Palms Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to meet professional standards of practice for three of eight sampled residents (Residents 8, 11 and 57) when: 1. Licensed Vocational Nurse (LVN) 2 failed to follow facility's procedure on Proper Inhalation Technique for Metered Dose Inhaler (MDI-small, hand-held device filled with medicine to treat breathing problem) when she administered MDI medication to Residents 11 and 8. This failure had the potential for Residents 8 and 11 to suffer from respiratory infection which could lead to serious health condition. 2. Licensed Nurses (LNs) were signing the Electronic Treatment Administration (eTAR- electronic version of standard paper treatment administration record) on Resident 57's order for splint/orthotic device (support to an injured or weakened body part) from 4/1/24- 4/17/24 and not following the treatment order on how the splint/orthotic device was to be applied to Resident 57. This failure had the potential for Resident 57 to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a physician Informed Consent (the process in which residents are given important information of the possible risk and benefits of psychoactive medications) for the use of psychotropic medication (medication capable of affecting mind, emotions, and behavior) was obtained for one of six sampled residents (Resident 26) when Resident 26 was administered quetiapine fumarate and risperidone (medications used to treat anxiety [intense excessive, and persistent worry and fear about everyday situations]) on 3/26/24 to 4/8/24 and informed consent was not obtained prior to medication administration. These failures resulted in Resident 26 to be administered psychotropic medications and not be fully informed of the risk and benefits and did not have the knowledge to make an informed decision which placed Resident 26 at a potential risk for negative side effects. Findings: During an observation on 4/15/24, at 12:25 p.m. in the dining room,…

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 honor resident's rights for one of eight sampled residents (Resident 12), when Resident 12 was not informed or allowed to decline plan of care. Resident 12 was placed on a low air loss mattress (LAL-enhancing circulation and reducing prolonged pressure in one area) that was contraindicated for fitted sheets and resident's request for fitted sheets was not addressed. This failure resulted in Resident 12 feeling frustrated, ignored, disrespected and physically uncomfortable when she was not allowed to have fitted sheets on her mattress. Findings: During a review of Resident 12's admission record (AR- document with resident demographic and medical diagnosis information) dated 4/17/24, the AR indicated Resident 12 was admitted on [DATE] with diagnosis of Injury of the Cervical (cervical- uppermost region) Spinal Cord, major depressive order (persistently low or depressed mood, decreased interest in pleasurable activities, feelings of guilt or…

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 a clean and homelike environment for one of 18 sampled residents (Resident 45), when Resident 45's room had chipped, missing and peeling paint on the walls of the bathroom and mirror. This failure had the potential for Resident 45 to not have living space in a homelike environment and possibly feeling depressed. Findings: During a review of the Resident 45's admission Record (AR- document with resident information), dated 4/17/24, the AR indicated Resident 45 was admitted on [DATE] with diagnosis of malnutrition (not getting enough nutrients for body to thrive), and anxiety disorder (feeling of fear, dread, and uneasiness). During a review of Resident 45's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/30/24, the MDS section C indicated Resident 4 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals…

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 Minimum Data Set assessment ((MDS -assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of three sampled residents (Resident 57) when Resident 57's functional limitation in range of motion was inaccurately coded on the MDS assessment. This failure had the potential to result in Resident 57's care needs not being met. Findings: During a concurrent observation and interview on 4/15/4, at 10:20 a.m. in room [ROOM NUMBER], Resident 57 was lying in bed and observed with right sided weakness. Resident 57 stated he was not able to move his right arm and right leg and used his left hand to move his right arm and right leg. During a review of Resident 57's admission Record (document with resident demographic and medical diagnosis information), dated 4/18/24, indicated Resident 57 was admitted in the facility on 1/30/24 with diagnoses which included cerebral…

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

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for one of six sampled residents (Resident 57) when Resident 57 was administered apixaban (anticoagulant-blood thinner) medication for atrial fibrillation (an irregular, often rapid heart rate that commonly caused poor blood flow and blood clot formation) and the facility did not initiate a care plan for apixaban. This failure placed Resident 57 at a potential risk for use of anticoagulant needs not met. Findings: During a concurrent observation, and interview on 4/15/24, at 10:20 a.m. in Resident 57's room, Resident 57 was lying down in his bed. Resident 57 stated he was not able to move the right side of his body and needed assistance with his care. Resident 57 stated he wanted to get stronger so he can go home to his ranch but needed someone to take care of him. During a review of Resident 57's admission Record (document with resident demographic and medical diagnosis information), dated 4/18/24, indicated Resident 57 was admitted in the facility on 1/30/24…

