Villa Las Palmas Healthcare Center

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 (Resident 3) was provided privacy during wound care when the resident's privacy curtain was not closed all the way. During Resident 3's wound treatment, a staff member came into the room when the resident ' s private areas were exposed. As a result, Resident 3 was not provided care in a private and dignified manner which had the potential to cause the resident emotional distress. Findings: A review of Resident 3 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis to include a stage 4 pressure ulcer (injury resulting from prolonged pressure to the skin and underlying tissues including muscle and/or bone) of the sacrum (area directly above the tailbone). On 12/26/23 at 1:20 P.M., an observation of Resident 3 ' s stage 4 pressure ulcer wound treatment was conducted with licensed nurse (LN) 1. Resident 3 was positioned in the middle bed of a three-bed room. LN 1 secured…

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 three residents ' (Resident 1 and Resident 3) written care plans were developed and implemented, when: 1. Resident 1 did not have an individualized care plan developed to address his multiple wounds. 2. Resident 3 ' s written care plan for activities of daily living (ADL, self-care activities) which required two staff to perform bed mobility (how a resident moves in bed) was not implemented. As a result of these failures, there was a potential for Resident 1 ' s wounds to deteriorate and for Resident 3 to experience discomfort and possible injury during care. Findings: 1. A review of Resident 1 ' s admission Record indicated the resident was admitted on [DATE] with diagnosis to include encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (beneath the first layer of skin), second degree (extends into subcutaneous tissue) burn of the right thigh and foot, and pressure ulcer stage three (injury…

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 three residents (Resident 2 and 3) reviewed for pressure injuries (damage to the skin and underlying tissues as a result of sustained pressure over long periods of time), had: - Physicians ' orders for pressure injury wound treatments that were followed. -Infection control practices that were adhered to during pressure injury treatments. As a result, there was the potential for Resident 2 and Resident 3 ' s pressure injuries to deteriorate and/or become infected. Findings: 1. A review of Resident 2 ' s admission Record indicated the resident was readmitted to the facility on [DATE] with diagnosis to include pressure induced deep tissue damage to the left ankle. On 12/26/23 at 11:30 A.M., an observation of Resident 2 ' s left ankle wound treatment was conducted with licensed nurse (LN) 1. A certified nursing assistant (CNA) was also present to help position the resident. The CNA, wearing gloves, proceeded to position 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 licensed nurse (LN) 1 performed wound care/treatment in a competent manner. In addition, the facility did not assess LN 1 ' s competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) prior to LN 1 providing wound treatment to two residents (Resident 2 and Resident 3). This failure had the potential to cause the residents ' wounds to worsen and/or become infected. Findings: A review of Resident 2 ' s admission Record indicated the resident was readmitted to the facility on [DATE] with diagnosis to include pressure induced deep tissue damage to the left ankle. A review of Resident 3 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis to include a stage 4 pressure ulcer (pressure injury extending into the muscle and/or bone) of the sacrum (area directly above…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement infection control standards of practice when: 1. A dedicated blood pressure cuff, stethoscope and thermometer were not available for eight residents who were on contact isolation precautions for a multi-drug resistant organism (MDRO-bacteria that developed resistance to one or more classes of antibiotics). 2. Face shields or eye protection were not available for staff to use upon entering a resident room with a diagnosis of Coronavirus (COVID-19 an infectious respiratory infection). These failures had the potential to expose other residents, staff, and visitors to infection. Findings: 1. An interview was conducted with the Infection Preventionist (IP) on 9/29/23, at 10:07 A.M. The IP stated the residents in rooms 123 (with three residents), 128 (with two residents) and room [ROOM NUMBER] (with three residents) were in contact isolation precautions. The IP stated the residents in room [ROOM NUMBER] had the diagnosis of candida…

