Willow Pass Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow infection control policies and procedures when: 1. staff did not answer COVID-19 screening questions before entering the facility; 2. Resident 14 and Resident 54's nasal cannula and bilevel positive airway pressure (BiPAP, a machine used to deliver pressured air to lungs) mask were not bagged and touching the floor; 3. Resident 54's BiPAP mask had brown matter sticking to the mask; and 4. staff did not clean the morphine sulfate (MS- medication to relieve moderate to severe pain) solution re-usable syringe for Resident 377 after use. This deficient practice had the potential to spread infection. Findings: 1. During a concurrent record review and interview of the facility document, Willow Pass Healthcare Center Visitor Symptoms Screening Log with Infection Preventionist (IP) on 10/13/22, at 1:13 p.m., nocturnal shift staff were not screened before their shifts from 10/5/22 through 10/13/22. IP stated this document was for all visitors who entered…

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 a clean and sanitary environment to three of three sampled residents (Resident 14, 54, and 6) when 1. Resident 14 and Resident 54's standing/ table fans had visible dust, dirt and debris; and 2. Resident 6 had rodent droppings next to her beds for three days. These failures placed Residents 6, 14, 54 at risk for infection and loss of a homelike environment due to unclean and unsanitary conditions. Findings: 1. During a concurrent observation and interview on 10/10/22, at 10:30 a.m., with Certified Nurse Assistant (CNA) 1, Resident 6 and Resident 14's shared room was observed. Resident 6 had a black standing fan next to the bedside table directed towards her. Resident 6's fan had dust, dirt and white papery debris on the fan casing. Resident 14 had a large white colored square fan sitting on top of her bedside table pointed at her. Resident 14's fan had a thick dark brown layer of dust over the fan casing. CNA 1 stated the fans were personal belongings of Resident 6 and Resident 14 and she did not know…

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 Activities of Daily Living (activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) care for one of one sampled resident (Resident 14) who required extensive assistance when Resident 14's scheduled showers and bed baths were missed. This failure placed Resident 14 at risk for infection and skin breakdown. Findings: During a record review of Resident 14's admission Record, dated 10/10/22, the record indicated Resident 14 was originally admitted to the facility in 6/2022. During a record review of the Minimum Data Set (MDS - an assessment tool used to guide care) dated 7/04/22, it indicated Resident 14 was alert and able to make her needs known. The MDS assessment also indicated Resident 14 required one staff's extensive physical assistance for bathing and showers. During a review of Resident 14's Activities of Daily Living Care Plan, dated 6/27/22, the care plan indicated, the goal was to maintain 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 follow its policies and procedures for oxygen administration for two (Resident 14 and Resident 68) of four sampled residents receiving oxygen therapy when there was no sign outside of Resident 14 and Resident 68's room stating Oxygen in Use and when Resident 68 was receiving oxygen therapy without a doctors order. These deficient practices may result in placing all individuals in the facility at risk of potential harm in the event smoke or fire in the vicinity of the oxygen container and ineffective oxygen therapy for Resident 68. Findings: A review of Resident 68's admission Record, dated 10/11/22 indicated Resident 68 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure (a chronic condition in which the heard doesn't pump blood as well as it should). A review of Resident 68's Minimum Data Set (MDS- an assessment tool) dated 9/18/22 indicated Resident 68 receives oxygen therapy while a resident in 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 accurate accountability and effective storage of controlled (those with high potential for abuse or addiction) and non-controlled medications when: 1. Random controlled medication use audits for five out of 5 residents (Residents 8, 14, 29, 45 and 63) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents; 2. An emergency kit (e-kit, a kit containing medications and supplies for immediate use during a medical emergency) containing oral medications had medication removed without the required documentation of the removal in accordance with the facility policy and procedures (P&P); and 3. Medications for disposal were not rendered unusable, irretrievable, and were not securely stored when old, clear plastic beverage bottles with holes cut out were used for drug disposal in 2 of 2 medication…

