Sierra View Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 4) had a safe and clutter-free room environment when:1. Resident 4's room was full of clutter on top of and alongside Resident 4's bed.2. Multiple packs of cigarettes were inside Resident 4's bedside drawer.3. Resident 4 had medications at the bedside without a physician's order and without locked storage for medications at the bedside.This failure placed Resident 4 at risk for danger of falls and injuries, and risk of fire with a cluttered area of flammable materials (ability to ignite easily and burn rapidly) on top of and alongside Resident 4's bed. This failure also had the potential for Resident 4 and other residents to have an unmonitored adverse reaction to medications.During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses which included bilateral spinal stenosis…

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) was assessed for readmission to the first available bed in a semi-private room after Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 7/22/2025, in accordance with the facility's policy and procedure (P&P) titled, readmission to Facility, when the facility failed to request Resident 1's updated information and referral from GACH 1 on 7/31/2025 after GACH 1 contacted the facility regarding Resident 1's readmission to the facility. This deficient practice resulted in Resident 1 remaining in GACH 1 from 7/31/2025 through 8/6/2025 following an inquiry from GACH 1 for Resident 1 to be transferred back to the facility.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/22/2025 without diagnosis information. During a review of Resident 1's Order Summary Report (OSR), dated 8/1/2025, the OSR indicated there was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the facility's policy on Advance Directives (AD, written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for three of three sampled residents (Residents 17, 28 and 31) by failing to: 1. Ensure Residents 28 and 31's Advance Directive Acknowledgement Form (ADA) was filled out. 2. Ensure a copy of Resident 17's AD was in the medical chart. These failures had the potential for Residents 17, 28 and 31's preferences not carried out by the facility staff, affecting the residents quality of life. Findings: a. During a review of Resident 31's admission Record (AR), the AR indicated Resident 31 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and lower back pain. During a review of Resident 31's History and Physical (H&P, formal document of a medical provider's examination of a patient)…

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 develop a specific and individualized person-centered care plan to meet the needs of trauma (a psychological and physiological response to an overwhelming, distressing, or life-threatening event or series of events) survivor residents for two of two sampled residents (Residents 17 and 54). These failures had the potential for Residents 17 and 54 not to receive the necessary care, treatment, and services. Findings: a. During a review of Resident 17's admission Record (AR), the AR indicated, Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing traumatic event). During a review of Resident 17's Trauma Informed Care Screener (TICS, a tool or process that helps identify if…

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 for infection control and prevention for three of five sampled residents (Residents 10, 59, and 74), by failing to: a. Ensure Staff wore the appropriate Personal Protective Equipment (PPE- minimizes exposure to hazards) while providing care five residents on Enhanced Barrier Precautions (EBP- infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms) while providing care to Resident 74. b. Ensure an appropriate signage indicating Resident 59's transmission-based precaution (TBP, set of infection control guidelines used in healthcare settings to prevent the spread of infectious diseases than can be transmitted through contact with an infected person) was posted outside the resident's room. c. Ensure Certified Nursing Assistant 4 (CNA 4) wore the required PPE when changing Resident 10's linen. These deficient practices had the potential to result in cross…

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 implement its policy and procedure (P&P) titled, Informed Consent, for the use of wander guard alarm (a system of wearable bracelets and sensors that helps keep residents safe in healthcare facilities) for one of three sampled residents (Resident 59). This failure violated Resident 59's right and placed Resident 59 at risk for psychological distress related to the discomfort from wearing the alarm and the sound of the alarm. Findings: During a review of Resident 59's admission Record (AR), the AR indicated Resident 59 was admitted to the facility on [DATE] with diagnoses that included osteoporosis (weak and brittle bones due to lack of calcium and vitamin D), unsteadiness (pattern of walking that's unstable) on feet, and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 59's Elopement Risk (ER), dated 12/22/2024, the ER indicated Resident 59 was at risk for elopement. 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, and record review, the facility failed to ensure call light was within reach for one of one sampled resident (Resident 89). This failure had the potential for Resident 89 not to received necessary care and services and put Resident 89 at risk for fall. Findings: During a review of Resident 89's admission Record (AR), the AR indicated Resident 89 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), depressive disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness, and loss on interest or pleasure in activities) and unsteadiness on feet (gait instability). During a review of Resident 89's Minimum Data Set (MDS, a resident assessment tool), dated 2/4/2025, the MDS indicated, Resident 89 had a severely impaired cognition (ability to understand and process information). The MDS indicated Resident 89 required supervision or touching assistance (helper provided verbal…

