Buena Vista Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the necessary care and services were provided for one of one final sampled resident (Resident 1) reviewed for accident hazards. * The facility failed to timely monitor and document the neurological assessments for Resident 1's unwitnessed fall incident on 5/1/25. This failure had the potential to place the resident at risk for serious injury.Findings: Medical record review for Resident 1 was initiated on 12/15/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's eINTERACT Change in Condition Evaluation - V 5.1 dated 5/1/25 at 0310 hours, showed Resident 1 had an unwitnessed fall and was found sitting on the floor beside his bed. Resident 1 was noted to have a small amount of blood and a small bump at the right temporal area (near the temples of the head) of his head. Resident 1 was on an anticoagulant (blood thinner) medication but Resident 1 refused an acute care hospital transfer.…

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, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation and administration of the medications. * The facility failed to ensure the oral and IV emergency medication kits were replaced timely. * The facility failed to ensure the administration of the controlled medications for Residents 53 and 81 were documented in the MAR. * LVN 4 failed to administer the full dose of the cranberry supplement via GT for Resident 2. These failures had the potential for diversion of the controlled medication, medication administration error, and negative residents outcomes.Findings: Review of the facility's P&P titled Administering Medications revised April 2023 showed:- Medications are administered in a safe and timely manner, and as prescribed.- The individual administering the medication initials the resident's MAR on the appropriate line or EMAR after giving each medication and before administering the next…

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, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 23.08% (for six medication errors out of 26 total opportunities). One of six licensed nurses (LVN 4) who were observed during medication administration was found to have errors. * LVN 4 failed to ensure all the medication residual was administered via GT to Resident 2 for six of 14 medications administered. This failure had the risk for the resident to have potential side effects or complications related to the medications.Findings: On 12/15/25 at 0818 hours, a medication administration observation for Resident 2 was conducted with LVN 4. LVN 4 prepared and administered the following medications to Resident 2:- One tablet of amlodipine (used to treat high blood pressure) 5 mg;- One tablet of aspirin (used to relieve pain, fever and inflammation; acts as a blood thinner) 81 mg;- One tablet of atenolol (used to treat high…

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, interview, facility document review, and facility P&P review, the facility failed to ensure food served was palatable, attractive, and at a safe and appetizing temperature for two of 87 Residents (Residents 53 and 81) who received food prepared in the kitchen. * Resident 53 and 81's meals were delivered and served cold. * Resident 53's beef was tough to cut with a knife and difficult to chew. These failures had the potential for decreased meal intake which could result in weight loss, decreased nutritive value, and negatively impact the residents' quality of life for all 87 residents who received food prepared in the kitchen. Findings: Review of the facility's Resident Matrix (list of all the residents currently in the facility and care areas triggered) received on 12/15/25, showed 87 out of 89 residents consumed food prepared in the kitchen. Review of the facility's policy titled Food Preparation and Service revised 11/2022 showed under Food Preparation, Cooking and Holding…

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, interview, facility P&P review, and document review, the facility failed to ensure the facility's P&P on Foods Brought by Family/Visitors was followed. * The facility failed to ensure the safe food handling practices of outside food were explained to family/visitors in a language and format they understood. This failure had the potential to cause foodborne illness to the medically vulnerable resident population who consumed food [NAME] from outside resources.Findings: Review of CMS S&C-09-39 dated 5/29/09, showed the residents had the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. The CMS guideline further showed the facility has the responsibility under the food safety regulation to help the visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit. Review of the facility's P&P titled Foods Brought by…

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

Based on observation, interview, and facility P&P review, the facility failed to maintain the essential equipment in a clean, sanitary, and safe operating condition for one of two washing machines inspected (Washing Machine 1). * Washing Machine 1 was observed with dark red, green, and white build up on the inner door window. In addition, the rubber lining of the inside of the washing machine door was observed with thick brown and white build up. These failures had the potential for the essential equipment to not function in the way it was intended and expose the residents to unsafe practices.Findings: Review of the facility's P&P titled Maintenance Service revised 12/2009 showed the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 1. On 12/15/25 at 1046 hours, an interview and concurrent…

