Sandstone Of Tucson Rehab Centre

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of one resident (#333) to be free from financial misappropriation/exploitation of resident property by another resident (#111). The deficient practice could result in further financial abuse of residents when appropriate actions are not taken.-Regarding Resident #111 (alleged perpetrator):Resident #111 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder, obesity, and life management difficulty.Review of the care plan dated August 19, 2023, revealed that the resident has psychological aspects of chronic illness. The interventions included providing the Resident/Representative a list of community resources, and identifying the disease progression and when to notify the health care provider.A care plan dated October 25, 2023, revealed the resident has a history of self-harmful ideation (thoughts) and/or behaviors. 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 review of facility documentation and policies, the facility failed to maintain documentation that an alleged violation related to the allegation of financial misappropriation of property for one resident (#333) by another resident (#111) was thoroughly investigated. The deficient practice could result in further financial abuse of residents when appropriate actions are not taken.-Regarding Resident #111 (alleged perpetrator):Resident #111 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder, obesity, and life management difficulty.Review of the care plan dated August 19, 2023, revealed that the resident has psychological aspects of chronic illness. The interventions included providing the Resident/Representative a list of community resources, and identifying the disease progression and when to notify the health care provider.A care plan dated October 25, 2023, revealed the resident has a history of self-harmful…

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 facility documentation and policies, the facility failed to develop a baseline care plan within 48 hours of a resident's admission for one resident (#191), which provides instructions to meet the resident's immediate needs. The deficient practice could result in resident's treatments and needs not appropriately addressed.Findings Include:Resident #191 was readmitted to the facility on [DATE], with diagnoses that included rhabdomyolysis (is a rare muscle injury where your muscles break down), adult failure to thrive, major depressive disorder, difficulty walking, and cognitive communication deficit.A review of the Clinical admission Evaluation progress note dated August 3, 2024, revealed that the resident's admission mode was wheelchair. The Resident was alert and oriented times 3; alert (some forgetfulness).A physician-admission history and physical progress note dated August 3, 2024, revealed per documentation that resident was in a medical center…

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 facility documentation and policies, the facility failed to review and revised the care plan for one resident (#191) after each fall incident. The deficient practice could place the resident at risk for more falls.Findings Include:Resident #191 was readmitted to the facility on [DATE], with diagnoses that included rhabdomyolysis (is a rare muscle injury where your muscles break down), adult failure to thrive, major depressive disorder, difficulty walking, and cognitive communication deficit.A review of the Clinical admission Evaluation progress note dated August 3, 2024, revealed that the resident's admission mode was wheelchair. The Resident was alert and oriented times 3; alert (some forgetfulness).A physician-admission history and physical progress note dated August 3, 2024, revealed per documentation that resident was in a medical center with a 2- day history of weakness and falls at home, unable to ambulate with associated dizziness.An…

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, facility documentation, policy and procedures, the facility failed to identify elopement risks, and plan for effective supervision for resident one of three sampled residents (#888) related to risk factors for cognitively intact residents, and to ensure that one resident (#511) was supervised during activity sessions, and that activities were conducted safely. The deficient practice could result in avoidable accidents.Findings Include: -Regarding Resident #511 Resident #511 was readmitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus, factitious disorder imposed on self, borderline personality disorder, major depressive disorder, anxiety disorder, and Huntington's disease (is an inherited disorder, and develop uncontrollable dance-like movements (chorea) and abnormal body postures, as well as problems with behavior, emotion, thinking, and personality). The Resident's Clinical Resident Profile revealed that she was her own…

