Rose Villa Health Care Center

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 12) who was incontinent (unable to voluntarily control retention of urine or feces in the body) of bowel and bladder, was provided a retraining and/or toileting program (a structured approach to help individuals regain or improve control over their bowel and bladder functions), to regain the resident's normal bowel and bladder function as much as possible. This failure had a potential to result in Resident 12's inability to regain control of bowel and bladder function and can lead to a loss of dignity. Findings: During a review of Resident 12's admission Record, the admission Record indicated, Resident 12 was initially admitted to the facility on [DATE] and last re-admission was on 9/24/2024 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), overactive bladder (a bladder has a strong urge to pass urine even when your bladder isn't really full), 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 17) received multivitamins with minerals in accordance with physician orders during medication administration. This deficient practice had the potential to result in weakness and fatigue due to low levels of vitamins and minerals for Resident 17. Findings: During a review of Resident 17's admission Record (a document containing demographic and diagnostic information), dated 4/22/2025, the admission record indicated Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE]. During a review of Resident 17's History and Physical, dated 2/2/205, the document indicated Resident 17 had the capacity to understand and make decisions. During a review of Resident 17's Minimum Data Set MDS (MDS - a federally mandated resident assessment tool), dated 1/28/2025, the MDS indicated Resident 17's cognition was moderately impaired. The MDS indicated that Resident 17 needed maximal…

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 Seroquel (generic name - quetiapine, a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought]) for one of four sampled residents (Resident 12) was indicated for a specific, diagnosed condition as documented in the medical evaluation and record. This deficient practice had the potential to place Resident 12 at risk for significant adverse events (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of an unnecessary psychotropic drug (a medication that affects brain activities associated with mental processes and behavior), which could result in impairment or decline in the resident's mental, physical condition, functional, and psychosocial status. Findings: During a review of Resident 12's admission Record (a document containing demographic and diagnostic information), dated 4/22/2025, the admission record indicated Resident 12 was originally admitted…

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 Resident 11's multivitamin liquid bottle indicated a manufacturer expiration date in accordance with manufacturer's specifications and facility's policy and procedures (P&P) titled, Medication Storage dated 2012 and Medication Ordering and Receiving from Pharmacy Provider, Medications Brought to Care Center by Resident or Family Member, dated 2012 in one of one inspected medication room (Station 1 Medication Room). This deficient practice had the potential to result in Resident 11 receiving multivitamin liquid that had become expired, ineffective, or toxic due to improper labeling and/or storage possibly leading to adverse effects from the multivitamin. Findings: During a review of Resident 11's admission Record (a document containing demographic and diagnostic information), dated [DATE], the admission record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including but not limited to, tinea unguium…

