Haven Of Cottonwood

The facility failed to ensure that staff followed appropriate infection control practices. The deficient practice could result in a spread of preventable illness to residents and staff. Findings included: On May 19, 2025 at 11:03AM, a Certified Nursing Assistant (CNA/Staff #64) was observed completing a resident's vitals near a nursing station. It was observed that Staff #64 did not sanitize or wash his hands before and after obtaining the resident's vital signs. Upon exiting the room the CNA was observed to write the vital signs of the resident on a clipboard and set the clipboard on the nursing station. Staff #64 was then observed entering another resident;s room without first sanitizing his hands. An interview was conducted on May 19, 2025 at 11:19AM with Staff #64, who stated that the facility's expectations regarding hand hygiene was to perform handwashing before and after providing care or coming in direct contact with a resident. Staff #64 also stated that hand hygiene and infection control practices are expected when obtaining the vitals of a resident. Staff #64 stated he…

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 records, and review of facility policy and procedure, the facility failed to ensure one resident (#326) was treated with respect and dignity. The deficient practice could lead to psychosocial harm of a resident. -Findings include: Resident #326 was admitted to the facility on [DATE], with diagnoses that included hypotension, unsteadiness on feet, degeneration of nervous system due to alcohol, and unspecified dementia. A Health Status Note dated November 8, 2021, by a Registered Nurse (RN / Staff #112), revealed Resident #326 had a smoker's patch in place on the right arm. The resident stated rudely, If you people would let me smoke and let me out of here, I would be content!, as the resident raised his hand at the nurse. Staff #112 was startled and told the resident to please settle down and stop acting like a a. Staff #112 offered to make the resident a sandwich, but, he settled with yogurt, and drank water. The resident was then resting peacefully. An admission minimum data set…

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, facility documentation and policy, the facility failed to ensure that one resident's (#47) consent was given prior to the administration of a psychotropic medication. The deficient practice could result in the resident not being informed of the risk and benefits of proposed care and not being given the opportunity to choose the care option of care he or she prefers. Findings include: Resident # 47 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation, dementia with mood disturbance, anxiety, muscle weakness, and cognitive communication deficit. The admission Minimum Data Set (MDS) dated [DATE], revealed the resident had a brief Interview for Mental Status (BIMS) of 10 indicating the resident had impaired cognition. In addition, the Resident Mood Interview screening, revealed the resident scored a 0, indicating no concerns of depressive symptoms over the past two weeks. The MDS revealed no evidence of high-risk drug classes for anti-anxiety 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 clinical record, staff interviews, review of facility documentation, policy and procedures and the State Agency (SA) database the facility failed to implement their policy regarding conducting thorough investigation of abuse/neglect allegation and protecting residents from further abuse for two residents (#26 and #171). The deficient practice could result in abuse/neglect continuing and not being prevented. Findings include: Regarding resident #26 (alleged victim) -Resident #26 was admitted to the facility on [DATE] with diagnoses that included hypotension, chronic kidney disease, and nocturia. Review of the SA database revealed that a self-report was submitted by the facility on January 4, 2023. The report indicated an allegation of neglect. However, it did not detail information on what occurred nor did it indicate who the alleged perpetrator was. The report did not identify that the perpetrator was a staff member and whether the staff member was suspended pending an investigation. However, 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 closed record review, staff interviews, and review of facility process and policy the facility failed to ensure that all transfer/discharge notifications were made for one resident (#176). The deficient practice could lead to notifications of resident transfer/ discharge not being made to all required parties. Findings include: Resident #176 was admitted to the facility with diagnoses that included hyperlipidemia, bipolar disorder, anxiety disorder, and gastro-esophageal reflux disease. Review of the resident's face sheet revealed that the resident #176 had a Public Fiduciary identified as his responsible party, guardian, and emergency contact. The face sheet also listed the contact information for the responsible party which included an office number, fax number, and e-mail address. A Discharge assessment dated [DATE] revealed the reason for the assessment as hospital transfer. The section Parties notified prior to transfer? indicated a check mark that responsible party was notified but did not…