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, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest physical well-being for one of five sampled residents (Resident 5). * The facility failed to provide the wound care treatments for Resident 5's left foot wounds as ordered by the physician. This failure had the potential for Resident 5 to not receive the appropriate care and services to treat his left foot wounds. Finding: Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown- Clinical Protocol dated 4/2018 showed the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. Medical record review for Resident 5 was initiated on 12/19/24. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's H&P examination dated 7/22/24, showed Resident 5 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 3) remained free from the accident hazards. * The facility failed to implement the bilateral floor mats as per the physician's order and plan of care for Resident 3 who was a high risk for falls and had a history of falls with injuries. This failure had the potential to place Resident 3 at risk for serious injury. Findings: Review of the facility's P&P titled Falls and Fall Risk, Managing revised 3/2018 showed the staff member, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Medical record review for Resident 3 was initiated on 12/23/24. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's H&P examination dated 9/13/24, showed Resident 3 was confused but was able 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 interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain management was provided for one of three sampled residents (Resident 2). * The facility failed to ensure Resident 2 was consistently provided the non-pharmacological pain interventions prior to the administration of acetaminophen (analgesic) medication. This failure had the potential to put Resident 2 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication. Finding: Review of the facility's P&P titled Pain Assessment and Management revised 10/2022 showed the non-pharmacological interventions may be appropriate alone or in conjunction with medications. Pharmacologic interventions (i.e. analgesic) may be prescribed to manage pain, however they do not usually address the cause of pain and can have adverse effects on the resident (e.g. drowsiness, increased risk of falling; loss of appetite). Closed medical record review for Resident 2 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 observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. The cool down process for time, temperature control for safety (TCS) food, food that need to be kept at specific temperatures to prevent bacteria growth and foodborne illnesses, was not monitored. 2. Food preparation surfaces were not sanitized. 3. Fresh lettuce was not washed prior to use. 4. A sanitizing solution was not available for manual dishwashing in emergency situations. 5. Gloves were not used appropriately. 6. Facial hair was not covered. 7. Two of 14 kitchen employees had drinking cups or personal drinking containers in the kitchen. 8. One of 14 kitchen employees wore artificial nails and jewelry during food preparation. 9. Food preparation equipment and utensils were not clean or in good working condition. 10. Meal preparation equipment was not air dried. 11. The kitchen environment was not clean or in good working order. 12. Cleaning equipment was not stored in a sanitary manner. 13. A food…

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 interview, medical record review, facility document review, and facility P&P review, the facility failed to effectively respond to the repeated concerns of cold food brought up in the monthly Resident Council meetings. This failure resulted in the Resident Councils concerns of cold meals being an ongoing issue, putting the residents at risk of undesirable outcomes. Findings: Review of the facility's P&P titled Resident Council, revised February 2021 showed the purpose of Resident Council is for residents to discuss concerns and suggestions for improvement. The facility department related to any issues will be responsible for addressing the items of concern. Review of the facility's P&P titled Food Temperature Policy updated March 2019 showed foods should be transported as quickly as possible to maintain temperatures for delivery and service. If food transportation time is extensive, food should be transported using a method that maintains temperatures. Foods sent to the unit for distribution will 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.

