Laguna Rainbow Nursing Center

Based on record review and interview, the facility failed to complete and document a timely and thorough investigation regarding allegations of abuse (knowingly causing physical or mental harm or failing to provide goods and services necessary to avoid physical or mental harm) for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for abuse and neglect allegations when staff failed to complete and submit a thorough follow-up report for an incident involving R #1. If facilities do not submit follow-up reports, then the State Agency (SA) cannot assure the residents are safe and free of abuse. The findings are: A. Record review of R #1's face sheet revealed an admission date of 08/03/24 and included a diagnoses of dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) with behaviors. B. Record review of a Facility Reported Incident (FRI), dated 04/06/25, revealed R #1 alleged that she was attacked by a black man on the night shift, resulting in a thumb injury. The resident was unable to provide specific details 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.

Based on interview and record review, the facility failed to report an unexpected death to the State Survey Agency for 1 (R #1) of 1 (R #1) resident reviewed for clinical decline and death. The facility failed to initiate an internal investigation, submit a reportable event to the State Agency, and document clinical findings in the medical record following the resident's death. If the facility fails to report unexpected deaths, then the State Survey Agency cannot evaluate compliance with Federal regulations.The findings are: A. Record review of R #1's face sheet revealed an admission date of 08/03/24 with the following diagnoses: End-stage renal disease (kidney disease). Chronic respiratory failures with hypoxia (respiratory system is unable to adequately get oxygen into the blood). Diabetes mellitus (DM; a disease in which the body cannot make or properly use insulin). Hypertension (HTN; high blood pressure). B. On 06/25/2025 at 9:26 a.m., during an interview, the Assistant Director of Nursing (ADON) stated R #1 passed away after going to dialysis (a treatment that filters waste,…

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 accurate and complete documentation in the medical record for 1 (R #1) of 1 (R #1) resident reviewed for death and discharge status. The facility failed to document the resident's death in the progress notes and inaccurately listed the resident as discharged to home, rather than deceased . If the facility fails to maintain complete and accurate records, then care outcomes cannot be appropriately tracked, regulatory compliance is compromised, and opportunities for review or improvement may be missed. The findings are: A. On [DATE] at 9:26 a.m., during an interview, the Assistant Director of Nursing (ADON) stated R #1 passed away after going to dialysis (a medical treatment which filters waste and excess fluid from the blood) on [DATE].B. Record Review of R #1's progress notes, dated [DATE], showed staff did not document the resident was transported to dialysis and died after arrival at the dialysis center. C. Record review of the facility's…

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

Based on record review, observation, and interview, the facility failed to assure medications were secured and inaccessible to unauthorized staff. This deficient practice had the potential to affect all 33 residents identified on the facility census list provided by the Administrator on 04/22/25. Improperly stored medications could result in a resident, staff member, or visitor taking the medications not prescribed to them. The findings are: A. Record review of the facility's Medication Storage Controlled Medication Storage policy (any type of chemical that can alter a person's physical or mental state.), dated January 2025, revealed the following: - Only authorized licensed nursing and pharmacy personnel had access to controlled medications. -The access system (key, security codes) used to lock controlled medications (medications or chemicals regulated by the government because they can be easily abused and lead to addiction) and other medications subject to abuse, could not be the same access system used to obtain the non-scheduled medications. - The facility must have a system 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 record review, observation and interviews, the facility failed to sanitize dishes when staff did not maintain the dish washing machine at 120 degrees (°) Fahrenheit (F), per manufacturer's instructions. This deficient practice was likely to affect all 33 residents of the facility. If the facility fails to ensure the dish machine reached the appropriate temperature, then residents could potentially be exposed to foodborne illnesses (illnesses caused by food contaminated with bacteria, viruses, parasites, or toxins.) The findings are: A. Record review of the facility's Dish Washing Policy, dated March 2010, revealed the policy did not address the temperature of the water for sanitizing dishes. B. Record review of the Ecolab Low Temperature (ELT) Dish Machine (low temperature dish washing machines utilize chemicals for sanitation) Manufacturer's Recommendations, dated 2022, revealed the dish machine should be operated at minimum temperatures of 120° F for washing and rinsing. C. On 04/23/25 at 10:26 A.M. during an observation and interview, staff utilized a low-temperature…

