Cottonwood Canyon Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview, and record review, the facility failed to ensure comprehensive resident-centered care plans were implemented for one of two sampled residents (1) when Resident 1 had no bowel movements for three days, and the physician's order was not followed. This deficient practice had the potential to affect resident's health and safety. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm (abnormal tissue growth) of ill-defined sites within the digestive (a group of organs that work together to digest and absorb nutrients from the food that was eaten) system, per the admission Record. A review of Resident 1's medical record was conducted. Per the Plan of Care, dated 11/21/24, Resident 1 was At risk for complications with bowel regimen due to risk for constipation due to decreased physical mobility, weakness, used of medications, under Interventions/Tasks, the LN was to Administer medications per physician order. Per the Order Summary Report,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the discharge medication list order from the hospital matched the facility's admission medication list for one of two sampled residents (1) when one tablet of Sennoside (a medication used to treat constipation) was omitted from the order. As a result, Resident 1 did not receive the desired dose of medicine to be effective. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm (abnormal tissue growth) of ill-defined sites within the digestive (a group of organs that work together to digest and absorb nutrients from the food that was eaten) system, per the admission Record. A review of Resident 1's medical record was conducted. Per the Hospital Discharge Order List, dated 11/21/24, the physician ordered for Sennosides 17.2 milligrams. Per the facility's Order Summary, dated 11/21/24, Resident 1 was to receive Sennosides 8.6 milligrams, take one tablet orally at bedtime for constipation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's medical record was complete for one of two sampled residents (1) when the licensed nurse (LN) had incomplete documentation after receiving an order, and the inventory sheet (record of resident's belongings) was not signed. As a result, the facility could not verify a physician's order and Resident 1's inventory sheet when discharged was not completed. Findings Resident 1 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm (abnormal tissue growth) of ill-defined sites within the digestive (a group of organs that work together to digest and absorb nutrients from the food that was eaten) system, per the admission Record. A review of Resident 1's medical record was conducted. Per the Progress Notes, dated; 11/28/24, LN 1 documented that Resident 1 insisted on going home because the Butalbital/Acetaminophen/Caffeine (a combination of medications to treat tension headaches) was not routine. LN 1 further…

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 offer written and follow-up initiation of the advance directives for seven of 20 sampled residents (Residents 10, 29, 77, 36, 237, 61 and 62). This failure resulted in staff not knowing residents' directives regarding care and the residents' legal health care agent. Findings: 1. Resident 10 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia (a severe mental disorder that may interfere with a resident's ability to think, manage emotions, make decisions, and relate to others) per the admission Record. Per the same document, Resident 10 was responsible for herself and had five emergency contacts. A review of Resident 10's medical record was conducted. Per the Physician Orders for Life-Sustaining Treatment (POLST), dated 7/29/24, under Section D, there was no information about the advance directive. Per the history and physical, dated 8/1/24, Resident 10 can make needs known but can not make medical…

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 opened dressings were labeled with an open date, and expired food was removed from the walk-in refrigerator in the kitchen. These failures placed residents at risk of acquiring foodborne illness. Findings: On 12/9/24 at 7:54 A.M., a joint observation and interview were conducted with the Director of Dietary Services (DDS). Inside the walk-in refrigerator were opened, undated gallons of mayonnaise and Asian artisan dressings, and an opened tub of cottage cheese with a USED BY (the last date recommended for the use while at peak quality) date of 12/3/24. The DDS stated the kitchen staff should have written the date when the food was opened and should have used the food before the used-by date or should have discarded the food item. The DDS further stated it was important to have foods labeled, dated, and discarded to ensure that the food served in the kitchen was safe and palatable for the residents. Per the facility's undated policy and procedure titled Food Receiving and Store, .7. Refrigerated foods…

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 four of 20 residents reviewed had accurate and complete medical records when: 1. Resident 66's treatment record was incomplete, 2. Resident 23's post dialysis note was incomplete and did not indicate reassessment after dialysis site bleeding, 3. Resident' 36 and Resident 63's Diabetic Administration Record was incomplete. This failure did not provide an accurate representation of the care provided to the residents and had the potential for residents to not receive the appropriate care. Findings: 1. Resident 66 was admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease (ESRD- kidney failure) per the admission Record. A review of Resident 66's medical record was conducted. Per the Order Summary Report, dated 12/1/24, the staff was to monitor Resident 10's dialysis site for bleeding and infection every shift. Per the December 2024 Treatment Administration Record (TAR), the monitoring for the 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 observation, interview, and record review, the facility failed to ensure infection control practices were followed when an expired disinfectant (kills or inactivates germs) wipes were removed from the cart, and a resident with a wound infection was not placed on Enhanced Barrier Precaution (EBP-infection control measure to prevent spread of infection) timely. These deficient practices could potentially spread infectious diseases in the facility. Findings: 1. On [DATE] at 9:46 A.M., an observation and interview was conducted with the Treatment Nurse (TN). Before the wound care observation, the TN stated she sanitized all her equipment with the wipes and placed the wipes back in the cart. After the wound care treatment, the TN rolled the used table and scissors out of the resident's room to the treatment cart in the hallway. The TN then got the wipes inside the treatment cart and showed that the expiration date was [DATE]. The TN stated she should not use the wipes since they were expired. The TN walked…