Based on observation, interview, and facility document review, the facility failed to ensure the menus were followed for 20 of 84 residents (two final sampled residents, Residents 1 and 31; and 18 nonsampled residents, Residents 2, 4, 9, 13, 15, 17, 21, 24, 51, 57, 59, 65, 69, 74, 85, 86, 446, and 791) who received a pureed diet; and 27 of 84 residents (two final sampled residents, Residents 27 and 31; and 25 nonsampled residents, Residents 2, 4, 7, 9, 13, 14, 17, 24, 32, 37, 38, 41, 45, 46, 49, 51, 57, 59, 61, 60, 69, 70, 80, 85, 791) who received a fortified diet when: 1. The pureed green bean recipe was not followed, 2. The correct portion size was not utilized for the pureed meat, 3. Mashed potatoes were not served to pureed diets, 4. Menu changes were not documented or approved by the Registered Dietitian, and 5. Fortified diets were not followed. These failures had the potential to not meet the resident's nutritional needs. Findings: Review of the facility's matrix showed 84 of 88 residents consumed food prepared in the kitchen. 20 of 84 residents (two final sampled 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 observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed for two of 20 final sampled residents (Resident 33 and 75) and three nonsampled residents (Residents 41, 61 and 791); in the laundry area; devices surfaces cleaning; hand washing; and preventing Legionella. In addition, the facility failed to ensure the infection control ;surveillance log was accurate. * Resident 41's bedside commode was not clean. * Resident 61's flush syringe touched the resident's blanket and the RN fanned the resident's uncapped iv port with her hand . * The facility's infection control surveillance logs were inaccurate. * The facility's laundry area had multiple infection control concerns. * The facility's decorative fountain was not monitored to prevent Legionella. * The facility's sit to stand device did not have a cleanable surface. * The facility failed to ensure the staff wore gloves and gown for 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 observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in the safe operating conditions when: * The ice machine was not clean. * The ice machine was not cleaned and sanitized as per the manufacturer's instructions. * The ice storage bin did not have an air gap to prevent backflow. These failures had the potential for the essential equipment not functioning in the way they were intended and in turn cause contamination of food, leading to illnesses for the residents. Findings: Review of the facility's matrix showed 84 residents consumed food prepared in the kitchen. Review of the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. 1. On 10/29/24 at 1048 hours, an observation and concurrent interview was conducted with the MS. When the MS was asked about the cleaning of the ice machine, 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, interview, medical record review, and P&P review, the facility failed to ensure the medications were safely administered for one of 20 final sampled residents (Resident 35) and one nonsmapled resident (Resident 69) to self- administer medications. * Resident 69 was observed to have two bottles of Nerve Shield Pro (used as supplement for Brain & Nervous System Health, Neuropathy, Nerve Pain) at the bedside and had self-administered the medication. * Resident 35 was observed to have Tums (medication to relieve heartburn/stomach upset) tablet at bedside. These failures had the potential to negatively impact the residents' physiological well-being and administer the medications inaccurately. Findings: Review of the facility's P&P titled Self-Administration of Medications revised 2/2021 showed the residents have the right to self-administer medications if the Interdisciplinary Team has determined that is clinically appropriate for the resident. 1. Medical record review for Resident 69 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 observation, interview, and medical record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 20 final sampled residents (Resident 67) and one nonsampled residents (Resident 41). * Resident 41's care plan failed to address the use of a bedside commode. * Resident 67's care plan failed to address the resident's psychosocial needs and failed to implement non-pharmacological interventions attempted for his behaviors were documented for risperidone use. These failures posed the risk of the residents not receiving services that were person-centered to meet the specific needs of each resident. Findings: 1. On 10/29/24 at 1418 hours, a strong constant urine odor was in the hallway outside the facility's conference room. On 10/29/24 at 1545 hours, a concurrent observation and interview was conducted with the IP. The IP identified the urine odor coming from Resident 41's bedside commode. The IP verified the bedside commode needed to be emptied. On 10/30/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide an ongoing program to provide activities designed to meet the specific needs of the residents and encouraging both independence and interaction in the community for two of 20 final sampled residents (Residents 66 and 67). This failure posed the risk of not supporting the residents' psychosocial well-being. Findings: 1. On 10/29/24 at 1049 hours, a concurrent observation of Resident 67 and interview was conducted with Resident 67's roommate, Resident 66. Resident 67 was observed lying in bed on his right side. Resident 66 stated Resident 67 screamed all evening, verbalizing wanting to go to the gym. Resident 66 further stated Resident 67 did not allow him to sleep. During this observation, Resident 67 kept repeating he wanted to go to the gym. Resident 67 then started whining, and stated he wanted to go to the gym. Medical record review for Resident 67 was initiated on 10/29/24. Resident 67 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 12) and one nonsampled resident (Resident 57) were free from the accident hazards. * The facility failed to store the razors in a secure area when not in use. This failure had the potential to place Residents 12 and 57 at risk for serious injury. Findings: Review of the facility's P&P titled Safety Information - Illness and Injury Prevention Program (undated) showed the facility does everything within reason to prevent injury and illness to employees, residents, and guests which includes supply and material handling: any sharp objects are put away when not in use. On 10/30/24 at 900 hours, during a follow-up observation in Residents 12 and 57's room, an opened pack of razors was observed in Residents 12 and 57's drawers at their bedsides. CNA 5 verified the the pack of razors from Residents 12 and 57's bedside drawer and removed the razors. a. Medical record…

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, interview, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for one of one final sampled resident (Resident 66) reviewed for IV care. * The facility failed to to ensure the IV catheter site for Resident 66 was labeled. This failure had the potential to delay the identification of catheter related complications for Resident 66. Findings: Review of the facility's P&P titled Peripheral Venous Catheter Insertion dated March 2023 showed IV sites are to have date, time, and initials on the dressing label. On 10/29/24 at 1101 hours, Resident 66 was observed in bed with his IV site unlabeled, with no date, time, or staff initials. Medical record review for Resident 66 was initiated on 10/29/24. Resident 66 was admitted to the facility on [DATE]. Resident 66 was admitted to the facility with diagnoses including UTI. On 10/31/24 at 1044 hours, an observation and concurrent interview was conducted with RN 1. When asked about the labeling…

