Monterey Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure nail care was provided for dependent residents. This affected four residents (#75, #91, #95, #104) of six residents reviewed for activities of daily living (ADL). The facility census was 108. Findings include: 1. Review of Resident #104's medical record revealed an admission date of 08/01/24 with diagnoses including bipolar disorder, secondary parkinsonism, schizoaffective disorder, mild cognitive impairment, and disorientation. Review of Resident #104's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had intact cognition. She required partial to moderate assistance with personal hygiene. Review of Resident #104's care plan dated 08/01/24 revealed she had an Activity of Daily Living (ADL) self-care deficit related to decreased mobility, use of assistive device, need of staff assistance, weakness, and diagnoses. Interventions included assisting with daily hygiene as needed, therapy evaluation as needed,…

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 there were sufficient activities in the memory care unit especially in the evening and weekend. This affected four residents (#75, #91, #95, and #99) of four residents reviewed for activities and had the potential to affect all 25 residents residing in the memory care unit. The facility census was 108. Findings include: 1. Review of Resident #95's medical record revealed an admission date of 10/10/23 with diagnoses including protein-calorie malnutrition, bilateral age-related nuclear cataracts, Alzheimer's disease, anxiety disorder, adult failure to thrive, cognitive communication deficit, depression, and bilateral sensorineural hearing loss. Review of Resident #95's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was not assessed. Review of Resident #95's plan of care dated 06/10/24 revealed the resident was sometimes dependent on staff for cognitive stimulation related to cognitive deficits. The resident could…

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 ensure resident dignity was maintained during dining experiences. This affected two residents (#35 and #103) observed for dining during the annual survey. The facility census was 108. Findings include: Observation on 11/20/24 at 8:05 A.M. revealed Resident #35 and Resident #103 were lying in bed and did not have breakfast meal trays. A newly admitted resident residing in the room with Resident #35 and Resident #103 was sitting up in bed consuming breakfast from a meal tray set up in front of her. Resident #35 and Resident #103 both confirmed they were hungry and would like a meal tray. Observation on 11/20/24 at 8:19 A.M. revealed Resident #35 and Resident #103 had still not been served a breakfast meal tray. Three unknown facility employees were standing at the end of the hall by the breakfast meal cart discussing who was responsible for Resident #103. All three employees stated the resident was not on their assignment and walked away. Observation on 11/20/24 at 8:29 A.M. revealed Registered Nurse (RN)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide residents with a bed hold notification prior to hospital stay. This affected two (Residents #15 and #39) of four residents reviewed for notification of bed hold. The facility census was 108. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 08/28/18 with diagnoses including epilepsy, clavicle fracture, humerus fracture, dysphagia, Alzheimer's disease, dementia, Lennox-Gastaut Syndrome, convulsions, idiopathic progressive neuropathy, anxiety, depression, cervical vertebrae fracture, and nontoxic thyroid nodule. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had severe cognitive impairment. Resident #15 was sent to the hospital on [DATE] following a fall with a laceration to her forehead. Review of the Notification of Bed Hold form with this resident's name written at the top revealed the form did not provide the total amount of bed hold days left.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure Thrombo-Embolic Deterrent (TED) hose were applied as ordered by the physician. This affected one resident (#57) of the eight residents reviewed for skin conditions during the annual survey. Additionally, the facility failed to timely collect urine and treat a urinary tract infection (UTI) for Resident #86. This affected one resident (#86) of one reviewed for UTI. The facility census was 108. Findings include: 1. Record review for Resident #57 revealed the resident was admitted to the facility on [DATE] and had diagnoses including history of venous thrombosis and embolism, chronic pain, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was assessed to be rarely/never understood. Review of the active physicians order dated 06/25/24 revealed the resident was to have knee high TED hose applied every morning and removed at bedtime for edema. Observation on 11/19/24 at 8:25 A.M.…

