Rosewood Health Facility

Based on observation, interview, and record review, the facility failed to follow their policy and procedure on change of condition for one of three sampled residents (Resident 1). This failure resulted in a delay in care and had the potential for negative medical outcomes. Findings: During a concurrent observation and interview on 12/3/24 at 2:35 p.m. with Resident 1 in the hallway, Resident 1 was observed with a large area of raised reddened scaly appearing skin from the bottom of her left side of neck stretching toward her left shoulder approximately 6 inches in length and width. Resident 1 was observed scratching at this reddened area as well as picking and scratching at her face. Resident 1 was confused to time and place. Resident 1 could not answer questions appropriately. During an interview on 12/3/24 at 2:40 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was assigned to Resident 1. LVN 1 stated Resident 1 is alert but confused. LVN 1 stated she did not know what the cause of the scaly redness was on Resident 1 ' s bottom of left side of neck toward her left…

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 record review, the facility failed to follow its policy and procedure (P&P) titled, Water Management Program for 71 of 71 sampled resident's when the facility cooling tower (device that removes heat from water and used to cool a building) tested positive for Legionella (bacteria causing lung infection). This failure had the potential to spread a highly contagious, infectious bacteria to residents, visitors, and staff. Findings: During an interview on 11/6/24 at 9:30 a.m. with Safety Officer (SO), SO stated the cooler connected to the water tower tested positive for Legionella and the water treatment company treated the water. SO stated he got the report on October 16th and he notified the facility Administrator, Infection Preventionist (IP), and Director of Operations (DO). During an interview on 11/6/24 at 9:35 a.m. with Director of Nursing (DON), DON stated the staff had not been in-serviced on Legionella or legionella pneumonia. During an interview on 11/6/24 at 12:26 p.m. with Field…

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 update the care plan for for one of three sampled residents (Resident 20). This failure resulted in Resident 20 developing Moisture Associated Skin Damage (MASD- caused by prolonged exposure to various sources of moisture). Findings: During an observation on 11/4/24 at 10:42 a.m. two staff members repositioned Resident 20. Resident 20 was non-verbal. During a review of Resident 20's admission Record (AR), the AR indicated diagnoses including, weakness or the inability to move on the left side of her body, severe loss of strength on the left side of her body, inability to talk, and obesity. During a concurrent interview and record review on 11/6/24 at 11:06 a.m. with Director of Nursing (DON), Resident 20's Care Plan (CP), revision date of 9/27/24, was reviewed. The CP indicated two staff were to reposition Resident 20 at least once a shift and as necessary. DON stated dependent residents are turned every two hours and as needed. DON stated Resident 20's CP should have been updated to turn every two hours…

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 follow their policy and procedure (P&P) titled Catheter Care, Urinary, for one of two sampled residents (Resident 49) when timely nursing assessment and interventions were not provided when Resident 49 complained of pain. This failure resulted in Resident 49 experiencing discomfort. Findings: During a concurrent observation and interview on 11/4/24 at 9:43 a.m. with Resident 49, in his room, a catheter (flexible tube that continually drains and empties urine from the bladder into a collection bag outside the body) urine collection bag was seen suspended from the left side of his bed. Resident 49 stated he had the catheter because he had a lot of kidney stones (small, hard deposits that form in the kidneys and are often painful when passed) and a lot of sediment (the material from a liquid that settles to the bottom) drained from his urine. During an interview on 11/5/24 at 9:56 a.m. with Resident 49, he stated he was having pain from his catheter, and he made his nurse aware of the discomfort. Resident 49…

