Sante Of Surprise

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews and facility policy review, the facility failed to ensure medications were administered according to physician instructions for two residents sampled out of five (#24 and #58). The deficient practice could result in medication errors that could harm residents. The universe was 62.Findings include:-Regarding Resident #58:Resident #58 was admitted to the facility on [DATE] with diagnoses that included: essential primary hypertension, type 2 diabetes mellitus, anxiety disorder, depression, pneumonia and muscle weakness.A care plan for resident #58 included for pain medication Oxycodone therapy related to chronic pain with a date of initiation of April 10, 2026. An intervention included to administer medications as ordered.The minimum data set (MDS) for Resident #58, dated April 13, 2026 revealed a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment.The orders for Resident #58 revealed Oxycodone oral tablet 10mg give 1 tablet by mouth…

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, interviews, and review of facility policy and procedure, the facility failed to ensure medications were locked in 1 medication cart while left unattended. The deficient practice could lead to unauthorized persons gaining access to medications.An observation conducted on May 26, 2026 at 8:38 A.M. of the facility hallway revealed that a medication cart labeled P2 was not locked. There was no staff observed at the medication cart. The Licensed Practical Nurse (LPN/Staff#29) returned to the cart a few minutes later and tried to push in the lock, but it did not push in. She then used her key and put it in the lock of the medication cart and the key moved but it did not lock the medication cart. Next, she pulled on the drawers of the medication cart (P2) and they opened.An interview was conducted with LPN (Staff #29), on May 26, 2026 at 8:41A.M. who stated she forgot to lock the medication cart (P2). She stated she was having difficulty with the lock since she started her shift at 6:00 A.M., but did not make anyone aware that the lock was not working on the P2…

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, the CMS (Centers for Medicare and Medicaid Services) system for MDS (Minimum Data Set) data, staff interviews, the Resident Assessment Instrument (RAI) 3.0 User's manual, and facility policy, the facility failed to ensure completion of a quarterly MDS assessments for one resident (#43) within the regulatory time frames. The deficient practice could lead to insufficient resident assessment and impact resident care. Findings Include: Resident #43 was admitted to the facility on [DATE] with the diagnosis that included unspecified fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing. The admission MDS (Minimum Data Set) for resident #43 revealed that it was completed on February 23, 2024. Review of the clinical record revealed that the quarterly assessment was completed on June 24, 2024, transmitted June 28, 2024 and accepted July 1, 2024. The quarterly assessment was due May 18, 2024. In an interview with MDS Coordinator (Staff # 80)…

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, the facility failed to ensure one resident (#15) received necessary services to maintain personal hygiene. The deficient practice may cause a decline or decrease in a resident's quality of life. Finding Includes: Resident #15 was admitted to the facility on [DATE] with diagnoses that included cellulitis of right lower limb, osteoporosis, chronic pain, dementia, and anxiety. Review of resident minimum data set (MDS) from June 16, 2024, the Brief Interview for Mental Status (BIMS) score was 15 which indicated resident cognition is intact. For performance of activities of daily living (ADL), the MDS documented that she needed substantial/maximum assistance with personal hygiene. Care plan initiated on June 12, 2024 stated that resident needed help with daily activities and 1-2 staff assistance with bathing, bed mobility, dressing and eating. The ADL shower sheet under task for June 2024 revealed that resident either refused shower…

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, the facility failed to ensure one resident (#123) received treatment and services in accordance with professional standards of practice regarding positioning. The deficient practice could result in residents not receiving the treatment and care based on their assessed needs. Findings include: Resident #123 was admitted on [DATE] with diagnoses that included unspecified fracture of left acetabulum, subsequent encounter for fracture with routine healing, unspecified injury of head, subsequent encounter, muscle weakness (generalized), other lack of coordination. Review of the MDS (Minimum Data Set) 5 day dated June 21, 2024 revealed a Brief Interview for Mental Status (BIMS) was conducted revealing a BIMS of 8 indicating moderate cognitive impairment. Further review of the MDS revealed resident requires substantial/maximal assistance with oral hygiene and upper dressing, dependent with toileting hygiene, lower body dressing. Resident requires…