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 complete the Level I Pre-admission Screening and Resident Review (PASRR) for one of 21 sampled residents (Resident 5) that were in the facility for more than 30 days. This failure had the potential to place the resident at risk for delayed care and to not receive care and services for a mental or intellectual disability. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility readmitted Resident 5 to the facility on 1/27/25 with diagnoses that included malignant neoplasm of esophagus (cancer of the tube that runs from the throat to the stomach) and bipolar disorder (episodes of mood swings from depressive lows to manic highs). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 2/3/25, the MDS indicated Resident 5 was severely cognitively impaired (ability to understand and process thoughts), and was totally dependent in lower body dressing and personal and toileting hygiene.…

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 interview and record review, the facility failed to develop a care plan (CP) for the use of Zoloft (medication used to treat depression [persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities]) for one of one sampled resident (Resident 41). This failure had the potential for inconsistency of care for Resident 41 and risk for unnecessary psychotropic medication use. Findings: During a review of Resident 41's admission Record (AR), the AR indicated Resident 41 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included major depressive disorder and hypertension (high blood pressure). During a review of Resident 41's History and Physical (H&P) dated 11/2/2023, the H&P indicated Resident 41 had the capacity to understand and make decisions. During a review of Resident 41's Order Summary Report (OSR) dated 10/24/2024, the OSR indicated Resident 41 had an active order for Zoloft 50 milligrams (mg, unit 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 and record review, the facility failed to provide the resident with management for constipation for five days (2/15/25, 2/16/25, 2/17/25, 2/18/25, 2/19/25) for one of one sampled resident (Resident 142). This failure resulted in a delay in receiving necessary care & services to manage Resident 142 constipation and had the potential to result in adverse consequences for Resident 142. Findings: During a review of Resident 142's admission Record (AR), the AR indicated the facility admitted the resident on 7/1/24 and readmitted on [DATE] with diagnoses that included othopedic aftercare following surgical amputation (care provided following a medical procedure that involves removal of a body part) and obesity (excessive accumulation of body fat). During a review of Resident 142's History & Physical (H&P) dated 2/16/25, the H&P indicated Resident 142 had the capacity to make medical decisions. During a review of Resident 142's Minimum Data Set (MDS, a resident assessment tool) dated 2/18/25, the MDS…

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 the facility's policy on foley catheter (FC, thin flexible tube that is inserted into the bladder to drain urine) care for one of one sampled resident (Resident 50) by failing to ensure the FC port was changed when visibly soiled and ensure a FC securement device was placed as ordered. These failures had the potential to put Resident 50 at risk for infection and injury. Findings: During a review of Resident 50's admission Record (AR), the AR indicated Resident 50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included benign prostatic hyperplasia (BPH, medical condition which the prostate grows making it difficult to urinate) and sepsis( life-threatening condition that arises when the body's response to infection injures its own tissues and organs). During a review of Resident 50's History and Physical (H&P) dated 8/11/2024, the H&P indicated Resident 50 did not have the capacity to understand…

