Life Care Center Of Tucson

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure that two residents (#222 and #223) and/or the resident's representative received an accurate and complete Advanced Beneficiary Notice (ABN) when Medicare services terminated. The deficient practice could result in residents not knowing of their potential liability for payment. Findings include: Resident #222 was admitted on [DATE] with diagnosis including urinary tract infection, difficulty walking, muscle weakness, arteritis, hypothyroidism, hyperlipidemia, repeated falls, neuromuscular dysfunction of the bladder, and protein-calorie malnutrition. A review of the admission MDS (minimum data set) dated January 7, 2024 revealed a BIMS (brief interview of mental status) score of 00, suggesting severe cognitive impairment. A review of the advanced beneficiary notification for resident #222 revealed the estimated cost for ongoing care effective on February 2, 2024 would be $345.00 a day. The form further revealed that both option 1 and option…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that initial and ongoing weights were conducted for one resident (Resident #36). The deficient practice could result in a change of condition not being assessed and monitored. Findings include: Resident #36 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, Parkinson's disease and chronic respiratory disease. Review of the clinical record revealed that the resident weighed 187 pounds on February 9, 2024. Review of the nutritional assessment dated [DATE] revealed that the resident was malnourished. The care plan dated February 22, 2024 revealed that the resident was at risk for weight fluctuation related to dysphagia and anoxic brain injury. Interventions included eternal feeding as ordered and weight as per the facility policy. The minimum data set (MDS) dated [DATE] included a staff assessment for mental status score of 2 indicating the resident had moderate…

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, a staff interview, and the facility policy and procedures, the facility failed to ensure that the daily staff posting included the correct information. Findings include: On July 14, 2024 at approximately 9:00 a.m. the daily staff posting was observed hanging on the wall just to the left of the reception desk. The information observed on the posting was: -July 12, 2024 -census 60 -number of each type of staff for each shift -the total hours scheduled for each type of staff for each shift -the actual hours worked was not completed During this time the Director of Nursing (DON/staff #59) approached and removed the daily staff posting dated July 12, 2024 and stated that she was just about to the change it. Review of the facility documentation revealed that the census was 58 on July 14, 2024. An interview was conducted on July 17, 2024 at 11:30 a.m. with the (DON/staff #59), who stated that the Central Supply Director/staffing coordinator (staff #95) is responsible for completing daily staff posting and works Monday through Friday. She stated that staff #95 prepares…

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 employee record review, staff interviews, and the facility policy and procedures, the facility failed to ensure that one staff (#110) was free of tuberculosis (TB) prior to working in the facility. The deficient practice could result in residents being infected with tuberculosis. Findings include: Staff # was hired as the Administrator (staff #110) for the facility on January 8, 2024, During an interview conducted on July 16, 2024 at 1:56 p.m. with the accounting clerk/human resources personnel (staff #73), she stated that (staff #110) did not provide a current TB test for herself. She stated that the Executive Director is probably supposed to have a TB test prior to working in the building. She stated that the reason for testing is to prevent the risk of TB spreading throughout the building. An interview conducted on July 17, 2024 at approximately 9:50 a.m. with the (staff #110), who stated that she did not have a tuberculosis test prior to working in the facility. She stated that she was tested yesterday, July 16, 2024, and the test results had not been read. An interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#6) received assistance with bathing. The deficient practice could result in poor hygiene and skin infections. Findings include: Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included a anxiety, depression, unspecified protein-calorie malnutrition, and a personal history of venous thrombosis and embolism. The care plan for activities of daily living (ADLs) dated March 25, 2024 revealed that the resident has an ADL self-care performance deficit related to weakness and decreased mobility due to acute kidney failure (AKF), pressure ulcer (PU), seizures (s/z) and depressive disorder (d/o). Interventions included that the resident requires assistance by staff with bathing/showering as necessary. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident was cognitively intact.…