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 record review, the facility failed to follow its policy and procedure (P&P) titled, Medication Labeling and Storage for two of 32 sampled residents (Resident 219, Resident 58) and two of two medication carts when: 1. Medications were at the bedside for two of 32 sampled residents (Resident 219, Resident 58). This failure had the potential for medication to be accessed by unauthorized staff and residents. 2. Four of 14 insulin (medication to lower sugar levels in the blood) vials were expired on two of two sampled medication carts. This failure had the potential to result in a loss of medication potency (strength), inaccurate test results, and adversely affect the residents' health. Findings: 1. During a concurrent observation and interview on [DATE] at 10:52 a.m. with Licensed Vocational Nurse (LVN) 2 in Resident 219's room, Resident 219 had Calazinc (helps protect and relieve minor skin irritation due to rashes) on the bedside table. LVN 2 stated medication should not be 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.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Resident Informed Consent for the use of Psychotherapeutic [medication to treat mental disorders] Drugs, for two of six sampled residents (Resident 48 and Resident 217) when their informed consents were not complete. This failure had the potential for Resident 48 and Resident 217 to receive psychotropic medication without knowing the risks and benefits of the medication. Findings: During an interview on 11/6/24 at 2:06 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the doctor was responsible for getting the informed consent and the nurse was the one who witnessed the resident's signature. During a review of Resident 48's Physician Orders (PO) dated 5/16/23, the PO indicated, Temazepam (used to treat inability to sleep) 15 mg capsule, 1 capsule through the feeding tube (tube inserted into stomach for nutritional and medication needs) one time daily. During a review of Resident 48's Informed Consent (IC) dated 5/19/23, the IC indicated This documentation is 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.

Based on interview and record review, the facility failed to ensure physician ordered medication was available for one of six sampled residents (Resident 217). This failure resulted in Resident 217's pain not being controlled as evidenced by Resident 217's statement of pain of 6 to 7 out of 10 (on a 10 point pain scale 0 is no pain, 1-3 mild pain, 4-6 moderate pain, 7-9 severe pain, 10 unbearable pain). Findings: During an review of Resident 217's Physician Order (PO), dated 11/1/24, Glucosamine-Chondritin Tablet (used to treat joint pain) 500mg-400 mg give 2 tablet by mouth two times a day. During a concurrent interview and record review on 11/7/24 at 8:23 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 217's Medication Administration Record (MAR), dated November 2024 was reviewed. The MAR indicated the following: 11/2/24 a.m. shift medication was not administered. 11/2/24 p.m. shift medication was not administered. 11/3/24 a.m. shift medication was not administered. 11/3/24 p.m. shift medication was not administered. 11/4/24 a.m. shift medication was not administered.…

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 follow its policy and procedure (P&P) titled, Repositioning for one of three sampled residents (Resident 20). This failure resulted in Resident 20 developing Moisture Associated Skin Damage (MASD- caused by prolonged exposure to various sources of moisture). Findings: During an observation on 11/4/24 at 10:42 a.m. two staff members repositioned Resident 20. Resident 20 was non-verbal. During a review of Resident 20's admission Record (AR), the AR indicated diagnoses including, weakness or the inability to move on the left side of her body, severe loss of strength on the left side of her body, inability to talk, and obesity. During a concurrent interview and record review on 11/6/24 at 11:06 a.m. with Director of Nursing (DON) stated dependent residents are turned every two hours and as needed. Care Plan (CP) with a revision date of 9/27/24 was reviewed. The CP indicated two staff were to reposition Resident 20 at least once a shift and as necessary. DON stated Resident 20's CP should have been updated to turn…