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 ensure one of three sampled residents (Resident 16) who was receiving tube feeding (TF, liquid form of nutrients given to people who cannot eat or drink by mouth safely) through a gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach, can be used to give nutrition and/or drugs), did not have the TF running while the resident was being changed in the supine (lying horizontally on the back with face and torso upward) position. This failure had the potential to result in Resident 16 aspirating (when small particles of food or drops of liquid are breathed into the lungs), which could cause aspiration pneumonia (an infection that occurs in the lungs due to aspiration) and other serious complications. Findings: During a review of Resident 16's admission Record (AR), the AR indicated Resident 16 was readmitted on [DATE] with diagnoses that included cerebral palsy (a group of disorders that affect 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 one of seven sampled residents (Resident 22) had pharmacy recommendations that were signed and dated by the attending physician. This deficient practice had the potential to result in a delay in necessary services, poor continuity of care, and a delay in follow-up on the resident's status. Findings: During a review of Resident 22's admission Record (AR), the AR indicated Resident 22 was readmitted to the facility on [DATE] with diagnoses that included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 22's History and Physical (H&P), dated 7/12/2024, the H&P indicated Resident 22 did not have the capacity to understand and make decisions. During a review of Resident 22's Minimum Data Set (MDS - 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 record review, the facility failed to ensure staffing information on the Nurse Staffing Sheet (posted information that contains the facility's current resident census and total number and actual hours worked by licensed and unlicensed nursing staff) was posted in a prominent place readily accessible to residents and visitors for one of two nursing stations. This failure resulted in nurse staffing information being inaccessible to other residents at the opposite side of the facility. Findings: During observations on 2/18/2025 at 9:10 am, 2/19/2025 at 11:15 am, and 2/20/2025 at 10:30 am, the Nurse Staffing Sheet was only posted at the reception desk near the entrance in the facility across from Nursing Station A. During an interview on 2/20/2025 at 11:30 am with the Director of Staff Development (DSD), the DSD stated staffing was only posted in the reception area and there were no other postings within the facility. The DSD stated, the posting was accessible to visitors and residents who visited the front lobby, but wasn't readily accessible 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 and record review, the facility failed to ensure the informed consent was signed for the use of Trazodone 50 milligrams (mg, unit of measurement) every night for insomnia (difficulty falling asleep) for one of five sampled residents (Resident 31). This failure had the potential for unnecessary psychotropic medication (drug affecting how the brain works and causes changes in mood, feelings and behavior) for Resident 31. Findings: During a review of Resident 31's admission Record (AR), the AR indicated Resident 31 was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome (persistent pain that lasts for at least three months and significantly impacts a person's life) and low back pain. During a review of Resident 31's History and Physical (H&P) dated 4/18/2024, the H&P indicated Resident 31 had the capacity to understand and make decisions. During a review of Resident 31's Order Summary Report (OSR) dated 12/10/2024, the OSR indicated Resident 31 had an active…

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 protect the residents' right to be free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one of one sampled resident (Resident 1). Resident 1 was hit by Family Member 1 (FM1- Resident 1's brother) during visitation on 5/21/24. This deficient practice resulted in discoloration of Resident 1's right lower lip and left temporal (side) area of the face. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 2/22/24 and readmitted on [DATE] with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and bipolar disorder (mental disorder with periods of depression [persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable…

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 obtain written informed consent for three of five sampled residents (Residents 81, 85 and 5) for the use of psychotropic (any medication capable of affecting the mind, emotions, and behavior) medication. These deficient practices had a potential for Residents 81, 85 and 5 to not receive adequate information regarding the use of psychotropic medication, necessary to make an informed decision. Findings: a. During a review of Resident 81's admission Record, the admission Record indicated Resident 81 was admitted on [DATE] with diagnoses that included hypertensive chronic kidney disease (high blood pressure caused by damaged kidneys), dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities), major depressive disorder or depression (a persistent sadness and loss of interest in activities that interferes with daily life) and psychosis (a severe mental condition in which thought and emotions…

