Rim Country Health & Retirement Community

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on documentation, interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#21) did not abuse another resident (#32). The deficient practice could result in residents being physically and/or emotionally injured. Findings include: -Resident #32 was admitted on [DATE] with diagnosis that included unspecified dementia with unspecified severity and without behavioral disturbance, psychotic disturbance, mood disturbance, schizoaffective disorder, Alzheimer's disease and anxiety. A review of the annual MDS (minimum data set) dated December 6, 2024 revealed a BIMS (brief interview of mental status) score of 01, indicating severe cognitive impairment. The MDS further revealed no noted potential indicators of psychosis, but did note physical behaviors 1-3 days and wandering 4-6 days within a week. The care plan revealed that resident #32 uses psychotropic medications for behavior management, schizoaffective disorder, anxiety and dementia with behaviors. Furthermore, 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 clinical record review, interviews, review of facility documentation and policy review, the facility failed to ensure resident #2 was free from abuse from resident #1. The deficient practice could result in residents experiencing emotional and mental trauma from abuse. Findings include: -Regarding Resident #1: Resident #1 was admitted to the facility on [DATE] with diagnoses of acquired absence of left leg below the knee, dementia, and aphasia. Review of a discharge Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 completed a Brief Interview for Mental Status (BIMS) and scored a 10 which indicated the resident was moderately cognitively impaired. The care plan was revised on November 11, 2024 included that the resident has potential for physical behaviors towards staff and other residents due to poor impulse control. Interventions included addressing the resident's trigger of loud noises, intervening and redirecting when inappropriate behaviors are observed and notifying the provider…

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, review of facility documentation and policy review, the facility failed to ensure resident #1's care plan was updated to accurately reflect the resident's care. The deficient practice could result in residents not getting the appropriate care they need. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses of acquired absence of left leg below the knee, dementia, and aphasia. A nurses' note, dated October 18, 2024 at 5:34 AM indicated resident #1 had raised his hand toward the nurse when the nurse refused to leave his morning medications on his table. No physical contact was made. A nurses' note dated, October 30, 2024 at 6:30 PM, revealed resident #1 had punched a Certified Nursing Assistant (CNA), on the front of the upper thigh, who was attempting to redirect him out of another resident's room. The note indicated the punch resulted in a large bruise which was 6 centimeters round on the CNA's thigh. A nurse's note, dated November 11,…

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, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#9) were free from physical abuse resulting in injury by other residents (resident #23). The deficient practice could result in further incidents of resident to resident abuse. Findings include: -Resident #9 was admitted to the facility on [DATE], with diagnosis that include Dementia, Psychotic disturbances, anxiety, and Alzheimer's disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had mild cognitive impairment. A behavioral care plan revised April 7, 2023 revealed the resident is at risk for impaired thought processes related to vascular dementia, with a noted intervention of keeping the resident's routine consistent in order to decrease confusion when able. However, review of the care plan revealed no care plan measures addressing…

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, facility documentation, resident and staff interviews, and policy review, the facility failed to protect the rights of one resident (#50) to be free from physical abuse by another resident (resident #99). The deficient practice could result in resident not protected from further abuse. Findings include: -Resident #50 was admitted on [DATE], with diagnoses of depression, hypertension, constipation, weakness, anxiety, and bursitis. A behavioral care-plan initiated February 10, 2023 revealed the resident was at risk for confusion. The goal was to maintain the resident's current level of cognitive function. Interventions included to keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03 which indicated the resident had severe cognitive impairment. The progress note dated August 25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, facility documentation and policy, and the State Agency (SA) complaint tracking system, the facility failed to ensure one resident (#10) was free from abuse from a staff member. The deficient practice could lead to further abuse of residents. Findings include: Resident #10 was admitted to the facility on [DATE] with a diagnoses of congestive heart failure, edema, paroxysmal atrial fibrillation and chronic respiratory failure with hypercapnia. An MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 14 indicating that resident #10 was cognitively intact. Review of the intake information submitted by the facility to the SA complaint tracking system on June 14, 2024 revealed that the ADON was advised by a RN (registered nurse/staff #3) of an incident with resident #10. The information included that after resident (#10) said he was not going to take the cup of medication until he saw his doctor the resident handed the cup back…