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 and record review, the facility failed to follow their policy and procedure (P&P) titled, Psychotropic Medication Use, for one of seven sampled residents (Resident 217), when the facility did not monitor changes in behavior and side effects for physician ordered medications, Mirtazapine (to treat depression) and Temazepam (to treat inability to sleep). This failure had the potential to affect the health and safety of Resident 217. Findings: During a concurrent interview and record review on 11/6/24 at 11:52 a.m. with Assistant Director of Nursing (ADON), Resident 217's Order Review History Report (ORHR), dated 11/4/24 was reviewed. The ORHR indicated, Resident 217 was on Mirtazapine 45 mg 1 tablet by mouth at bedtime. ADON stated the facility was not monitoring for behavior changes and no monitoring for side effects of Mirtazapine. Licensed nurses administered four doses of Mirtazapine to Resident 217 between 11/2/24-11/5/24 in p.m. During a concurrent interview and record on 11/6/24 at 11:54 a.m. with ADON, Resident 217's ORHR, dated 11/4/24 was reviewed. 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 interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Resident Food and Dining Preferences for two of six sampled residents (Resident 58 and Resident 48) when: 1. One of six sampled residents (Resident 58) was not offered an alternative food item. 2. One of six sampled residents (Resident 48) tie preference for dinner was not honored. These failures had the potential for Resident 48 and Resident 58's nutritional needs to be not be met and the potential for weight loss. Findings: 1. During a concurrent interview and record review on 11/4/24 at 12:53 p.m. with Certified Nursing Assistant (CNA) 2, Resident 58's Meal Tray Ticket (MTT) dated 11/4/24 was reviewed. The MTT indicated, Dislikes: Asparagus. CNA 2 stated Resident 58 disliked asparagus and Resident 58's meal tray included asparagus. During a concurrent observation, interview, and record review on 11/4/24 at 1:15 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 58's MTT dated 11/4/24 was reviewed. The MTT indicated, Standing Orders: Garden Salad Garden Salad [sic] (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 record review, the facility failed to provide safe transportation for one of three sampled residents (Resident 1). This failure resulted in Resident 1 being dropped off alone at a wrong address and had the potential for harm. Findings: During a review of Resident 1 ' s Minimum Data Set (MDS- an assessment tool) under the section BIMS (Brief Interview for Mental Status – an assessment of cognition [mental processes including perception, memory, and thought]), dated 9/10/24, the BIMS indicated, Resident 1 had a score of 4 (severe cognitive impairment). During a review of Resident 1 ' s admission RECORD (AR), dated 10/15/24, the AR indicated, Resident 1 was a [AGE] year-old male with the following diagnosis: a. Hemiplegia (weakness or inability to move one side of the body) and Hemiparesis (inability to move the arm, leg, and trunk of one side of the body) following cerebral infarction (loss of blood flow to part of the brain) affecting the right dominant side. b. Memory deficit following…

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 and record review, the facility failed to ensure one of three sampled resident (Resident 1) was treated with dignity and respect. This failure had the potential for Resident 1 experiencing psychosocial distress. Findings: During an interview on 9/27/24 at 1:09 p.m. with Administrator, Administrator stated Resident 1 reported Certified Nursing Assistant (CNA) 1 stated you don ' t tell me what to do, I tell you what to do. During an interview on 9/27/24 at 1:33 p.m. with Resident 1, Resident 1 stated, I did not report it [what CNA 1 stated] when it happened because I was afraid physically and mentally. During a review of Resident 1 ' s Minimum Data Set (MDS-assessment tool), dated August 30, 2024, the MDS indicated Resident 1 ' s Brief Interview for Mental Status (BIMS) (an assessment to determine cognition), score was 15 (score of 13 to 15 indicates cognitively intact). Resident 1's MDS indicated Resident 1 required Maximum assistance (helper does more than half the effort) for bathing and lower body dressing and Moderate assistance (helper does less than half 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 observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living [tasks people do to manage one's basic needs, including personal hygiene or grooming, dressing, toileting, transferring or ambulating, and eating]) care assistance for one of four sampled residents (Resident 2) when Resident 2's fingernails were not cleaned and trimmed. This failure had the potential to result in Resident 2 developing infection due to the spread of germs from fingernails. Findings: During a review of Resident 2's admission Record (AR), dated 9/4/24, the AR indicated, Diagnosis Information. Need for assistance with personal care. During a concurrent observation and interview on 9/5/24 at 10:45 a.m. with Resident 2 in Resident 2's room, Resident 2 had dark gray debris underneath her long fingernails. Resident 2 stated her fingernails had not been cleaned and trimmed for days. Resident 2 stated, They're (fingernails) quite long and sharp. Resident 2 stated she needs assistance with cleaning and trimming her fingernails. During a review of Resident 2's…