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, facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to accurately complete a comprehensive Minimum Data Set (MDS) assessment within the required timeframe for one resident (#34). The deficient practice could result in delayed identification of potential risks and care needs. Findings include: Review of resident #34's hospital records prior to his admission to the facility revealed a progress note dated January 10, 2023 which documented that the resident is incompetent to make his own decision. The note indicated that the resident has a public fiduciary. A hospital progress note date January 24, 2023 documented that the resident had a history of cognitive impairment. The note indicated that resident was inpatient status at the hospital and needed long term care that can accommodate his needs. The note stated that the hospital was waiting on public fiduciary for assistance to place resident in a facility. Resident #34 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 review of the clinical record, staff interviews, facility documentation, policy and procedure, the facility failed to ensure that one resident's (#34) cognitive communication deficit was appropriately care planned and implemented. The deficient practice could result in a plan of care that does not meet the resident's needs. Findings include: Review of resident #34's hospital records prior to his admission to the facility revealed a progress note dated January 10, 2023 which documented that the resident is incompetent to make his own decision. The note indicated that the resident has a public fiduciary. Resident #34 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of mandible, tempomandibular joint disorder, and severe protein-calorie deficit. A speech therapy eval dated February 3, 2023 documented that the resident had a history of cognitive impairment and had a guardian. A progress note dated February 6, 2023 documented that the resident was a poor historian, had…

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, review of records, and review of facility policy and procedure, the facility failed to ensure a resident's comprehensive care plan was reviewed and revised to meet the resident's needs for one resident (#324). The deficient practice could lead a resident not receiving care and services to meet their needs, which could lead to harm or injury. -Findings Include: Resident #324 was re-admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, personal history of traumatic brain injury, dementia, unspecified abnormality of gait and mobility, cognitive communication deficit, anxiety disorder, and need for assistance with personal care. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) assessment that was not completed. Section J revealed the resident had two or more falls with injury since admission, re-entry, or prior assessment. A care plan initiated February 6, 2023, revealed…

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 documentation, staff interviews, and facility policy and process, the facility failed to ensure pain medications as needed (PRN) was administered within the Pain Parameters for one resident (#54). The deficient practice could result in residents being overmedicated. Findings include: Resident #54 was admitted to the facility on [DATE] with diagnoses that included hepatic encephalopathy and alcoholic cirrhosis of the liver with ascites The order summery included Morphine Sulfate (concentrate) Solution 20 mg/ml give 5 mg by mouth every 3 hours as needed for pain 7-10 ordered April 25, 2025. The medication administration record (MAR) dated May 2025 revealed that Morphine Sulfate (concentrate) Solution 20 mg/ml give 5 mg by mouth every 3 hours as needed for pain 7-10 was administered on May 16, 2025 three times for a pain level of 6, 3, 6. An interview was conducted on May 20, 2025 at 11:33 a.m. with the registered nurse (RN/staff #3), who stated that an order for pain medication as needed (PRN) requires…

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, facility documentation and policy, the facility failed to ensure that one resident (#94) did not receive medications against their wishes. This deficient practice can result in not respecting the rights of the resident. Findings include: Resident # 94 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation, dementia with mood disturbance, anxiety, muscle weakness, and cognitive communication deficit. The admission Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. An order for one Bupropion HCL Extended release tablet for anxiety was dated May 11, 2025. According to the Medication Administration Record (MAR), 150 mg of Bupropion HCL ER was given to the resident for anxiety on May 11, 2025 - May 13, 2025. A progress note dated May 13, 2025, revealed the antidepressant was considered a good option and was started. The note further explains…

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, facility documentation and policy, the facility failed to ensure that two of four sampled medication carts had medications stored according to professional standards. The deficient practice can result in cross-contamination of medications and medication errors. Findings include, During medication cart storage observation with the Director of Nursing (DON/Staff # 56), the following was observed on March 19, 2025 at 8:09 a.m. : Medication Cart # 1: -An unrefrigerated vial of Lorazepam 2 mg/ml , with the affixed label stating keep refrigerated, was located in the narcotic storage area of the cart. -A pink like solution was crusted on the outside of a Geri-Tussin bottle. -Product crusting was present on an opened and unlabeled sixteen-ounce bottle of Milk of Magnesia. - A bottle of Wild Cherry Pro-Stat with the open date of April 5, 2025 had a crusted solution extending down the sides of the bottle. - Geri-Lanta bottle was opened but not dated. -Pepto Bismol Ultra was opened and not dated. Medication Cart # 2 -A medicine cup, contained two tablets,…

