Veterans Home Of California - Yountville - SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment when: 1. Three of five staff (Contract Staff [CS] 1, Certified Nursing Assistant [CNA] 6, and Custodian Worker [HSK] 1) did not perform hand hygiene or utilize personal protective equipment (PPE- equipment worn to minimize exposure to infectious or hazardous materials, e.g. gown, gloves, mask, eye protection) in accordance with policy and procedure and nationally recognized infection prevention and control guidelines. 2. One of one custodian worker (HSK 1) did not follow facility procedure for the cleaning and disinfection of an occupied room. 3. Five of five staff (Laundry Supervisor [LS] 1, LW 1, LW 2, LW 3, and HSK 1) did not know the dwell time (the amount of time a disinfectant must remain visibly wet on a surface to effectively kill specific germs) of facility products used for disinfection. 4. Enhanced Barrier Precautions was not identified…

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 one of 29 sampled residents (Resident 31) remained free from restraint when Resident 31's bed was placed against the wall with four bedrails in the upright position and the bedside table positioned over Resident 31's body. This failure had the potential to obstruct Resident 31's mobility and cause injury. Findings: During a review of Resident 31's Face Sheet [FS- a quick summary sheet that healthcare providers use to access key information, like name and medical history], the FS indicated Resident 31 had diagnoses of Alzheimer's Disease (a brain disorder that gradually destroys memory and thinking skills) and Vascular Dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain). During an observation on 3/3/25 at 9:04 a.m. in Resident 31's room, Resident 31 laid on his back awake in bed. The right side of the bed was pushed up against the wall with the bedside table placed between the bedrails, over Resident 31'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 interview and record review, the facility failed to ensure Resident 57's medication was documented when Registered Nurse (RN) 6 did not document medications were given. This failure had the potential to cause negative health-related outcomes to Resident 57. Findings: During a review of Resident 57's Minimum Data Set (MDS- a tool for implementing standardized assessment and for facilitating care management in nursing homes) Section I- Active Diagnoses dated 2/6/25, the MDS indicated Resident 57 had the following diagnoses: Anemia (body does not produce enough healthy red blood cells to carry oxygen), Hypertension (high blood pressure), Diabetes Mellitus (high blood sugar), and Hyperlipidemia (too much fat in the blood). During a review of Resident 57's Current Medication Orders, the orders indicated, . Isosorb Mono (isosorbide mononitrate) Tab (tablet) 30 milligram (mg- unit of measure) ER (extended release) Take one (1) tablet by mouth every evening for heartbeat abnl (abnormal) . Atorvastatin Tab 80 mg . Take one (1) tablet by mouth every evening for Hyperlipidemia .…

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 a walk-in freezer when there was a large amount of ice build-up on the ceiling as well as ice build-up on boxes of food. The failure to maintain one freezer in one out of two kitchens had the potential to result in decreased quality and contamination of food. Findings: An observation in a walk-in freezer (referred to as the warehouse freezer) located in the Main Kitchen (where food was stored and prepared for the licensed care kitchen) on 3/4/25 at 10:25 a.m., showed ice build-up on the ceiling between wall mounted fans. The ice measured more than 24 inches long, 18 inches wide, and 2 inches thick. In addition, boxes of food stored below the fan had a layer of ice build-up on the top surface of the boxes. During a concurrent interview on 3/4/25 at 10:25 a.m., Food Manager (FM) 1 stated he did not know what the ice build-up was from. FM 1 confirmed there was ice build-up on boxes of food and stated he was unaware of the ice build-up. During an interview on 3/6/25 at 3:08 p.m., the Dietary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a safe environment by ensuring the safety of their residents for one of three sampled residents when Resident 1 was found dead outside the facility basement exit door. Findings: During a review of Resident 1's Interdisciplinary Note, dated [DATE] at 8:00 p.m., the note indicated Resident 1 was identified as missing at 6:00 p.m. on [DATE] when Resident 1 failed to return to the unit. A search for Resident 1 was initiated in the ward and throughout the building where the Skilled Nursing Facility (SNF) unit was located. A high-risk reportable incident was initiated. During a review of Resident 1's Patient Care Plan, dated [DATE], the plan indicated Resident 1 had the potential for Injury or Accident with his risk factors listed in Problem # 2 as a history of falls, chronic pain, neuropathy (a nerve condition that can lead to pain, numbness, weakness or tingling), weakness/unsteady gait, history of hypotensive (low blood pressure),…