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 notify the attending physician in a timely manner regarding weight loss for three of three sampled residents. (Resident 10, 5 and 12). This failure had the potential to result in delayed care for the residents and were not given appropriate interventions to correct weight loss. Findings: Resident 10 was admitted to the facility on [DATE] with the diagnoses including moderate protein-calorie malnutrition (lack of proper nutrition) according to the facility's admission Record. On 10/3/23, at 10:17 A.M., Resident 10 was observed sitting up in bed with eyes closed. An overbed table was in front of Resident 10 with an opened and unconsumed milk carton and juice. An interview was conducted with CNA 6 on 10/3/23, at 10:21 A.M. CNA 6 stated Resident 10 did not talk much and required set-up with meals. CNA 6 stated Resident 10 was able to feed herself, however needed to be monitored due to episodes of not eating. During an interview and concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents' nutritional status were monitored and meal intakes were accurately maintained for three residents with weight loss when: 1. Resident's weights were not taken weekly. (Resident 10, Resident 5 and Resident 12) 2. Staff did not know how to take and record residents' meal percentage. These failures had the potential for residents to experience further weight decline and risk for functional decline, pressure sores and infection. Findings: 1. An interview was conducted with the Restorative Nurse Assistant (RNA- nurse assistants who help residents regain their ability to perform daily activities) on 10/5/23, at 11:05 A.M. The RNA stated residents who required weekly weights were taken on Saturdays and monthly weights were taken at the beginning of the month. The RNA stated a list of residents who required weekly weights were provided by a licensed nurse (LN). Resident 10 was admitted to the facility on [DATE] with the diagnoses…

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 MDS (a clinical assessment tool) were accurately coded for: 1. Two of two sampled residents (343, 446) and five of nine unsampled residents (12, 112, 115, 124, 137) who smoked; 2. One of three residents (34) reviewed for pressure ulcer/injury (PUI, damage to an area of the skin caused by constant pressure on the area). This failure had the potential to affect the provision of care and provided inaccurate information to the Federal database. Findings: 1a. Resident 343 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD-breathing disorder), according to the facility's admission Record dated 7/27/22. Resident 343 was identified as a smoker per the facility's 7/24/22 census. On 7/26/22 at 1:02 P.M., Resident 343 was observed smoking in the smoking area. Resident 343 stated she signed a smoking consent when she was admitted on [DATE], agreeing to follow the facility's smoking…

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 person-centered care plans to meet the needs for: 1. Two of two sampled residents (343, 446) and seven of nine unsampled residents (15, 79, 112, 115, 124, 125, 137), when there was no care plan with specific interventions for smoking safety. This failure had the potential for inadequate monitoring of the residents who smoked. 2. Two of five residents (40, 452) with indwelling urinary catheters (a tube to drain urine). These failures had the potential for complications such as blockage of the catheter, infection, or dislodgement. 3. Two residents (73, 100) with behavior issues. This failure had the potential for disruptive behaviors to not be appropriately addressed. 4. One resident (60) with a hip abduction pillow (an orthopedic device placed between the legs). This failure had the potential for complications such as dislocation or re-injury of the resident's hip fracture (Cross Reference F684). Findings: 1a. Resident 15 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. Smoking assessments were consistently conducted to determine the residents' ability to safely use tobacco products for two of two sampled residents (343, 446) and eight of nine unsampled residents (12, 14, 15, 79, 112, 125, 137, 343). This failure had the potential to place residents at risk for accidental burns and injuries. 2. Resident 18 was adequately supervised to prevent falls. This failure had the potential to place Resident 18 at risk for injuries. Findings: 1a. Resident 12 was admitted to the facility on [DATE] with diagnoses to include sepsis (blood infection), according to the facility's admission Record dated 7/27/22. Resident 12 was identified as a smoker on the facility's census. On 7/27/22, Resident 12's EHR was reviewed. According to the MDS comprehensive assessment, conducted 4/29/22, Resident 12 had a BIMS (cognitive assessment of the ability to think and reason) of 13, indicating no cognitive impairment. 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 ensure infection control practices were followed when urinary catheter (a tube to collect urine) collection bags and drainage tubing were in contact with the floor for three of three sampled residents, (40, 449, 452) and two unsampled residents (47, 444), reviewed for catheter care. As a result, Residents 40, 449, 452, 47, and 444 were at risk for urinary tract infections (an infection in part of the urinary system) from cross contamination. Findings: 1. Resident 40 was admitted to the facility on [DATE], with diagnoses which included cellulitis (a soft tissue infection) of the right lower leg, per the facility's admission Record. On 7/25/22 at 9:04 A.M., an observation was conducted of Resident 40, while in his room. Resident 40's urinary catheter drainage bag was attached to the left side of the bed frame and was visible from the doorway. A dignity bag (a dark-colored bag, which covers the urine collection) covered the drainage bag and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure four of 27 residents (Residents 62, 94, 100, 118) were treated in a dignified manner when: 1. Resident 62 was provided assistance with eating while CNAs stood over the resident. 2. Resident 94 was provided peri-care (washing of the genital region after an incontinence episode) while the resident's privacy curtain and door to the room was open. In addition, Resident 118 observed her roommate's (Resident 94) peri-care take place. 3. Resident 100's room and person had a pungent odor that permeated the hallway on the residential unit. As a result of these deficient practices, residents had the potential to experience shame and embarrassment. Findings: 1. A review of Resident 62's admission Record indicated the resident was readmitted to the facility on [DATE] with paralysis of the left side of the body, contractures (muscle shortening) of the right hand, and anoxic (lack of oxygen) brain damage. On 7/25/22 at 12:59 P.M., a lunch time…