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, review of records, and review of facility policy and procedure, the facility failed to ensure the medical record was complete and accurate for one resident (#324) The deficient practice could lead to care team members not being aware of a resident's status, and could lead to missed or delayed treatment. -Findings Include: Resident #324 was re-admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, personal history of traumatic brain injury, dementia, unspecified abnormality of gait and mobility, cognitive communication deficit, anxiety disorder, and need for assistance with personal care. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) assessment that was not completed. Section J revealed the resident had two or more falls with injury since admission, re-entry, or prior assessment. Review of the clinical record revealed no evidence of any neuro check logs for 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 observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure one resident (#2) was provided care and services to meet professional standards regarding following physician orders for assessment of a resident post-fall. The deficient practice could lead to an injury being missed and a delay of care provided to a resident. -Findings include: Resident #2 was admitted to the facility January 10, 2025, and re-admitted to the facility on [DATE], with diagnoses that included pneumonia, end-stage renal disease, acute pulmonary edema, hemiplegia and hemiparesis affecting the left side, and dysarthria. An admission MDS (minimum data set) assessment, dated January 16, 2025, revealed the resident had a brief interview for mental status (BIMS) score of 12, indicating the resident had moderately impaired cognition. A physician order dated March 4, 2025, indicated for an x-ray of Resident #2's right arm to rule out a fracture. A progress note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure the medical record was complete, accurate, and readily accessible for one resident (#55). The deficient practice could lead to care team members not having accurate, complete, and current resident information to coordinate care, which could lead to a decreased quality of care for residents. -Findings include: Resident #55 was admitted [DATE], and re-admitted [DATE], with diagnoses that included encounter for surgical aftercare following surgery on the genitourinary system, urinary tract infection, functional quadriplegia, depression, anxiety disorder, post-traumatic stress disorder, and conversion disorder. An admission MDS (minimum data set) assessment dated [DATE], revealed the resident had a BIMS (brief interview for mental status) score of 12, indicating the resident had moderately impaired cognition. A care plan dated February 18, 2025 for the resident experiencing impacts 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 clinical record review, staff interviews, and facility policy, the facility failed to ensure that a resident received care and services according to physician orders regarding weight monitoring for one resident (#10). The deficient practice could result in a residents not receiving treatment to meet their needs. -Findings include: Resident #10 was admitted on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, dysarthria, dysphagia, acute respiratory failure with hypoxia, and methicillin susceptible staphylococcus aureus infection. A care plan dated February 1, 2025, revealed that the resident was at risk for nutritional problems with an intervention to monitor weights per orders. A physician order dated February 1, 2025, indicated for an enteral feed of Osmolite 1.5 to start at 35 ml/hr to increase by 10 ml/r until goal of 65 ml/hr and 90 ml of free water flushes every 2 hours. A physician order dated February 1, 2025, indicated for Weekly Weights: 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, observations, policy review and the State Agency (SA) complaint tracking system, the facility failed to ensure that two residents (#1 and #2) received treatment and care in accordance with professional standards of practice by failing to provide wound care as ordered by a physician. The sample size was 5. The deficient practice could lead to residents acquiring wound infections. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that include osteoporosis, acute post-hemorrhagic anemia, and chronic obstructive pulmonary disease (COPD). A review of a Minimum Data Set (MDS) assessment dated [DATE], indicated resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of the physician's orders revealed resident #1 was to have wound care by cleaning the Right surgical area with normal saline, pat dry, and apply dressing at the surgical site once a day every three days.…

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 the facility policy and procedures, the facility failed to ensure a thorough investigation for a resident to resident complaint. The deficient practice could result in residents not being protected from further abuse and appropriate corrective action not taken. Findings include: Resident #1 was admitted on [DATE] with diagnosis including anemia, dysphagia, protein-calorie malnutrition, pulmonary fibrosis, macular degeneration, insomnia, intervertebral disk degeneration-lumbar region, anxiety disorder, spinal stenosis-lumbar region, radiculopathy-lumbar region, mild cognitive impairment, age related osteoporosis, chronic kidney disease, palmar fascial fibromatosis and depression. A review of the quarterly MDS (minimum data set) dated November 4, 2022 revealed a BIMS (brief interview of mental status) score of 15, suggesting the resident was cognitively intact. The facility final incident report dated January 10, 2023 revealed that an alleged incident 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 clinical record review, staff interviews, review of facility documentation, and policy, the facility failed to ensure that the electronic health record for resident #2 was complete and accurately documented. The deficient practice could result in incomplete and/or inaccurate clinical records. Findings include: Resident #2 was admitted on [DATE] and discharged on September 21, 2023 with diagnosis including pleural effusion, alcoholic cirrhosis of the liver with ascites, congestive heart failure, thrombocytopenia, hypothyroidism, dorsalgia, anxiety disorder, gastrointestinal hemorrhage, hepatorenal syndrome, urinary tract infection, chronic kidney disease, and paroxysmal atrial fibrillation. A review of the MDS (minimum data set) dated September 6, 2023 revealed a BIMS (brief interview of mental status) score of 13 suggesting that the resident was cognitively intact. A review of the electronic health record for resident #1 revealed no evidence of a personal inventory form at admission or subsequent prior…

