Granite Creek Health & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and policy review, the facility failed to ensure the areas used for preparing, cooking and serving food were cleaned and maintained sanitary in accordance with professional standards for food service safety. The deficient practice could result in foodborne illnesses among residents. Findings include: On September 30, 2024 at 10:51 a.m., an observation was conducted of the facility's kitchen with the dietary supervisor (staff #14). At this time, the stove and stacked oven was observed to have grease build-up and burned debris under and behind the stove and stacked oven. Also, there was burned debris on the metal shelf on the front side of the deep fryer. Crackers and an applesauce cup were observed on the floor in the dry storage room. During this observation, staff #14 stated that cleaning of the kitchen happens daily, reported that the expectation in the kitchen is proper hand hygiene to prevent foodborne illness, that also includes hair and beard covering. Temperature…

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 and policy review, the facility failed to adhere to infection control policies while serving, preparing, and distributing food to residents, and while providing care to one resident (#65). The deficient practices could result in foodborne illnesses among residents and the transmission of infection. -Regarding food preparation and distribution to residents: On September 30, 2024 at 10:51 a.m., an observation was conducted inside the facility's kitchen with the dietary supervisor (staff #14) who did not have a beard covering. At that time, staff #14 reported that the expectation in the kitchen is proper hand hygiene to prevent foodborne illness, that also includes hair and beard covering. On October 1, 2024 at 10:33AM, an observation was conducted of the facility's kitchen with the dietary supervisor (staff #14), cook (staff #123), and dietary aide (staff #11). At that time, staff #14 was observed without a beard covering. Staff #123 was observed at the sink rinsing their…

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, record review, interviews, and facility policy review, the facility failed to ensure respiratory services were provided according to professional standards, specifically that an order was obtained for the use of oxygen, for one resident (#339). The deficient practice could result in residents receiving unnecessary supplemental oxygen, and the provider not being aware of the resident's status. -Findings include: Resident #339 was admitted into the facility on September 27, 2024, with diagnoses that included congestive heart failure, hypertension, and coronary artery disease. A review of the resident's hospital discharge orders dated September 27, 2024 revealed no orders for oxygen use. The admission minimum data set assessment (MDS) had not yet been completed due to the resident's newly admitted status. Review of the facility's physician orders conducted on September 30, 2024 at 1:19 PM, revealed no evidence of orders for oxygen administration. On October 01, 2024 at 10:44 AM an additional review of resident #339 physician orders revealed no evidence of orders…