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

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles when Licensed Vocational Nurse (LVN) 6 did not lock her medication cart and went inside a resident room to administer medication. This failure had the potential for residents, staff, and visitors to have access to the unlocked medication cart. Findings: During a review of Resident 12's admission Record (document with resident demographic and medical diagnosis information), dated 4/18/24, indicated Resident 12 was re-admitted in the facility on 9/2/22 with diagnoses which included asthma (difficulty breathing), quadriplegia (weakness of upper and lower body) and heart failure. During a concurrent observation and interview on 4/16/24, at 12:06 a.m. during medication pass observation in south wing hallway. LVN 6 observed preparing medications for Resident 12, after LVN 6 prepared Resident 12, she turned her back on her medication cart, did not locked the medication cart and went inside Resident 12's room 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 and interview, the facility failed to establish and maintain an infection control program to provide a safe, sanitary, and comfortable environment to help prevent infection for one of three sampled residents (Resident 40) when Licensed Vocational Nurse (LVN) 7 failed to sanitize (disinfect) the blood pressure cuff (device used to measure the pressure of blood in the circulatory system), stethoscope (device used to listen to internal sounds of a human body or an animal) after use and did not wash her hands after checking the blood pressure of Resident 40. These failures had the potential to result in cross contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and transmission of infection between residents. Findings: During a concurrent observation and interview on 4/16/24, at 4:05 p.m. in the east wing hallway by Resident 40's room, LVN 7 was passing medications. LVN 7 checked Resident 40's blood pressure…

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 maintain an environment free from accident hazards for three of three sampled residents (Resident 1, Resident 3 and Resident 4) when Residents were not educated on oxygen safety precautions. This failure resulted in Resident 1 being burned from when her oxygen tubing caught fire and had potential for Resident 3 and 4 being burnt. Findings: During a record review of Resident 1's admission Record (AR-a document with personal identifiable and medical information), dated October 11, 2023, the AR indicated Resident 1 was admitted to the facility on [DATE] diagnoses which included chronic kidney disease (condition in which kidneys are damaged and cannot filter blood as well as they should), heart failure (condition that develops when the heart does not pump enough blood for the body's needs), and chronic ulcer (an open sore) of lower leg. Resident 1 required staff assistance for activities of daily living. During a review of Resident 1 ' s…

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

Based on interview and record review, the facility failed to provide sufficient staffing to provide care and services to ensure residents received the needed care to attain and maintain their highest practicable physical, mental and psychosocial well-being for five of six sampled residents (Residents 3, 10, 18, 19 and 20) when residents' needs, preferences, and accommodations were communicated to staff, and staff did not respond in a timely manner. These failures resulted in Residents 3, 10, 18, 19 and 20's needs not being met. Findings: During an interview on 11/2/21, at 2:56 p.m., with Resident 10, Resident 10 stated, the facility was understaffed and would call for assistance which took up to an hour for staff to respond. During an interview on 11/2/21, at 3:37 p.m., Resident 18's responsible party (RP), RP stated, she couldn't remember how long ago it was that Resident 18 was not showered by staff for one and a half weeks. During an interview on 11/3/21, at 9:19 a.m., with Certified Nursing Assistant (CNA) 7, CNA 7 stated, the facility had problems keeping staff since COVID-19…

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.

3. During a concurrent observation and interview on 11/2/21 at 2:26 p.m., with Resident 32, in Resident 32's room, Resident 32 was laying in bed with the catheter bag touching the ground. Resident 32 stated, after lunch the Certified Nursing Assistant (CNA) emptied his catheter bag. During a concurrent observation and interview on 11/2/21, at 2:35 p.m., with CNA 6, in Resident 32's room, Resident 32's catheter bag was touching the ground. CNA 6 stated, the catheter bag should not be on the ground because there was a risk for infection and cross contamination. During a review of Resident 32's Care Plan, dated 11/2/21, the Care plan indicated, .Alteration in elimination of bowel and bladder .Keep drainage bag of catheter below the level of the bladder at all times and off floor . During concurrent interview and record review on 11/3/21, at 3:46 p.m., with the DON, the facility policy and procedure titled Catheter-Care of dated 6/2020 indicted, .Take care to ensure the collection bag does not touch the floor at any time . The DON stated, the catheter bag should not touch the ground at…