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, family, and staff interviews, and policy review, the facility failed to protect the resident's (#10) rights to be free from abuse by another resident (#5). This deficient practice could result in further incidents of resident to resident abuse. Findings include:-Resident #5 (Alleged Perpetrator) was admitted to the facility on [DATE], with diagnosis that include depression, psychosis, anxiety, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated November October 6, 2025 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognitive function. A review of Resident #5's care-plan revealed the resident had a confirmed resident to resident altercation, and a history of such, as well as a history of resident to staff altercations, with noted goals including, resident will have no altercations with staff or residents through the review date, and noted interventions of remove resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, review of facility documentation and policies, the facility failed to protect The rights of one resident (# 07) to be free from verbal and physical abuse by another resident (#33). This deficient practice has the potential to violate the resident's right to safety and prevent further harm. The sample size was 5. The facility census was 122. Findings include: -Regarding resident #7 Resident # 7 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; unspecified mood (affective) disorder, and autistic disorder. A review of the Interdisciplinary Team (IDT) Care Conference dated June 24, 2025, revealed the resident had a Brief Interview Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. A review of the shower sheet dated December 2, 2025 revealed no issues were identified on the skin.A review of the 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, and facility policy and procedure, the facility failed to protect the residents rights to be free from abuse by staff and other resident (#21, #9, #13, #2, #44, #10, #16, #40, #41, #42). The deficient practice could lead to further instances of abuse, thereby promoting an unsafe environment.Findings Include: -Regarding Resident #9 Resident #9 was admitted on [DATE] with diagnosis including paranoid schizophrenia, altered mental status, drug induced subacute dyskinesia, unspecified mental disorder due to known physiological condition, muscle weakness, lack of coordination, abnormalities of gait and mobility, cognitive communication deficit, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. A review of the modification of admission MDS (minimum data set) dated February 2, 2024 revealed a BIMS (brief interview of mental status) score of 0, indicating severe cognitive impairment. No potential indicators 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 clinical record review, staff interviews, facility documentation and policy review, the facility failed to implement policies and procedures for the documentation and reporting of alleged violations involving abuse for resident (#26). The deficient practice resulted in an allegation of abuse not being reported timely, and the potential for a resident not being protected from further abuse.-Regarding Resident #26Resident #26 was admitted on [DATE] and subsequently discharged on October 26, 2022 with diagnosis including morbid obesity with alveolar hypoventilation, chronic obstructive pulmonary disease, hypertension, type 2 diabetes mellitus with hyperglycemia, cellulitis, anemia, chronic pain syndrome, anxiety disorder, chronic and acute respiratory failure with hypoxia and unspecified schizoaffective disorder.Review of the physician orders revealed an order dated October 13, 2022 for a behavioral health services consultation. Additionally, an order was observed for Quetiapine Fumarate 100mg tablet to be…

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 (#200) was free from physical abuse from other residents (resident #300), and the facility failed to ensure that one resident #400 was free from abuse from staff. This deficient practice could result in further incidents of resident to resident abuse. Findings include:- Regarding resident #200 and resident #300. Review of information received from the SA complaint tracking system on October 18, 2025 at 5:40 a.m. revealed that on October 16, 2025 a complaint was received that revealed that resident #200 and resident #300 got into a verbal altercation in the dining room. The residents were separated, and then resident #300 took her electric chair and hit resident #200 in the leg, then the residents were again separated. -Resident #200Resident #200 was admitted to the facility on [DATE], with diagnosis that include heart disease, pneumonia, dementia, anxiety,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to protect the rights of 2 of 8 sampled residents (Resident #2 and #6) to be free from abuse by another resident (Resident # 1 and #5). The deficient practice could result in other residents being abused.Regarding Resident #1 on Resident #2 Abuse:-Regarding Resident #1:Resident # 1 was admitted [DATE] with diagnoses that included, sepsis, bacteremia, urinary tract infection, Schizophrenia, restlessness and agitation.A Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) that was unable to be completed due to Resident # 1 not understanding the questions and having a severely impaired altered level of consciousness. The MDS also revealed a history of physical behavior directed toward others.A comprehensive care plan dated October 22, 2025, revealed that Resident #1 had Schizophrenia symptoms that are manifested by cognitive memory impairment, and decreased…

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 protect the rights of on resident to be free from abuse (#2) by another resident (#4). The deficient practice could result in residents being physically and emotionally injured.-Regarding Resident #2Resident #2 was admitted to the facility March 27, 2025 with diagnosis including; cerebral palsy, unspecified, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, unspecified dementia, moderate, with other behavioral disturbance, mild cognitive impairment of uncertain or unknown etiology, major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified, impulse disorder, unspecified.Review of a care plan, initiated March 29, 2025, revealed the following areas of focus:Behaviors, the individual exhibits disruptive interpersonal behavior characterized by initiating or exacerbating conflicts among peers.Impaired physical mobility and cognitive impairment such as memory…

