Regency at Fremont

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dignified care and treatment of two facility residents (R136 and R66) and failed to ensure communication for self-determination of care for one resident (61) of three residents reviewed for dignity. Findings: R136 Review of the admission Record reflected R136 admitted to the facility on [DATE] with diagnoses that included Osteomyelitis (bone infection) of the left ankle and foot. The medical record reflected R136 was able to make his own medical decisions. Review of the Care Plan for R136 reflected Toileting. (name of R136) will require assistance to the toilet every two hours and as needed. He may utilize a urinal, bed pan, or use the full body lift to the toilet. Initiated 4/4/25. The Care Plan reflected Ambulation/Locomotion (name of R136) is unable to ambulate at this time (due to) NWB (non-weight bearing) status of BLE (bilateral lower extremities) initiated 4/4/25. And the Care Plan reflected Put the call light within reach…

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 record review, the facility failed to maintain the dignity of one of three residents (Resident #29) reviewed for dignity and respect. Findings: Resident #29 (R29) Review of an admission Record revealed R29 was a [AGE] year old male, last admitted to the facility on [DATE], who suffered from severe cognitive impairment and depended on staff to meet all of his daily needs. During an observation on 04/09/25 at 11:56 AM, R29 sat in a broda chair at the dining room table and his pants were visibly wet with urine. During an observation on 04/09/25 at 01:04 PM, R29 remained in the broda chair at the dining room table, his pants were visibly wet with urine. During an observation on 04/09/25 at 01:07 PM staff brought R29 from the dining room to the nurses station and placed him next to two other residents. R29's sweat pants remained visibly wet in the crotch area. During an observation on 04/09/25 at 01:23 PM staff took R29 to his room to change his clothing and provide peri-care.

Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS) assessments in 1 (R23) of 18 residents reviewed for accuracy of MDS assessment, from a total sample of 18. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1, October 2024, Chapter 3 Section O: Special Treatments, Procedures and Programs, revealed .The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods .The treatments, procedures, and programs listed in Item O0110, Special Treatments, Procedures, and Programs, can have a profound effect on an individual's health status, self-image, dignity, and quality of life .Reevaluation of special treatments and procedures the resident received or performed, or programs that the resident was involved in during the 14-day look-back period is important to ensure the continued appropriateness of the treatments, procedures, or programs . J1. Dialysis,…

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 formulate and implement a comprehensive communication Care Plan for one non-English speaking resident (R61) of one resident reviewed for communication. Findings: Review of the admission Record reflected R61 admitted to the facility 3/20/25 with diagnoses that included absence of left and right legs. The medical record reflected R61 was her own responsible party and was a Spanish speaking resident. Review of the Electronic Medical Record (EMR) for R61 did not reveal a communication Care Plan to provide guidance to staff on meeting the needs of this Spanish speaking Resident. Review of the medical provider documentation of 4/4/25 acknowledged the Resident is Spanish speaking only. The documentation reflected that She (R61) says she is painful today but cannot rate it. Denies chest pain, shortness of breath. The documentation reflected Exam Findings appears painful and Resident was weaning off narcotics, will try to continue this with family approval despite the medical record indicating R61 was her own decision maker. 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 1.) ensure comprehensive nursing assessments were completed and 2.) identify and notify the provider of a change in condition for 1 resident (Resident #85) out of 3 residents reviewed for quality of care. Findings: Resident #85 (R85) Review of an admission Record revealed R85 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Progressive multifocal leukoencephalopathy (progressive damage/inflammation of brains white matter.) Review of R85's provider Progress Note dated 1/9/25 revealed, .Resident guardian has continued to request resident be sent to hospital for any acute changes in health status. Due to resident decline it is expected that he will be resent to hospital at some point . Review of R85's Hospital Discharge Records revealed the following hospitalizations since his admission to the facility: *10/31/24-11/6/25 severe sepsis *11/9/24-11/10/24 fever with unspecified fever cause…