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, interview, medical record review, and facility P&P review, the facility failed to ensure the respiratory care orders were properly maintained and administered as ordered for two of 20 final sampled residents (Residents 1 and 83). * The facility failed to follow the physician's order for Resident 83's oxygen therapy. * The facility failed to ensure Resident 1's oxygen tubing was dated. These failures had the potential for the residents to not receive oxygen as ordered and adequate respiratory care. Findings: Review of the facility's P&P titled Oxygen Administration revised on 10/2010, showed to verify that there is a physician's order for this procedure, and to review the physician's orders or facility protocol for oxygen administration. 1. On 10/29/24 at 0906 hours, during the initial tour observation, Resident 83 was observed lying in bed with oxygen on via nasal cannula which was attached to the oxygen machine concentrator setting at 4 liters per minute. On 10/29/24 at 1603 hours, 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, interview, record review and the facility P&P, the facility failed to ensure pharmaceutical procedures were followed for one of one final sampled residents (Resident 27) investigated for pain and one of two residents (final sampled resident, Resident 35) reviewed for self-administration of medication * Resident 27's Percocet (an opioid based pain reliever) was removed from the supply but not documented as administered in the MAR on six occasions. * Resident 35 was observed with the medications at bedside. Resident 35 did not have a physician's order, assessment, and care plan for the self-administration of medications. These failures had the potential to put the resident at risk of unsafe pharmaceutical practices. Findings: 1. Review of Resident 27's Order Summary Report dated 10/30/24, showed a physician's order for Percocet 7.5-325 mg every six hours as needed for severe pain. Review of Resident 27's Antibiotic or Controlled Drug Record form initiated 9/14/24, showed one tablet 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 observation, interview, and medical record review, the facility failed to ensure the following was completed for two of 20 final sampled residents (Residents 66 and 67): * Non-pharmacological interventions for Resident 67's risperidone were not documented * There was no clear indication for Resident 67's risperidone * The valproic acid level was not completed for Resident 67's use of valproic acid * There was no montioring and no documentation for discoloration related to Resident 66's use of humalog These failures posed the risk of inadequate monitoring. Findings: 1. Review of the facility's P&P Psychotropic Medication Use effective 6/21, showed facility staff should document the resident's response to staff interventions for residents' behaviors. Medical record review for Resident 67 was initiated on 10/29/24. Resident 67 was admitted to the facility on [DATE]. Review of Resident 67's H&P examination dated 9/28/24, showed Resident 67's diagnoses included developmental delay and psychosis. Resident 67…

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 interview, medical record review, and facility P&P review, the facility failed to ensure one of five residents (one final sampled resident, Resident 30) reviewed for unnecessary medications was free from unnecessary psychotropic (medications which affect the brain and the nervous system to treat mental illness and conditions which impact behavior and emotions) drugs. * The facility failed to ensure Resident 30 was properly monitored for orthostatic blood pressures (measure the blood pressure while laying down or sitting and again upon standing up) as ordered by the physician for the use of the olanzapine (a medication for mental disorders including schizophrenia and bipolar disorder). This failure had the potential for Resident 30 to experience adverse consequences from the psychotropic medication. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 7/2022 showed the residents receiving psychotropic medications are monitored for adverse consequences, including cardiovascular…

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, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.69 %. * The facility failed to ensure LVN 3 administered Resident 75's metformin HCl (medication to lower blood sugar) and cholecalciferol (vitamin D supplement) as ordered. This failure had the potential to cause negative outcome for Resident 75. Findings: Review of the facility's P&P titled Administrating Medications dated 4/2019 showed the medications are administered in accordance with prescriber orders, including any required time frame. Medical record review for Resident 75 was initiated on 10/29/24. Resident 75 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 75's Order Summary Report 10/31/24, showed the following physician's orders: - dated 7/15/24, to administer cholecalciferol 50 mcg one tablet by mouth one time a day. - dated 8/2/24, to administer metformin HCl 500 mg one…

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, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper medication storage when: * The facility failed to ensure the expired medications were removed from Medication Cart C. * The facility failed to store internal and external medications separately. These failures had the potential to negatively impact the residents' well-being, and medication errors. Findings: 1. Review of the facility's P&P titled Disposal of Medications and Medication-Related Supplies dated 12/2018, showed the following: - When medications are expired, discontinued by a prescriber, a resident is transferred or discharged and does not take medication with him/her, or in the event of a resident's death, the medications are marked as discontinued or stored in a separate location and later destroyed. - If a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified or shall be stored in 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.