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, record reviews, and observations, the facility failed to implement its policies for preventing and prohibiting abuse were implemented consistently by staff, resulting in a delay in reporting resident to resident abuse to the state agencies, physician, abuse coordinator and family.Findings include:Review of the Facility Reported Incident (FRI) follow-up report dated August 22, 2025, revealed on August 21, 2025 at Resident #2 and Resident #4 were in their shared room and a Licensed Practical Nurse (LPN/staff #8) documented that Resident #4 told Resident #2 to stop yelling or he was going to beat him up. A Certified Nursing Assistant (CNA/staff #10) was present in the resident's room and was able to stand in between the residents, redirecting Resident #4 back to the bed on his side of the room. The facility conclusion verified the allegation. -Regarding Resident #2Resident #2 was admitted to the facility March 27, 2025 with diagnosis including cerebral palsy, hemiplegia and hemiparesis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, review of documentation, and review of facility policies, the facility failed to ensure that all allegations of abuse were reported to the state agency and other mandated entities within the required timeframe for two residents (#2) and (#4). The deficient practice could lead to a failure of the facility to report allegations of abuse timely, and could lead to continued abuse for a resident.Findings include:Review of the Facility Reported Incident (FRI) follow-up report dated August 22, 2025, revealed on August 21, 2025 at Resident #2 and Resident #4 were in their shared room and a Licensed Practical Nurse (LPN/staff #8) documented that Resident #4 told Resident #2 to stop yelling or he was going to beat him up. A Certified Nursing Assistant (CNA/staff #10) was present in the resident's room and was able to stand in between the residents, redirecting Resident #4 back to the bed on his side of the room. The facility conclusion verified the allegation. -Regarding Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, and policy review, the facility failed to protect the rights of two residents (#69, #77) to be free from abuse by another resident (#81, #76). The deficient practice could result in other residents being abused.Findings include: -Regarding Abuse allegation between Resident #77 (alleged victim) and Resident #76 (alleged perpetrator): Resident #77 (alleged victim) Resident #77 was originally admitted on [DATE] with diagnoses that included vascular dementia, type 2 diabetes mellitus and delirium. The assessment also indicated no evidence of behavioral symptoms were exhibited. A care plan revealed the following areas of focus:-Elopement risk/wanderer, , with interventions that included offering diversions and structured activities. -A second focus of elopement risk and/or exhibits wandering behavior related to vascular dementia. Interventions included to offer diversions, structured activities when wandering has increased.-On a secured unit related 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 an allegation of abuse was reported to the State Agency for one resident (#69). The deficient practice could result in abuse allegations not being reported. Findings include:Resident #69 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder, type 2 diabetes mellitus, opioid abuse, anxiety disorder, borderline and personality disorder. A nursing note dated July 12, 2025 at 10:45 AM signed by a Licensed Practical Nurse (LPN/staff #7) revealed that Resident #89 became upset, asking the nurse to do something to calm down Resident #81, because he was upset talking to himself, and when Resident #69 approached Resident #81 he cursed. The nurse wrote that she asked Resident #69 not to disturb Resident #81, but Resident #69 kept going back and forth from her room to the hallway looking at Resident #81. The nurse's note continued relaying that Resident #81 started putting…

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 policy and procedures, the facility failed to ensure that an allegation of verbal abuse and neglect, for one resident (#4), was reported to the State Survey Agency within the required timeframe. Findings include: Resident #4 was admitted on [DATE] with diagnosis including spinal stenosis-lumbar region without neurogenic claudication, hyperlipidemia, left foot drop, anxiety disorder, hypertension and chronic venous hypertension with ulcer and inflammation of bilateral lower extremities. A review of the quarterly MDS (minimum data set) dated February 28, 2025 revealed a BIMS (brief interview of mental status) score of 14 indicating that the resident was cognitively intact. The MDS further revealed that the resident had noted behavioral symptoms toward others 1-3 days a week and exhibited rejection of care 1-3 days a week. A review of the care plan revealed that the resident had an impaired coping mood disorder manifested by foul and abusive language to and about…

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 ensure that behaviors were monitored and documented prior to medication administration for 2 out of 3 residents sampled (#1, #2). The deficient practice could result in residents being over-medicated. Findings include: -Resident #1 was admitted on [DATE] with diagnosis including unspecified atrial fibrillation, chronic kidney disease, cerebral infarction without residual effects, major depressive disorder-recurrent, unspecified psychosis, hallucinations, cognitive communication deficit. A review of the MDS (minimum data set) dated August 8, 2024 revealed a BIMS (brief interview of mental status) score of 06 indicating severe cognitive impairment. A review of the physician orders revealed the following orders: Paroxetine HCI 10mg , 1.5 tablets by mouth once a day for antidepressant; Risperidone 0.5mg 1 tablet two times a day for psychotic disorder-delusions, paranoia, hallucinations. A 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 clinical record review, interviews, and policy review, the facility failed to ensure that one residents (#2) received treatment and care in accordance with professional standards of practice. The sample size was 3. This deficient practice could lead to residents not reciving the required care. Findings include: Resident #2 was admitted on [DATE] and discharged from the facility on December 9, 2024 with diagnosis including a wedge compression fracture of the first lumbar vertebra, unspecified fall, type 2 diabetes mellitus with hyperglycemia, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. A review of the MDS dated [DATE] revealed a BIMS score of 06, indicating severe cognitive impairment. A review of the care plan revealed that the resident was at risk for falls and interventions included: administer medications as ordered, monitor for potential side effects, ensure call light is within reach and respond promptly, and ensure resident is wearing…

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, facility documents and facility policy, the facility failed to ensure residents were free from abuse. This deficient practice could result in psychosocial harm and further instances of abuse. Findings include: Resident #114 was admitted on [DATE] with diagnoses of dementia and Bipolar Disorder. A 5 day MDS dated [DATE] included that this resident was moderately cognitively impaired with fluctuations of altered level of conscious, disorganized thinking and inattention. This resident requires partial/moderate assistance with lower body dressing and was independent with mobility. A care plan dated September 18, 2024 included that the resident had behavior concerns wandering into other resident rooms, and hoarding other resident's items/food related to dementia with an intervention to anticipate and meet the residents needs. A care plan included that the resident is on frequent checks for safety/wandering and includes an intervention on October 11, 2024 of safety…