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

Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure staff followed contact precautions (used for individuals with infections that can spread through direct or indirect contact with the patient or their environment) before contact with a resident and his environment for 1 (R #13) of 1(R #13) residents. This practice could likely lead to an increased risk of transmission of the bacteria to other patients and healthcare workers, potentially causing more infections due to direct contact with contaminated surfaces or the infected patient, which could result in serious complications like sepsis (presence of bacteria and infectious organisms in the blood stream) or even death if left untreated. 2. Demonstrate its measures to minimize the risk of Legionella (a type of bacteria that can cause legionellosis; a serious chest infection) and other opportunistic pathogens in the building water systems by not having a documented water management program. This failure to affect all residents in the facility. This deficient practice is likely to increase the risk…

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 designate one or more individuals as the Infection Preventionist (IP) who was responsible to assess, develop, implement, monitor, and manage the infection prevention and control program (IPCP; a set of practices and procedures that aim to reduce the spread of infections in healthcare facilities and other settings). This practice could likely cause a lack of dedicated oversight and implementation of proper infection control practices across the facility and lead to potential resident harm and a greater risk of outbreaks. The findings are: A. On 12/18/24 at 9:48 am, during an interview with Nurse #4/MDS Nurse, she stated the previous Director of Nursing resigned at the end of November 2024 and did not involve her (Nurse #4) in the process of infection control. She stated the Interim Administrator did not ask her to do any infection control duties, and she did not have any qualifications to perform infection prevention and control duties. B. On 12/18/24 at 10:00 am, during an interview with the facility's Interim…

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 record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required dementia and abuse training for 12 (CNAs #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 and #12) of 19 (CNAs #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) CNAs reviewed for dementia and abuse training. This deficient practice could likely result in the nurse aides not receiving the necessary training to meet the care needs of the residents. The findings are: A. Record review of the facility's most current abuse and dementia training list, dated December 2023 to December 2024, revealed 12 CNAs did not receive abuse training, dementia training, or both. B. On 12/18/24 at 10:10 am, during an interview with the Social Services Director, she stated she did not think the staff received dementia. C. On 12/19/24 at 3:30 pm, during an interview with the Interim Administrator, she stated the abuse and dementia training list, dated December 2023 to December 2024, was the most current employees who worked at the facility. She confirmed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to assist a resident in gaining access to vision services when staff failed to make appointments or arrange for transportation for 1 (R #30) of 1 (R #30) residents. This practice could likely lead to an increase in the risk of missing early signs of serious eye diseases like glaucoma (a group of eye conditions that can cause blindness) and macular degeneration (a medical condition which usually affects older adults and results in a loss of vision in the center of the visual field because of damage to the retina), which often have no noticeable symptoms in their early stages, potentially leading to significant vision loss or blindness if left untreated. Additionally, it could likely lead to missing a resident's prescription needs, causing eye strain and difficulties with daily activities. The findings are: A. Record review of R #30's Minimum Data Sets (MDS; a federally mandated assessment instrument completed by facility staff) revealed the following: -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure 1 (R #13) of 1 (R #13) resident reviewed for pressure ulcers (a wound caused by prolonged pressure occurring in bony areas of the body) received the necessary treatment and services to promote healing and prevent new ulcers from developing when staff failed to perform wound care for multiple days. This deficient practice likely worsened the wound for R #13, exposing bone and osteomyelitis (bone infection). The findings are: A. Record review of R #13's face sheet revealed the resident was initially admitted to the facility on [DATE] with multiple diagnoses to include: - Muscle wasting and atrophy (loss of skeletal muscle mass), - Type 2 diabetes mellitus with diabetic neuropathy (type of nerve damage that can occur with diabetes), -Chronic kidney disease, stage 4 (severe.) B. Record review of R #13's care plan, dated 08/05/24, revealed the following: - R #13 was readmitted to the facility with a Stage 2 pressure ulcer to the coccyx (tail bone…