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 documentation, policy and procedures, and the State Survey Agency database, the facility failed to develop and implement their policy on abuse reporting and investigation for one resident #67. The deficient practice could result in abuse continuing and not being prevented. Findings include: - Resident #67 was admitted to the facility on [DATE] with diagnoses that included visual disturbance, schizoaffective disorder, bipolar disorder depressed severe with psychotic features, generalized anxiety disorder, major depressive disorder, insomnia, difficulty walking, and aphasia. Resident #67 was discharged home on December 4, 2023. The resident's Brief Interview for Mental Status (BIMS) score was 14 on May 25, 2023 and August 19, 2023, indicated that she was cognitively intact. A review of resident #67's clinical records revealed a progress note dated June 3, 2023 at 1:46 PM, the Nurse Practitioner (NP/staff #85) included that the patient suffered from…

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, facility documentation, review of the State Agency database, staff interviews, and review of policy and procedure, the facility failed to ensure two allegations of abuse were thoroughly investigated and prevent further potential abuse and take appropriate corrective action for two residents. The deficient practice could lead allegations of abuse not being investigated and abuse occurring in the facility. Findings Include: Regarding resident #67 and resident #66 -Resident #67 was admitted to the facility on [DATE] with diagnoses that included visual disturbance, schizoaffective disorder, bipolar disorder depressed severe with psychotic features, generalized anxiety disorder, major depressive disorder, insomnia, difficulty walking, and aphasia. Resident #67 was discharged home on [DATE]. -Resident #66 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, and post-traumatic stress disorder. Resident #66 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, facility documentation, and facility policies and procedures, the facility failed to allow one resident the right to exercise his rights without coercion or interference or coercion from the facility and to be supported by the facility in the exercise of his rights. The deficient practice could result in other residents not being able to exercise their rights. Findings include: -Resident #66 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, chronic obstructive pulmonary disease, muscle weakness, congestive heart failure, major depressive disorder, hypothyroidism, hypertension, and post traumatic stress disorder. A progress note dated June 30, 2023 at 12:30 PM. The progress note stated that resident #66 was discharged from the facility at 12:30 PM and transported to the emergency room accompanied by staff. The progress note also stated that the resident was alert and oriented, vital signs were stable, and that he 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, facility documentation, policies and procedures, the facility failed to ensure that two residents (#36, #68) were free from abuse from another resident. The deficient practice could result in other residents being abused. Findings include: Regarding resident #38 and resident #68 -Resident #38 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, paranoid personality disorder, muscle weakness, dysphagia, epilepsy, depressive disorder, and anxiety disorder. The medication administration record revealed that she had been taking Risperdal 1 mg by mouth twice daily for schizoaffective disorder since [DATE]. Review of resident #38's clinical records revealed a Brief Interview for Mental Status (BIMS) score of 10 on [DATE], which indicated moderate cognitive impairment. A progress note dated [DATE] at 1:00 PM, stated that another resident had grabbed onto resident #38's jacket and wouldn't let go, so staff #8 stepped in between…

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 documentation, review of policy and procedures, and the State Survey Agency database, the facility failed to ensure an allegation of resident to resident abuse was reported within the required timeframe to the State Agency for one resident (#67). The deficient practice could result in further allegations of abuse not being reported in a timely manner as required. Findings include: -Resident #67 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, bipolar disorder depressed severe with psychotic features, generalized anxiety disorder, major depressive disorder, insomnia, difficulty walking, and aphasia. Resident #67 was discharged home on December 4, 2023. -Resident #66 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, and post-traumatic stress disorder. Resident #66 was transferred/discharged on June 30, 2023. A review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, review of facility documentation, policy and procedures, the facility failed to implement their policy on abuse reporting and investigation for four residents (#15, #218, #220, and #221). The deficient practice could result in abuse continuing and not being prevented. Findings include: -Regarding Resident #218 Resident #218 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included mental disorder, psychosis, bipolar disorder, anxiety disorder, and schizophrenia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS assessment indicated that at the resident exhibited indicators of psychosis such as delusions. The MDS also revealed that the resident wandered and that this type of behavior occurred 4-6 days at the time of the assessment. A care plan initiated on August 2, 2012 indicated 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 review of the clinical record, facility documentation, review of the State Agency database, staff interviews and review of policy and procedure facility failed to ensure two allegations of abuse and two injuries of unknown origin were fully investigated. The deficient practice could result in allegations of abuse and injuries of unknown origin not being investigated and abuse/neglect occurring in the facility. Findings include: -Regarding Resident #218 Resident #218 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included mental disorder, psychosis, bipolar disorder, anxiety disorder, and schizophrenia. A report was received by the State Agency on November 26, 2019 that indicated that a resident-to-resident altercation occurred between resident #218 and #219. Review of the SA database revealed that the facility failed to submit a completed thorough investigation of the allegation to the SA. Furthermore, review of the facility investigation/incident 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, staff interviews and facility policy and procedures, the facility failed to revise and update care plans to include non-pharmacological interventions for psychotropic medications for three residents (#52, #5, #24). The deficient practice could result in resident needs not being met. Findings include: Resident #52 was admitted to the facility on and admitted on [DATE] with diagnoses that included bipolar disorder, major depressive disorder, low back pain. The Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating indicating the resident is cognitively intact. Review of the care plan dated October 14, 2022 revealed acute pain and resident is fearful of moving related to pain. Interventions included to administer analgesia, and to evaluate the effectiveness of pain interventions each shift and PRN (as needed). Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional…

