxe assist bed handles up…

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 necessary respiratory care and services were provided to three of 13 final sampled residents (Residents 1, 2, and 19) reviewed for the respiratory care. * The facility failed to ensure Resident 19 received the oxygen as per the physician's order. * The facility failed to ensure Residents 1 and 2 were provided with the No Smoking/Oxygen in Use sign indicating the oxygen use continuously. These failures had the potential to negatively affect the residents' well-being and posed the risk for safety due to the residents' use of the oxygen continuously. Findings: 1. Medical record review for Resident 19 was initiated on 4/1/25. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's H&P examination dated 1/10/25, showed Resident 19 had the capacity to understand and make decisions. Review of Resident 19's Order Summary Report dated 4/2/25, showed a physician's order dated 1/14/25, 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, facility record review, and facility P&P review, the facility failed to ensure the necessary pharmacy services were provided to one of 13 final sampled residents (Resident 25) and the proper accounting and safeguarding was performed to prevent loss, or diversion of the controlled medications. * The facility failed to provide the insulin medication (medication used to lower the blood sugar) to Resident 25 as ordered by the physician. * The facility failed to ensure the Narcotic Shift Count sheets were completely signed by the incoming and outgoing licensed nurses assigned to Medication Cart 1. These failures posed the risk to negatively affect the resident's well-being and loss or diversion of the controlled medications. Findings: 1. Review of the facility's P&P titled Administering Medications revised 4/2019 showed the individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 4 and 26) reviewed for the unnecessary medications were free from the unnecessary psychotropic medications. * The facility failed to ensure Resident 26's quetiapine (antipsychotic medication) order had the necessary diagnoses to treat a specific condition. * The facility failed to ensure Resident 4 was monitored for the adverse effects related to the use of the risperidone medication (antipsychotic medication). These failures had the potential for Residents 4 and 26 to receive the unnecessary psychotropic medications and negatively affect the residents health. Findings: 1. Review of the facility's P&P titled Psychotropic Medication Use dated July 2022 showed the residents are not prescribed the psychotropic medication unless this medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. Medical record…

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 medication error rate was below 5%. The facility's medication error rate was 22.58%. Two of two licensed nurses (LVNs 1 and 2) were observed to have made the errors during the medication administration. * LVN 2 failed to ensure the correct medications were administered to Resident 591 as per the physician's orders. * LVN 1 failed to ensure the education provided for not chewing the extended release medications for Residents 19 and 29. Additionally, LVN 1 failed to assess or ask Residents 19 and 29 if they had any signs or symptoms of bleeding or bruise. These failures had the potential to negatively affect the residents' health conditions. Findings: 1. On 4/2/25 at 0809 hours, during the medication administration observation, LVN 2 administered the following medications to Resident 591 orally: - Metformin (antidiabetic)1000 mg one tablet - Oyster Calcium (supplement) 500 mg with Vitamin D 10 mcg one…

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 medications were stored in a safe and secure manner. * The facility failed to the medications were properly stored in the location where they could not be accessible by the non-licensed staff. * The facility failed to ensure Medication Cart 1 was locked when not in use. These failures had the potential for unauthorized persons to have access to locked medications. Findings: Review of the facility's P&P titled Storage of Medications, revised 11/2020 showed the facility stores all the drugs and biologicals in a safe, secure and orderly manner. The drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only the person authorized to prepare and administer medications have access to locked medications. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators , carts and boxes) containing drugs and biologicals are locked when not in use. 1. On 4/02/25 at 1355 hours, an interview and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' medical records were complete and accurate for six of 13 final sampled residents (Residents 16, 17, 25, 28, 29, and 339) and two nonsampled residents (Residents 640 and 641). * The facility failed to ensure the signatures on the informed consent for the buspirone (antianxiety medication) medication for Resident 16 matched the printed names on the consent form. Additionally, Resident 16's MAR entries failed to show the job designation of the staff signing. * The facility failed to ensure the MAR entries showed the job designation of the staff signing the MAR for Residents 17, and 339. * The facility failed to ensure Resident 28's medication administrations, treatments, and monitorings were documented in the MAR after it was administered or provided. Additionally, the consent to treat and consent for the use lorazepam (antianxiety medication) was incomplete. * The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were maintained. * The facility failed to accurately classify which residents met the McGeer's Criteria in the infection control surveillance. This failure posed the risk of inaccurately identifying if the residents met the criteria for true infections and appropriate antibiotic use. * The facility failed to implement the neutropenic precautions for Resident 17. Fresh flowers were observed at bedside, the door was not kept closed, and the IP was observed entering the room without a mask. * The facility failed to ensure the enhanced barrier precautions for Resident 591 were observed. * The sink in Medication Room A was not clean. These failures posed the risk of potential transmission of communicable diseases to other residents in the facility. Findings: 1. According to the CDC, unnecessary antibiotic use promotes development of antibiotic-resistant bacteria. Every time a person…

