Yuba City Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview and Record Review the facility failed to report a crime or abuse incident for 1 of 3 residents (Resident 1) when Resident 2 ' s Family Member (FM) exposed himself to Resident 1 while in Resident 1 and Resident 2 ' s shared room. This failure to report to proper authorities placed all residents at risk for allegations of abuse to go unreported. Findings: During a review of the facility ' s policy and procedure titled, Abuse Investigation and Reporting, revised December 2018, the Abuse Investigation and Reporting policy indicated, All reports of resident abuse .(and) mistreatment .shall be promptly reported to local state and federal agencies . A review of Resident 1 ' s medical record indicated Resident 1 was admitted on [DATE] with diagnoses that included, Right Femur Fracture, R Femur Surgical Intervention, and History of Falls. The Minimum Data Set (MDS, Tool for evaluating and implementing a standardized assessment) Brief Interview for Mental Status (BIMS, Section C assessing cognitive…

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 adequate supervision based on individual resident needs, for three out of three sampled residents (Residents 34, 50, and 28) when: 1. Facility staff was aware Resident 34 wandered (roamed from place to place) in and out of other resident rooms. 2. Facility staff was aware Resident 50 wandered in and out of other resident rooms. 3. Facility staff was aware that Resident 28 demonstrated daily episodes of increased agitation and volatility exhibited by yelling, cursing, and throwing items. This failure had the potential to impact resident safety, privacy, dignity, and placed residents at an increased risk for resident-to-resident altercations. Findings: 1. A review of the facility's policy and procedure (P&P) titled, Wandering and Elopement, revised 10/1/23, indicated, the facility staff would identify residents who were at risk for unsafe wandering and develop a plan to keep the residents safe. A review of the Resident [NAME] of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assure that there was sufficient, qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for 11 of 30 residents (Resident 215, 28, 57, 45, 5, and 365), and Confidential Interview Residents), when call lights were observed and reported to go unanswered for extended periods of time resulting in: 1. Residents being left in soiled briefs with bowel movement and/ or urine. 2. Residents being left on the toilet for extended periods of time. 3. Residents left waiting for assistance in bed for a variety of reasons, including for generalized needs, or attempting to receive assistance to go to the to toilet. 4. Residents experiencing health concerns such as pain and shortness of breath (SOB). This failure had the potential to result in skin breakdown, increased overall pain, increase of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure complete Medication Regimen Reviews (MRR) were performed for medication irregularities, appropriate indication (reason for use), and/or unnecessary psychotropic (affecting mental state) medications for two of four sampled residents (Residents 50 and 25) when: 1A. The indication for Seroquel (medication affecting mental processing and behaviors) use of mood disorder as evidenced by (AEB) striking during care was determined appropriate for Resident 50 on two MRRs by Consultant Pharmacist (CPH), though medication necessity and effectiveness had not been evaluated (50 days after admission) by the Psychotropic Interdisciplinary Team (IDT - group of professional healthcare providers including physician(s), nurses, pharmacists who meet to determine appropriateness of resident medication treatment plans). 1B. No medication irregularities were reported by CPH for Resident 50 despite Seroquel being administered in combination with donepezil…

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

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5 percent for two of six sampled residents (Residents 25 and 216) when: 1. For Resident 25, Licensed Nurse D (LN D) administered one oxybutynin extended-release (ER) 5 milligrams (mg - a unit of measure) tablet rather than the ordered oxybutynin chloride 5 mg, an immediate-release (IR) tablet, to treat overactive bladder. 2. For Resident 216, LN D did not administer scheduled or as-needed pain medications when Resident 216 stated his pain was 10 on a scale of 1 to 10 (1 being the lowest pain, 10 being the highest). These failures resulted in two medication errors identified out of 29 opportunities, resulting in a medication error rate of 6.9 percent, with the potential for adverse health consequences from medication toxicity effect and unaddressed pain. FINDINGS: 1. During a review of Resident 25's medical records, the record indicated Resident 25 was admitted in 10/2023 with diagnoses of unspecified symptoms of the genitourinary system (organs of the urinary…