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 call lights were answered in a timely manner for a confidential group. This failure resulted in resident's suffering a lack of dignity when the confidential group voiced anger and frustration over call light incidences with the facility staff. The facility census was 86. Cross reference F851 Findings: On 12/10/24 at 10 A.M., a confidential group meeting was conducted. Three out of seven in attendance indicated complaints regarding the facility call light response time. According to the confidential group, the facility call light response depended on the shift, when staff were busy and there were times, staff took break all at the same time. The confidential group stated there were times they waited an hour for staff to answer call lights any time of the day. According to the confidential group the facility was understaffed and there were times, residents waited for an hour to get medications including pain medications. On 12/10/24, a record review of Resident Council Minutes on call light from September to November…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident had an authorized responsible party to sign the informed consent for the use of the psychotropic medication (medications that affect brain activities associated with mental processes and behaviors) for one of five sampled residents reviewed for unnecessary medications (Resident 10). This failure may result in a conflict that impacts the decision-making process for Resident 10. Findings: Resident 10 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia (a severe mental disorder that may interfere with a resident's ability to think, manage emotions, make decisions, and relate to others) per the admission Record. Per the same document, Resident 10 was responsible for herself and had five emergency contacts. A review of Resident 10's medical record was conducted. Per the Physician Orders for Life-Sustaining Treatment (POLST), dated 7/29/24, under Section D, there was no information about the advance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an advanced beneficiary notice (ABN- waiver of liability) was offered in one of six residents (Resident 39) reviewed for discharge . This failure had the potential for Resident 39 to not have options with regards to Resident 39's discharge placement or location and care. Findings: A review of the facility's admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses that included primary hypertension (high blood pressure) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). A record review of the Physician's Order Summary dated 12/2/24 indicated Resident 39 had an order for discharge for 12/3/24 to home with home health and durable medical equipment (DME). An interview on 12/12/24 at 11:02 A.M., with the Business Office Manager (BOM) was conducted. The BOM stated Resident 39 exhausted her Medicare (government insurance) benefits, but we did not offer an ABN when…

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 comprehensive resident-centered care plans were developed and implemented for two of 20 sampled residents (Resident 29 and 62) when: 1. Resident 29 was not assisted in repositioning while in bed, and nail care was not performed. 2. Resident 62's pressure ulcer was not care planned. These failures had the potential to affect resident's care needs. Findings: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (blood flow to the brain was blocked) per the admission Record. A review of Resident 29's medical record was conducted. Per the Care Plan, under Focus [problem], Resident 29 was at risk for skin breakdown related to activity intolerance, impaired mobility, incontinence, and bedbound. In addition, the care plan indicated under Interventions/Tasks, the staff should assist in turning and repositioning Resident 29 as indicated or tolerated. Per the Care Plan, the facility's focus…

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 2. A review of the facility's admission Record indicated Resident 286 was admitted to the facility on [DATE] with diagnoses that included morbid obesity and malignant neoplasm (cancer) of the body of the stomach. An interview on 12/9/24 at 9:35 A.M., with Resident 286 was conducted. Resident 286 stated she arrived Thursday night 12/2/24. Resident 286 stated no one has done the treatment to her jejunostomy tube site (JT- a tube inserted into the small intestine to help with nutrition and hydration) and other LNs administered her medications by mouth instead of through her JT. A review of Resident 286 Minimum data set (MDS- a federally mandated assessment tool) dated 12/12/24 indicated a BIMS (brief interview for mental status) score of 15 which meant Resident 286's cognition was intact. An interview on 12/10/24 2:45 P.M., with LN 31 was conducted. LN 31 stated she had admitted Resident 286 and did not accurately transcribe the physician's order for Resident 286's JT site. A record review of the physician'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to arrange an appointment for audiology (measure and evaluate hearing) for one of one residents reviewed for Vision and Hearing (Resident 59). This failure resulted in Resident 59 not having access to hearing aids to maintain his hearing. Findings: Resident 59 was readmitted to the facility on [DATE] per the facility admission Record. A review of Resident 59's Brief Interview of Mental Status (BIMS, an assessment tool) dated 10/19/24 indicated 12 out of a possible 15 which meant moderately impaired mental cognition. A review of the physician's History and Physical Examination dated 8/12/24 indicated Resident 59 has the capacity to understand and make decisions. A review of the physician's order dated 8/9/24 indicated audiology evaluation and treatment. A review of the social services progress notes there was no documentation to indicate Resident 59 was seen by an audiologist (ear specialist). A review of Resident 59's appointments indicated…

