Rancho Rehab And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the physician orders were accurately recorded and updated for three sampled residents (Residents #46, #18 and #6) out of 18 sampled residents. The facility failed to serve Resident #46 with physician ordered double portions. The facility also failed to ensure oxygen tubing was dated and oxygen equipment was covered per infection control standards for Resident #18. In addition, the facility failed to obtain documentation of Resident #18's cardiology progress notes from the most recent appointment when Resident #18 received a blood pressure machine that reported results directly to the cardiologist. The facility also failed to ensure Resident #6's neurological checks (medical assessments used to evaluate the function and health of the nervous system) were completed and maintained in the medical record. The census was 79. Review of the facility's Physician's Orders policy, dated 10/24/22, showed: -Purpose: This will ensure that 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 provide activities of daily living (ADL) care for three residents by failing to ensure one resident received his/her showers as scheduled (Resident #38) and failed to ensure residents were clean and odor free (Residents #38, #2 and #6). The sample was 18. The census was 79. 1. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/27/25, showed: -Cognitively intact; -Required substantial/maximal assistance with shower/bath; -Required set-up or clean assistance with personal hygiene; -Occasional urinary incontinence; -Frequent bowel incontinence; -Diagnoses included heart disease, high blood pressure, traumatic brain injury, anxiety disorder and manic depression. Review of the resident's care plan, in use at time of survey, showed: -Focus: Resident has an ADL self-care performance deficit; -Goal: Resident will maintain current level of function in ADLs;…

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

Based on observation, interview and record review, the facility failed to ensure a motorized wheelchair was in working order after it was reported to facility staff that there were broken or missing parts (Resident #29). The sample was 18. The census was 79. Review of the facility's Maintenance Work Orders policy, dated 10/24/22, showed: -Purpose: To protect the health and safety of residents, visitors, and Facility Staff; -Policy: Maintenance work orders shall be completed in an effort to sustain maintenance services as a priority; -Procedure: To enable the Maintenance Department to prioritize tasks PE - 02 - Form A - Work Order Form or other similar document will be filled out and forwarded to the Director of Maintenance; -Department directors/supervisors are responsible for completing such work orders and forwarding them to the Director of Maintenance; -Work order requests are reviewed during stand-up meetings; -Emergency requests are given priority; -Emergency requests should be delivered directly to the Director of Maintenance; -The Director of Maintenance will maintain…

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 residents who received dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys are not working properly) services had written communication with the dialysis center. The facility identified two residents who received dialysis services. Two residents were sampled (Resident #62 and #53), and issues were found with both residents. The sample was 18. The census was 79. Review of the facility's Dialysis Care policy, dated 10/24/22, showed: -Purpose: To provide care for residents diagnosed with renal disease requiring ongoing dialysis treatments; -Policy: -The facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment, and providing all non-dialysis needs of the resident including during the time period when the resident was receiving dialysis; -The facility maintains a contract with a dialysis service…

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 an as needed (PRN) controlled pain medication, as ordered by the prescriber, to meet the needs of one sampled resident (Resident #38). The census was 79. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/27/25, showed: -Cognitively intact; -Required substantial/maximal assistance with shower/bath; -Occasional urinary incontinence; -Frequent bowel incontinence; -Diagnoses included heart disease, high blood pressure, traumatic brain injury, anxiety disorder and manic depression. Review of the resident's care plan, in use at time of survey, showed: -Focus: Resident is on pain medication therapy, opioid analgesics related to chronic neck pain, lower back pain, and right leg pain; -Goal: Resident will be free of any discomfort or adverse side effects from pain medication; -Interventions: Administer analgesic medications as ordered by physician. Review of the resident's order summary, dated 12/5/24, showed a physician…

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

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, three errors occurred during medication administration for one resident (Resident #7), resulting in a 10% error rate. The census was 79. Review of the facility's Medication Administration Policy, dated October 24, 2022, showed: -Medication will be administered by a licensed nurse per the order of an attending physician or licensed independent practitioner, or as consistent with state law; -Nursing staff will keep in mid the seven rights of medication when administrating medications: the right medication, the right amount, the right resident, the right time, the right route, the right indication and the right outcome; -Additional considerations: the resident has right to know what the medication does; the resident has the right to refuse the medication (unless court ordered) and the rule of three, the licensed nurse administering medications will perform three checks comparing the physician's order, pharmacy label, and Medication…

