Arizona State Veteran Home-Phx

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to provide adequate supervision which resulted in the elopement of one resident (#22). The deficient practice could result in residents being physically and/or psychosocially harmed. Findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease without dyskinesia, unspecified dementia, and a cognitive communication deficit. Review of the brief interview for mental status (BIMS) dated January 10, 2025 revealed, that the resident is rarely understood; and that, the interview could not be completed. The care plan dated February 16, 2025 revealed that the resident demonstrated unsafe travel outside the facility without a responsible party or proper authorization. An elopement dated February 16, 2025. Interventions included to apply Wander-guard to reduce risk of elopement and hourly checks. Review of the order summary revealed an order: -March 22, 2024, 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 reviews, staff and resident interviews, facility documentation, and policy and procedures, the facility failed to ensure residents (#3 and #4) were free from abuse. The deficient practice could lead to further resident to resident abuse. Findings include: -Regarding Resident #3 Resident #3 was admitted to the facility on [DATE] with diagnoses including Neurocognitive disorder with Lewy bodies, encephalopathy, and post-traumatic stress disorder. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Review of the careplan revealed, initiated on July 19, 2023, a problem that indicated that the resident had socially inappropriate and disruptive behavioral symptoms. This entry addressed that the resident is occasionally aggressive towards staff. The entry was revised on January 4, 2025 to include that the resident had shown sexually inappropriate behaviors; and that, the resident had 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 review of the clinical record, staff interviews, facility documentation, policy and procedure, the facility failed to ensure the care plan was implemented related for fall prevention for one resident's (#2). The deficient practice could result in residents sustaining falls with injuries that may be preventable. Findings include: Resident #2 was admitted on [DATE] with diagnoses of multiple sclerosis, mood disorder due to known physiological condition with depressive features, adjustment disorder, unspecified, weakness. A review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview Of Mental Status) score of 13 indicating resident's cognition was intact. The assessment also included that the resident required extensive assistance of 2 for bed mobility and transfers. Further review of the MDS revealed resident had lower extremity impairment on both sides. Review of the progress notes dated September 9, 2023 revealed resident was found on the floor close to his…

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 the facility policy and procedures, the facility failed to ensure an order for blood pressure medication was administered within the prescribed parameters for Resident # 7. The deficient practice could result in undesirable medication-induced harm. Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses that included generalized body pain, osteoarthritis, and essential (primary hypertension). The care plan dated November 15, 2023 revealed that the resident requires pain monitoring and management related to a diagnoses of chronic pain; and that, is at risk for complications related to diagnosis of hypertension. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident was cognitively intact. Review of the order summary revealed: -March 27, 2024 Amlodipine 2.5 mg tablet oral every 12 hours for hypertension. Hold if systolic blood pressure (SBP) less than 110 or diastolic blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that adequate supervision was provided to prevent resident (#55) to resident (#12) abuse. The deficient practice could result in residents harming each other physically and emotionally. Findings include: Resident #12 was admitted on [DATE] to the facility on with diagnoses that included major depressive disorder, mood disorder due to known physiological condition with depressive features, and an adjustment disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 8 indicating a moderate cognitive impairment. A care plan dated November 21, 2022 revealed that the resident is receiving a mood stabilizer medication for a diagnosis of adjustment disorder with mixed anxiety and depressed mood disorder, depression, major depressive disorder, delirium, anxiety disorder, and other signs and symptoms involving cognitive functions following cerebral infarction.…

