Prescott Village Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, interviews, and review of the facility's policies and procedures, the facility failed to ensure a physician's order was in place prior to one resident's (#60) discharge. The sample size was three and the universe was 50. The deficient practice could result in a resident having an unsafe discharge.Findings include:Resident #60 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the right dominant side, dysphagia, acute kidney failure, and major depressive disorder.The admission Minimum Data Set (MDS), dated [DATE], revealed Resident #60 did not complete a Brief Interview for Mental Status (BIMS) assessment. Instead, staff assessed his cognitive skills for daily decision making as moderately impaired.The discharge MDS, dated [DATE], revealed that staff assessed his cognitive skills for daily decision making as severely impaired.The progress notes revealed an entry, dated November 24,…

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 complete and accurate level I PASARR was assessed on admission for one resident (#10). The universe was 50. The deficient practice could result in specialized services not being identified and provided to residents.Findings include:Resident #10 was admitted to the facility on [DATE] with diagnoses that included: generalized anxiety disorder, bipolar disorder, major depressive disorder, bariatric surgery status, post-traumatic stress disorder (PTSD), muscle weakness and morbid obesity.Resident #10's minimum data set (MDS) revealed a brief interview mental status (BIMS) score of 15, meaning the resident was cognitively intact.A care plan focus for Resident #10 revealed the resident was receiving psychotropic medication, Aripiprazole related to diagnosis of (PTSD)/bipolar disorder (behavior management. The date of initiation was January 25, 2026 with a revision on January 26, 2026. 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 interviews and facility policy and procedures, the facility failed to ensure that a new level I PASARR was completed when a resident was in the facility for more than 30 days for one resident (#10) out of 13. The universe was 50. The deficient practice could result in specialized services not being identified and provided to residents.Findings include:Resident #10 was admitted to the facility on [DATE] with diagnoses that included: generalized anxiety disorder, bipolar disorder, major depressive disorder, bariatric surgery status, post-traumatic stress disorder (PTSD), muscle weakness and morbid obesity.Resident #10's minimum data set (MDS) revealed a brief interview mental status (BIMS) score of 15, meaning the resident was cognitively intact.A care plan focus for Resident #10 revealed the resident was receiving psychotropic medication, Aripiprazole related to diagnosis of (PTSD)/bipolar disorder (behavior management. The date of initiation was January 25, 2026 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 observations, clinical record reviews, resident and staff interviews, facility documentation and policy and procedures, the facility failed to ensure nail care was provided for one resident #7 out of 14 sampled. The universe was 50. The deficient practice could result in the resident not having their personal grooming needs met, potential injury or infection.Findings include: Resident #7 was admitted on [DATE] with diagnosis including gastrointestinal hemorrhage, sequelae of cerebral infarction, systolic (congestive) heart failure, anemia, acute kidney failure, acute respiratory failure with hypoxia, age-related osteoporosis, major muscle wasting and atrophy, muscle weakness, dysphagia-oropharyngeal phase, abnormalities of gait and mobility, cognitive communication deficit, need for assistance with personal care and neuromuscular dysfunction of the bladder. The 5-day MDS (minimum data set) dated February 9, 2026 revealed a BIMS (brief interview of mental status) score of 14, indicating 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 observations, record review, staff interviews and policy review, the facility failed to ensure that medications/treatments are stored properly and not left at the bedside for one resident (#46). The facility census was 50. The deficient practice could result in harm to the residents, and/or visitors who have access to medications.Findings include:Resident #46 was admitted to the facility on [DATE] with the diagnosis that included left hand contracture, dysphagia, major depressive disorder and muscle weakness.The minimum data set (MDS), revealed a brief interview of mental status (BIMS) score of 10 which revealed resident with moderate cognition impairment.The care plan revealed no documentation for medications at the bedside.An observation was conducted on March 03, 2026 at 10:53 a.m. in Resident #46 's room and revealed an overbed table with a disposable bed pad covering the top of the overbed table. Items included a clear resealable bag with gauze, an abdominal pad package and band aids. An opened…