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, facility documents and facility policy, the facility failed to ensure a residents' care was not neglected. Neglected care could result in increased morbidity for residents. Findings include: Resident #48 was admitted on [DATE] with diagnoses of depression, anxiety disorder, generalized muscle weakness and difficulty in walking. A 5 day Minimum Data Set (MDS) dated [DATE] included that this resident was cognitively intact and needed partial/moderate assistance with toileting hygiene. A care plan dated 5/16/23 included that this resident requires Activities of Daily Living (ADL) assistance and therapy services needed to maintain or attain highest level of function. Interventions include to assist with mobility and ADL's as needed. However, a complaint/Incident Investigation Report dated 2/1/24 included that a resident is stating that on Saturday, January 20, at approximately 9:00 PM, a Certified Nursing Assistant (CNA) came into the room to provider…

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 review, the facility failed to ensure that one resident's representative (#4) was able to exercise her rights regarding decisions about the resident's care. This deficient practice could result in resident's or their representatives not being able to make their own healthcare decisions. Findings include: Resident #4 was admitted to the facility on [DATE], with diagnoses that include Dementia, anxiety, Diabetes mellitus type 2, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment. Review of the facility's investigation report revealed that on December 24, at approximately 12:00 p.m. the Resident's daughter approached the nursing station expressing that there was a large bruiser to her…

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, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#4) was free from neglect by staff. The deficient practice could result in further incidents of neglect of the residents. Findings include: Resident #4 was admitted to the facility on [DATE], with diagnoses that include Dementia, anxiety, diabetes, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation. An anticoagulant care plan created on December 14, 2023 revealed that the resident was on anticoagulant therapy. The goal was to not experience uncontrolled bleeding through the next review period, with noted interventions that staff will observe and report adverse reactions of anticoagulant therapy such as lethargy, sudden changes in mental status, blurred vision, significant or sudden changes in vital signs, and bruising. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief…

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 review, the facility failed to ensure an injury of unknown origin was reported to the Administrator, and state agency within 24 hours. Findings include: Resident #4 was admitted to the facility on [DATE], with diagnoses that include Dementia, anxiety, Diabetes mellitus type 2, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment. Review of the facility's investigation report revealed that on December 24, at approximately 12:00 PM, the Resident's daughter approached the nursing station expressing that there was a large bruiser to her mother's face that was not present during her visit the day prior. Review of State agency documentation revealed the report for this incident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#4) was assessed according to professional standards. The deficient practice could result in a delay of clinically necessary treatment. Findings include: Resident #4 was admitted to the facility on [DATE], with diagnoses that include Dementia, anxiety, diabetes, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation. An anticoagulant care plan created on December 14, 2023 revealed that the resident was on anticoagulant therapy. The goal was to not experience uncontrolled bleeding through the next review period, with noted interventions that staff will observe and report adverse reactions of anticoagulant therapy such as lethargy, sudden changes in mental status, blurred vision, significant or sudden changes in vital signs, and bruising. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE]…

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, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#10) was free from physical abuse by staff. The deficient practice could result in further incidents of staff to resident abuse. Findings include: -Resident #10 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's disease, weakness, aphasia, Bipolar disorder, depression, and anxiety. A behavioral care plan revised February 6, 2023 revealed the resident was at risk for mobility performance deficit related to Alzheimer's dementia. The goal was to maintain a current level of functional mobility through the next review period, and a noted intervention that staff are to assist her turn and reposition in bed as necessary. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had significant cognitive impairment. A 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 and staff interviews, the facility failed to ensure that three residents (#17, #67, #275 ) and/or the resident's representative received the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) when Medicare services terminated. The sample size was 3. The deficient practice could result in residents not being informed of their potential liability for payment. Findings include: Resident #17 was admitted [DATE] with diagnosis including congestive heart failure, metabolic encephalopathy, chronic kidney disease-stage 4, unspecified dementia, and type 2 diabetes mellitus. The resident was discharged to home with home health services on March 6, 2023. However, review of the clinical record for resident #17 did not reveal the resident and/or the resident's representative had been provided the SNFABN. Resident #67 was admitted [DATE] with diagnosis including intracapsular fracture of the left femur, severe protein-calorie malnutrition, and pressure ulcer of the sacral…