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 residents were free from significant medication errors. The facility failed to ensure one resident's (Resident #11) treatment plan was transcribed on the physician order sheet. This failure resulted in one anti-seizure medication not being adjusted for 46 days. The sample was 18. The census was 79. Review of the facility's Physician Order policy, dated 10/24/2022, showed: -Purpose: this will ensure that all physician orders are complete and accurate; -Telephone orders: a licensed nurse will record telephone orders on the telephone order sheet with the date, time and signature of the person receiving the order or in the electronic health record (EHR); -The order is transcribed onto the physician's order form at the time the order is taken; -Whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order; -Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health 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 See Event ID Y0PE12. Based on interview and record review, the facility failed to follow physician's orders and facility policies for one resident with a history of pain. The resident was admitted to the facility from the hospital on [DATE], with an order for acetaminophen (non-narcotic pain medication for mild pain) PRN (as needed/as necessary) and Oxycodone (narcotic pain medication for moderate to severe pain) PRN and diagnoses that included advanced metastatic (the cancer has spread from where it started to another part of the body) cervical cancer (cancer of the cervix (the lowest region of the uterus)) and pressure ulcers (localized skin and soft tissue injuries). The facility failed to process the resident's orders for the Oxycodone and acetaminophen upon admission. On 10/23/24, the resident was readmitted to the hospital and returned to the facility on [DATE], with orders for acetaminophen PRN and Oxycodone PRN and the facility initiated the orders at that time (23 days after admission on [DATE]). 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.

See Event ID Y0PE12. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 10/1/24. Based on interview and record review, the facility failed to follow their policy when staff failed to thoroughly document pain assessments and interventions (pain location, what pharmacological/non-pharmacological interventions were attempted in response to pain, and follow-up to determine if an intervention was effective) for one resident when staff identified the resident had pain based on pain scale rating of 1-10 (Resident #11). Twelve resident's were sampled and problems were identified with one. The census was 88. Review of the facility's Pain Management policy, last revised on 10/24/22, showed: -Purpose: To ensure accurate assessment and management of the resident's pain; -Policy: A Licensed Nurse will assess residents for pain on admission and routinely as indicated by the resident's health and functional status. Facility Staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or…

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 immediately notify the Department of Health and Senior Services (DHSS) as required by state and federal regulations, when an allegation of staff to resident abuse was made. On the evening shift of 9/19/24, Licensed Practical Nurse (LPN) A forced a resident (Resident #2) onto the floor, held the resident's hands down and placed his/her knee on the resident to keep the resident on the floor. After pulling the resident up off the floor and to a standing position, the LPN forced the resident to go to his/her room. The abuse was witnessed by nursing staff on the unit and a nurse aide provided a statement to the Director of Nursing showing the resident was took to the ground by LPN A, however, clarification was not sought until the evening of 9/20/24, when staff at the nurses' station were overheard discussing LPN A holding the resident's hands down and forcing the resident onto the floor. The facility began an investigation on the evening shift on 9/20/24, however, did not notify DHSS of the allegations. Five residents were…

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 follow physician's orders and facility policies for one resident with a history of pain. The resident was admitted to the facility from the hospital on [DATE], with an order for acetaminophen (non-narcotic pain medication for mild pain) PRN (as needed/as necessary) and Oxycodone (narcotic pain medication for moderate to severe pain) PRN and diagnoses that included advanced metastatic (the cancer has spread from where it started to another part of the body) cervical cancer (cancer of the cervix (the lowest region of the uterus)) and pressure ulcers (localized skin and soft tissue injuries). The facility failed to process the resident's orders for the Oxycodone and acetaminophen upon admission. On 10/23/24, the resident was readmitted to the hospital and returned to the facility on [DATE], with orders for acetaminophen PRN and Oxycodone PRN and the facility initiated the orders at that time (23 days after admission on [DATE]). In addition, the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure pharmacological interventions were only used when non-pharmacological interventions are ineffective or when clinically indicated for one (Resident #2) of five sampled residents. On the evening of 9/19/24, Licensed Practical Nurse (LPN) A removed the resident's oxygen concentrator from his/her room. The resident had diagnosis of chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems). Removing the concentrator caused the resident to yell, curse, and hit LPN A. LPN A forced the resident onto the floor, and then forced the resident to his/her room. LPN A contacted the Director of Nurses (DON) who contacted the resident's psychiatrist and received an order for a Haldol (an antipsychotic) injection. When LPN A entered the resident's room and administered the Haldol and Benadryl (antihistamine that can be used to induce sleep), the resident was calm and no longer yelling, cursing or…