Based on observation, interview and facility document review, the facility failed to ensure the CDM was competent in managing the day-to-day functions of the food services department. In addition, the facility failed to ensure the RD had adequate oversight of the food service department. This failure to employ staff with the skills and abilities to effectively implement departmental processes in accordance with standards of practice had the potential to jeopardize the health and well-being of the 84 residents who received food prepared in the kitchen. Findings: Review of the facility's matrix showed 84 residents consumed food prepared in the kitchen. Review of the facility's document titled Dietary Manager signed and dated by the CDM on 4/16/20 showed, the purpose of job description is to organize, plan and supervise the dietary department functions in accordance with current applicable federal, state, and local standards that govern the facility and as directed by the Administrator and/or Dietitian. Under essential duties and responsibilities, monitoring staff to confirm they…

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 facility P&P review, the facility failed to ensure nutritive value was preserved when pureed vegetables were prepared two hours prior to meal service and held on a hot steam table. This failure had the potential for the resdients who received a pureed diet to not meet their nutritional needs. Findings: Review of the facility's matrix showed 84 of 88 residents consumed food prepared in the kitchen. 20 of 84 residents received a pureed diet. Review of the facility's P&P titled Guidelines for the Food and Nutrition Service Department revised 2/4/2020, showed F. Vegetable Preparation 2. Vegetables are high in nutritive value and contribute to the attractiveness and acceptability of the meal. Care should always be taken to prevent destroying their nutritive valve. Vegetables should be cooked in a small amount of water and only long enough to make them tender. On 10/31/24 at 0844 hours, during the lunch meal puree food preparation with [NAME] 1, [NAME] 1 stated he boiled the frozen green beans with water, vegetable broth, garlic and pepper. [NAME] 1…

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 facility document review, the facility failed to ensure 20 residents of 84 (three final sampled residents, Residents 12, 30, and 47; and 17 nonsampled residents, Residents 11, 14, 16, 18, 29, 32, 41, 49, 50, 63, 66, 68, 71, 80, 84, 444, and 791) who were on mechanically altered diets received ground meat. This failure had the potential for these residents to be at risk for choking. Findings: Review of the facility's matrix showed 84 of 88 residents consumed food prepared in the kitchen. 20 of 84 residents (Residents 11, 12, 14, 16, 18, 29, 30. 32, 41, 47, 49, 50, 63, 66, 68, 71, 80, 84, 444, and 791) received a mechanical soft ground diet. Review of the facility's Diet Manual revised August 2023 showed the Mechanical Soft (Ground) diet should provide meat that is ground or chopped. Ground meat was defined as 1/8 or less. Review of the facility's document titled Therapeutic Spreadsheet dated 10/31/24, showed the Mechanical Soft diets should have received two ounces of ground chicken and Soft Bite Sized diet should have received two ounces of bite…

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, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurately documented for three of 20 final sampled residents (Resident 30, 33, and 60) and one closed record (Resident 90). * The facility failed to ensure Resident 33's blood pressure access site was accurately documented in the resident's medical record. * Resident 60's TAR had two blank treatment administrations. * Resident 90's POLST was incomplete. * The facility failed to ensure the scratched-out Depakote dosage on Resident 30's Facility Verification of Informed Consent form was signed and dated and failed to complete the informed consent when a change of indication for the use of Olanzapine was noted as per the physician's order for Resident 3. These failures had the potential for the residents' care needs not being met as their medical information was inaccurate. Findings: Review of the facility's P&P titled Hemodialysis Access Care revised 9/2010, showed…

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, facility P&P review, and facility document review, the facility failed to ensure the kitchen was free from flies. This failure posed the risk for pests to contaminate the resident's food. Findings: Review of the facility's P&P titled Pest Control revised May 2008 showed the facility shall maintain an effective pest control program. Review of the facility's documents from a pest elimination company dated 8/20, 9/17, and 10/22/24, showed pests treated/inspected for were ants, roaches, mice, and rats. Review of the facility's document titled Maintenance Request Log completed by the CDM dated 7/6, 8/31, and 10/11/24, showed, Need screen door for dietary door, too hot in the kitchen and need screen door on delivery door to keep insects out. On 10/31/24 at 1136 hours, during the lunch meal tray line observation, an interview was conducted with the CDM. The back door to the kitchen which was adjacent to the trash in the parking lot was open. The back door did not have a screen. Two flies were observed in the kitchen near the lunch meal tray line. The CDM…