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 equipment was maintained in a safe and operable manner. * The sink faucet in Medication Room A was leaking. * The facility failed to ensure the ice machine in the main kitchen was cleaned and sanitized as per the manufacturer's specifications. * The facility failed to ensure there was no ice build-up in the walk-in freezer in the main kitchen, the freezer in the satellite kitchen, and the freezer of the refrigerator used for residents' food brought from outside source. * The facility failed to ensure the thermometer used in the satellite kitchen was calibrated properly. These failures had the potential for the equipment to not function in the way it was intended. Findings: 1. Review of the facility's P&P titled Maintenance Service revised 12/2009 showed the maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' beds were inspected and the entrapment assessments were conducted when identifying areas of possible entrapment with the use of bed rails for two of four final sampled residents (Residents 26 and 339) investigated related to the use of side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: 1. According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review and facility P&P review, the facility failed to develop a plan of care to reflect the individual care needs for one of two sampled residents (Resident 1). * The facility failed to develop the care plan problem and interventions to address Resident 1's behavior of getting up from the wheelchair. This posed the risk of not providing appropriate, consistent, and individualized care to the resident. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed for a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Medical record review for Resident 1 was initiated on 3/4/25. Resident 1 was originally admitted to the facility on [DATE], 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 facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure proper hand hygiene were practiced by the dietary staff in the satellite kitchen. * The facility failed to ensure hair and beard restraint were worn by a non-dietary personnel inside the main kitchen. * The facility failed to ensure the meat thawing in the refrigerator in the main kitchen was labeled with the use-by date, and the date when the meat was pulled from the freezer. * The facility failed to ensure the proper labeling and dating of the food items in the main kitchen and satellite kitchen. * The facility failed to ensure the proper labeling and dating of the foods in refrigerator was in placed for the residents' food brought in by visitors. In addition, the facility failed to ensure the food items were discarded after a resident has been discharged . * The facility failed to ensure the expired food items in the main kitchen were discarded. * The facility failed to ensure the plates, storage…

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

Based on observation, interview, and facility document review, the facility failed to maintain the essential kitchen equipment in safe operating condition. * The facility failed to ensure the dish machine in the satellite kitchen was working. * The facility failed to ensure the sink in the main kitchen was not leaking. * The facility failed to ensure there was no ice buildup and brownish stain in the freezer of the refrigerator used to store residents' food brought in by the visitors. These failures had the potential for the equipment to not function in the way it was intended, which could cause food borne illnesses for the residents. Findings: Review of the facility's Diet Type Report dated 1/24/24, showed 30 of the 34 residents residing in the facility received foods prepared in the kitchen. According to USDA Food Code 2022, Section 4-501.11, Good Repair and Proper Adjustment, showed the proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations 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 interview and medical record review, the facility failed to ensure one of 13 final sampled residents (Resident 330) was informed in advance of the proposed treatment regarding the use of psychotropic medications (medications affecting brain activity). * The facility failed to ensure the informed consent was obtained from Resident 330's responsible party before administering sertraline (antidepressant medication) to Resident 330. This failure had the potential to compromise the right of the resident or her responsible party (person designated to make decisions on behalf of the resident) to be fully informed regarding the medication and its potential side effects. Findings: Medical record review for Resident 330 was initiated on 1/23/24. Resident 330 was readmitted to the facility on [DATE]. Review of Resident 330's History and Physical examination dated 1/15/24, showed Resident 330 had no capacity to understand and make decisions. Review of the Order Summary Report showed a physician's order dated…