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 accurately document an event that occurred with one resident (Resident #2) on 9/19/24. Documentation did include Licensed Practical Nurse (LPN) A's actions of forcing the resident onto the floor, holding the resident's hands down, placing his/her knee on top of the resident, and making the resident return to his/her room. In addition, LPN A failed to document in the resident's progress notes, physician's order sheet (POS) and the medication administration record (MAR) the orders for and administration of Haldol (an antipsychotic) 5 milligrams (mg) intramuscular (IM) and Benadryl 25 mg by mouth (PO) as ordered by the psychiatrist. Five residents were sampled. The census was 89. Review of the facility Physician Orders policy, revised on 10/24/22, showed: -Purpose: This ensure that all physician orders are complete and accurate; -Policy: The Medical Records Department will verify that physician orders are complete, accurate and clarified; -Procedure: -A Licensed Nurse will record telephone orders on the telephone order sheet…

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 one resident (Resident #1) arrived for his/her heart valve surgery with blood thinners placed on hold per order. The resident missed two surgery appointments due to facility error. The facility also failed to ensure one resident (Resident #2) was properly dressed and safe when he/she was sent to dialysis with no pants on, only a brief and no lift pad under him/her despite physician orders for transfers via mechanical lift. The sample was 12. The census was 92. 1. Review of Resident #1's electronic medical record, showed the resident was admitted to the facility on [DATE] with diagnoses that included Type II Diabetes Mellitus, flaccid (soft or weak) hemiplegia (paralysis on one side of the body) affecting the left non-dominant side, atrial fibrillation (an irregular and often very rapid heart rhythm), and chronic kidney disease. Review of the resident's Care Plan, in use during the investigation, showed: -Focus: Activities of Daily Living (ADL,…

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 staff failed to provide protective oversight for one resident (Resident #3) who eloped, leaving the facility and facility grounds. The resident was missing for at least 30 minutes without staff's knowledge. The facility noted the resident was missing when the police department brought the resident back to the facility, asking if he/she belonged there. Staff failed to document the resident's activity preferences in the care plan, which would distract the resident from wandering. This had the potential to affect all residents who wander and/or exit seek. The sample was 12. The census was 92. Review of the facility's Abuse Prevention and Prohibition Program, revised 10/24/22, showed: -Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to…

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

Based on observation, interview and record review, the facility failed to provide activities of daily living (ADL) care for one resident. Staff failed to provide personal hygiene for one resident who readmitted to the facility from the hospital and had not received personal hygiene care for over 8 hours (Resident #1). In addition, staff failed to provide eating assistance for the residents. The sample size was 3. The census was 93. Review of the facility's Perineal Care (cleansing of the area to include the buttocks and genitals) policy, revised 10/24/22, showed: -Purpose: To maintain the cleanliness of the perineal area, to reduce odor and prevent skin infection and breakdown; -Policy: perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need. Review of the Facility's Nutrition/Hydration Management policy, revised 10/24/24, showed: -Purpose: To ensure each resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is…

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 See Event ID 8D9Z12 Based on observation, interview and record review, the facility failed to provide care and services to ensure residents were free from accident hazards when staff failed to ensure a resident who was a fall risk, had left sided weakness and required total assistance from staff for personal care (Resident #300) had an appropriate bed to provide stability while staff provided care. The census was 94. Review of Resident #300's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/6/23, showed: -Moderate cognitive impairment; -Impairment to one side of upper extremities; -Required substantial assistance from staff to roll from left to right in bed; -Always incontinent of bowel and bladder; -Diagnoses included diabetes, hemiparesis (paralysis on one side), malnutrition and depression. Review of the resident's care plan, in use during the survey, showed: -Focus: Activities of Daily Living (ADLs, personal care) Status: Resident is alert and…

