Pleasanton North Nursing And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #3) reviewed for care plan revision/timing. The facility failed to ensure Resident #3's care plan was revised in a timely manner to reflect falls on (4) occasions. This deficient practice could affect residents' care/services and may cause a delay in treatment and/or decline in health. Findings included: Record review of Resident #3's admission Record, dated 5/30/25, revealed Resident #3 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to: Unsteadiness on Feet and Dementia (General term for memory loss,…

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 reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources are reported not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 3 Residents (Resident #1) reviewed for Abuse, in that: The facility did not report an allegation of Abuse to the State Survey Agency (HHSC) within 24 hours of Resident #1 falling off the bed. This deficient practice could affect any resident and could contribute to further neglect. The findings were: Review of Resident's # 1 face sheet dated 4/16/ 2025, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: schizoaffective disorder ( mental disorder that changes how people think, feel…

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 reviews the facility failed to ensure each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; and the health of individuals in the facility would otherwise be endangered for 1 of 3 (Resident #4) reviewed for discharge. Resident #4 was transferred to the hospital for a psychological evaluation on 3/25/2025 and was not allowed to return to the facility. The facility failed to document the bases of Resident #4's discharge. This could affect all residents and could result in residents not having the opportunity to appeal the discharge from the facility. The Finding were: Record review of Resident #4's admission record dated 4/15/2025 was documented he was admitted on [DATE] and re-admitted on [DATE]…

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 a comprehensive person-centered care plan for each resident, consistent with the resident rights and includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 10 ( Resident #3) residents in that: Resident #3's care plan for his pacemaker was not complete with name, serial number and when he last seen the cardiac physician. This failure could affect residents by placing them at risk of not receiving necessary services and care. The Findings were: Record review of Resident #3's admission record dated 4/15/2025 indicated an admission date of 10/18/24 and readmission date of 3/25/2025. Resident #3 had a diagnosis of cardiac pacemaker. Record review of Resident #3's significant change MDS dated [DATE] revealed he had a BIMS score of 15/15 (cognitively intact) and had a cardiac pacemaker. Record review of Resident #3's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure residents received treatment and care based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 (Resident #3) resident in that: Resident #3's care plan for his pacemaker was not his last cardiac physician appointment. This failure could place residents at risk for not receiving appropriate care and treatment and/or a decline in their health. The Findings were: Record review of Resident #3's admission record dated 4/15/2025 with admission date of 10/18/24 and readmission date of 3/25/2025. Resident #3 had a diagnosis of cardiac pacemaker. Record review of Resident #3's consolidated physicians orders for April 2024 was documented in his diagnosis was a pacemaker, but not as an order for cardiac pacemaker serial # and how to care for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview and record review, the facility failed to ensure that 1 of 12 residents (Resident #2) reviewed for medication errors was free of any significant medication errors. The facility failed to administer medication (Glargine, a drug to lower blood sugar) as prescribed for Resident #2. This deficient practice could place residents at risk of inadequate therapeutic outcomes, increased adverse side effects, and a decline in health. The findings included: Record review of admission face sheet, dated 4/16/2005, revealed Resident # 2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis that included vascular dementia ( occurs when there is damage to regions in the brain, affecting memory ), Type two diabetes ( condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and major depressive disorder ( persistent feeling of sadness and loss of interest). Record review of the quarterly MDS assessment, dated 3/3/2025, revealed Resident # 2…

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

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Meat products were stored above other food items in the facility kitchen freezer. These deficient practices could place 34 residents who ate food from the kitchen at risk for foodborne illness. The findings were: During an observation of the facility kitchen, on 04/03/2025 at 9:45 a.m., the freezer was observed to have the following items, slabbed bacon 18/2 count box, 2-2 lb bags of diced turkey, 2-3 lb honey hams, 10 lb box of chicken, 50 portion box of beef fritters, 10 lb box of chicken sausage, stored above a box of 300 count bread rolls, a box of cookie dough, package of sweet potato fries, and a box of individual size pizzas. During an interview with the Dietary Manager, on 04/03/2025 at 10:00 a.m., the Dietary Manager stated she was responsible for storing the food in the freezer and ensuring the food was stored safely. The Dietary Manager stated meat should be stored…

