Victoria Post Acute Care

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices in dietary services were maintained for food storage according to standards of practice when: 1. One ice machine, and two three-compartment sinks did not have a proper air gap system to adequately prevent backflow of contaminated foods. 2. One facility prep sink was covered with white stained deposits, rust, and discolored raised pebble sized rock-like substance permanently embedded on the surface was being used. 3. The facility mixer for preparing food did not have a splash guard to prevent contaminating floor and kitchen equipment surfaces during use. 4. The facility did not safely prepare a meat recipe by using unpasteurized eggs. Cross Reference (F804) These failures had the potential to cause widespread food borne illness among all 110 residents who received food from the kitchen. Findings: 1. On 9/10/24 at 8:00 A.M., an observation and interview was conducted with the Dietary Supervisor (DS), in the kitchen. The ice machine was piped directly through a food…

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 food served was in a palatable, flavorful manner that maintained the nutritional value of the menu items served when: 1. Food complaints were not being addressed appropriately. 2. The recipe was not followed during the preparation for a meat recipe. Cross-reference (F812) This failure had the potential to decrease residents' meal intake and contribute to weight loss. The facility census was 110. Findings: 1. A document review was conducted on 9/10/24 at 9:57 A.M., of the facilities policy titled Meal Service indicated 1. Meal times . Lunch at 11:00-12:30 P.M . An interview was conducted on 9/10/24 at 11:28 A.M., with the licensed nurse (LN) 1. LN 1 stated Due to coronavirus (COVID: a highly contagious respiratory virus caused by the SARS-COV-2 virus) outbreak only the front dining room was being used but mainly for residents that were on restorative nursing assistant (RNA) dining. A dining observation was conducted on 9/10/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews the facility failed to provide a safe, sanitary (clean), and comfortable environment to help prevent highly contagious infections when: 1. Facility did not store respiratory equipment properly for Resident 261. 2. Licensed Nurses (LN) did not have interventions in place to clean Resident 33's continuous positive airway pressure (CPAP) mask according to professional standards of practice. 3. Three certified nursing assistants (CNA) did not practice infection control protocols with hand hygiene and/or the use of protective personal equipment (PPE: clothing or equipment that protects people from injury or infection in the workplace) for residents (Resident 45, Resident 95, and Resident 108) on transmission-based precautions. a) Resident 45 with droplet precautions for corona virus (COVID-19: A highly contagious respiratory infection caused by the SARS-2 virus). b) Resident 95 with droplet precautions for corona virus (COVID-19: A highly contagious respiratory…

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 treat two of seven residents reviewed for resident rights, in a dignified manner when staff stood over while feeding the residents (Resident 63 and Resident 67). In addition a resident (Resident 65) was served food in a Styrofoam (foam-like) food container. This deficient practice had the potential for residents' self-esteem and self-worth to be devalued and as a result Resident 65 had a difficult time with self feeding requiring feeding assistance from the nursing staff. Findings: 1. Resident 63 was re-admitted to the facility on [DATE] with diagnoses including unspecified Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills and eventually the ability to carry out simple tasks) and dementia (a condition characterized by loss of memory, language, problem solving and other thinking abilities) according to the facility's admission Record. During an observation on 9/10/24 at 8:41 A.M., a staff member 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 provide a safe, clean, comfortable, and homelike environments for five of 22 sampled residents (Resident 33, Resident 80, Resident 9, Resident 14 and Resident 54) when: 1. Resident 33's sliding door was stuck in a position that was unable to open and close fully causing safety concerns along with a damaged closet door and an ineffective overhead bed lighting to cause safety and emotional distress for Resident 33. 2. Resident 80's telephone wall jack was detached and hanging from the wall causing the telephone line to dangle with concerns for pests and safety concerns to cause accidents. 3. Resident 9, Resident 14 and Resident 54's rooms were not comfortable. These failures have caused and/or had the potential to place residents, staff, and visitors at risk for harm due to safety concerns and emotional distress. Findings: 1. A review of Resident 33's admission Record indicated Resident 33 was admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission for one of three residents (Resident 94) reviewed for dialysis. This deficient practice had the potential to delay the care planning process that would have been identified by Resident 94's care area assessments (CAA) to meet Resident 94's individualized care needs. Findings: A review of Resident 94's admission Record indicated Resident 94 was admitted to the facility on [DATE] with diagnoses which included a history of end stage renal disease (the last stage of long-term (chronic) kidney disease when the kidneys are no longer able to carry out their daily functions). A record review of Resident 94's Minimum Data Set (MDS- a nursing assessment tool that is used to develop a plan of care) dated 8/28/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 14 points out of 15 possible…