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 F-580 Notification of Changes Based on interview and record review the facility failed to immediately notify the physician of a significant change of condition in Resident 1's breathing status with life threatening clinical complications warranting a transfer to the hospital. This failure resulted in a delay of care for Resident 1. Findings: During a review of Resident 1's hospital records titled, Emergency Department Provider Notes, dated [DATE] at 3:00 a.m., the note indicated around 6:30 p.m. [[DATE]] Resident 1 had a choking episode involving a hard-boiled egg at dinner. At around 1 a.m. [[DATE]] staff noted Resident 1 was in respiratory distress, with oxygen saturations (oxygen levels in the blood) in the 70's (normal range is 90-100). EMS (Emergency Medical System) transferred Resident 1 to the emergency department. The provider note indicated Resident 1 was a DNR/DNI (do not resuscitate/do not intubate, no artificial breathing or chest compressions) with selective treatment. Resident 1 was given morphine…

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 Doctor on Call (DOC 1) responded promptly to the notification of Resident 1's change of condition by nursing staff. This failure resulted in nursing staff not having the guidance of a physician to manage Resident 1's change of condition and transport to the emergency department. Findings: During an interview on 8/21/24 at 9:46 a.m. with LVN 2, LVN 2 stated, I tried to call the doctor, but she did not answer. I called two times, one after the other. I then notified the supervisor who advised me to call 911. LVN 2 could not recall the times. During an interview on 8/26/24 at 9:50 a.m. with the Doctor on Call 1 (DOC 1), DOC 1 stated on 8/2/24-8/3/24 NOC shift, I wanted to be notified if there was any change in condition. DOC 1 stated she received two calls from the facility that night, one at 1:02 a.m. and the other at 1:09 a.m. DOC 1 stated, I inadvertently turned my ringer off instead of down, so it would not bother my husband. Both calls were missed .I returned the call at 4:42 a.m., as soon as I realized I…

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 document complete and accurate records of assessments and interventions provided to Resident 1 during his change in medical condition. This failure resulted in Resident 1's medical records being incomplete and inaccurate. Findings: During a review of Resident 1's hospital records titled, Emergency Department Provider Notes, dated 8/3/24 at 3:00 a.m., the note indicated around 6:30 p.m. [8/2/24] Resident 1 had a choking episode involving a hard-boiled egg at dinner. At around 1 a.m. [8/3/24] staff noted Resident 1 was in respiratory distress, with oxygen saturations (oxygen levels in the blood) in the 70's (normal range is 90-100). EMS (Emergency Medical System) transferred Resident 1 to the emergency department. The provider note indicated Resident 1 was a DNR/DNI (do not resuscitate/do not intubate, no artificial breathing or chest compressions) with selective treatment. Resident 1 was given morphine (an opiate, a strong drug used to treat serious pain. Sometimes given to ease the feeling of shortness of breath) for air…