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, interviews, and record review the facility failed to provide a safe, functional, and comfortable environment for residents for 1 of 5 residents (Resident #4) reviewed for environment. Resident #4's footrest on the electric bed was in an elevated position and reported to Maintenance on 03/29/2025. Resident #4's bed was not repaired until 04/03/2025. This deficient practice could place residents at risk of being uncomfortable and at risk of injury from equipment that was not functioning properly. The findings were: Record review of Resident #4's undated face sheet revealed Resident #4 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease (a buildup of fat in the artery walls), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), chronic venous hypertension with ulcer of left lower leg (high blood pressure in the legs), chronic kidney disease (gradual loss 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 interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #4) reviewed for accuracy of medical records. Resident #4 had a physician's order and care plan for hospice services on his medical record after he was discharged from hospice services. This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. The findings were: Record review of Resident #4's undated face sheet revealed Resident #4 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease (a buildup of fat in the artery walls), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), chronic venous hypertension with ulcer of left lower leg (high blood pressure in 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 observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #4) reviewed for infection control. Resident #4 had an order for enhanced barrier precautions related to a wound and did not have a sign on his door identifying a need for enhanced barrier precautions for Resident #4. This deficient practice could affect residents on enhanced barrier precautions and place them at risk for infection. The findings were: Record review of Resident #4's undated face sheet revealed Resident #4 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease (a buildup of fat in the artery walls), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs),…

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 review the facility failed to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 3 of 5 residents (Resident #2, Resident #3, and Resident #4) reviewed for care plans. 1. The facility failed to ensure Resident #2's care plan was revised to reflect a fall sustained on 7/19/24. 2. The facility failed to ensure Resident #3's care plan was revised to reflect falls sustained on 8/17/24 and 8/18/24. 3. The facility failed to ensure Resident #4's care plan was revised to reflect a fall sustained on 8/30/24. These failures could place residents at risk of current needs not being met. Findings included: 1. Record review of Resident #2's admission Record, dated 9/16/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia (group of thinking and social symptoms that interferes with daily functioning),…

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 that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents (Resident #3) reviewed for quality of care. The facility failed to ensue that staff conducted (4 of 14 neuro checks done) neurological assessments for 72 hours per facility protocol after an unwitnessed fall with laceration to above right eye on 08/18/2024 for Resident #3. These failures could result with residents not receiving the necessary interventions in a timely manner, by not recognizing a change of condition that could result in a decline in health. Findings included: Record review of Resident #3's admission Record, dated 9/16/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia (group of thinking and social symptoms that interferes with daily functioning) , hypertension (high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 5 residents (Resident #4) reviewed for clinical records. The facility failed to ensure Resident #4's neurological assessments were accurately documented in the resident's record following a fall on 8/30/24. This failure could place residents at risk for improper care due to inaccurate records. Findings included: Record review of Resident #4's admission Record, dated 9/16/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease (disease affecting memory and other important mental functions) , Hemiplegia (paralysis of one side of the body) , Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy) , Major Depressive Disorder…

