Desert Peak Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure services/treatment and accommodation of needs are provided per plan of care and physician orders for one resident (#2) regarding the need for a bariatric bed and opioid medication. The deficient practice could result in residents not receiving the services as outlined in their care plan. Findings include: Resident #2 was admitted on [DATE] with diagnoses that included borderline personality disorder, chronic systolic (congestive) heart failure, chronic pain syndrome, major depressive disorder, recurrent severe without psychotic features, type 2 diabetes mellitus with diabetic neuropathy, unspecified, morbid (severe) obesity due to excess calories, anxiety disorder, unspecified, opioid dependence. Review of the Care Plan date-initiated February 19, 2025 revealed the resident had a focus for bowel and bladder incontinence. Interventions included providing peri-care after each incontinent episode 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 facility policy, the facility failed to ensure one resident (#2) was provided services consistent with professional standards of practice. The deficient practice could result in unmanaged pain for the resident. Findings include: Resident #2 was admitted on [DATE] diagnoses of borderline personality disorder, chronic systolic (congestive) heart failure, chronic pain syndrome, major depressive disorder, recurrent severe without psychotic features, type 2 diabetes mellitus with diabetic neuropathy, unspecified, morbid (severe) obesity due to excess calories, anxiety disorder, unspecified, opioid dependence. Review of the Care Plan date-initiated February 19, 2025 revealed the resident had a focus for chronic pain requiring opioid medication. Interventions included Administer medications and analgesia as per orders, anticipate the resident's need for pain relief and respond immediately to any complaint of pain. A review of the admission Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, interviews and policy review, the facility failed to provide a designated room to accommodate residents dining and activities while undergoing construction. The deficient practice could result in resident's individual needs and preferences not accommodated. Findings included: During a complaint survey on February 11, 2025 at 1:08 pm, the administrator/Staff #20 stated that one of their locked unit, had an emergency plumbing issue last week, Monday, so they moved residents from that unit to their open rooms throughout the facility and for the other remaining residents, they were moved in the dining room/activity room, day care room and medical record room. On February 11, 2025 at 1:18 pm the administrator ushered the surveyor to the dining room/activity room which is currently being use for ten resident beds and another room across the hallway from the dining room is the medical record room and day care room which is currently being use to place seven resident beds.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, interviews and policy review, the facility failed to ensure safe and comfortable environment for residents. The deficient practice could impact the residents' safe, sanitary, and homelike environment. Findings included: During a complaint survey on February 11, 2025 at 1:08 pm, the administrator/Staff #20 stated that one of their locked unit, had an emergency plumbing issue last week, Monday, so they moved residents from that unit to their open rooms throughout the facility and for the other remaining residents, they were moved in the dining room/activity room, day care room and medical record room. On February 11, 2025 at 1:18 pm the administrator ushered the surveyor to the dining room/activity room which is being use for ten beds for ten residents and another room across the hallway from the dining room is the medical record room and day care room which is being use to place seven beds for seven residents. An interview was conducted on February 11, 2025 at 1:40 pm with 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 clinical record review, residents and staff interviews, facility documentation and policies and procedures, the facility failed to ensure two residents (#1 and #3) were free from abuse. The deficient practice could result in continued abuse to residents. Findings included: Regarding Resident #1: -Resident #1 was admitted to the facility on [DATE] with diagnoses of Schizoaffective disorder, bipolar type, dementia and dysphagia. Review of resident's baseline care plan dated January 23, 2025 revealed skin is intact. Review of care plan dated January 25, 2025 revealed resident is at risk for behaviors related to Schizophrenia. The interventions included assist the resident to develop more appropriate methods of coping and interacting, encourage the resident to express feelings appropriately, explain all procedures to the resident before starting, allow the resident time to adjust to changes, and intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert…

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 (#93) with a diagnosis of a serious mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review. The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: Resident #96 was admitted to the facility on [DATE] with diagnoses of Vascular Dementia Depression, and Anxiety. Review of the Pre-admission Screening and Resident Review (PASARR) Level I Screening dated February 9, 2024 completed prior to admission, revealed the resident did not have primary diagnosis of dementia and no diagnoses of a serious mental illness and mental disorder. Further review of the Level I Screening revealed mental disorders include anxiety disorder and depression (mild or situational) which were not checked. The quarterly admission Minimum Data Set (MDS) assessment dated [DATE] included an active diagnosis…