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 two residents (#1) and (#2) were free from physical abuse. The deficient practice could result in further incidents of resident to resident abuse. Findings include: -Regarding resident #1 Resident #1 was admitted on [DATE] with diagnosis including alcohol-induced persisting amnestic disorder, Wernicke's encephalopathy, chronic obstructive pulmonary disease, epilepsy, cognitive communication deficit osteomyelitis and major depressive disorder-recurrent. A review of the care plan revealed a focus area indicating that the resident has a potential risk for alteration in mood state and psychological well-being with interventions including encouraging alternative communication, admission to a secure unit, documentation of all behaviors and monitoring of interactions and the presence of negative thoughts and feelings. The care plan further revealed a focus area of resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and review of facility policies the facility failed to ensure an avoidable elopement was prevented. The deficient practice could result in residents finding themselves in unsafe situations in the community, unsupervised. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses of mild cognitive impairment, nontraumatic intracerebral hemorrhage, schizoaffective disorder and aphasia. A review of the facility's assessment called Wander Risk Scale, completed on July 10, 2024, indicated resident #1 was a low risk for wandering/elopement. A review of the resident's electronic health record (EHR) revealed no other Wander Risk Scale assessment being completed during resident #1's stay. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 was unable to complete a Brief Interview for Mental Status (BIMS) assessment. As a result, staff assessed his cognitive skills for daily decision making as modified…

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 resident council minutes, resident and staff interviews, and policy and procedures, the facility was unable to demonstrate that resident council meetings were held regularly and that their response and rationale to grievances and recommendations voiced during resident council meetings were addressed. The facility census was 154. The deficient practice could result in residents' concerns, views, grievances or recommendations not being considered or acted upon by facility staff. Findings include: A review of the resident council minutes for the past 6 months, revealed no evidence of written documentation of feedback provided to residents regarding issues brought forth during resident council. A review of the grievance log revealed no evidence of written documentation that grievances had been addressed. The log denotes an open date but not a closed date. The grievance log provided by the director of social services, staff #8, revealed no evidence of any grievances logged prior to August 15, 2023.…

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

Based on observations, staff interviews and facility policy, the facility failed to ensure that meals were provided to residents seated together at the same time. This practice could result in compromised dignity for the residents and a decrease of mental health. Findings include: An observation was conducted on 11/01/23 at 12:30 PM of the downstairs B hall dining room of residents seated at tables with drinks. A food cart was brought to dining room, and trays are passed to residents as they are encountered on the cart without regard to the residents seating arrangements. A corner table seating 2 residents are served first and second to last, and all other tables are provided food in a similar manner. An interview was conducted on 11/02/23 at 2:01 PM with the Food Service Director (staff #81) who said that staff are supposed to serve all persons at the table at the same time and that they did not do so. An interview was conducted on 11/02/23 at 3:26 PM with the Administrator (staff #150) who said that staff should be serving tables all at once, not sporadically, and that residents…

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 procedure, the facility failed to ensure that one resident (#401) was informed of their rights during their stay at the facility. The deficient practice could result in residents not understanding their rights and being able to advocate for themselves. Findings include: Resident was admitted on [DATE] with a fracture of the left patella. During the resident interview, #401 stated that she was curious about her rights as a resident. When asked if she was provided a copy of here resident rights, she replied no. An interview was conducted on November 2, 2023 at 03:22 PM, with Licensed Practical Nurse (LPN staff #44). He stated when a new resident is admitted , the nurse reviews an admission packet with the resident, and has them sign the documents in the packet. Once signature is completed, the documents go to medical records for scanning into the electronic medical record. A review of the admission packet did not reveal a copy of the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and review of policy and procedure, the facility failed to ensure one was resident (51) was not physically abused by another resident (154). Findings include: Resident #51 was admitted on [DATE] with diagnoses that included dementia, major depressive disorder, and encephalopathy. Her orders included mirtazapine and trazadone to treat her depression, and donezepil and Depakote to manage dementia and behaviors. In a Minimum Data Set (MDS) assessment done on 01/26/2023 that recorded data from a 7 day look back period, Resident #51 scored an 8 on a Brief Interview for Mental Status which suggested moderate cognitive impairment. She did not display any behaviors such as aggression or wandering in the look back period. In her Care plan initiated in August 2023, Resident #51 has goals related to her disorientation and social skills with interventions that included orientating her to her environment and helping increase her comfort level and awareness. In a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1. Based on clinical record review, staff interviews, and policy review, the facility failed to ensure a referral for a PASARR (Preadmission Screening and Resident Review) level II determination was obtained timely for two residents (#56 and #38). The deficient practice could result in the resident not receiving the appropriate level of services. Findings include: Resident #56 was admitted [DATE] with diagnosis including schizoaffective disorder, unspecified bipolar disorder and epilepsy. A review of the quarterly MDS (minimum data set) dated October 18, 2023 revealed a BIMS (brief interview of mental status) score of 13, indicating the that the resident is cognitively intact. The same MDS revealed, under section I, active diagnosis including seizure disorder or epilepsy, bipolar disorder and schizophrenia. An interview was conducted on November 2, 2023 at 3:35 PM with the Director of Social Services, staff #8. Staff #8 stated that resident #56 did require a level II PASARR review and that he had sent the PASARR…