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, resident and staff interviews, medical record review, and facility policy review, the facility failed to ensure staff assisted one resident (#13) with the placement of bilateral hearing aids daily as ordered. This affected one resident (#13) of one reviewed for hearing services. The facility census was 108. Findings include: Review of the medical record for Resident #13 revealed an initial admission date on 04/25/17 and a readmission date on 09/25/23. Medical diagnoses included dementia without behavioral disturbance, unspecified bilateral hearing loss, anxiety disorder, depression, and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13's cognition had not been assessed for the assessment. Resident #13 had minimal difficulty hearing and used hearing aids. Resident #13 required a varied amount of assistance from staff ranging from supervision to partial/moderate assistance to complete Activities 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 observations, interviews, record reviews, and review of facility policy, the facility failed to ensure pressure ulcer prevention interventions were in place per the plan of care, failed to ensure pressure ulcers were comprehensively evaluated upon admission, and failed to ensure staff were educated on the appropriate settings for Low Air Loss (LAL) mattresses. This affected two residents (#43 and 362) out of the five residents reviewed for pressure ulcers during the annual survey. The facility census was 108. Findings include: 1. Record review for Resident #43 revealed the resident was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparalysis following cerebral infarction affecting the left non-dominant side, presence of pressure ulcers, and contracture of the muscle of the left hand. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to have moderately impaired cognition. The resident was assessed to have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure care and services to prevent the development or worsening of contractures were timely and appropriately implemented. This affected two residents (#43 and #91) out of two residents reviewed for limited range of motion during the annual survey. The facility census was 108. Findings include: 1. Record review for Resident #43 revealed the resident was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparalysis following cerebral infarction affecting the left non-dominant side, presence of pressure ulcers, and contracture of the muscle of the left hand. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to have moderately impaired cognition. The resident was assessed to have an impairment in functional range of motion present on one side of the upper body. Review of the active care plans for the resident revealed no plan of care had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure fall interventions were in place per the plan of care. This affected one resident (#57) of the four residents reviewed for falls during the annual survey. The facility census was 108. Findings include: Record review for Resident #57 revealed the resident was admitted to the facility on [DATE] and had diagnoses including muscle weakness, unsteadiness on feet, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/05/24, revealed the resident was assessed to be rarely/never understood. Review of the care plan, initiated 08/01/23, revealed the resident was at risk for falls and potential injury. Interventions included grip strips to the floor in front of the bed. Observation on 11/20/24 at 11:00 A.M. revealed there were no grip strips present on the floor by Resident #57's bed. Interview with Unit Manager #144 at the time of the observation confirmed there were no grip strips…

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 medical record review, resident interview, and staff interview, the facility failed to complete timely follow up to obtain sleep study results for one resident (Resident #13). This affected one (Resident #13) of four residents reviewed for respiratory care. The facility census was 108. Findings include: Review of the medical record for Resident #13 revealed an initial admission date on 04/25/17 and a readmission date on 09/25/23. Diagnoses included dementia without behavioral disturbance, anxiety disorder, depression, obstructive sleep apnea, and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13's cognition had not been assessed for the assessment. Resident #13 required a varied amount of assistance from staff ranging from supervision to partial/moderate assistance to complete Activities of Daily Living (ADLs). Review of the Order Summary Report dated February 2024 revealed Resident #13 had an order to place…

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 staff interview, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the resident's PTSD and minimize triggers and/or re-traumatization. This affected one (#46) of three resident identified by the facility as having PTSD/trauma. The facility census was 108. Findings include: Record review for Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses included anxiety, cognitive communication deficit, depression, and suicidal ideations. Resident #46 was assessed to have an active diagnosis of PTSD initiated on 08/28/24. Review of the Minimum Data Set (MDS) assessment, dated 10/28/24, revealed Resident #46 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14. Review of the active care plans for Resident #46 revealed no plan of care was in place addressing the cause of PTSD, triggers which may cause re-traumatization, or interventions…