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 an accurate medical diagnosis was documented for one of three sampled residents (Resident 21), by failing to ensure Resident 21's diagnoses of adjustment disorder with depressed mood a specific type of adjustment disorder where the dominant symptoms are those associated with depression, such as low mood, tearfulness, and feelings of hopelessness, in response to a stressful event or life change was reflected. This deficient practice had the potential to negatively impact the provision of necessary care and services and portray an inaccurate reflection of resident receiving care in the facility. Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension ([HTN], high blood pressure), hyperlipidemia (too much fat particles in the blood), diabetes mellitus ([DM]-a disorder characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation. interview and record review, the facility failed to implement infection control measures by failing to ensure: A. Resident 148's visitor was wearing Personal Protective Equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while the visitor (Vistor 1) was assisting the resident. B. To place Resident 148 in Contact Isolation (a preauction that is used for patients with diseases caused by bacteria and viruses that are spread through direct and indirect contact) due to possible clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) infection while waiting for lab result. This failure had the potential to result in compromised infection control measures to prevent the potential spread of infection among residents, staff, and visitors. Findings: During a review of Resident 148's admission Record, the admission Record indicated, Resident 148 was admitted to the facility on [DATE] 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide treatment and services to maintain or prevent further decrease in joint range of motion (ROM, full movement potential of a joint) and/or mobility for four of 12 sampled residents (Resident's 11, 20, 30, and Resident 43). The facility failed to ensure that Resident's 11, 20, 30 and Resident 43 received Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) treatment five times a week as indicated in the residents' care plans. This deficient practice had the potential for Resident's 11, 20, 30 and Resident 43 to have an avoidable decline in range of motion and mobility. a. During a review of Resident 11's admission Record (Face Sheet), the Face Sheet indicated the resident was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder which causes a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment and services to maintain or prevent further decrease in joint range of motion (ROM, full movement potential of a joint) and/or mobility for four of 12 sampled residents (Resident's 11, 12, 30, and Resident 43). The facility failed to ensure that Residents 11, 12, 30 and Resident 43 received Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) treatment five times a week as ordered. This deficient practice had the potential for Resident's 11, 12, 30 and Resident 43 to have an avoidable decline in range of motion and mobility. Findings: A. During a review of Resident 11's admission Record (Face Sheet), the Face Sheet indicated the resident was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder which causes a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to communicate the following consultant pharmacist's recommendations in the Medication Regimen Review ([MRR] a thorough evaluation of the medication list of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to the physician for two of twelve residents (Resident 20 and 13). The facility failed to: a. Attempt the gradual dose reduction (GDR), of Resident 20's Escitalopram (medication for depression), and b. Gradually discontinue Resident 13's Pantoprazole (medication that reduces acid in the stomach. These deficient practices had the potential to result in Resident 20 and 13's continued use of unnecessary medications which leads to adverse drug reactions and negative health outcomes for the residents. Findings: a. During a review of Resident 20's admission Record (Face Sheet), the Face Sheet indicated Resident 20 was originally admitted to the facility on [DATE] 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the licensed nurses acted upon the Pharmacists' Consultation Report by notifying Resident 20's physician about the pharmacist recommendation to attempt a gradual dose reduction of Escitalopram Oxalate (medication used to treat depression [a constant feeling of sadness and loss of interest, which stops a person from doing normal activities]) 5 milligrams ([mg] a unit of measure of weight) give one tablet by mouth (PO) one time a day for depression manifested by verbalization of feeling depressed. This deficient practice resulted in a recommended gradual dose reduction not performed for Resident 20 and had the potential to place other residents who were receiving antidepressant (medication used to treat depression) medications at risk for use of unnecessary medication. Findings: During a review of Resident 20's admission Record (Face Sheet), the Face Sheet indicated Resident 20 was originally admitted to the facility on [DATE] and re-admitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Obtain informed consent (process by which a healthcare provider educates a resident about the risks and benefits, and alternatives of a given procedure or intervention) prior to the administration of psychotropic drugs (medication that affects brain activities associated with mental process and behavior) for one out of four sampled residents (Resident 35) as indicated in the facility's policy and procedure (P&P). 2. Do a Gradual Dose Reduction ([GDR] an attempt to decrease or discontinue psychotropic) medication after three months of starting on the psychotropic medication, unless clinically contraindicated) for two of twelve sampled residents (Resident 5 and Resident 20). These deficient practices resulted in Resident 5 receiving Lorazepam (brand name Ativan, a medication used to treat anxiety [feeling of fear, dread, and uneasiness], and Resident 20 receiving Escitalopram (brand name Lexapro, a medication used to treat depression [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. Ensure monitoring of the medication refrigerator temperature on 4/5/2024 was done per the facility's policy and procedure (P&P) titled, Storage of Medication. This deficient practice had the potential for exposure of the medication to extreme temperatures potentially leading to loss of strength of the medications, causing residents to receive ineffective medication dosages. 2. Ensure Resident 52's one opened Insulin Glargine -Yfgn (brand name Semglee Pen, a medication used to control the level of sugar [glucose] in the blood) and one opened Insulin Lispro Kwikpen (brand name Humalog Kwikpen, a medication used to control the level of sugar in the blood) stored in the medication refrigerator was labeled with an open date per the facility's policy and procedure (P&P) titled, Medications with Special Expiration Date Requirements. This deficient practice of failing to label medications per the manufacturers' requirements and the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the call lights for two out of four residents sampled (Residents 8 and 155) were within reach. The deficient practice had the potential to result in delayed care and services that promote the residents' well-being. Findings: During a review of Resident 8's admission record, dated 4/6/2024, the admission record indicated Resident 8 was initially admitted to the facility on [DATE] and recently readmitted to the facility on [DATE] with diagnoses including muscle weakness, schizophrenia (mental illness that affects how a person thinks, feels and behaves), diabetes mellitus (disorder where the body cannot regulate glucose or sugar like it should), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 8's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/7/2024, the MDS indicated Resident 8 had severe impairment in…