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 policies and procedure, the facility failed to ensure skin pathologies and/or injuries for three residents (#9, #14, #25) were documented accurately. The deficient practice may result in suboptimal care to the residents due to pertinent clinical information being unavailable. Findings include: -Resident #9 was admitted into the facility on November 22, 2023 with diagnoses of unspecified dementia, type 2 diabetes mellitus with hyperglycemia, and adjustment disorder with mixed anxiety and depressed mood. The annual minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 2, which indicated the resident was severe cognitive impairment. The showers sheets for May 13, 16 and 20, 2024 revealed no skin issues identified. An interview was conducted on May 22, 2024 at 12:35 p.m. with a registered nurse (RN/staff #18) who stated that the skin lesion on the right arm of resident #9 appeared to be 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 record review, interviews, and review of facility policies and procedure, the facility failed to develop a discharge plan that meet the needs and goals of one of 3 sampled residents (Resident #8). The deficient practice could result in complicate the resident's recovery as well as the likelihood of regression in physical capability of the resident. Findings include: Resident # 8 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, hypertension, fall on same level, weakness, dependence on wheelchair, and spinal stenosis. Review of the Automated Application for State Home Care Form 10-10SH electronically signed by the primary medical physician (staff #14) of the resident dated November 15, 2023 revealed the resident had participated in physical therapy to aid right-sided hemiplegia, had shown improvement and was now recommended by his primary care physician for a lower level of care such as discharge to home or assisted living as…

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 documentation, policy and procedure, the facility failed to ensure one resident (#7) was treated with dignity and respect by another resident (#25). The deficient practice could impact residents' emotional and psychological wellbeing. Findings include: -Resident #7 was admitted on [DATE] with diagnoses of quadriplegia, chronic kidney disease, and Type II Diabetes. The minimum data set (MDS) assessment dated [DATE] included brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact. Review of behavior analysis report revealed that resident #7 did not exhibit any behaviors during the month of April 2024. -Resident #25 was admitted on [DATE] with diagnoses of Alzheimer's disease, unspecified dementia, unspecified severity, with other behavioral disturbance. The care plan dated April 6, 2024 revealed that the resident had socially inappropriate/disruptive behavioral symptoms as evidenced by verbal…

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 an allegation of sexual abuse for one resident (#12) was completed. The deficient practice could result in residents not protected from further abuse and appropriate corrective action not taken. Findings include: Resident #12 was admitted on [DATE] with diagnoses of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side. The cognitive loss/dementia care plan dated February 20, 2024 revealed the resident was alert and oriented to person and place and semi-oriented to time; and that, the brief interview for mental status (BIMS) assessment indicated that the resident had a slight cognitive deficit in short-term memory, which may be tied-in with having a diagnosis of cerebral infarction. A progress note dated April 10, 2024 at 7:13 p.m. revealed that during a conversation, the veteran reported allegations of abuse…

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 documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#35) was free to exercise his rights regarding independent travel. The deficient practice could result in the resident not being able to exercise his rights without interference. The findings include: Resident #35 was admitted to the facility on [DATE] with diagnosis of functional quadriplegia. The annual minimum data set (MDS) dated [DATE], included a brief interview for mental status (BIMS) score of 13 indicating the resident was cognitively intact. The MDS also indicated that the resident has mild depression and trouble falling or staying asleep or sleeping too much. The MDS also included that the resident did not exhibit any behaviors. Review of resident #35 care plan initiated on 04/10/2023 and revised on 01/05/2024 stated the Veteran is able to make leisure choices known and structure time independently. Based on the MDS assessment, he states 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 clinical documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to ensure that three residents (#35, #42 and #55) was free to exercise their rights regarding independent travel. The deficient practice could result in the resident not being able to exercise his rights without interference and psychosocial harm. Findings Include: 1) Regarding Resident #35: Resident #35 was admitted to the facility on [DATE] with diagnosis of functional quadriplegia. The annual minimum data set (MDS) dated [DATE], included a brief interview for mental status (BIMS) score of 13 indicating the resident was cognitively intact. The MDS also indicated that the resident has mild depression and trouble falling or staying asleep or sleeping too much. The MDS also included that the resident did not exhibit any behaviors. Review of resident #35 care plan initiated on 4/10/2023 and revised on 1/5/2024 stated the Veteran is able to make leisure choices known and structure time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and review of facility policies, the facility failed to ensure one resident (#4) was transferred safely using a Hoyer or similar lift in a manner consistent with professional standards. This deficient practice could result in accidental injuries related to Hoyer transfers. Findings include: Resident #4 was admitted [DATE] with pertinent diagnoses including quadriplegia, hypertension, depression, peripheral vascular disease, weakness, and pressure ulcers. A review of the quarterly MDS (minimum data set) dated August 24, 2023 revealed the resident has a BIMS (brief interview for mental status) of 12, indicating mild cognitive impairment. A review of the care plan created June 15, 2021, revealed that the resident requires assistance with activities of daily living (ADL's) related to a spinal cord injury. The last care plan revision was noted to be November 27, 2023. A review of progress notes on October 6, 2023 revealed a nursing note detailing an incident where two…