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 professional standards of practice when: 1. Physician's order for oxygen was not followed (Resident 16), 2. There was no order for oxygen (Resident 237). As a result, Resident 16 was provided with more oxygen than what was ordered. In addition this failure had the potential to affect Resident 237's respiratory status. Findings: 1. Resident 16 was admitted on [DATE] to the facility with diagnoses to include chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) per the admission Record. On 12/9/24 at 3: 15 P.M., an observation was conducted with Resident 16's oxygen (air) level at five liters per minute. A review of Resident 16's physician orders dated 11/3/24 indicated oxygen at four liters per minute via nasal cannula (tube place in resident's nose which provides oxygen) continuous and monitor oxygen saturation, if oxygen saturation (oxygen level in blood) is 92%, start oxygen at four…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of two residents reviewed (Resident 9), received Trauma Informed Care (TIC- an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health). This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past torture experience). Findings: Resident 9 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD- a mental and behavioral disorder that can develop because of exposure to a traumatic event) and suicidal ideations [thoughts of ending one's own life] according to the facility's admission Record. During observation of Resident 9 on 12/9/24 at 11:53 A.M., Resident 9 was in bed in his room with eyes closed. During observation and interview of Resident 9 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR- a thorough evaluation of the resident's current medications) was completed monthly for one of five sampled residents selected for an unnecessary medication review (Resident 10). As a result, there was a potential for Resident 10 to receive unnecessary medications and medication irregularities to go unattended. Findings: Resident 10 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia (a severe mental disorder that may interfere with a resident's ability to think, manage emotions, make decisions, and relate to others) per the admission Record. Resident 10's medical record and the facility's MRR were reviewed. There was no evidence that the MRR was conducted monthly for Resident 10. On 12/12/24 at 9:49 A.M., a joint interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 10 did not have an MRR in October and November…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five selected sampled residents (Resident 10) reviewed for psychotropic (a drug or substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) had specific behavior monitoring in place for the use of antipsychotic ( a class of drugs that treat symptoms of mental disorder by altering brain function). This failure had the potential to result in unnecessary use of psychotropic medication. Findings: Resident 10 was admitted to the facility on [DATE] with diagnoses which included paranoid (a pattern of behavior where someone feels distrustful, suspicious, and fearful of others), schizophrenia (a severe mental disorder that may interfere with a resident's ability to think, manage emotions, make decisions, and relate to others) per the admission Record. A review of Resident 10's medical record was conducted. Per the Order Summary Report, dated 10/17/24, Resident 10 was taking Olanzapine 10…

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 staffing based on payroll data on quarterly schedule to Centers for Medicare & Medicaid Services (CMS-government agency overseeing nursing health facilities) for one of four fiscal quarters (4th quarter of 2024 [07/01/24 to 09/30/24]). This failure in excessively low weekend staffing resulted in not meeting staffing requirements by CMS. Cross Reference F550 Findings: A review of the facility [NAME] Report PBJ (Payroll-based journal) Staffing Data Report for Quarter 4 2024 July 1 to September 30, 2024 indicated the metric (method of measuring) for excessively low weekend staffing was triggered which meant the facility submitted PBJ reports with excessively low weekend staffing. On 12/12/24 at 5: 44 P.M., a concurrent interview and record review was conducted with the DON, Staffing Coordinator and Human Resource (HR)/Payroll Personnel was conducted. The HR/Payroll stated facility corporate submitted quarterly but it triggered because the facility had one day of low staffing in July 2024. The DON stated we had a lot…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a person-centered comprehensive care plan related to refusal of care, for one of two residents (Resident 1) who repeatedly refused to ingest the prescribed medications, reviewed for Quality of Care. The failure had the potential for medical complications and a decline in health status. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (a brain disorder), per the facility ' s admission Record. On 9/17/24, Resident 1 ' s clinical record was reviewed. According to the facility ' s census dated 9/17/24, , Resident 1 was no longer at the facility. The annual Minimum Data Set (MDS-a clinical assessment tool), dated 6/23/24, listed a cognitive score of 3, indicting cognition was severely impaired. According to the physician orders, dated 1/11/24, Sertraline (used for major depression) 25 milligrams (mg) Give one tablet by mouth one time a day for depression, Carvedilol (used to treat…