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

Based on observation, interview, and record review, the facility failed to ensure medications and medication supplies were stored and labeled in accordance with currently accepted professional principles when: 1. A discontinued medication was not removed and discarded from an active medication drawer in Medication Cart A (MC A), 2. Six multi-dose tubes of noncontrolled medicated creams (prescription medications with less risk of addiction and abuse) were in a facility supply basket in Treatment Cart 1 (TC 1) without patient-specific labeling, 3. A used oral medication syringe was affixed with a rubber band to a bottle of liquid Keppra (anti-seizure medication) for reuse and was stored in a drawer of TC 1, 4. A bottle of glucose test strips was open and undated in MC A, 5. Eight loose pills were found in drawers and on the bottom of MC A, 6. A bottle of ketoconazole shampoo (antifungal) in TC 1 was being used on a resident despite an expiration date of 7/2023, and 7. An intravenous (IV) line filter (filters potential impurities to prevent infection) that expired 9/1/23 was in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the food and nutrition services department failed to provide food that was palatable (good temperature, tasted good) when residents from a confidential interview and 11 out of 22 sampled residents (Residents 5, 16, 28, 30, 37, 38, 43, 45, 57, 59, and 215) stated the food did not taste good and was cold. This failure had the potential for unintended weight loss. Findings: A review of the facility's undated policy and procedure titled, Meal Service, indicated, Temperature of the food when the resident receives it is based on palatability. The goal is to serve cold food cold and hot food hot. A review of the undated admission Record, indicated, Resident 57 was admitted to the facility on [DATE] with the diagnoses of type 1 diabetes and type 2 diabetes (body could not regulate the amount of sugar in the blood). Resident 57 was her own responsible party (RP, made own decisions). A review of Resident 57's Minimum Data Set (MDS, an assessment), dated 7/20/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse to local, state, and federal agencies, including the California Department of Public Health (CDPH), when Certified Nurse Assistant (CNA) E stated, CNA E observed Resident 48 shaking a fist and making verbal threats to harm Resident 50. This failure placed all residents at risk for allegations of abuse to go unreported. Findings: A review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, revised 7/1/17, indicated, reports of alleged abuse would be reported to local, state, and federal agencies. A review of the facility's P&P titled, Abuse Prevention Program, revised 2/1/24, indicated, residents had the right to be free from abuse. A review of the State Operation Manual, revised 8/8/24, defined abuse as a willful infliction that included verbal abuse or intimidation, which could affect a person's psychosocial well-being. A review of the undated admission Record, indicated, Resident 48…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise care plans (a document that described health conditions, the level of care the resident required, and how that care would be provided) for two out of two sampled residents (Residents 34 and 50) when: 1. Resident 34's care plan was not revised to include wandering behaviors (roaming from place to place). 2. Resident 50's care plan was not revised to include a change in wandering behaviors. This failure had the potential to cause a decline in physical, mental, and psychosocial well-being and placed Residents 34 and 50 at risk for harm. Findings: 1. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive, indicated, the care plan would Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The P&P indicated, the care plan would Incorporate identified problem areas and that care plans would be revised when 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents' pain was managed for 1 of 30 residents (Resident 216) sampled for pain management when Resident 216 complained of having pain in their ribs and low back while making facial expressions and exhibiting body movements that demonstrate signs related to the experience of pain. Resident 216 was unable to verbalize a specific number to represent the level of pain being experienced per the Pain Scale (standardized numeric scale to identify an individual's pain level. Scale rates pain from 0-10; 0 = no pain to 10 = most severe pain). Thus, Resident 216 did not receive pain medication per the medical doctor's (MD) orders. This failure had the potential to result in an overall increase of pain, decline in mobility, increased health issue complications, and diminished mental, emotional, and psychosocial well-being. Findings: During a review of the facility's policy and procedure titled, Pain Assessment and Management, 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, and record review, the facility failed to review indications for continued use or attempt Gradual Dose Reduction (GDR - tapering of a dose to determine if symptoms, conditions, or risks can be managed by lowering or discontinuing medication) for 50 days for one of one sampled resident (Resident 50) receiving four psychotropic medications: (1) lorazepam (anti-anxiety medication that slows brain activity for relaxation), (2) Seroquel (anti-psychotic medication, indicated for psychosis, that improves mood, thoughts, and behaviors), (3) trazodone (anti-depressant medication), and (4) sertraline (anti-depressant - increases serotonin, a mood-enhancing chemical, in the brain). Psychotropic medications affect brain activities associated with mental processes and behaviors and include anti-psychotic, anti-depressant, and anti-anxiety medications. This deficient practice had the potential for Resident 50 to experience adverse (negative, potentially harmful) side effects 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.

