The Ching Villas

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the nursing staff provided the standard of quality care to one of three Residents (R)1 sampled. 1.) R1 had a peripheral intravenous access (PIV) in his right arm for three days, with no order. 2) Staff used R1's hospital weight as his baseline weight upon admission, and 3) Licensed Staff (LS)4 did not document a neurological assessment and monitoring as required, to ensure there was no change of condition. The deficient practice placed R1 at an increased risk of infection at the catheter site; an increased the risk of his nutritional needs not being met; and an increased risk of acquiring an unidentified medical condition that may result in a negative outcome. Findings include:R1's electronic medical record (EMR) reviewed. R1 was an [AGE] year-old male admitted to the facility on [DATE] for Physical and Occupational Therapy after hospitalization for a stroke. As a result of his stroke, he had dysphagia (difficulty swallowing), and expressive…

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 an interview and record review, the facility failed to identify and report a medication error to the Administrator or Director of Nursing (DON) for review and appropriate action as required by facility policy. Resident (R) 1 was ordered Lisinopril (to treat high blood pressure) 2.5 mg (milligrams) orally and hold the medication if the resident's Systolic Blood Pressure (SBP) was less than 120 millimeters (mm) of mercury (Hg). Although R1's SBP was documented as 113 mm Hg, the Lisinopril was administered, when it should have been held. Findings Include: R1's Electronic Medical Record (EMR) reviewed on 10/09/25. The physician orders documented an order for Lisinopril 2.5 mg, to be given once an evening, hold for systolic blood pressure (SBP) less than 120 (started on 09/03/25, ended 09/16/25). R1's September 2025 Medication Administration Record (MAR) reviewed. On 09/12/25 R1's SBP was documented to be 113, lower than the required parameter for administering the medication. The medication order was not followed, and the resident was administered Lisinopril 2.5 mg. On 10/09/25…

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 safe handling and disposal of a soiled bed pad/brief for one Resident (R)1. R1 was transferred to the hospital from the facility on 09/18/25. The resident's belongings were collected from R1's room, bagged, and placed at the nursing station until it was picked up by R1's Family Member (FM)3 on 09/22/25. FM3 discovered a soiled bed pad/brief in a bag marked as the resident's belongings. Findings Include: On 09/25/25 at 07:50 PM, the State Agency (SA) received a complaint via email that a soiled (with urine and feces) bed pad/ brief was found in a bag given to them as part of the resident's belongings. The bag was labeled with R1's name and room number. Pictures of all the resident's belongings bags (five bags; one gift bag with a balloon, two blue personal belongings bags, and two clear bags). In a picture (P1), in one of two Clear Bags (CB)1, any reasonable person could identify blue material (bed pad/brief), inside the bag just by looking at it. A second picture (P2) documented the inside of CB1, which contained 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 facility failed to identify, support, and honor the preferences of 3 of 11 Residents (R) sampled for Choices. Specifically, the facility failed to honor R60's and R79's preference to be informed of a time range that rehabilitation therapy services would occur and failed to honor R21's preference to be assisted outside periodically for fresh air. As a result of this deficient practice, these residents did not have their needs met and were placed at risk of not attaining their highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility. Findings Include: 1) R60 is a [AGE] year-old female admitted to the facility on [DATE] for wound care, and antibiotic and rehabilitative therapy. A review of her Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 10/30/24 noted R60 was determined to have a Brief Interview for Mental Status (BIMS) score of 15, indicating no 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.