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 reviews, and policy, the facility failed to ensure the medication error rate was not 5% or greater by failing to administer a medication as ordered for two of three sampled residents (#26 and #48). The medication error rate was 10.71%. The deficient practice could result in additional medication errors. Findings include: -Resident #26 readmitted to the facility on [DATE] with diagnoses which included primary hypertension, type 2 diabetes mellitus with diabetic chronic kidney disease and major depressive disorder, single episode. A physician's order dated 12/04/22 included duloxetine HCl (antidepressant) capsule delayed release sprinkle 60 milligrams (mg); give one capsule once daily for depression as evidenced by verbalizing sadness. On 03/13/23 at approximately 8:56 a.m. an observation of medication administration was conducted with a Licensed Practical Nurse (LPN/staff #45). Per review of the resident's duloxetine medication card, the dose per capsule…

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 maintain an environment for residents that was free of pervasive odors. The deficient practice could result in residents not having a homelike environment. Findings include: During a facility observation conducted on March 13, 2023 at 09:11 AM, a strong urine odor was noted in the vicinity of resident #38's room. It was noted again at 12:10 PM, and 3:27 PM the same day. On March 14, 2023 the same strong urine odor was noted outside resident #38's room at 9:23 AM, 12:04 PM, and 2:38 PM the same day. An interview was conducted on March 13, 2023 with the Resident #38 at 12:15 PM. The resident stated that the room always smells of urine and that it comes from her bathroom which is regularly cleaned but the smell remains. She stated that the smell is of urine and stated that it always smells that way. An interview was conducted on March 15, 2023 at 11:53 AM with a Certified Nursing Assistant (CNA/staff #67), who stated that she has noticed a urine odor this morning but that typically it doesn't smell. She…

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 clinical record review, resident interview, staff interviews, observation, and review of facility policy and procedure, the facility failed to ensure nail care was provided for one resident (#18). The deficient practice could result in residents not receiving necessary care and services to maintain good grooming and personal hygiene Findings include: Resident #18 was admitted on [DATE] with diagnosis that included cerebrovascular disease, type 2 diabetes, long term use of insulin, polyneuropathy, neuralgia, neuritis and other symptoms and signs involving the circulatory system. The MDS (minimum data set) dated December 29, 2022 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident is cognitively intact. The MDS further did not reveal psychosis or behaviors. Review of the care plan goal dated February 11, 2023 included that resident #18 has an ADL (activities of daily living) self-care deficit due to left-sided hemiparesis. The noted intervention included…

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 (#60) received care and services in accordance with physician's orders, professional standards of practice and his person-centered care plan. The sample size was 23. The deficient practice could increase the risk for complications and/or rehospitalization. Findings include: Resident #60 readmitted to the facility on [DATE] with diagnoses including urinary tract infection, acute respiratory failure with hypoxia and heart failure. A physician's order dated 02/24/23 included monitoring for edema every shift for congestive heart failure (CHF). A physician's order dated 02/25/23 revealed for furosemide (diuretic) 20 milligrams (mg); give one tablet a day for fluid retention for 14 days. The Admission/readmission Collection Tool dated 02/26/23 included the resident's most recent weight at 298.2 pounds (lbs). A physician's order dated 02/26/23 included weight every night shift for CHF before breakfast.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, clinical record review, and review of facility policy, the facility failed to ensure one resident (#4) received appropriate catheter care and services in accordance with professional standards. Two residents were reviewed for urinary catheter/Urinary Tract Infection (UTI). The deficient practice could result in complications with indwelling urinary catheters, including infection. Findings include: Resident #4 admitted to the facility on [DATE] with diagnoses including displaced comminuted fracture of shaft of humerus, right arm, subsequent encounter for routine healing, acute kidney failure with tubular necrosis and a UTI. An indwelling Foley catheter care plan dated 02/21/23 related to obstructive uropathy had a goal for no complications related to indwelling catheter use. Interventions included catheter care every shift. A skilled nursing note dated 02/26/23 at 10:36 a.m. included that the resident's Foley catheter was intact and patent and draining yellow…