Based on observation, interview, and record review, the facility failed to honor resident food preferences (food that was liked or disliked) and did not serve accurate portions when: 1. One out of five sampled residents (Resident 45) stated, the facility served food that Resident 45 did not like. 2. The facility did not provide the correct portion size of fish to residents during lunch on 8/29/24. These failures had the potential for unintended weight gain or unintended weight loss which could negatively impact resident health. Findings: 1. A review of the facility's undated policy and procedure (P&P) titled, Foods Brought by Family/Visitors, indicated, resident food choices would be honored when able. A review of Resident 45's undated admission Record, indicated, admission to the facility on 5/14/24 with the diagnoses of gastro-esophageal reflux disease (stomach acid backs up into the tube that connected the stomach to the throat) and major depressive disorder (a sad mood). Resident 45 was her own responsible party (RP, made own decisions). A review of the Minimum Data Set (MDS, an…

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

Based on observation, interview, and record review, the facility failed to maintain equipment in good repair when the pots and fry pans had a black build up on the outside, the inside protective layer of the fry pans was missing (caused metal to be exposed), and one fry pan had a thick, black buildup of material on the inside where food was cooked. This failure had the potential to contaminate food and cause a decline in resident health. Findings: The facility's undated policy and procedure (P&P) titled, Sanitation, indicated, all equipment would be kept clean and in good repair. During a concurrent observation and interview on 8/29/24 at 11:10 a.m., located in the facility's kitchen, with the Certified Dietary Manager (CDM), the pots and fry pans were observed. The pots and fry pans had a black build up on the outside, the protective layer on the inside of the fry pans was missing, and one fry pan had a thick, layer of black residue on the inside, where resident food was cooked. CDM confirmed the findings and stated, CDM had ordered new pots and pans last week. A copy 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 record review, the facility failed to provide the necessary care and services to ensure that a resident's needs and choices for personal hygiene (dressing, grooming, and oral care) were met for three of three sampled residents (Resident 1, 2, and 3). This failure had the potential to adversely affect the resident's psychosocial well-being by not receiving hygiene and feeling dirty. Findings: A review of the facility's policy, titled Activities of Daily Living (ADLs), Supporting , revised 3/2018, the policy indicated: 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLS independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). b. Mobility (transfer and ambulation, 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 observation, interview and record review, the facility failed to provide reasonable accommodation to meet the resident's need and preferences for one of three sampled residents (Resident 3), when a shower schedule was not provided and a shower was offered before bedtime, which was too late according to the resident's preferences. This failure resulted in Resident 3 missing her shower and feeling disappointed. Findings: During a review of the facility policy titled Activities of Daily Living (ADLs), Supporting , revised 3/2018, the policy indicated: 1. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. During a review of Resident 3's clinical record, indicated that she was admitted…

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 that their Quality Assurance and Performance Improvement plan (QAPI) committee identified and developed action plans to correct the deficient practices in the delivery of quality nursing care, prior to the survey findings. These failures resulted in a substandard quality of nursing care and actual harm to one resident (Resident 99). These failures had the potential to further affect the health, safety and well-being of all of the residents in the facility and leave them vulnerable to poor quality nursing care. Findings: On 10/14/2021 at 1:15 PM, a concurrent interview and review of the facility's QAPI binder was conduced with the Admin. The Admin stated that it is the responsibility of each department manager to identify resident care areas that need improvement. The department manager should then bring their quality of care concerns to the QAPI committee meetings that are held monthly and quarterly. The purpose of the meetings were to identify and develop action plans to correct these deficient areas. This should…

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 ensure nursing staff completed timely a comprehensive quarterly assessment for one of 12 residents (Resident 99). This failure resulted in no plan of care for Resident 99's non-verbal pain to go unrecognized and untreated. Findings: A review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, indicated a comprehensive, person centered care plan is developed within seven days of the completion of the required Minimum Data Set (MDS, resident assessment). At least quarterly the Interdisciplinary Team (IDT- group of health care disciplines that discuss resident care needs) in conjunction with the quarterly MDS will meet to review and update the care plan. Assessments of residents are ongoing and care plans are revised as information about the resident's conditions change. A review of Resident 99's record indicated she was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease…