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, and policy and procedures, the facility failed to ensure that one resident (#41) received nail care as needed and showers, and one resident (#12) received assistance with showers as needed. The deficient practice could result in poor hygiene and infection. Findings include: Resident #41 was admitted on [DATE] with diagnoses that included chronic kidney disease, Type II diabetes, and acquired absence of the left leg below the knee. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 8 indicating the resident had a moderate impairment. The assessment also included that the resident needed substantial/maximal assistance with bathing. Review of the care plan dated March 12, 2024 revealed that the resident was at risk for functional self-care deficits. Interventions included the resident required substantial/max-total assist to bathe. Review of the shower task sheet for the month of March 2024 revealed that 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, staff and resident interviews, facility policy and procedures, and CMS (Centers for Medicare and Medicaid Certification) guidance, the facility failed to ensure that staff used appropriate enhanced barrier precautions (EBP) for two residents (#23 and #172). The deficient practice could result in the transmission of infections to residents and staff. Findings include: -Resident #172 was admitted on [DATE], with diagnoses of acute cystitis without hematuria and acute kidney failure. The Minimum Data Set (MDS) assessment included that indwelling catheter was not coded for resident #172. The nursing admission evaluation on April 2, 2024 revealed the resident was oriented to person, place, and situation and had bowel and bladder incontinence. The care plan dated April 3, 2024 included that the resident had an indwelling catheter for bladder outlet obstruction. Interventions included to change catheter as ordered and catheter care every shift. An observation was conducted on April 10, 2024 at…

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 there was a physician order for the use of an indwelling catheter for one resident (#172). The deficient practice could result in inappropriate use of an indwelling catheter for residents who do not need them. Findings included: Resident #172 was admitted on [DATE], with diagnoses of acute cystitis without hematuria and acute kidney failure. The Minimum Data Set (MDS) assessment included that indwelling catheter was not coded for resident #172. The nursing admission evaluation on April 2, 2024 revealed the resident was oriented to person, place, and situation and had bowel and bladder incontinence. The care plan dated April 3, 2024 included that the resident had an indwelling catheter for bladder outlet obstruction. Interventions included to change catheter as ordered and catheter care every shift. Review of the catheter evaluation dated April 3, 2024 revealed the justification for use of indwelling…

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

Based on staff interviews and facility policy, the facility failed to designate a qualified individual as the Infection Preventionist (IP) on an ongoing basis. The deficient practice could result in improper infection prevention practices in the facility. Findings include: An interview was conducted with the [NAME] President of Clinical Operations (staff/#68) and telephone interview with the Registered Nurse/Infection Preventionist (RN/IP/staff #9) on November 17, 2022 at 11:26 AM. The IP stated that she comes in once a month to do rounds and the last time she was in the facility was at the end of September 2022. It was then stated that the Director of Nursing (DON/staff #25) is overseeing the day to day infection control and education. They stated the DON is not certified. A policy regarding Infection Control included that the facility will identify one or more individuals with training in infection control to provide on-site management of the infection prevention control program.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to develop a complete baseline care plan that included the instructions needed to provide effective and person-centered care for three residents (#97, #102, and #147). The sample size was 19. The deficient practice could result in resident care needs not being met. Findings include: -Resident #97 was admitted to the facility on [DATE] with diagnoses that included biventricular heart failure, lobar pneumonia, acute respiratory failure with hypoxia, pleural effusion, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and pulmonary hypertension. Review of the admission evaluation dated November 5, 2022 revealed the resident exhibited shortness of breath while lying flat, with exertion, and while sitting at rest and used oxygen (O2). Review of the November 5, 2022 physician's orders included: -O2 at 0-5 liters per minute (LPM) as needed to keep O2 saturation above 89%. -Albuterol Sulfate…