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 observations, interviews, and record review, the facility failed to ensure effective pain management services were provided to residents when two of four residents (1, 2) complained of inadequately controlled pain. This failure resulted in psychological harm when the residents experienced unrelieved pain. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses that included: Type 2 diabetes (a chronic condition of the body's inability to regulate blood sugar levels) with diabetic polyneuropathy (a complication of diabetes affecting nerves in the body, causing sensations of numbness, stabbing pain, burning, tingling or pricking, and can cause insensitivity to temperature changes); other chronic pain. Resident 2 was admitted to the facility on [DATE], with diagnoses that included: other acute (recent) osteomyelitis, (bone infection) right ankle and foot; acute embolism and thrombosis (blood clot blocking vein) of left axillary (upper arm) vein; chronic (over 6 weeks) embolism (a sudden…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to:(1) document a change in the resident's condition's or status for one of three sampled residents (Resident 1) before starting Lorazepam (a medication that affects mood, emotions, and behaviors), and (2) ensure the licensed nurse (LN) correctly transcribed the physician's order for one of three sampled residents (Resident 1). As a result, Resident 1 had the potential to receive unnecessary medication without proper monitoring of the behavior. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements), per the admission Record. A review of Resident 1's medical record was conducted. Per the Order Summary Report, dated 4/16/24, Resident 1 was to receive Lorazepam 1 mg (milligram) two times a day [routinely]. There was no change of condition or documentation in the medical record regarding Resident 1's behavioral symptoms 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 the interview and record review, the facility failed to ensure the MDS (Minimum Data Set- a comprehensive resident assessment) was accurate for 1 of 2 sampled residents (1) with an indwelling catheter (a tube inserted into the bladder to drain urine out of the body). As a result, Resident 1 did not consistently receive appropriate treatment and service. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction (a disease that affects the function of muscles due to problems with the nerves and muscles) of the bladder, per the admission Record. On 1/29/24 at 11:33 A.M., Resident 1 reported that he fell and caused pain to the indwelling catheter. A review of Resident 1's medical record was conducted. Per the Physician's order, dated 1/16/24, Resident 1 had an indwelling catheter change when pulled out. Resident 1's catheter bag was to be placed inside the privacy bag, and the catheter was to be secured with a leg strap at all times. Per the MDS dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not assess one resident, (Resident 1), for PTSD (Post Traumatic Stress Disorder, a disorder that develops when a person has experienced or witnessed a terrifying or dangerous event. The disorder can cause intense distress at real or symbolic reminders of the trauma) when, Resident 1 was admitted with a known diagnosis of PTSD. This failure had the potential to expose Resident 1 to trauma triggers while in the care of the Facility. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included PTSD, MDD (Major Depressive Disorder, a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure). On 11/14/23 at 1:00 P.M., an observation and interview were conducted…

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 did not provide for the Resident's (2) Rights related to transportation services. This failure caused the Resident to miss a medical appointment. Findings: Resident 2 was admitted to the facility on [DATE] diagnoses that included myelodyspastic syndrome (MDS-pre-leukemia) according to the facility's admission Record. A review of Resident 2's medical record was conducted on 10/23/23 at 9:50 A.M. A physician's order, dated, 8/1/23, indicated, .oncology f/u for MDS with . on Monday at GH Cancer Center . An interview was conducted on 10/23/23 at 9:55 with the director of nursing (DON). The DON stated, Appointments and transport are co-ordinated by our Scheduler. He is new to the role. There was some confusion about the appointment and transport; it was canceled and re-scheduled. The Resident was upset. An interview was conducted on 10/23/23 at 10 A.M. with the scheduler. The scheduler stated, There was a complication with Resident 2's transport to her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop comprehensive care plans for two Residents (1) and (2). This failure had the potential for Residents 1 and 2 to not receive needed care. Findings: a. Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes (inability to control blood sugar), anemia (low iron), and venous embolism (blood clot in an artery) according to the facility's admission Record. An interview was conducted on 10/23/23 at 9:18 A.M. with the director of nursing (DON). The DON stated, Resident 1 takes anti-coagulants (blood thinners) which can cause bruising. On 10/23/23 at 10 A.M. a concurrent observation and interview of Resident 1 was conducted. Resident 1 was sitting on the side of his bed. His right arm was observed to have a bruise near the elbow, blue-green in color. Resident 1 stated: I don't know how I got it. It is not painful. A review of Resident 1's medical record was conducted on 10/23/23 at 9:25 A.M. No nursing care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a baseline care plan (detailed plan with information about a patient's treatment, goal, and interventions) of a resident's aggressive behavior (Resident 2) for one of two sampled residents. As a result, the facility staff were not aware of what to expect during Resident 2's episodes of aggressive behavior. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses which included Huntington's disease (genetic disease that attacks the brain, causing unsteady and uncontrollable movements, cognition [perception, awareness, thinking, judgement] and mental health), per the facility's admission Record. A review of Resident 2's H & P dated 6/6/23, indicated Resident 2 could make needs known but could not make medical decisions. A physician's progress notes dated 6/6/23 indicated Resident 2 had increased agitation, his behaviors were not controlled in the facility and was sent to general acute care hospital. A review of…