Based on observation and interview, the facility failed to ensure the ice and water equipment for the residents were kept in clean and sanitary conditions in accordance with professional standards for food service safety. Residents risk serious complications from foodborne illness as a result of their compromised health status. Unsanitary food handling and/or equipment maintenance practices represent a potential source of pathogen exposure for all residents receiving ice or water on the affected floor. Findings include: On 12/10/24 at 12:15 PM, an inspection of the resident nourishment room on the 4th floor was done. Observed a buildup of hardened brown sediment/material around the bottom edge of the plastic chute dispensing water and ice for the residents. A concurrent interview was done with Registered Dietician (RD)1 who was present in the nourishment room. RD1 stated that Maintenance was responsible to clean the ice and water machine. While RD1 could not say what the brown buildup was or if it was acceptable, RD1 did agree that the ice/water dispenser should be cleaned regularly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect and promote patient's rights for 1 of 26 residents sampled (Resident (R)60) by ensuring that she was treated with respect and dignity. This deficient practice has the potential to affect all residents in the facility. Findings Include: R60 is a [AGE] year-old female admitted to the facility on [DATE] for wound care, and antibiotic and rehabilitative therapy. A review of her Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 10/30/24 noted R60 was determined to have a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. On 12/10/24 at 04:17 PM, an interview was done with R60 at her bedside. R60 described an incident where she fired a traveling nurse for repeatedly waking her for things that could have waited, such as unscheduled pain medication, and for not listening to R60 regarding the proper way to complete her dressing change. R60 reported she felt that Registered Nurse…

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 and interview, the facility failed to provide privacy for one resident (Resident (R)274) and failed to protect the confidentiality of another resident's (R113) electronic health record. These failed practices have the potential to negatively impact the psychosocial well-being of the affected residents. Findings Include: 1) On 12/12/24 at 02:30 PM, while exiting the 3rd floor recreation room, made observations into room [ROOM NUMBER] at the end of the hall. Observed Certified Nurse Aide (CNA)3 assisting Resident (R)274 from the bathroom, located just inside the room entrance, back to her bed located next to the window. R274 was wearing a top that ended above her hips and an adult incontinence brief. CNA3 glanced at the State Agency (SA), observing from down the hall, yet neglected to attempt to preserve R274's privacy in any way, such as providing her with a towel or gown to cover, or by closing a door or privacy curtain. On 12/13/24 at 08:29 AM, an interview was done with CNA5 outside R274's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide Resident (R)107's completed Interact Nursing Home to Hospital Transfer Form to the hospital R107 was sent to when his condition changed and he became unstable, requiring a transfer and admission to an acute hospital. Findings Include: Record Review (RR) was done of R107's Electronic Health Record (EHR). On 11/17/24 Registered Nurse (RN) 25 documented R107 was sent to the emergency room (ER) because R107 complained of shortness of breath and could not breath and his Oxygen (O2) saturations were in the 70's. R107 was sent to the ER by 911 ambulance. Progress note dated 11/17/24 stated R107 was admitted to the hospital for diagnosis of AFib (Atrial fibrillation (AFib) is an irregular and often very rapid heart rhythm.). On 12/12/24 at 10:59 AM met with and interviewed Resident Care Manager (RCM) 5. Inquired where the documents are kept that were sent to the ER with R107. RCM5 stated the form is under the observation tab and labeled Interact Nursing…

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 record review, the facility failed to implement a comprehensive person-centered care plan to meet the medical, physical, and psychosocial needs for two of two Residents (R) 36 and R228 in the sample. The deficient practice has the potential to diminish both resident's quality of life. Findings Include: Cross reference to F698. Physical medicine and rehabilitation note 12/09/24 17:14 reviewed. R36 is a [AGE] year-old female admitted to the facility on [DATE] for subacute rehab services for decline in Activities of Daily Living (ADL's) and functional mobility after hospitalization. Care plan dated 11/15/24 reviewed. Approach: Check bruit and thrill. Assess site for bleeding. If bleeding, call the physician. Review of the medical record revealed there was no documentation of bleeding to the access site, or that it was reported to the physician (cross reference to F697). 2) Cross reference to F697, F684. Electronic medical record face sheet 11/29/24 reviewed. R228 is a [AGE] year-old female admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the involvement of one resident (Resident (R)79) in the development of his comprehensive care plan (CP). As a result of this deficient practice, staff did not have all the information necessary to assist R79 in meeting his highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility. Findings Include: R79 is a [AGE] year-old male admitted to the facility on [DATE] for wound care, and antibiotic and rehabilitative therapy. A review of his Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 10/29/24 noted R79 was determined to have a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. On 12/11/24 at 09:21 AM, an interview was done with R79 at his bedside. When asked about his participation in his care planning, R79 stated that he had not been invited nor had he participated in any 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 provide resident centered care and services in accordance with the goals to meet the physical, mental, and psychosocial needs for three residents of 26 in the sample, Resident (R) 55, R228 and R34. Specifically the facility failed to meet R55's complex physical needs that resulted in frequent hospitalizations. Failed to schedule R228's Physical Therapy (PT) per her preference to coincide with her higher energy level in the morning and better pain management with as needed pain medication before PT. Failed to clarify and correct ambiguous insulin orders for R34 and failed to ensure standards of good clinical practice were followed with regards to documenting a hypoglycemic (low blood sugar) episode. As a result of this deficient practice, the facility placed R34 at risk for avoidable declines and injuries. This deficient practice has the potential to affect all residents on insulin. Findings Include: 1) Electronic Health Record (EHR)…