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 policies and procedures and prevent a facility acquired pressure ulcer, had conflicting assessment documentation, and revise the care plan for one (R27) of three residents reviewed for pressure ulcers. Findings include: Review of the Facility Matrix provided by the facility at beginning of this survey on 4/8/25 revealed R27 was not documented as having a pressure ulcer. Resident #27 (R27) Review of a Face Sheet revealed R27 admitted to the facility on [DATE] with pertinent diagnoses of a displaced fracture of the left humerus (long bone in arm from the shoulder to the elbow), diabetes, and obesity. No pressure ulcers. Review of an admission Nursing Comprehensive Evaluation dated 2/24/25 for R27 revealed no pressure ulcers upon admission. Review of the admission Braden Scale for Predicting Pressure Sore Risk for R27 dated 2/24/25 revealed she was at a low risk for developing pressure sores. Review of a Skin and Wound Evaluation 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 in interview and record review the facility failed to act upon a Pharmacy recommendation for a psychoactive medication for one facility resident (R137). Findings: Review of the Electronic Medical Record (EMR) reflected R137 admitted to the facility 3/20/25 with diagnoses that included non-Traumatic Brain Dysfunction. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated moderate cognitive impairment. Review the EMR revealed a medication pharmacy review for R137 was conducted on 3/22/25 and the pharmacist had documented a recommendation. Review of the EMR documentation titled Consultation Report dated 3/22/25 revealed a pharmacy recommendation that R137 had a (as needed) Doctor's Order for the anxiolytic medication Lorazepam without a stop date. The pharmacy recommendation reflected the requirement for as-needed non-antipsychotic psychotropic drugs be limited to 14 days unless the prescriber documents the diagnosed specific…

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 infection control practices for wound and peri-care for two (R66 and R29) of two residents and follow blood borne practices for one (Resident #30) of one residents, reviewed for infection control. Findings include: Resident #66 (R66) Review of a Face Sheet revealed R66 re-admitted to the facility on [DATE] with pertinent diagnoses of necrotizing fasciitis and diabetes. During an observation on 4/8/25 at 7:37 AM, Licensed Practical Nurse (LPN) O was providing surgical wound care for R66. LPN O removed the old dressing that was packed into the wound and cleansed the wound with normal saline. She changed her gloves with no hand hygiene and proceeded to pack the wound with long gauze soaked with Dakins solution. The tail end of the gauze was touching the residents clean brief and her leg. LPN O continued with packing the wound. When LPN O completed the dressing change, she removed her gown that was caught on her hair tie and removed…

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 review and revise the facility assessment. Findings: During an entrance conference interview with the Nursing Home Administrator (NHA) on 2/5/25 at 8:50 AM, the NHA reported the current census was 93 residents. Review of the Facility Assessment provided to the surveyor during the abbreviated survey reflected the assessment was based on a Resident Population Profile from July 11, 2023-July 10, 2024. At this time, the average daily census was 73 residents. The assessment had not been updated to reflect the increased census and acuity. A Core Staffing and Personnel Audit attached to the assessment had not been reviewed since August 6, 2024 . Further review of the facility assessment indicated the NHA and the Director of Nursing (DON) had not been updated to reflect individuals currently in those roles, which had changed since July 10, 2024. During an interview on 2/5/25 at 1:28 PM, the NHA reported she had been the facility Administrator for 90 days and did not know she needed to update the Facility Assessment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's (Resident #2) right to be free from sexual abuse by a resident (Resident #1). Findings: Resident #1 (R1) Review of an admission Record reflected R1 admitted to the facility with diagnoses that included dementia, mood disorder due to known physiological reason and a personal history of traumatic brain injury. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R1 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 4/15. R1 exhibited A. Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching grabbing, abusing others sexually as well as wandering behaviors in 1-3 days during the look back period. Review of a mental health consult note dated 12/10/24 reflected R1 had sexually inappropriate behavior on 11/19/25 (it was alleged R1 touched a female resident's breast). The note indicated R1 started to masturbate in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI000149220 Based on interview and record review, the facility failed to monitor blood pressures and/or follow physician ordered parameters prior to administering blood pressure medications for 1 of 3 residents (R3) reviewed for medication parameter monitoring, resulting in the potential for serious adverse effects of medications. Findings include: A review of the facility's Medication Administration policy, last revised 10/17/23, revealed, Medications are administered in accordance with written orders of the attending physician . 5. If applicable and/or prescribed, take vital signs or tests prior to administration of the dose, e.g , pulse with digitalis, blood pressure with anti-hypertensive, etc . A review of R3's admission Record, dated 1/24/25, revealed R3 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's admission Record revealed multiple diagnoses that included hypertension (high blood pressure) and Torsades de Pointes (a potentially fatal…

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 This citation pertains to intake MI00146674 Based on observation, interview and record review, the facility failed to ensure one resident (Resident #2) was free from abuse of three reviewed, resulting in Resident #2 being abused by a staff member. Findings include: Review of Abuse Prohibition Policy last revised 9/9/22 revealed Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse, corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for purposes of discipline or convenience that are not required to treat guest's/resident's medical symptoms. Further review of the policy reflects Verbal Abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the guest/resident to experience humiliation, intimidation, fear, shame, agitation or degradation regardless of their age, ability to comprehend or disability. Verbal…