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

Based on interview and record review, the facility failed to ensure the facility's policy and procedure (P&P) on dental services was followed for one of four sampled residents (Resident 1). This failure had the potential to result in Resident 1's weight loss due to difficulty eating. Findings: During a review of Resident 1's Missing Property Report (MPR), dated 5/23/24, the MPR indicated Resident 1's family reported Resident 1's bottom dentures was missing. The MPR indicated, 6-6-24 facility is coordinating (with) Lumina Dental for eval (evaluation) on replacement of bottom dentures. During a review of Resident 1's medical records (MR), dated 5/23/24 to 6/24/24, the MR indicated no documentation of what the facility had done to ensure Resident 1 was able to eat and drink adequately while awaiting the dental services. During a review of Resident 1's meal intake log (MIL), dated May 2024, the MIL indicated: a. On 5/23/24, Resident 1 had 25% meal intake during breakfast, lunch, and dinner. b. On 5/24/24, Resident 1 had 75% meal intake during breakfast and lunch, and less than 25% 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 interview and record review, the facility failed to implement its policy and procedure for one of three sampled residents (Resident 1) when staff was not removed from resident care when an allegation of abuse was made. This had the potential to put the Resident 1 at risk for further abuse. Findings: During a review of the facility's Reporting Form (RF), undated, the RF indicated, Date of the allegation.11/28/2023. Brief description of the allegation/injury: Physical Abuse. Around 8:35 p.m., [Resident 1] told this nurse that his CNA (Certified Nursing Assistant 1) hit him while providing care, [Resident 1] stated 'Nurse take her out of here I wanna report her she hit me with a towel to the right side of my face'. Immediately removed team member from resident's care. During an interview on 12/6/23, at 11:12 a.m., with Administrator, Administrator stated, on 11/28/23, between 8:30 and 9:00 p.m., Resident 1 accused CNA 1 of hitting him with a towel. Administrator stated, CNA 1 was removed from Resident 1's care and was assigned to other residents until the end of her shift 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.

Based on interview and record review, the facility failed to protect the privacy of two of four sampled residents (Resident 1 and Resident 2). This failure resulted in violation of Resident 1's rights to privacy and confidentiality. Findings: During an interview on 10/4/23, at 12:06 p.m. with Social Services Assistance (SSA), SSA stated Resident 2's daughter called on 9/25/23, informed her Resident 2 was given some paperwork which did not belong to Resident 2. SSA stated Resident 2's daughter return the paperwork and she shredded the two pages belonging to Resident 1. SSA stated at the time the facility had a printer down and multiple nurses were printing to the same printer. During an interview on 10/4/23, at 12:26 p.m. with Administrator, Administrator stated on 9/25/23, Resident 1's face sheet and order for x-ray was given to Resident 2 in the paperwork Resident 2 was given for an outside appointment. Administrator stated Resident 2's daughter caught the mistake. Administrator stated Nurse 1 handed the paperwork to Resident 2 but Nurse 2 prepared the paperwork. Administrator…

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 record review, the facility failed to ensure one of three sampled residents (Resident 1) received medications as ordered by the attending physician (AP). This failure had the potential for Resident 1's infection to worsen and PICC (peripherally inserted central - is a long, thin tube that is inserted through a vein in your arm and passed through to the larger veins near your heart) line to become clogged. Findings: During an interview on [DATE], at 1:52 p.m. with Resident 1, Resident 1 stated there had had been a problem with having an available Registered Nurse (RN) to give him his IV (intravenous) medication. He stated it happened three times. During a review of Resident 1's Physician Order Sheet, (POS) dated [DATE], the POS indicated, Cefazolin [antibiotic - (ABX) medications used to treat infection] 2 gram [unit of measure] solution . Intravenous . Every Eight Hours for Six Weeks Starting [DATE] scheduled 7:00 [7 a.m.] 15:00 [3p.m.] 23:00 [11 p.m.] During a review of Resident 1's POS,…

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 record review, the facility failed to ensure appropriate staff was available to provide medications intravenous (IV- giving medicines or fluids through a needle or tube inserted into a vein) for one of three sampled residents (Resident 1). This failure had the potential for Resident 1's infection and healing to be negatively affected. Findings: During an interview on [DATE], at 1:52 p.m. with Resident 1 stated there had been a problem with having an available Registered Nurse (RN) to administer his IV medication. He stated it happened three times. During a review of Resident 1's Physician Order Sheet, (POS) dated [DATE], the POS indicated, Cefazolin [antibiotic - (ABX) medications used to treat infection] 2 gram [unit of measure] solution . Intravenous . Every Eight Hours for Six Weeks Starting [DATE] scheduled 7:00 [7 a.m.] 15:00 [3p.m.] 23:00 [11 p.m.] During a review of Resident 1's Care Plan Report, (CPR) undated, the CPR indicated, Problem [Resident 1] has infection following Right…

