Desert Cove Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that medications were accurately acquired and administered to meet the needs of one resident (#58). This deficient practice could lead to mismanagement of the residents' symptoms.Resident #58 was initially admitted to the facility on [DATE], and most recently admitted on [DATE], with diagnoses that included paraplegia, hypertension, chronic pain, heart failure, major depressive disorder, and anxiety disorder.During initial pool screening, on September 21, 2025, at 11:58 AM, Resident #58 explained that the facility oftentimes runs out of his scheduled pain medication, leaving the resident to experience extreme pain.Resident #58's initial care plan indicated he was at risk for pain related to neuropathy, chronic pain, and generalized pain. One of the interventions was to administer pain medications as ordered.A review of Resident #58's provider orders revealed an order for Oxycodone, 15 milligrams (mg), one tablet every four…

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, record review, and staff interviews, the facility failed to ensure that one resident (#8) was free from significant medication errors. This deficient practice could lead to adverse outcomes for residents.Findings include:Resident #8 was admitted to the facility on [DATE], with diagnoses that included paraplegia, neuromuscular dysfunction of the bladder, diabetes mellitus, hypertensive heart disease, and bipolar disorder.A review of Resident #8's medication administration record (MAR) indicated the resident had the following medications due at 8:00 AM:-Dapagliflozin Propanediol, 10 milligrams (mg), one tablet in the morning-Aspirin EC (enteric coated) Delayed Release, 81 mg, one tablet one time a day-Baclofen, 10 mg, one tablet three times a day-Famotidine, 20 mg, one tablet two times a day-Fluticasone Propionate Nasal Suspension, 50 mcg/act (micrograms per actuation), one inhalation two times a day-Gabapentin, 100 mg, one tablet three times a day-Insulin Glargine 100 units/ml (milliliter),…

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.

Number of residents sampled: Number of residents cited: Based on observations, staff interviews, and a review of facility policies, the facility failed to ensure that expired medications were properly discarded and not available for use. These deficient practices could result in residents receiving expired medications, and could result in resident injury, medication overdose, or contradictions. The facility census was 69.An observation was conducted of the Central medication room on September 22, 2025, at 02:46 PM with the Assistant Director of Nursing (ADON/staff #104). The following expired medications were identified: Five boxes of unopened one-daily Multivitamin dietary supplement, with an expiration date of April 2025. One unopened box of zinc 50mg, with an expiration date of March 2025. Four unopened boxes of vitamin B-12 100mcs, with an expiration date of July 2025.During this observation, an interview was conducted with the ADON (Staff # 104). Staff #104 stated that all the nurses are responsible for checking and disposing of expired medications. Staff # 104 stated that 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 observations, record review, and staff interviews, the facility failed to ensure that the medication administration record (MAR) was accurately documented for one resident (#8). This deficient practice could lead to adverse outcomes for residents.Findings include:Resident #8 was admitted to the facility on [DATE], with diagnoses that included paraplegia, neuromuscular dysfunction of the bladder, diabetes mellitus, hypertensive heart disease, and bipolar disorder.A review of Resident #8's MAR indicated the resident had the following medications due at 8:00 AM:-Dapagliflozin Propanediol, 10 milligrams (mg), one tablet in the morning-Aspirin EC (enteric coated), Delayed Release, 81 mg, one tablet one time a day-Baclofen, 10 mg, one tablet three times a day-Famotidine, 20 mg, one tablet two times a day-Fluticasone Propionate Nasal Suspension, 50 mcg/act (micrograms per actuation), one inhalation two times a day-Gabapentin, 100 mg, one tablet three times a day-Insulin Glargine 100 units/ml (milliliter), 35…