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 staff interview, the facility failed to ensure staff secured the medications inside the medication room and made them inaccessible to unauthorized staff and residents. This practice could likely give access to unauthorized staff, residents, and visitors, and could lead to medication misuse. The findings are: A. On 12/16/24 at 1:42 pm, during an observation, Nurse #2 put the medication room key inside a drawer at the nursing station. B. On 12/16/24 at 1:45 pm during an interview, Nurse #2 stated she kept the medication room key inside an unlockable drawer at the nurses station. She stated somebody was always available at the nurses station to guard the drawer. C. On 12/16/24 at 2:15 pm during an observation, the nursing station was unattended by nurses or staff. D. On 12/17/24 at 10:11 am during an interview, Nurse #4 stated the Certified Medication Aids (CMAs) were responsible to hold the medication room key, and sometimes they were not available when nurses needed the key. Nurse #4 stated they lost many keys when staff took them home, so she decided to keep…

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

Based on interviews and record review, the facility failed to ensure nurses educated a resident or a resident's representative on the benefits and potential side effects of the pneumococcal immunization (a shot that helps protect you from serious bacterial infections caused by pneumococcal bacteria) before nurses offered the immunization for 1 (R #7) of 1 (R #7) residents. This practice could likely lead to improper decision making by R #7's legal guardian due to inadequate discussion on the risks and benefits of the immunization. The findings are: A. Record review of R #7's physician orders, dated 11/25/24, revealed an order to administer Prevnar vaccine (pneumococcal immunization) 0.5 milliliter intramuscular (administered in the muscle.) B. Record review of R #7's face sheet dated 08/01/24, revealed R #7's son was her legal guardian and consented to her pneumococcal immunization. C. Record review of R #7's progress notes, dated 11/19/24, revealed Nurse #5 called R #7's legal guardian to obtain consent to R #7's pneumococcal immunization. The notes did not mention any education on…

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

Based on record review and interview, the facility failed to notify the Power of Attorney (POA; health care power of attorney grants, in writing, a particular agent the power to make healthcare decisions on another's behalf) and health care provider of 1 (R #1) of 1 (R #1) resident reviewed when staff found R#1 with a injury of unknown origin and did not notify the POA and the facility provider within two hours. If the facility is not notifying the resident's POA or provider when the resident has a change of condition, then the POA and provider are unable to make decisions related to treatment and advocate for the resident's care. The findings are: A. Record review of R #1's face sheet, dated 04/30/18, revealed the following: - admission date of 04/30/18. - Dementia (a chronic disease that causes a progressive decline in memory, judgment, including poor decision making). - Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). - Emergency contact #1 and POA - relationship daughter B. Record review of R #1's…

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

Based on observation and interview, the facility failed to: 1. Discard fresh produce that was older than seven (7) days; 2. Provide a splash guard for items that are stored on the bottom shelf of a wire rack. This deficient practice has the potential to affect all 42 residents listed on the census that was provided by the facility on 09/25/23. This deficient practice could likely lead to a foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in residents if food and equipment are not being stored properly. The findings are: A. Record review of the facility's policy titled Food Receiving and Storage, last revised October 2017, revealed the following: 7. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated ('use by' date). Such foods will be rotated using a 'first in- first out' system. B. On 09/25/23 at 9:14 am, during an initial tour of the kitchen, the following items were observed: -Food located in the walk-in fridge: 1. Spring mix- brown in appearance, dated 08/07/23, 2. Cilantro- brown 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 observation, interview, and record review, the facility failed to maintain proper infection prevention measures by: 1. Propping open the door open from the dirty utility to the clean utility. 2. Having a fan on in the dirty utility room circulating air around where dirty linen was kept. 3. Staff failing to wear Personal Protective Equipment (PPE) when sorting through dirty linen. Transmission Based Precautions (TBCP-Wear gloves, gown, eye protection, and apron when in contact with residents' dirty linen) These deficient practices could likely result in residents being exposed to or developing infections they may otherwise have avoided. These findings are: Findings for propping open the door between dirty and clean linen: A. On 09/26/23 at 12:39 pm, an observation of the laundry room revealed staff propped open the door of the dirty linen room, which led to the clean linen room, using a large, stand-up dustpan. B. On 09/26/23 at 12:41 pm, during an interview with laundry aide #1 she stated, I get claustrophobic, and I can't breathe. It is hot in here, so I have to prop it…