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 and record review, the facility failed to notify one of four sampled residents (Resident 1) responsible party (RP) of a change in condition (COC). This failure had the potential for Resident 1 ' s RP not to be fully informed of Resident 1 ' s health condition. Findings: During an interview on 7/12/23, at 1:55 p.m. with Registered Nurse (RN 1), RN 1 stated if the condition is not something she can treat with the PRN (as needed) medication she would notify the resident ' s attending physician, the family, and follow up on the new physician orders. RN 1 stated she documents on the SBAR (situation, background, appearance, review, and notify - a communication form). During an interview on 7/12/23, at 2:26 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated she notifies the resident ' s family of all COC and change in medication or treatment. During a concurrent interview and record review on 7/12/23, at 3:56 p.m. with Director of Nursing (DON), Resident 1 ' s SBAR dated 4/22/23, was reviewed. The SBAR indicated [Resident 1] has increased confusion 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.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) physician ' s orders were carried out and treatment was administered promptly. This failure resulted in the delay of treatment and worsening of Resident 1 ' s health condition. Findings: During an interview on 7/27/23, at 11:41 a.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated if there are laboratory (lab) orders she notifies the resident ' s responsible party (RP) and the resident, place the order, and informed the lab department. LVN 2 stated if the lab orders are regular/routine, the labs are completed within 24 hours. LVN 2 stated she notifies the resident ' s attending physician as soon as the results come in. LVN 2 stated for new medications due to a change of condition (COC) she notifies the resident, resident ' s RP and then place the order. LVN 2 stated she administers antibiotic within four hours. LVN 2 confirmed Rocephin (medication use to treat infections) 1gm (grams- unit of measure) IM (intramuscular – medication administered into a muscle) 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 and record review, the facility failed to provide the fluid requirements for one of four sampled residents (Resident 1). This failure resulted in Resident 1 receiving inadequate fluid and worsening of her health condition. Findings: During an interview on 7/12/23, at 1:46 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated during change of shift, the nurse and the outgoing CNA informed her of residents who are on fluid intake (I & O) monitoring. CNA 1 stated she writes down all the fluids intake and output of the resident and give it to the nurse. CNA 1 stated if she sees any change in the residents fluid intake and output, she informs the nurse right away. During an interview on 7/12/23, at 1:52 p.m. with CNA 2, CNA 2 stated for resident on fluid I & O monitoring, the nurse gives verbal report, she gives a certain amount of fluids to the resident and keep track. CNA 2 stated she documents in the electronic medical record (EMR). CNA 2 stated if she sees a decrease in fluid intake, she notifies the nurse. During an interview on 7/12/23, at 1:55 p.m. with…

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 and record review, the facility failed to obtain physician order laboratory (labs), and report results to the physician timely for one of three sampled resident (Resident 1). These failures resulted in delayed evaluation and treatment for Resident 1. Findings: During an interview on 7/27/23, at 11:41 a.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated if there are laboratory (lab) orders she notifies the resident ' s responsible party (RP) and the resident, place the order, and informed the lab department. LVN 2 stated if the lab orders are regular/routine, the labs are completed within 24 hours. LVN 2 stated she notifies the resident ' s attending physician as soon as the results come in. During an interview on 7/27/23, at 12:01 p.m. with LVN 1, LVN 1 stated she puts the lab order in the computer, notifies the resident and family of the labs that were ordered and the reason why the labs were ordered. LVN 1 stated the lab order will be ordered and carried out the same day depending on the time of day, she stated within 24 hours. LVN 1 stated she notifies 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 interview and record review, the facility failed to ensure medication irregularities noted by the consultant pharmacist in the Medication Regimen Review (MRR-a comprehensive pharmacy evaluation of the residents' medications) for 11 of 29 sampled residents (Resident 6, Resident 9, Resident 10, Resident 15, Resident 16, Resident 24, Resident 39, Resident 42, Resident 46, Resident 61, and Resident 165) were reviewed and acted upon by the attending physician and the Director of Nursing (DON) promptly. This failure had the potential to place residents at risk for adverse consequences and other medication-related problems. Findings: During a concurrent interview and record review on 2/8/23, at 1:58 PM, with Minimum Data Set (MDS-resident assessment tool) Nurse (MDSN), Resident 16's Consultant Pharmacists Recommendations (CPR), dated 1/24/23 was reviewed. The CPR indicated, The consultant pharmacist reviewed Resident 16's MRR. MDSN stated, there was no documentation of the pharmacy recommendation and the attending physician's review and action to the MRR. During an interview 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.