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 policy review, the facility failed to ensure one resident (#114) or resident's representative was able to participate in the care planning process. The sample size was 31. The deficient practice could result in residents and representatives not participating in and understanding their plan of care. Findings include: Resident #114 was admitted on [DATE] with diagnosis including peripheral vascular disease, morbid obesity, gout, difficulty walking, weakness, hypothyroidism and hypertension. A review of the quarterly MDS (minimum data set) dated October 3, 2023 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident is cognitively intact. A review of the progress notes in the resident's electronic health record did not reveal evidence of the resident's participation in the care plan conference. A review of the IDT (interdisciplinary care conference) summary did not reveal evidence of the resident's participation…

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 and policy, observations, and staff interviews the facility failed to ensure that at least one medication was not administered as ordered for three residents # 448, # 38, and # 99 out of five residents observed. The deficient practice of incorrect medication administration does not align with accepted professional standards of practice and may result in undesirable medication-induced harm due to residents receiving medications that were not ordered or incorrect doses of prescribed medications. Findings include: 1) Resident # 448 admitted into the facility on October 30, 2023 with diagnoses of Type 2 Diabetes Mellitus (DM2) with Hyperglycemia, Hypothyroidism, and Essential (Primary) Hypertension, had a medication order of Insulin Detemir: Insulin Detemir Subcutaneous Solution 100 unit/ml (Insulin Detemir) Inject 65 unit subcutaneously every morning and at bedtime for DM2. On November 2, 2023 at 7:46 AM, a medication administration observation was conducted with Licensed Practical Nurse (LPN/Staff # 44) on the 2nd floor A wing. Staff # 44 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.

Based on personnel file review, staff interviews, and the job description, the facility failed to ensure the activities program was directed by a qualified professional. Findings include: A review of the personnel file for the Activity Director (staff #80), revealed she was hired for the Activities Director position on February 28, 2023. Further review of the file did not reveal any evidence staff #80 had the qualifications for the position. An interview was conducted on November 2, 2023 at 01:30 PM, with the Director of Human Resources, (staff #58). She stated staff #80 transferred from another facility in Utah that is also a Sandstone property. At the time of her transfer, she did not have the training course for Activity Directors and the owners and Administrator (staff #63) knew that . The intention was to have staff #80 complete the training course at some point. However, as of now, there has not been any further discussion about it. She did state she will be following up on this. Review of the job description for the Activity Director revealed, the Activity Director provides…

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 records and policy, observations, and staff interviews the facility failed to ensure the environment for Resident # 58 remained free of accident hazards existing from medications at bedside and a potential risk of medication self-administration. The deficient practice of medication at bedside may result in undesirable medication-induced harm. Findings include: Resident # 58 was admitted initially into the facility on October 05, 2021 and re-admitted on [DATE] with diagnoses of Gram-negative Sepsis, Type 2 Diabetes Mellitus, and Major Depressive Disorder. The Annual Minimum Data Set assessment of Resident #58 dated October 29, 2023 reveals a Brief Interview for Mental Status score of 15 indicating the resident is cognitively intact. Review of medical records reveals no evidence of any medication self-administration assessment, request, or approval order by IDT (interdisciplinary team) for Resident # 58. Room observation of Resident # 58 was conducted twice on October 30, 2023 at 9:03…

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, interview and record review, the facility failed to ensure medication error rate was below 5% after 3 medication errors were observed during a combined 27 randomly selected medication administration opportunities by four licensed nurses for residents # 448, # 38, # 99. The facility's medication error rate was 11.11% as a result of three of four licensed nurses having at least one medication administration error upon individual observation. The deficient practice of medication errors at or exceeding 5% may result in undesirable medication-induced harm. Findings include: 1. Resident # 448 admitted into the facility on October 30, 2023 with diagnoses of Type 2 Diabetes Mellitus (DM 2) with Hyperglycemia, Hypothyroidism, and Essential (Primary) Hypertension, had a medication order of Insulin Determine: There was an order for Insulin Determine Subcutaneous Solution 100 unit/ml (Insulin Determine) Inject 65 unit subcutaneously every morning and at bedtime for DM 2. On November 2, 2023 at 7:46 AM, a medication administration observation was conducted with Licensed…