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 one sampled residents (Resident 37's) 7-day-bed-hold (a guaranteed reservation for residents that are transferred out emergently) was honored, by admitting a new resident to Resident 37's bed. This deficient practice violates Resident 37's right to come back to his guaranteed bed and is against the facility's policy and procedure for bed hold. Findings: During a record review of Resident 37's admission Record, the admission Record indicated the resident was admitted on [DATE] then re-admitted on [DATE] to the facility with diagnoses that included acute respiratory failure with hypoxia (often caused by a disease or injury that affects your breathing, such as pneumonia, opioid overdose, stroke, or a lung or spinal cord injury), essential primary hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition). During a record review of Resident 37's Minimum Data Set ([MDS] standardized screening…

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, Licensed Vocational Nurse (LVN) 3 failed to check for gastrostomy tube ([G-tube] a surgical opening made into the stomach to provide nutritional support) placement (the correct positioning or location of something) and patency (being open) per the physician's orders, prior to administering medications for one of one sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for peritonitis (inflammation, swelling of the lining of the belly or abdomen), pain, and unnecessary hospitalization from administering medications into a G-tube which may have been dislodged. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral palsy (a group of permanent movement and posture disorders which limit activity), abnormalities of gait and mobility, abnormal posture, and seizures (sudden,…

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 quality of care and services in accordance with professional standards of practice for one of three residents (Resident 8) when: 1. The facility failed to ensure the physician and the Registered Dietician ([RD] a health professional who has special training in diet and nutrition) were notified immediately, as indicated in the nutrition care plan, after Resident 8 was identified with severe weight loss on 2/5/2024 and 4/5/2024. a. On 2/5/2024, Resident 8 was identified to have a 9.73 % weight loss and the physician and RD were notified of the weight loss on 2/8/2024, three days later. b. On 4/5/2024, Resident 8 was identified to have 7.7 % weight loss and the physician and RD were notified of the weight loss on 4/6/2024, a day after the weight loss was identified. 2. The facility failed to ensure the Interdisciplinary team's ([IDT] resident's health care team consisting of various specialties) recommendations made on 2/8/2024 were…

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 enteral (method of supplying nutrients directly into the gastrointestinal tract) feeding administration set, and piston syringe were signed and dated per facility's policy and procedure, to prevent complications of gastrostomy tube ([G-tube] an artificial opening into the stomach to deliver medication, nutrition, and hydration) for one of one sampled residents (Resident 1). This failure had the potential for Resident 1 getting infections due to the enteral feeding set being used beyond it's use-by date. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the resident was admitted on [DATE] then re-admitted on [DATE] to the facility with diagnoses that included acute respiratory failure with hypoxia (often caused by a disease or injury that affects your breathing), pneumonia (an infection of the air sacs in one or both the lungs), hypotension (low blood pressure). During a record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure: 1. The primary care physician visited Resident 37 to assess and continue admission orders from the hospital and complete a history and physical (H&P) making sure the facility provided the care needed during the stay in the facility for one of one sampled resident (Resident 37). 2. Ensure Resident 29's physician conducted a monthly visit for the month of 3/2024. This deficient practice has the potential to not provide Resident's 37 and 29 the appropriate medical interventions during their facility stay and had the potential to have issues or concerns missed which they may have wanted to discuss with their physician. Findings: 1. During a record review of Resident 37's admission Record, the admission Record indicated the resident was admitted on [DATE] then re-admitted on [DATE] to the facility with diagnoses that included acute respiratory failure with hypoxia (often caused by a disease or injury that affects breathing) essential primary…

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.