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

Based on observation, interview and record review, the facility failed to provide food and drink to the residents that was palatable, attractive, and at an appetizing temperature during the survey. The findings include: On 9/19/23 at approximately 12:10 p.m. an observation of the lunch meal was made in the main dining room. Resident (R) #347 was observed having difficulty cutting into a sweet potato. The resident placed a piece of the sweet potato in her mouth briefly before spitting it out into a napkin. Observation of the sweet potatoes being served revealed that they were bright orange (raw) and appeared to be undercooked. R #347 was interviewed on 9/19/23 at approximately 12:30 p.m. during lunch while at a table with other residents. She confirmed that the sweet potato was hard and undercooked. Residents complained of broccoli being overcooked and that there was no bread available. At 12:13 p.m. on 9/19/23, R #55 was observed at a table in the dining room giving his ham and broccoli to his tablemates. R #55 stated he would have made a ham sandwich, but he stated, They said they…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one (1) of one (1) kitchen reviewed for food service, in that: 1. Dented cans were found in the for-use section of the dry storage. 2. One pound box of potato pearl was no dated nor sealed. 3. The ice machine was not clean. 4. The indoor central air conditioning unit's return vent was not clean. 5. The backsplash had a black and greenish- substance speckled around the dish machine and pre-wash area. 6. Carts used to distribute resident meal trays were not clean. 7. Hair restraints were not used to cover facial hair and head hair by six (6) of eight (8) dietary staff. 8. There were no sanitizing wipes to clean off the food thermometer when staff took the food temperatures during the lunch meal observed. 9. Cook BB was not aware of the required minimum temperatures for the wash and rinse cycles the dish machine must reach to properly sanitize dishes and equipment. [NAME] BB was also not aware 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.

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for one (1) of one (1) dumpster reviewed for garbage disposal. The facility also failed to ensure the dumpster lids for two (2) of two (2) dumpsters and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. The findings include: An observation and interview on 9/19/23 at 10:38 am with the Dietary Manager revealed the facility's dumpster area, which was in the parking lot behind the dietary department, had two (2) commercial dumpsters that each had one (1) of the two (2) lids opened, exposing the contents inside. The Dietary Manager confirmed the observations. The Dietary Manager reported the dumpster lids were hard to close sometimes. Record review of the facility policy for Garbage and Trash Can Use and Cleaning, dated 10/24/22, revealed food waste will be placed in covered garbage and trash cans.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for one (1) of one (1) dish machine. The dish machine in the kitchen was not operated within the manufacturer's specification. This failure could place residents who received meals and snacks from the kitchen at risk of foodborne illness. The findings include: During the kitchen initial tour with the Dietary Manager on 9/19/23 at 9:56 a.m., the Dietary Manager reported the dish machine was a high temperature machine and the wash cycle was supposed to be at 165 degrees (deg.) Fahrenheit (F) and the rinse cycle was supposed to be 180 deg. F. Observation on 9/21/23 at 11:56 a.m. in the kitchen, revealed [NAME] BB placed the Robot Coupe food processor components into the dish machine after he/she used it to make pureed green beans, and in preparation to use it puree the Salisbury steak. [NAME] BB put the Robot Coupe parts inside the dish machine and pulled the handle/door closed to initiate the wash cycle of the dish…

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 an effective pest control program as evidenced by flies in the facility for residents for three (3) of four (4) facility units (Halls 100, 200 and 300) and one (1) of one (1) dining room observed for environment. The facility had an ineffective pest control program with observations of flies in the 100, 300 and 300 halls of the facility. The findings include: Observation on 9/19/23 at 11:11 a.m. in room [ROOM NUMBER] revealed two (2) flies flying around the resident's room. Observation on 9/19/23 at 11:41 a.m. in room [ROOM NUMBER] revealed Resident #4 seated on his bed and there was a fly flying around the room. Resident #4 confirmed that there was a fly in the room. Resident # 4 also stated while eating his meal yesterday a fly landed on his plate. Observation on 9/19/23 at 11:53 a.m. in room [ROOM NUMBER] revealed at the left corner of the sink, the paneling trim around the sink was peeled off and exposed the wood underneath.…