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 had a 31.03% error rate when nine medication errors out of 29 opportunities were observed during a medication pass for four of eight residents (Residents 4, 22, 53 and 63). These failures resulted in medications not given in accordance with the prescriber's orders and may affect the residents' clinical conditions. Findings: During a medication pass observation on 10/10/22, at 9:21 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed preparing eight medications, including oyster shell calcium 500 milligrams (mg, a unit of measure) plus vitamin D 5 micrograms (mcg, a unit of measure) tablet, multivitamin with minerals, and losartan (medication to treat high blood pressure) 100 mg for Resident 53. A review of Resident 53's medical record indicated the following physician's orders: - Calcium 500 mg: 1 tablet two times a day, dated 4/21/16 - Multivitamin: 1 tablet one time a day, dated 8/24/18 - Losartan 100 mg: 1 tablet one time a day, hold for SBP (systolic blood pressure, a measurement of blood pressure) less…

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: -Thirteen expired medications were not available for resident use; -Three medications were labeled properly with a pharmacy label to ensure it was used for the right resident; -Two multi-dose injectable insulin (medication to lower blood sugar level) products were dated with an open and discard date, to ensure they were not used beyond the discard date; -One medication had a legible expiration date; and -Six medications with discontinued physician's orders were removed from facility stock. The deficient practices had the potential for residents to receive the wrong medication or medications that were unsafe or with reduced potency from being used past their discard date. Findings: On 10/10/22 at 10:46 a.m., an inspection of the medication storage room and refrigerator with Infection Preventionist/Nurse Manager (IP/NM) identified and confirmed the following: - Expired medications: o 1 vial Tubersol (an injectable solution used to test for tuberculosis), expired 9/1/2022 o 1 container Tucks medicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1. Expired food items were found in the dry storage room; 2. Multiple dry food items did not have a use by date or open date on them; 3. Food was left uncovered and unlabeled and undated in freezer; 4. Ice machine was not clean with brown residue; 5. Expired test strips were used for testing the sanitizer strength used to sanitize food contact surfaces; 6. A box of popcorn was leaking in the dry storage area; 7. There was no air gap (a gap of air between the floor and a drainpipe to prevent backflow of sewage into the equipment) for 3-part compartment sink; 8. Kitchen vents were dirty with black and brown residue; 9. Kitchen counters over the cooking range were dusty with black/brown residue; 10. Five frying pans used for cooking food were not in good condition; 11. Two cutting board was scratched and significantly worn out; and 12. Used face shields 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.

Based on observation, interview, and record review, the facility failed to ensure self-administered medications kept at bedside for one of 18 sampled residents (Resident 4) were reviewed and approved by the physician. This failure had the potential for unsafe medication use, exposure to unwanted side effects and duplication of therapy. Findings: During an observation on 10/10/22, at 10:14 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed administering medications to Resident 4. To the left of Resident 4's bed was a nightstand, covered in personal items as well as an over-the-counter (OTC, medications available without prescription) lidocaine (a topical medication used to treat pain) 4% roll-on and a nighttime cold and flu syrup. Resident 4 asked LVN 1 to apply the lidocaine 4% roll-to her body and stated it was a medication the facility was not able to provide to her, so a family member had brought it to the facility for Resident 4. During an interview and record review on 10/10/22, at 1:25 p.m., with LVN 1, Resident 4's physician's orders were reviewed. LVN 1…