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 interview, medical record review, and facility P&P review, the facility failed to notify the physician of a change of condition for one of two sampled residents (Resident 1). * Resident 1 had a change of condition on 10/7/23 at 2106 hours, in which her blood pressure was measured at 196/90 mmHg and another change of condition on 10/18/23 at 1622 hours, in which her blood pressure was measured at 180/86 mmHg. The facility failed to conduct a change of condition assessment specific to Resident 1's episodes of hypertension and failed to notify Resident 1's physician in accordance with the facility's P&P. This failure posed the risk for changes in Resident 1's health condition not being identified, potentially delaying necessary care and treatment, which posed the risk for negative health outcomes to Resident 1. Findings Review of the facility's P&P titled Change in a Resident's Condition or Status revised 2/2021 showed the nurse will notify the resident's attending physician when there has been 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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the care needs of three nonsampled residents (Residents A, B, and C). * The facility failed to ensure Resident A's call light was within reach. * The facility failed to ensure Resident B had a call light attached to the wall and available for use. * The facility failed to ensure Resident C's call light was answered promptly. These failures had the potential to negatively impact the resident's psychosocial well-being or delay to provide care and services to the residents. Findings: Review of the facility's P&P titled Call System, Residents dated 10/2022 showed each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities, and from the floor. Call system communication may be audible or visual. Calls for assistance are answered as soon as possible, but no later than five minutes. Urgent requests for…

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

Based on observation, interview, and facility document review, the facility failed to notify the residents of a change in the lunch menu when Brussel sprouts were not available for lunch as per the facility's menu. This failure resulted in the residents not receiving their meal as per the menu, which had the potential to negatively impact the residents' well-being. Findings: On 2/6/23 at 1220 hours, an observation of the residents' lunch menu was conducted. The residents' lunch menu was posted in the hallway adjacent to the nursing station. The residents' lunch menu for 2/6/23, showed the lunch menu included savory Brussel sprouts. On 2/6/23 at 1226 hours, an observation and concurrent interview was conducted with Resident 24. Resident 24 was observed eating his lunch in his room. Resident 24's lunch tray was observed without savory Brussel sprouts as per the lunch menu. Resident 24's lunch tray was observed with peas (not reflected on the menu). Resident 24 was asked if he liked Brussel sprouts, to which he replied, yes, Brussel sprouts are healthy. Resident 24 was asked if he 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 observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by the following: * The facility failed to air dry the blender during the puree preparation. * The facility failed to ensure the kitchen utensils had smooth cleanable surface. * The facility failed ensure the appropriate food grade sanitizing wipes were used to disinfect countertops and tables where the food was prepared. * The facility failed to ensure the chlorine test strips had not expired. * The facility failed to ensure the kitchen staff performed hand hygiene and changed gloves during dishwashing. * The facility failed to ensure the labeling and dating of the foods stored in the refrigerator, freezer, and open, dry storage area. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the Form CMS-672 titled Resident Census and Conditions of Residents completed by the facility dated 2/6/23,…

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 interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their infection control surveillance program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program for the months of [DATE] through [DATE]. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobial medications. The facility failed to determine whether the residents who exhibited signs and/or symptoms of infections and were not prescribed antimicrobial medications met the facility's criteria for infection (McGeer's Criteria), and thus failed to include these residents in the facility's infection control surveillance program. * The facility failed to include COVID-19 positive residents in their infection control surveillance program for the month of [DATE] as per the facility's P&P, for one of 25 final sampled residents (Resident 61) and nine nonsampled 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.