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 medication was obtained and available to meet the needs of one resident (#43). The sample size was 5. The deficient practice may result in residents not receiving medications necessary to treat their medical conditions. Findings include: Resident #43 readmitted to the facility on [DATE] with diagnoses including atherosclerosis of coronary artery bypass graft(s) without angina pectoris, type 2 diabetes mellitus with diabetic neuropathy and hyperlipidemia. A history of nonrheumatic aortic valve disorder care plan dated 02/01/23 related to a history of myocardial infarction had a goal for the resident to verbalize less difficulty breathing. Interventions included to give medications as ordered. Review of a physician's order dated 02/08/23 included rosuvastatin calcium (HMG-CoA reductase inhibitor) 40 milligrams (mg) at bedtime for hyperlipidemia. The admission Minimum Data Set assessment dated [DATE] 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, and policy, the facility failed to ensure that medications were stored safely and secured in the medication cart. The deficient practice could increase the risk for unsecured medications, including/and/or schedule II - V medications, to be unsecured. Findings include: Prior to a medication administration observation conducted on 03/13/23 at 8:31 a.m. a medication cart was identified on the [NAME] hallway near room [ROOM NUMBER]. A medication cup containing approximately 8 pills was noted on top of the cart. The medication cart was unlocked. The computer on top of the cart had been left open and a resident's private health care information was visible. There were no residents identified in the hallway. The nurse returned to the cart within approximately 3 minutes. An interview was conducted on 03/13/23 at 8:58 a.m. with a Licensed Practical Nurse (LPN/staff #45). He stated that the earlier situation was not normal. He stated that typically, he does keep his cart locked. He…

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, review of facility policy and procedure, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessments were complete for 3 residents (#45, #34, and #4). The sample size was 23. The deficient practice could result in incomplete resident assessments impacting residents' plan of care. Findings include: -Resident #45 admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, cognitive communication deficit, dementia, and pressure ulcer of sacral region. Review of the admission MDS assessment dated [DATE] revealed the assessment areas for cognitive patterns (section C); mood (section D); behavior (section E); and unhealed pressure ulcers/injuries, including current number of unhealed pressure ulcers/injuries at each stage (section M) only contained dashes which meant the areas were not assessed for the MDS. An interview was conducted on March 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 clinical record review, staff interviews, review of facility policies and procedures and the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate and complete for 3 residents (#10, #30, and #58). The sample size was 23. The deficient practice could result in residents' MDS assessments not being accurate and complete. Findings include: -Resident #10 admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment, major depression, anxiety disorder, bipolar disorder, and schizophrenia. Review of a Significant Change in Status MDS assessment dated [DATE] and a quarterly MDS assessment dated [DATE] revealed under section C/Cognitive Patterns that the Brief Interview for Mental Status (BIMS) should be conducted. However, the BIMS interview and the Staff Assessment for Mental Status contained only dashes which means the areas were not assessed. The assessment, under section D/Mood, indicated that the mood…

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 policies and procedures, the facility failed to ensure the accurate completion of a Pre-admission Screening and Resident Reviews (PASRR), and failed to complete/update a PASRR when the resident's stay exceeded 30 days for one sampled resident (#10). The deficient practice could result in failure to refer a qualifying resident to level 2 services. Findings include: Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included major Depressive Disorder, Bipolar Disorder, Anxiety Disorder, and Schizophrenia. The resident's primary diagnosis was listed as chronic respiratory failure with hypoxia. Review of a PASRR Level 1 (version 04/2020) dated May 18, 2021 revealed the PASRR Level 1 review type to be pre-admission. The form was marked no for the question: Does the individual have any of the following Serious Mental Illnesses, which included the options of Schizophrenia, Major Depression, and Bipolar…