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, staff interviews, and review of policy, the facility failed to ensure that professional standards of practice were followed during medication administration when staff left medications at the bedside unattended and did not assure that the resident (#10) took an inhaled medication according to physician's orders, that medications are not left unattended on the medication cart, and a medication was left unlocked and unattended. The deficient practice could result in residents not receiving the prescribed dose of medication and resident's having access to unprescribed medications. Findings include: -Regarding Medications left unattended During a medication administration observation conducted on June 7, 2023 at approximately 8:10 AM through 9 :30 AM with a Registered Nurse (RN/registry staff #90). A bottle of aspirin 81 milligram (mg), and a clear medication cup with one tablet inside were observed to be sitting on the top of the medication cart at the start of the observation. The medication…

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 documentation, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. Findings include: Review of the facility's staffing documentation revealed there was not a registered nurse on duty for the month of November 2022 and December 2022 on the following dates: November 12, 2022 November 26, 2022 December 10, 2022 December 24, 2022 During an interview conducted June 8, 2023 at approximately 3:00 p.m. with the Director of Nursing (DON/staff #99) and the Regional Nurse (staff #81), the schedule, daily staff posting, and time cards were reviewed for the above dates and it was determined that that a registered nurse did not work for 8 consecutive hours. The DON stated that she was aware of the problem and has hired two registered nurses. The Facility Assessment updated April 1, 2023 states that the staffing plan requires at least one registered nurse per a 24 hour period.

Based on observations, staff interviews, and review of policy and procedures, the facility failed to ensure infection control standards were maintained regarding hand hygiene. The deficient practice could result in transmission of infection. Findings include: During a medication administration observation conducted on June 7, 2023 at approximately 8:10 AM with a Registered Nurse (RN/staff #90), was observed to drop a pantoprazole sodium tablet on the floor next to the nursing cart. The RN was observed to pick up the tablet from the floor without gloves, and disposed of the tablet. He was then observed to remove another tablet from the blister pack and place into a medication cup without firs sanitizing his hands, after touching the floor with his hands. Continued medication observation conducted on June 7, 2023 at 8:36 AM with the RN, revealed the RN removing a Carbidopa-levodopa tablet from a blister pack. The RN was observed to drop the tablet on top of the medication cart, picked it up without gloves and place in a medication cup. The RN was not observed to sanitize the top 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, facility documentation, staff interviews, and policies and procedures, the facility failed to ensure two residents (#220, #221) were not neglected resulting in injury of unknown origin. The deficient practice could result in residents suffering from preventable injuries due to neglect. Findings include: -Regarding Resident #220 Resident #220 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included schizophrenia, major depressive disorder, Alzheimer's disease, and dementia. Review of a care plan initiated on June 10,2010 revealed that the resident exhibited impaired cognition due to Alzheimer's and Schizophrenia with psychosis as evidenced by confusion and memory loss. The care plan also indicated that resident had a communication deficit and speaks mainly Navajo but does understand some English. Interventions included to obtain interpreter when staff is unable to understand resident needs. Additionally, the care plan indicated 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, staff interviews, facility documentation and policy review, the facility failed to ensure an order for hospice was obtained for one resident #54. The resident census was 68, and the sample was 17. The deficient practice could result in residents not receiving the treatment and care based on their needs. Resident #54 was re-admitted on [DATE] with diagnoses that included major depressive disorder, cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, and dementia. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident received hospice as a resident. Review of a Hospice notes dated March 20, 2023 that revealed the resident was transferred to the facility. Further review of Hospice progress notes dating from March 20, 2023 through June 6, 2023, revealed that hospice nurses had seen the resident. However, review of the clinical record revealed no Physician's order for the resident to receive hospice care. Review of 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 clinical record review, staff interviews, and policy review, the facility failed to ensure appropriate services for mental or psychological difficulty for one resident (#60). Findings include: Resident #60 was admitted to the facility on [DATE] with diagnoses that included Anxiety Disorder, Unspecified and Unspecified Dementia, Unspecified Severity, with Psychotic Disturbance An admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 09 which indicated the resident was moderately cognitive impaired. The MDS documented the resident had delusions with physical behavioral symptoms directed towards others in the past 1 to 3 days, verbal behavioral symptoms directed towards others in the past 4 to 6 days, other behavioral symptoms not directed towards other in the past 1 to 3 days, and wandering in the past 1 to 3 days. The MDS documented the resident had anxiety. Review of the physician orders revealed a Psychiatrist specialist referral 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 observations, staff interviews, review of records, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for one resident (#31). The medication error rate was 10%. The deficient practice could result in further medication errors. Findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, anxiety disorder, hypertension, heart failure and type 2 diabetes mellitus. During a medication administration observation conducted on June 7, 2023 at approximately 8:36 AM with a Registered Nurse (RN/staff #90), the RN was observed to administer -One Furosemide 20mg tablet was administered to resident #31. However, review of the physician's order revealed a physician's order for Furosemide 20mg tablet, give 3 tablets by mouth, dated October 24, 2022. -One Lisinopril 5mg tablet was administered. However, review of the physician's order revealed an order for…