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 safely for 1 of 1 kitchen reviewed for kitchen sanitation. 1. Failed to ensure food was not expired in dry storage. 2. Failed to ensure food was maintained at freezing temperatures in the freezer. 3. Failed to ensure that the icemaker was sufficiently cleaned. 4. Failed to ensure all food storage items were labeled and dated. 5. Failed to ensure dry grains storage bins remained closed when not in use. These deficient practices could place residents at risk for cross-contamination and foodborne illness. The findings included: Observation on 06/02/2024 at 10:15 AM revealed the following: 1 unit of Hershey's cocoa mix dated best by 2023. Freezer internal temperature gauge of 52 degrees with boxes of unfrozen, thawed food. 2 open bins containing rice and white flour in the dry storage area of the kitchen. Interview on 06/02/2024 at 10:28 AM, the DM stated she was not aware of the expired Hershey's cocoa mix 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 interview and record review, the facility failed to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 21 residents (Resident #23, Resident #27, and Resident #39) reviewed for care plans. The facility failed to ensure Resident #23's code status was reflected within the care plan. The facility failed to ensure Resident #27's code status was reflected within the care plan. The facility failed to ensure Resident #39's psychotropic used was reflected within the care plan. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate or incomplete care plan interventions. The findings included: Resident #23 Record review of Resident…

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 inform residents in advance of the risks and benefits of proposed care and treatment for 3 of 16 residents (Resident #12, Resident #14, and Resident #20) reviewed for resident rights, in that: 1. The facility failed to ensure Resident #12 had a documented psychiatric diagnosis for a psychotropic drug, Quetiapine, he was receiving daily. 2. The facility failed to ensure Resident #12 had orders for no longer than 14 days for lorazepam PRN (as needed). The orders were written for 90 days or no end date. 3. The facility failed to obtain an updated and signed consent for antipsychotic medication, Quetiapine fumarate that was administered to Resident #12. 4. The facility failed to ensure Resident #14 had a documented psychiatric diagnosis for a psychotropic drug, Mirtazapine (a medication primarily used to treat depression), he was receiving daily. 5. The facility failed to ensure Resident #20 had a documented psychiatric diagnosis for a psychotropic drug,…

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 that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused result in serious bodily injury for 1 of 9 Residents (Resident #11) whose records were reviewed for abuse and neglect, in that; The facility failed to report to the state reporting agency (HHSC) in a timely manner possible neglect or abuse of Resident #11 when he sustained injuries after care from CNA A. This deficient practice could affect residents by contributing to further abuse and neglect. The findings were: Record Review of Resident #11's admission record revealed an [AGE] year-old male initially admitted [DATE] and readmitted on [DATE] with diagnoses to include neurogenerative disorder with Lewy bodies (It is characterized by the presence of Lewy bodies-abnormal protein deposits-in the brain. These deposits affect brain…

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 individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASARR) Screening for 1 of 8 residents reviewed for PASRR (Resident #29). The facility failed to ensure Residents #29 had an accurate PASARR Level 1 Screenings indicating diagnoses of mental illness and refer the residents to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Record Review of Resident #29's admission record, dated 6/3/24, revealed a [AGE] year-old male admitted [DATE] with diagnoses to include anorexia, depression, PTSD, and insomnia. Record Review of Resident #29's care plan, last updated 3/26/24, stated he verbalized or demonstrates sadness at times and had depression, and would get nervous and anxious at times. Resident #29 had a diagnosis of PTSD.…

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 the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 2 of 2 residents (Resident #34 and Resident #11) 1. The facility failed to ensure LVN C followed facility policy while providing wound care to a resident by not dating and initialing the dressing. 2. The facility failed to ensure LVN C completed treatment orders for Resident #11. LVN C documented she completed wound care orders and did not complete them. These deficient practices could place residents at risk for injury, infection, and harm. The findings included: 1. During an observation on 6/4/24 at 3:39 p.m. LVN C provided wound care to Resident #34. LVN C covered the residents wounds on her feet with a wound dressing and covered the bandage with an ace wrap. LVN C did not date or initial the bandage when she was done. During an interview on 6/4/24 at 3:52 p.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 observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 3 residents (Resident #6) reviewed for oxygen therapy in that: Residents #6 oxygen tubing was dated as 4/15/24 and had not been changed weekly as ordered. These deficient practices could place residents who received oxygen therapy at risk for an increase in respiratory complications and or infections. The findings were: Record review of Resident # 6's face sheet dated 6/2/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with the diagnosis that included Chronic systolic (congestive) heart failure (is also called heart failure with reduced ejection fraction and other seasonal allergic rhinitis. Record review of Resident # 6's Quarterly MDS dated [DATE] revealed her cognition was severely impaired for daily decision making and indicated she received oxygen therapy. Record review 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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of each resident, for 1 of 10 residents (Resident #26) reviewed for medication administration, in that: The facility failed to ensure LVN C followed facility policy while administering insulin to a resident in a muscle instead of subcutaneous tissue (uses a short needle to inject a medication into the fatty tissue layer between your skin and muscle. Typically, medication delivered this way is absorbed by your body slowly) as ordered for Resident #26. These deficient practices could affect residents who received medication and place them at risk of an adverse reaction or a decline in health. Findings included: Record review of Resident #26's admission record, dated 6/4/24, revealed at [AGE] year-old male resident was admitted on [DATE] with diagnosis that included…