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

Based on observation, interview, and record review, the facility failed to accurately assess one of one sampled resident (Resident 38) for oral/dental status on one annual and two quarterly Minimum Data Set (MDS - an assessment used to guide care) assessments when Resident 38's MDS assessment was coded No to Broken or loosely fitting partial or full dentures and Resident 38 was not able to wear dentures. This failure resulted in an inaccurate reflection of Resident 38's oral/dental status and not triggering the facility to develop and implement a care plan for Resident 38's ill-fitting dentures for nine consecutive months. Findings: During a record review of Resident 38's admission Record, dated 10/12/22, the record indicated Resident 38 was admitted to the facility in 2018. During a record review of Resident 38's MDS Assessment, dated 8/8/22, the assessment indicated Resident 38 was cognitively intact, able to express herself, and able to make her needs known to others. During a concurrent observation and interview on 10/10/22, at 8:41 a.m., Resident 38 was lying in bed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete the Preadmission Screening and Resident Review (PASARR) assessment for one of three sampled residents (Resident 8) when the PASARR did not to reflect Resident 8's diagnosis of Anxiety (emotion we feel when we experience fear, nervousness, or a sense that something bad will happen), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and use of psychotropic medication (any medication capable of affecting the mind, emotions, and behavior). This failure placed Resident 8 at risk to not receive care and services appropriate to her needs. Findings: During a review of Resident 8's admission Record Report printed on 10/13/22, it indicated Resident 8 was originally admitted to the facility on [DATE]. During a concurrent interview and record review on 10/13/22, at 11:11 a.m., with the Registered Nurse (RN) 2, Resident 8's PASARR assessment was reviewed. RN 2 stated Resident 8's most recent PASARR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and provide a written summary of a baseline care plan to one of one sampled resident (Resident 14) when Resident 14's baseline care plan was not developed within 48 hours of admission to the facility. This failure placed Resident 14 at risk of not receiving person-centered care and facility staff to be unaware of Resident 14's needs. Findings: During a record review of Resident 14's admission Record, dated 10/10/22, the record indicated Resident 14 was originally admitted to the facility 6/25/22 and readmitted on [DATE]. During an interview and record review with Minimum Data Set Coordinator (MDSC) on 10/12/22, at 1:39 p.m., an untitled binder was reviewed. MDSC stated she was responsible for developing the baseline care plans and used the binder to keep the baseline care plans for all residents at the facility. MDSC stated the baseline care plans were arranged in alphabetical order of resident's names. MDSC then looked for Resident 14'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 and interview, the facility failed to follow professional standards of practice for one (Resident 126) of two residents receiving enteral feeding (a way of delivering nutrition directly to your stomach or small intestine) when staff did not label and date Resident 126's enteral bottle and tubing. This deficient practice may result in a risk for contamination. Findings: A review of the document titled, admission Record, dated 10/12/22 indicated Resident 126 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (paralysis of one side of the body) and dysphagia (difficulty or discomfort in swallowing). A review of the document titled, Order Summary Report, indicated a doctors order on 10/8/22 for Resident 126 for continuous enteral feeding of Jevity (a therapeutic nutrition for tube feeding) 1.0 at 50 cc/hour via pump. During a concurrent observation and interview on 10/10/22 at 10:35 a.m. with Registered Nurse (RN) 1, Resident 126 was observed receiving feeding from an enteral…

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 accurate renal (kidney) dialysis (therapy used to remove waste and extra chemicals and fluid from your blood) documentation and dialysis food preferences were provided for one of one sampled resident (Resident 65) with end stage renal disease (kidneys are no longer able to work as they should to your body's needs) when 1. Resident 65's renal dialysis access site was documented on the incorrect arm; 2. Resident 65 was not provided snacks during dialysis days; and 3. Resident 65 was not assessed before and after dialysis for various dates. This failure resulted in Resident 65's inaccurate pre- and post-dialysis assessments, Resident 65 feeling very hungry after dialysis, and the potential for unmet needs. Findings: 1. During a review of Resident 65's admission Record, dated 10/14/22, indicated Resident 65 was admitted to the facility on [DATE], with diagnoses including end stage renal (kidney) disease dependence on renal dialysis…

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 record review and interview, the facility failed to ensure one of three residents (Resident 32) receiving anticoagulation medication (medication to thin blood) was free from unnecessary medication when staff did not monitor the side effects of Resident 32's use of eliquis (medication used to thin blood). This failure had the potential to result in side effects of the medication to go unnoticed. Findings: A review of Residents 32's admission Record indicated Resident 32 was admitted to the facility on [DATE], with a diagnosis of cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture) and history of venous thrombosis (a blood clot in a deep vein of the leg, pelvis and sometimes arm) and embolism (obstruction of an artery, typically by a clot of blood or an air bubble). A review of Resident 32's Minimum Data Set (MDS- an assessment tool to guide care) dated 7/28/22 indicated Resident 32 received anticoagulant medication. A review of Resident 32's Order…