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, review of clinical record, and review of facility policy and procedure, the facility failed to ensure a resident (#5) was provided assistance with bathing or showering according to the resident's preference and to meet the resident' needs. The deficient practice could lead to a breakdown in skin integrity and/or psychosocial harm of a resident.Findings include:Resident #5 was admitted to the facility April 27, 2022, with diagnoses that included paraplegia, hypertension, and other chronic pain, and re-admitted to the facility on [DATE], with diagnoses that included sepsis and infection and inflammatory reaction due to indwelling urethral catheter.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section GG revealed the resident was dependent on caregivers for showering and/or bathing.A care plan initiated May 1, 2022, and another care plan initiated September 9, 2025,…

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, review of clinical record, and review of facility policy and procedure, the facility failed to ensure a resident (#5) was provided care and services for a urinary catheter according to physician orders. The deficient practice could lead to infection.Findings include:Resident #5 was admitted to the facility April 27, 2022, with diagnoses that included paraplegia, hypertension, and other chronic pain, and re-admitted to the facility on [DATE], with diagnoses that included sepsis and infection and inflammatory reaction due to indwelling urethral catheter.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section H revealed the resident had an indwelling catheter, and Section I revealed the resident had the active diagnoses of neurogenic bladder.A care plan for a catheter related to obstructive uropathy initiated October 20, 2022, revealed interventions to provide catheter care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of clinical record, and review of facility policy, the facility failed to ensure an allegation of abuse was reported to mandated entities within 2 hours for one resident (#2). The deficient practice could lead to an allegation of abuse not being investigated by all mandated entities timely, resulting in possible ongoing abuse to a resident.-Findings include: Resident #2 was admitted to the facility July 7, 2025, with diagnoses that included encounter for surgical aftercare following surgery on the circulatory system, peripheral vascular disease, type 2 diabetes mellitus, and major depressive disorder.A brief interview for mental status (BIMS) assessment dated [DATE], revealed the resident had a score of 14, indicating intact cognition.A Weekly Skin Integrity Data Collection dated July 19, 2025, revealed the resident's groin had a surgical incision, no redness, no bruising, no swelling to peri-area.An email receipt dated July 19, 2025, revealed that an Adult Protective Services report…

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 clinical record review, interviews, and facility documentation and policy, the facility failed to ensure that one resident (# 23) received wound care in accordance with physician orders. This deficient practice can result in diminished quality of life, and suboptimal clinical outcomes. Findings include: Resident # 23 was admitted to the facility April 3, 2023 with diagnoses that included heart failure, cellulitis of left lower limb, Diabetes Type 2 with ulcers, obesity, and muscle weakness. Review of the resident's Break in Skin Integrity care plan, initiated on February 20, 2023 revealed the resident was to have treatment as ordered and weekly skin checks. Review of the Nursing Home Comprehensive Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status score of 15, indicating cognition was intact. The MDS also identified the resident as having an infection of the foot, and a diabetic foot ulcer(s). Review of the residents wound care order, initiated on April…

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 clinical record review, staff interviews, and facility policy review, the facility failed to ensure one resident (#26) was free from sexual abuse. The deficient practice resulted in a resident being inappropriately touched by another resident. Findings include: Resident #26 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderate cognitive impairment. Review of the care plan and nursing progress notes revealed no evidence of sexual abuse occurring. Additionally, there were no psychiatric notes or evaluations created following the abuse. Review of physician orders revealed no evidence of new orders following the abuse, including no new orders for psychiatric evaluation. Resident #13 was admitted to the facility initially on August 9, 2024. He was later re-admitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, and staff interviews, the facility failed to ensure three residents (#1, #2 and #3) were provided adequate supervision to prevent resident abuse. The deficient practice could result in residents being at risk for abuse. Findings include: -Resident #1 was admitted to the facility on [DATE] which include a diagnoses of Hypertension, Diabetes Mellitus, Aphasia, Cerebrovascular Accident (CVA), and Bipolar Disorder. A review of resident's care plan dated August 14, 2023 revealed resident has the potential to be physically aggressive -strikes at others related to poor impulse control, non verbal, multiple cerebrovascular accident, confusion/impaired cognition. Resident will try to interact with others by tapping/patting them on the arm which can be misconstrued as hitting especially due to his hand contractures which appear fistlike , resident enjoys music via his headphones. Interventions include to administer medication as ordered, assess and anticipate…