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

Based on observations, interviews and policy review the facility failed to ensure the carrots served during lunch were warm and palatable. This deficient practice has the potential for residents who disliked a meal to experience dissatisfaction with their meals or to experience a nutritional problem. While on steam table, the temperature of the foods prepared for lunch was measured with registered dietician (staff #68) On June 7, 2023 11:18 AM for the following foods: pot roast was 157 degrees, potatoes was 150 degrees, sautéed carrots was 148 degrees, gravy was 150 degrees and mechanical soft potatoes were 160 degrees. At 11:32 AM the temperature of mechanical soft meat was 142 degrees. A test tray was prepared for survey team on June 7, 2023. At 12:38 AM trays were passed by various staff members until reaching the room farthest away from the kitchen. Temperature of last food tray was obtained with and verified by staff #68 at 12:41 PM. Temperatures of foods were as follows: pot roast was 126 degrees, carrots were 98 degrees. Test tray was tested at approximately 12:45 PM. The pot…

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 resident and staff interviews, observation, the facility assessment, facility documentation, and review of policy and procedure, the facility failed to ensure there was sufficient nursing staff to meet the needs of residents. The deficient practice resulted in resident needs not being met and/or not being met timely. Findings include: During the initial phase of the survey, multiple resident interviews were conducted on April 4, 2022 and revealed the following: -A resident stated that staffing in the building was a drastic problem. He stated when staff called off it took a long time to find a replacement. He stated that the previous night the nurse was assigned three halls and that for a period of time there were no CNAs (Certified Nursing Assistants). He stated that this resulted in residents receiving their medications almost an hour late. He stated that if he needed something it took a long time to get help, sometimes over an hour. He stated that he hesitated to call for help because he knew the facility was short on help. -A resident stated that she has had to wait a…

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

Based on facility documentation, staff interviews, the glucometer manual, and facility documentation, the facility failed to ensure that quality control testing was consistently completed on the glucometers. The deficient practice could result in not being aware of glucometers that were not functioning properly and therefore providing inaccurate blood glucose level results for residents. Findings include: Review of the Daily Quality Control Record form revealed sections for the meter serial #, month/year, Station/Shift, operator initials/shift, meter cleaned, check strip result, lot #, expiration date, code #, Level 1 control range, Level 1 control result, Level 2 control range, Level 2 control range and corrective action. -Observation of the Way Station hall medication cart revealed two glucometers in use for that hall. Review of the Daily Quality Control Record forms dated November 2021 and December 2021 revealed that the meter serial # was not documented on the forms on the Way Station hall, with no indication of which of the two meters had been used for the test controls. Review…