Basedoninterviewandrecordreviewthefacilityfailedtoensurethecomputedtomographyscan([CT]imagingteststodetectinternalinjuriesanddisease withintravenouscontrast(toadministermaterialsdirectlytothepersonsveintoenhancetheimagesofthetest, orderedon3/14/2024, toruleoutClostridioidesdifficile(germthatcausesinfectionofthecolon / Colitisrelapsediagnosiswithdiarrhea(loosewaterystools foroneofoneresident(Resident48) wascompleted ThedeficientpracticehadthepotentialtoresultinanundiagnosedproblemwhichcouldhaveplacedResident48 athigherriskforphysicaldecline Findings DuringareviewofResident48'sAdmissionRecord dated4/6/2024, theadmissionrecordindicatedResident48 wasadmitted tothefacilityon3/1/2024 withdiagnosesincludinginfectiousgastroenteritis(aninflammation[responsetoinjurycausingredness swelling pain lossoffunctionandheat]oftheliningofthestomachandintestines andcolitis(diseasecharacterizedbyinflammationoftheinnerliningofthecolon andcystitis(infectionofthebladder[organthatholdstheurine] withouthematuria(bloodintheurine. DuringareviewofResident48'sMinimumDataSet(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 ensure Resident 8 received the ordered Consistent Carbohydrate Diet (CCHO, diet with the same amount of carbohydrates [sugars], main nutrients in our diet, every day), regular texture, thin liquids consistency, fortified (extra nutrients added), with chopped meat, on 4/7/2024. This deficient practice placed Resident 8 at higher risk for continued severe weight loss (weight loss greater than 5 percent in one month and greater than 7.5 percent in three months) and at higher risk for malnutrition (body does not get enough nutrients). Findings: During a review of Resident 8's admission record, dated 4/6/2024, the admission record indicated Resident 8 was initially admitted to the facility on [DATE] and recently readmitted to the facility on [DATE] with a diagnoses including sepsis (infection of the blood), muscle weakness, dysphagia (difficulty swallowing), mild calorie protein-calorie malnutrition (nutritional status in which reduced…

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's Quality Assessment and Assurance ([QAA] to develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] designated to bring about constant and measurable improvement in the services provided at the facility for continual improvement of quality care) committee failed to ensure the facility's administrator attended the monthly meetings. This deficient practice has a potential for the QAA committee not to identify and not to respond to systemic problems to improve services for the residents. Findings: During the entrance conference on 4/6/2024 at 10:46 a.m. with the Director of Nursing (DON), the DON stated that they do the monthly QAPI meeting to identify the concerns of residents', to improve the services and care of the residents in the facility. During a concurrent interview and record review of the QAA meeting minutes for the month 3/2024 on 4/7/2024 at 6:00p.m., with the Director of Nursing (DON), the DON stated that the admin is present…

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 offer the influenza (Flu-an infection of the nose, throat and lungs, which are part of the respiratory system) vaccine and pneumococcal vaccine (vaccine that helps prevent pneumonia, an infection that inflames the air sacs in one or both lungs) to two of six sampled residents (Resident 1 and Resident 104). This failure had the potential to result in Residents 1 and 104 acquiring and transmitting the flu and pneumonia to other residents, staff, and visitors. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the resident was admitted on [DATE] then re-admitted on [DATE] to the facility with diagnoses that included acute respiratory failure with hypoxia (often caused by a disease or injury that affects breathing) pneumonia (an infection of the air sacs in one or both the lungs), hypotension (low blood pressure). During a record review of Resident 1's Minimum Data Set ([MDS] standardized screening tool) dated…