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 interviews, and policy and procedures, the facility failed to ensure one medication cart was locked, when left unattended. The deficient practice could result in residents, staff, and visitors having access to medications. Findings include: An observation of a medication cart on Hall D on the first floor was conducted on December 18, 2023 at 12:10 p.m. The medication cart was unlocked and was parked outside and right next to the resident room door where the LPN was administering medications to the resident inside the room. When the LPN exited the resident room, she stated that she left the medication cart unlocked while she was in the resident's room administering medications. The LPN also said that leaving the medication cart unlocked creates a risk because the residents will have access to the medications inside or contained in the cart. An interview was conducted on December 18, 2023 at 1:59 p.m. with a registered nurse (RN/staff #46) who stated that the medication cart should be locked when the nurse is not present; and that, if the cart was 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.

Based on observation, staff interviews, and facility documentation and policy review, the facility failed to ensure proper hand hygiene was implemented during suprapubic catheter care and flushes. The sample size was one. The deficient practice could result in infection. Findings include: A suprapubic catheter care and catheter flushing observation was conducted with a licensed practical nurse (LPN/staff#2) on November 1, 2023 at 3:20 p.m. During the observation, the LPN sprayed the cleansing gauze with a solution from the treatment cart and had prefilled the syringe for irrigation prior to entering the resident's room, donned a clean pair of disposable gloves, and then touched the resident. However, the LPN did not perform hand hygiene prior to donning the gloves. The LPN then removed the old soiled split gauze from the suprapubic catheter site, cleansed the site with the pre-moistened gauze, and then proceeded to apply the new sterile split gauze. The LPN proceeded to perform the catheter flush, separating the catheter from the draining bag tubing using the same pair of gloves…

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 procedures, the facility failed to notify resident (#5) in writing regarding the reason for transfer to the hospital on two different dates and did not notify the office of the ombudsman. Findings include: Resident #5 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, epilepsy, and an anxiety disorder. A progress note dated March 19, 2023 at 12:02 p.m. revealed that the nurse manager( RN/staff # 143) checked on the resident who was taking a nap. Upon speaking with the physician about the resident's vital signs, the physician made a determination to start an IV with normal saline on the resident. Upon trying to rouse the resident to get verbal consent for the IV, she was unarousable. The nurse sternal rubbed the resident for about about 15 seconds before she was aroused. After she opened her eyes, she mumbled unintelligible words and closed her eyes again. She did not respond to her name being called. She was sent 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.

Based on observation, staff interviews, and review of the facilities policy the facility failed to secure hazardous chemicals. The deficient practice could result in an increased risk of harm to residents. The census was 82. Observations were made on 07/19/2023 at 12:00 PM and 07/20/2023 at 11:36 AM of the kitchen area. The door to the kitchen supply room was propped open and a silver metal cabinet was observed. The door to the cabinet was open. The cabinet contained approximately 15 bottles that appeared to be cleaning products. The supply room was adjacent to areas containing cooking utensils, cups and trays. A list of the chemicals in the unlocked, open cabinet was provided. The list included; Ecotemp ultra Klene- Listed as Danger, causes severe skin burns and eye damage. Greasestrip Plus- Listed as Danger, causes severe skin burns and eye damage. Laundry Destainer- Listed as Danger, causes severe skin burns and eye damage. Lime-A-Way- Listed as Danger, causes severe skin burns and eye damage. Oasis 115 XP- Listed as Danger, causes severe skin burns and eye damage. Oasis 137…