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 assure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, for 1 of 1 medication cart reviewed for labeling and storage, in that: The facility failed to ensure the medication cart was clean, free of unknown debris, loose pills, a dirty pill cutter, a sticky pill [NAME], and a bottle of medication without label with an expiration date. These deficient practices could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications. The findings were: During an observation on 6/4/24 at 2:19 p.m. revealed the facility's one medication cart had a loose pill in the bottom drawer of the cart, a loose pill in the top left drawer with shreds of paper, foil, other pieces of broken pills, an earring, and other unknown debris. There was a pill [NAME] with white powder on it and an unknown brown sticky substance. The pill…

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 an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 1 of 2 staff (LVN C) reviewed for infection control, in that: The facility failed to ensure LVN C washed her hands properly prior to wound care on a resident. These deficient practices could place residents at-risk for infections. The findings included: During an observation on 6/4/24 at 3:48 p.m. LVN C washed her hands in the residents restroom prior to wound care. LVN C turned on the water, washed her hand with soap, rinsed them, and then touched the paper towel dispenser with her bare hand to dispense a paper towel. During an interview on 6/4/24 at 3:59 p.m. LVN C stated she contaminated her hands after she washed them by touching the handle on the paper towel dispenser to get a paper towel. LVN C stated someone told her if she dispensed the paper towel prior to washing her hands she would not be able to use the paper towel…

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 maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 dishwasher and 1 of 1 vent hood observed for safely functioning equipment. -The chemical dishwasher was not operating at the manufacturer's minimum requirements for rinsing and sanitization. -The vent hood was not inspected and cleaned on the appropriate timeframe. This deficient practice could result in residents not having access to hygienically clean dishes creating a potential for foodborne illness and create a risk of fire exposure in the kitchen. The findings included: Observation and Interview on 06/03/2024 at 10:38 AM revealed a singular over-head kitchen vent hood which contained an inspection sticker that reflected the last service on 02/2024 and the next service on 05/2024. The DM stated the vent hood was inspected by a contracted vendor who was coordinated to visit by the MS. The DM stated she has not had a vent hood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly in the cart for 1 (Licensed Nurse Medication Cart) of 2 medication carts, in that: The facility failed to ensure controlled medications for Resident's #1, #5, #8, and #19 were kept in their original packaging, appropriately labeled and secured with two locks when LVN J pre-dispersed DEA controlled substances which included: 1. One dosage of clonazepam for Resident #1 2. One dosage of Lyrica and one dosage Ativan for Resident #5 3. One dosage of Lyrica for Resident #8 4. Two dosages of liquid morphine for Resident #19. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions. The findings included: 1. Record review of Resident #1's face sheet dated 4/15/2024 revealed an admission date of 1/21/2021 with readmission date of 4/15/2024 with diagnoses which included: dementia moderate with behavioral disturbance, unsteadiness on feet…