Based on observation, interview, and record review, the facility failed to implement its policy and procedure (P&P) on Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices when one of one sampled staff member (Activities Staff- AS) did not wear hair net properly upon entering kitchen. This failure had the potential to put residents at risk for foodborne illnesses. Findings: During a concurrent observation and interview on 2/7/23, at 11:14 AM, with Certified Dietary Manager (CDM) 2, in the Resident dining room, AS was observed going into and coming out of the kitchen with approximately one half of the back of his head uncovered by a hair net. CDM 2 confirmed his hair should have been completely covered and asked AS to cover his hair with the hair net. During a review of the facility's P&P, titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated 10/2017, the P&P indicated, Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were implemented when: 1. Occupational Therapist (OT) exited Resident 366's Room, on transmission-based precaution (a set of practices specific for patients with known or suspected infectious agents to prevent transmission), and laid down contaminated equipment, barbell and a long stick, on top of the Personal Protective Equipment (refers to gowns, gloves, masks, face shields, or goggles to protect the wearer from infection or injury) cart outside of Resident 366's room. OT held the contaminated equipment with bare hands, and walked away without performing hand hygiene. 2. Licensed Vocational Nurse (LVN) 1 exited Resident 19's Room and without performing hand hygiene, put on a new pair of gloves to disinfect the box of Flonase Nasal Spray (provides relief of allergy symptoms, itchy, runny nose, sneezing), which was taken inside the resident's room. LVN 1 did not have a hand sanitizer in her cart. 3. LVN 2 prepared the medications for two of six sampled…

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 and record review, the facility failed to follow its policy and procedure on Advance Directive (AD-written statement of persons' wishes regarding medical treatment and end-of-life) for six of 29 sampled residents (Resident 16, Resident 31, Resident 39, Resident 42, Resident 9, and Resident 49). This failure had the potential to result in procedures and treatment to be implemented against residents' rights and preferences. Findings: During a concurrent interview and record review on 2/7/23, at 8:21 AM, with Minimum Data Set (MDS-resident assessment tool) Nurse (MDSN), Resident 16's electronic medical record (EMR) titled Social History dated 11/3/22 was reviewed. The EMR/Social History indicated, Resident has Do Not Resuscitate (DNR) Code Status per her request and facility will comply. Resident states she does have an AHCD (Advanced Healthcare Directive) but she is in the process of completing one. MDSN was unable to find documentation of Resident 16's AD or a documentation Social Services followed up on Resident 16's AD. During a concurrent interview and 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.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) on Departmental Policy (Respiratory Therapy) -Prevention of Infection when the water of the humidifier bottles were not monitored for three of three sampled residents (Resident 40, Resident 49, and Resident 165). This failure had the potential for the residents to experience nasal, throat, and mouth dryness while inhaling dry oxygen. Findings: During a concurrent observation and interview on 2/8/23, at 8:55 AM, with Minimum Data Set (MDS-resident assessment tool) Nurse (MDSN), inside Resident 49's room, Resident 49's oxygen concentrator (oxygen delivery device) was observed turned on at four (4) Liters per minute (unit of measure) via nasal cannula. The oxygen concentrator had no distilled water in the prefilled humidifier bottle (a device that moisturizes the air). MDSN confirmed the finding and stated, the water inside the humidifier should be monitored by the nurses and changed before the water level becomes low. During a concurrent observation and interview on 2/8/23,…