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 adequate supervision and follow their policy and procedure Missing resident and Elopement – Code Purple (SNF / ICF), for one of two sampled residents (Resident 1) when Resident 1 signed out of the unit and did not specify where he was going and gone for two days. The assigned nurse was aware that Resident 1 was out of the unit all night and didn't alert anyone. Unit staff initiated the policy for missing resident and elopement on the following day. These failures placed Resident 1's safety at risk for accidents, injuries, and resulted in Resident 1 going without scheduled and as needed medications for two days while he was at a motel in a nearby city. Findings: During a review of Resident 1's Face Sheet (FS-a document which contains patient medical history and contact details), undated, the FS indicated, Resident 1 had diagnoses of Schizoaffective Disorder (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1. Live roaches were found in a sticky trap on the floor under the stainless-steel counter in the nourishment area, behind the ice machine, in the room with the 3-compartment sink, and in the dish washing room of the staging kitchen of the [NAME] Building. Pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. 2. Floor under the counter tops had food crumbs and trash in the nourishment area, behind the ice machines, under the tray line assembly (where staff serve the food on plates for the residents), and in the house keeping closet in the staging kitchen in the [NAME] Building. In the main kitchen there was food crumbs and build up on the floors in the food production area, behind the tumble chill machine (large batches of food can be rapidly chilled), behind the steamer and under…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an effective pest control program when a roach infestation in the [NAME] staging kitchen persisted since 6/8/23, unsanitary conditions were observed that provide harborage conditions for pests (cross-reference F 812) and pests were being allowed entry into the kitchen. This had the potential for pests to transmit disease to residents by contaminating food and food-contact surfaces for 197 medically compromised residents who received food from the kitchen. Findings: During observations on 4/8/24 between 10:12 a.m. and 10:28 a.m., there were multiple sticky traps in the [NAME] staging kitchen that contained roaches. One of the sticky traps had three (3) live roaches. During multiple observations on 4/8/24 between 10:12 a.m. and 10:43 a.m., in the [NAME] staging kitchen, the floor under equipment had a build-up of food crumbs, trash and spilled liquid. During multiple observations on 4/8/24 between 10:12 a.m. and 10:38 a.m., in the…

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

Based on observation, interview and record review, the facility failed to provide reasonable accommodations for one of 35 sampled residents, Resident 120, and unsampled Residents 9, 185, and 64, by failing to ensure call lights were within reach in the restrooms. This failure had the potential to result in residents unable to request assistance when needed. Findings: During an observation on 4/8/24 at 11:07 a.m. in [NAME] 3, the restroom call-light pull-cord for Residents 120, 3, 185, and 64, were dangling from the wall, not within reach, and not properly latched to the toilet railing. During a concurrent observation and interview on 4/10/24 at 10:55 a.m. with Certified Nursing Assistant 1 (CNA 1) in [NAME] 3, CNA 1 was assisting Resident 9 with transferring to the restroom. The call-light pull-cord was observed to be not properly latched to the toilet railing and out of reach. CNA 1 demonstrated how to utilize the call-light and stated yes this cord needs to be latched on the railing. During an interview on 4/10/24 at 10:55 a.m. with Registered Nurse 2 (RN 2), RN 2 stated, The…

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

Based on observation, interview, and record review, the facility failed to ensure a clean environment when: 1. A visibly soiled wheelchair was stored in a hallway. 2. Staff did not clean the lift equipment after use. These failures had the potential to result in spreading disease causing organisms to residents using the unclean equipment. Findings: 1. During an observation on 4/8/24 at 11:12 a.m. in the main hallway of Unit 1B, there were four wheelchairs stored in the hallway. One wheelchair had dried brown substance along the front of the seat cushion. During an interview on 4/8/24 at 11:22 a.m. with (Minimum Data Set) MDS Coordinator (MDSC 2), MDSC 2 stated that the wheelchairs were usually cleaned on a schedule during the night shift. During a concurrent observation and interview on 4/8/24 at 11:22 a.m. with Supervising Registered Nurse (SRN 6), SRN 6 was observed using her gloved finger to remove some of the dried brown substance from the seat cushion. SRN 6 stated, It's coming off, it looks like it's coming off. During a review of the facility's policy and procedure (P&P)…