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 review of facility policy and procedure, the facility failed to ensure dental needs were met for one sampled resident (#58). The deficient practice could result in residents not receiving necessary services for oral and dental care. Findings include: Resident #58 was admitted to the facility on [DATE] with diagnoses that included subluxation of the right shoulder joint, sequelae of cerebral infarction, hypertension, major depressive disorder, hyperlipidemia, and acute kidney failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. Further review of the MDS did revealed that Section L - Oral/Dental Status was blank. Review of a physician order dated December 20, 2023 revealed dental consultation and treatment as needed. Review of the quarterly Nutrition evaluation dated March 19, 2024 revealed that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and record review, the facility failed to ensure one resident's (#58) dietary needs were met. The deficient practice could place residents at risk of malnutrition and dissatisfaction with their meals. Findings include: Resident #58 was admitted to the facility on [DATE] with diagnoses that included subluxation of the right shoulder joint, sequelae of cerebral infarction, hypertension, major depressive disorder, hyperlipidemia, and acute kidney failure. Review of the nutrition care plan initiated on December 21, 2023 indicated a goal in which resident will maintain adequate nutritional status by maintaining weight with no signs and symptoms of malnutrition. Interventions included: provide, serve diet as ordered and registered dietitian to evaluate and make diet change recommendations PRN (as needed). Further review of the care plan did not indicate or address the resident's gluten allergy. A quarterly Nutrition evaluation dated March 19, 2024 revealed that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, staff interviews and facility policy review, the facility failed to provide resident (#1) with physician ordered necessary wound care services. The deficient practice can put resident at risk for wound infection. Findings include: Resident #1 was admitted on [DATE], with diagnoses that included acute kidney failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic chronic kidney disease, end stage renal disease, and recent surgical history of resection of the perforated bowel and placement of an ostomy. The Care plan initiated on July 21, 2024 stated the resident has actual impairment to skin integrity related to abdominal surgery present on admission. The goal stated that the resident will not have rehospitalization within 30 days. The interventions included to float heals, monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to 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 review, resident and staff interviews, and review of facility documentation and policy, the facility failed to ensure that medication was available for administration as ordered by the physician for one resident (#1). The deficient practice could result in the resident not receiving the needed medication. Findings include: Resident #1 was admitted on [DATE] with diagnoses of other seizures, hypertension, and neuropathy. A hospital progress note dated 5/21/2024 revealed that the resident had a history of myoclonic seizures; and, had tried Keppra (anti-seizure) in the past but could not tolerate this. The hospital clinical summary dated 5/23/2024 included that the resident had a diagnosis of seizure disorder. It also included to continue clonazepam 1 mg by mouth once a day at bedtime. A physician order dated 5/23/2024 included for clonazepam 1 mg at bedtime for anxiety AEB (as evidenced by) restlessness. The facility medication administration record (MAR) for 5/23/2024 revealed 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, resident and staff interviews, review of facility documentation and policy, the facility failed to ensure that infection control guidelines related to oxygen use was followed for one resident (#2). The deficient practice could result in the spread of spread of disease to residents. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses of primary pulmonary adenocarcinoma (lung cancer) and dyspnea. A physician order dated 6/19/2024 included for 1-5 liters of oxygen as needed via nasal cannula to keep oxygen saturation greater than 90% for shortness of breath related to ineffective gas exchange. Another physician order dated 6/19/2024 included to change oxygen tubing every night shift and as needed. The daily skilled note dated 6/20/2024 revealed that the resident was alert and oriented x3; and that, the resident had no respiratory treatments. The physician admission progress note dated 6/20/2024 included that the resident was alert, ill-appearing, had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, staff interviews, personnel files, and facility policy, the facility failed to ensure that one resident (#5) received treatment and care in accordance with professional standards of practice. This deficient practice may result in resident not receiving trearment and care. Findings include: Resident #5 was admitted [DATE] with pertinent diagnoses including Ischemic cardiomyopathy, atrial fibrillation, stage 4 chronic kidney disease, diabetes mellitus type 2, hypertension, and hyperlipidemia. Review of the facility assessment dated [DATE], revealed care required by resident populations include residents who require assistance with bed mobility and transfers, and some who require total mechanical lift transfers, and some who are independently mobile. It further states that some residents are ones who can bear some weight, and who require assistance with sit-stand lift transfers. Types of assistance provided include but are not limited to bathing, showers, responding 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 the facility's policy, the facility failed to ensure that all resident shower rooms were in good repair. Findings include: During an initial observation and walk-through of both shower rooms conducted with the Maintenance Director (staff #10) on January 24, 2024 at 2:40 p.m., the following was observed: - Area 100/200 shower room only had 2 out of 5 shower stalls functional. - Area 100/200 shower room had an area on the tile floor that was either dirty or stained/discolored. - Area 300/400 shower room also only had 3 out of 5 shower functional stalls. - Area 300/400 shower room had cracked tiles on both the floor and lower wall of shower stalls. During an interview with the Maintenance Director (Staff #10) conducted on January 24, 2024 at 2:40 PM, staff #10 stated that having only 2 out of 5 shower stalls was not an issue since the staff try to only have one resident in the shower room at a time. Additionally, he stated that the broken and discolored tiles were not a concern. He said that they do a deep cleaning of the shower rooms. Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and policy review, the facility failed to ensure that one resident's medications were administered as ordered by the provider based on standards of practice for one resident (#350). The deficient practice could result in residents not receiving prescribed doses of medications. Findings include: Resident #350 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included urinary tract infection, chronic obstructive pulmonary disease, depression, gastro-esophageal reflux disease, hypertension, and convulsions. A care plan initiated on [DATE] indicated that the resident has acute/chronic pain. The goal was for resident to have adequate pain relief or be able to cope with pain. Interventions included to administer analgesia medication as ordered. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that a Brief Interview for Mental Status (BIMS) could not be conducted. The MDS indicated that the resident has moderately…