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 clinical record review, observations, staff interviews, and review of policy, the facility failed to provide necessary services to maintain good grooming and personal hygiene for one resident (#39) and that assistance with meals was provided for one resident (#10). The sample size was 16. The deficient practice had the potential for not providing services and assistance to residents. Findings include: Resident #39 was admitted on [DATE] with diagnoses that included paraplegia, chronic pain, polyneuropathy, retention of urine, anxiety disorder, benign prostatic hyperplasia with lower urinary tract symptoms, calculus in the bladder, neuromuscular dysfunction of the bladder and muscle weakness. A review of the care plan regarding activities of daily living initiated on May 1, 2022 revealed that resident #39 is totally dependent on 2-staff members to provide a bath/shower twice a week and as necessary. A review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview…

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 review of clinical records and policy, observations, and staff interviews, the facility failed to ensure the environment remained free of accident hazards by not leaving medications unattended. The deficient practice had the potential to cause an accident and may result in undesirable medication-induced harm. Findings included: On February 08, 2024 at 9:34 A.M. a small clear plastic measuring cup with a red capsule was observed to be on top of a medication cart with no staff present. The Director of Nursing (DON/Staff # 98) also observed the unattended medication on a medication cart located by the DON's office, while walking towards her office. The DON was then observed picking up the medication cup with the capsule and disposed of it in an uncovered rectangular bin located at the bottom end of the medication cart. An interview was conducted on February 08, 2024 at 9:34 AM with a registered nurse (RN/Staff # 71) who stated the medication on top of the medication cart was docusate that belonged to resident #55. An interview was conducted on February 08, 2024 at 9:34 AM 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.

Based on review of facility documentation, staff interviews and facility policy, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 63. The deficient practice has the potential to affect resident care. Findings include: Review of the staff schedules punch details for January 2023 and March 2023 there were no Registered Nurse (RN) on duty for 8 consecutive hours for at least 4 days each month. In November and December 2023, there were no RNs for 8 consecutive hours for one day in each month. In an interview conducted with the staffing coordinator (staff #34) on February 8, 2024 at 10:24 A.M. she stated that she was aware of the regulations for scheduling an RN for 8 hours each day, and that there is typically an RN in the building. She stated the Infection Preventionist, who is an RN, or the Director of Nursing (DON) would be there. In an interview conducted with the DON on February 7, 2024, she stated that if there is not a licensed nurse available in a 24 hour period, the DON will come in to cover.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical review, staff interviews, and facility policy and procedures, the facility failed to administer pain medication within the pain scale parameters for two resident (#39, #17). The deficient practice could result in residents being overmedicated. Findings include: Resident #39 was admitted on [DATE] with diagnosis including paraplegia, chronic pain, polyneuropathy, anxiety disorder, difficulty walking and muscle weakness. A review of the quarterly MDS (minimum data set) dated January 10, 2024 revealed a BIMS (brief interview of mental status) score of 12, indicating mild cognitive impairment. The MDS further revealed that resident #39 received both regularly scheduled medications as well as PRN (pro re nata-as needed) medications. A review of the physician orders revealed an order for 10 milligrams (mg) of oxycodone, 1 tablet by mouth, every 4 hours as needed for pain ranging from a pain level of 4 to a level of 10. Review of the MAR (medication administration record) for January 2024 and February…