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

Based on observation, interview, and record review, the facility failed to ensure dental services were provided for one of one sampled resident (Resident 38) when Resident 38's upper and lower dentures were loosely fitted, needed realignment and Resident 38 was not able to wear dentures for nine consecutive months. This failure resulted in Resident 38 to not receive timely dental care, be able to wear lower dentures, and develop oral sores on the roof of their mouth. (Cross-reference F 641) Findings: During a record review of Resident 38's admission Record dated 10/12/22, the record indicated Resident 38 was admitted to the facility in 2018. During a record review of Resident 38's MDS Assessment, dated 8/8/22, the assessment indicated Resident 38 was cognitively intact, able to express herself, and able to make her needs known to others. During an observation and interview on 10/10/22, at 8:41 a.m., Resident 38 was lying in bed without lower teeth or dentures. Resident 38 stated I have dentures, the lower ones do not fit anymore, and the upper dentures partially fit and are causing…

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 one sampled resident (Resident 38)'s medical record reflected accurate meal intake when Resident 38's meal intake was documented but was not served breakfast and lunch. This failure resulted in an inaccurate reflection of Resident 38's meal intake. Findings: During an observation on 10/10/22, at 9:00 a.m., Resident 38 was lying in bed. Resident 38 stated I do not eat breakfast, I only eat lunch and dinner, every day. During multiple observations between 8:30 a.m. and 12:05 p.m., on 10/12/22, Resident 38 was not served any breakfast or lunch. During a concurrent interview and record review with Certified Nursing Assistant (CNA) 2 on 10/12/22, at 12:00 p.m., Resident 38's electronic health record for Nutrition - Amount Eaten was reviewed. CNA 2 stated she was the assigned CNA for Resident 38 on 10/12/22. CNA 2 stated she served breakfast and had already served lunch to Resident 38. CNA 2 also stated Resident 38 ate about 51-75 % breakfast at 10:51 a.m., and 51-75% lunch at 11:07 a.m. on 10/12/22.…

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.

5. During a concurrent observation and interview on 2/3/20, at 12:38 p.m., with CNA 2 at Station 1, CNA 2 was seen removing a dirty meal tray from a resident's room and placing it inside a meal conveyor cart with the clean meal trays that were being served to residents in their rooms. CNA 2 stated, It is an infection and contamination issue. 6. During a concurrent observation and interview on 2/4/20, at 1:42 p.m., with the Dietary Supervisor (DS), of the ice machine located at Station 1, the ice machine had a pinkish, blackish substance inside the ice bin. The DS stated, This is dirty, I will tell the administrator. During an interview on 2/4/20 at 1:44 p.m., with the Administrator (ADM) and the Maintenance Supervisor (MS), MS stated he cleaned the ice machine monthly and the manufacturer's representative came every six months for maintenance. ADM admitted the ice machine was dirty and stated he will monitor and increase the cleaning schedule for the ice machine. During a review of the facility and manufacturer's ice machine cleaning schedule, the schedule indicated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the privacy and dignity of two of 22 sampled residents (Residents 45 and 71) was protected when urinary drainage bags were left uncovered and visible to other residents, as well as visitors. This failure had the potential to negatively affect the emotional well-being of the residents. Findings: During a review of Resident 45's admission Minimum Data Set (MDS, an assessment tool used to guide care), dated 12/28/19, indicated Resident 45 had a Brief Interview for Mental Status (BIMS, a tool used to assess mental function) score of 8, meaning Resident 45 was moderately cognitively impaired. The MDS also indicated Resident 45 had an indwelling urinary catheter (a tube that drains urine from the bladder into a bag outside the body). During a concurrent observation and interview on 2/6/20, at 12:50 p.m., with Registered Nurse 2 (RN 2), Resident 45 was observed asleep in his bed in room [ROOM NUMBER]-B, and his urinary drainage bag was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure two of two sampled residents (Resident 11 and 36) with limited range of motion were able to notify staff they required assistance when the call lights for Residents 11 and 36 were not within reach. This failure had the potential for both residents to have unmet physical, medical, and psychological needs. Findings: During a review of Resident 11's Minimum Data Set (MDS, an assessment tool used to guide care), dated 11/4/19, the MDS indicated Resident 11 required extensive assistance of at least one staff member with bed mobility, transferring from one surface to another, dressing, eating, toilet use, and personal hygiene. The MDS also indicated Resident 11's Brief interview for Mental Status (BIMS, a tool used to assess mental function) score was 00, indicating the resident was severely cognitively impaired. During an observation on 2/3/20 at 9:58 a.m., Resident 11 was observed laying in her bed, waiving her hand and pointing to 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 respond in a timely manner to concerns brought up by Resident Council members (Residents 8, 16, 21, 42, 47, 64, 71, and 74). This failure resulted in residents' concerns not being addressed or followed up on. Findings: During an interview with members of the Resident Council on 2/4/20 at 10 a.m., Residents 8, 16, 21, 42, 47, 64, 71, and 74 indicated the administrator listens to their concerns but does not follow through and do anything about their concerns. During a review of Resident Council minutes, dated 6/27/19, the minutes indicated residents question the purpose of Resident Council meetings when no changes were made. During a review of Resident Council minutes, dated 9/26/19, the minutes indicated the need to fix dry rot and water damage to the front dining room floor. During an observation on 2/4/20, at 10:48 a.m., of an area of the front dining room floor approximately 2 feet by 1 foot showed a floor board missing and other floor boards lifting up and not flush with the floor and containing dark…