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 rules of the State Board of Nursing, the facility failed to administer medications as ordered by the physician for two residents (#4 and #5). The deficient practice could result in residents not receiving necessary medications. Findings include: -Resident #4 was admitted on [DATE] with diagnoses of Parkinson's Disease, osteoarthritis, acquired clubfoot - left foot, difficulty in walking and muscle weakness. The care plan initiated on May 26, 2021 revealed the resident had Parkinson's. Intervention included medication administered as ordered. The physician order dated August 9, 2022 included the following orders: -Carbidopa-levodopa (anti-Parkinson's agent) 50-200 mg (milligrams) tablet by mouth at bedtime; and, -Carbidopa-Levodopa 25-250 mg 2 tablets by mouth three times a day for Parkinson's Disease. This order was transcribed onto the Medication Administration Record (MAR) for September 2023 and revealed that the medication was not administered on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and the rules of the State Board of Nursing, the facility failed to ensure that an accurate accounting of controlled medications was maintained and reconciled for one resident (#5). The deficient practice could result in potential diversion of residents controlled medications. Findings include: Resident #5 was admitted on [DATE] with diagnoses of multiple sclerosis, benign prostatic hyperplasia, neuromuscular dysfunction of bladder, major depressive disorder, muscle weakness, difficulty walking, and cognitive communication deficit. The physician order dated July 24, 2023 included for oxycodone (opioid/narcotic) 10 mg (milligrams) tablet by mouth every 6 hours as needed for pain. The care plan initiated on July 25, 2023 revealed the resident was taking an opioid for pain. Interventions included to administer the medication as prescribed and to educate on potential risks that included death. Review of the MAR (medication administration record) for August 2023…

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 review, the facility failed to ensure infection prevention and control standards were maintained during medication administration. The deficient practice could result in the transmission of infection. Findings include: An observation of medication administration was conducted with a licensed practical nurse (LPN/staff #19) was conducted on October 11, 2023 at 7:25 a.m. The LPN entered the rooms of 7 residents and administered the prepared medications to each resident. However, during the entire observation, the LPN did not perform hand hygiene before and after preparation and administration of the medications to each resident and after exiting each resident's room. An interview with the Assistant Director of Nursing (ADON)/Infection Control Nurse/staff #7) and Associate Director of Nursing (DON) was conducted on October 11, 2023 at 1:45 p.m. The ADON and Associate DON both stated that their expectation was for staff to sanitize their hands before and after each resident and wash their hands with soap and water after every fourth…

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, clinical record review, and facility policy and procedure, the facility failed to ensure one resident (#233) was treated with dignity and respect. The deficient practice could result in the resident's rights not promoted and protected. Findings include: Resident #233 was admitted on [DATE] with diagnoses that included cellulitis of right and left lower limb, adult failure to thrive and alcoholic polyneuropathy. A daily skilled note dated [DATE] revealed the resident was alert and oriented x 4 with no active symptoms or treatments affecting level of consciousness, cognition, sleep, mood or behavior. Review of facility documentation revealed the roommate (resident #241) expired on [DATE]; and that, the deceased resident was left in the room with resident #233 until 1:00 p.m. on [DATE]. There was no evidence found in the clinical record that resident #233 was asked about leaving the room until the deceased body was transferred; or that, resident #233 agreed to leave 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 resident and staff interviews, review of the clinical record, facility documentation, and policy and procedure, the facility failed to ensure the resident representative for one resident (#234) was notified after he had a significant change in condition and was transferred to acute care facility. The deficient practice may result in resident representatives not notified and make any required decisions according to resident's treatment preferences and choices. Findings include: Resident #234 was admitted facility on July 13, 2022 with diagnoses of flail chest, traumatic pneumothorax, acute pain, muscle weakness, atrial fibrillation, Ogilvie syndrome, and anxiety disorder. Review of the clinical record face sheet included the resident had a DPOA (Durable Power of Attorney) and a financial responsible party. The HIPAA communication method request form signed by the resident and dated July 14, 2022 revealed the resident wanted information shared with the DPOA. A nursing note dated July 14, 2022 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 observation, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate and comfortable temperature levels was provided to meet the needs for one resident (#50). The deficient practice could result in the resident's room not having a homelike and comfortable environment. The facility census was 88 and the sample was 18. Findings include: Resident #50 was admitted on [DATE] with diagnoses of atrial fibrillation, chronic kidney disease, muscle weakness and difficulty in walking. Review of an admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated resident had intact cognition. The assessment also revealed the resident required extensive assistance with bed mobility and transfers. The clinical record revealed documentation the resident was alert and oriented and able to make needs known. During an interview conducted on January 9, 2022, resident #50 stated that his room was cold at night; and 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 review, facility documentation, staff interviews, and policy, the facility failed to ensure one resident (#184) was free from abuse. Findings include: -Resident #184 was readmitted [DATE], with diagnoses that included hepatitis, liver cirrhosis, hypocalcemia, and muscle weakness. Review of the admission Minimum Data Set assessment dated [DATE], revealed resident #184 had a Brief Interview of Mental Status (BIMS) score of 12 indicating resident had moderately impaired cognition. The nursing clinical note dated 11/12/2022 at 18:15 revealed after yelling and shaking at the resident (#184) the spouse appeared elevated, face flushed and speaking in loud voice. Verbal de-escalation techniques were used and the resident's spouse was able to be re-directed; and that, the spouse agreed to leave the building and get some rest. The documentation also included the resident remained only oriented to self; and was assessed and there was no injury found. Further, the documentation included the spouse…