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 records, staff interviews, resident interview, review of facility documents, policy and procedure, and observation of current practice, the facility failed to ensure one resident (#15 )was free from abuse. The deficient paractice could allow residents to be abused. The findings include: -Resident #15 was initially admitted to the facility on [DATE] and re-admitted on [DATE] for diagnoses that included incomplete quadriplegia, adjustment disorder with anxiety, and infection and hydronephrosis. The MDS (Minimum Data Set) assessment dated [DATE] included a BIMS (Brief Interview of Mental Status) score of 15, indicating the resident was cognitively intact. A progress note dated July 10, 2023 revealed that resident reported that a certified nursing assistant (CNA) pinched his left cheek very hard for no reason and it was sore. The note revealed that the CNA had previously pinched the residents cheek after the resident's call light clip pinched the CNA's finger. Review of an email from staffing…

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 procedures, the facility failed to give resident (#5) a bed-hold policy when transferred to the hospital on two different dates. Findings include: Resident #5 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, epilepsy, and an anxiety disorder. A progress note dated March 19, 2023 at 12:02 p.m. revealed that the nurse manager(RN / Staff # 143) checked on the resident who was taking a nap. Upon speaking with the physician about the resident's vital signs, the physician made a determination to start an IV with normal saline on the resident. Upon trying to rouse the resident to get verbal consent for the IV, she was unarousable. The nurse sternal rubbed the resident for about about 15 seconds before she was aroused. After she opened her eyes, she mumbled unintelligible words and closed her eyes again. She did not respond to her name being called. She was sent to the hospital via 911. The minimum data set (MDS) 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.

Based on observations, staff interviews, facility documentation, and policy reviews, the facility failed to ensure staff members wore hair restraints, food items were labeled and dated, the dishwasher sanitation was monitored, kitchenware was clean and dry, and that a fan was clean. The deficient practice could increase the risk of foodborne illness. Findings include: Regarding hair restraints During the initial kitchen observation conducted on May 23, 2022 at 9:01 a.m., two staff members were observed not wearing a hair restraint. Another staff member did not have all of her hair restrained. She had part of her hair in a bun on top of her head covered by a hairnet, but the rest of her hair was exposed and hanging around her neck. A second observation of the kitchen was conducted on May 25, 2022 at 10:05 a.m. During this observation, a staff member who was in the kitchen and washing dishes was observed without a hairnet. In an interview conducted with the dietary manager (staff #257) on May 25, 2022 at 12:25 p.m., he stated that staff have to wear hairnets while in the kitchen. 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.

Based on staff interviews and facility documents, the facility failed to develop and implement their policy to ensure that contracted staff were vaccinated for COVID-19. The deficient practice may result in other staff not being vaccinated for COVID-19. Findings include: A request was made on May 25, 2022 for the COVID-19 vaccination status records for the pest control company and food vendor company that the facility contracted with. Review of the pest control logs revealed the facility was serviced by the company from May 2021 through March 2022. Review of food vendor delivery logs revealed 13 deliveries were made to the facility from March 2022 through May 2022. During an interview conducted with the Infection Preventionist (IP/staff #230) on May 25, 2022 at 3:00 PM, she stated a call was made to the pest control company and she was told that they were not going to give the facility their employee medical information. Regarding the food vendor company, the IP stated they come to the back dock and do not come into the building. In an interview conducted with the Administrator…