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 ensure that efforts were made to ensure the reasonable accommodation of resident needs and preferences in relation to call light access for residents on two (2) of four (4) halls the facility. (100 and 200 halls). The findings include: Observations and interviews made during tours of the 100 and 200 halls on 9/19/23 revealed call light cords were not in reasonable reach of residents. The following were observed: On 9/19/23 at 9:33 a.m., in room [ROOM NUMBER]-1, the resident was observed sitting up in bed. The call light was not accessible as it was on the floor behind the resident's bed. On 9/19/23 at 9:36 a.m., in room [ROOM NUMBER]-2 the call light was observed clipped to a blanket that was on the overbed table out of the resident's reach. The resident's daughter, who was present at the time of observation, stated the call light is not long enough to reach around to the right side of the bed so the resident can use it with her right hand. The daughter…

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 maintain an adequate surety bond for the resident trust fund account in the amount of one and one half times the average monthly balance for the past 12 months. The census was 97. Review of the facility's Resident Funds-Handling and Recording Policy, dated 5/1/23, showed the following: -Purpose: To provide a means to protect resident funds managed by the facility and account for funds received and disbursed on the resident's behalf; -Policy: In the event that the facility manages the resident's funds, resident funds will not be commingled with the facility's operating funds. The facility maintains accounting records of resident funds and has a surety bond to protect such funds on deposit with the facility. Review of the resident trust account for the past 12 months, from September 2022 through August 2023, showed an average monthly balance of $98,000.00 (this would yield a required bond in the amount of $147,000.00 (one and one half times the average monthly balance)). Review of the bond report for approved facility bonds…

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 and staff interviews the facility failed to provide a safe, clean, comfortable, and homelike environment. Specifically, the facility failed to ensure two (2) of four (4) units were cleaned and well-maintained to provide for a homelike environment. The findings include: Observation on 9/19/23 at 11:11 a.m. in room [ROOM NUMBER] revealed gray rubber/plastic molding at the base of the wall leading to the front of the closet was peeling off the wall. The air vent had little black spots on it and there was a brown stain about three to four (3-4) inches in length on the air vent. Observation on 9/19/23 at 11:41 a.m. in room [ROOM NUMBER] revealed on the wall of the closet close to the dresser there was a black streak about six to seven (6-7) inches in length that appeared to be a wheelchair scraping. Observation on 9/19/23 at 11:53 a.m. in room [ROOM NUMBER] revealed at the left corner of the sink, there was paneling trim around the sink that was peeled off and exposed the wood underneath.…

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, record review, and policy review, the facility failed to assist one (1) of 32 sampled residents to maintain his/her dignity by ensuring the resident was dressed appropriately. Resident #79, who was identified as having a self-care deficit with self-performance of activities of daily living (ADLs), was observed wearing his/her T-shirt on inside-out and backwards with the resident's last name and first initial printed across the top in large letters with a black marker. Staff interview revealed the resident did not independently dress himself/herself and did not disrobe after being assisted with dressing. The findings include: The facility policy titled Privacy and Dignity, revised 6/2020, stated: Policy: The Facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality. Procedure: . I. Staff assists the resident in maintaining self-esteem and self-worth. V. Resident clothing is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, policy review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to conduct a comprehensive assessment when indicated for one (1) of 32 sampled residents. On 7/23/23, Resident #18 was determined to have a life expectancy of less than six (6) months and the resident was admitted into hospice services. A comprehensive assessment was not completed within 14 days of the determination of terminal prognosis and election of the hospice benefit. The findings include: The facility policy titled Change in a Resident's Condition or Status, revised February 2021, stated: Policy Interpretation and Implementation . 9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA [Omnibus Budget Reconciliation Act] regulations governing resident assessments and as outlined 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.

Based on staff interview, record review and policy review, the facility failed to ensure that a resident's Care Plan was reviewed and revised after an emergency transfer to the hospital due to a change of condition (Resident #57). The findings include: Review of the facility policy titled, Change in a Resident's Condition or Status, revised February 2021, revealed under the section titled, Policy Interpretation and Implementation, 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); . c. requires interdisciplinary review and/or revision to the care plan; A review of Resident #57's electronic medical record revealed an initial admission date of 12/14/21 with a readmission date of 8/10/23. Resident #57's primary diagnoses included End Stage Renal Disease, Schizophrenia and Chronic Kidney Disease. A review of the electronic medical record for Resident #57 revealed a Nursing Note…