Based on observation, interview, and facility document review, the facility failed to ensure the confidential resident roster for the last recertification survey was removed from the survey binder. This failure had the risk of exposing the residents' confidential information. Findings: On 2/8/23 at 1109 hours, the facility's survey results binder located in the hallway by the DON's office door was reviewed. The facility's recertification survey completed date of 8/21/19, was observed with the confidential resident roster in the binder. On 2/8/23 at 1115 hours, a concurrent interview and facility document review was conducted with the DON. The DON verified the confidential resident roster was included in the survey binder and stated it should not have been in the binder.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to inform and provide the written information regarding the rights to formulate the advance directive to one of 25 final sampled residents (Resident 5). This had the potential for violating the resident's rights to formulate an advance directive. Findings: Review of the facility's P&P titled Advance Directives dated 9/22 showed the section for If the Resident Does not have an Advance Directive showing if the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. Review of Resident 5's medical record was initiated on 2/7/23. Resident 5 was readmitted to the facility on [DATE]. Review of the Physician H&P examination and Progress note dated 11/22/22, showed Resident 5 had the capacity 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 observation, interview, and medical record review, the facility failed to ensure the necessary treatment and services were provided to prevent the risk of contractures for one of 25 final sampled residents (Resident 30). * Resident 30's splints were not applied to her bilateral elbows as ordered. This failure posed the risk for this resident to develop complications from immobility and not achieve their highest practicable level of independence. Findings: Medical record review for Resident 30 was initiated on 2/6/23. Resident 30 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 30 had cognitive impairment. Resident 30 received RNA program using a splint. Review of the Physician's Order Summary Report dated 1/30/23, showed an order, RNA order for bilateral elbow extension splints. Review of the care plan addressing Resident 30's increased risk of joint immobility in bilateral elbows showed the interventions to provide bilateral elbow extension splints. On 2/6/23 at…

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, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for the GT feeding for one of 25 final sampled residents (Resident 74). * The facility failed to ensure Resident 74 received the accurate amount of water in between medications during the medication administration. This failure posed the risk for complications related to the use of the GT. Findings: Review of the facility's P&P titled Administering Medications through an Enteral Tube revised 11/2018 showed the purpose of the procedure was to provide guidelines for the safe administration of medications through an enteral tube. The P&P further showed if administering more than one medication, flush with 15 ml warm purified water (or prescribed amount) between medications. Medical record review for Resident 74 was initiated on 2/7/23. Resident 74 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Order Summary Report showed a physician's order…

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, interview, and medical record review, the facility failed to provide the necessary respiratory care for one of 25 final sampled residents (Resident 24). * The facility failed to follow a physician's order for the administration of continuous oxygen for Resident 24. This failure had the potential to negatively impact Resident 24's medical condition. Findings: Medical record review for Resident 24 was initiated on 2/6/23. Resident 24 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 24's acute care hospital Pulmonary Consultation Note dated 1/10/23 at 1206 hours, showed Resident 24 received a consultation for pneumonia and respiratory failure. Review of Resident 24's physician's order dated 1/12/23, showed to administer continuous oxygen at 2 liters per minute via nasal cannula for shortness of breath. Review of Resident 24's care plan problem titled Impaired Respiratory Function Related to COPD and Pneumonia initiated on 1/16/23, showed an intervention 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 interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for one of 25 final sampled residents (Resident 27). * The facility failed to notify the physician when Resident 27's medications were not administered during dialysis days. In addition, the facility failed to ensure the physician's order for a 1200 ml fluid restriction (a diet which limits the amount of daily fluid consumption) was followed and carried out accordingly. This had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled End-Stage Renal Disease, Care of a Resident With revised 9/2010 showed the residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Further review of the P&P showed the education and training of staff includes specifically (f)-timing and administration of medications, particularly those before and after dialysis care. a. Medical…

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

Based on observation, interview, medical record review, and facility P&P review, the facility failed to administer the medications as ordered for one nonsampled resident (Resident 42). * The facility staff failed to administer Resident 42's medications within 60 minutes of the scheduled time at 0900 hours. This placed the resident at risk for delays in treatment and increased risk of adverse events. Findings: Review of the facility's P&P titled Medication Administration revised April 2019 showed to administer the medications within 60 minutes of the scheduled time. On 2/7/23 at 1037 hours, observation and concurrent interview was conducted with LVN 1. LVN 1 stated the medications being passed were for 0900 hours. LVN 1 stated she was late in passing the medications for Resident 42 because she got busy, there were interruptions, and there was something that she had to do like restroom or something. LVN 1 stated Resident 42's medications were administered at 1050 hours, which was one hour and 50 minutes after the scheduled medication administration time at 0900 hours. Review 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 interview, medical record review, and facility P&P review, the facility failed to ensure one of 25 final sampled residents (Resident 30) were free from unnecessary psychotropic medications. * Resident 27's psychiatrist failed to document the reason why the GDR for the use of Seroquel as recommended by the pharmacist was contraindicated for Resident 27. This failure had the potential for Resident 27 to experience adverse effects or receive unnecessary antipsychotic medications. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 6/2021 showed, Antipsychotic medications used to treat Behavioral or Psychological Symptoms of Dementia (BPSD) must be clinically indicated, be supported by an adequate rational for use and may not be used for a behavior with an unidentified cause. Antipsychotics used to treat BPSD must receive gradual dose reduction and behavioral interventions, unless contraindicated. GDR may be considered clinically contraindicated for reasons that include, but 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.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. * The facility's medication error rate was 20.5 %. This had the potential to negatively impact the residents' health outcomes. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one hour of their prescribed time unless otherwise specified (for example, before and after meal orders). The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include checking identification band; checking photograph attached to medical record; and if necessary, verifying the resident identification with other facility personnel. The P&P also showed the staff is to follow established the facility…