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

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 reasonable accommodation to meet the needs of one of 13 final sampled residents (Resident 8). * The facility failed to ensure the call light for Residents 8 was within the resident's reach. This had the potential for the resident to not be able to call for assisstance when needed. Finding: Review of the facility's P&P titled Answering Call Light revised September 2022 showed the facility should ensure the call light is accessible to the resident when in bed, from the toilet, from the shower, from the shower or bathing facility & from the floor. During the initial tour of the facility on 1/23/24 at 1047 hours, Resident 8 was observed lying in her bed, awake, with the call light hanging on a metal rod on the right side of the head of bed. Medical record review for Resident 8 was initiated on 1/23/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's History and Physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the residents' advance directives were part of their medical records for three of 13 final sampled residents (Residents 19, 25, and 429). This failure had the potential for the residents' wishes for provisions of health care not being followed. Findings: Review of the facility's P&P titled ADM- Advanced Directives dated 9/1/22, showed upon admission, the facility will ask the resident or the resident's representative if they have an Advance Directive, and copies are obtained and maintained in the residents' medical record. 1. Medical record review for Resident 429 was initiated on 1/23/24. Resident 429 was admitted to the facility on [DATE]. Further review of Resident 429's medical record failed to show a POLST and if the resident had an advance directive. Review of Resident 429's Generations Care Conference -V3 dated 1/17/23, the section for advance directive was incomplete. On 1/24/24, at 1009 hours, an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the timely notification of changes for one of 13 final sampled residents (Resident 16). * The facility failed to notify the physician, RD, and resident responsible party for the resident's weight changes. This failure had the potential for a delay of the interventions to prevent further weight loss/gain. Findings: Review of the facility's P&P Weight Assessment and Intervention dated 12/1/22, showed the following: - A weight change of 5% or more since prior weight assessment will be rechecked the next day, and if verified, nursing will immediately notify the dietitian. - Unless notified of a significant weight change (5% weight loss in a one month period; greater than 5% is severe weight loss.) Review of the facility's P&P Change in a Resident's Condition or Status revised 2/2021 showed the facility promptly notifies the resident's physician and responsible party of changes in the resident's medical status, including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plans related to the fall risk was developed for one of 13 final sampled residents (Resident 379). This failure had the potential for the resident to not receive the necessary care and services in accordance with their care needs. Findings: Review of the facility's P&P titled Baseline Care Plans for New Residents dated 6/22 showed the baseline care plans should be completed upon admission based on the resident's individual needs. Medical record review for Resident 379 was initiated on 1/24/24. Resident 379 was admitted to the facility on [DATE]. Review of Resident 379's Order Summary Report for January 2024 showed a physician's order dated 1/22/24, to place the bilateral floor mats to prevent and/or minimize further injury from fall, and another physician's order for Joerns deluxe assist handle (a assistive device attached to the resident's bedframe to assist with mobility) times two for better…

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 develop the comprehensive care plans to reflect the individual care needs for three of 13 final sampled residents (Resident 25, 330, and 679) when: * The facility failed to develop a comprehensive care plan for Resident 25's use of Risperdal (a medication used to treat a number of mental health disorders including psychosis.) and sertraline hcl (a medication used to treat certain mood disorders such as depression.) * The facility failed to develop a care plan problem to address Resident 330's use of sertraline hcl. * The facility failed to develop a care plan problem to address the PVR monitoring for Resident 679. These failures posed the risk of not providing the appropriate, consistent, and individualized care to the residents. Findings: 1. Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised March 2022 showed the comprehensive, person-care plan that includes measurable objectives 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, and medical record review, the facility failed to provide the services to attain or maintain the highest practicable well-being for three of 13 final sampled residents (Residents 8, 9, and 679). * Resident 9 was administered olmesartan medoxomil (medication to treat high blood pressure) and metoprolol (medication to treat high blood pressure) when Resident 9's systolic blood pressure was below the parameter prescribed by the physician. * The facility failed to continue to monitor and document assessment every shift for 72 hours after the change in condition identified for Resident 8. * The facility failed to ensure the physician's orders were followed related to monitoring of Resident 679's urinary output and PVR. These failures had the potential to negartively affect the residents' health condition and well-being. Findings: 1. Medical record review for Resident 9 was initiated on 1/23/24. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's Order Summary…