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 policies and procedures, the facility failed to ensure information was provided to the receiving provider during transfer to hospital for one resident (#234). The deficient practice could result in the delay in treatment at the receiving facility because of lack of information regarding the reason for the transfer/discharge. Findings include: Resident #234 was admitted to the facility on [DATE] with diagnoses of flail chest, traumatic pneumothorax, acute pain, muscle weakness, atrial fibrillation, Ogilvie syndrome, and anxiety disorder. Review of an admission note dated July 14, 2022 at 11:00 PM that revealed the resident agreed to transfer to the hospital due to multiple issues of pain overnight. The nursing note dated July 14, 2022 revealed the resident transferred to the hospital per resident's choice. Review of the discharge Minimum Data Set (MDS) dated [DATE] revealed an unplanned discharge to an acute hospital on July 14, 2022. However, 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 facility policies and procedures, the facility failed to notify the Ombudsman regarding transfer/discharge to the hospital for one resident (#234). The deficient practice could result in Ombudsman not being informed of the reason for the transfer/discharge. Findings include: Resident # 234 was admitted to the facility on [DATE] with diagnoses of flail chest, traumatic pneumothorax, acute pain, muscle weakness, atrial fibrillation, Ogilvie syndrome, and anxiety disorder. An admission note dated July 14, 2022 at 11:00 PM that revealed the resident agreed to transfer to the hospital due to multiple issues of pain overnight. The nursing note dated July 14, 2022 revealed the resident transferred to the hospital per resident's choice. Review of the discharge Minimum Data Set (MDS) dated [DATE] revealed an unplanned discharge to an acute hospital on July 14, 2022. However, review of the clinical record revealed no evidence that the Ombudsman was notified regarding…

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 and procedure, the facility failed to ensure consistent treatments were provided to two residents (#13, #233) with pressure ulcers. Findings include: -Regarding Resident #13 Resident # 13 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer sacral region, local infection of the skin and subcutaneous tissue, pressure ulcer left elbow stage 3, pressure ulcer of right heel, unstageable, type 2 diabetes mellitus with foot ulcer, diabetic neuropathy, and bacteremia. The skin pressure ulcer weekly assessment dated [DATE] revealed a deep tissue injury (DTI) on the right heel and a stage 4 sacral pressure ulcer. The care plan initiated on July 27, 2022 revealed a care plan regarding pressure ulcer development with interventions to administer treatments as ordered. The physician order summary revealed the following active orders: -Weekly skin assessment every day shift every Saturday; -Clean the sacrococcygeal wound with Puracyn,…

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, review of the clinical record, facility documentation, and policy and procedure, the facility failed to ensure pain management consistent with professional standards of practice was provided for one resident (#234). The deficient practice could result in unmanaged pain for residents. Findings include: Resident #234 was admitted to the facility on [DATE] with diagnoses of flail chest, traumatic pneumothorax and acute pain. The admission care plan dated July 13, 2022, revealed that resident had acute pain related to left scapula fracture. Goal was that the resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain. Interventions included to administer analgesia medications per orders, anticipate need for pain relief and respond immediately to any complaint of pain, follow pain scale to medicate as ordered, and pain assessment every shift. Review of physician orders dated July 13, 2022 revealed the following: -Tylenol extra strength…

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.