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, facility documents, resident and staff interviews, and policy reviews, the facility failed to ensure that unit freezer temperatures were monitored and adaptive equipment was cleaned in a sanitary manner for one resident (#1). The deficient practice has the potential to cause foodborne illness. Findings include: Regarding adaptive equipment Resident #1 was admitted on [DATE] with diagnoses of paraplegia and muscle weakness. A Care Plan with a review start date of January 3, 2022 revealed the resident requires assistance for Activities of Daily Living (ADLs) related to paraplegia, is unable to take care of himself and needs 24-hour care. A quarterly Minimum Data Set assessment dated [DATE] included that this resident had a Brief Interview for Mental Status score of 15 which indicated intact cognition. This assessment also included that this resident required supervision and set up help while eating. During an interview conducted with the resident on April 4, 2022 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.

Based on observations, facility documentation, staff interviews, and review of the Centers for Disease Control (CDC) guidelines and facility policy, the facility failed to ensure staff donned required Personal Protective Equipment (PPE) upon entering resident rooms on Transmission-Based Precautions (TBP), that staff donned the required PPE during conducting Covid-19 testing, and that staff completed the screening process prior to beginning their shift. The deficient practice could result in the spread of infection to residents and staff. Findings include: Regarding PPE for residents on TBP: -On 04/06/22 at 8:23 a.m., an observation was conducted on hall 500, an area where new admissions who had declined Covid-19 vaccinations resided. PPE carts were noted outside the doorway and included supplies of gowns, gloves, N95 masks inside each one. Additionally, signage was posted outside the door indicating that the resident was in quarantine until the designated date. The sign stated that the residents must wear an N95 mask when they were out of their room and that staff must 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.

Based on facility documentation, staff interviews, and review of policy and procedures, the facility failed to implement their policy to ensure that 2 employees had received at least one dose of COVID-19 vaccine, after having been granted a temporary delay, and that one employee received a second of COVID-19 vaccine. The deficient practice may result in further staff not being vaccinated for COVID-19. Findings include: Review of the staff COVID-19 vaccination matrix revealed the following: Regarding a dietary cook (staff # 56): Review of a COVID-19 Religious Exemption form dated 02/14/22 revealed a hand-written note by staff #56 which included that he had received a tuberculosis test on 02/08/22 and that he was required to wait 4 weeks before he could receive a COVID vaccination. However, review of the facility documentation did not indicate that he had received his first dose of vaccine on or before 03/21/22 in accordance with CMS (Centers for Medicare & Medicaid Services) guidelines. Regarding a member of the housekeeping staff (staff #21): Per an undated COVID-19 Vaccine Medical…

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 facility policy, the facility failed to ensure two residents (#36 and #34) were informed in advance of the risks and benefits of proposed treatment with psychotropic medications. The sample size was 5. The deficient practice could result in residents receiving high risk medications without education, their knowledge, or consent. Findings include: -Resident #36 admitted to the facility on [DATE]. Diagnoses included major depression, anxiety disorder, and chronic post-traumatic stress disorder. Review of the physician's orders revealed an order dated February 8, 2022 for buspirone hydrochloride (antianxiety medication) 5 milligram (mg) tablet by mouth one time a day for depressed affect. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The assessment included the resident receiving daily use of an antidepressant…

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, staff and responsible party interviews, and review of policy and procedure, the facility failed to ensure that one sampled resident (#58) was free from staff to resident abuse. The deficient practice could result in further resident abuse. Findings include: Resident #58 admitted to the facility on [DATE] with diagnoses that included acute cerebrovascular insufficiency, schizophrenia, unspecified, and unspecified dementia without behavioral disturbance. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 2 on the Brief Interview for Mental Status, indicating severe cognitive impairment. According to the assessment, the resident demonstrated inattention, being easily distractible, or having difficulty keeping track of what was said, and that disorganized thinking was continuously present. The resident did not exhibit signs or symptoms of psychosis. The resident demonstrated verbal behavioral symptoms directed toward…