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 record review, observation, and interview the facility failed to provide treatment and services to prevent complications of enteral feeding for one resident (Resident (R)10) in the sample. The facility did not ensure the formula bag was changed every 24 hours when enteral feeding was initiated using a bag past the stated discard date and time. This deficient practice has the potential to put residents on enteral feeding at risk for preventable complications. Findings Include: Record review of R10's Electronic Health Record (EHR) revealed the resident is an [AGE] year-old admitted to the facility for surgical aftercare following surgery on the digestive system. Diagnoses included but not limited to diverticulosis (condition in which pockets develop on the inside of the colon) and nontraumatic perforation of intestine. R10 had an order for enteral feeding (use of a feeding tube to supply nutrients and fluids to the body) four times a day. On 12/11/24 at 11:02 AM, observed Licensed Practical Nurse (LPN)5…

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 correctly dispense oxygen for one resident with a respiratory infection of two residents in the sample. The deficient practice may increase the resident's risk of illness. Findings include: 1) Electronic Health Record (EHR) reviewed. Physician order written on 12/10/24 at 07:36 AM reviewed. The Resident (R) 20 was diagnosed with Respiratory Syncytial Virus (RSV) and placed in isolation on droplet/ contact precautions. Minimum data set (MDS) admission assessment date 11/25/24 reviewed. R20 is a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis includes complex medical conditions, Diabetes Mellitus, (DM), and Respiratory infection, (Pneumonia). R20 observed in his room on 12/10/24 at 11:47 AM wearing oxygen (O2) via nasal cannula (NC) and sleeping. The O2 monitor read in the off position. The Family Member (FM) was sitting at the bedside. FM said R20 was tested for RSV yesterday and today he had a positive test result. He 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 effectively manage the pain for one resident of 26 in the sample based on professional standards of practice. The deficient practice diminished the resident's quality of life due to decreasing the ability to successfully participate in Physical Therapy (PT) and family visit. Findings Include: Cross reference to F656 & F684. Observation and interview with Resident (R) 228 in the rehabilitation gym with her Family Member (FM) on 12/11/24 at 10:45 am, who said R228 is having a bad day and is in a lot of pain. R228 was speaking sharply in her native language with her face in a scowl. Surveyor asked the FM if R228 was medicated prior to coming to Physical Therapy (PT). He said no, but the nurse is going to bring the medicine now. The nurse came and gave R228 one Tramadol 25 milligram (mg) tab for the pain. The PT started doing exercises with R228's neck. The FM said that when he came in this morning that R228's was having very bad pain in her…

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

Based on observation, interview and record review, the facility failed to provide care and services for the provision of dialysis consistent with professional standards of practice for one of one resident in the sample. The deficient practice may increase the risk for an adverse outcome. Findings Include: Cross reference to F656. Observation and interview in Resident (R) 36 room on 12/10/24 at 2:20 PM. She stated that her hemodialysis access site is in her left arm, and sometimes after her dialysis session, the site continues to bleed. When that happens, she has to keep a dressing with pressure to the site. Observation and interview in R36 room on 12/12/24 at 8:30 AM with the Registered Nurse (RN) 35. R36 had an ace wrap to her left upper arm, she stated that she had bleeding to her arterio-venous fistula (AVF) after her dialysis last night. RN35 stated, we will keep the wrap on a while longer. Observation and interview with R36 in her room on 12/12/24 at 1:00 PM, she still had the ace wrap on her left upper arm, she stated that she usually keeps it on for one day when she has…