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 review of policy, the facility failed to ensure dementia and psychotropic drug use was included in one resident's (#45) baseline care plan; and failed to ensure antihypertensive medication use was included in one resident's (#130) baseline care plan. The sample size was 23. The deficient practice could result in residents' needs not being identified and interventions not being in place to address those needs. Findings include: -Resident #45 admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, dysphagia, cognitive communication deficit, and dementia. Review of the physician's orders dated January 6, 2022 revealed for: -Quetiapine Fumarate/Seroquel (antipsychotic) tablet 25 milligram (mg) give one tablet by mouth two times a day for anxiety as evidenced by (AEB) crying; -Document number of hours of anxiety AEB crying. The provider's progress note dated January 7, 2022, included a diagnosis of dementia. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff and resident interviews, and review of policies and procedures, the facility failed to ensure communication was provided to hospice for one sampled resident (#128) regarding a change in condition; failed to ensure one of three sampled resident (#387) received surgical incision monitoring according to physician's orders; and failed to ensure wound assessment and treatment were conducted for two of three sampled resident (#278). The deficient practice could result in reduced quality of care for residents. Findings include: Regarding communication with Hospice: Resident #128 admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, cachexia, and weakness. Review of the resident's care plan initiated on February 25, 2020 revealed the resident had a terminal prognosis. The interventions included to work cooperatively with the hospice team to provide the resident's spiritual, emotional, intellectual, physical, and social needs. 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, observations, staff and resident interviews, and review of policies and procedures, the facility failed to ensure two of two sampled residents (#42 and #45) received care, consistent with professional standards of practice, to prevent and promote the healing of pressure ulcers. The deficient practice could result in wound complications and further pressure ulcer formation for residents. Findings include: -Resident #45 admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, cognitive communication deficit, need for assistance with personal care and pressure ulcer of sacral region, unspecified stage. Review of the physician orders revealed an order dated January 6, 2022 to monitor for signs and symptoms of infection to sacral ulcer every shift for decubitus. A Braden Scale for Predicting Pressure Sore Risk and Risk Factors dated January 6, 2022, revealed the resident was at high risk with a score of 14 and included a potential problem…

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 three residents (#56, #11, and #4) with limited range of motion and mobility consistently received restorative nursing services to maintain or improve range of motion and mobility. The sample size was 5. The deficient practice could result in residents experiencing a decrease in range of motion and mobility. Findings include: -Resident #56 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, muscle weakness (generalized), and difficulty in walking, not elsewhere classified. Review of the Rehabilitation/Restorative Care Referral form dated 12/29/21 from OT (occupational therapy) revealed a Level 1 functional maintenance program (no physician order needed) for 3 times a week for 8 weeks. The referral included for transfer, active ROM (range of motion), and eating services and included instructions/precautions, set up required, and equipment. Review of the care plan…

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, facility documentation, and policy review, the facility failed to ensure there was sufficient nursing staff to meet the needs of the residents. The deficient practice could result in residents' needs not being met. The census was 99. Findings include: Review of the facility assessment tool reviewed 02/22/22 reflected an average daily census of 75 residents. Pertinent facts or descriptions of the resident population that must be considered when determining staffing and resource needs included daily review of schedules, utilization of the [NAME], and be based on resident needs and requests. According to the facility assessment the required number of direct care staff hours per patient day (HPPD) included 2.25 hours for Certified Nursing Assistants (CNAs), 0.76 hours for Licensed Practical Nurses (LPNs), and 0.79 hours for Registered Nurses (RNs). In addition, 0.12 hours were assigned for Restorative CNAs (RCNAs). The total number of HPPD was 3.81. Review of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and review of policies and procedures, the facility failed to ensure medications were administered as ordered to three residents (#45, #49, and #130). The sample size was 5. The deficient practice could result in residents receiving medications that are not necessary. Findings include: -Resident #45 admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, type 2 diabetes mellitus, and hypertension. Review of the physician's orders dated January 6, 2022 revealed for; -Lisinopril give 2.5 milligram (mg) by mouth one time a day for hypertension, hold for Systolic Blood Pressure (SBP) less than 110. -Metoprolol Tartrate tablet 50 mg give one tablet by mouth two times a day for hypertension, hold for SBP less than 110. -Terazosin hydrochloride capsule 10 mg give one capsule by mouth at bedtime for hypertension, hold for SBP less than 110. -Humalog solution 100 units/milliliter (ml) subcutaneously before meals and at bedtime for diabetes.…

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 facility documentation, staff and resident interviews, observation, and review of facility policies and procedures, the facility failed to provide each resident with food and drink that was at an appetizing temperature. The deficient practice could lead to issues with nutrition and impact resident quality of life. Findings include: During the initial portion of the survey on February 28, 2022 and March 1, 2022, multiple complaints were received from residents related to food served at the facility. Twelve residents stated food was served to them cold and that the staff response to the cold food was that staff had specific orders not to warm anything up for the residents; yes, they know; and there is no microwave for resident use. One resident stated staff were in and out of the room very quickly when delivering the meal and did not answer the call light during that time so the resident could tell staff the food was cold. One resident stated that meal times are getting later and later. Two residents stated they were not offered anything else when they told 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.