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 interview, and policy review, the facility failed to ensure that expired medications and devices were not readily accessible for use in the medication supply room and medication cart according to professional standards. The deficient practice may result in the use of expired supplies against manufacturer recommendation resulting in undesirable harm or alterations in effectiveness of medications and devices. Findings include: During a medication storage observation conducted on November 2, 2023 at 7:46 AM with a Licensed Practical Nurse (LPN/Staff # 44), a random inspection of expiration dates was performed of supplies stored in the 2nd floor medication storage supply room. Upon close inspection of enteral feeding supplies, 13 tube feeds tubing entraflo H2O safety spike connectors 1000 ml water bag pump sets were found to be expired. The expiration date on the 13 devices was written as July 28, 2023 on the outside of each of the sealed plastic bags. Staff # 44 confirmed expiration dates on the 13 tube feeds confirming that they were expired and all…

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 resident and staff interviews, a food test tray, and policy review, the facility failed to ensure food was provided that was palatable and at an appetizing temperature. The deficient practice has the potential for residents who disliked a meal to experience nutritional problems or dissatisfaction with their meals. Findings include: Review of resident council meeting minutes found 3 of 4 months included food complaints. An interview was conducted on 10/30/23 at 2:57 PM with the ombudsman who said that food had been brought up on several occasions as a concern. An interview was conducted on 10/30/23 at 10:27 AM with resident #95 who said that the food is not hot when it is supposed to be hot. An interview was conducted on 10/31/23 at 8:19 AM with resident #49 who said that the food is not good and often cold. An observation was conducted on 11/01/23 at 12:42 PM of a test tray. The test tray temperatures were taken by staff as follows: - beans 123 F - rice 106 F -taco meat 103 F An interview was conducted on 11/01/23 03:25 PM with resident #77 who said that the taco meal…

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 facility policy, the facility failed to ensure that a unit refrigerator was maintained to ensure food items were dated, expired foods were not available for consumption, and that foods were distributed in a manner to prevent illness. Findings include: An observation was conducted on 11/01/23 at 12:54 PM of an uncovered cart loaded with uncovered cakes brought from the kitchen and into a downstairs B hall dining room. Some trays were not served in the dining room and drinks including coffee and juice were added to the remaining trays. The drinks and cakes were not covered and were pushed down B hall, past COVID-19 isolation rooms before being served to the residents. An observation was conducted on 11/01/23 at 3:14 PM of a upstairs resident refrigerator/ freezer. A notice was posted on the outside of the refrigerator/ freezer to please make sure items are clearly marked with the resident's name, room number and date. The inside of the refrigerator door was marked with a brown spatter. This refrigerator included a fruit plate dated 10/31…

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 three residents (#s 10, 42, and 44) with a diagnosis of a serious mental illness were referred to the appropriate state-designated mental health or intellectual disability authority for review. The sample size was 8. The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: -Resident #10 was initially admitted on [DATE] with diagnoses that included quadriplegia, major depressive disorder, and dysphagia. Review of the clinical record revealed a Pre-admission Screening and Resident Review (PASRR) Level 1 was completed on May 25, 2022 with a diagnosis of major depressive disorder, and a PASRR Level 2 completed. Further review of the medical record revealed no evidence that the facility received notification of a Level 2 review and recommendation. Review of the clinical record revealed no evidence of psychiatric evaluation /treatment from admission 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 reviews, staff and family interviews, and policy review, the facility failed to initiate a baseline care plan within the required timeframe and provide a summary of that baseline care plan to residents (#s 405, 506, and 510) and their representatives. The sample size was 31. The deficient practice could result in residents not having a plan of care and not being aware of their plan of care. Findings include: -Resident #506 was admitted on [DATE] with diagnoses of rectal abscess, type 2 Diabetes Mellitus, and acquired absence of left leg above knee. Review of the clinical record did not reveal a baseline care plan. Review of a care plan initiated on July 11, 2022 revealed that it consisted of 1 focus for nutrition/hydration. However, this care plan did not include infection, the resident's requirements for assistance, wound care, pain or any other required elements other than nutrition/hydration. A Social Services note dated July 11, 2022 revealed the writer called the resident's spouse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the clinical record review, facility documents, staff interviews and facility policy, the facility failed to ensure that bathing assistance was provided for three residents (#s 38, 510, and 132). The sample size was 9. The deficient practice could result in residents' hygiene needs not being met. Findings include: -Resident #38 was admitted on [DATE] with diagnoses of dementia, type 2 diabetes mellitus and anxiety disorder. This resident was out of the facility from May 19, 2022 to May 26, 2022. Review of the Activities of Daily Living (ADL) Lookback Reports for May 2022 revealed this resident received bathing assistance on May 4, 2022. However, no other showers were recorded for May 2022. Review of the shower sheets for May 2022 indicated this resident had 1 shower on May 4, 2022. No other showers were recorded for May, 2022. A quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that an allegation of staff to resident abuse was reported to the State agency within the required 2-hour timeframe for one resident (#19). The deficient practice could result in allegations of abuse not being reported. Findings include: Resident #19 admitted to the facility on [DATE] with diagnoses that included pneumonia, type 2 diabetes mellitus with hyperglycemia, and unspecified protein-calorie malnutrition. Review of an admission 5-day Minimum Data Set assessment dated [DATE] revealed the resident scored 4 on the Brief Interview for Mental Status assessment, indicating severe cognitive impairment. The resident required supervision to extensive 1-person physical assistance for most activities of daily living. On 09/12/22 at 2:02 p.m., a phone interview was conducted with the resident's family member/representative. The representative stated that he had been talking to the resident on 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 policies and procedures, the facility failed to ensure one resident (#81) had a level I PASRR (Pre-admission Screening and Resident Review), upon admission. The sample size was 8. The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: Resident #81 was admitted to the facility April 6, 2022 with diagnoses that included bipolar disorder, current episode depression (mild to moderate severity), adjustment disorder with mixed anxiety and depressed mood, anxiety disorder, and recurrent major depressive disorder. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15, which indicated the resident's cognitive status was intact. The active diagnoses included anxiety disorder, depression (other than bipolar), and bipolar disorder. However, further clinical record review revealed no evidence of a PASRR (Medicaid…