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, clinical record reviews, staff interviews, and review of policy and procedures, the facility failed to implement appropriate standard and transmission-based precautions. The deficient practice could result in transmission of infection. Findings include: An interview was conducted on November 14, 2022 at 10:07 a.m. with the Director of Nursing (DON/staff #25). She stated the residents in the rooms marked with signs were COVID-19 positive residents. She stated that you would need to don personal protective equipment (PPE), gown, gloves, N95 mask, and eye protection, from the supply cart in the hallway prior to entering the marked transmission-based precautions (TBP) rooms. She stated when you are finished in the TBP room, the PPE should be doffed and put in the receptacles in the hallway. The DON indicated an open trash can which contained discarded PPE including face shields, masks and gloves and a covered canister marked gowns only. She stated if the eye protection is to be re-used it would need to be disinfected with the provided disinfecting wipes. The DON…

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, and review of the clinical record, the facility failed to ensure a resident (#98) had means to communicate with staff, by failing to ensure the call device was accessible to the resident. The sample size was 19. The deficient practice can result in residents' needs not being met in a timely manner. The findings include: Resident #98 was admitted to the facility on [DATE] with diagnoses that included repeated falls, and acute kidney failure, and unsteadiness on feet. The admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 10 which indicated the resident had moderate impaired cognition. A review of the care plan initiated on September 28, 2022 revealed the resident was at risk for falling related to deconditioning and gait/balance problems. Interventions included ensuring the resident's call light is within reach, encouraging the resident to use the call light for assistance, and promptly responding to all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to notify two residents (#1 and #45) and residents' representatives in writing of the reason for the transfer/discharge. The sample size was 2. The deficient practice could result in residents not knowing their discharge rights. Findings include: -Resident #1 was admitted to the facility on [DATE] with diagnoses that included acute on chronic systolic congestive heart failure, atrial fibrillation, hypertensive urgency, and urinary tract infection. Review of a nurse's progress note dated November 5, 2022 included that the resident had a change in level of consciousness, low blood pressure, and a low heart rate. The note included the resident's family member was present in the room. The Nurse Practitioner was notified and an order was received to send the resident to the emergency room for evaluation. The note stated the resident left the facility and was admitted to the hospital. Review of the resident'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 clinical record reviews, staff interviews, and review of policy and procedure, the facility failed to notify the residents and/or the residents' representatives of the facility policy for bed hold at the time of discharge/transfer from the facility for two residents (#1 and #45). The sample size was 2. The deficient practice could result in residents not being informed of the bed hold policy. Findings include: -Resident #1 was admitted to the facility on [DATE] with diagnoses that included acute on chronic systolic congestive heart failure, atrial fibrillation, hypertensive urgency, and urinary tract infection. Review of a nurse progress note dated November 5, 2022 revealed the resident left the facility and was admitted to the hospital. Review of the resident's census list included a transfer to the hospital on November 5, 2022. Review of a discharge return anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had an unplanned discharge to the hospital. Review of the clinical…

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, clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#14) had a referral for a Level II PASRR (pre-admission screening and resident review form). The sample size was 2. The deficient practice could result in resident's not receiving needed care in the facility. Findings include: Resident #14 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, post-traumatic stress disorder, schizoaffective disorder, anxiety disorder, depression and sleep terrors. Review of the clinical record revealed a Level I preadmission screening and resident review form (PASRR) dated September 6, 2022 from an acute care hospital. Upon review of the document, the box indicating that the resident qualified for a 30-day convalescent care was selected. No selections regarding mental illness in section B were selected. The remainder 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 clinical record review, staff interview, and review of facility policy and procedure, the facility failed to develop the person-centered care plan to include the resident's medication/medical needs for one resident (#14). The sample was 19. The deficient practice could result in an incomplete plan of care for the resident. Findings include: Resident #14 was readmitted on [DATE] with an original admission date of September 6, 2022 with diagnoses to include diabetes mellitus type 2, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), nicotine dependence, chronic post-traumatic stress disorder (PTSD), schizoaffective disorder, depression, anxiety disorders and sleep terrors. Review of the admission assessment dated [DATE] revealed the resident was incontinent of bowel and bladder, had shortness of breath while lying flat and upon exertion, used oxygen, was a current smoker and had hypokalemia (low potassium level). Review of the admission minimum data set (MDS)…