Based on observations, interviews, and policy review, the facility failed to ensure that infection prevention protocols were implemented in the processing of laundry. The deficient practice could result in contamination of clean linen. Findings include: During an observation conducted of the laundry facilities on 03/03/22 at 12:04 PM, a laundry assistant (staff #52) was observed on the dirty side of the laundry facility, sorting bags of dirty laundry. Blue bags and clear bags were observed in the laundry cart. Staff #52 was donned in a yellow gown and was wearing gloves. The gown was observed to be tied at the neck and not the waist, and was falling off her shoulders. When asked about what different the colors of laundry bags indicated, staff #52 stated that blue was general laundry, and yellow was isolation laundry. Staff #52 stated the yellow bags of laundry had to be washed separately from the regular laundry in the blue bags, and that she had not seen any yellow laundry bags recently. At 12:06 PM, staff #52 was observed pulling up the top of the gown over her shoulders while…

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, policy review, and the Centers for Medicare & Medicaid Services (CMS) and Center for Disease Control (CDC) guidelines, the facility failed to ensure infection control protocols were maintained during COVID-19 testing. The deficient practice could lead to the spread of infection. Findings include: During an interview conducted with the Infection Preventionist (IP/staff #60) on 03/03/22 at 8:52 AM, a Licensed Practical Nurse (LPN/staff #3) was observed to enter the L shaped office and remove testing supplies from the testing cart. The LPN was observed to place the testing supplies on the counter next to the microwave and begin the self-testing process. The LPN was not observed to perform hand hygiene, don gloves, or sanitize the counter next to the microwave before self-testing for COVID-19. Immediately following this observation, the IP was asked what their testing for COVID-19 process was. The IP stated that she would demonstrate their COVID-19 testing process. The IP moved the completed test card for staff #3 to the COVID-19 testing cart…

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 interview, facility document, and policy review, the facility failed to ensure their policy was implemented, by failing to ensure 4 residents (#378, #381, #387, and #388) and/or their representatives were educated regarding the benefits and potential side effects associated with the COVID-19 vaccine and offered the vaccine. The deficient practice could result in residents not being aware of the risks and benefits, and potential side effects of COVID-19 vaccines and not being offered the COVID-19 vaccine. Findings include: -Resident #378 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease and dementia. Review of the clinical record revealed no evidence the resident was educated regarding the benefits and risks, and potential side effects of the COVID-19 vaccine or that the resident was offered the COVID-19 vaccine. -Resident #381 was admitted to the facility on [DATE] with diagnoses that included infection and inflammatory reaction due 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, resident and staff interviews, and policy review, the facility failed to ensure that advance directives were consistent in the clinical record for one resident (#185). The sample size was 2. The deficient practice could result in residents receiving services which are not in accordance with their wishes. Finding include: Resident #185 was admitted to the facility on [DATE] with diagnoses that included a left femur fracture, anemia and heart failure. Review of the face sheet revealed the resident was a DNR (Do Not Resuscitate). Review of the Advance Directive signed 2/1/22 by the resident/responsible party and facility representative/title revealed the resident wishes to be a Full Code. The care plan initiated on 2/9/22 revealed the resident has an Advance Directive and is a Full Code. The goal was that the resident's Advance Directive will be honored. Interventions included the resident has decided to remain a Full Code. A physician order dated 2/24/22 stated the resident was 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, staff interviews, and facility policies and procedures, the facility failed to ensure the care plan was revised to include wounds for one resident (#45). The sample size was 23. The deficient practice could result in comprehensive care plans not being updated to include wounds for multiple residents. Findings include: Resident #45 admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, cognitive communication deficit, need for assistance with personal care, and pressure ulcer of sacral region. Review of a nurse progress note dated January 7, 2022 included a foam dressing to the coccyx was in place. Review of the Physical Therapy evaluation dated January 8, 2022 revealed the resident had skin tears, wounds to the bilateral lower extremities and arms, and that the number of wounds was 5. Review of a nurse progress note dated January 10, 2022 revealed zinc oxide was applied to the buttocks to prevent skin breakdown. Review of a nurse…