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 that Resident 104 received the covid-19 (an disease caused by a virus, which is characterized mainly by fever and cough and can progress to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccination. This deficient practice placed Resident 104 at risk of acquiring serious infections such as pneumonia and covid-19 that could result in serious symptoms. Findings: During a record review of Resident 104's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included hypertension (high blood pressure), falls and spinal stenosis (happens when the space inside the backbone is too small). During a review of the History and Physical (H&P) dated 4/2/2024, the H&P did not indicate if Resident 104 had the capacity to make decisions. During a concurrent interview and record review of the immunization (administered resistance 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, facility failed to ensure a baseline care plan for one of three sampled residents (Resident 1). Resident 1 did not have a baseline care plan that identified that Resident 1 refused and Resident 1 ' s family member (FM) refused to attend the Integrated Discharge Disciplinary Team (IDT the Residents health care team made up of various specialties). This deficient practice had the potential for Resident 1 to not receive appropriate care and treatment specific to her needs. Findings: During a review of Resident 1 ' s admission Record the admission Record indicated the facility admitted Resident 1 o the facility on 12/31/2022 and readmitted her on 1/25/2024 with diagnoses of essential (primary) hypertension (high blood pressure, pulmonary fibrosis, unspecified (a disease where there is scarring of the lungs making it hard to breath) and rheumatoid arthritis , unspecified (a chronic progressive disease-causing inflammation in the joints). During a review of Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to readmit one out of two sampled residents (Resident 1) from the General Acute Care Hospital 1 (GACH1) after the resident was cleared by GACH 1 to return to the facility on 9/14/2022. This deficient practice resulted in denial of Resident 1 ' s right to return to the facility where she lived. Findings: During a review of the facility census (daily official count and list of residents admitted to the facility) dated 10/13/2023, the census indicated 40 in house residents and 3 bed holds (if a resident is transferred out, the facility reserves the resident ' s bed for seven days) for residents not in the facility. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses including cerebral palsy (a condition that affects muscle tone, movement, and coordination that limit activity), dysphagia (difficulty swallowing), muscle weakness, diabetes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Do a Gradual Dose Reduction ([GDR] an attempt to decrease or discontinue psychotropic [medications that act on the mind] medication after three months of starting on the psychotropic medication, unless clinically contraindicated) for two of three residents (Resident 16 and Resident 36). This deficient practice resulted in Resident 16 receiving Escitalopram (brand name Lexapro, a medication to treat depression), and Resident 36 receiving Aripiprazole (brand name Abilify, a medication to treat depression) and Fluoxetine (brand name Prozac, an antidepressant medication that works in the brain) without clinical justification for use. 2. Ensure a proper physician consultation evaluation for Aripiprazole for one of three residents (Resident 36). This deficient practice had the potential for Resident 36 to take medications and experience side effects and adverse effects without being evaluated by a mental health proffesional for appropriateness, before…

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 adequate space for therapy in the rehabilitation gym as evidenced by multiple binders, cardboard boxes, plastic containers, a laptop, bags, a water bottle, and office supplies were placed on the therapy mat (an adjustable padded surface used for therapy treatment) that is used for residents during therapy. This deficient practice had the potential to minimize equipment use and usable treatment space for residents during therapy. Findings: During an observation of the rehabilitation gym on 04/06/2022 at 3:47 p.m., six binders, two clipboards, two cardboard boxes, three plastic containers, a laptop, two bags, one water bottle, and office supplies were observed on top of therapy mat. During an observation and interview with the Director of Rehabilitation Services (DOR) on 04/06/2022 at 4:00 p.m., DOR stated that the therapy mat was used for residents who had trouble standing, sitting, and/or demonstrated decreased endurance. The DOR stated that there were multiple binders, cardboard boxes, plastic…

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 routinely clean and remove lint from the dryer. This deficient practice had the potential to cause a fire and/or injury to all residents and staff in the facility. Findings: During an observation, interview, and record review, with the Director of Maintenance (DM) and housekeeper/laundry aide (HKLA) on 04/07/2022 at 8:57 a.m., the dryer filter was observed to be dirty and entirely covered in lint and debris. The DM stated that the lint trap was dirty and that it needed to be cleaned. The DM proceeded to clean the dryer filter and stated that it was supposed to be cleaned after every two loads. The DM and HKLA stated that it was important to clean the filters regularly due to fire risk. The DM stated staff needed to document and initial on the dryer filter cleaning log. Upon review of the dryer filter cleaning log, the DM and HKLA stated the log was blank for today, 04/7/2022 for 6:00 a.m. and 8:00 a.m. The DM and HKLA stated if the log was not initialed and was blank, then it indicated that the task was 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 40 sampled residents (Resident 12) was not provided grooming of fingernails. This deficient practice had the potential to result in Resident 12 being predisposes to microorganisms that can cause infection and a decrease self-esteem. Findings: On 4/7/2022 at 11:00 a.m., a review of the electronic medical record indicated that Resident 12 was admitted at the facility on 7/28/2012 with the diagnosis of Osteomyelitis (inflammation of the bone or bone marrow due to infection) of the Lumbar (lower part of the back) region of the Vertebra (series of small bones forming the backbone); Malignant Neoplasm (a disease in which abnormal cells divide uncontrollably and destroy body tissue) of the Prostate; Unspecified Anemia ( a condition in which the blood does not have enough healthy red blood cells); Chronic Obstructive Pulmonary Disease ( a group of diseases that cause airflow blockage and breathing related problems) with Acute Lower Respiratory Infection; Hypertension (blood pressure higher than normal);…