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 quiet atmosphere was promoted for three of three unsampled residents (24, 58, 102). As a result, the environment was disruptive to the residents. Cross-reference to F656 no. 3a Findings: 1. Resident 24 was admitted to the facility on [DATE] per the facility's admission Record. On 7/25/22 at 11:10 A.M., an interview with Resident 24 was conducted. Resident 24 stated, the resident from across the hall screamed all the time. On 7/26/22 at 10:40 A.M., an interview with Resident 24 was conducted. Resident 24 stated the resident's screaming was worse last night. On 7/27/22 at 8:40 A.M., an interview with Resident 24 was conducted. Resident 24 stated she was woken up three times during the night before due to the resident's screaming. 2. Resident 58 was admitted to the facility on [DATE] per the facility's admission Record. On 7/25/22 at 3:45 P.M., an interview with Resident 58 was conducted. Resident 58 stated he was bothered by his…

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 Minimum Data Set (MDS, a comprehensive assessment and care screening tool) for one of two sampled residents was transmitted in a timely manner to the Centers for Medicare and Medicaid Services (CMS, an agency which oversees federal health care programs) following a resident's death (Resident 2). This failure resulted in noncompliance with regulatory requirements. Findings: Resident 2 was admitted to the facility on [DATE], per the facility admission Record. On [DATE], a record review was conducted. Per the CMS timeline, Resident 2 had an MDS record overdue by 120 days or more. A nurses note, dated [DATE], indicated Resident 2 had expired. On [DATE] on 8:57 A.M., an interview was conducted with MDSN. Per the MDSN, the information regarding Resident 2 should have been communicated to her for coding. The MDSN stated her department got the information from the facility census. The MDSN stated once informed of a resident expiration the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed when one of five residents (Resident 449) reviewed for urinary catheters (a tube to drain urine from the bladder ) had a physician's order. As a result, there was the potential for Resident 449 to have urinary complications. Findings: Resident 449 was admitted to the facility on [DATE], with diagnoses which included dementia, (progressive memory loss), per the facility's admission Record. On 7/25/22 at 3:51 P.M., Resident 449 was observe wheeling himself down the hallway and returning to his room. Resident 449's urinary collection bag was clipped to the back of the wheelchair. The bottom of the urinary collection bag and tubing was dragging on the floor as the resident wheeled himself back to his room. On 7/25/22 Resident 449's clinical record was reviewed. There was no physician's order for a urinary catheter. The admission MDS, dated [DATE], Section H-0100, Bladder and Bowel, 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 one of 27 sampled residents (Resident 60) reviewed for quality of care, had a hip abduction pillow (orthopedic device placed between the legs) consistently applied and monitored as ordered by the physician. As a result, Resident 60 was at risk for further hip injury. Findings: A review of Resident 60's admission record indicated the resident was admitted on [DATE] with diagnoses to include left sided paralysis following a stroke. A review of Resident 60's Hospital History and Physical Exam dated 7/16/22, indicated the resident had been sent to the hospital after having a fall in the facility on 7/16/22. Resident 60 sustained a right hip fracture that required surgical repair before returning to the facility. A review of Resident 60's Order Summary Report indicated the resident had a physician order dated 7/23/22, to monitor placement of hip abduction pillow every shift for right hip fracture. On 7/25/22 at 8:58 A.M., an observation…