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.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%) when: 1. Diltiazem CD (medication to treat blood pressure and chest pain) 120 mg (milligram, a unit of measurement) PO (oral), Furosemide (water pill) 80 mg, Glimepride (medication to lower blood sugar) 4 mg were omitted for one of six sampled residents (Resident 35). 2. Licensed Vocational Nurse (LVN) 2 did not follow the manufacturer's direction to administer Linzess (medication to treat abdominal pain, bloating, and helps with bowel movement) 290 mcg (microgram, a unit of measurement) for one of six sampled residents (Resident 5). 3. LVN 3 did not check blood pressure and pulse prior to administering two medications, Isordil ER (medication to prevent chest pain) 30 mg and Metoprolol ER (medication to lower blood pressure) 25 mg for one of six sampled residents (Resident 5). The cumulative medication error rate was 13.04% consisting of six total number of errors and 46 opportunities (6/46 x 100 = 13.04%). These failures resulted in residents not…

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

Based on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents (Resident 8) was assessed and determined appropriate to self-administer medication. This failure had the potential to result in undetected adverse effect from the medications. Findings: During a concurrent observation and interview on 2/6/23, at 10:36 AM, with Resident 8, in Resident 8's Room, two medications, Biofreeze Cream (pain relieving cream) and Dermeleve Cream (medication to stop the itch) were found on the bedside table. Resident 8 stated, I use biofreeze and apply it on my knees. The dermeleve cream, I just got it on Friday. My daughter brought it to me. The nurses have not said anything about them. During a concurrent observation and interview on 2/6/23, at 4:23 PM, with Licensed Vocational Nurse (LVN) 4, in Resident 8's room, LVN 4 confirmed biofreeze and dermeleve creams were on Resident 8's bedside table and stated, I am not aware [Resident 8] has biofreeze and dermeleve cream at bedside. During a concurrent interview and record review on 2/6/23, at 4:30 PM,…

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 record review, the facility failed to accurately assess the need for denture care for one of 29 sampled residents (Resident 19). This failure resulted in Resident 19 having loose dentures and being unable to chew properly, and the potential for Resident 19 to experience difficulties in maintaining nutritional needs. Findings: During a concurrent observation and interview on 2/6/23, at 10:00 AM, with Resident 19, Resident 19's dentures appeared loose while speaking. Resident 19 stated, his dentures were supposed to be adjusted over six months ago but were not. Resident 19 stated, his loose dentures made it very difficult to chew and he had considered asking for a pureed (blended until smooth) diet. During a concurrent interview and record review on 2/9/23, at 8:51 AM, with Minimum Data Set (MDS- resident assessment tool) Nurse (MDSN), Resident 19's MDS Section L (Oral/Dental status), dated 10/11/22, was reviewed. MDSN stated, Resident 19 was readmitted on [DATE] and 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 interview and record review, the facility failed to ensure Social Services performed annual and quarterly resident assessments for three of 29 sampled residents (Resident 39, Resident 42, and Resident 54). This failure had the potential for unmet care needs. Findings: During an interview on 2/6/23, at 12:04 PM, with Resident 39, Resident 39 stated, I am feeling depressed all the time. I asked [for] something for depression and for my insomnia. I am stressed that I cannot go home. I have a son who has not talked to me in a month. I left him several messages but he has not talked to me for a petty thing. I don't have any other family who talks to me. My son does not understand that I cannot take a bus to visit him. During a review of Resident 39's admission Record (AR), dated 9/25/21, the AR indicated, Resident 39 is a [AGE] year-old female, admitted on [DATE], with diagnosis including, but not limited to Major Depressive Disorder [a mood disorder that causes persistent feeling of sadness and loss 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.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for one of 29 sampled residents (Resident 19). This failure resulted in Resident 19 having unmet care needs. Findings: During a concurrent observation and interview on 2/6/23, at 10:00 AM, with Resident 19, in Resident 19's room, Resident 19's dentures appeared loose while speaking. Resident 19 stated, his dentures were supposed to be adjusted over six months ago but were not. Resident 19 stated, his loose dentures made it very difficult to chew and he had considered asking for a pureed (blended until smooth) diet. During an interview on 2/9/23, at 8:37 AM, with Director of Nursing (DON), DON stated, there was no dental care plan in place for Resident 19 and there should be one. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, A comprehensive, person-centered care plan that indicates measurable objectives and timetables to meet the resident's physical, psychosocial…