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 develop and/or revise the care plans for three of three sampled residents (Resident 346, 29, and 99) when: 1. Resident 346 had no care plan developed for a pressure injury (bed sore) and for psychotropic drug use (drugs that alter mood and behavior). This resulted in Resident 346 having no plan for the treatment of her pressure injury and no goals for using psychotropic drugs. 2. Resident 29's care plan was not revised with specific interventions for irrigating a suprapubic catheter (a tube that goes directly into the bladder from the abdomen to drain urine when the kidneys no longer work). This resulted in Resident 29 receiving unsterile catheter care when it should have been sterile. 3. Resident 99 did not have a care plan developed for non verbal pain and for her peripheral vascular disease (decreased blood flow). This resulted in Resident 99's non verbal signs of pain and decreased blood flow in her right leg to go unrecognized 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 record review, the facility failed to implement it's care plan for one of 37 residents (Resident 10) according to policy on falls. This resulted in the resident experiencing a fall, and created the potential for further falls, injury, illness and death. Findings: Resident 10 was admitted to the facility on [DATE] with acute respiratory disease (rapid onset of a breathing problem), multiple sclerosis (a disease that attacks muscle coordination), Alzheimer's, dementia, and a history of falling. A review of the facility's record titled Falls: Policy and Implementation (Revised March, 2018) indicated: The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Further, In conjunction with the attending physician, staff will identify and implement relevant interventions. A review of Resident 10's medical record included a Fall 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 interview and record review, the facility failed to accurately complete pain management assessment, develop and implemented a comprehensive person-centered plan for non verbal pain for one of four residents (Resident 99). As a result, Resident 99 suffered unnecessary severe pain from a blot clot that required surgical intervention for a right above knee amputation. Findings: A review of a facility policy titled, Administering Pain Medications, revised October 2017, indicated pain management is the process of alleviating residents pain to a level that is acceptable to the resident. Be familiar with non verbal signs of pain for example: groaning, crying, screaming, facial expressions of grimacing and frowning, changes in skin color, behaviors such as resisting care, irritability, decreased participation in activities, guarding, and loss of appetite. Wong-Baker faces pain rating scale for non verbal cognitively impaired (dementia) residents. Conduct an interview or observation for resident pain status, 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, and record review the facility failed to ensure that nursing staff possessed the competencies and skill set necessary to provide nursing care for 3 of 12 sampled residents (Residents 20, 29 and 99) when: 1. Nursing staff did not have sufficient knowledge to appropriately assess and manage a PICC line for Resident 20 when a Peripherally Inserted Central Catheter (PICC) (a medical device that was placed into a large vein to allow access to the bloodstream) clotted two times, the tip of the PICC was not in a favorable position for IV therapy to be administered, two doses of antibiotic therapy were missed, the PICC line cap was missing, and physcian orders for catheter flush was incorrect; 2. Nursing staff did not have sufficient knowledge of sterile bladder irrigation technique for Resident 29; and 3. Nursing staff failed to do skin assessments for Resident 99 and Resident 20. Findings: 1. A review of the facility's contracted pharmacy's ( the pharmacy that provided and supported…

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 Dietetic Services observation, Registered Dietitian and Dietary Services Supervisor interview, and departmental document review, the facility failed: 1) To ensure the Dietary Services Supervisor (DSS) completed the required 6 hours of State regulatory training prior to assuming the leadership role. 2) To ensure the Registered Dietitian and/or Dietary Services Supervisor provided comprehensive oversight and staff guidance when: 2A) Staff did not perform food safety procedures such as food thawing, labeling and dating, food temperature monitoring, according to professional standards of practice. 2B) There was not an effective system in place to ensure cooks prepared adequate food to meet resident nutrition needs and preferences. 2C) There was not an effective system in place to ensure staff initial training, competency, and adequate monitoring of competence or performance during day to day operations. These failures have to potential to result in foodborne illness and to negatively impact meal satisfaction, meal intake and overall health of residents who receive food from 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 staff were competent to perform food preparation and food safety processes according to professional standards when: 1. Two staff did not monitor food cooking and serving temperatures consistently to ensure food safety and palatability. 2. Two staff did not follow menu spreadsheets or prepare and serve adequate amounts of food to meet menu requirements and resident needs. 3. Staff did not correctly label and date food. 4. Staff did not use safe food thawing processes. Failure to ensure staff are competent to complete essential job and food safety functions increases the potential for foodborne illness to occur and also increases the risk that meals provided will not meet the nutritional needs and preferences of residents. It has the potential to negatively impact resident's meal satisfaction, meal intake and overall health. Findings: Review of a document titled Job Description: Cook showed the cook is responsible to ensure that foods are prepared and served at the proper temperature and at the proper…