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 review, staff interview, and the job description, the facility failed to ensure that the activities program was directed by a qualified professional. Findings include: A review of the personnel file for the activities director (AD/Staff #1) revealed that she was hired on December 4, 2024 to be the full time AD. However, review of the personnel file did not reveal evidence that staff #1 possessed the qualifications to be the AD. Review of the facility's job description for the activities director position revealed that an activities director certification was required. Further review of the requirements revealed that experience in a social or recreation program within the last five (5) years or must be a qualified occupational therapist or occupational therapy assistant licensed by the state and is eligible for certification as a recreation specialist or as an activity professional. An interview was conducted on January 10, 2025 at 11:56 a.m. with the activities director (staff #1). Staff #1 stated she had been serving as the AD for a month and was still…

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, resident and staff interviews, and a review of policies and procedures, the facility failed to ensure insulin treatment was provided in accordance with professional standards of practice for one of six sampled residents (#89), as ordered by the physician. This deficient practice could have resulted in uncontrolled blood sugar levels. Findings include: Resident #89 was admitted on [DATE], with diagnoses that included Dementia and Type 2 Diabetes Mellitus. An order summary dated December 12, 2024, indicated that insulin should be administered per sliding scale: if 0-200 = 0; 201-250 = 2; 251-300 = 4; 301-350 = 6; 351-400 = 8; 401-450 = 10; 451-999 = 12 (Notified MD), subcutaneously before meals and at bedtime for DM. The order summary revealed that the resident should be administered Insulin Lispro per sliding scale. A Medication Administration Record (MAR) dated December 18, 2024, revealed that the resident was not administered an 8 PM insulin dose for a blood sugar level of 280…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one resident (#117) was transported to and from dialysis in a timely manner. The deficient practice could result in the full dialysis treatment not being administered, which could result in a decline in the resident's health. Findings include: Resident #117 was admitted to the facility on [DATE] with diagnoses that included Acquired absence of the right and left legs below the knee, type 2 diabetes mellitus with diabetic neuropathy, and end stage renal disease. Review of the care plan revealed a focus initiated on November 8, 2023, indicating that Resident #117 needs dialysis, with interventions including to encourage the resident to go to scheduled dialysis appointments and that the resident may attend dialysis without an escort. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The follow-up instruction…

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 ensure that liquid diet order for one of two sampled residents (#23) was administered as ordered by the physician. The deficient practice could result in resident's assessed dietary needs not met. Findings include: Resident #23 was readmitted to the facility on [DATE] with diagnoses of dysarthria following other cerebrovascular disease, paralysis of bilateral vocal cords and larynx, dysphagia oropharyngeal phase, dysarthria and anarthria. A physician order dated November 21, 2023 included for regular pureed texture with honey/moderate thick consistency. A physician order dated November 23, 2023 revealed an order for the resident to be upright in chair for all meals, 1:1 assist with all oral intake, giving small bites; alternating bites/sips; and for resident to tolerate liquids via a teaspoon or managed sips by straw only to facilitate single sips and prevent silent aspiration. Review of a quarterly…

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 ensure two residents (# 8, 12) out of five sampled remained free from abuse. The deficient practice may result in physical and/or psychosocial harm to residents as an outcome of abuse. Findings include: -Regarding Resident # 8 and Resident # 26 Resident # 8 was admitted into the facility on July 05, 2024 with diagnoses that included bipolar disorder, unspecified dementia with agitation, depression, and unspecified mood disorder. A review of the admission MDS (minimum data set) assessment dated [DATE] for Resident # 8 revealed a BIMS (brief interview of mental status) score of 3, which indicated the resident was severely cognitively impaired. Resident # 26 was admitted into the facility on June 14, 2021 with diagnoses that included schizophrenia, secondary parkinsonism, major depressive disorder, and auditory hallucinations. A review of the admission MDS assessment dated [DATE] for Resident # 26 revealed…