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 follow the physician's order for the RD consult for one of 13 final sampled residents (Resident 16). * The RD did not review the resident's enteral feeding formula for more concentrated formula as ordered by the physician on 12/25/23, and failed to conduct the RD consultation for weight loss timely as ordered on 1/4/24, for Resident 16. This failure had the potential for a delay or dietary interventions putting the resident at risk of further undesirable outcomes. Findings: Medical record review for Resident 16 was initiated on 1/23/24. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's History and Physical examination dated 12/4/23, showed the resident was unable to eat food by mouth and received nourishment through their G-tube. a. Review of Resident 16's MAR for December 2023 showed starting 12/7/23, Resident 16 received Glucerna 1.2 (an enteral feeding formula) via G-tube to run at 70 ml/hr 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 provide the necessary enteral tube care and services for two of 13 final samples residents (Residents 16 and 629). * The facility failed to ensure Resident 629's J-tube placement was verified prior to the administration of medications. * Resident 16's enteral formula bottle was left at bedside after being opened. These failures posed the risk for developing complications related to enteral feeding. Findings: Review of the facility's P&P titled Administering Medications through an Enteral Tube revised 11/2018 showed steps in the procedure to verify placement of feeding tube prior to the administration of medication through enteral tube. On 1/23/24 at 1045 hours, an observation of medication administration was conducted with LVN 1. LVN 1 was observed to have instilled 15-20 cc of air through Resident 629's J-tube, without use a stethoscope . LVN 1 did not verify the placement of the J-tube prior 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.

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 13 final sampled residents (Residents 429) received the appropriate care for peripheral intravenous catheter. * The facility failed to ensure Residents 429's IV site was assessed and monitored as per the facility's P&P. This failure posed the risk for a delay in identify and provide necessary care if the resident developed complications such as catheter-related infections. Findings: Review of the facility's P&P titled Administering Medications by IV Push revised 3/2022 showed assessment, inspect intravenous catheter site and system for signs of complications. On 01/23/24 at 0833 hours, an IV medication administration observation with RN 1 was conducted. RN 1 was observed cleansing Resident 429's IV port with alcohol wipes then proceeded with administering ceftriaxone (an antibiotic) 1 gm via IV pump. Medical record review for Resident 429 was initiated on 1/23/24. Resident 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.

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 respiratory services were provided as ordered for three of 13 final sampled residents (Residents 330, 429, and 629). * The facility failed to ensure Resident 330 received continuous oxygen via nasal cannula as per the physician's order. * Resident 429's physician's order for oxygen failed to show if the order was continuous or PRN. * Resident 629's nasal cannula was found in the floor and physician's order for oxygen failed to show if the order was continuous or as needed. These failures had the potential for these residents to not receive appropriate respiratory care and increase risks of infection. Findings: Review of the facility's P&P titled Oxygen Administration revised dated 10/2010 showed to verify there is a physician's order for this procedure and review the physician's orders of facility protocol for oxygen administration. 1. On 1/24/24 at 1044 hours, 1/25/24 at 0945 hours, and 1/26/24 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 observation, interview, medical record review, and facility P&P review, the facility failed to complete the entrapment assessments, obtain the physician's orders, and an informed consents prior to the use of side rails for five of 13 final sampled residents (Residents 9, 25, 330, 379, and 629). These failures had the potential to put the residents at risk for serious injuries. Findings: Review of the facility's P&P titled Bed Rails, Side Rails dated 4/12/21, showed the resident's assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. The resident assessment must also assess the resident's risk from using bed rails. The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself. Informed consent from the resident or resident representative must be obtained after appropriate alternative have 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for one of 13 final sampled residents (Resident 629) and one nonsampled resident (Resident 23) to meet the needs of each resident as evidenced by: * The facility failed to ensure the medications were administered as ordered to Resident 629. * The facility failed to ensure the controlled drug, hydrocodone-acetaminophen 10 mg-325 mg tablet,signed out from the controlled drug record were documented as administered on the MAR for Resident 23 * The facility failed to ensure the disposed medications were destructed and mixed with undesirable substance or a medication destroyer chemical. These failures had the potential for poor health outcomes to the residents and controlled medications diversion. Findings: 1. On 1/23/24 at 0903 hours, medication administration observation was conducted with LVN 1. LVN 1 was observed administering one medication via J-Tube to Resident 629.…