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 of discharged residents, and medications that were past their discard date are disposed of and not administered to the residents. The facility also failed to implement a thorough process to assure accurate reconciliation and accounting of all controlled medications, for 1 of 12 medication carts, in order to promptly identify loss or potential diversion. Findings Include: 1) On 12/12/24 at 08:51 AM, inspection of one of the medication carts on the fifth floor was conducted with Registered Nurse (RN)8. An open box Wixela Inhub (inhaler medication for asthma) was found in one of the drawers. The box had a label where the open and discard dates were written. Discard date stated 12/09/24. Asked RN8 if a dose of the Wixela Inhub was administered to the resident recently. RN8 said Yes, I administered a dose this morning. Showed RN8 the label with a discard date of 12/09/24. RN8 said she will discard the medication and get a new one. 2) On 12/12/24 at 10:57 AM, while inspecting medication cart #2…

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 all medications used in the facility were stored and labeled in accordance with professional standards. Proper storage and labeling of medications is necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility who take medications. Findings include: 1) On 12/12/24 at 08:16 AM, while conducting an inspection of the medication storage room on the 4th floor, found a bottle of magnesium citrate that had a manufacturer's expiration date of 10/24, and a bottle of Colace liquid with a manufacturer's expiration date of 10/31/24. On 12/12/24 at 08:32 AM, conducted an interview with Resident Care Manager (RCM)4 in the medication storage room. RCM4 stated that she checks the medication storage room every week for expired medications. Acknowledged the two medications were missed and should have been identified and discarded. 2)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement infection prevention and control measures. Specifically, the facility did not ensure that staff were wearing applicable personal protective equipment (PPE) when providing care to a resident on transmission-based precautions (TBP) and perform hand hygiene after exiting the room and between glove changes. This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases. Findings include: 1) On 12/10/24 at 12:38 PM, observed Certified Nurse Aide (CNA)38 deliver lunch tray to Resident (R)323. Signage was posted on the left side of the door to R323's room that stated he was on contact precautions and staff must clean their hands before entering and when leaving the room, wear gloves and gown before entering the room. CNA38 entered R323's room without donning gloves and gown to deliver his lunch tray and did not perform hand hygiene after exiting the room. Asked CNA38 if she 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 interviews, document and record review, the facility failed to ensure one Resident (R)1 of a sample size of three received the monitoring in accordance with the nursing professional standards of practice, the resident's individualize care plan or the physician's (MD)1 orders. Specifically, the nursing staff did not complete orthostatic blood pressures (BP) and pulse (P) as ordered. As a result of this deficiency, R1's vital signs were not monitored as needed, which resulted in lack of timely data and made R1 at higher risk of not reaching his highest physical practical wellbeing. Findings include: 1) R1 was admitted on [DATE] for deconditioning post acute hospitalization where he had surgery for a fractured left hip after a fall. He had a medical history that included but not limited to Advanced Parkinson's Disease, Diabetes Mellitus with current use of insulin, anemia post hip fracture, Hypertension, and orthostatic hypotension (sudden drop in blood pressure when you stand up). R1 usually gets around…

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 interviews and record review, the facility failed to treat resident (R)337 with dignity. R337 had an interaction with a nursing staff during which the staff told the resident she had Dementia due to not recalling information correctly, R337 does not have Dementia. As a result of this deficient practice, the resident is at potential risk of psychosocial harm. Findings include: On 12/19/23 at 02:33 PM, conducted an interviewed with R337 and inquired if the staff treat her with respect. R337 replied, no then stated a nurse told her that she has dementia during an interacting with her. R337 stated she told the nurse she made doo doo that day and the nurse told her it was the other day. R337 said she couldn't remember, and nurse told the resident she has dementia. R337 reported it was rude of the nurse to say this. R337 now keeps a log, writes down when she has a bowl movement. Asked how this made her feel and she stated Hurt your feelings. I was going to ask her name, but I don't care Record Review (RR) of R337's Electronic Health Record (EHR) documented the resident'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 interviews and record review, the facility failed to ensure an assessment accurately reflected the residents' status at the time of the assessment for one of twenty-four residents (Resident (R)82) sampled. This deficient practice places all the facility residents at risk for assessment inaccuracy. Findings include: On 12/21/23 at 01:14 PM, conducted a review of R82's Electronic Health Record (EHR). R82's EHR did not include documentation that the resident was hospitalized during his stay in the facility. R82's discharge assessment, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/04/23, documented in Section A., A2105. Discharge Status, R82 was being discharged to a short-term general hospital (acute hospital, IPPS). Reviewed R82's discharge assessment, MDS with an ARD of 10/04/23, with MDS Nurse (MDSN)2. After reviewing form, MDSN2 stated, R82's discharge status was an error and needed to be corrected and confirmed the MDS should have documented R82 was discharged home and not to a short-term general hospital.