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

Based on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety when two spices were expired, one applesauce container was not labeled and did not contain the use by date (last date recommended for the use of a product while at peak quality). These food items were available in the kitchen for use to prepare food for 57 out of 57 residents. This failure placed 57 residents at risk for foodborne illnesses (illnesses caused by consuming contaminated food or drink) from consuming potentially contaminated food (unclean) and exposure to harmful pathogens (bacteria or viruses that can cause illness) and decrease palatability of the food. Findings: During a concurrent observation and interview on 11/2/21, at 11:13 a.m., with Dietary Supervisor (DS), in the kitchen, the refrigerator had a small container of applesauce that had the open date of 10/30/21 and due date of 11/1/21. The DS stated the applesauce should not be used after the written date on the container. The DS threw away the…

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

Based on interview and record review, the facility failed to develop a policy and procedure allowing residents to have outside food brought in by the family and/or visitors ensuring sanitary and safe food storage for six of six sampled residents (18, 19, 35, and 51) when residents were informed, they were not allowed to store and/or reheat prepared food brought to them by family. This failure had the potential for unsafe and unsanitary food storage and handling brought from outside for later consumption and placed Residents 18, 19. 35 and 51at high risk for food borne illnesses. Findings: During a concurrent observation and interview on 11/02/21, at 3:37 p.m., with Resident 18 and Resident 18's Responsible Party (RP) 2, RP 2 brought in carrot cake. Resident 18's RP 2 stated food could be brought in for Resident 18, if eaten during the visit. Resident 18's RP 2 stated there was no refrigerator to store foods brought from home. During Resident Council Meeting (an organized group of residents who meet regularly to discuss concerns about their rights) and interviews on 11/03/21, at…

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

Based on interview, and record review, the facility's Administrator (ADM) failed to ensure effective oversight and necessary resources to ensure resident care services were met to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when the ADM did not provide oversight to the facility's day to day operations when: 1. The facility failed to ensure five of five Residents (Residents 6, 8, 11, 16, and 55) were assessed for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard (raised) or lowered) prior to installation and had no consent (form signed by resident or family explaining the risks of side rail use), physician order, indication for use, and care plans prior to the use of side rails. These failures had the potential to cause entrapment, serious harm, injury, or death to Residents 6, 8, 11, 16, and 55. (Cross reference F700). 2. Licensed…

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

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1.One of three sampled residents (Resident 27's) gastrostomy tube (a tube inserted through the wall of the abdomen directly into the stomach. The tube allows patients to receive nutrition directly through stomach) gravity bag (gravity feeding is a way to deliver feeding formula through the feeding tube. With this feeding method, formula flows out of a bag and into the tube by gravity) lid was left open when the feeding formula was being administered. This failure had the potential to result in Cross contamination for Resident 27. 2. Certified Nursing Assistant did not disinfect the mechanical lift (used to move patients who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) in between used for Resident 3, Resident 41 and Resident 20. These failures placed Resident 3, 41 and 20 at risk for cross contamination. 3. The facility lobby door was left unlocked, with access to anyone to enter the facility without…

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 designated Infection Preventionist (IP-professional who ensures healthcare workers and patients are doing all the things they should to prevent infections) completed the specialized training for IP certification program in accordance with the facility's policy and procedure and CMS (Centers for Medicare and Medicaid Services) guidelines. This failure resulted in the IP not meeting the qualifications that would ensure residents were provided with quality care to prevent or minimize the transmission or spread of COVID-19 (a contagious serious respiratory infection transmitted from person to person) and/or other infections to all residents and staff. Findings: During an interview on 11/10/21 at 2:08 p.m., with the Infection Preventionist (IP), the IP stated she does not have an IP certification and was in the process of getting certified. The IP stated the Administrator (ADM) was aware she does not have an IP certification. During an interview on 11/10/21, at 4:43 p.m., with the ADM, the ADM stated she was aware…

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 emergency exit routes must be clear and unblocked to allow quick and safe exit for facility residents, staff and visitors in case of an emergency when mechanical lifts, wheelchairs, shower beds where stored in front of the emergency exit doors in the hallway. This failure had the potential to create delay, panic, and confusion to residents, staff, and visitors in case of an emergency. Findings: During an observation on 11/3/21, at 8:55 a.m., in the hallway the mechanical lift was stored in front of the emergency exit door. During a concurrent observation and interview, on 11/3/21, at 9 a.m., with the Director of Maintenance (DOM) in the hallway, the DOM verified the mechanical lift was stored in front of the emergency door and was blocking the emergency exit door. The DOM stated the emergency exit door should be unblocked. During a concurrent observation and interview, on 11/3/21, at 3:02 p.m., with License Vocational Nurse (LVN) 4 in the hallway, LVN 4 verified one shower chair, two wheelchair, and…