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 staff interview and record review, the facility failed to administer medications as order to one (1) of 32 sampled residents (Resident #196). The findings include: Review of Resident #196's closed record revealed he/she was admitted to the facility on [DATE] at 12:00 midnight, and diagnoses included: Huntington's Disease, Anemia, Atrial Fibrillation, Hypertension, Diabetes Mellitus, Alcoholic Cirrhosis of the Liver, Ascites, Irritable Bowel Syndrome (IBS), and Gastroesophageal Reflux Disease. Review of Resident #196's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. According to this MDS, the resident required the extensive assistance of two (2) or more persons for all activities of daily living (ADLs) except bathing, for which the resident was totally dependent upon two (2) or more persons. Record review reviewed the following Physician Orders, with start dates of 4/1/23: Lactulose Oral Solution…

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 staff interview, record review and policy review, the facility failed to ensure quality of care for two (2) of 32 sampled residents, including failure to ensure a resident who went to the hospital due to a change of condition (Resident #57) had an updated Care Plan to reflect the change of condition. The facility also failed to ensure a resident who was dependent on staff for bed mobility, was positioned for comfort and safety. (Resident #18) The findings include: Review of the facility policy titled, Change in a Resident's Condition or Status, revised February 2021, revealed under the section titled, Policy Interpretation and Implementation, 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); 3. Prior to notifying the physician or health care provider, the nurse will make detailed observations 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 provide care and services to ensure residents were free from accident hazards when staff failed to ensure a resident who was a fall risk, had left sided weakness and required total assistance from staff for personal care (Resident #300) had an appropriate bed to provide stability while staff provided care. The census was 94. Review of Resident #300's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/6/23, showed: -Moderate cognitive impairment; -Impairment to one side of upper extremities; -Required substantial assistance from staff to roll from left to right in bed; -Always incontinent of bowel and bladder; -Diagnoses included diabetes, hemiparesis (paralysis on one side), malnutrition and depression. Review of the resident's care plan, in use during the survey, showed: -Focus: Activities of Daily Living (ADLs, personal care) Status: Resident is alert and oriented to person,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews and record review, the facility failed to ensure that a resident who was continent of bladder and bowel received the necessary services and assistance to maintain continence for one (1) of one (1) resident reviewed (Resident #73) for catheter care services out of 31 sampled residents. Specifically, the facility failed to receive a Physician's Order for catheter use to ensure appropriate care was provided to the resident. The findings include: Review of the facility policy titled, Catheter - Care of, last revised 10/24/22, was provided on 9/21/23. It stated: Purpose To prevent catheter-associated urinary tract infections while ensuring that residents are not given indwelling catheters unless medically necessary. Policy I. Each resident who is incontinent of urine is identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible . V. A resident, with or without a catheter, receives the appropriate 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, record review, and policy review, the facility failed to ensure medications were stored appropriately and not kept past their expiration dates. Unsecured medications were stored at the bedside without a physician's order for one (1) for 32 sampled residents (Resident #40), and expired stock medications, prescription medications, and glucose monitoring sensors were found in one (1) of two (2) medication rooms. The findings include: 1. The facility policy titled Medication - Self Administration, revised on [DATE], stated: Procedure: . V. If the resident is assessed as clinically appropriate for medication self-administration, by the IDT [Interdisciplinary Team], the Licensed Nurse obtains a physician's order for self-administration of selected medications. VIII. If the IDT team and Attending Physician approve self-administration of medications, the medications will be placed in a secured drawer or cabinet that is easily accessible to the resident. IX. The Administrator/Director 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 residents were provided the therapeutic diets as prescribed by the attending physician for one (1) of five (5) residents (Resident #34). Resident #34 was not served double portions of protein for the lunch meal as ordered by physician. This could affect all residents with supplements and could result in a decrease in calories and potential for weight loss. The findings include: Record review of the Diet Spreadsheet for the lunch meal on Thursday (9/21/23), revealed the resident was on a regular diet and was to receive one (1) Salisbury steak, one (1) #8 (number eight; ½ cup) scoop of mashed potatoes, two (2) ounces of country gravy, four (4) ounces of seasonal vegetables and one (1) serving of fruit. Record review of Resident #34's face sheet revealed he was admitted to the facility on [DATE] with diagnoses of Encephalopathy, Hypomagnesemia, and Hypokalemia. Record review of Resident #34's Quarterly Minimum Data Set (MDS) 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 provide nutritional supplements as ordered by the physician or recommended by the dietician, to residents identified with impaired nutritional status (Residents #24, #56, #54 and #12). The census was 72. 1. Review of Resident #24's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/30/19, showed: -Supervision required while eating; -Weight: 154 pound (lbs); -No weight loss noted. Review of the resident's medical record, showed: -Diagnoses included dementia without behavioral disturbance, nutritional anemia, and protein-calorie malnutrition; -A physician's order, dated 1/13/20, for mechanical soft diet with double portions at breakfast and health shakes three times a day; -Weighed 156.8 lbs in December 2019; -Weighed 144.4 lbs in January 2020. This represents a severe weight loss of 12.4 lbs or 7.91% for one month (a weight loss of 5% in one month is considered significant, 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 interview and record review, the facility failed to provide documentation that one physician, the facility Medical Director, saw residents according to time frames as mandated by the Centers for Medicare and Medicaid Services (CMS). The facility identified 48 residents as patients of the physician. Of those 48 residents, 12 were sampled and four of those twelve were identified by the facility as being able to provide an accurate interview. Three of those four residents said they had not seen their physician, only the physician's nurse practitioner (NP). The fourth resident was in the hospital and unavailable at the time of the interviews (Residents #42, #274 and #3). The census was 72. 1. Review of Resident #42's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/20/19, showed: -admission date of 5/20/19; -Adequate hearing and vision; -Clear speech - distinct intelligible words; -Makes self understood: Understood; -Ability to understand…