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 that medications were stored in a secure manner that prevents accident hazards. The deficient practice could result in medication being taken by someone other than the intended recipient. Findings include: On July 2, 2024 around 7:52 AM, surveyors observed two medicine cards left unattended on top of a medicine cart. The surveyors picked up the cards and confirmed there was still medication left in the cards. A Licensed Practical Nurse (LPN / Staff #13) shortly after emerged from a resident room and agreed to assist the surveyors once she finished in the room. The LPN then re-entered the resident room, closing the door behind her. Surveyors waited approximately 2 minutes for the LPN to return. After the LPN returned, she continued with the med pass and did not touch or move the medication cards. An interview was conducted with Staff #13 on July 3, 2024 at 10:20 AM, who stated that medications should always be put away in the cart and the cart should be locked. She denied recalling any…

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, staff interviews, and policy review, the facility failed to ensure one resident (#123) had an order for oxygen use. The deficient practice could result in residents receiving oxygen without a physician's order. Findings include: Resident #123 was admitted to the facility on [DATE], with diagnoses that included unspecified fracture of left acetabulum, subsequent encounter for fracture with routine healing, diffuse large b-cell lymphoma, unspecified site, unspecified asthma, uncomplicated, personal history of nicotine dependence. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed a score of 08 on the Brief Interview for Mental Status (BIMS) which suggests the resident had moderate cognitive impairment. The assessment included the resident experienced shortness of breath with exertion, when sitting at rest and when lying flat. The assessment also included the resident did not receive oxygen therapy during the look-back period. During an observation…

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 review of clinical records, facility policy and staff interviews, the facility failed to ensure an order for pain medication was followed as prescribed for one resident (#15).The deficient practice may result in undesirable medication-induced harm. Findings Include: Resident #15 was admitted into the facility on June 12, 2024 with diagnoses that included cellulitis of right lower limb, osteoporosis, chronic pain, dementia, and anxiety. Review of the physician orders revealed the following: - Percocet Oral Tablet 10 -325 milligram (Oxycodone with Acetaminophen/ Narcotic), give 1 tablet by mouth every 6 hours as needed for pain 4-6 and give 2 tablets by mouth every 6 hours as needed for pain 7-10 with start date of June 10, 2024. Resident #15's minimum data set (MDS) assessment from June 16, 2024 included the Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. Review of June 2024 Medication Administration Records (MAR) revealed that Percocet 10-325 milligram 1 tablet was administered 6 times when resident pain level was below 4 and when…

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 policy review, the facility failed to ensure that EBP (Enhanced Barrier Protection) was implemented when providing care for one resident (#324). Findings include: Resident #324 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, dysphagia, and unspecified severe protein-calorie malnutrition. Review of the physician orders dated June 28, 2024 revealed that resident #324 received enteral feed of Glucerna 1.5 via G-tube (Gastrostomy tube/ tube that's surgically inserted into the stomach to provide direct access for feeding, hydration, or medicine) every 6 hours. He received water flushes every 6 hours and between medications. According to physician orders dated June 27, 2024, the resident was to be receiving nothing by mouth (NPO) and medications should be crushed and given through his G-tube. On June 30, 2024, surveyors observed that resident #324 had a gastrostomy tube (G-tube) in which he received enteral feeding and medications…

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

Based on observation, staff interviews, and facility policy, the facility failed to ensure that one medication in the medication storage refrigerator was not expired and one medication in a cart was not expired. Findings include: During a medication storage observation of the medication cart for the 100 hall, on February 22, 2023 at 9:05 AM, an over-the-counter bottle of Iron 325mg (milligrams) was observed with an expiration date on January 31, 2023. During a medication storage room observation conducted on February 22, 2023 at 9:35 AM, one of two storage rooms contained a bottle of Omeprazole Oral Suspension for a discharged resident, in the refrigerator with an expired date of February 16, 2023. An interview was conducted on February 22, 2023 at 9:52 AM with a Licensed Practical Nurse (LPN/Staff #69). The LPN stated that medications in the cart are expired and should be disposed of and not administered to a resident. Medication dates are checked by the nurses and by supervisors periodically for expired medications. An interview was conducted with the Director of Nursing…

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.