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 a care plan for activities for one of 40 sampled residents (Resident 12). This deficient practice had the potential to negatively impact the resident's physical, cognitive and emotional health. Findings: On 4/5/2022 at 1:00 p.m., a review of the electronic medical record indicated that Resident 12 was admitted at the facility on 7/28/12 with the diagnosis of Osteomyelitis (inflammation of the bone or bone marrow due to infection) of the Lumbar (lower part of the back) region of the Vertebra (series of small bones forming the backbone); Malignant Neoplasm (a disease in which abnormal cells divide uncontrollably and destroy body tissue) of the Prostate; Unspecified Anemia ( a condition in which the blood does not have enough healthy red blood cells); Chronic Obstructive Pulmonary Disease ( a group of diseases that cause airflow blockage and breathing related problems) with Acute Lower Respiratory Infection; Hypertension (blood pressure higher than normal); Atrial Fibrillation (irregular and very rapid…

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 treatment and services to maintain or prevent further decrease in joint range of motion (ROM, full movement potential of a joint) and/or mobility for one of 12 sampled residents (Resident 6). The facility failed to ensure that Resident 6 received Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) treatment five times a week as ordered. This deficient practice had the potential for Resident 6 to have an avoidable decline in range of motion and mobility. Findings: A review of Resident 6's admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including chronic pain syndrome (persistent pain that lasts over three months), hypertensive heart disease without heart failure (heart disease that occurs due to long periods of high blood pressure), and morbid obesity (health condition…

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 clarify physician orders for an accurate dose of MiraLAX AX (medication used to treat occasional constipation) for one of three residents (Resident 38). This deficient practice had the potential to result in Resident 38 having unintended complications related to bowel patterns that can lead to constipation. Findings: During an observation on 4/7/2022 at 8:46 a.m., in front of resident 38's room, Licensed Vocational Nurse (LVN) 5 was observed preparing MiraLAX for administration to Resident 38. LVN 5 poured 1 cap full in a cup of 6 ounces of water. During a review of Resident 38's Order Summary Report (OSR), dated 6/30/2021, the OS indicated, MiraLAX Powder (Polyethylene Glycol 3350) Give 25 gram (gm) by mouth two times a day for bowel management dissolve with 6-8 ounces of water or juice. During a concurrent observation and interview on 4/7/2022, at 11:27 a.m., with LVN 5 in front of medication cart, MiraLAX bottle directions printed as,…

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. Administer two medications necessary to treat Resident 12's anemia. The deficient practice had the potential to result in a delay of alleviating of or worsening of Resident 12's anemia. 2. Replace inhalation (INH) solution medication in the Emergency Kit ([E-kit] medications needed immediately) in a timely manner, taken for Resident 202 for Nurses Station (Station 1). The deficient practice had the potential to result in a delay in administration of necessary emergency medication for the residents. 3. Properly document resident names on E-kit slips at one of two Nurses Stations (Station 1). The deficient practice had the potential to result in unclear communication which could have led to issues with follow-up evaluations and treatment. Findings: 1. During a concurrent observation and interview on 4/6/2022, at 1:46 p.m., at Station 1, with Director of Nursing (DON), there was a full dose syringe of Epogen (medication used to treat low…

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 communicate the consultant pharmacist's recommendation in the Medication Regime Review (MRR), (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to the physician for one of five residents (Resident 16) for unnecessary medications. This deficient practice resulted in a recommended gradual dose reduction not performed for Resident 16, with a potential for adverse drug reaction for the resident. Findings: a. During a review of the admission face sheet, the face sheet indicated Resident 16 was admitted to the facility on [DATE], with diagnoses not limited to diverticulitis (infection or inflammation of pouches that can form in your intestines), depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (feeling of fear, dread, and uneasiness). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of seven residents (Resident 16), who had a physicans order for insulin (used to control the level of the sugar-glucose in the blood) according to a sliding scale (a dosing regimen that prescribes how much insulin to give for different levels of blood sugar) was free from significant medication error when insulin was potentially omitted. This deficient practice placed the resident at risk of inadequate blood sugar management, which can cause hyperglycemia (high blood sugar), or hypoglycemia (abnormal low blood sugar) which untreated can lead to complications, such as eye, kidney, or heart disease, nerve damage, loss of consciousness and even death. Findings: During a review of the admission face sheet, the face sheet indicated Resident 16 was admitted to the facility on [DATE], with diagnoses of type 2 diabetes mellitus ([DM] impairment in the way the body regulates and uses sugar [glucose] as a fuel), chronic kidney disease (kidneys are…