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

Based on observation, interview, and record review, the facility failed to provide care with dignity for one of one sampled residents (Resident 5) when Certified Nurse Assistant 7 (CNA 7) did not cover Resident 5 completely when transporting him down the hall after showering. This failure resulted in Resident 5 feeling embarrassed that his back-side was exposed for everyone to see. Findings: During a review of Resident 5's admission Record, dated 2/3/20, the admission Record indicated Resident 5 was admitted with multiple diagnoses, including hemiplegia (paralysis on one side of the body) and hemiparesis (a slight paralysis or weakness on one side of the body) due to a cerebrovascular accident (a stroke), and legal blindness. During a review of Resident 5's Minimum Data Set (MDS, an assessment tool used to guide care), dated 10/25/19, indicated Resident 5 had a Brief Interview for Mental Status (BIMS, a tool used to assess mental function) score of 15, meaning the resident was cognitively intact. The MDS also indicated Resident 5 required extensive assistance from at least one staff…

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

Based on observation, interview, and record review, the facility failed to properly label medications when: 1. Six of 30 house supply medications did not have the date they were opened written on the bottles; and 2. One of one intravenous (IV, given in a vein) antibiotic that had been mixed in a bag of normal saline (a combination of salt and water) did not have an expiration date written on the bag. This failure had the potential to result in residents receiving old or expired medications. Findings: 1. During a concurrent observation and interview on 2/4/20, at 10:25 a.m., with Licensed Vocational Nurse 2 (LVN 2), six of 30 house supply medications, on one of four medication carts, did not have the date they were opened written on their bottles. LVN 2 stated all house supply medications are good until their expiration date. During an interview on 2/5/20, at 1:53 p.m., with Registered Nurse 2 (RN 2), RN 2 stated they only need to write the date the medication was opened on liquid medications, eye drops, insulin, and inhalers because they expire after 28 days of being opened. RN 2…

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

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices when: 1. The Dietary Supervisor's (DS) hair was not totally covered by her hairnet while she was in the food preparation area. 2. There were two 3-gallon containers of sherbet in the freezer that had been opened and were not completely covered. 3. There was one 4-ounce (oz, a unit of measurement) tub of cream cheese in the walk-in refrigerator that had the aluminum seal pulled opened with no 'opened on' date recorded and had fluid build up on the surface of the cream cheese. These deficient practices had the potential to cause food-borne illnesses throughout the facility. Findings: 1. During a concurrent observation and interview on 2/3/20, at 8:30 a.m., with the DS, in the kitchen, the DS was wearing a hairnet that only covered the crown and back of her head, with her bangs extending out uncovered on her forehead. DS stated, Oh, my bangs. I should cover it. The DS pulled the hairnet forward, but her hair was not completely contained in the hairnet. During…