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 medical record review, the facility failed to ensure one of 25 final sampled residents (Resident 27) received two medications scheduled at 0900 hours as per the physician's orders and facility's P&P. This failure had the potential for negatively affect the resident's well-being. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are to be administered in accordance with the prescriber's orders, including any required time frame. During a medication administration observation on 2/14/23 at 0859 hours, with LVN 4, the following medications were prepared and administered to Resident 27 by LVN 4: - clopidogrel (blood thinner) 75 mg one tablet - amlodipine (antihypertensive) 75 mg one tablet - quetiapine fumarate (antipsychotic) 50 mg one tablet - clonidine HCL (antihypertensive) 0.1 mg one tablet - hydralazine HCL (antihypertensive) 100 mg one tablet - divalproex (anticonvulsant) 125 mg one capsule - buspirone HCL (antianxiety) 5 mg one tablet - Clear Lax (laxative) 17 gm for bowel…

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 facility P&P review, the facility failed to ensure the medications were safely stored and properly labeled. These had the potential for medication errors. Findings: Review of the facility's P&P titled Interpretation and Implementation revised April 2019 showed the labels for stock medications include all necessary information, such as: (c) the expiration date when applicable. 1. On 2/8/23 at 1434 hours, during a medication cart observation in Station 1 and concurrent interview with LVN 2, the following medications were observed: - Allergy Relief Diphenhydramine HCl 25 mg bottle did not have any visible expiration date. - Senna S with the expiration date of January 2023 - valproic acid solution bottle was sticky. LVN 2 verified the above findings. 2. On 2/8/23 at 1452 hours, during the medication storage observation in Medication Room A and concurrent interview with LVN 2, the following was observed: - one box of Refresh tears was stored next to these oral medications: loratadine 10 mg, magnesium oxide 400 mg, folic acid 100 mcg, and loperamide 2…

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 interview and medical record review, the facility failed to ensure the medical records for six of 25 final sampled residents (Residents 11, 33, 41, 69, 73, and 74) and one nonsampled resident (Resident 48) were accurate and complete. This failure had the potential for the residents' care needs not being met as their medical information was incomplete. Findings: 1. Medical record review for Resident 33 was initiated on [DATE]. Resident 33 was admitted to the facility on [DATE]. Review of Resident 33's POLST dated [DATE], showed to attempt resuscitation/CPR and provide full treatment with trial artificial treatment options. However, the section for the physician's signature was left blank. On [DATE] at 1632 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD acknowledged Resident 33's POLST did not have the physician's signature. The SSD stated there was a physician's order to perform CPR and provide full treatment. 2. Medical record review for Resident 69 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 interview, medical record review, facility document review, and facility P&P review, the facility failed to accurately determine whether six of 25 final sampled residents (Residents 30, 33, 71, 74, 85, and 88) and seven non-sampled residents (Residents A, B, C, D, E, 22, and 31) who were prescribed antibiotics had met the McGeer's criteria. As a result, the facility failed to inform the residents' physicians that the residents did not meet McGeer's Criteria for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antibiotics. This potentially resulting in adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria. Findings: According to the Centers for Disease Control and Infection, an estimated 70% of nursing home residents receive one or more courses of antibiotics during a year. Studies have shown that 40% to 75% of the antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Frail and older adults are at significant risk of harm from antibiotic overuse including…

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 facility P&P review, the facility failed to ensure the freezer compartment inside the medication refrigerator was free of ice buildup. This had had the potential for the refrigerator not being maintained in a safe operating condition. Findings: Review of the facility's P&P titled Storage of Medications revised date 11/2020 showed the facility stores all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. On 2/8/23 at 1108 hours, Medication Room A inspection and concurrent interview was conducted with LVN 2. On 2/8/23 at 1136 hours, the medication refrigerator was observed to have ice build in the freezer compartment. LVN 2 verified the findings and stated the ice build up in the freezer was indicated that the temperature may be too cold. LVN 2 stated she noticed the ice buildup in the freezer in the morning but did not do anything because she did not know what to do when there was an ice buildup in the freezer…

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.