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

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department when: 1. A [NAME] (CK 1) did not monitor the dry storage room by correctly checking the quality of the food supply and the temperature, and 2. CK 1 did not prepare the tuna salad correctly using the cool down process for ambient temperature foods. These failures had the potential for food contamination, resulting in food borne illnesses for all residents who consume food from the kitchen. The census was 66. Cross reference 812 and 925 Findings: 1. On 7/12/21, at 9:02 A.M., an observation of the kitchen's dry storage was conducted. A fly was observed flying in the dry storage room. There was an opened box of bananas, a small container of uncovered red onions, and two opened boxes of potatoes. Next to the box of potatoes was a large and shallow, clear plastic bin, measuring 17 inches by 25.5 inches and 6 inches in depth. The bin contained roughly 70 to 80 white onions, with the lid loosely sitting on 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 food was stored in a safe and sanitary manner, according to the facility policy and standards of practice within the Food and Nutrition Services department when: 1. The dry storage room was: a) not pest-free, b) contained a large bin of white onions some with black mold spots, c) at a temperature of 82 degrees Fahrenheit (F); 2. The tuna salad and egg salad was not prepared in a food safe manner when the kitchen staff did not use the cool down process for ambient temperature foods; 3. The dishes were stored wet. These failures had the potential to put the residents at risk for foodborne illnesses. Cross reference, F802 and F925. Findings: 1a, b. On 7/12/21, at 9:02 A.M., during the initial kitchen tour, an observation of the kitchen's dry storage was conducted. A fly was observed flying in the dry storage room. There was an opened box of bananas, a small container of uncovered red onions and two boxes of potatoes. Next to the box of potatoes was a large and shallow, clear plastic bin, measuring 17…

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 environment was free of pests. This failure had the potential for the cross-contamination of foods stored in the kitchen, foods being prepared during tray line, and during meal times, resulting in food-borne illnesses. Findings: On 7/12/21, at 9:02 A.M., an observation of the kitchen's walk-in dry storage was conducted. A fly was observed flying in the midst of the walk-in dry storage. There was an opened box of bananas, a small container of uncovered red onions, and two opened boxes of potatoes. Next to the box of potatoes was a large and shallow, clear plastic bin, measuring 17 inches by 25.5 inches and 6 inches in depth. The bin contained roughly, 70 to 80 white onions, with its lid loosely sitting over the white onions. Many small black fruit flies flew out of the bin of white onions. On 7/12/21, at 9:18 A.M., an observation of the bin of white onions in the walk-in dry storage, and an interview with the RD was conducted. There were many fruit flies hovering among the white onions. The RD…

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 four of four residents reviewed for Activities of daily living (ADL, which includes good nutrition, grooming, personal and oral hygiene) had adequate personal hygiene care (Residents 11, 15, 48, 58). This failure had the potential to cause infection, and impact quality of life and self-esteem. Findings: 1. Resident 11 was admitted to the facility on [DATE] with diagnoses to include Parkinson's disease (a disorder of the brain, affecting movement), per the Resident Face Sheet. On 7/12/21 at 3:44 P.M., an observation of Resident 11 was conducted at her bedside. Resident 11 was in bed, lying on her back. Her hands were contracted (joints stiffen and become rigid), and soft rolls were inserted into the center of each hand to stretch out the contractures. The finger nails on both hands were long and touching the palms of her hands. On 7/15/21, a record review was conducted. Shower sheets from 6/23/21 to 7/14/21 were reviewed. Three of…