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 assess the clinical necessity of a urinary catheter (a tube inserted into the bladder to drain urine) for one of three residents reviewed for catheters (113). This failure had the potential to increase Resident 113's risk for infection. Findings: Resident 113 was admitted to the facility on [DATE] with diagnoses to include dependence on a respirator (a machine for breathing) and urinary tract infection, per the facility's admission Record. On 7/25/22 at 12:22 P.M., an observation of Resident 113 was conducted in his room. Resident 113 was in a wheelchair, with a urinary catheter hooked to the side of the chair. On 7/25/22, Resident 113's EHR was reviewed. A hospital Discharge summary, dated [DATE], did not indicate Resident 113 had a urinary catheter or a diagnosis appropriate for a catheter. A physician's order, dated 7/15/22, indicated the rationale for the urinary catheter was benign prostatic hyperplasia (BPH, prostate enlargement). On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the staff followed physician's orders for tube feeding (feeding through a tube into the stomach) for one of six residents reviewed for tube feeding (21). As a result, there was a potential Resident 21 was fed more than what was prescribed. Findings: Resident 21 was re-admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty of swallowing) per the facility's admission Record. On 7/25/22 at 9:24 A.M., an observation of Resident 21's tube feeding was conducted. The tube feeding pump displayed Resident 21 received 1791 milliliters (ml) of tube feeding. A review of Resident 21's records was conducted. The physician order dated 6/26/22 indicated, Resident 21 was to be provided a total of 990 ml of tube feeding per day. On 7/28/22 at 9:23 A.M., a joint interview and record review was conducted with LN 21. LN 21 stated on 7/25/22 Resident 21 received more than the total volume prescribed. LN 21 stated the 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 ensure medications were administered according to the physician's order to meet the needs of the residents when: 1a. Resident 14's insulin glargine (long-acting insulin to decrease the level of blood sugar in diabetic person) doses were held against the physician order; 1b. Resident 14's metoprolol (blood pressure lowering medication) doses were given despite the parameter to hold when systolic blood pressure (the upper number in a blood pressure reading) was less than 110 and heart rate less than 60; and 2. Resident 30's fosinopril (blood pressure lowering medication) dose was given despite the parameter to hold when systolic blood pressure was less than 110. These had the potential to expose the residents to side effects from elevated blood sugar (BS) and low blood pressure. Findings: 1a. On 7/27/22, Resident 14's medical record was reviewed and the following was noted: The resident was admitted to the facility on [DATE] with diagnoses that included…

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 residents were free from unnecessary medications when Resident 30 was placed on apixaban (an anticoagulant; blood thinner) 5 mg without the careplan that included monitoring for signs and symptoms of bleeding. This had the potential to cause harm to the resident from bleeding. Findings: On 7/27/22, Resident 30's medical record was reviewed and the following was noted: The resident was admitted to the facility on [DATE] with diagnoses that included hypertensive chronic kidney disease, atrial fibrillation (irregular heart rhythm), and systolic (congestive) heart failure. There was a physician order on 3/25/22 for apixaban 5 mg with the instruction to give one tablet by mouth every 12 hours for atrial fibrillation. The resident's electronic medication administration record (eMAR) indicated the medication was administered daily with no documented monitoring for signs and symptoms of bleeding. The resident's care plan did not include monitoring for…

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 5 percent. There were 27 opportunities. Two medication errors were identified. The error rate was 7.4 percent. Findings: 1. On 7/26/22, at 8:30 A.M., during a medication pass observation, it was observed LN 35 prepared two tablets of ascorbic acid (vitamin C; supplement) 250 mg (milligram; unit of measurement) with other morning medications and administered them to Resident 31. In a concurrent interview, LN 35 stated the dose of ascorbic acid for the resident was 500 mg and two of 250 mg tablets would make 500 mg. Review of the resident's medical record indicated there was a physician order on 2/5/22 for ascorbic acid 500 mg with the instruction to give four tablets by mouth once a day for supplement. On 7/26/22, at 1:05 P.M., in an interview, LN 35 stated two tablets of vitamin C 250 mg were prepared and given to the resident because the dose was 500 mg. LN 35 stated, after reviewing the resident's physician order for ascorbic acid,…