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 develop a menu in accordance with physicians' orders, cultural/ethnic needs and/or resident preference for 3 out of 3 residents (Residents 27, 39 and 195) with a vegetarian diet order. This failure increased the risk that meals provided to vegetarian residents would not meet their nutritional needs and had the potential to negatively impact resident's meal satisfaction, meal intake and overall health. Findings: A tray ticket is a document placed on each resident's meal tray every meal. It provided direction for what staff should place on each resident's tray. It showed the resident's name, room number, diet order, food allergies/dislikes, beverages/special equipment to be provided, and food preferences. During an observation, concurrent record review, and interview with the Registered Dietitian (RD) on 10/11/21 at 9:15 AM, the RD was asked to provide a copy of the facility menu titled Good For Your Health Menus Fall, Week 2, dated October…

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

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared and distributed in accordance with professional food safety standards when: 1) Food was not thawed, labeled, dated, or discarded appropriately. 2) Cooked food temperatures were not consistently monitored or documented. 3) Food service equipment was not clean, and manufacturer's instructions were not followed when sanitizing fixed equipment. 4) Staff personal food and personal possessions were in use in food preparation areas. These practices have the potential to result in foodborne illness for residents consuming food from the facility food services. Findings: 1) Food was not thawed, labeled, dated, or discarded appropriately. 1.A. Thawing Nutritional Shakes - During an observation in the kitchen on 10/11/21 at 9:00 AM the single door reach-in refrigerator near the coffee machine contained a plastic bin of individual cartons of nutritional shakes dated Prepared on date 10/11. The shakes were completely thawed and did not feel cold. The external temperature indicator read 33…

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 have an effective process in place to ensure one of three sampled residents (Resident 39) and all residents that had food items brought into the facility, were able to receive safe and sanitary food brought in by family or others, and receive assistance with reheating and preparation of food when: 1. Food was not allowed if it did not comply with the resident's diet order. 2. Hot food brought in by family or others was discarded if not eaten within an hour. 3. Nursing would not reheat food for residents. Findings: During an observation of tray line on 10/11/21 at 9:50 AM, the tray tickets (list resident diet order, allergies, food preferences) showed 3 residents (Res) (Res-27, Res-39, Res195) had diet orders including Vegetarian. During an observation and concurrent interview on 10/12/21 09:58 AM, a small, white, refrigerator for storage of resident food was in the nursing station medication room. It contained nutrition supplement…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow their infection prevention policies and procedures for 3 of 7 sampled residents when: 1. They performed bladder irrigations (using a large syringe with a solution to flush out sediment and matter that may plug the drainage of the catheter) on the resident without using a sterile technique (creating a sterile (germ free) field for the procedure) or sterile supplies (sterile gloves and sterile bladder irrigation kits) and; 2. Nursing staff provided incontinent care (cleansing after emptying the bowel and bladder) without changing gloves or sanitizing their hands before continuing with other care and; 3. Oxygen tubing was observed on the floor beneath the oxygen concentrator (a machine powered by electricity that separates oxygen from the air and delivers it to the resident via the tubing). These failures had the potential to negatively impact the resident's quality of life and quality of care by exposing them to unnecessary bacteria…