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, staff interviews, observations, and review of facility policies and procedures, the facility failed to follow infection control standards related to catheters for one resident (#27) out of 14 sampled. The deficient practice could lead to a high risk of CAUTI (catheter-associated urinary tract infections), contamination transfer or tube obstruction.Findings include:Resident # 27 was re-admitted on [DATE] with diagnosis including chronic kidney disease, mild cognitive impairment, weakness, acute kidney failure, urinary tract infection, muscle wasting and atrophy, infection and inflammatory reaction due to other urinary catheter, cognitive communication deficit, obstructive and reflux uropathy, and pneumonia.The 5-day MDS (minimum data set) revealed a BIMS (brief interview of mental status) score of 7, indicating severe cognitive impairment. The MDS further revealed that the resident had an indwelling catheter.The physician's orders revealed an order summary dated February 5, 2026 noting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure a care plan was developed and implemented to meet the needs of a resident (#2) regarding falls. The deficient practice could result in residents not receiving necessary individualized care and services to meet their specific needs.-Findings include:Resident #2 was admitted to the facility on [DATE], with diagnoses that included unspecified intracranial injury without loss of consciousness, Alzheimer's disease with late onset, bipolar disorder, chronic obstructive pulmonary disease, and major depressive disorder.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Section GG revealed the resident had no upper or lower extremity functional range of motion impairments on one side. Additionally, Section GG revealed the resident required supervision or touching assistance…

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, observation, clinical record review, and policy review, the facility failed to ensure one sampled resident (#22) was provided adequate supervision to prevent elopement. The deficient practice could result in other residents eloping. Findings include: Resident #22 was admitted on [DATE] with diagnoses that included displaced fracture of left tibia, dementia, disorientation, concussion and need for assistance with personal care. An admission elopement risk assessment dated [DATE] revealed the resident was a moderate risk with a score of 6. Review of the Minimum Data Set (MDS) dated [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS) summary score of 10 indicating moderate cognitive impairment. A BIMS assessment conducted on April 15, 2025 revealed that the resident had a summary score of 3/15 indicating severe cognitive impairment. Review of the clinical record revealed an order on April 24, 2025 at 13:00 by the primary care physician (PCP) 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 documentation and policy review, the facility failed to ensure that one resident (#2) was assessed timely and that notification was provided to the physician and the resident's family following an incident resulting in injury. The deficient practice could result in a delay of care to a resident, and/or a physician and resident's family not being aware of the resident's condition, leading to harm. Findings include: Resident #2 was admitted to the facility on [DATE], with diagnoses including unspecified open wound of right foot, multiple fractures of pelvis with stable disruption of pelvic ring, hypothyroidism, epilepsy, and disorder of bone density and structure. Review of the quarterly minimum data set (MDS) assessment dated [DATE], revealed the resident had a BIMS (brief interview for mental status) score of 15, indicating Resident #2 was cognitively intact. Review of the physician orders revealed no evidence of orders for monitoring a change of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff interviews, and facility policy and procedure review, the facility failed to ensure that the medical record for one resident (#2) was complete and accurate, and additionally that requested facility documentation for one resident (#8) was provided in a timely manner. The deficient practice resulted in decreased or delayed care for a resident, and/or a delay in the survey process. Findings Include: -Regarding Resident #2: Resident #2 was admitted to the facility on [DATE], with diagnoses including unspecified open wound of right foot, multiple fractures of pelvis with stable disruption of pelvic ring, hypothyroidism, epilepsy, and disorder of bone density and structure. A physician order dated March 12, 2025, at 1:45 PM, indicated to send the resident to the emergency room (ER) for further evaluation of the right knee. Review of the clinical record revealed no evidence of any progress notes, or incident report (risk management report), or incident log was completed for an incident…