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

Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for one of 22 sampled residents (Resident 177) when Resident 177's fall care plan did not include nursing interventions. This failure had the potential for Resident 177 to receive inconsistent care and not reach desired outcomes. Findings: During a review of Resident 177's admission Record, the record indicated Resident 177 was admitted to the facility with multiple diagnoses, including Parkinson's disease (a disease of the central nervous system that produces progressive movement disorders and changes in cognition and mood) and was at high risk for fall with a fall risk score of 75 on the Morse Fall Scale assessment done on admission. During a review of Resident 177's Minimum Data Set (MDS, an assessment tool used to guide care), dated 1/30/20, the resident's Brief Interview for Mental Status (BIMS, a tool used to assess mental function) score was 11, meaning the resident is mildly cognitively impaired. During an interview on 2/3/20, at 8:45 a.m., with Resident 177,…

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 assistance with activities of daily living (ADLs), including assistance with personal hygiene (grooming, combing hair, nail care, oral care), to one of 22 sampled residents (Resident 8) when the resident's nail care was neglected. This failure resulted in Resident 8 having long, chipped, fingernails. Findings: During a review of Resident 8's admission Record, the record indicated Resident 8 was admitted to the facility for long term care and had multiple diagnoses, including chronic kidney disease, high blood pressure, dementia, and venous thrombosis and embolism (a condition where a blood clot forms, most often in the deep veins of the leg or groin and travels in the circulation, lodging in the lungs). During a review of Resident 8's Quarterly Minimum Data Set (MDS, an assessment tool used to guide care), dated 11/3/19, indicated Resident 8 needed extensive assistance from at least one staff member with her personal grooming. The MDS also indicated a Brief Interview for Mental Status (BIMS, a tool…

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

Based on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 54) received care to prevent pressure ulcers (PU, injuries to skin and underlying tissue resulting from prolonged pressure on the skin) when the staff did not identify a newly developed pressure ulcer on his tailbone. This failure resulted in the delay in the initiation of appropriate treatment and could result in worsening of the pressure ulcer. Findings: During a review of Resident 54's Quarterly Minimum Data Set (MDS, an assessment tool used to guide care), dated 12/14/19, the Brief Interview for Mental Status (BIMS, a tool used to assess mental function) score was 15, meaning Resident 54 was cognitively intact. The MDS indicated Resident 54 was at risk for developing pressure ulcers and that Resident 54 needed extensive assistant from at least one staff member for bed mobility, transferring from one surface to another, dressing, toilet use, and personal hygiene. During a review of Resident 54's medical record, the medical record contained a Braden Scale form…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the physician's order for oxygen (O2) administration for one of four sampled residents (Resident 68), when Resident 68's O2 flow rate was not at the specific ordered rate. This failure had the potential to result in adverse effects for Resident 68 due to O2 toxicity. Findings: During a review of Resident 68's admission Record, the record indicated Resident 68 was admitted with multiple diagnoses, including Chronic Obstructive Pulmonary Disease (COPD, a progressive lung disease encompassing emphysema, chronic bronchitis, and non-reversible asthma) and acute and chronic respiratory failure. During a review of Resident 68's Annual Minimum Data Set (MDS, an assessment tool used to guide care), dated 1/15/20, the resident's Brief Interview for Mental Status (BIMS, a tool used to assess mental function) score was 15, meaning Resident 68 was cognitively intact. The MDS also indicated Resident 68 required O2 therapy. During a concurrent…

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

Based on observation, interview, and record review, the facility failed to document the correct amount of liquid morphine sulfate (a narcotic medication used to treat moderate to severe pain). This failure resulted in 2 milliliters (ml, a unit of measurement) of liquid morphine sulfate for which the facility could not account. Findings: During a concurrent observation, interview, and record review on 2/3/20, at 11:15 a.m., with Licensed Vocational Nurse 1 (LVN 1), a medication cart with a bottle of morphine was observed. Inspection of the morphine sulfate label dated 10/13/19 showed the medication was prescribed for Resident 69 and contained 10 ml (volume) of liquid, at a concentration of 20 milligrams (mg, a unit of measurement) of morphine sulfate per ml of liquid. Using the scale on the side of the bottle, further inspection showed 8 ml of liquid remaining in the bottle. A review of the complete narcotic record for Resident 69's morphine sulfate showed that on 12/24/19 there was 8 ml of liquid morphine sulfate in the bottle. LVN 1 was unable to provide documentation accounting…