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 medical record review, the facility failed to ensure Resident #69's blood pressure was monitored as ordered. This affected one (#69) of five residents reviewed for unnecessary medications. The facility census was 108. Findings include: Review of Resident #69's medical record revealed an admission date of 09/03/21 with diagnoses including senile degeneration of the brain, dementia, and hypertension. Review of Resident #69's quarterly Minimum data Set (MDS) 3.0 assessment dated [DATE] revealed her cognition was not assessed and staff was not interviewed. Review of Resident #69's plan of care dated 09/29/22 revealed the resident had tendency for fluctuation in blood pressure related to hypertension, orthostatic blood pressure, cardiac medications, anemia, pain, and anxiety. Interventions included administering medications as ordered, diet as ordered, monitoring blood pressure as ordered, and monitoring for signs of hypotension. Review of Resident #69's physician order dated 08/03/24…

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

Based on observation,staff interview, and review of medical record, the facility failed to ensure Resident #29 was served his meal as physician ordered. This affected one resident (#29) of 25 residents in the memory care unit. The facility census was 108. Findings include: Review of Resident #29's medical record revealed an admission date of 08/09/24. Diagnoses included dementia, cognitive communication deficit, schizoaffective disorder, anxiety disorder, dysphagia, and hypertension. Review of Resident #29's physician order dated 08/09/24 revealed the resident was to receive a regular diet with double entree portions. Observation on 11/18/24 at 12:07 P.M. of Resident #29 revealed his lunch tray included one sandwich. Review of Resident #29's tray ticket for lunch revealed he was on a regular diet. No double entrees were indicated on his tray ticket. Interview on 11/18/24 at 12:07 P.M. with State Tested Nursing Assistant (STNA) #162 verified Resident #29's physician order indicated he was to receive double entrée portions, and verified Resident #29 did not receive double entree…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure resident received appropriate set up assistance and adaptive equipment during meals necessary to maintain adequate nutrition. This affected one resident (#43) out of the five residents reviewed for nutrition during the annual survey. The facility census was 108. Findings include: Record review for Resident #43 revealed the resident was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparalysis following cerebral infarction affecting the left non-dominant side, muscle weakness, and contracture of the left hand. Review of the significant change Minimum Data Set (MDS) assessment, dated 10/08/24, revealed the resident was assessed to have moderately impaired cognition. Review of the care plan, revised 10/12/24, revealed the resident had a history of declined intake with liberated diet and appetite had improved. Interventions included to provide feeding and set up assistance…

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 provide a safe and sanitary environment for residents who use the facility shower rooms. This had the potential to affect all 118 residents in the facility. Findings included: Observation on 11/13/23 at 10:30 A.M. of the shower room at the corner of the South and East hallways revealed three large, untied garbage bags on the floor with soiled linens, three small tiles missing from the floor, the back wall of the shower had a black, filmy substance on it, a container of sharps that was overfilled, several large, red biohazard bags piled in the front left corner, a pair of used gloves on the sink, a rancid odor, and several linens were laying out on an over the bed table in the right front corner. Interview on 11/13/23 at 10:35 A.M. with Licensed Practical Nurse (LPN) #117 confirmed findings in the shower room at the corner of the South and East hallways. Observation on 11/13/23 at 10:47 A.M. revealed two shower rooms at the corner of the South and [NAME] hallways. The shower room to the right had a black mold-like substance…

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, facility reported incident review, and interviews, the facility failed to ensure residents remained free from staff to resident abuse and resident to resident altercations. This affected three residents (#144, #158, and #214) of 13 residents reviewed for abuse. The facility census was 118. Findings included: Record review revealed Resident #144 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, conversion disorder with seizures, anxiety disorder, sciatica, hypertension, major depression, post-traumatic stress disorder, nightmare disorder, and gastro-esophageal reflux disease. A minimum data set completed on 10/19/23 revealed Resident #144 had intact cognition and exhibited no behaviors. Interview on 10/13/23 at 10:10 A.M. with Resident #144 revealed Activity Director (AD) #257 would come up behind her to give her a hug, kiss the top of her head, and say inappropriate terms of endearment to her, such as you're fine as wine and you're sexy. Resident #144…