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 record review and interview, the facility failed to ensure staff implemented a comprehensive antibiotic stewardship program (The effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Improving antibiotic prescribing and use is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance). This deficient practice has the potential to affect any of the 42 residents identified on the census provided by the Executive Director (ED) on 09/25/23, and who might be placed on antibiotics, which could result in the inappropriate use of antibiotics and that can lead to resistance of a multi-drug resistant organism. These findings are: A. Record review of the facility's Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and outcomes, dated 12/16, revealed, Policy Statement: Antibiotic usage and outcome data will be collated and documented using a facility- approved antibiotic surveillance tracking form. The data will be used to guide decisions 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 safeguard (secure or protect) clinical record information by leaving protected health information (PHI; personal identifying information) unattended. This deficient practice has the potential to affect all residents residing on Hall B (residents were identified by the Resident Census List provided by the Administrator on 09/25/23). If resident's clinical information is not adequately safeguarded, resident's PHI is likely to be accessed (obtained or examined) by unauthorized (not having permission or approval) residents, visitors, and/or staff. The finding are: A. On 09/27/23 at 9:14 am, observation revealed, Certified Medication Aide #1 (CMA) left the medication cart computer unlocked, showing PHI for resident #2, as she walked into R #2's room to deliver her medications. B. On 09/27/23 at 2:30 pm, during an interview, Director of Nursing (DON) stated the staff should lock their medication cart and computer whenever they leave their cart.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure 3 (R #25, #30 and #38) of 3 (R #25, #30 and #38) residents reviewed for behavioral health concerns received necessary behavioral health services and monitoring to meet the resident's need by: 1. Not providing counseling services/referral as ordered for R #38 and R #30. 2. Staff being inconsistent of identifying what is considered behaviors versus what is considered resident choice/self determination. This deficient practice could potentially cause poor communication and monitoring by staff, creating issues between the residents who are involved in relationships. The findings are: A. Record review of R #25's face sheet indicated R #25 was admitted on [DATE] with the following diagnoses: - Unspecified dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), - Depression (is a common and serious mental illness that affects your mood and interest in life), - Atherosclerotic heart disease…

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

Based on observation, interview and record review the facility failed to: 1. Properly store medications in a medication cart; 2. Lock treatment carts when they were unattended. These deficient practices have the likelihood to result in all 16 residents in A hall, that were identified on the census list provided by the administrator on 09/25/23, allow access to discontinued medications that could be accidentally administered, allow residents treatments and treatment medications to be accessed by unauthorized (not having permission or approval) staff or residents. The findings are: A. Record review of R #6's physician orders revealed Flovent was ordered on 05/08/2019 and discontinued on 08/31/23. B. On 09/25/23 at 9:18 AM, observation of medication cart A revealed an open inhaler of Flovent (medication used to treat breathing problems) with an open date of 07/04/23 for resident (R) #6. C. On 09/25/23 at 9:25 AM, during an interview, certified medication aide (CMA) #2 stated the Flovent inhaler for R #6 had been discontinued and should not be stored with currently ordered medications…

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, record review, and interview, the facility failed to ensure the resident call light system was in complete working order as evidenced by hallway indicator lights not activating for 5 (R #4, R #42, R# 38, R #26 and R #16) of 15 (R #4, R #42, R #16, R #12, R #28, R #19, R #33, R #34, R #38, R #30, R #35, R #26, R #16, R #13, and R #9) resident call lights tested. This deficient practice could likely lead to residents being unable to indicate the need for help when in bed or in the restroom. The findings are: A. On 09/25/23 at 09:44 AM, the following observations were made: -Surveyor used the wall switch to turn on the call light for R #4 and R #42's restroom; the hallway light did not activate. -Surveyor used the wall switch to turn on the call light near R #38's bed; the hallway light did not activate. -Surveyor used the wall switch to turn on the call light for R #26 and R #16's restroom and R #26's bed; the hallway light did not activate. B. On 09/27/23 at 01:44 PM during an interview, LPN #2 stated she was only aware the call light for R #4 and R #42's…