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 observation, the facility failed to provide functional environment when there was no towel hook in Shower room [ROOM NUMBER]. This failure resulted in residents not having a towel readily available to dry off after showering. Findings: During an interview on 2/6/20, at 4 p.m., with a Family Member (FM), FM stated she helps with her mother's shower in the evenings but has a difficult time because there is no place to hang a towel in the shower room (room [ROOM NUMBER]). FM stated she brought it to the Administrator's (ADM) attention 10 months ago, but nothing has changed. During an observation on 2/7/20, at 10:15 a.m., of Shower room [ROOM NUMBER], no hook was present on the back of the door and the only place to put a towel was on the grab bar where it would get wet. During an interview on 2/7/20, at 10:12 a.m., with Certified Nursing Assistant 9 (CNA 9), CNA 9 indicated she does not like to use the shower in room [ROOM NUMBER] because there is no place to hang a towel. All the other…

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 complete quarterly psychosocial assessments on seven (Residents 11, 21, 22, 40, 52, 54, 56) of 38 sampled residents. This failure had the potential to cause residents not to have their medical and/or psychosocial needs met. Findings: Review of the Minimum Data Set (MDS - an assessment tool used to direct health care needs) dated 10/5/18 showed Resident 11 was admitted to the facility on [DATE] with multiple diagnoses including diabetes mellitus (a condition when the body does not produce enough insulin). Resident 11 also wore corrective lens. During an observation and concurrent interview on 1/7/19 at 10:40 a.m., Resident 11 was sitting up in bed wearing glasses and holding a piece of paper close to her eyes. Resident 11 stated she needed new glasses because she could not see clearly with the glasses she was wearing. Review of Resident 11's medical record showed no social services assessment for the quarterly assessments due for 1/2/18,…

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 three (Residents 11, 21, 22) of 38 sampled residents with medically-related social services. These failures resulted in Resident 11 not receiving adequate visual aid, Resident 21 not receiving dental services as recommended, and Resident 22 not receiving supportive mental health services. This placed all three residents at risk for not meeting their highest practicable well-being. Findings: Review of the Minimum Data Set (MDS - an assessment tool used to direct health care needs) dated 10/5/18 showed Resident 11 was admitted to the facility on [DATE] with multiple diagnoses which included diabetes mellitus (DM - a condition when the body does not produce enough insulin). Resident 11 also required the use of glasses for visual aid. During an observation and concurrent interview on 1/7/19 at 10:40 a.m., Resident 11 was sitting up in her bed wearing glasses. Resident 11 was holding a piece of paper close to her eyes. Resident 11…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete an assessment of one (Resident 22) of 38 sampled residents after a significant change in condition occurred. This failure had the potential to result in Resident 22 not receiving the appropriate mental health services. Findings: Review of the Minimum Data Set (MDS - an assessment tool used to direct health care needs) for Resident 22 dated 10/25/18 showed Resident 22 was re-admitted to the facility with a Significant Change In Condition on 10/18/18 with multiple diagnoses which included Schizophrenia (a mental disorder) and delirium (a state of confusion). Review of Resident 22's MDS dated [DATE] showed an unplanned discharge to an acute care hospital setting on 10/15/18. Review of Resident 22's medical record showed, Interdisciplinary Discharge Summary, dated 10/16/18 at 2:16 p.m., Sent to the acute care hospital for behavior evaluation of psychosis, schizophrenia and PTSD (Post Traumatic Stress Disorder - a trauma and stress disorder usually…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a baseline care plan for one (Resident 22) of 38 sampled residents upon admission to the facility. This failure had the potential to result in Resident 22 not receiving the appropriate psychosocial services. Findings: Review of the Minimum Data Set (MDS - an assessment tool used to direct health care needs) dated 10/25/18 showed Resident 22 was admitted to the facility on [DATE] with a diagnosis of Schizophrenia (a mental disorder). Review of the History and Physical from the acute care hospital physician dated 4/26/18 showed Resident 22 had Schizophrenia. Review of Resident 22's medical record dated for 4/20/18 showed that a Level 1 PASRR screen indicated the need for Level II evaluation (Preadmission Screening and Resident Review Level II - done to assess mental health care needs and intellectually developmental care needs; Level II indicating that the resident requires an evaluation of what those services would be) was needed. 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.