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

Based on interview and record review, the facility failed to perform reference checks for one of one CNAs (CNA 11) reviewed for a complaint. This failure had the potential to place residents at risk for abuse or neglect. Findings: On 7/14/21, a record review was conducted. CNA 11's employee file was reviewed for required documentation for new hires. CNA 11s reference checks were not documented. On 7/14/21 at 10:12 A.M., a concurrent interview and review of CNA 11's employee file was conducted with the DSD. The DSD stated she was the CNA supervisor, and responsible for completing the reference checks for all CNA applicants. The DSD acknowledged CNA 11's reference checks were not performed prior to employment. The DSD stated that it was important to complete the reference checks to ensure the facility responsibly hired qualified individuals of good character. The facility policy and procedure dated, 6/1/201, titled Background Screening, indicated, .3. Reference checks will be performed an all applicants, in accordance with state requirements .5. Background checks do not take the place…

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 physician's orders when: 1. Restorative Nursing Assistant services (RNA, exercises and stretching to help maintain function of the muscles of the limbs) were not provided for four of four residents reviewed for limited range of motion (Residents 11, 15, 48, 58). 2. Medication administration was completed via a gastrointestinal tube (GT, a tube inserted into the wall of the abdomen directly into the stomach, Resident 38), and 3. A controlled drug was administered to Resident 47. As a result, the residents were at risk for: 1. Muscle weakness and an inability to function independently. 2. Occlusion (blockage) of the GT which could lead to an unnecessary and invasive procedure of replacing GT. 3. Overmedication of controlled drugs, which could have resulted in respiratory failure (inability to breath). Findings: 1.a. Resident 11 was admitted to the facility on [DATE] with diagnoses to include Parkinson's disease (a disorder of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent a deep tissue injury (DTI, damage of the underlying soft tissue from intense and/or prolonged pressure) from developing for two of three residents reviewed for wounds (Residents 66, 56). As a result, the residents had the potential for increased pain and prolonged wound healing. Findings: 1. Resident 66 was re-admitted to the facility on [DATE] with diagnoses which included thrombosis (increased risk of blood clots), and diabetes (elevated blood sugar) per the Resident Face Sheet. On 7/15/21 at 11:28 A.M., an observation and interview of Resident 66 was conducted prior to wound treatment with LN 14. Resident 66 was observed in bed, lying on his right side. His left heel was in a large soft boot heel protector, elevated on a pillow. Resident 66 stated he was having pain on a scale of 8/10 (severe pain) on his left foot and would like his pain medication. On 7/15/21 at 12:48 P.M., an interview was conducted with LN 17. LN 17 stated…

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 after dialysis (a treatment to remove waste from the body) for one of one residents reviewed for dialysis (Resident 12). As a result, there was the potential for undetected, potentially life-threatening complications after dialysis. Findings: Resident 12 was readmitted to the facility on [DATE] with diagnoses to include dependence on renal dialysis, per the Resident Face Sheet. On 7/12/21 at 10:41 A.M., an interview was conducted with Resident 12. Resident 12 stated he goes to dialysis three times a week. Resident 12 stated when he returned each evening, he removed the dressing from his dialysis site himself. Resident 12 stated he had never seen staff assess his dialysis site upon his return. On 7/15/21, a record review was conducted. Per a physician's order report, dated 4/5/21, Resident 12s dialysis site was to be assessed upon return from dialysis. Per the Facility-Dialysis communication Report, dated 7/6/21 and 7/13/21,…

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

Based on interview and record review, the facility failed to follow their policy for two of three residents (Residents 41 & 47) reviewed for controlled drugs (drugs at high risk for abuse). As a result, the facility was at risk for controlled drug loss and theft. Findings: 1. On 7/14/21, a record review was conducted on Resident 41's medical record. The Controlled Drug Record (CDR) and the Medication Administration Record (MAR) were compared: 1a. The CDR indicated two tablets (10 mg per tablet) of as needed (PRN) Oxycodone (a strong pain medication) was removed for Resident 41 on 7/8/21 at 6:41 P.M. There is no documented evidence in Resident 41's MAR indicating the resident received two tablets (10 mg per tablet) of PRN Oxycodone on 7/8/21 at 6:41 P.M. b. The CDR indicated two tablets (10 mg per tablet) of as needed (PRN) Oxycodone was removed for Resident 41 on 7/9/21 at 7:30 P.M. There is no documented evidence in Resident 41's MAR indicating the resident received two tablets (10 mg per tablet) of PRN Oxycodone on 7/9/21 at 7:30 P.M. c. The CDR indicated two tablets (10 mg per…