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 determine one of 35 sampled residents, (Resident 159) required a Significant Change in Status Assessment (SCSA) within 14 days of a significant decline with the Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents) when Resident 159 had an: 1. Emergence of a new unstageable (unable to determine where the injury begins and ends) pressure injury. 2. Emergence of unplanned weight loss problem. This failure had the potential to further complicate Resident 159's medical status as the facility did not convene in a timely manner to address interdisciplinary measures from the care team. Findings: 1. During a review of Resident 159's Physicians Orders, dated 2/15/24, the Physicians Orders indicated the need for a wound consult. During a review of Resident 159's Care Plan, dated 2/27/24, the Care Plan indicated date of onset for pressure injury was 2/27/24. During a review of Resident 159's Progress Note Wound Care, dated 3/1/24, the wound care note written by the wound care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to update the comprehensive care plan for Resident 120 that accurately stated assistive devices resident required. This failure resulted in the inability to track resident progress to provide continued comprehensive care for one of 35 sampled residents, Resident 120. Findings: During a review of Resident 120's medical record, the medical record indicated Resident 120 was admitted to the facility on [DATE], with diagnoses of Age-Related Cognitive Decline (gradual decline in memory, thinking, or other brain processes associated to age) and Generalized Muscle Weakness (lack of muscle strength), and Spondylosis of thoracic region (deterioration of the middle of the spine). During multiple observations on 4/8/24 at 10:46 a.m., on 4/9/24 at 1:49 p.m., on 4/10/24 at 12:24 p.m. and on 4/11/24 at 8:52 a.m., Resident 120 was observed sitting in a wheelchair. Resident 120 needed assistance from staff for ambulation with the wheelchair. Resident 120 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.

Based on interview and record review, the facility failed to revise a care plan for one of 35 sampled residents (Resident 99) when Resident 99's wound care orders were changed. This failure had the potential for miscommunication among staff and for Resident 99 to receive care that was no longer required, and to delay wound healing. Findings: During a review of Resident 99's Podiatry Clinic Note, dated 3/29/24, the Podiatry Clinic Note indicated, Resident 99 had bilateral heel wounds from ischemia (lack of blood supply to a part of the body) and peripheral arterial disease (narrowed arteries that reduce blood flow to the legs or arms). During a review of Resident 99's Physician Orders, dated 3/29/24, the Physician Orders indicated, Wound Care Orders . Frequency QOD [every other day] . apply a generous amount of betadine to all wound sites . The Physician Orders further indicated, D/C [discontinue] old orders. During a concurrent interview and record review on 4/10/24 at 10:12 a.m. with (Minumum Data Set) MDS Coordinator 2 (MDSC 2), Resident 99's Care Plan, dated 3/8/24 was reviewed.…

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 facility sponsored community activities for one of 35 sampled residents (Resident 80). This failure had the potential to prevent Resident 80 from obtaining a meaningful connection with his community and improving his quality of life. Findings: During an interview on 4/8/24 at 3:41 p.m. with Resident 80, Resident 80 stated, There is much to be desired with the 'facility' activities program. When I first came here, there were a lot of activities to choose from, outdoor experiences . Now I just get in my chair and go. We would go out to dinner and visit culinary schools .There is a fire house just down the street, I'd like to go there . I haven't seen that kind of outing in the last 3 years . I have requested these many times. During an interview on 4/9/24 at 10:41 a.m. with Recreational Therapist 1 (RT 1), RT 1 acknowledged Resident 80's preferences for community outings and stated he does not participate in outings within the community (outside of the facility). During an interview on 4/10/24 at 10:56 a.m., RT 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 35 sampled residents (Resident 597 and Resident 71) received the following: 1a. Resident 597 failed to receive timely cardiology (branch of medicine that deals with diseases and abnormalities of the heart) follow up after a fall as ordered by the Physician. This failure had the potential to adversely affect Resident 597's medical condition. 1b. Resident 597's referral to neurosurgery (medical specialty that diagnosis and treats diseases/disorders of the spine) was completed, as recommended by the Physician. This failure had the potential to adversely affect Resident 597's medical condition. 2. Resident 71's compression stockings were not changed regularly or when visibly soiled. This failure had the potential for Resident 71 to acquire skin irritation. Findings: 1a. During a review of Resident 597's admission Face Sheet Record (demographics), undated, the Face Sheet Record indicated, Resident 597 was admitted to Unit 1B on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an audiology assessment was conducted and right hearing aid was replaced in a timely manner for one of 35 sampled residents (Resident 120). This failure resulted in Resident 120 not receiving an audiology (branch of science and medicine concerned with the sense of hearing) assessment and replacement of the hearing aid. Findings: During a review of Resident 120's medical record, the medical record indicated that Resident 120 was admitted to the facility on [DATE], with diagnoses of Age-Related Cognitive Decline (gradual decline in memory, thinking, or other brain processes associated to age) and Sensorineural Hearing Loss (a type of hearing loss that stems from damage to inner ear). During a concurrent observation and interview on 4/8/24 at 3:27 p.m. with Resident 120 in [NAME] 3, Resident 120 was observed without his hearing aids. Resident 120 stated, things go missing all the time. When asked what things were missing, he mentioned…