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

Based on observation, interview and record review, the facility failed to provide services which meet professional standards of quality for three of 43 sampled residents (Resident 40, Resident 110, and Resident 56 .) when: 1. Resident 40 was administered oxygen without following physician's order. This failure resulted in Resident 40 to receive a high dose of oxygen and had the potential to experience oxygen toxicity (a lung damage that happens from breathing too much (supplemental) oxygen. It can cause coughing and trouble breathing. In severe cases it can even cause death.) Which can lead to difficulty in breathing and death. 2. License Vocational Nurse administered insulin by way of an insulin pen to Resident 110 and Resident 56 without disinfecting the insulin pen rubber seal, did not prime (a method to remove air bubbles from the needle to ensure it is working, and full dose administration) the pen, and did not hold the pen at the injection site for 5-10 seconds prior to pulling the needle out. This failure placed Resident 110 and Resident 56 at risk for an inaccurate insulin…

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 facility medication error rate did not exceed five percent when the facility medication error rate was 16 percent when 25 opportunities of medication administration were observed and four of the 25 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 12 percent. These failure placed Resident 110, and Resident 56 at risk for inaccurate insulin dosage and impaired insulin absorption (movement of a medication from the site of administration to bloodstream) and not getting the full therapeutic effects of all the administered medications. Findings: During a medication administration observation, on 11/04/21, at 10:09 a.m., in the hallway, with License Vocational Nurse (LVN) 8, LVN 8 administered Sodium Bicarbonate (a medication use to relieve heartburn and acid indigestion) tablet 650 mg (milligrams - unit of measurement) one tablet, Amoxicillin-Pot Clavulanate (a medication use to treat infection) Tablet 500-125 mg one tablet, and NovoLOG…

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 residents were free from significant medication error for two of six sampled residents (Resident 110, and Resident 56) when: 1. Licensed Vocational Nurse (LVN) 8 administered Amoxicillin-Pot Clavulanate (a medication use to treat infection) not following physician's order administration time, and administered insulin (medication used to treat high blood sugar) by way of an insulin pen (a device used to inject insulin) to Resident 110 without priming prime (a method to remove air bubbles from the needle to ensure it is working, and provides insulin full dose administration) the insulin pen and without allowing the pen needle to remain under the skin for 5 to 10 seconds. 2. LVN 3 administered insulin by way of an insulin pen to Resident 56 without disinfecting the insulin pen rubber seal prior to attaching the needle, did not prime the insulin pen, and did not allow the pen needle to remain under the skin for 5 to 10 seconds. These failure placed Resident 110, and Resident 56 at risk for inaccurate…

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 protect the privacy of personal information for one of 43 sampled residents (Resident 110) when Licensed Vocational Nurse (LVN) 8 did not close Resident 110's Electronic Health Record (EHR- are electronic versions of the paper charts. An EHR includes resident's medical history, notes, and other information about health including symptoms, diagnoses, medications, lab results, vital signs, immunizations, and reports from diagnostic tests). The EHR were left open, unattended and exposed for public viewing. This failure had the potential for unauthorized access to resident's personal information and violated Resident 110's right to privacy and confidentiality. Findings: During an observation on 11/4/21, at 9:54 a.m., in the hallway, Resident 110's EHR was left open and unattended. LVN 8 was inside the medication room. During an interview on 11/4/21, at 10 a.m., with LVN 8, LVN 8 verified Resident 110's EHR was left open and unattended in the hallway. LVN 8 stated Resident 110's EHR should not be left open and…