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 interviews, and record review, the facility failed to accurately code the Minimum Data Set (MDS: a nursing assessment tool) for one of two residents (Resident 45) reviewed for dementia care. As a result, the facility sent Resident 45's MDS to the federal database with inaccurate picture of the Resident 45's current health status. Findings: A review of Resident 45's admission Record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses which included a history of bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). A record review of Resident 45's Minimum Data Set (MDS- a nursing assessment tool that is used to develop a plan of care) dated 9/3/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points which indicated Resident 45 had moderate cognitive (pertaining to memory, judgement and reasoning…

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 three of seven residents reviewed for activities of daily living (ADL- self- care activities such as grooming, bathing, and toileting), who were unable to carry out their ADLs, received assistance with nail care (cleaning, trimming and/or filing of nails) and grooming. (Resident 7, 63 and 67) This deficient practice had the potential for the residents' personal well-being to be affected. Findings: 1. Resident 7 was re-admitted to the facility on [DATE] with diagnoses including hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (disrupted blood flow to the brain, stroke) affecting right side of the body according to the facility's admission Record. During an observation on 9/11/24 at 8:38 A.M., Resident 7 was observed sitting up in bed, eating, using a fork with Resident 7's left hand. Resident 7's right hand was contracted…

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 left medications unattended at the bedside for one of eight residents (Resident 80) reviewed for medication storage. These failures had the potential for medication misuse, divergence (another person taking medications or medications used wrongfully), and/or severe allergic complications. Findings: A review of Resident 80's admission Record indicated Resident 80 was admitted to the facility on [DATE] with diagnoses which included a history of hemiplegia (one sided muscle weakness) and hemiparesis (inability to move one side of the body) following cerebral infarction affecting left dominant side (a brain attack known as a stroke that stops blood flow to the brain causing left sided weakness and movement to the body). A review of Resident 80's admission Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 7/7/24, indicated that Resident 80 understood or understood others, and had no cognitive (mental process involved in…

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

Based on interview and record review the facility's Quality Assessment and Assurance Committee (QAA-facility group that monitors concerning trends in a facility) failed to identify and include in the facility's Quality Assurance Performance Improvement plan (QAPI-plan developed by QAA to help improve conditions in the facility), trends identified by surveyors during the recertification survey concerning grooming/hygiene and the cleaning of bi-level positive airway pressure/continuous positive airway pressure machines (BIPAP/CPAP- a type of noninvasive ventilation that helps you breathe). This failure had the potential for the facility to overlook trends in resident care that might have affected residents' dignity and/or health. Cross Reference: F677, F880 Findings: On 9/13/24 at 2:15 P.M., a concurrent interview with the Administrator (ADM) and the Director of Nursing (DON) and a review of QAPI program was conducted. The ADM stated that the main areas that the QAPI team monitored were Falls, Abuse, Staffing and Retention, and Infection Control. In addition, the ADM stated some new…

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 of 2 residents (Resident 1) reviewed for 1:1 feeding assistance (staff member present to watch/help resident to eat during meals), was supervised during a meal. This failure placed Resident 1 at risk for aspiration (inhaling food particles into the lungs), choking, and weight loss. Findings: According to the admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), cognitive communication deficit, and pneumonia (an infection in the lungs). A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 8/22/24, indicated the resident had severely impaired cognitive skills (problems with person's ability to think, learn, remember, use judgement, and make decisions). On 8/29/24 at 12:16 P.M., an observation was conducted inside Resident 1 ' s room. Resident 1 was sitting in his wheelchair with his lunch tray in front of him. There was no 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect one resident (1) when Resident 1 reported being treated roughly by a staff member/licensed nurse (LN) 1. As a result, LN 1 was not immediately removed from providing care to the resident, per the facility ' s abuse policy and procedure. This failure had the potential to affect Resident 1 ' s feeling of safety and protection while at the facility. (Cross-reference F609) Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of non-traumatic intracranial hemorrhage (a brain attack that caused bleeding in the brain). A record review of Resident 1 ' s Minimum Data Set (MDS; assessment tool) dated 5/24/24, indicated a Brief Interview for Mental Status (BIM- developed by reviewing the resident's status during the prior seven day period) score of 15 out of 15 possible points, which indicated Resident 1 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. An interview 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 interview and record review, the facility failed to report an alleged abuse complaint to the State Agency (SA), protective services, and/or law enforcement entities per facility policy. As a result, a resident ' s (1) allegation of being mishandled was not completely investigated, which had the potential to affect Resident 1 ' s safety, comfort, and well-being. (Cross-reference F600) Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of non-traumatic intracranial hemorrhage (a brain attack that caused bleeding in the brain). A record review of Resident 1 ' s Minimum Data Set (MDS- assessment tool) dated 5/24/24, indicated a Brief Interview for Mental Status (BIM- developed by reviewing the resident's status during the prior seven day period) score of 15 out of 15 possible points which indicated Resident 1 had no cognitive (pertaining to memory, judgement, and reasoning ability) deficits. An interview was conducted on 7/16/24 at 10:15 A.M., with the Social…