Based on observations, interviews, record review, the facility failed to ensure the resident and the resident representative participated in the development of the comprehensive care plan or documented explanation must be included in the resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan for one of four residents (Resident (R)236) sampled. Findings include: On 12/19/23 at 11:20 AM, conducted an interview with R236's Family Member (FM1), FM2, and FM3 in the resident's room. Inquired if the facility invited FM1, FM2, and/or FM3 to participate in R236's care plan meeting. FM1, FM2, and FM3 confirmed the facility had not invited the family to participate in a meeting. FM2 stated, We're not even sure who her (R236) nurse is today. We have not spoken to her doctor and are completely unaware of what the plan is. FM3 stated, No one has come to see us and tell us what R236 has to do in order to go home; we don't know when or how often she get therapy; no one has come to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a resident was free of accident hazards as is possible. Resident (R)84 sustained second-degree burn on her right thigh after hot tea spilled on her lap. As a result of this deficient practice, the resident sustained physical harm. Findings include: R84 was an [AGE] year-old female admitted to the facility on [DATE] for skilled rehabilitation services and was discharged after completion of services. Diagnoses include but not limited to, fracture of left femur, unspecified dementia without behavioral disturbance, and Type 2 diabetes. On 12/20/23 at 12:23 PM, reviewed the facility's completed report and investigation. The facility reported on 10/30/23 Certified Nursing Aide (CNA)5 prepared hot tea using water provided by a dietary carafe during meal service. While CNA5 arranged R84's bedside table the hot beverage tipped over and spilled on R84's lap. R84 sustained a second-degree burn to right inner thigh 2.5 centimeters (cm) and 1 cm. 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 interviews and record review, the facility failed to ensure medication reconciliation on admission was accurate and met the needs of one Resident (R)236 sampled. R236 has insulin- dependent, type 2 diabetes mellitus and received a sliding scale of short-acting and scheduled long-acting insulin at home and in the acute hospital, prior to admission to the facility. On admission, a nurse reconciled R236's medications with a Non-Physician Practitioner (NPP)1 and omitted the insulin. There was no documentation by NNP1, physician, or nursing for a plan of care regarding R236's insulin. Insulin was only ordered after the resident's representative (Family Member (FM)1) questioned staff. As a result of this deficient practice, all newly admitted residents are at risk for potential harm. Findings include: On 12/19/23 at 11:20 AM, conducted an interview with R236's Family Member (FM1), FM2, and FM3 regarding the overall care provided to the resident and any concerns the family may have. FM1, FM2, and FM3 confirmed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a resident was free of any significant medication errors. Resident (R)29's routine insulin was not administered in accordance with the prescriber's order. Findings include: R29 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus with hyperglycemia. R29 physician's order included insulin glargine, 5 units subcutaneous once a day with special instructions to hold if blood sugar is less than 120 milligrams per deciliter (mg/dL) and to rotate site of injection, ordered on 11/24/23. On 12/20/23 at 02:31 PM, reviewed R29's December 2023 Medication Administration Record (MAR). R29's MAR documented: 12/01/23 Blood Sugar (BS) 117 mg/dL: administered insulin 12/09/23 BS 121 mg/dL: not administered out of parameter 12/11/23 BS 118mg/dL: administered insulin On 12/21/23 at 08:47 AM, a concurrent record review and interview with Unit Manager (UM)4 was done. UM4 reported R29 was ordered insulin once a day and was scheduled 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, interviews, and facility policy review, the facility failed to ensure drugs and biologicals are stored in a locked compartment and failed to appropriately label eye drops. Observed Resident (R)340's eye drops in the medication cart which was not labeled with an open and discard by date once it was opened. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of resident medications. The deficient practice could affect all residents who receive medications at the facility. Findings include: 1) On 12/21/23 at 08:57 AM, during inspection of a medication cart on the third floor with Registered Nurse (RN)5, found eyes drops with an open and discard by date label, which did not have discard by date filled out. R340 Brimonidine 0.2% eye drops, had an open date of 12/15/23 on the box the eye drops were kept in. RN5 and Unit Manager (UM)3 confirmed the label was blank. Requested facility policy from UM3 on medication storage. On 12/21/23, the Director of Nursing (DON) provided a copy of the facility'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 resident (R)338 and staff interview the facility failed ensure the resident's right to dietary choices for one Resident (R)338 sampled. The deficient practice could affect all the residents who provide the input in ordering their meals. Findings include: On 12/20/23 at 02:03 PM, conducted an interview with R338. The resident reported she was given the wrong lunch today at 12:30 PM. R338 stated she did not want to let staff know because she was worried that if she asked for the correct lunch her lunch would not be delivered until 1 PM. R338 stated she ordered the panko chicken with gravy and was given the pulled pork sandwich instead. R338 stated she had received her insulin for her diabetes and did not want to get her lunch late since she had already received her medication. On 12/20/23 at 02:38 PM, spoke with Kitchen Manager who delivered the printout for R338's lunch meal and admitted the wrong meal was delivered to the resident. He stated he told the resident the kitchen's phone number is on the menu and she can call them to request for the meal to be changed out and he…