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

Based on observations, staff interviews, and policy review, the facility failed to ensure staff followed infection control standards related to personal protective equipment (PPE). The deficit practice could result in transmission of infection. Universe was 130. Findings include: An observation was conducted on October 24, 2023 at 9:00 AM, of multiple resident rooms with enhanced barrier precautions. Observation revealed glove boxes and hand sanitizing stations were on walls in the hallway, but no PPE carts were outside of rooms. It was also observed that within these rooms were two washable PPE gowns hanging on hooks. However, some rooms had multiple gowns stacked on top of each other hanging from hooks. All gowns were touching each other in every room. Further observations showed that neither the hooks or the gowns were labeled. It was observed that a Licensed Practical Nurse (LPN staff# 297) told (CNA staff #342), to get a hazard bag and remove the gowns from the room. An Interview was conducted on October 25, 2023 at 8:29 AM, with Regional Resource Nurse/Infection Control…

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 resident and staff interviews, the facility investigation report and documents, clinical record review, and policy review, the facility failed to ensure one resident (#123) was treated in a dignified manner. The deficient practice could negatively impact the psychosocial well-being of residents. The universe was 130 as all residents could be affected, the sample was one. Findings include: Resident (#123) was admitted to the facility on [DATE] with diagnoses that included Type I Diabetes Mellitus with Diabetic Neuropathy, Unspecified, Acquired absence of right leg below knee, Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs, End-stage renal disease. During the initial part of the survey, an interview was conducted with resident (#123) on October 23, 2023 at 11:40 AM, who stated that CNA (certified nursing assistant) identified as (Staff #34) had come into his room, after he had turned on his call light. Resident (#123) stated the CNA turned off the call…

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, and resident and staff interviews the facility failed to ensure a resident (#6) had the means to communicate with staff, by failing to ensure the call device was accessible to the resident. The deficient practice can result in residents' needs not being met in a timely manner. The universe was 130 and the sample was one. The findings include: Resident #6 was readmitted to the facility on [DATE] with diagnoses that included coronary artery disease, hypertension, gastroesophageal reflux disease, anxiety disorder, and manic depression. The admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12 which indicated the resident had moderate impaired cognition. During the initial observation of resident #6 conducted on October 23, 2023 at 10:07 AM, the call device was observed on the top of the light fixture, and out of resident's reach. During an interview with the resident #6 conducted on October 23, 2023 at 10:07 AM, he stated that the call…

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 one resident (#10) had the correct advance directive in place. The deficient practice could result in residents not being allowed to make their own medical decisions. The universe is 130 and the sample is one. Findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease, chronic kidney disease, and unspecified protein-calorie malnutrition. Review of the clinical record revealed an advanced directive statement dated February 26, 2022 for a do not resuscitate (DNR) status. Review of the clinical record also revealed an advanced directive statement form that was not completed, signed or dated with documentation of refusal to sign. Review of the order summary revealed an order dated August 5, 2022 for full code status. The care plan dated May 12, 2023 revealed that the resident was a full code status. Interventions included 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 observations, staff interviews, and policy reviews, the facility failed to ensure that maintenance and comfortable interior was provided for 1 resident (#106). The deficient practice could result in resident rooms not having a homelike environment. The universe was 130 the sample was one. Findings include: An interview was conducted with resident #106 on October 23, 2023 at 11:42 AM. Resident # 106 stated that the baseboards in his room is coming off and that there is a huge cut out hole in his room where cockroaches are coming out. An observation was conducted of resident #106's room on October 23, 2023 at 11:42 AM. An area approximately 2-feet in high and 1-foot wide was discovered on the wall by the foot of the A-side bed. An additional observation was conducted of resident #106's room on October 25, 2023 at 8:24 AM. It revealed that the hole on the wall was still present. However, no evidence of pest coming out of the hole was found. An interview with a Certified Nursing Assistant (CNA/staff #118) was conducted on October 25, 2023 at 8:24 AM. Staff # 118 stated 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 record reviews, facility documentation, staff interviews, and policy review, the facility failed to ensure that allegations of misappropriation of resident property were reported to the State Agency and that the results of the investigations were submitted to the State Agency within the required time frame for one resident (#123). The universe was 130 the sample was one. Findings include: Resident (#123) was admitted to the facility on [DATE] with diagnoses that included Type I Diabetes Mellitus with Diabetic Neuropathy, Unspecified, Acquired absence of right leg below knee, Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs, End-stage renal disease An admission MDS (Minimum Data Set) assessment dated [DATE] revealed the resident scored 15 on a BIMS (Brief Interview for Mental Status) assessment, which indicated the resident was cognitively intact. A progress note dated 09/30/2023 1:40 AM, revealed resident stated the last time he had seen his card…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review and staff interviews the facility failed to ensure that all transfer/discharge notifications were made for one resident (#13). The deficient practice could lead to notifications of resident transfer/ discharge not being made to all required parties. The universe was 130 the sample was 1. Findings include: Resident #13 was initially admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses that includes schizophrenia, bipolar disorder, dementia, anxiety disorder, personality disorder, and pseudobulbar affect. A nurse practitioner order dated September 22, 2023 revealed an order to send the resident to the hospital immediately for hypoxia. Review of the resident's clinical record did not reveal that a transfer to hospital form (e-Interact) was completed for the incident on September 22, 2023. A progress note dated September 22, 2023 revealed that the resident was sent to the emergency room immediately and that the Director of Nursing and Administrator were…