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 resident's (#19) comprehensive care plan included diabetes management and related insulin use. The sample size was 31. The deficient practice may result in an incomplete plan of care for residents. Findings include: Resident #19 admitted to the facility on [DATE] with diagnoses including pneumonia, type 2 diabetes mellitus (DM) with hyperglycemia, and unspecified protein calorie malnutrition. Review of physician orders included: -pioglitazone HCl (thiazolidinedione) 30 milligrams (mg); give 1 tablet one time a day for DM. Order dated 05/25/22. -Metformin (biguanide) HCl tablet 500 mg; give 500 mg two times a day for DM. Order dated 06/03/2022. The admission 5-day Minimum Data Set assessment dated [DATE] revealed the resident scored 4 on the Brief Interview for Mental Status, indicating severely impaired cognition. The resident required supervision to extensive assistance with most activities…

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 facility policies, the facility failed to ensure services provided to one resident (#16) met professional standards of quality care. The deficient practice could result in residents receiving services that do not meet standards of quality. Findings include: Resident #16 was initially admitted on [DATE] with diagnoses that included pneumonia, seizures, encephalitis and encephalomyelitis, cerebral cryptococcosis and disorder of the brain. Review of the physician order summary report (order date range: June 2, 2022 - September 30, 2022) revealed: -Enteral feed order two times a day Osmolite 1.5 at 60 ml (milliliter)/hour x 20 hours/day per peg via pump (off at 10:00 AM and on at 2:00 PM). -Turn off feeding at 10:00 AM, turn back on at 2:00 PM every day shift. -Enteral feed order every 4 hours, flush the peg tube with 100 ml of water. -Vancomycin HCL Solution 500 mg (milligram)/100 ml, use 500 mg intravenously every 12 hours for bacteremia for 28…

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 the clinical record review and staff interviews, the facility failed to ensure that one sampled resident (#38) was provided care in accordance with professional standards of care regarding an ultrasound. The deficient practice could result in delayed treatment for residents. Findings include: Resident #38 was admitted on [DATE] with diagnoses of dementia, type 2 diabetes mellitus and anxiety disorder. This resident was out of the facility from May 19, 2022 to May 26, 2022. A nurse's note dated May 14, 2022 included the resident had a swollen right foot and the writer assessed it. The note also included the resident's feet were elevated and the provider would be notified. A physician's order dated May 14, 2022 included venous ultrasound of the right foot STAT for edema. A nurse's note dated May 19, 2022 revealed the writer called the mobile diagnostic company on May 14, 2022 to order the STAT venous ultrasound order and the company said the soonest the ultrasound would be done was Monday, May 16, 2022.…

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, clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#16) received care and treatments consistent with professional standards of practice to promote healing and prevention of pressure ulcers. The sample size was 4. The deficient practice could result in delayed healing of pressure ulcers. Findings include: Resident #16 was initially admitted on [DATE] with diagnoses that included pneumonia, seizures, encephalitis and encephalomyelitis, cerebral cryptococcosis and disorder of the brain. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated the resident had intact cognition. The assessment also revealed the resident required extensive assistance of two-person physical assistance for bed mobility, and was admitted with three deep tissue injuries. Review of the census report revealed the resident had been discharged on July 28, 2022 and re-admitted on [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 review, staff interviews, and review of policy and procedure, the facility failed to ensure one resident (#205) with extensive behavioral health needs was transferred or discharged due to her welfare, and/or her needs could not be met in the facility, and/or the safety of individuals in the facility were being endangered due to the clinical/behavioral needs of the resident. Findings include: Resident #205 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included paranoid schizophrenia, obsessive-compulsive disorder, and anxiety disorder. A Level II Pre-admission Screening and Resident Review (PASRR) dated 02/16/17 was identified in the clinical record. A behavioral care plan revised on 04/02/21 related to a history of refusing care, being combative with care, making false accusations, non-compliance in care and treatments, obsession and delusions regarding time and tasks, and verbal aggression. A nursing note dated 04/20/21 at 3:04 p.m. included 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 interview, and policy review, the facility failed to act upon the pharmacy Medication Regimen Review for one resident (#81). The sample size was 5. The deficient practice could result in MRRs not being followed through. Findings include: Resident #81 was admitted to the facility April 6, 2022 with diagnoses that included diabetes type 2, essential (primary) hypertension, and heart failure. Regarding heparin Review of the physician orders dated April 6, 2022, revealed an order for Heparin Sodium Solution 5000 unit/milliliter, inject 5000 units subcutaneously every 12 hours for clotting prevention. Review of a quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 15, which indicated the resident's cognitive status was intact. The active diagnoses included heart failure, hypertension, and diabetes mellitus. The MDS assessment revealed the resident received 7 days of injections and anticoagulant medication during…