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 proper label and dating of foods and documentation of food temperatures effecting 70 residents receiving meals from the kitchen resulting in increased the risk of contaminated foods and the risk of food borne illness. Findings include: During an initial tour of the kitchen on 4/16/2024 at 9:57 AM the following was observed in the reach in the freezer: 12 cups of strawberry shortcake ice cream in Styrofoam cups without a label and date During an initial tour of the kitchen on 4/16/2024 at 9:57 AM the following was observed in the reach in the refrigerator: 1 peanut butter and jelly sandwich in a plastic bag in a shallow pan with no date Approximately 20-8 oz cups of juice on a tray with no label and date During the initial tour, Dietary Manager (DM) H stated that the ice cream, peanut butter and jelly sandwich and juices should have labels and dates on them. On 4/17/2024 at 11:26 AM, during kitchen rounds, review of the time/temperature food preparation log from 4/2/2024 revealed that the temperature for…

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

Based on observation and interview the facility failed to effectively maintain the outdoor dumpsters effecting 70 residents, resulting in the increased potential for odors and the attraction of pests and rodents. Findings include: On 4/17/2024 at 10:20 AM it was observed that 2 dumpsters, 1 trash dumpster and 1 cardboard boxes dumpster didn't have the lids closed. On 4/17/2024 at 1:32 PM, it was observed with Maintenance Assistant (MA) I that the same trash dumpster and cardboard boxes dumpster lids were not closed. MA I stated that the door to close the trash dumpster was stuck and he was not able to close the lid. MA I was able to close the cardboard boxes dumpster lid. On 4/17/2024 at 2:05 PM, Maintenance Director (MD) J stated that he wasn't aware that the trash dumpster lid didn't close until MA I told him. MD J said that MA I' told him that the frame was bent so he might have to call the dumpster company to come and fix it. When asked who makes sure the dumpster lids are shut, MD J said that anyone that uses it should shut it and stated, I close it a lot. On 4/17/2024 at 3:15…

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 protect the resident's right to be free from physical abuse by other residents for 7 residents (R56, R62, R103, R104, R105, R106, R107) out of 13 residents reviewed for abuse and neglect, resulting in the potential for physical harm, pain and mental anguish. Findings: During an revisit investigation, Facility Reported Incidents (FRIs) since the facility's stated date of compliance (5/14/2024) revealed there were 6 resident-to-resident abuse incidents. Each incident occurred between residents living on the secure unit and are summarized as follows: -In the evening on 5/28/2024 R105 was observed slapping R104's leg and saying, She's in my bed, get out. The nurse on duty at the time heard a commotion but did not witness the resident-to-resident abuse. The other CNA working on the secure unit at the time did not witness the incident. The residents were separated and placed on 15-minute checks. The facility changed rooms for R105. -In the afternoon on 5/29/2024 around shift change a laundry aide near the 500-hall lounge on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure sufficient levels of nursing staff to meet resident needs for three residents (Resident #13, #59, and #62), resulting in allegations of sexual abuse, fall with fracture, and the potential for unmet care needs and facility residents to not attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #13(R13) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R13 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included Alzheimer, heart disease, heart failure, pacemaker, hypertension (high blood pressure), cerebral vascular accident, frequent falls, anxiety and depression . The MDS reflected R13 had a BIM (assessment tool) score of 8 which indicated his ability to make daily decisions was moderately impaired. Resident #62(R62) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R62 was a [AGE] year…

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 report allegations of abuse for three (Resident #13, #59 and #62) of 5 reviewed, resulting in allegations of sexual abuse that were not reported to the State Agency and the potential for further allegations of abuse to go unreported. Findings include: Review of the facility, Abuse Prohibition Policy, dated 9/9/22, reflected, Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse, corporal punishment, involuntary seclusion and any physical or chemical restraints imposed for purposes of discipline or convenience that are not required to treat the guest's/resident's medical symptoms .Sexual Abuse is non-consensual sexual contact of any type with a guest/resident .Sexual abuse includes, but is not limited to: unwanted intimate touching of any kind especially of breasts or perineal area; all types of sexual…

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 the protection of residents and thoroughly investigate allegations of abuse that involved 3 residents (Resident #13, #59 and #62) of 5 reviewed for abuse, resulting in the potential for further abuse to occur and allegations of abuse not being thoroughly investigated. Findings include: Review of the facility, Abuse Prohibition Policy, dated 9/9/22, reflected, Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse, corporal punishment, involuntary seclusion and any physical or chemical restraints imposed for purposes of discipline or convenience that are not required to treat the guest's/resident's medical symptoms .Sexual Abuse is non-consensual sexual contact of any type with a guest/resident .Sexual abuse includes, but is not limited to: unwanted intimate touching of any kind especially of breasts…