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

Based on observation and record review, the facility failed to have the Interdisciplinary team (IDT) (Consists of a team of professionals of various roles within the facility who review and determine resident needs and abilities) determine if residents could self-administer medication for 1 R #17) of 1 (R #17) residents viewed for treating a fungus infection. If the facility is not assessing the residents to determine if a resident is capable of self-administering medications then this deficient practice is likely to result in residents self-administering medications inappropriately and or incorrectly, causing harm. The findings are: A. On 09/25/23 at 9:25 am, an observation of R # 17's room revealed two bottles of Nystatin powder (used to treat fungal or yeast infections of the skin) on his bedside table. B. On 09/25/23 at 9:25 am, during an interview, R #17 revealed staff left his medication at bedside, and he was unable to self-administer. C. Record review of R #17's Physicians orders revealed Nystatin ointment, 100,000 unit/gram; amt (amount) 1 application twice daily; topical…

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 prevent resident-to-resident abuse/neglect for 1 (R #30) of 3 (R #25, 30 and 38) residents reviewed for abuse/neglect. This deficient practice could likely cause physical and emotional harm to the resident when staff were unable to protect a resident from another resident physically assaulting her. The findings are: A. On 09/25/23 at 1:05 pm, R #30 stated she and another resident had an altercation. She stated the other resident went crazy and held onto her. It took two staff people to get him to stop and let go of her. She stated he was pounding her head against the wall or something. She stated the police came, and she went to the hospital to get checked out. She stated she moved to another hall to get away from him. B. Record review of the nursing progress notes for R #30, dated 12/15/22 at 6:11 pm, indicated, Resident was attacked in (name of) hallway by another male resident (R #23). She attempted to get away from the other resident but was being held by her hair and being hit in the face. When staff responded she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to update a care plan for 1 (R #41) of 3 (R #'s 21, 31, and 41) care plans reviewed for care plan accuracy. This deficient practice could likely result in staff not being aware of resident care needs. The findings are: A. Record review of the facility's policy, titled Goals and Objectives, Care plans, last revised April 2009, revealed: 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. 2. When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. B. Record review of R #41's face sheet revealed R #41 was admitted to the facility on [DATE] with the following pertinent diagnoses: - Pressure ulcer (injury to skin and underlying tissue as a result from prolonged pressure on the skin) of right buttock- stage 4 (the severity of a pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to have physician orders for 1 (R #17) of 1 (R #17) resident by allowing the patient and staff to apply absorbase moisturizing cream to his coccyx without physician orders. This deficient practice could likely result in allowing residents to use over the counter medication and could cause residents to suffer adverse (unintended) reactions to medications that are not appropriate for the resident. The findings are: A. On 09/26/23 at 2:40 pm, during observation of R #17's room, a large container of absorbase moisturizing cream sat on the bedside table. Absorbase cream is used to treat or prevent dry, rough, itchy skin and minor skin irritations. All over the counter medications must be ordered by a physician in order to be used in a skilled nursing facility. B. On 09/26/23 at 2:45 pm, during an interview, R #17 stated he applied the absorbase moisturizing cream to his coccyx every evening, and he brought the cream with him when he was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a comprehensive discharge summary that would include a recapitulation of the resident's stay, for 1 (R #46) of 1 (R #46) residents reviewed for the discharge process. This deficient practice could likely result in an intermittent continuation of care due to the lack of information. The findings are: A. Record review of the facility's policy titled Discharge Summary and Plan, last revised December 2016, revealed the following: 2. The discharge summary will include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge . The discharge summary shall include a description of the resident's: . b. Medical history; c. Course of illness, treatment and/or therapy since entering the facility; B. Record review of R #46's EHR (Electronic Health Record) revealed R #46 was admitted to the facility on [DATE] and was discharged on 08/25/23. C. Record review of R #46's discharge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to update 1 (R #1) of 3 (R #1, R #2, and R#3) resident care plans when reviewed for a change in course of care. This deficient practice could likely result in a resident's course of care and treatment options not being clearly documented or established. The findings are: A. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, last revised [DATE], revealed the following: - 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframe; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe the services that would otherwise be provided for the above. - 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. - 14. The Interdisciplinary Team must review and update the care plan: a. When there…

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.