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 observation, interview, and record review the facility failed to provide the necessary care and services to assist resident's activities of daily living for three of three sampled residents (Residents 18, 48 and 49) by failing to: a. Ensure Resident 18 was provided a communication device with the language that the resident understood. b. Ensure Resident 48 was provided a communication device with the language that the resident understood. These deficient practices had the potential for Residents 18 and 48 to not be able to express their needs and receive the necessary care and services. c. Assist Resident 49 who required assistance, encouragement and cueing with eating, during mealtime, in accordance with facility's policy titled Activities of Daily Living (ADL's). This deficient practice had the potential to result in a decline in Resident 49's activities of daily living, including the ability to eat which could lead to weight loss. Findings: a. During a review of the Resident 18's admission record, 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, and record review, the facility failed to provide needed care and services to two of two sampled residents (Residents 239 and 73) that will meet each resident's physical, mental, and psychological needs, when the facility failed to: a. Address Resident 239's edema of the left leg by elevating the leg or provided measures to elevate the affected leg. b. Address elevated blood glucose levels for Resident 73. These deficient practices had the potential to result in negative outcome to Residents 239 and 73, affecting the residents' quality of life. Findings: a. During a review of Resident 239's admission Record, the admission record indicated the facility admitted the resident on 5/26/2022 and readmitted on [DATE], with diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder that affects the blood vessels outside of the heart) and venous insufficiency (when the veins have trouble sending blood from the limbs back to the heart, causing blood 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 record review, the facility failed to ensure the low air loss mattress (LAL, a bed that alternates pressure to help heal and prevent pressure injuries) was set accurately for two of three sampled residents (Residents 84 and 11) reviewed for pressure ulcers (an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure). This failure had the potential for Resident 84's and Resident 11's skin conditions to worsen or develop further skin breakdown. Findings: a. During a review of Resident 84's admission Record, the admission Record indicated Resident 84 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included necrotizing fasciitis (a bacterial infection that cause skin, tissue and muscle death), type II diabetes (DM2- a condition that happens because of a problem in the way the body regulates and uses sugar as fuel) with skin ulcer (an open sore caused by poor blood flow) and methicillin resistant…

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 ensure the bed was at the lowest position for two of six sampled residents (Residents 39 and 69) who were assessed as high risk for falls. This deficient practice had the potential to result in injury secondary to falls. Findings: During a review of Resident 39's admission Record, the admission record indicated the facility admitted the resident on 8/17/2018, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and hemiplegia and hemiparesis (weakness and paralysis on one side of the body.) During a review of Resident 39's Fall Risk assessment dated [DATE], the assessment indicated the resident was at risk for falls due to intermittent confusion, required assistance with elimination, poor vision, balance problem while standing and required the use of assistive devices. During a review of Resident 39's Minimum Data Set (MDS - 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, and record review, the facility failed to: 1. Attempt appropriate alternatives prior to installing side (bed) rail for two of six sampled residents (Residents 65 and 85). 2. Follow the physician's order for bilateral (on both sides) side rails with length to be at one quarter (rails at the head of the bed that are less restrictive for movement) use as an enabler (bedrails used to aid movement) for one of six sampled residents (Resident 78). These deficient practices had the potential to present a safety hazard and risk of entrapment to Residents 65, 85 and 78. Findings: 1.a. During a review of Resident 65's admission Record, the admission Record indicated the facility admitted the resident on 7/5/2022 and readmitted on [DATE] with diagnoses that included epilepsy (brain disorder in which a person has repeated seizures [convulsions] over time. During a review of Resident 65's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 1/26/2024, the MDS…

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 two of two sampled residents (Residents 140 and 241) reviewed for the use of antibiotics (medication to treat infection), received the medication with adequate indication for its use. a. Resident 140 did not meet the criteria to receive Cefazolin (an antibiotic medication) intravenously (IV, a way of giving a drug or other substance through a needle or tube inserted into a vein), which started on 2/6/2024, and Maxipime (Cefepime HCl, an antibiotic medication) intravenously, which started on 2/13/2024 for Resident 140's right forearm cellulitis (skin infection) in accordance with the facility's antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). b. For Resident 241, the medication criteria was not met for the use of fluconazole (medication to treat and prevent fungal infection) as treatment of Methicillin Resistant…