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, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure one resident (#125) was consistently served food that accommodated the resident's food allergies. The sample size was 9. The deficient practice increases the risk for food-related allergic reactions. Findings include: Resident #125 was admitted to the facility on [DATE] with diagnoses that included morbid obesity due to excess calories, necrotizing fasciitis, and type 2 diabetes mellitus with hyperglycemia. Review of the resident Medical Diagnosis profile indicated the resident food allergies included fish, peaches, and seafood. A nutrition/hydration care plan revised on 09/14/22 related to morbid obesity had a goal for the resident to maintain adequate nutritional status. Interventions included providing and serving diet as ordered. On 09/15/22 at 12:24 p.m., an observation of the resident was conducted. The resident was in the process of sending the meal tray back to 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.

Based on staff interview, facility policy, and review of the Center for Disease Control (CDC) recommendations, the facility failed to designate a qualified individual as the Infection Preventionist (IP) on an ongoing basis. The deficient practice could result in improper infection prevention practices within the facility. Findings include: During an interview conducted on September 14, 2022 at 2:30 PM with the interim Director of Nursing (DON/staff #141), the DON stated the previous DON last day of employment at the facility was on June 10, 2022. The DON further stated that the facility did not have Infection Preventionist (IP) coverage until August 25, 2022. She also stated that there was no one else in the facility that had been trained as an IP. She stated that she knew that this did not meet the requirements. The DON stated that she has been covering as IP since August 25, 2022. Review of the facility policy titled, Infection Prevention, revealed the infection prevention and control (IPC) program is coordinated and overseen by an infection prevention specialist (Infection…

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 clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that residents, their representatives and families were notified of positive COVID-19 cases occurring in the facility, within the required timeframe. The deficient practice could result in residents and their representatives/families not being aware of new COVID-19 cases in the facility and the actions implemented to reduce the risk of transmission. Findings include: Review of the facility Line Listing revealed evidence of two staff members (#61 and #51) that had positive COVID-19 tests: -Staff #61 had a positive COVID test result on August 26, 2022 with signs/symptoms that included congestion, runny nose. -Staff #51 had a positive COVID test result on August 28, 2022 with symptoms that included fever, cough, headache, congestion, and runny nose. Further review of the facility website for COVID-19 Reporting revealed evidence that the website had been updated on September 1, 2022, and prior to that, notification was on August 25, 2022. Further review of the website…

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 staff interview and facility policy, the facility failed to develop and implement their policy to ensure that contracted staff were vaccinated for COVID-19. The deficient practice may result in other staff not being vaccinated for COVID-19. Findings include: A request was made on September 13, 2022 upon entrance to the facility, for the COVID-19 vaccination status records for contract staff that enter the facility. Further request for the list of vaccination status records for contract staff on September 14, 2022 at 2:33 PM was not provided. An interview was conducted with the interim Director of Nursing (DON/staff #141) on September 14, 2022 at 2:30 PM, who stated that they do not have a list of the vaccination status of contract staff that enter the facility. She also stated that they do not have a way to track or ensure vaccination status for contracted staff. The DON stated that she was aware this requirement was issued at the beginning of 2022. Review of the facility policy titled, Coronavirus Disease (COVID-19) Vaccination of Staff, revealed that all staff are…

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

Based on personnel file review, staff interviews, and policy reviews, the facility failed to provide evidence that 1 out of 10 sampled staff (#143) received training regarding abuse, neglect, exploitation, misappropriation of resident property, and dementia management. The deficient practice could result in staff not being educated regarding abuse, neglect, exploitation, misappropriation of resident property, and dementia management. Findings include: Staff #143 was hired on 02/2022 as a Registered Nurse (RN) through a contracted agency. Review of staff #143's personnel file revealed no evidence that she had completed training during orientation, which included training on abuse, neglect, exploitation, misappropriation of resident property, or dementia management. On 09/15/22 at 11:23 a.m., an interview was conducted with the Director of Human Resources (staff #82). She stated the competencies that are required on a yearly basis included skills, abuse, resident rights, and dementia care for staff that work in direct care positions such as Certified Nursing Assistants, nurses, and…

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