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 interviews and record review, the facility failed to ensure a safe and appropriate discharge for one of three sampled residents (Resident 1). As a result, Resident 1 was inappropriately discharged to an independent living facility (ILF; a residence for individuals who have the mental capacity to live independently without medical or physical assistance with their daily living tasks) that placed Resident 1 at risk for harm and/or injury. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was re-admitted to the facility on [DATE], and discharged on 2/16/24 to an ILF with diagnoses that included a history of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with behavioral disturbances. A record review of Resident 1 ' s History and Physical dated 9/1/23 completed by Resident 1 ' s medical doctor (MD) indicated .This resident does NOT have the capacity to understand and make decisions . A record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement an ongoing infection surveillance monitoring for 3 of 5 sampled residents (Resident 8, 9, and 11) when: 1. Resident 8's infection surveillance (infection care area and screening tool) assessment did not include Resident 8's symptoms of dysuria (painful or uncomfortable urination) as a urinary tract infection (UTI) symtpom, for on-going surveillance. 2. Resident 9's infection surveillance assessment did not include Resident 9's burning to vaginal area related to the use of a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag), for on-going surveillance. 3. Resident 11 was diagnosed with corona virus 19 (COVID-19; sickness caused by a virus- severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) upon admission, and was not re-tested or tracked for, infection surveillance. These failures had the potential to affect residents' health and well-being, and spread infections throughout…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer and administer pneumococcal vaccine (PV, immunization against bacteria that causes pneumonia [lung infection]) for two of five sampled residents (2 and 5). This failure had the potential to cause health complications for the residents. Findings: 1. A record review of Resident 2's clinical record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included influenza (viral infection that causes symptoms including fever, chills, sneezing, coughing, and sore throat) and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). Resident 2 was over [AGE] years of age. A record review of Resident 2's clinical record indicated that resident received Prevnar 13 (a vaccine to prevent pneumonia) on 9/30/15 (historical; administered outside of facility). Resident 2 also received the pneumonia vaccine 23 (PPSV23; a vaccine to prevent pneumonia) on 12/26/17 (historical).…

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 for four of 21 sampled residents (92, 90, 7, and 155). 1. A care plan was not developed for Resident 92's PICC line. A PICC line is a peripherally inserted central catheter that provides access to the large vein carrying blood to the heart to administer medication for long-term use. 2. A care plan was not developed for an Antipsychotic medication for Resident 90. Antipsychotic medications control psychotic symptoms such as delusions, hallucinations, and unstable moods. 3. A care plan was not developed for Resident 90's actual falls, which occurred on two occasions. 4. A care plan did not include a physician's order for a specific fall intervention for Resident 7 (cross reference F689 #2). 5. A care plan was not developed for Resident 155 related to smoking (cross reference F689 #3). These failures could potentially affect these residents in the care areas that were not 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.

Based on observation, interview, and record review, the facility's QAPI/QAA (Quality Assurance and Performance Improvement/ Quality Assessment and Assurance) Committee failed to ensure action plans for a complaint investigation (exit date 6/10/22) related to change of resident condition and notification of change of condition were fully implemented as their plan of correction (POC) indicated. The following deficient areas as it related to resident change of condition were identified: -Notify of Changes (cross reference F-Tag 580) -Accidents and Hazards (cross reference F-tag 689 # 1) As a result, the facility remained noncompliant with the deficiency cited during the prior complaint survey, which had the potential to affect the health and safety of residents. Findings: A review of the facility's POC for complaint (exited 6/10/22) with compliance date 7/8/22, indicated, .Following any identified change in resident condition .licensed nurse in charge will consult and notify the resident attending physician, report pertinent information and/or concern, and document any change of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, the facility failed to ensure one of 21 sampled residents (28) had a completed end of life wishes or a POLST (physician orders for life sustaining treatment) in their record. As a result, there was a potential for residents to not have their end of life wishes honored. Findings: Resident 28's record was reviewed on 9/21/22, Resident 28 was admitted to the facility on [DATE], per the facility's admission Record. Resident 28's record contained a POLST, signed by the resident, and the physician, but was not dated by either. According to the instructions on the back of the POLST form, Skilled Nursing Facility Procedures .III. Initiating a POLST .6. After the physician, NP or PA discusses treatment options and goals of care with the patient/decision maker, the POLST form should be completed and signed and dated by all parties. Physicians, NPs and PAs should not sign POLST forms on nursing home residents without confirming that the form accurately reflects the known wishes or, if wishes not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the MDS (Minimum Data Set- an assessment tool) was accurate for one of 21 sampled residents (48) related to weight loss. This failure had the potential to affect the care provided to Resident 48. Findings: A review of Resident 48's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses to include cerebral infarction (stroke). A review of Resident 48's MDS Assessment, Section K: Swallowing/Nutritional Status dated 7/21/22, indicated under Weight Loss, . loss of 10% or more in the last 6 months had been coded as zero or No. On 9/23/22 at 3:20 P.M., a joint interview and record review was conducted with the MDS coordinator (MDS) 1. MDS 1 stated she had done the 7/21/22 MDS assessment for Resident 1 related to a significant change in the resident's condition. MDS 1 stated the director of dietetic services (DDS) had completed Section K, including .loss of 10% or more…