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 Physical Therapy (PT) per physician's order in a timely manner for one of 35 sampled residents (Resident 120). This failure resulted in delay of care (greater than one month) for Resident 120, that contributed to prolonged use of wheelchair and decline in mobility. Findings: During multiple observations on 4/8/24 at 10:46 a.m., 4/9/24 at 1:49 p.m., 4/10/24 at 12:24 p.m. and 4/11/24 at 8:52 a.m., Resident 120 was observed sitting in a wheelchair. Resident 120 required assistance from staff for ambulation with the wheelchair. Resident 120 was not observed using any other assistive devices. During a review of Resident 120's Restorative Nurse Referral Note, dated 1/7/24, the Restorative Nurse Referral Note indicated, Resident 120's reason for referral: to maintain range of motion . strength, functional mobility, maintain endurance and prevent deconditioning . ambulate with 4WW (four-wheeled walker) assistive device and stand by assistance . Care plan initiated 1/7/24- plan of care: range of motion…

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 a discontinued Novolin R Insulin Sliding Scale (dose of insulin based on blood glucose level) was not carried over to the current physician's order for one of 35 sampled residents (Resident 79). This failure had the potential for medication administration error. Findings: During a review of Resident 79's current physician's recapitulation order, dated 2/1/24, indicated two different Novolin R Insulin Sliding Scales which included the following; 1. 12/21/23 Novolin R insulin per sliding scale . 150 - 200 = 3 units 201 - 250 = 6 units 251 - 300 = 9 units 301 - 350 = 12 units > (greater than) 351 = 15 units. 2. (undated) * Sliding Scale * Novolin R : 150 - 200 = 3 units 201 - 250 = 6 units 251 - 300 = 9 units 301 to 350 = 12 units 351 - 400 = 15 units 401 - 450 = 18 units >451 = 21 units. During an interview on 4/10/24 at 1:30 p.m. with the Nurse Practitioner 1 (NP 1), NP 1 stated the undated sliding scale was discontinued on 8/5/22. NP 1 stated the discontinued sliding scale should not have been carried over to…

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

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals used in the facility were properly stored when Resident 43's Voltaren (a topical medication for pain) was found stored without a cap in a container with other residents medications. This failure had the potential to result in medication contamination and compromised effectiveness. Findings: During a concurrent observation and interview on 4/10/24 at 8:20 a.m. with MDS (Minimum Data Set) Coordinator 2 (MDSC 2), of Unit 1B's treatment cart, Resident 43's Voltaren was found stored in a cassette mixed with other resident medications. The cap was missing from the Voltaren tube. The MDSC 2 stated that the medication should have a cap on it to keep it moist and clean. During a review of the facility's policy and procedure (P&P) titled, Medication, Storage & Labels, dated 3/14/23, the P&P indicated, Drug Containers . Containers which are cracked, soiled, or without secure closures will not be used.