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 record review, the facility failed to implement its policy and procedure (P&P) on Repositioning when one of two sampled resident (Resident 316) was not turned every two hours. This failure had the potential to worsen Resident 316's deep tissue injury (DTI- injury to underlying tissue) on left ankle and contribute to the worsening of her right buttocks pressure injury (area of tissue damage that develops from prolonged pressure to skin) to stage II (two - skin breaks open and extends into deeper layers). Findings: During a review of Resident 316's Face Sheet (FS), undated, the FS indicated, Resident 316 was admitted to the facility on [DATE] with a diagnosis of fractured right fibula (broken leg bone), DTI of right buttock and DTI of other site. During a concurrent interview and record review, on 2/8/23, at 3:25 PM, with Director of Nursing (DON), Resident 316's Clinical Notes Report (CNR), dated 1/23/23 was reviewed. The CNR indicated, Skin assessment done r/t [related to] new admission.…

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 two of seven staff members (Certified Nursing Assistant (CNA) 3 and Housekeeper 1) were trained in fall prevention measures. This failure had the potential to increase the frequency of resident falls and resident injury. Findings: During a concurrent observation and interview on 2/6/23, at 9:59 AM, with Housekeeper 1, on the [NAME] wing, Resident 37 and Resident 115's orange colored room name plates with a butterfly picture, on the wall near the entryway door, were observed. Housekeeper 1 stated, the resident name plates informed the family which residents were in the room. Housekeeper 1 stated, she did not know what the color of the resident's name plates indicated. During an interview on 2/8/23, at 10:08 AM, with Director of Nursing (DON). DON stated, all staff were trained yearly in fall prevention which included the meaning of resident name plate colors and what the butterfly wings indicated. DON stated, the number of wings on the butterfly picture indicated the number of staff required when staff…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure poured medications temporarily held were appropriately labeled and secured for three of six sampled residents (Resident 27, Resident 368 and Resident 5) in the medication cart. This failure had the potential for adverse consequences in the health condition of the residents. 2. Ensure medications were available for one of six sampled residents' (Resident 35) use. This failure had the potential for Resident 35 to miss her medications and not receive its therapeutic benefits. 3. Ensure Licensed Vocational Nurse (LVN) 2 signed/initialed the Medication Administration Record (MAR) after giving the medications for two of six sampled residents (Resident 35 and Resident 6). This failure had the potential for healthcare providers to be misinformed of the residents medications and medication administration, which could result in adverse consequences. Findings: 1. During a concurrent observation and interview on 2/8/23, at 8 AM, with LVN 1 in the East Wing Hallway, in Resident 27's room during medication pass…

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 provide dental service for one of 29 sampled residents (Resident 19) promptly. This failure had the potential for the delay of dental care and provision of services. Findings: During a concurrent observation and interview on 2/6/23, at 10 AM, with Resident 19, Resident 19's dentures appeared loose while speaking. Resident 19 stated, his dentures were supposed to be adjusted over six months ago but were not. Resident 19 stated, his loose dentures make it very difficult to chew and he had considered asking for a pureed (blended until smooth) diet. During a concurrent interview and record review on 2/9/23, at 9:27 AM, with Social Service Designee (SSD) 1, Resident 19's Dental Notes (DN), dated 8/19/22 was reviewed. The DN indicated, PLD [partial lower denture] not fitting. Dremel [dental tool] not working unable to adj [adjust]. Adj PLD ASAP [as soon as possible] 1 wk [week]. SSD 1 stated, dental appointment for Resident 19 was not scheduled and Resident 19 was not seen again until 1/31/23. During a 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.