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 21 residents (51 and 48) had timely and appropriate care plan review and revision, when: 1. Resident 51's written fall care plan did not reflect the resident's current condition and care needs. 2. Resident 48's written nutrition care plan was revised without a nursing assessment (cross reference F 692). These failures had the potential to affect the delivery of care. Findings: 1. A review of Resident 51's admission Record indicated the resident was readmitted on [DATE] with diagnoses to include Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors), dementia (memory loss), contractures in multiple areas (muscle shortening and tightening), and dysphagia (difficulty swallowing). On 9/20/22 at 8:27 A.M., an observation of Resident 51 was conducted while inside the resident's room. Resident 51 was observed laying in bed and the resident was receiving a tube feeding (liquid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident safety for two of 4 residents investigated for falls (90 and 7), and did not do a smoking safety assessment or provide education for Resident 155, when: 1. The facility did not document a change of condition for Resident 90 after 2 separate falls or initiate an Interdisciplinary Team (IDT) for either fall to investigate or assess the resident after those falls. 2. The facility did not implement a physician's order for landing mats for Resident 7, who was at risk for falls. 3. The facility did not ensure Resident 155 was educated and assessed for safe smoking before allowing the resident to smoke. In addition, Resident 155 was in possession of a lighter. These failures had the potential to contribute to additional falls with injury for Resident 90 and 7 and potential for injury for Resident 155 when smoking. Findings: 1. Resident 90 was admitted to the facility on [DATE] with diagnoses including a fracture of the right…

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 21 residents (Resident 48) who had severe weight loss was provided assistance with feeding as it was indicated on the resident's comprehensive assessment and the resident's written plan of care. As a result of this deficient practice, there was the potential for Resident 48 to experience further weight loss. Findings: A review of Resident 48's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include cerebral infarction (stroke), vascular dementia (a condition characterized by memory loss), and need for assistance with personal care. A review of Resident 48's weights were as followed: 3/5/22 204.2 # (pounds) 4/2/22 199.4 # 5/7/22 196 # 6/4/22 175 # 6/11/22 173.6 # 6/18/22 174.4 # 6/25/22 178 # 7/2/22 175.6 # 7/9/22 174 # 7/19/22 172.6 # 7/23/22 171.6 # 7/30/22 167.8 # 8/6/22 170.2 # 8/13/22 168 # 8/20/22 167 # 8/27/22 167 # 9/3/22 162.2 # 9/10/22 163 #…

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 they had a physician's order to administer oxygen for one resident, Resident 41. As a result, Resident 41 was at risk for harm from over oxygenation. Findings: Review of Resident 41's admission Record indicated, Resident 41 was admitted on [DATE] with diagnoses including encephalopathy and COPD (chronic obstructive pulmonary disease). On 9/20/22 at 10:50 A.M., an observation and interview was conducted with Resident 41. Resident 41 was alert and conversant. Resident 41 stated, I've had oxygen on every day since I've been here. Resident 41 was observed with a nasal cannula (tubing that deliver oxygen through the nose) and the tubing was secured behind each ear. The nasal cannula was attached to a humidifier, the humidifier was attached to an oxygen concentrator. The oxygen concentrator was set at 3.5 LPM (liters per minute). The container for distilled water used to humidify the oxygen was observed to be empty and there was no date…