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 document review, the facility failed to monitor the temperatures of their medication refrigerator per the facility's policy. This failure had the potential to affect the integrity of the refrigerated medications administered to the facility's residents, putting their health at risk. On 7/14/21 at 12:02 P.M., an observation, interview, and concurrent document review were conducted with the facility's DSD. The facility's document titled Med Room Refrigerator Temp Log dated June 2021, indicated, no staff signatures or temperature readings were documented on 7/1/21 for A.M and P.M., 7/7/21 for A.M. and P.M., and 7/12/21 for P.M. The facility's DSD stated the medication refrigerator temperatures should be checked and documented per the facility's policy. The DSD acknowledged that there was no documented temperatures or staff signatures on the log, per the policy. DSD stated if the refrigerator temperatures are not kept in the proper temperature range it could cause the integrity of the refrigerated medications to be compromised. Per a facility policy,…

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 residents (32 and 36) received food that accommodated their food preferences. This failure had the potential to result in decreased food intake and weight loss. Findings: 1. Resident 32 was admitted to the facility on [DATE], per the facility's Resident Face Sheet. Resident 32's MDS (Minimum Data Set; an assessment tool), dated 5/21/21, indicated the resident had a BIMS (Brief Interview for Mental Status; an assessment tool) score of 14 (13 - 15 indicated a cognitively intact status). On 7/13/21, at 12:11 P.M., an observation and interview with Resident 32 was conducted. Resident 32 was eating his lunch in his room. Resident 32 stated his dislikes included gravy. On his meal tray was a serving of pork chops, and a bowl of gravy. A review of Resident 32's tray card for 7/13/21, indicated, Dislikes: .No Gravy . 2. Resident 36 was admitted to the facility on [DATE], per the facility's Resident Face Sheet. Resident 36's MDS, dated…

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

Based on observation, interview, and record review, the facility failed to ensure the safe and sanitary handling of residents' foods brought in from the outside, as per the facility's policy, and the standards of practice. This failure had the potential to expose the residents to food contamination. Findings: On 7/12/21 at 3:43 P.M., an interview with CNA 16 was conducted. CNA 16 stated, resident food brought from outside must have a label with the resident's name and the date. CNA 16 stated food could only be kept in the facility for one day, 24 hours, but was not sure how long the food could be stored in the Nourishment Room refrigerator. On 7/15/21, at 10:02 A.M., an interview with the RD was conducted. The RD stated foods brought from outside can be stored in the Nourishment Room refrigerator for three days, from the received date, and must be checked by the nurses to ensure the food is okay and consistent with the resident's diet. The RD further stated, perishable foods can be kept for 72 hours from the received date. On 7/15/21, at 11:25 A.M., an interview with CNA 17 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: 1. Resident medications were available for administration for two of 18 sampled residents (58, 238). As a result, there was the potential for ineffective pain management for the residents. 2. Resident medications were administered as ordered through a J-tube (jejunostomy tube is a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine) for one resident sampled for J-tube medication administration (9). As a result, there was the potential to negatively impact the resident's ability to maintain the highest level of practicable well-being. 3. The pharmacy reviewed medications for irregularities for a new resident (78). As a result, there was potential for the resident to experience harmful, medication-related side effects. Findings: 1a. Resident 58 was admitted to the facility on [DATE] with diagnoses to include polyarthritis (pain, swelling, and stiffness in multiple joints) and opioid…

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 staff followed infection control policy and accepted standards when staff members did not perform hand hygiene between seven unsampled residents (15, 35, 77, 109,188, 190, and 241) or sanitize resident equipment. As a result, there was the potential for the spread of infection. Findings: a. On 7/10/19 at 8:24 A.M., a medication administration observation for Residents 15, 35, 188 and 190 was conducted with LN 2. LN 2 placed the medication administration tray on resident bedside tables and on the seat of a walker as he administered medications to the residents. LN 2 did not perform hand hygiene between residents, or sanitize the medication tray used to deliver medication to the residents. On 7/10/19 at 9:50 A.M., an interview was conducted with LN 2. LN 2 stated he had last been educated on infection control about a month ago. LN 2 stated he should have washed or sanitized his hands, and sanitized the medication administration tray before and after each resident medication administration to prevent…