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 interviews, and review of policies and procedures, the failed to ensure staff conducted appropriate hand hygiene during kitchen food preparation and dining services, as well as donning beard guards/ nets in the presence of facial hair. The deficient practice could result in infection and or contamination of food. Findings include: A kitchen observation was conducted on February 5, 2024 at 8:13 A.M. Staff #77, dietary aide, was observed in the kitchen, with facial hair present and not wearing a beard guard/ net. A kitchen observation was conducted on February 6, 2024 at 10:00 A.M. for puree observation. Staff #5, cook, was observed answering the kitchen phone and returning to the puree preparation without first conducting hand hygiene. A dining room observation was conducted on February 6, 2024 at 11:46 A.M. Staff #47, activities director, was observed pulling up his pants, scratching his face and then proceeding with passing out dining trays. A dining room observation occurred on February 6, 2024 at 11:49 A.M. Staff #34, staffing coordinator, 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 observation, interviews, and review of policy, the facility failed to ensure infection control practices were observed. The deficiency in practice can lead to the spread of infections. Regarding failure to ensure transmission-based precautions: Resident # 60 was admitted on [DATE] with diagnoses of unspecified hydronephrosis, malignant neoplasm of endometrium, and Type 2 Diabetes Mellitus. Review of a Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 15 indicatING the resident was cognitively intact. Review of a care plan initiated on June 27, 2018 by Infection Preventionist (IP)/Registered Nurse (RN) (Staff # 26), revealed Resident # 60 had a foley catheter. Interventions included to place resident in enhanced barrier precautions in order to prevent signs or symptoms of urinary infection. During an observation conducted on February 6, 2024 at 10:12 A.M. revealed personal protective equipment (PPE) and Centers for Disease Control and Prevention (CDC) signage…

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 and policy review, the facility failed to ensure one resident (#6) was assessed to self-administration medication. The deficient practice could result in residents self-administering medications without assessment. Findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, spinal stenosis, heart failure, and essential hypertension. Review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview for mental status) score of 15, indicating the resident was cognitively intact. On February 5, 2024 at 11:16 A.M. a medication, hydrocortison ointment 1% max strength, was observed on a bedside table with resident #6. There were no staff present. Resident #6 stated that staff were aware that resident had the medication. On February 6, 2024 at 8:59 A.M. a vicks vaporub was observed on an over bed table by resident #6. There were no staff present. An interview was conducted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and facility policy, the facility failed to ensure one resident (#123) received safe monitoring of vital signs. Vital signs were obtained using the arm with the shunt contrary to the facility policy and care plan. The deficient practice could result in the potential for complications and the resident not receiving appropriate care and treatment. Findings included: Resident #123 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD), dependence on renal dialysis, and bacteremia. A progress note dated January 31, 2024 revealed a not indicating resident has left arm fistula. Review of a progress note dated February 4, 2024 revealed patient has shunt in left arm. Review of Dialysis Treatment Notification forms from January 26, 2024 through February 5, 2024 indicated resident had dialysis access on an arteriovenous fistula on was located on the left upper arm. A review of a minimum data set (MDS) dated [DATE] revealed 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 review of clinical records and policy, observations, and staff interviews the facility failed to ensure unused medication were disposed of according to accepted professional standards. The deficient practice of erroneous medication disposal may result in undesirable medication-induced harm. Findings included: On February 08, 2024 at 9:34 A.M. a small clear plastic measuring cup with a red capsule was observed to be on top of a medication cart with no staff present. The Director of Nursing (DON/Staff # 12) also observed the unattended medication on a medication cart located by the DON's office, while walking towards her office. The DON was then observed picking up the medication cup with the capsule and disposed of it in an uncovered rectangular bin located at the bottom end of the medication cart. An interview was conducted on February 8, 2024 at 10:11 A.M. with Registered Nurse (RN/Staff # 20) who stated unused medications should be disposed of in sharps container. Staff # 20 stated all pills,…

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 clinical record review, staff interviews, and review of facility policy, the facility failed to ensure that one resident (#208) and/or their representative were informed of the risks and benefits of psychotropic medications prior to the administration of the medications. The sample size was 8. The deficient practice could result in residents and/or resident representatives not being aware of the benefits and the potential adverse side effects of psychoactive medications. Findings include: Resident #208 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic kidney disease, and major depressive disorder. The physician's orders revealed the following orders for antidepressant medications: -March 14, 2022 Fluoxetine HCL capsule 20 mg (milligrams), give 1 capsule by mouth once a day for depression. -March 14, 2022 Trazodone HCL tablet 50 mg give 1 tablet at bedtime for depression. -March 14, 2022 Venlafaxine HCL tablet 50 mg give 1 tablet by mouth twice a day for depression.…