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 process and procedures, the facility failed to ensure that dishes and utensils were cleaned under sanitary conditions. The deficient practice could result in residents becoming ill. Findings include: The initial walk through of the kitchen was conducted on January 22, 2024 at 10:37 AM with the senior cook (staff #76), who stated that he was in charge of the kitchen. Staff #76 stated that the temperature gauge on the dishwasher had not been working since December 31, 2023, but he had been using an external thermometer in a red plastic cover to manually temp the dishwasher to ensure that the dishwasher was 160 degrees during the washing and rinse cycle. -The first attempt to temp the dishwasher during the wash cycle resulted in a 118-degree reading. -The second attempt to temp the dishwasher during the wash cycle resulted in a 140-degree reading. -The third attempt to temp the dishwasher during the wash cycle resulted in a 203-degree reading. Staff #76 stated that he was responsible for temping the dishwasher from January 1, 2024 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documents, and facility policy, the facility failed to ensure that two residents (#6 and #139) were not abused. Findings include - 1) Resident #6 was admitted on [DATE] with diagnoses of traumatic ischemia of muscle, and systemic Lupus Erythematosus. A significant change Minimum Data Set (MDS) dated [DATE] included that this resident was cognitively intact. A care plan initiated 8/23/2022 included that this resident had an Activities of Daily Living (ADL) self care performance deficit related to generalized weakness, osteoarthritis and rhabdomyolysis. This included that the resident has limited ADL function due to Bilateral Lower Extremity (BLE) weakness and that she needs assistance with toilet use and personal hygiene. A Reportable Event Record/Report included that at 9:00 AM on 4/25/2023, a Laundry Technician (staff #65) was walking by resident room and couldn't make out what resident had stated, but she heard Certified Nursing Assistant (CNA/staff #70) reply I am not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and the facility policy and procedures, the facility failed to ensure three residents were provided with a notification transfer/discharge in writing as soon as practicable. (#36, #3, and #37). Findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, unspecified systolic congestion, and generalized anxiety. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 13 indicating the resident was cognitively intact. The fall care plan dated September 3, 2022 revealed that the resident has had an actual fall with injury related to poor safety awareness, lacks insight, impulsive, cognitive impairment, impaired safety awareness, unsteady gait, risk taking behaviors, history of falls evidenced by not using the call-light for assistance, declined safety interventions. Review of the hospital transfer form dated November 14, 2022 revealed that the resident was transferred to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical review, staff interviews, and facility policy and procedures, the facility failed to assess and administer pain medications according to accepted standards of clinical practice for three residents (#16 and #30). The deficient practice could result in residents being over or under medicated. Findings include: 1) Resident #16 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, chronic kidney disease, Type II Diabetes, and major depression. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 5 indicating the resident has a severe cognitive impairment. The order summary revealed an order dated April 26, 2023 for Acetaminophen tablet 325 mg give 650 mg by mouth every 4 hours as needed for pain. Acetaminophen not to exceed 3,000 mg per day. Contact provider/practitioner if a fever is present. Review of the Medication Administration Record (MAR) dated January 2024 revealed that Acetaminophen tablet 325 mg give 650 mg by…

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 documents, and staff interviews, the facility failed to ensure that a pharmacy medication recommendation was reviewed and implemented. Findings include: Resident #15 was admitted on [DATE] with diagnoses of Major Depressive Disorder and epilepsy. A care plan dated 11/12/23 included that the resident is on anticonvulsant medication therapy related to seizures and included interventions to monitor resident condition based on clinical practice guidelines or clinical standards of practice related to use of divalproex. A physician's order dated 5/5/2023 included Divalproex Sodium (anticonvulsant/valproic acid) Oral Tablet Delayed Release 125 MG give 4 tablets by mouth three times a day for seizures related to epilepsy. A pharmacy Consultation Report dated October 18, 2023 included Please monitor a valproic acid trough concentration on the next convenient lab day, 1 week after any dosage changes, every 6 months thereafter, and as clinically indicated. However, review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and review of facility policies, the facility failed to ensure a resident's (#37) clinical record included the required information for transfer/discharge. The deficient practice could result in resident not receiving a safe and effective transition of care. Findings include: Resident #37 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), acute and subacute