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, and resident and staff interviews, the facility failed to fully assess one resident's (#97) nutritional status and needs by not obtaining a baseline weight. The sample size was two residents. The deficient practice could result in unmet nutritional needs and unidentified weight loss. Findings include: Resident #97 was admitted to the facility on [DATE] with diagnoses that included biventricular heart failure, hyperlipidemia, anemia, and hypo-osmolality and hyponatremia. Review of the physician's orders revealed: -November 5, 2022 orders for: A regular diet, regular texture, thin liquids consistency, fluid restrictions, fortified foods; and weights per facility protocol. -A November 10, 2022 order for Pro-stat supplement 30 milliliters (ml) one time a day. -A November 15, 2022 order for Ensure clear nutritional supplement two times a day for weight management. Review of a Nutritional Data Collection and assessment dated [DATE] revealed no weight for the resident, that the goal…

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, clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one resident (#14) had an order for oxygen use. The sample size was 2. The deficient practice could result in residents receiving oxygen without a physician order. Findings include: Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, post-traumatic stress disorder, schizoaffective disorder, anxiety disorder, depression and sleep terrors. Review of the admission note dated September 9, 2022 revealed the resident used oxygen at home for chronic COPD as well as during the stay at the acute care hospital prior to admission to the facility. The nursing admission note on this date stated that respiratory equipment (oxygen) was in place. Review of the clinical record revealed several head to toe evaluations dated September 9, 2022, October 2, 2022 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 clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to complete behavior monitoring for one resident (#14). The sample size was 2. The deficient practice could result in the resident not receiving appropriate care and services to attain their highest practicable mental and psychosocial well-being. Findings include: Resident #14 was readmitted on [DATE] with an original admission date of September 6, 2022 with diagnoses to include diabetes mellitus type 2, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), nicotine dependence, chronic post-traumatic stress disorder (PTSD), schizoaffective disorder, depression, anxiety disorders and sleep terrors. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed the resident scored 15 on the brief interview for mental status (BIMS) indicating the resident was cognitively intact. Review of the physician note dated October 26, 2022 revealed the 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.

Based on observation, staff interview, and policy review, the facility failed to ensure expired food was not available for consumption. The deficient practice could cause food-borne illness. Findings include: During the initial kitchen walk-thru on November 14, 2022 at 9:47 a.m. with the dietary manager (staff #43) a reach-in refrigerator was observed to contain two pudding-like in disposable mini cups with a lid labeled peanut butter pudding with a use by date of November 7, 2022. A large clear square graduated container with apple sauce was observed labeled use by November 10, 2022. Staff #43 stated that they must have been mislabeled. They were not disposed of at that moment. At 11:02 a.m. that same day, the food items were observed still in the refrigerator. This time staff #43 was observed disposing of them immediately. An interview was conducted on November 17, 2022 at 7:32 a.m. with staff #43. She stated that she conducts inventories every Thursday after food deliveries are made and that she attempts to check every day for expired food. Staff #43 stated there is a risk 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 clinical record review and staff interviews, the facility failed to develop and implement a policy to ensure two residents (#9 and #1) were administered influenza and pneumococcal immunizations. The sample size was 5. The deficient practice could result in residents not receiving immunizations. Findings include: -Resident #9 was admitted to the facility on [DATE] with a diagnosis of moderate protein-calorie malnutrition. Review of the clinical record revealed the resident received the influenza vaccine in 2016. Continued review of the clinical record revealed the resident was educated and offered the influenza vaccine, and the consent was signed October 25, 2022. Additional review of the clinical revealed the vaccine was added to the schedule but not administered. Further review of the clinical record revealed the resident had received the pneumococcal (PCV13) vaccine October 15, 2013. Review of the clinical record revealed the resident was educated and offered the pneumococcal vaccine, the consent 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 clinical record review, staff interviews, and policy review, the facility failed to develop and implement policies and procedures to ensure two residents (#9 and #1) received the COVID vaccine. The sample size was 5. The deficient practice could result in residents not receiving the COVID vaccine per their request. Findings include: -Resident #9 was admitted to the facility on [DATE] with a diagnosis of moderate protein-calorie malnutrition. Review of the clinical record revealed the resident received a COVID vaccine series on March 11, 2021 and April 5, 2021. Continued review of the clinical record revealed the resident was educated and offered the COVID booster, and the consent was signed October 25, 2022. Additional review of the clinical revealed the vaccine was added to the schedule but not administered. -Resident #1 was admitted to the facility on [DATE] with a diagnosis of acute chronic systolic congestive heart failure. Review of the clinical record revealed the resident had received the primary…

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.