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 13 final sampled residents (Resident 25) was provided the management for the use of psychotropic medications (medications that affect the mind, emotions, and behavior). * The facility failed to ensure non-pharmacological approaches to care were provided for Resident 25 while receiving risperidone (Risperdal, a medicine that helps with symptoms of some mental health conditions where someone may see, hear, or feel things that are not there or believe things that are not true or you feel unusually suspicious) and sertraline (Zoloft, a medication used to treat depression). This failure had the potential to cause harm to Resident 25. Findings: Review of facility's P&P titled Use of Psychotropic Medication dated 5/23/23, showed the residents who use psychotropic drugs shall receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. Medical record review 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 document review, the facility failed to ensure the medication error rate was below 5%. The facility's medication rate was 18.52%. Two of two licensed nurses (LVNs 1 and 3) observed administering the medications was found to have errors while administering the medications to four nonsampled residents (Resident 14, 17, 23, and 630). * The facility failed to ensure Resident 17 received the prescribed eye drops in accordance with the facility's P&P. * The facility failed to ensure Resident 14's inhalation medication was administered in accordance with the facility's P&P. *The facility failed to ensure Resident 25's hydroxychloroquine (a medication used to treat discoid lupus erythematosus (a chronic inflammatory condition of the skin) was given with food or meal. * The facility failed to ensure Resident 630's blood pressure was obtained just before giving the medications to control the blood pressure. * The facility failed to ensure Resident 630's…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were properly stored and labeled. * The facility failed to ensure the discontinued medication was locked and not left unattended on top of the medication cart. * The facility failed to monitor the temperature of the resident's refrigerator in the medication room. * The facility failed to appropriately label multiple ointments with open date, dispose of the prescription ointments such as triamcinolone and mupirocin, dispose of the expired solutions, and maintain cleanliness of the treatment cart. * The facility failed to dispose opened sterile packages for IV therapy such as IV holder or lock and transparent dressing from the IV cart. * The facility failed to appropriately label the bottle of the iron tablets (supplement) and eye medication drops with open date. * The facility failed to dispose of the insulin pen beyond the used by date. * The facility failed to store the external and internal medications separately. These failures had the potential to negatively impact the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and the facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operation of the Food and Nutrition Services Department. * Dietary Aides 1 and 2 were unable to demonstrate the thermometer calibration procedure. * Dietary Aide 1 used the wrong strip to test the chemical concentration measured in parts per million of quaternary sanitizing solution used to sanitize food contact surfaces, and to test the chlorine concentration of the dish machine. * Dietary Aide 2 was unable to correctly describe how to manually wash dishes. These failures had the potential to lead to foodborne illnesses in a highly susceptible population of residents who received food prepared in the kitchen. Findings: Review of the facility's Diet Type Report dated 1/24/24, showed 30 of the 34 residents residing in the facility received foods prepared in the kitchen. Review of the facility's P&P titled Operation 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 3. On 1/23/24 at 1240 hours, a concurrent meal observation and interview was conducted with Resident 632 in his room. Resident 632 complained his meal tray was missing some of the food he ordered, and he received a food he did not order. Resident 632's meal ticket showed cob salad, cucumbers, fruit x3, and ice cream x3 marked off. Resident 632's meal tray was observed with missing cobb salad, cucumbers, fruit x3, and ice cream x3 and there was a light orange pureed food in a small bowl that was not listed in the meal ticket. The Culinary Director came to the room and verified there were missing food listed in the meal ticket and there was a pureed food which was a butterscotch pudding in the tray that was not listed. Medical record review for Resident 632 was initiated on 1/23/24. Resident 632 was admitted to the facility on [DATE]. Review of Resident 632's H&P examination dated 12/27/23, showed Resident 632 had the capacity to understand and make his own decisions. On 01/25/24 at 0930 hours, an interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the food preferences were honored for one of 13 final sampled residents (Resident 9). * Resident 329's tray card showed the resident preferred chef salad and cranberry juice. However, this was not served to the resident. This had the potential to negatively impact the resident's well-being. Findings: On 1/23/24 at 1230 hours, during the dining observation, Resident 329 was observed with a mixed green salad, ravioli with cream sauce, and steamed spinach on her tray. Resident 329 stated she preferred chef salad and a cranberry juice as per tray card. On 1/23/24 at 1235 hours, Dietary Aide 1 verified Resident 329 was not served chef salad and cranberry juice as per the resident's tray card. Medical record review for Resident 9 was initiated on 1/23/24. Resident 329 was admitted to the facility on [DATE]. Review of Resident 9's Selection Sheet dated 1/25/24, showed Resident 329's preferred cranberry…