endocarditis (infection of tissue in the heart), and supraventricular tachycardia (irregular rapid heartbeat). A review of the admission Minimum Data Set (MDS), dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 07 out of 15, which indicated the resident had severe cognitive impairment. Per resident #37's clinical notes, the resident was discharged to Yavapai Regional Medical Center, via ambulance, on November 10, 2023 due to shortness of breath. Review of the clinical record revealed no evidence that a discharge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and facility policy, the facility failed to ensure that a care plan was revised for 2 residents (#15, #21) Findings include: 1) Resident #15 was admitted on [DATE] with diagnoses of hemiplegia and epilepsy. An admission Minimum Data Set (MDS) dated [DATE] included that this resident was moderately cognitively impaired, required extensive 2 person assist for transferring. Review of the clinical record included that this resident had a fall on 7/4/23. However, review of the clinical record did not find any new interventions for this fall. 2) Resident #21 was admitted on [DATE] with diagnoses of vascular dementia and generalized anxiety disorder. A 5 day Minimum Data Set (MDS) dated [DATE] included that this resident was moderately cognitively impaired, required extensive 2 person assist for transferring. This MDS included that this resident had a fall in the last month. Review of the clinical record included that this resident had fallen on 9/27/22. A progress note…

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 -Resident #2 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of thoracic 9-10, atrial fibrillation, and age-related osteoporosis without current pathological fracture. Review of a physician order dated August 31, 2022 included Cymbalta (antidepressant medication) Capsule Delayed Release Particles 60 MG (Duloxetine HCl), 1 capsule by mouth one time a day related to age related osteoporosis without current pathological fracture. Review of the MARs dated August 2022, September 2022, and October 2022 revealed the medications were administered per physician order. However, further review of the clinical record revealed no evidence of adverse effects monitoring for the use of an anti-depressant medication. An interview was conducted on October 6, 2022 at 9:28 a.m. with the DON (staff #43). Staff #43 stated it was her expectation that adverse effects for antidepressants are monitored and care planned. Staff #43 stated the process when an antidepressant is ordered by 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 the facility's policy and procedure, the facility failed to provide evidence that one resident (#29) was informed of the right to formulate an advanced directive. The sample size was 6. The deficient practice could result in residents' not being provided the opportunity to formulate an advance directive. Findings include: Resident #29 was admitted on [DATE] with diagnoses that included acute myocardial infarction, displaced intertrochanteric fracture of left femur, and cerebrovascular disease. A physician's order dated [DATE] revealed do not resuscitate (DNR). However, review of the clinical record revealed no evidence that resident #29 consented to be a DNR, or if the resident was informed of the right to formulate an advanced directive. An admission MDS (Minimum Data Set) assessment dated [DATE] included a BIMS (Brief Interview for Mental Status) score of 15, which indicated resident #29 was cognitively intact. An interview was conducted on [DATE] at 10:06…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and the facility's policy and procedure, the facility failed to ensure a comprehensive care plan was completed for one resident (#2). The sample size was 12. The deficient practice could result in residents' not having care plans to address all their care needs and potential risks. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of T-9-T10, atrial fibrillation, and age-related osteoporosis without current pathological fracture. Review of physician orders revealed the following: -Apixaban 2.5 milligrams two times a day for anticoagulant dated March 23, 2022 -Cymbalta (antidepressant) Capsule Delayed Release Particles 60 MG (Duloxetine HCl), one time a day related to age related osteoporosis without current pathological fracture dated August 31, 2022. A quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS of 14, which indicated the resident was cognitively intact. 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 policy and procedure, the facility failed to ensure the comprehensive care plan was revised to include the use of an antipsychotic medication for one resident (#30). The sample size was 12. The deficient practice could result in residents not receiving consistent monitoring of antipsychotic medications, behaviors, and side effects, and non-pharmacological interventions. Findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included chronic atrial fibrillation, insomnia, and a generalized anxiety disorder. Review of the Order Summary Report revealed an order dated August 26, 2022 for Haloperidol Lactate (antipsychotic medication) Concentrate 2 milligrams/milliliters, give one milliliter every 6 hours for behavior management. Order to remain in place during the term of hospice. Medication supplied by the hospice agency. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, and policy reviews, the facility failed to ensure there was an order for hospice services for one resident (#9) and that coordination of services was consistently communicated. The sample size was 2. The deficient practice could result in residents not receiving care. Findings include: Resident #9 was admitted to the facility on [DATE] with diagnoses that included malnutrition, Alzheimer's disease, mood disorder and generalized anxiety disorder. Review of hospice documentation revealed the resident was admitted to hospice on May 4, 2022. Review of the care revised on May 5, 2022 revealed the resident was receiving hospice services. The quarterly Minimum Data Set assessment dated [DATE] revealed the resident received hospice care while a resident. However, continued review of the clinical record did not reveal an order for the resident to be admitted to or receive care from Hospice. An interview was conducted with a licensed practical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and policy review, the facility failed to ensure one resident (#2) had a physician's order for oxygen use. The sample size was 2. The deficient practice could result in the improper and unsafe administration of oxygen. Findings include: Resident #2 was admitted on [DATE] with diagnoses which included atrial fibrillation, hypothyroidism, dorsalgia, and hyperlipidemia. Review of the nursing note dated March 25, 2022 revealed the resident's oxygen saturation was low, but that the resident recovered quickly when given oxygen. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 8 which indicated the resident moderate impaired cognition. The assessment also revealed the resident received oxygen therapy while a resident. A nursing note dated March 30, 2022 revealed the resident was stable on oxygen at 3 liters via nasal cannula. Review of the quarterly MDS assessments dated June 26, 2022 and September…

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 policy review, the facility failed to ensure an anticoagulant medication was monitored for adverse effects for one resident (#2) receiving anticoagulant therapy. The sample size was 5. The deficient practice could result in adverse effects to residents. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, and age-related osteoporosis without current pathological fracture. Review of physician order dated March 23, 2022 revealed an order for apixaban 2.5 milligrams by mouth two times a day for anticoagulant. A quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. The primary medical diagnoses included atrial fibrillation, and age-related osteoporosis without current pathological fracture. The MDS assessment also revealed the resident received an anticoagulant medication for 7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and review of facility policy and procedure, the facility failed to ensure that outdated and/or unmarked food was not available for resident consumption in a unit nourishment refrigerator. The deficient practice may allow residents to consume foods that are unsafe for consumption. Findings include: An observation of the refrigerator located on station 2 was made on October 4, 2022 at 11:15 a.m. The observation revealed several unmarked items in the refrigerator and several items that were beyond the usable date stamped on the package. The items were stacked on top of one another and some items were laying on their side. The observed items were as follows: -a covered blue bowl with a resident name but no date -an aluminum tray marked with a resident name and dated September 26, 2022 -yogurt -3 count strawberry banana with the stamp use by October 2, 2022 and 4 containers stamped use by [DATE] -4 count individual milk cartons vitamin D milk- stamped best by October 3, 2022 -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 observations, staff interviews, clinical record and policies and procedures, the facility failed to ensure appropriate hand hygiene practices were performed when providing wound/dressing care for one resident (#20). The deficient practice could result in the spread of infection. Findings include: Resident #20 was admitted to the facility on [DATE] with diagnoses that included systemic lupus erythematosus and chronic respiratory failure. A review of the care plan initiated on August 23, 2022 revealed the resident had a right heel pressure ulcer. The goal was that the resident would have no complications related to the pressure ulcer of the right heel. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted with a stage 2 pressure ulcer. A physician order dated 10/01/2022 stated to clean the right heel pressure ulcer with normal saline, pat dry, cover wound bed with calcium alginate, apply bordered foam dressing, wrap with gauze, and secure with tape daily…

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.