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 super cereal (calorie dense oatmeal) was prepared and served to residents with nutritional needs and orders to receive it during one meal observation. The facility identified six residents as receiving super cereal. The census was 72. Observation on 1/16/20 at 6:24 A.M., showed [NAME] A gathered brown sugar, cinnamon, butter and whole milk to prepare super cereal. As he/she went to obtain the oatmeal, he/she said they did not have enough oatmeal to make super cereal. The residents who were to receive super cereal would not receive it on today (1/16/20). During an interview on 1/16/20 at 7:50 A.M., the Dietary Manager said they ran out of oatmeal and the food delivery was scheduled for 1/16/20, around 8:00 A.M. Food is delivered to the facility on Monday and Thursday. During an interview on 1/21/20 at 8:39 A.M., the administrator said it was unacceptable to run out of super cereal. She would have expected staff to have gone to a local grocery store to buy the oatmeal. Super cereal was important to meet the 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.

Based on observation and interview, the facility failed to label and properly store opened food items in the main walk-in freezer during three of four days of observation. The census was 72. Observation of the kitchen's main walk-in freezer on 1/14/20 at 8:48 A.M., showed: -Two bags of what appeared to be various frozen chicken pieces. The items were in a plastic bag, unlabeled and undated; -One bag of what appeared to be frozen chicken breast patties. The items were in an unsealed plastic bag, unlabeled and undated; -A bag of what appeared to be frozen meatballs in a plastic bag. The plastic bag was tied in a knot, unlabeled and undated; -A bag of frozen pancakes in a plastic bag. The plastic bag was tied in a knot, unlabeled and undated; -A bag of an unknown food item, in a plastic bag, tied in a knot. The item was light brown, with brown crumbs at the bottom of the bag. Observation of the kitchen's main walk-in freezer on 1/15/20 at 7:02 A.M., showed: -Two bags of what appeared to be various frozen chicken pieces. The items were in a plastic bag, unlabeled and undated; -One bag…

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 signs were posted at the front and side visitor entrances, requesting visitors not to visit if they were experiencing a cold or flu or had symptoms of either, and the facility had no personal protection supplies such as gloves or masks for visitors to use if they chose to visit while experiencing a cold or flu symptoms or if the facility was experiencing an outbreak among the residents. The census was 72. Observations of the facility's front and side visitor entrances, from 1/14/20 through 1/17/20 and on 1/21/20, showed no signs posted requesting visitors not to visit if they were experiencing cold or flu symptoms, and no signs directing visitors where they could find personal protection supplies such as masks or gloves if they chose to visit while experiencing cold or flu symptoms or if the facility was experiencing an out break of illness. During an interview on 1/21/20 at 11:30 A.M., the administrator said she had placed a sign at the front entrance only, requesting visitors not to visit if they had cold or flu…

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.