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 facility document review and staff interview, the facility failed to fully participate in Quality Assurance and Assessment (QAA) committee activities. This had the potential to affect 85 of 85 residents in the facility. Findings Include: Review of facility QAA meeting sign in sheets, dated March 2021 to March 2022, revealed the only meeting that the facility medical director attended was in April 2021. Review of facility Medical Director Monthly Reports, dated January 2022, October 2021, and July 2021, revealed hand written notes that indicated the QAA meeting minutes were reviewed with the medical director. There was no documentation to support which QAA meeting minutes and information was reviewed at that time, so there was no documentation to support the information reviewed with the medical director was current/relevant to what was discussed in each monthly/quarterly QAA meeting. Also, there was no documentation/evidence to support the medical director was provided, or offered meaningful participation in the QAA program. Interview with Director of Nursing (DON) 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 observations, staff interview, and facility policy review, the facility failed to properly store/date food in the main kitchen. This had the potential to affect 82 of 85 residents who receive food from the facility kitchen (Residents #8, #16, and #19 receive no food by mouth). The census was 85. Findings Include: Observations on 05/02/22 from 8:38 A.M. to 8:47 A.M. revealed the following items were found in the walk in freezer as opened and undated/improperly dated: opened bag of country friend steak that had a delivery date of 01/05/22 on the opened box, but no date on the bag of steak that was opened, and bags of chicken patties, breadsticks, green peas, and chicken tenders were opened and undated as to when they were opened or should be used by. Observations on 05/02/22 from 8:50 A.M. to 8:55 A.M. revealed the following items were found in the walk in refrigerator as opened and undated/improperly dated: bag of hot dogs, cole slaw, and two bags of lettuce were all opened and had no dates indicated as to when they were opened or when to use by. Also, there was a pan 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 observation, resident and facility staff interview the facility failed to maintain a safe home like environment. This had the potential to affect three residents (#133, #15 and #68) of 24 residents reviewed. The total facility census was 85. Findings Include: During initial observation of rooms on the secured hallway on 05/02/22 at 9:40 A.M. it was observed Resident #133's room had 10 floor tiles that were gouged through the top layer of the tile. The wall at the head of the resident's bed was damaged with the top layer of the drywall removed exposing the inner surface of the drywall. At this time, observation of Resident #15's room revealed the wall, the resident's bed was against, had multiple divots in the drywall. During an interview and observation of Resident #68's room on 05/02/22 at 10:29 A.M. it was revealed the cold water side of the sink did not work. The resident stated the sink has water but only on the hot side. At this time, the cold water faucet was turned on and no water came out of the faucet. The cold side of the faucet was turned off and the hot side was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, resident interview, staff interview and facility policy review, the facility failed to provide a resident the opportunity to participate in a plan of care meeting. This affected one Resident (#4) of one resident reviewed for care planning. The facility census was 85. Findings Include: On 05/02/22 at 1:12 P.M., an interview with Resident #4 was conducted. Resident #4 stated she was concerned about a wound that was bothering her on her head and a loose tooth causing discomfort in her mouth. Resident #4 further stated she did not remember talking to the staff about her concerns. She also stated she had not been asked to participate in a plan of care meeting to discuss those concerns. A review of the medical record for Resident #4 revealed an admission date of 08/17/21 and diagnoses that included diabetes mellitus, hypertension, renal insufficiency, chronic pain, fibromyalgia. Review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #4 was alert and oriented, able to make…

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 facility staff interview the facility failed to ensure a resident who had discontinuation of hospice services had timely monitoring and evaluation of anti-seizure medication. This affected one resident (#38) of one resident reviewed for change of condition. The total facility census was 85. Findings Include: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that include but are not limited to unspecified dementia adult failure to thrive, seizures, unstable angina, repeated falls. hypertension and trans ischemic attack. Review of a significant change Minimum Data Set, dated [DATE] revealed the resident is not able to complete the brief interview of mental status score, resident had no behaviors, delusions, hallucinations, rejection of care but had one instance of wandering during the review period. Resident #38 required extensive assist with bed mobility, dressing, toileting, and hygiene, and limited assist with…