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

Based on observation, interview, and facility P&P review, the facility failed to follow their policy to ensure foods brought into the facility for residents by visitors were properly stored and safely consumed. * The facility failed to ensure the nursing staff were trained on properly labeling the food items brought in by the visitors for the residents. This failure had the potential for unsafe food handling. Findings: Review of the facility's P&P titled Food Brought in by Family dated 8/27/21, showed the following: - Family members and visitors are requested to inform nursing staff of their desire to bring food into the facility; - Nursing staff will provide family/ visitors who wish to bring foods to the facility with a copy of this policy. Residents will also be provided a copy in a language and format they can understand; and - All personnel involved in preparing, handling, serving or assisting the resident with meals or snacks will be trained in safe food handling practices. On 1/23/24 at 0834 hours, an inspection of the refrigerator used for the residents' food brought in from…

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, record review and facility P&P, the facility failed to ensure the complete and accurate medical records for six of 13 final sampled residents (Residents 16, 19, 24, 25, 330, and 430) and one nonsampled resident (Resident 24). *Resident 24's insulin was documented incorrectly as being administered in their axilla for 13 instances. *Resident 16's insulin was documented incorrectly as being administered in their axilla for seven instances. In addition, Resident 16's Care Conference assessment was not completed timely. *Resident 25's insulin was documented incorrectly as being administered in their axilla for three instances. *Resident 19's insulin was documented incorrectly as being administered in their axilla for two instances. In addition, Resident 19's Care Conference assessment was not completed timely. *Resident 330's insulin was documented incorrectly as being administered in their axilla for one instance. *Resident 429's and 430's Care Conference assessments were incomplete. * Resident…

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

Based on interview and facility document review, the facility failed to implement their POC dated 2/6/23. There was no documentation to show the facility was monitoring the results of audits to the QAPI committee meetings to identify if they had achieved compliance threshold of 100% for repeated deficient practice cited at F695 in accordance with their POC for recertification survey dated 2/6/23. This failure had the potential to affect the quality of care for all the residents in the facility. Findings: On 1/26/24 at 1304 hours, an interview and concurrent facility document review was conducted with the Administrator and DON. Review of the POC submitted by the facility to the CDPH, L&C Program for the recertification survey completed on 2/6/23, showed the deficient practice cited at F695 related to oxygen order not indicating whether the oxygen should be continuous or as needed. The POC included the following: * Medical Records, RN Supervisor, the DON and/or designee will monitor daily all oxygen administration orders. * Findings will be discussed and reviewed daily during stand-up…

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, observation, facility document review, and facility P&P, the facility failed to ensure an appropriate infection control practices for one of 13 final sampled residents (Resident 429), two nonsampled residents (Residents 630 and 633) and in the facility laundry service area. * The facility failed to follow appropriate transmission-based precautions for Resident 429. * The facility failed to ensure the staff implemented handwashing with soap and water after caring for Resident 429 who was on contact isolation for C. Difficile to care for another resident. * The facility failed to ensure equipment used for Resident 429 who was infected with C. Difficle were appropriately disinfected. * The bedpans and basins for Residents 630 and 633 in a double bed room were not labelled. * The facility failed to ensure Resident 679's urinary drainage bag was kept off the floor. * The facility failed to ensure the employee's personal belongings were not in the clean linen folding area. These failures had the…

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

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 monitor and address the use of antibiotic to identify if the resident's condition did or did not meet the McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for four of 12 nonsampled residents (Residents 11, 13, 634, and 635). The facility failed to complete the criteria for indication of antibiotic use for Residents 11, 13, 634, and 635. In addtion, Resident 13's antibiotic order was not clarified with the physician regarding the stop date. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Infection Control 10-Antibiotic Stewardship dated 7/28/23, showed Infection Preventionist to utilize expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotics starts, monitoring adherence to evidence-based published criteria during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' bed were inspected, entrapment assessments were completed, and with the record of the bed inspection when identifying areas of possible entrapment with the use of bed rails for four of 13 final sampled residents (Residents 9, 25, 330, and 379). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between…

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 maintain the effective pest control program to prevent the presence of gnats in the main kitchen and the satellite kitchen. This failure had the potential to lead to food-borne illnesses (illnesses caused by food contaminated with bacteria, viruses, parasites or toxins) to the residents who eat food prepared in the kitchen. Findings: Review of the facility's Diet Type Report dated 1/24/24, showed 30 of the 34 residents residing in the facility received foods prepared in the kitchen. According to the USDA Food Code 2022, 6-501.111 Controlling Pests, showed insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. Review of the facility's P&P titled Pest Control revised May 2008 showed the facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. On 1/24/24 at 0832 hours, 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.