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 clinical record review, resident and staff interviews, and policy reviews, the facility failed to ensure one resident (#212) was assessed to self-administer medications. The sample size was 18. The deficient practice could result in medications not being administered as ordered. Findings include: Resident #212 was admitted on [DATE] with diagnoses that included fracture of left arm humerus, type 2 diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. During an observation and resident interview conducted on October 31, 2022 at 9:20 AM, an Albuterol sulfate HFA inhaler was observed on the resident #212's bedside table. The resident stated the inhaler is always left on the bedside table. Review of physician's orders revealed no evidence of orders for an inhaler to be left at the bedside. Review of the clinical record revealed no evidence of an assessment for self-administration of medications. Review of the care plan revealed no evidence that self-administration of medication 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 observation, clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#26) had an order for a multi-podus boot. The sample size was 3. The deficient practice could result in residents having multi-podus boots without an order. Findings include: Resident #26 was readmitted to the facility on [DATE] with diagnoses that included osteomyelitis, cellulitis of right limb, chronic obstructive pulmonary disease, difficulty in walking and major depressive disorder. During an observation conducted on October 31, 2022, the resident was observed lying on the bed with a multi-podus boot on the right foot. Review of the physician orders revealed no evidence of an order for application/use of a multi-podus boot. Review of the October 2022 Treatment Administration Record (TAR) revealed no evidence regarding the multi-podus boot. Review of the care plan did not reveal pressure relief of the left foot, using a multi-podus boot. Review of the admission…

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 clinical record review, resident and staff interviews, and review of policy and procedure, the facility failed to ensure necessary services were consistently provided to maintain good personal hygiene for one resident (#25). The sample size was 5. The deficient practice could result in personal hygiene needs not being met for residents. Findings include: Resident #25 was readmitted to the facility on [DATE], discharged [DATE] and readmitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, chronic obstructive pulmonary disease, morbid (severe) obesity due to excess calories, and heart failure. A review of the care plan revised 10/27/21 revealed the resident had an Activities of Daily Living (ADL) self-care performance deficit related to respiratory failure. The goal was that the resident would maintain the current level of function in ADLs and needed assistance with bathing/showering. Interventions revealed the resident required assistance of one person 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 clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#212) was free of unnecessary drugs, by failing to ensure pain medication was administered as ordered by the physician. The sample size was 5. The deficient practice could result in residents receiving medications that may not be necessary. Findings include: Resident #212 was admitted on [DATE] with diagnoses that included anxiety disorder, major depressive disorder, fracture of left arm humerus, type 2 diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. Review of the physician orders dated October 25, 2022 included Oxycodone HCL (an analgesic opioid) 5 milligram (mg) tablet by mouth every 4 hours for severe pain 7-10. Review of the resident's care plan initiated on October 26, 2022, revealed the resident had pain/discomfort related to a left arm fracture with interventions to administer pain medications as ordered. Review of the Medication Administration Record (MAR) 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 clinical record review, staff interviews, and policy review, the facility failed to ensure a PRN (as needed) psychotropic medication had a stop date within the required time frame for one resident (#212). The sample size was 5. The deficient practice could result in residents receiving medication that is not necessary. Findings include: Resident #212 was admitted on [DATE] with diagnoses that included anxiety disorder, major depressive disorder, fracture of left arm humerus, type 2 diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. A physician order dated October 26, 2022 included Alprazolam (a benzodiazepine for anxiety) 0.5 milligrams (mg) tablet by mouth every 12 hours as needed (PRN). The admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident intact cognition, with no behaviors exhibited. Review of the Medication Administration Records (MARs) for October 2022 and November 2022…

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.