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 (#42) and/or their representative were informed of the risks and benefits of a psychotropic medication prior to receiving the medication. The sample size was 6. The deficient practice could result in residents and/or their representatives not being aware of the risks and benefits of psychoactive medications. Findings include: Resident #42 was admitted to the facility on [DATE] with diagnoses that included colon cancer, liver cancer, prostate cancer, splenic flexure cancer, anxiety, depression, mood disorder, schizoaffective disorder, Parkinson's disease, dementia, and diabetes. Review of the physician's orders revealed an order dated February 4, 2022 for Lorazepam concentrate 2 milligrams per milliliter (mg/ml); administer 0.25 ml orally every 6 hours as needed for anxiety/restlessness. Review of the Medication Administration Records (MARs) for February 2022 through April 2022, revealed Lorazepam 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 facility policy, the facility failed to ensure one resident's (#42) Preadmission Screening and Resident Review (PASARR) was updated after 30 days. The sample size was one resident. The deficient practice increases the risk that individuals identified with mental disorders may not be evaluated to receive care and services in the most integrated setting appropriate to their needs. Findings include: Resident #42 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, schizoaffective disorder, Parkinson's disease, dementia without behavioral disturbance, and adjustment disorder with mixed anxiety and depressed mood. Review of a physician's order dated January 4, 2022 revealed the resident was to be admitted to hospice services. Review of the resident's care plan, initiated on January 10, 2022, revealed the resident was admitted to hospice services with a diagnosis of malignant neoplasm of the colon as well as diagnoses of dementia…

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, facility documentation, and policy and procedures, the facility failed to provide evidence that mouth care was consistently provided to one resident (#54). The sample size was 2. The deficient practice could result in residents needing assistance not being provided oral care. Findings include: Resident #54 was admitted to the facility on [DATE], with diagnoses that included functional quadriplegia with left side hemiparesis, lumbar spinal stenosis, and neuromuscular dysfunction of the bladder. Review of an Activity of Daily Living (ADL) care plan initiated on August 6, 2020 revealed the resident had self-care deficits related to hemiplegia of the left side and required assistance with ADLs. The goal was to have ADL needs met with staff assistance as needed. The approach stated the resident requires one-person assistance with mouth care. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status…

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, resident and staff interviews, and policy review, the facility failed to ensure a broken piece of kitchen equipment did not contaminate the food of one resident (#31). The deficient practice could put residents at risk of injury from non-food items in their food. Findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses that included chronic congestive heart failure, type 2 diabetes with hyperglycemia, bipolar disorder, chronic obstructive pulmonary disease, and shortness of breath. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating he was cognitively intact. A social service progress noted dated May 2, 2022 revealed the resident recently found a piece of metal in his cream of wheat. The note identified the metal as a brillo pad. The note also revealed the resident brought up the issue with the dining hall manager but the manager informed the resident that…

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 a pharmacist recommendation was reviewed and acted upon for one resident (#30). The sample size was 5 residents. The deficient practice could result in medication irregularities that go unnoticed or are not acted upon. Findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, Post Traumatic Stress Disorder (PTSD), and peripheral vascular disease. Review of the physician's orders revealed an order dated June 18, 2021 for sertraline (an antidepressant medication) 50 milligrams (mg) per day for major depressive disorder. The resident's mood care plan, initiated on June 25, 2021, indicated that the resident had a diagnosis of major depressive disorder. The interventions included a psychiatric consult as needed, and to monitor for any changes. Review of the Medication Administration Record (MAR) for June 18, 2021 through December 2021 revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure a PRN (as needed) psychotropic medication had a stop date within the required timeframe for one resident (#13). The sample was five residents. The deficient practice could result in residents receiving medication that is not necessary. Findings include: Resident #13 was admitted on [DATE] with diagnoses that included Parkinson's disease, delirium due to known physiological condition, other Alzheimer's disease, unspecified psychosis not due to a substance or known physiological condition, restlessness, and agitation. Review of the physician's orders revealed the following: -An order with a start date of December 5, 2021 for Lorazepam (a benzodiazepine for anxiety) 0.5 milligrams (mg) tablet through the G-tube (gastrostomy tube) crushed every 6 hours as needed (PRN). This order was discontinued on December 30, 2021. -An order with a start date of December 30, 2021 for Lorazepam 0.5 mg tablet through the G-tube…

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.