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 two bags of meat in a plastic box were not placed directly on the floor in the kitchen preparation area in accordance with facility's Policy and Procedure (P&P), titled Food Storage. This deficient practice had the potential for food borne illnesses (infections caused by ingesting contaminated food or beverages). Findings: During an initial tour of the kitchen on 2/13/2024 at 8:32 am, together with the facility's Assistant Director of Nutrition Services (ADNS), two bags of meat in a plastic box were placed directly on the floor in the meal preparation area. During a concurrent observation and interview on 2/13/2024 at 8:32 am, the ADNS stated, food and food containers should not be placed directly on the floor. ADNS stated, the floor was dirty and putting food directly on the flow can cause food contamination and sickness if eaten by the residents. The ADNS stated food or food containers needed to be placed on a rack. During a concurrent observation and interview on 2/13/2024 at 8:34 am, with 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, and record review, the facility failed to ensure staff wear required Personal Protective Equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses.) when assisting two of three residents (Resident 33 and Resident 240) with meal. These deficient practices had the potential for the spread of infection. Findings: During a review of Resident 33's admission Record, the admission record indicated the facility admitted the resident on 8/25/2023 with diagnoses that included multiple fracture (broken bone) of ribs. During a review of Resident 33's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 11/16/2023, the MDS indicated the resident had moderate cognitive (ability to understand) impairment and required supervision with rolling left and right and sit to lying mobility. During a review of Resident 240's admission Record, the admission record indicated the facility admitted the resident on 2/6/2024 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 observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced the resident's dignity and respect, by standing in front of the resident while assisting a meal for one of one sampled resident (Resident 49) in accordance with facility's policy on Promoting/Maintaining Resident Dignity During Mealtimes. This deficient practice had the potential to affect Resident 49's self-esteem and self-worth. Findings: During a review of Resident 49's admission Record, the admission record indicated the facility admitted Resident 49 on 5/25/2018 with diagnoses that included cataract (clouding of the lens in the eye leading to a decrease in vision) and hypertensive retinopathy (damage of retinas [inner back lining of your eyes] from long-term high blood pressure). During a review of Resident 49's History and Physical (H&P), dated 10/31/2023, the H&P indicated Resident 49 did not have the capacity to understand and make decision. During a review of Resident 49's Minimum Data Set (MDS, a standardized assessment and care planning tool),…

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 safety during self-administration of medications for one of one sampled resident (Resident 19.) This deficient practice had the potential to result in unsafe medication use. Findings: During a review of Resident 19's admission Record, the admission record indicated the facility admitted the resident on 3/28/2022, with diagnoses that included diabetes mellitus (high blood sugar,) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning.) During a review of Resident 19's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 2/1/2024, the MDS indicated the resident had moderate cognitive (ability to understand) impairment. The MDS indicated the resident required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with rolling left and right and dependent with toileting and showers. During an observation in Resident 19's room and interview…

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

Based on observation, interview and record review, the facility failed to provide reasonable accommodation of needs for one of one sampled resident (Resident 83) who was at risk for fall, by failing to ensure the resident's call light was within reach as indicated in the facility's Policy and Procedure, titled Call Lights: Accessibility and Timely Response and the resident's care plan. This deficient practice had the potential for Resident 83 not to receive or received delayed care. Findings: During a review of Resident 83's admission Record, the admission record indicated the facility admitted Resident 83 on 10/24/2023 with diagnoses that included epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain). During a review of Resident 83's untitled care plan initiated on 10/25/2023, the care plan indicated Resident 83 was at risk for falls and injuries. The care plan interventions indicated for nursing staff to place Resident 83's call light within…

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 develop a care plan for one of one sampled resident (Resident 239) with edema (swelling caused by fluid retention) of the left leg. This deficient practice had the potential to result in worsening of edema for Resident 239. Cross Reference: F684 Findings: During a review of Resident 239's admission Record, the admission record indicated the facility admitted the resident on 5/26/2022 and readmitted on [DATE], with diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder that affects the blood vessels outside of the heart) and venous insufficiency (when the veins have trouble sending blood from the limbs back to the heart, causing blood to pool in the veins on the legs.) During a review of Resident 239's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 1/8/2024, the MDS indicated the resident had no cognitive (ability to understand) impairment. Resident 239 required…