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: 1. Room temperatures were comfortable and safe for four of 18 residents (35, 81, 238, 239) sampled for environment. This failure caused Residents 35, 81, 238 and 239 to feel cold and uncomfortable, and had the potential to cause hypothermia. 2. The wall and ceiling in the laundry room were in good repair. This failure had the potential to contaminate the clean laundry, and to affect all residents in the facility. Findings: 1. On 7/8/19, at 8:03 A.M., during a tour of Station 1, cool air was felt in the hallway blowing out from room [ROOM NUMBER]'s door. On 7/8/19 at 8:05 A.M., an observation and interview was conducted. Resident 35 was lying in bed with a blanket which covered her from her feet to her neck. Resident 35 stated the room had been uncomfortable and cold and really cold air had blown out of the vent all morning. On 7/8/19 at 8:07 A.M., an observation and interview was conducted. Resident 238 was lying in bed with 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 care plans were resident-centered for 3 of 3 residents (3, 24, 74 ) sampled for care plans. 1. Resident 74's care plan did not include person-centered, non-pharmacological (non-medication) interventions when anxiety was displayed, which had the potential to result in the administration of unnecessary psychotropic medications and reduce the resident's quality of life. 2. Resident 3 and 24's care plans did not include their preferences for activities, which had the potential to affect their quality of life. Findings: 1. Resident 74 was admitted to the facility on [DATE], with diagnoses which included unspecified anxiety disorder (a mental disorder that causes someone to worry and feel fearful), and bipolar schizoaffective disorder (a mental disorder that causes feelings of overexcitement and irritability), per the facility's Resident Face Sheet. On 7/8/19 at 10:19 A.M., an observation and interview was conducted with Resident 74.…

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 evaluate resident's activity preferences and offer meaningful, person-centered activities that met the interest and needs for 2 of 3 residents (3, 24) sampled for activities. This failure had the potential to cause boredom, depression and decreased quality of life. Findings: a. Resident 3 was admitted to the facility on [DATE], and re-admitted to the facility on [DATE], with diagnoses which included dementia and unspecified anxiety disorder, per the facility's Resident Face Sheet. Resident 3's MDS (an assessment tool), dated 6/16/19, indicated Resident 3 had a BIMS (a screening tool to assess mental cognition) score of 10 (a BIMS of 8-12 indicated a person was moderately mentally impaired). On 7/8/19 at 9:44 A.M., an observation and interview was conducted. Resident 3 was lying in bed. Family member 1 (FM) was at the bedside and stated Resident 3 was always in bed when they visited. On 7/8/19 at 11:15 A.M., an observation was conducted.…

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 evidence of documentation of non-pharmacological behavior interventions, prior to the administration of a psychotropic medication (a medication that affects mental processes and behavior), for 1 unsampled resident (74). This failure had the potential to result in the administration of unnecessary psychotropic medications and reduce Resident 74's quality of life. Findings: Resident 74 was admitted to the facility on [DATE], with diagnoses which included unspecified anxiety disorder (a mental disorder that causes someone to worry and feel fearful), and bipolar schizoaffective disorder (a mental disorder that causes feelings of over excitement and irritability), per the facility's Resident Face Sheet. On 7/8/19 at 10:19 A.M., an interview was conducted with Resident 74. Resident 74 was observed in bed. Resident 74 stated she had hollered out but did not know why. Resident 74 stated she was on hospice and she had become afraid, crying…

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 prescribing physician documented an evaluation and rationale for a psychotropic medication (a medication that affects mental processes and behavior) for 1 unsampled resident (74). This failure had the potential to result in the administration of unnecessary psychotropic medications and reduce Resident 74's quality of life. Findings: Resident 74 was admitted to the facility on [DATE], with diagnosis which included unspecified anxiety disorder (a mental disorder that causes someone to worry and feel fearful), and bipolar schizoaffective disorder (a mental disorder that causes feelings of over excitement and irritability), per the facility's Resident Face Sheet. On 7/8/19 at 10:19 A.M., an observation and interview was conducted with Resident 74. Resident 74 was in bed. Resident 74 stated she had hollered out but did not know why she had done it. Resident 74 stated she was on hospice and sometimes she had become afraid. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a hospice agency's documentation of services and prospective visit calendar was present in the clinical record for two of two hospice residents (46, 58). As a result, there was the potential to put the residents at risk for delayed or uncoordinated care between the facility healthcare team and the hospice agency. Findings: 1. Resident 46 was admitted to the facility on [DATE] with diagnoses which included heart failure (severe failure of the heart to function properly and adult failure to thrive (weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity) per the facility's Resident Face Sheet. Resident 46 was placed on hospice (comfort) care on 4/29/19 per the Hospice Nurse Practitioner Or Non-Certifying Physician Face to Face form. A review of Resident 46's hospice medical record indicated the last documentation of services by hospice staff was dated 5/10/19 On 7/10/19 at 2:10 P.M., a telephone…

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.