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, staff interviews, and policy and procedure, the facility failed to ensure that the risks and benefits were explained prior to the use of bedrails, and that the use of bedrails was ordered and monitored appropriately for one sampled resident (#58). The deficient practice may result in improper use of bedrails. Findings include: Resident #58 admitted to the facility on [DATE] with diagnoses that included acute cerebrovascular insufficiency, schizophrenia, unspecified, and unspecified dementia without behavioral disturbance. An accident potential care plan dated 09/15/21 related to aging, disease process, and confusion included for bed rails to assist with boundary identification as requested by the resident's family. The goal is to comply with safety precautions. Interventions included offering food, fluids, pain management, and elimination assistance routinely. However, review of the clinical record did not include a physician's order for a device/restraint use review…

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 facility documentation, clinical record review, staff interviews, and review of policy, the facility failed to implement their policy regarding reporting an allegation of abuse for one sampled resident (#58). The deficient practice could result in further abuse allegations not being reported in a timely manner. Findings include: Resident #58 admitted to the facility on [DATE] with diagnoses that included acute cerebrovascular insufficiency, schizophrenia, unspecified, and unspecified dementia without behavioral disturbance. A nursing progress note dated 03/15/22 at 12:35 p.m. included that the resident had become agitated while a Certified Nursing Assistant (CNA) was performing personal care. The note stated that the resident had called her family and told them that the CNA hit her in the face and grabbed her hand. The family arrived at the unit and wanted details of the incident. The resident's family member requested that the CNA not care for the resident again. However, the documentation 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, facility documentation, staff interviews, the State Survey Agency database, and review of policy and procedures, the facility failed to ensure an allegation of staff to resident abuse was reported in the required timeframe to the State Agency for one sampled resident (#58). The deficient practice could result in further allegations of abuse not being reported as required. Findings include: Resident #58 admitted to the facility on [DATE] with diagnoses that included acute cerebrovascular insufficiency, schizophrenia, unspecified, and unspecified dementia without behavioral disturbance. A nursing progress note dated 03/15/22 at 12:35 p.m. included that the resident had become agitated while a Certified Nursing Assistant (CNA) was performing personal care. The note stated that the resident had called her family and told them that the CNA hit her in the face and grabbed her hand. The family arrived at the unit and wanted details of the incident. Review of the facility's investigation…

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 documentation, and policy review, the facility failed to prevent further potential abuse, by failing to remove a staff member from providing direct care to residents regarding an allegation of abuse for one sampled resident (#58), and failed to submit the results of the facility investigation regarding the abuse to the State Survey Agency. The deficient practice could result in further abuse and results of investigations not being sent to the State Agency within the required timeframe. Findings include: Resident #58 admitted to the facility on [DATE] with diagnoses that included acute cerebrovascular insufficiency, schizophrenia, unspecified, and unspecified dementia without behavioral disturbance. A nursing progress note dated 03/15/22 at 12:35 p.m. revealed the resident had become agitated while a Certified Nursing Assistant (CNA) was performing personal care. The note stated that the resident had called her family and told them that the CNA hit her…

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 Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for one resident (#58). The sample size was 21. The deficient practice could result in residents' MDS assessments not being accurate. Findings include: Resident #58 admitted to the facility on [DATE] with diagnoses that included acute cerebrovascular insufficiency, schizophrenia, unspecified, and unspecified dementia without behavioral disturbance. An accident potential care plan dated 9/15/21 related to bed rails on the bed to assist with boundary identification as requested by the resident's family had a goal to usually comply with safety precautions. Interventions included to provide a structured routine and staff to reduce confusion. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 2 on the Brief Interview for Mental Status, indicating severe cognitive impairment. The assessment…

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 ensure one resident (#53) with a diagnosis of a serious mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review. The sample size was 2. The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: Resident #53 was readmitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder, insomnia, schizoaffective disorder, major depressive disorder, mood disorder, altered mental status, Parkinson's disease and schizoaffective disorder, bipolar type. Review of the PASRR (Pre-admission Screening and Resident Review) Level 1 Screening dated January 6, 2020 completed during resident stay at the facility, revealed the resident had serious mental illnesses that included schizoaffective disorder and major depression and had mental disorders that included anxiety disorder 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 policy and procedures, the facility failed to develop a comprehensive person-centered care plan for one resident (#23) to include risk for pressure ulcer formation. The sample size was 21. The deficient practice could result in a plan of care that did not meet the resident's needs. Findings include: Resident #23 admitted to the facility on [DATE] and most recently re-admitted on [DATE] with diagnoses that included type two diabetes, hypertension, atherosclerotic heart disease, and acute embolism and thrombosis. Review of the current care plan revealed a focus, initiated June 10, 2019, that the resident was incontinent of bowel and bladder which included a goal that through staff monitoring and interventions, the resident would not have skin breakdown related to incontinence. The interventions included for barrier cream to be utilized with incontinence care to prevent skin breakdown, and performing thorough peri-care after each incontinent episode.…