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 pharmacy provided two routine medications for one randomly sampled resident (40) identified during medication pass observation. As a result, Resident 40 did not receive two of her morning medications. Findings: The medication pass observation was made on 9/21/22 at 8:28 A.M., Resident 40 was randomly sampled. After the med pass observation was completed, the reconsolidation was done. In addition to the medications given, there were two additional physicians orders dated 6/19/22 for Dulera Aerosol (used to control and prevent symptoms ) 200-5 mg/act 2 puffs inhale orally 2 times a day for COPD, Rinse mouth well after use, and 3/8/22 for Spiriva HandiHaler (prevent bronchospasm caused by COPD and reduce flare-ups of serious symptoms) capsule 18 mcg inhale orally one time a day for COPD take 2 inhalations from hand held device. Rinse mouth after each use. Neither of these medications were given. On 9/21/22 at 11:45 A.M., LN 33 stated the 2 medications were reordered, but the pharmacy would not deliver…

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 target behaviors monitored for the use of Antipsychotic medication were clear and specific for one of five residents (90) selected for an unnecessary medication review. Antipsychotic medications control psychotic symptoms such as delusions, hallucinations, and unstable moods. This failure had the potential for inconsistent behavior monitoring and could affect the ordering physician's ability to determine the effectiveness of the medication. Findings: Resident 90 was admitted to the facility on [DATE] with diagnoses that included unspecified psychosis (loss of contact with reality) and unspecified dementia per the facility's admission Record. A telephone interview was conducted with Resident 90's responsible party (RP) on 9/23/22 at 8:35 A.M. The RP stated the resident had mental illness before developing dementia and had been on one Antipsychotic (Olanzapine) prior to hospitalization. Additionally, the RP stated that Quetiapine was a new…

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 medication error rate for medication pass observation did not exceed five percent. There were 35 opportunities, two medication errors were identified. The error rate was 5.7 percent. Findings: On 9/21/22 at 8:28 A.M., during a medication pass observation, it was observed LN 33 failed to administer two inhaled medications. The resident's medical record indicated there were two physician's order dated 6/19/22 for Dulera Aerosol (used to control and prevent symptoms ) 200-5 mg/act 2 puffs inhale orally 2 times a day for COPD, Rinse mouth well after use, and 3/8/22 for Spiriva HandiHaler (prevent bronchospasm caused by COPD and reduce flare-ups of serious symptoms) capsule 18 mcg inhale orally one time a day for COPD take 2 inhalations from hand held device. Rinse mouth after each use. On 9/21/22 at 11:45 A.M., LN 33 stated the two medications were reordered, but the pharmacy would not deliver them due to insurance payment issues.

Based on interview and record review the facility failed to ensure a physician's order for laboratory tests were carried out for one of 21 sampled residents (Resident 11). As a result, there could have been a delay in identifying abnormal lab values. Findings: Resident 11's clinical record was reviewed on 9/28/22. A physicians order dated 9/15/22 at 12:15 P.M., for a cbc (complete blood count), and cmp (comprehensive metabolic panel) to be done. On 9/28/22 at 11:11 A.M., LN 34 could not find the lab request in the lab request in lab book, or any lab results for the cbc, cmp. LN 34 then said the lab tests were not authorized by the resident's insurance.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement their Infection Prevention Program, when a Licensed Nurse (LN) 81 did not disinfect the vital sign machine between residents (8, 40). This failure had the potential to spread infections between residents. Findings: 1. Resident 8 was admitted to the facility on [DATE], per the facility's admission Record. 2. Resident 40 was readmitted to the facility on [DATE], per the facility's admission Record. On 11/15/22 at 8:11 A.M., a med pass observation for Resident 8 was conducted with LN 81. LN 81 prepared medications for Resident 8. LN 81 took Resident 8's vital signs and gave the resident his medications. LN 81 did not disinfect the vital sign machine after used. On 11/15/22 at 9:03 A.M., a med pass observation for Resident 40 was conducted with LN 81. LN 81 prepared medications for Resident 40. LN 81 used the same vital sign machine and took Resident 40's vital signs. On 11/15/22 at 9:43 A.M., an interview with LN 81 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 interview and record review, the facility failed to fully implement its antibiotic stewardship program for one of 5 residents (40) observed during medication administration. Resident 40 was on continuous antibiotic therapy without a clear indication. This failure could potentially increase the risk to Resident 40 for adverse side effects or the development of multi-drug resistant organisms (germ not killed by antibiotics). Findings: Resident 40 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) per the facility's admission Record. COPD is a group of diseases, including emphysema and chronic bronchitis, that blocks airflow and causes breathing difficulty. During an interview with the infection preventionist (IP) on 9/23/22 at 11:15 A.M., the IP stated he reviewed all residents on antibiotics using McGeer criteria (a set of guidelines to assess appropriate antibiotic use). In addition, the IP stated they screened all residents with antibiotics…

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.