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 set up the lunch tray for one of one sampled resident (Resident 44) with severely impaired vision. This failure had the potential to result in Resident 44 losing weight and becoming dehydrated (when the body does not have enough fluid to function properly) due to the inability to feed himself. Findings: During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (when the body's metabolism causes brain dysfunction), blindness in one eye, low vision in the other eye, and glaucoma (a group of eye conditions that cause blindness). During a review of Resident 44's Care Plan, revised on 10/7/2022, the care plan indicated Resident 44 had an activity of daily living (ADL) self-care performance deficit related to his conditions and required supervision by one staff member for eating. During a 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.

Based on observation, interview, and record review, the facility failed to ensure the nasal cannula (tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen) was placed properly by placing both nasal prongs in the resident's nostrils for one of one sampled resident (Resident 83) in accordance with the facility's policy titled Oxygen Concentrator. This deficient practice placed Residents 83 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues). Findings: During a review of Resident 83's admission Record, the admission record indicated the facility admitted Resident 83 on 10/24/2023 with diagnoses that included acute respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) unspecified with hypoxia or hypercapnia (high levels of carbon dioxide [waste product that the body gets rid of when a person exhales]). During a review of Resident 83's History and Physical (H&P), dated 11/2/2023, the H&P indicated Resident 83 did not have the capacity to understand and make…

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 conduct reassessment after a routine pain medication was administered for one of two sampled residents (Resident 239.) This deficient practice resulted in Resident 239 to continue to experience pain, affecting the resident's quality of life. Findings: During a review of Resident 239's admission Record, the admission record indicated the facility admitted the resident on 5/25/2022 and readmitted on [DATE], with diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder that affects the blood vessels outside of the heart) and venous insufficiency (when the veins have trouble sending blood from the limbs back to the heart, causing blood to pool in the veins on the legs.) During a review of Resident 239's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 1/8/2024, the MDS indicated the resident had no cognitive (ability to understand) impairment. The MDS indicated Resident…

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

Based on interview and record review, the facility failed to ensure the irregularities of the Medication Regimen Review (MRR) identified by the facility's Pharmacy Consultant was acted upon for one of five sampled residents (Resident 83) in accordance with facility's policy and procedure titled, Consultant Pharmacist Reports. This deficient practice had the potential for harm due to missed opportunity by the physician and the licensed staff to act upon the reported irregularities. Findings: During a review of Resident 83's admission Record, the admission record indicated the facility admitted Resident 83 on 10/24/2023 with diagnoses that included epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain). During a review of Resident 83's History and Physical (H&P), dated 11/2/2023, the H&P indicated Resident 83 did not have the capacity to understand and make decision. During a review of Resident 83's Minimum Data Set (MDS, a standardized assessment…

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 five sampled staff (Licensed Vocational Nurse 3 [LVN 3]) was aware to report an allegation of abuse to the Long-Term Care Ombudsman (assist residents in long-term care facilities with issues related to day-to-day care) as required by State and Federal regulations. This deficient practice had the potential for facility staff not to report an abuse incident to the Long-Term Care Ombudsman, which could lead to possible harm and risk of further abuse of the residents. Findings: During an interview on 2/15/2024 at 12:06 pm, with LVN 3 (Charge Nurse), LVN 3 stated, I don't know what is an Ombudsman when asked about reporting agencies if an abuse allegation occurred. LVN 3 stated the two agencies to report allegation of abuse were the State Agency and the local law enforcement. LVN 3 stated LVN 3 received abuse in-service training last month. During an interview on 2/15/2024 at 12:21 pm, with Director of Staff Development (DSD), DSD stated any allegation of abuse should be reported in a timely manner to the State,…

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.