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 policies and procedures, the facility failed to ensure the comprehensive care plan was revised to include skin breakdown for one resident (#23). The sample size was 21. The deficient practice could result in inaccurate/incomplete plans of care for residents. Findings include: Resident #23 admitted to the facility on [DATE] and most recently re-admitted on [DATE] with diagnoses that included type two diabetes, hypertension, atherosclerotic heart disease, and acute embolism and thrombosis. Review of the current care plan revealed a focus, initiated on June 10, 2019, that the resident was incontinent of bowel and bladder which included a goal that through staff monitoring and interventions the resident would have not skin breakdown related to incontinence. The interventions included for barrier cream to be utilized with incontinence care to prevent skin breakdown, and performing thorough peri-care after each incontinent episode. The care plan included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record reviews, staff interviews, and review of facility policy and procedures, the facility failed to ensure resident rights were followed during medication administration regarding two residents (#49 and #32). The deficient practice could result in adverse effects and residents receiving unnecessary medications. Findings include: -Resident #49 admitted to the facility on [DATE] with diagnoses that included hypothyroidism, major depressive disorder, and insomnia. During an interview conducted with resident #49 on April 4, 2022 at 2:16 p.m., a staff member later identified as Licensed Practical Nurse/orientee (LPN/staff #16), entered the room and stated that she had the resident's medications. The LPN asked the resident's name and the resident stated her name for the nurse. The LPN then gave the resident a small plastic cup that contained two medications. The resident looked at the medications and told the LPN that the medications were not hers. The staff member took the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility documents, staff interviews, and policy review, the facility failed to provide one sampled resident (#1) the necessary services to maintain good grooming and personal hygiene. The deficient practice could result in residents' hygiene needs not being met. Findings include: Resident #1 was admitted on [DATE] with diagnoses of paraplegia and muscle weakness. A quarterly Minimum Data Set (MDS) assessment dated [DATE] included that this resident had a Brief Interview for Mental Status score of 15, which indicated intact cognition. This assessment also stated that this resident required extensive assistance of two+ person assistance with bed mobility and is totally dependent on one person for physical assistance for bathing. A current Care Plan revealed that this resident requires assistance for Activities of Daily Living (ADLs) related to paraplegia, and needs 24-hour care. Interventions stated to assist with bathing, hygiene, dressing and toileting as needed. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility documents, staff interviews, and policy review, the facility failed to provide an ongoing program of activities for one sampled resident (#24). The deficient practice could result in residents not being provided activities. Findings include: Resident #24 was admitted on [DATE] with diagnoses of unspecified psychosis, Major Depressive Disorder, and vascular dementia with behavioral disturbance. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed that this resident had a Brief Interview for Mental Status score of 1 which indicated severe cognitive impairment. This assessment also revealed the Interview for Daily and Activity Preferences was conducted with the resident and included being around animals such as pets, participating in religious services or practices, and having snacks between meals were somewhat important to the resident. A Care Plan revealed that this resident is dependent upon staff for activities that provide cognitive…

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, observation, staff interviews and review of policy and procedure, the facility failed to ensure that one sampled resident (#23) received the necessary care and services to prevent pressure ulcers and to treat acquired pressure ulcers. The deficient practice could result in formation or worsening of pressure ulcers. Findings include: Resident #23 admitted to the facility on [DATE] and most recently re-admitted on [DATE] with diagnoses that included type two diabetes, hypertension, atherosclerotic heart disease, and acute embolism and thrombosis. Review of the current care plan revealed a focus, initiated on June 10, 2019, that the resident was incontinent of bowel and bladder which included a goal that through staff monitoring and interventions the resident would have no skin breakdown related to incontinence. The interventions included for barrier cream to be utilized with incontinence care to prevent skin breakdown, and performing thorough peri-care after each incontinent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the clinical record review, staff interviews and policy reviews, the facility failed to ensure one resident (#20) weight was obtained as ordered. The sample size was 2. The deficient practice could result in residents with unplanned weight loss. Findings include: Resident #20 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, altered mental status, disorientation and constipation. The admission MDS (Minimum Data Set) assessment dated [DATE] included the BIMS (Brief Interview of Mental Status) score was 3 which indicated the resident had severely impaired cognition. The MDS assessment revealed the resident had no weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Review of the care plan initiated on February 6, 2022 revealed the resident was at risk for nutrition, weight loss and dehydration related to dementia. Interventions included for weekly weights for 4 weeks from admit date , monitor weights…