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 immediately inform the resident's physician, and notify, consistent with his or her authority the resident representative when there was a change in condition status for 1 of 8 residents (Resident #1) reviewed for restraint and abuse, in that:. The facility failed to ensure Resident #1's physician and RP were notified when it was discovered on 3/01/2024 Resident #1 had been restrained by facility staff including RN A. This failure could place all residents at risk of a delay in medical treatment and could result in not receiving appropriate care and interventions. The findings included: Record review of Resident #1's face sheet dated 4/15/2024 revealed an admission date of 1/21/2021 with readmission date of 4/15/2024 with diagnoses which included: dementia moderate with behavioral disturbance, unsteadiness on feet and generalized muscle weakness. Record review of Resident #1's significant change MDS assessment dated [DATE] revealed a BIMS…

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, interviews and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 1 of 4 residents (Resident #3) reviewed for ADL care, in that; The facility failed to ensure Resident #3 was provided incontinent care when he pressed the call light and requested assistance from NA H. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. The findings included: Record review of Resident #3's face sheet dated 4/15/2024 revealed an admission date of 6/02/2023 with diagnoses which included: progressive supranuclear ophthalmoplegia [Steele-[NAME]-[NAME] disease} (a rare disease that gradually destroys nerve cells in the parts of the brain that control eye movements, breathing, and muscle coordination) depression, and aphasia (the loss of ability to use and comprehend language). Record…

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 1 of 1 Nurses' Aides (NA H) were not working in the facility longer than four months without having completed a competency evaluation program. The facility failed to ensure NA H was certified within four months of hire as full-time staff. This deficient practice place residents at risk for receiving care from an individual whose skill level was unproven. The findings included: Record review of the facility staff roster (undated) provided upon entrance revealed NA H was listed as a Nursing Assistant with a hire date of 10/11/2022. Record review of employee personnel files revealed NA H had a completed and notarized LTCR Form 3767 dated 6/01/2023 which indicated the DON (former ADON) was the instructor and had provided training from 11/01/2022 through 12/31/2022 to NA H. The personnel file indicated NA H was still listed as non-certified. During an observation/interview on 4/15/2024 at 10:15 p.m., NA H was observed working in the facility during evening/night shift providing resident care. NA H stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 2 of 4 Residents (Resident #14 and Resident #35) and 1 of 2 staff (LVN A) reviewed for medication administration in that: 1. Resident #14's liquid lorazepam (A medication used to decreased anxiety) narcotic log was inaccurate. The bottle of liquid lorazepam was stored in the medication storage room and did not have a pharmacy label on the bottle. 2. LVN A administered regular insulin to Resident #35 without priming the insulin pen (removing air bubbles from the needle) prior to administering. These deficient practices could affect residents who received medication and place them at risk of not receiving the appropriate amount of medication and could result in an adverse reaction or a decline in health. The findings were: 1. Record review 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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 5 residents (Resident #22) reviewed for care plans in that: Resident #22's comprehensive person-centered care plan did not reflect their bowel or bladder incontinence. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. The findings included: Record review of Resident #22's face sheet, dated 4/17/23, reflected a [AGE] year-old male originally admitted on [DATE] with a primary diagnosis of peripheral vascular disease, unspecified (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs.) Record review of Resident #22's most recent quarterly MDS assessment, dated 4/8/23 revealed the resident was severely cognitively impaired for daily…

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 an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 1 of 2 residents (Residents #1) and 1 of 4 staff (LVN A) reviewed for infection control, in that: 1. LVN A used her barehand to turn off the sink faucet after washing her hands prior to wound care for Resident #1 and again after wound care. These deficient practices could place residents who receive wound care at-risk for infections. The findings included: During an observation on 04/17/23 at 2:18 p.m. LVN A prepared wound care supplies to treat Resident #1's stage III pressure ulcer wound (bedsores or wound that affects the top two layers of skin, as well as fatty tissue) on her back. LVN A went to wash her hands in the Residents bathroom. LVN A turned on the water, wet her hands, dispensed soap, and lathered her hands. LVN A then rinsed her hands off, turned the sink off with her barehand, grabbed paper towels, dried hers,…

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.