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

Based on observation, interview and record review, the facility failed to maintain proper temperature controls for medications requiring storage in the medication room. This deficient practice had the potential of medication exposure to extreme temperatures in the medication storage room in station 1, potentially leading to loss of strength of the medications, causing residents to receive ineffective medication dosages. Findings: During a concurrent observation and interview on 4/6/2022, at 1:46 p.m., with Director of Nursing (DON), in station 1 medication room, the medication room did not have a room thermometer. DON stated, she did not know the temperature in the medication room because there was no thermometer as they do not monitor the inside of the medication room. During a review of the facility's policy and procedure (P&P) titled, Medication Storage dated 9/10, the P&P indicated, Medications requiring storage at 'room storage' are kept at temperatures ranging from 15°C (59°F) to 30°C (86°F).

Based on observation, interview and record review, the facility failed to ensure expired food was not stored in the kitchen and accessible to be used in preparing foods in accordance with professional standards for food service safety. This practice had the potential to result in the residents ingesting expired food and can result in foodborne illnesses and can lead to symptoms such as nausea, vomiting, stomach cramps, and diarrhea including decrease in food flavoring and taste. Findings: a). During an observation on 4/5/2022 at 8:26 a.m. of the spice shelf, there was an egg shade pure food color bottle with an open date of 2/10/2021, with no expiration date. The egg shade pure food color, was missing on the Dry food storage guidelines. There was a rum flavor liquid with an open date of 2/10/2021, with no expiration date. The rum flavor liquid was missing on the Dry food storage guidelines. There was poultry seasoning with an open date of 5/10/2021, with a best by date of 10/6/2021. During an interview on 4/6/2022 at 2:22 p.m. with DS, DS stated, for all the products we check 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 interview and record review, the facility failed to provide physical therapy (PT) and occupational therapy (OT) evaluations as ordered for one of 12 sampled residents (Resident 6). This deficient practice had the potential to prevent Resident 6 from maximizing her functional mobility (the way in which one moves in the environment to complete everyday tasks), joint range of motion (ROM, full movement potential of a joint), and activities of daily living (ADL, basic activities such as eating, dressing, toileting) while residing in the facility. Findings: A review of Resident 6's admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including chronic pain syndrome (persistent pain that lasts over three months), hypertensive heart disease without heart failure (heart disease that occurs due to long periods of high blood pressure), and morbid obesity (health condition involving excessive body mass). 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 interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship by failing to: 1). Ensure Resident 46 was prescribed an antibiotic drug without meeting the criteria, after being screened for a urinary tract infection UTI (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract), and failing to provide a McGeer's criteria surveillance list. 2). Provide a McGeer's criteria surveillance documentation for (Resident 198). Resident 198 was prescribed antibiotic drug without following McGeer's surveillance. These deficient practices had the potential to result in antibiotic resistance (not effective to treat infection) due to unnecessary or inappropriate antibiotic use. Findings: a). During a review of the admission record for Resident 46 dated 3/21/2022, the record indicated Resident 46 had diagnosis that included traumatic subdural hemorrhage without loss of consciousness subsequent encounter (It is caused by a traumatic head injury, such as a blow to the head or a fall.…

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 pneumonia (PNA) (an infection of the lungs) vaccinations (medication to prevent a particular disease) was administered timely (within admission)) to one of one resident (Resident 36). This deficient practice placed Resident 36 at a higher risk of acquiring and transmitting pneumonia to other residents in the facility. During a review of the admission record for resident 36 dated 2/23/2022, the admission record indicated diagnosis that included end stage renal disease (ESRD) (kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), muscle weakness (generalized) (lack of strength in the muscles.) anemia, unspecified (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues.) During a review of Resident 36 History and Physical (H&P), dated 2/23/2022, the H&P indicated Resident 36 has the ability to understand and make medical decisions. During a 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.