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 observations, interviews, and record review, the facility failed to ensure infection control practices were implemented to help prevent the development and transmission of communicable disease and infections. Observed Physician (P)1 not wearing Personal Protective Equipment (PPEs) in direct contact with Resident (R)234, who was on contact precaution for Clostridioides Difficile (C. diff which is a highly contagious bacteria that causes diarrhea and inflammation of the colon (colitis) and is spread through contact with any contaminated surface, device, or material). Observed Certified Nurse Aide (CNA)99 did not disinfect his/her hands with soap and water after disposing trash (contained fecal matter) from R234's room of trash which contained fecal matter. As a result of this deficient practice, residents are at the potential risk of harm of exposure to a communicable disease. Findings include: 1) According to the Centers for Disease Control and Prevention (CDC), contact precautions are used for residents with known or suspected infections that represent an increased risk for…

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

Based on interviews and record review, the facility failed to ensure each resident's medical record includes documentation that indicates, at minimum, the resident or resident representative was provided education regarding the benefits and potential side effects of the influenza/pneumococcal immunization and documentation that the resident either received or did not receive the influenza/pneumococcal immunization due to medical contradiction or refusal for one of five residents (Resident (R)25) sampled. As a result of this deficient practice, all residents are potential risk of exposure and/or an increase potential for harm. Findings include: Conducted a review of R25's Electronic Health Record (EHR) regarding the resident's influenza and pneumococcal immunizations. R25's EHR did not contain any documentation of the resident's vaccination status, education of benefits and potential side effects, and if R25 refused the immunization or if it was medically contradicted. On 12/21/23 at 11:14 AM, conducted an interview and record review of R25's EHR with the facility's Infection…

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 observations, staff interview, review of policy and vendor procedure, the facility failed to properly dispose of seven filled medication disposal containers (Rx Destroyer) as evidenced by the containers being stored in an unsecured Trash Room. As a result of this deficiency, the facility put the safety and well-being of the residents as well as the public at risk for accident hazards. Findings include: During an observation of 2nd Floor Nursing Unit on 12/19/23 at 09:45 AM, the Trash Room was not secured and noted to have seven filled Rx Destroyer containers stored in a trash bin. No staff members were in the immediate vicinity to prevent any residents and/or visitors from accessing the Trash Room and/or Rx Destroyer. During staff inquiry on 12/20/23 at 10:45 AM, the Facilities Coordinator revealed that the filled Rx Destroyer containers supposed to be kept in a secured room to await proper disposal. Facilities Coordinator then said they would immediately remove the containers from the Trash Room and place them in a secured area while awaiting disposal. Review of facility…

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