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 facility policy and procedures, the facility failed to ensure two residents (#32 and #34) were provided pain management consistent with professional standards of practice, the person-centered care plan, and the resident's goals and preferences. The sample size was 6. The deficient practice could result in residents' pain not being managed. Findings include: Resident #32 was admitted on [DATE] with diagnoses that included aphasia, essential (primary) hypertension, other insomnia, schizoaffective disorder, bipolar disorder, bipolar disorder, current episode depression, severe, without psychotic features, and other chronic pain. A care plan initiated on September 18, 2017 for pain included a goal that the resident would have pain relief and that the pain would not interfere with normal daily activity. The interventions for these goals included administering analgesics as ordered by the MD (medical doctor), assessing effectiveness of pain medication…

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 policies and procedures, the facility failed to ensure one resident (#36) was free of unnecessary drugs, by failing to administer medications according to parameters as ordered by the physician. The sample size was 5. The deficient practice could result in residents receiving unnecessary medications. Findings include: Resident #36 admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome, muscle weakness, and major depression. Review of the care plan revealed a focus dated August 18, 2021 and revised August 24, 2021 that stated the resident was at risk for pain related to dislocation of T3/T4 with a goal that the resident would verbalize relief of pain and that pain would not interfere with normal daily activities. The interventions included administering analgesics as ordered by the medical doctor. Review of the physician's orders revealed: -August 18, 2021, order for oxycodone hydrochloride (HCL) 5 milligram (mg)…

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 (#34) was free of an unnecessary medication, by failing to ensure the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for a psychotic medication. The sample size was 5. The deficient practice could result in residents receiving medications that are not necessary. Findings include: Resident #34 was admitted to the facility on [DATE] with diagnoses that included pain, chronic migraine without aura, major depressive disorder, weakness and anxiety. A physician order dated January 18, 2022 included for Haloperidol (antipsychotic) tablet 5 mg give 0.5 tablet by mouth two times a day for behaviors. However, the order did not include the diagnosis or target behaviors for the use of Haloperidol. The quarterly MDS assessment dated [DATE] revealed the BIMS score was 10 which indicated the resident's cognition was moderately impaired. The MDS assessment…

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, review of the clinical records, staff interviews and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered to two residents (#56 and #12). The error rate was 7.69%. The deficient practice could result in further medication errors. Findings include: -Resident #56 was admitted to the facility on [DATE] with diagnoses that included protein-calorie malnutrition, obesity, left leg pain, and right artificial knee joint. A medication administration observation conducted on April 5, 2022 at approximately 8:20 AM with a Registered Nurse (RN/staff #6) who was orienting a Licensed Practical Nurse (LPN/staff #16). The LPN was observed to administer Calcium-Vitamin D tablet 600 milligrams (mg)/400 international units (IU) to resident #56. However, review of the physician's orders revealed an order dated June 29, 2021 for calcium-vitamin D tablet 600/200mg-unit one time a day for supplement. -Resident #12 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.

Based on personnel file reviews, staff interviews, and policy review, the facility failed to provide evidence that 1 out 10 sampled staff (#27) was provided training for abuse, neglect, and exploitation as per their policy. The deficient practice could result in staff not being knowledgeable of how to prevent, identify, investigate, and report allegations of abuse. Findings include: A review of a Certified Nursing Assistant's (CNA/staff #27) personnel file was conducted on 04/05/22 at 2:06 p.m. with the Human Resource (HR) Director (staff #43). Review of the file indicated staff #27 was hired 06/26/12. Per the review, a Certified Nursing Assistant job description dated 06/26/12 included duties and responsibilities which were expected for CNAs to perform including staff development. The description further specified that the expectation was attendance and participation in scheduled training and educational classes to maintain current certification as a Nursing Assistant. The document was signed by staff #27 on 06/26/12. A Student and Group Transcript Report revealed that staff #27…

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.