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

Based on observation, interview, and record review, the facility failed to implement and timely revise a person-centered comprehensive care plan for one of three sampled Residents (Resident 18) when: 1. Resident 18's care plan for use of indwelling urinary catheter (IUC-a catheter drains urine from your bladder into a bag outside the body) was not reviewed or revised by the Interdisciplinary Team (IDT-group composed of a physician, a nurse and appointed facility staff who meet and discuss the care of the residents). This failure had the potential for Resident 18's to develop urinary tract infections (UTI-infection of the urinary tract) and not following his specific care needs for the IUC. Findings: During an interview on 11/03/21, at 2:03 p.m., with Licensed Vocational Nurse (LVN) 9, LVN 9 stated Resident 18 had an IUC since admission and is diagnosed with obstructive uropathy (is a structural or functional hindrance of normal urine flow, sometimes leading to renal dysfunction). LVN 9 stated Resident 18's care plan was not personalized or revised since admission. During 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 ensure bowel and bladder training program was developed for one of three sampled residents (Resident 18) when Resident 18' s bowel and bladder (B&B) training program (a training program to overcome bladder problems) was not developed for the indwelling urinary catheter (IUC-a catheter drains urine from your bladder into a bag outside your body). This failure had the potential for Resident 18's to develop urinary tract infections (UTI-infection of the urinary tract) and loss of opportunity to regain bowel and bladder function. Findings: During a concurrent interview and record review, on 11/3/21, at 2:03 p.m., with LVN 9, Resident 18's electronic health record (EHR- are electronic versions of the paper charts. An EHR includes resident's medical history, notes, and other information about health including symptoms, diagnoses, medications, lab results, vital signs, immunizations, and reports from diagnostic tests) was reviewed. The EHR…

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 enteral G-tube (Gastrostomy tube that is placed directly into the stomach for administration of food, fluids, and medications) feeding per physician order, for one of three sampled residents (Resident 42) when; Resident 42 did not have training to self-administer enteral feeding and administered an incorrect formula by adding water to his enteral feeding. This failure resulted in Resident 42 receiving more water than prescribed and had the potential to cause adverse complications. Findings: During a concurrent observation and interview on 11/2/21, at 12:12 p.m., with Resident 42, in Resident 42's room, Resident 42 stated, he had been a carpenter and was able to pick up on this quickly. Resident 42 stated, he had watched nurses do the enteral feeding a thousand times and was able to do it by himself. Resident stated he would demonstrate how he self-administered the enteral feeding via his G-tube. Resident 42 proceeded by opening the…

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

Based on observation, interview and record review, the facility failed to ensure drugs were labeled in accordance with currently accepted professional standards of practice for one of 43 sampled residents (Resident 2) when Resident 2's artificial eye drops container was stored in the medication cart in the hallway without an open and used by date. These failures had the potential to result in the contamination, decreased efficacy of eye drops which placed Resident 2 at risk for decrease eye moisture and getting an eye infection. Findings: During a concurrent observation and interview, on 11/4/21, at 9:16 a.m., with License Vocational Nurse (LVN) 2, the medication cart stored Resident 2's artificial sterile eye drops. The eye drops had no open date and used by date (last date recommended for the use of a product while at peak quality) and was ready for Resident 2's use. LVN 2 stated the artificial sterile eye drop once open should have an open date and used by date to ensure medication potency and prevent eye infection. During an interview on 11/9/21 at 4:26 p.m., with the Director…

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

Based on observations, interviews and record reviews, the facility failed to ensure the food service staff had the appropriate competencies and skills sets to carry out the functions of the food service when one of seven dietary staff (Cook-CK 4) worked in the kitchen with an expired food handler card (FHC-proof of certification required of all food handlers in certain states within the United States. A food handler is defined as a person who works in a food facility and performs any duties that involve the preparation, storage or service of food in a facility). This failure had the potential to place residents at risk for unsafe food practices and handling which may lead to food borne illnesses (is any illness resulting from the spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food). Findings: During a concurrent interview and record review, on 11/05/21, at 10:23 a.m., with Dietary Supervisor (DS), the [NAME] (CK) 4, DS, CK 1, Dietary Aide (DA) 1, CK 3, DA 2 and CK 2's FHCs were reviewed. CK 4's FHC was issued on 6/11/2018 and expired on…

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

Based on interview and record review, the facility failed to maintain an effective abuse training program for one of three employees (Licensed Vocational Nurse (LVN) 6) when employee training was not tracked, and employee did not complete the mandatory training necessary to identify and report abuse to meet the needs of the residents. This failure placed residents at risk for abuse, neglect, and exploitation. Findings: During a concurrent interview and record on 11/10/21, at 10:16 a.m., with Director of Staff Development (DSD), DSD reviewed LVN 6's employee file and training binder. DSD validated that LVN 6 had not completed abuse training in 2020 and 2021. DSD stated, the abuse training was not done, the abuse training was supposed to be for all the staff every year. DSD stated, she was responsible for ensuring staff complete the mandatory training and was her expectation that all staff complete mandatory training. DSD stated, all staff in-service training had been a problem at the facility for the past year. During an interview on 11/10/21, at 4:43 p.m., with the Administrator…

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