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, the Facility Assessment, facility documentation, and policy review, the facility failed to ensure one resident (#278) received consistent assistance with Activities of Daily Living (ADL). The sample size was 5. The deficient practice could result in residents not receiving assistance needed for ADL care. Findings include: Resident #278 was admitted on [DATE] with diagnoses of encounter for surgical aftercare following surgery on the circulatory system, muscle weakness and need for assistance with personal care. This resident was discharged from the facility on September 24, 2021. Review of the Care Plan initiated on September 14, 2021 revealed the resident needed ADL assistance and therapy services to maintain or attain the resident's highest level of function. The goal was that the resident wished to attain their prior level of function. Interventions included assisting the resident with mobility and ADLs as needed. Review of the ADL Task record for 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 review of policy and procedure, the facility failed to ensure one of three sampled residents (#128) received adequate supervision and assistive devices to prevent accidents. The deficient practice could result in increased resident injuries. Findings include: Resident #128 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, weakness, and cachexia. Review of the resident's care plan initiated on June 3, 2020 revealed the resident was at risk for fall. The goal was that the resident would not sustain serious injury requiring hospitalization. The interventions included for floor mats next to the bed. A review of the significant change in status Minimum Data Set assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The assessment included the resident had one fall since the prior assessment and sustained a major injury. The assessment also included 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 and resident interviews, and review of policies and procedures, the facility failed to provide bowel care as needed for one sampled resident (#45). The deficient practice could result in residents having constipation. Findings include: Resident #45 admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, oropharyngeal phase dysphagia, cognitive communication deficit, and difficulty in walking. Review of the physician orders dated January 6, 2022 revealed the following: -May use facility standing orders/protocols; -Milk of Magnesia suspension 400 milligrams (mg)/5 milliliters (ml) (magnesium hydroxide) give 30 ml by mouth as needed for constipation-no bowel movement (BM) on previous 9 shifts; -bisacodyl suppository 10 mg insert 1 suppository rectally as needed for constipation daily; -Fleet enema 7-19 grams (gm)/118 ml (sodium phosphates) insert one application rectally as needed for constipation if no results from suppository;…

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 policies and procedures, the facility failed to ensure one sampled resident (#45) diagnosed with dementia received the appropriate treatment and services. The deficient practice could result in residents with dementia not obtaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #45 admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, dementia without behavioral disturbance, history of a transient ischemic attack and cerebral infarction. Review of the physician's progress notes for January 7, 11, 15, and 19, 2022 included a diagnosis of dementia. Review of the baseline care plan signed January 11, 2022 did not address the resident's diagnosis of dementia. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed no assessment of cognitive patterns, mood, or behavior for this resident. Diagnoses included Non-Alzheimer's…

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, review of policies and procedures and the National Institute of Mental Health, the facility failed to ensure there was adequate indication for the use of an antipsychotic medication for one resident (#45). The sample size was 5. The deficient practice could result in residents receiving antipsychotic medications unnecessarily. Findings include: Resident #45 admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, dementia without behavioral disturbance, history of a transient ischemic attack and cerebral infarction. Review of the physician's orders dated January 6, 2022 revealed for Quetiapine Fumarate/Seroquel (antipsychotic) tablet 25 milligram (mg) give one tablet by mouth two times a day for anxiety as evidenced by (AEB) crying; and document the number of hours of anxiety as evidenced by (AEB) crying. Review of the Psychoactive Medication Informed Consent for Seroquel dated January 7, 2022 revealed an illegible single…

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.