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 comprehensive care plans for 1 (Resident #56) of 18 residents reviewed, resulting in the potential for unmet care needs and impaired wound healing/wound deterioration. Findings include: Review of the medical record revealed that Resident #56 (R56) was initially admitted to facility on 11/14/22 with ongoing diagnoses including unspecified dementia, adult failure to thrive, difficulty in walking, generalized muscle weakness, and pressure ulcer of right heel. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/11/24 reflected that R56 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 7 (severe cognitive impairment). Section M of the same MDS revealed that R56 was at risk for developing pressure ulcers, had an unhealed facility acquired stage 3 pressure ulcer, and was not on a turning/repositioning program. Review of R56's ADL (Activities of Daily Living) Care Plan…

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

Based on observation, interview, and record review, the facility failed to ensure opened medications were appropriately labeled and that expired medications were disposed of in 2 of 3 medication carts reviewed for labeling and storage, resulting in the potential for decreased medication efficacy and adverse side effects. Findings include: On 4/17/24 at 8:00 AM, Oak Hall Medication Cart was reviewed in the presence of Registered Nurse/Unit Manager (RN/UM) D. During the review, an opened Lantus Solostar Insulin Pen with a pharmacy label reflecting R10's name was observed in the top left medication cart drawer. A separate label on the pen indicated, Date Opened__________Discard After 28 Days with no corresponding open date noted. RN/UM D confirmed that Lantus was an active medication for R10, that she did not know when it had been opened as lacked an open date and would be disposing of and getting a new one as had no way of knowing if the pen had been opened and used for more than the indicated 28 days. Review of R10's medical record revealed an active order, dated 12/14/2022, 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 This citation pertains to intake M100138378. Based on interview and record review, the facility failed to assess, document, monitor and treat for changes in condition, follow physician orders, notify physician, have effective communication with outside medical care providers, and thoroughly investigate a fall, and have complete and accurate medical records for 1 (Resident #1) of 4 residents reviewed for quality of care. Findings include: Resident #1 (R1) Review of a Face sheet revealed R1 admitted to the facility on [DATE] with pertinent diagnoses of dementia, diabetes, mixed incontinence, and stage III chronic kidney disease. Review of the Hospital emergency room (ER) medical records dated 7/19/23 with an arrival time of 4:49 PM for R1 revealed the reason for the visit was Altered mental status Pt (patient) has been unresponsive since 2 PM. Came in via EMS (emergency medical services) from the Nursing Home. Able to follow some commands. Nursing home staff was concerned about possible UTI (urinary tract…

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 properly label medications for 1 of 2 medication rooms (Masters Unit Medication Room) and properly secure 1 of 3 medication carts (400/500 Hall Medication Cart), potentially affecting all residents admitted to the Masters Unit that receives a TB test and all residents of the 400/500 Hall (J-Wing), resulting in the potential for expired Tuberculin Protein Derivative being administered, the potential for inaccurate tuberculin test results from possible oxidation and degradation of the solution, and the potential for unauthorized access to the medication cart. Findings include: During an inspection of the Masters Unit Medication Room with Registered Nurse (RN) A on [DATE] at 05:00 PM, a vial of tuberculin purified protein derivative (TB PPD) was discovered without an open date on the vial. There was date of 4/27 written on the box. RN A stated that even though the box was labeled, she did not know for sure if that was when the vial was…

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

Based on observation and interview, the facility failed to keep kitchen equipment in a state of repair that would allow for regular use and operation of the plate warmer, and proper maintenance of the ice machine drain lines. This deficient practice has the potential to decrease food palatability/meal satisfaction and has the potential to contaminate ice inside the machine. During the initial tour of the kitchen, on 5/23/23 at 10:03 AM, Dietary Manager (DM) R revealed, the plate warmer has not been working for months. DM R further revealed, they (kitchen staff) sometimes heat the plates in the microwave to help with temperatures and food palatability. The purpose of a plate warmer is to assist in maintaining food temperatures and to aide in keeping hot foods hot while individual resident trays are prepared, placed in carts, and delivered to unit staff for residents eating in their rooms. During the initial kitchen tour on 5/23/23 at 10:03 AM, observation of submerged ice machine drain lines into a floor drain are observed. All ice machine drains require a few inches of space (known…

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 safeguard the confidentiality of medical records for one resident (R34), resulting in the potential for unauthorized access and the potential for the loss of resident privacy and confidentiality of their personal health information. Findings include: During an observation on 05/24/23 at 01:00 PM, the computer screen located on top of the 400/500 Hall Medication Cart was left open to R34's medication administration record (MAR), including her insulin order page. R34's name, room number, diagnoses, and medications were clearly visible to anyone walking by the medication cart. Residents were walking by the medication cart and the nurse (RN C) was in a resident's room out of sight of the medication cart. During an interview on 05/25/23 at 09:25 PM, LPN B, stated when she walks away from her medication cart, she will lock the computer screen. She stated she does this so unauthorized people cannot look at the residents' personal information on the computer screen. During an interview on 05/25/23 at 09:30 AM, RN D,…

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.