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 facility staff interview the facility failed to ensure a physician was directing the care of a resident. This affected one resident (#38) of one reviewed for change of condition. The total facility census was 85. Findings Include: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that include but are not limited to unspecified dementia adult failure to thrive, seizures, unstable angina, repeated falls, hypertension, and trans ischemic attack. Review of significant change Minimum Data Set, dated [DATE] revealed the resident is not able to complete the brief interview of mental status score, resident had no behaviors, delusions, hallucinations, rejection of care but had one instance of wandering during the review period. Resident #38 required extensive assist with bed mobility, dressing, toileting, and hygiene, and limited assist with transfers, walk in the room and eating. The resident is coded as requiring supervision…

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, staff interview and policy review, the facility failed to provide clean storage of china plates used for resident meals, a clean can opener, and clean ice scoop/container. This had the potential to affect all 130 residents who consumed meals in the kitchen. The facility identified one resident (#70) who received nothing by mouth. Findings include: On 08/04/19 at 9:34 A.M. kitchen observations with [NAME] #8 revealed 37 ivory china plates had been washed and stored stacked soaking wet. The kitchen can opener blade was very soiled. [NAME] #8 verified the wet stored china plates and soiled can opener blade at the time of the observation. On 08/04/19 at 5:01 P.M. observations with Dietary Manager #126 revealed the inside bottom of blue ice container was wet and soiled with the ice scoop sitting inside container. Dietary Manager #126 verified the ice container was soiled and had a scoop inside at the time of the observation. Review of the policy titled Handling Clean Equipment and Utensils dated 01/01/12 revealed clean equipment and utensils were to be stored in a…

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

Based on observation, staff interview and facility policy review, the facility failed to ensure lids were placed on trach cans. This had the potential to affect all 130 residents who consumed meals in the kitchen. The facility identified one resident (#70) who received nothing by mouth. Findings include: Observations on 08/04/19 at 9:34 A.M. with [NAME] #8 verified there was an open bin full of trash near the back door with no lid near the food storage/production. There were several gnats above the trash. In addition, the trash bin outside had no lid and was full of of trash. [NAME] #8 verified the finding at the time of the observation. Review of the policy titled Waste Disposal dated 01/01/12 revealed all waste was to be kept in leak proof covered containers.

Based on observations, resident and staff interviews, the facility failed to ensure baseboard heaters were secured in resident rooms. This had the potential to affect 19 residents (#286, #84, #104, #118, #40, #72, #81, #105, #23, #115, #87, #101, #133, #67, #90, #122, #31, #75, and #19). In addition, the facility failed to control urine odors potentially affecting all 131 residents of the facility. Findings include: 1. Interview and observation with Resident #286 on 08/04/19 at 11:11 A.M. revealed she was a newly admitted resident. The observation revealed her baseboard heater in her room was hanging off the wall. Observations of the environment on 08/06/19 starting at 11:15 A.M. revealed old/dirty baseboard heaters not in use which were hanging off the walls with a two/three inch gap in 19 resident (#286, #84, #104, #118, #40, #72, #81, #105, #23, #115, #87, #101, #133, #67, #90, #122, #31, #75, and #19) rooms. Some of the gaps had visible dust, pipes, wires and coils. Interview with the Administrator and Chief Operating Officer (COO) #142 on 08/06/19 at 12:00 P.M. verified the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and review of facility policy, the facility failed to implement interventions and treat a resident for constipation. This affected one resident (#29) of five reviewed for unnecessary medications. The facility census was 131. Findings include: Review of Resident #29's medical record revealed an admission date of 05/04/19 with diagnoses including Lewy body dementia, toxic encephalopathy, dysthymic disorder, and depression. Review of Resident #29's care plan dated 05/15/19 revealed the resident was at risk for constipation due to impaired mobility and medication usage. The goal was for the resident to have a medium to large bowel movement every two to three days. Intervention included if no bowel movement in three days to assess for nausea, vomiting, abdominal distention, pain, bowel sounds, monitor bowel patterns and notify the physician if needed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had severe cognitive impairment 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.