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 make sure that the call system was within reach for one of twelve sampled residents (Resident 9). This failure had the potential to put Resident 9 at risk for not getting help when needed which could have threatened their well-being. Findings: Review of the facility policy, titled, Answering the Call Light, dated 1/1/2001, indicated that staff were instructed to make sure that the call light was within easy reach of the resident. Staff were to have reported all defective call lights to the nurse supervisor promptly. Review of the facility document, titled, C.N.A. Clinical Performance Evaluation, dated 9/1/2019, showed a checklist of skills that Certified Nursing Assistants (CNAs) were to have demonstrated. Under the Performance Area category of Safety Awareness, the first item listed was, Call cord within reach. Review of Resident 9's clinical record showed admission to the facility on 3/20/2021 with diagnoses that included Parkinson's disease (a chronic disease of the central nervous system that affected…

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 notify a physician of a change of condition for one of 12 residents (Resident 99) when she had severe pain caused by decreased blood circulation in her right leg. This resulted in Resident 99 having continued severe pain due to a blood clot that required surgical intervention of removing her right leg above the knee. Findings: A review of a facility policy titled, Change in Resident's Condition or Status, revised December 2016, indicated the facility staff should promptly notify the resident, attending physician in changes in a residents medical/mental condition. The Licensed Nurse (LN) will notify physician when a significant change in the resident's physical/emotional/mental condition and the need to alter the resident's medical treatment. A significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff. The nurse will make detailed observations and gather relevant…

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 services to maintain good grooming and hygiene for one of twelve sampled residents (Resident 9) when the resident's fingernails were long and dirty. This failure had the potential to cause breaks in Resident 9's skin and to spread germs which could have caused infections. Findings: Review of the facility document, titled, C.N.A. Clinical Performance Evaluation, dated 9/1/2019, showed a checklist of skills that Certified Nursing Assistants (CNAs) were to have demonstrated. Under the Performance Area category of Personal Care Skills, one of the items listed was, Fingernails clean. Review of the facility policy, titled, Care of Fingernails/Toenails, revised 10/1/2010, indicated its purpose was to clean the nail bed, to keep nails trimmed, and to prevent infections. Under the general guidelines listed, the policy indicated that trimmed and smooth nails prevented the resident from accidentally scratching and injuring their skin. Staff were instructed not to trim the nails of diabetic residents or residents…

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 ensure nursing staff developed and implemented a resident plan of care for two of four residents (Resident 99 and ) when: 1. Resident 99's change of condition for skin and pain were not identifed through the nursing assessments. This failure resulted in Resident 99 to have severe pain and required surgical intervention for a right above knee amputation. 2. The nursing staff failed to provide appropriate care and services according to facility's policy and professional standards of care to assess and maintain Resident 20's Peripherally Inserted Central Catheter (PICC) (A soft, long catheter that is inserted into a vein in the arm and the tip is positioned in a large vein near the heart). This failure caused the PICC line to be replaced two times, two doses of antibiotic therapy to be missed, and an increased risk of infection for Resident 20. Findings: A review of Resident 99's record indicated she was admitted to the facility on [DATE], with diagnoses…

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 protect one of three residents (Resident 10) from accidental hazards when it did not follow its policy for resident safety. This resulted in a resident's fall and the potential for further falls, injury, illness and death. Refer to tag F658. Findings: Resident 10's record was reviewed. Resident 10 was admitted to the facility on [DATE] with diagnoses which included acute respiratory disease (onset of a breathing problem), multiple sclerosis (a disease that attacks muscle coordination), Alzheimer's, dementia, and a history of falling. A review of the facility's record titled Safety and Supervision of Residents dated January 2011 indicated, Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QA&A (Quality Assessment and Assurance) reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all…

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 that 3 of 5 sampled Residents were free from unnecessary psychotropic drug use (drugs that are used to control or alter mood and behavior such as antipsychotic, antianxiety, antidepressant and hypnotic medications), when they either monitored the wrong side effect for the drug, had no monitor in place, or had not monitored a target symptom (behavior). This lack of correct monitoring had the potential to negatively impact the Residents quality of life by subjecting them to unrecognized potentially life-threatening and uncomfortable adverse medication side effects and impair their mental, physical and emotional well-being. (Residents 29, 38 and 346). Findings: According to LexiComp, an online drug information site for professionals: The adverse side effects of ANTIPSYCHOTIC drugs include; Life threatening heart rhythms, Akathisia (muscle quivering and inability to sit still), Parkinsonism (tremors, stiffness, slow movements, and loss…

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.