Based on observation, interview, and record review, the facility failed to maintain Transmission Based Precautions (infection control precautions) for one of 35 sampled residents (Resident 156) and one unsampled resident (Resident 130) when: 1. An Xray Technician (XT) did not wear the required Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards) while providing care for Resident 156, who was on droplet isolation precautions (measures used to protect residents, staff, and visitors from exposure with infectious agents). 2. Resident 130 was exposed to contaminated Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards), when placement of a PPE disposal bin obstructed the path to his bed. These failures had the potential to result in cross-contamination and the spread of infectious diseases to residents, staff and visitors. Findings: 1. During an observation on 4/9/24 at 11:25 a.m., in [NAME] 3 of Resident 156's room, XT was observed performing a procedure while wearing only a surgical mask and no other articles of PPE. XT was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide residents with a safe, functional, sanitary, and comfortable environment when: 1. Unit [NAME] 1D had visibly soiled windows in the entry hallway. 2. In room [ROOM NUMBER], a urinal was unlabeled and undated for Resident 188. These failures resulted in an unsafe and unsanitary environment for the residents. Findings: 1. During an observation on 4/8/24 at 8:50 a.m., Unit [NAME] 1D had three (3) windows near the main entrance visibly soiled from the outside, and had spider webs on the inside. During an observation and concurrent interview on 4/9/24 at 8:55 a.m. with Supervising Registered Nurse 1 (SRN 1), SRN 1 confirmed and stated three (3) North facing windows near the entry to the unit looked dirty from the outside and had spider webs on the inside. SRN 1 stated she did not know how long the windows had been like that. SRN 1 stated it didn't look homelike. SRN 1 stated housekeeping was responsible for the cleaning of the windows.…

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 three residents (Resident 1) had an updated Care Plan. This failure had the potential to place Resident 1 at risk for preventable falls and potential injury. Findings: During a review of the facility Occupational Therapy (OT) Evaluation Note, dated 2/12/24, the Occupational Therapist 1 (OT 1) documented for a visit occurring on 2/5/24. The assessment indicated, Patient (Pt) will benefit from Stand By Assist (SBA)-(CGA) Contact Guard Assist for out of bed mobility and activity/transfers/functional ambulation for safety .Pt will benefit from line-of-sight supervision from nursing. Pt with impaired safety, ADL's, functional mobility, fall risk, impaired cognition. During an interview on 3/15/24 at 11:45 AM with OT 1, OT 1 stated that a home evaluation was ordered for weakness. OT 1 stated her assessment found the resident would benefit from stand by assistance (SBA) to contact guard assistance (CGA) while ambulating for safety. OT 1 stated her recommendations included line-of-sight supervision from nursing staff.…

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 three sampled residents (Resident 1) was 1.) Provided a timely occupational therapy (OT) evaluation. 2.) Followed occupation therapy recommendations for care. This failure led to several potentially preventable falls for Resident 1 and had the potential for additional falls and injury. Findings: 1.) During a review of OT Communication Note dated 1/30/24, the note indicated an OT evaluation order was placed on 1/8/24 for diagnosis of weakness. It indicated on 1/30/24 OT 1 attempted to evaluate Patient 1. The note indicated, Nurse reports patient feels his Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) is progressing. Patient in computer room per RN will f/u (follow up) when patient is available. During a review of the facility's policy and procedure (P&P) titled, Physical and Occupational Therapy Services, dated 7/31/23, the P&P indicated, Physical/Occupational Therapy Evaluation referrals for acute…

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 maintain medical records that were accurately documented for 1of 1 sampled residents (Resident 1) when Resident 1's medical record contained numerous inaccurate entries. This failure resulted in health information and diagnoses that did not pertain to Resident 1 and had the potential that planning of patient care and treatment could be effected. Findings: During a review of the admission Face Sheet Record for Resident 1, print date 5/15/23, the admission record indicated Resident 1 was an [AGE] year old individual admitted to the facility on [DATE]. During a review of a PNP (Primary Nurse Practitioner) 30 Day Note for Resident 1, dated 5/19/23, the progress note indicated, Addedndum: [sic] 7/27/2023 Corrections. Documentation indicated multiple corrections were noted to address inaccurate entries in the medical record pertaining to Resident 1. Corrections included the areas of Resident 1's diagnoses, social history, age, health care maintenance…

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.