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, an interview, and policy, the facility failed to provide one resident (#13) and/or the resident's representative with bed-hold policy information before a transfer to the hospital. The deficient practice could result in residents being unaware of their bed-hold rights. The universe is 130 the sample is one. Findings include: Resident # 13 was initially admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses that includes schizophrenia, bipolar disorder, dementia, anxiety disorder, personality disorder, and pseudobulbar affect. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment. Review of nursing note dated September 22, 2023 revealed that the resident left with Emergency Medical Services (EMS) and that the resident was sent to the hospital. A progress note dated September 23, 2023 indicated that the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews and facility policy and procedures, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) level I was completed accurately and a level II was sent to the state for determination for one resident (#13). The deficient practice could result in specialized services not being identified and provided to residents. The Universe was 22 the sample was 1. Findings include: Resident #13 was initially admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses that includes schizophrenia, bipolar disorder, dementia, anxiety disorder, personality disorder, and pseudobulbar affect. Review of the resident's facesheet revealed the following new diagnoses and date of onset: dementia, with other behavioral disturbance dated January 3, 2023 and undifferentiated schizophrenia dated January 15, 2023. Review of the PASRR Level I Screening Tool dated March 5, 2023 revealed the form was not adequately filled out. Section B. Mental…

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 1. Based on clinical record review, staff interviews and contract review, the facility failed to ensure one resident (#43) received treatment and care in accordance with professional standards of practice. The facility failed to ensure communication was provided to the family of the care and services provided by hospice. This failure has the potential for confusion between resident's family, the facility and the hospice provider. The universe is 130 the sample was 2. Findings: Resident (#43) was admitted to the facility on [DATE] with diagnosis that included, Unspecified Dementia, Unspecified severity; without behavioral disturbance, Psychotic Disturbance, Mood Disturbance and anxiety, Cerebrovascular disease; unspecified, Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side. Review of the quarterly MDS dated [DATE] Section O - Special Treatments, Procedures, and Programs revealed resident (#43) is receiving Hospice Care. Review of the physicians orders revealed resident…

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

Based on observations, staff interview, and policy reviews, the facility failed to ensure pharmaceutical services were adequately provided for medication administration for four residents. The census was 130. This deficient practice could result in adverse effects in the facilities residents. Findings include: During observation of medication pass with a Licensed Practical Nurse (LPN/staff #297) conducted on October 24, 2023 at 7:00 AM, the LPN administered medications to four residents (#82, #28, #58, #127). In each medication prep on the cart, the LPN verified the right resident from the resident's electronic medial record photograph, right medication, right dose, and right route per the order. In each bedside encounter, the LPN kindly greeted each resident and assisted each resident in sitting in a fowlers or semi-Fowlers position but the LPN did not verify each resident's identity by checking the identification band at bedside before giving the resident medications. A review of each resident's face sheet, BIMS score, and orders revealed: Resident #82: admission October 20, 2020…

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 the facility policy and procedures, the facility failed to ensure one resident (#10) received required specialized services. The deficient practice could result in residents not being able to obtain the services needed to achieve medical/therapy goals. The Universe was 130, the sample is 1. Findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, chronic kidney disease, and acquired absence of left leg below the knee. The minimum data set (MDS) dated [DATE] revealed that the brief interview score of 10 indicating the resident has a moderate cognitive impairment. It also included that the resident used a wheelchair and received training on walking with prostheses for 3 days out of the 7-day look-back period. Review of the order summary report revealed: September 2, 2022, cleanse right stump daily with ¼ Dakin's soaked gauze apply thin layer of medihoney to medial and lateral open areas…

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, and the State Agency (SA) complaint tracking system, the facility failed to ensure one resident (#1) was provided with treatment and care related to shearing in accordance with professional standards of practice. The deficient practice could result in non-healing of shearing and development of complications. Findings include: Resident #1 was re-admitted on [DATE] with diagnoses of chronic kidney disease stage 5, dependence of renal dialysis, schizoaffective disorder bipolar type, and chronic obstructive disease. Review of a care plan initiated on January 17, 2023, revealed the resident required extensive assistance of two with bathing, bed mobility, to turn/reposition and transfers related to chronic kidney disease, and schizoaffective disorder. It also included that the resident was frequently incontinent of bladder, occasionally incontinent with bowel and had potential for pressure ulcer development. Interventions…

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 Bases on clinical review, staff interviews, and policy and procedure, the facility failed to ensure consistent pressure ulcer treatments were provided to one of 3 sampled resident (#2) as ordered by the physician. The deficient practice could result in worsening of pressure ulcers and/or development of new pressure ulcers. Findings include: Resident #2 was admitted on [DATE] with diagnoses of dementia, osteomyelitis of sacral-coccygeal region, stage IV pressure ulcer of sacral region, type 1 diabetes mellitus and stage III pressure ulcer of right and left buttocks. The care plan initiated on September 15, 2022 included the resident had a stage IV pressure ulcer to sacrum. Interventions included low air loss mattress, monitor for progression and wound care treatments as ordered. The skin care plan revised on March 28, 2023 included the resident had potential for impaired skin integrity. Interventions included to monitor/document location, size and treatment of skin, report abnormalities, failure to heal,…

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 and staff interviews the facility failed to ensure medications were administered as ordered by a physician for one resident. The census was 122. This deficient practice could result in adverse effects to the resident. Findings include: Resident #79 was admitted on [DATE] with diagnoses that included hypertension. The quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview of mental status (BIMS) score of 9 that indicated the resident had moderately impaired cognition. The review of the clinical record revealed a physician order included an order for Lisinopril (antihypertensive) 10 mg (milligram) tablet give 1 tablet by mouth and to hold for systolic BP (blood pressure) of less than 105. During observation of medication pass with a licensed practical nurse (LPN/staff #24) conducted on April 26, 2023 at 7:52 a.m., the LPN administered Lisinopril 10 mg tablet to without taking the resident's BP prior to administration of the medication 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 observations and staff interviews, the facility failed to ensure medication error rate was less than 5%. The failure to prepare or administer 2 medications correctly of 26 medication observations resulted in a medication error was 7.69%. The deficient practice could result in additional medication errors. Findings include: -Resident #10 was admitted on April7, 2015 with diagnoses of hypertension, schizophrenia, drug-induced tremor and other chronic pain. The clinical record revealed a physician order for Lactulose (laxative) 10 mg (milligrams)/15 ml (milliliter) give 30 ml by mouth. During observation of medication pass with a licensed practical nurse (LPN/staff #24) conducted on April 26, 2023 at 7:52 a.m., the LPN prepared 15 ml of Lactulose and proceeded to administer the medication to resident #10. However, resident #10 refused the medication. A review of the physician order for Lactulose was conducted with the LPN who stated that there wasa potential medication error had he administered 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.