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 a Scheduled II controlled substance (legally prescribed dangerous medication with the highest addictive potential) was administered as ordered by a physician for one unsampled resident, Resident 61. The resident received twice the ordered dose. This had the potential for the resident to experience dangerous side effects such as unable to wake up due to respiratory depression and sedation. Findings: On 7/25/22, at 12:30 P.M., during an inspection of one (#1) of three medication carts located in East Wing Nursing Station with LN 22, the following was noted: The locked narcotic drawer of the medication cart had a blister pack containing Resident 61's medication, oxycodone (narcotic pain medication) with the label that read: Oxycodone 10 mg .Take 1 tablet by mouth every 4 hours as needed for sev-pain (severe pain). Review of the form titled, Controlled Medication Count Sheet (CMCS) for the resident's oxycodone 10 mg indicated on 7/24/22 at 5 A.M., two doses (tablets) of oxycodone 10 mg were signed out by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: 1. Residents' medication labels on the blister packs included the date of expiration; and 2. An open date was written on the insulin glargine (medication to control blood sugar level in diabetics) 3-ml pen when it was removed from the medication refrigerator and stored in the medication cart at room temperature. These failures had the potential for residents receiving expired medications. 3. Medications were secured and locked for one (sub-acute medication cart) of six medication carts, reviewed for medication storage. As a result, the was the potential for unsecured medication to be diverted (stolen) by residents, staff, and visitors. Findings: 1. On 7/26/22, at 2 P.M., during an inspection of one of the two medication carts, two blister pack medications for two residents with prescription labels that did not contain expiration dates. It was observed the expiration date had been excluded from the bottom of the label and there 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 the correct therapeutic diet to one of four residents, (Resident 44), reviewed for nutrition. This failure had the potential for Resident 44 to aspirate (food enters the airway) food during meal service. Findings: Resident 44 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing) following a cerebral infarction (stroke), per the facility's admission Record. On 7/25/22 at 8:38 A.M., an observation and meal ticket review was conducted with CNA 1, at Resident 44's bedside during breakfast. CNA 1 was sitting to the left of the resident and assisting her with the morning meal. Resident 44's plate contained a brown pureed (blended food in a thickened liquid texture) substance and yellow scrambled eggs. The meal ticket was reviewed which read pureed diet. On 7/25/22 at 8:40 A.M., an interview was conducted with CNA 1. CNA 1 stated Resident 44 received tube feedings (a liquid formula meal…

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 one sampled resident (29) with a urinary catheter (a tube to help drain urine) was provided with a dignity (cover) pouch for the drainage bag. As a result, Resident 29's dignity was not respected. Findings: Resident 29 was admitted to the facility on [DATE] with diagnoses which included urinary retention (inability to empty the bladder), per the facility's Resident Face Sheet. On 3/19/19 at 10 A.M., Resident 29's urinary catheter drainage bag was observed without the dignity pouch. On 3/19/19 at 12:34 P.M., Resident 29's urinary catheter drainage bag was observed without the dignity pouch. On 3/20/19 at 8:51 A.M., Resident 29's urinary catheter drainage bag was observed without the dignity pouch. On 3/20/19 at 3:32 P.M., an interview with CNA 6 was conducted. CNA 6 stated a urinary catheter drainage bag should have a cover all the time to preserve a resident's dignity. On 3/20/19 at 3:50 P.M., an interview with LN 7 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 ensure informed consent was verified and documented in the clinical record, for the use of an antipsychotic medication for one of six residents (34) selected for unnecessary medication review. As a result, the facility staff was not able to verify the ordering practitioner had discussed the psychotropic medication's use, risks, and benefits to Resident 34's RP. Findings: Resident 34 was readmitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and dementia (memory loss) with behavioral disturbance, per the facility's Resident Face Sheet. Resident 34's clinical record was reviewed on 3/21/19. On 3/12/19, the physician discontinued Zyprexa (an antipsychotic medication) 2.5 mg twice a day as needed, and ordered Zyprexa 2.5 mg to be given routinely once a day at 3 P.M. for psychosis (hallucinations). There was no informed consent documented in Resident 34's clinical record for the increase in frequency for Zyprexa. An interview…

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 safeguard confidential medical records for one unsampled resident (129). As a result, there was a potential for Resident 129's confidential medical records to have been viewed by non-medical staff, other residents and visitors. Findings: On 3/21/19 at 4:37 P.M., an observation was conducted in the hallway in front of a resident's room. A computer screen was observed mounted to the wall. A photograph and the name of Resident 129 was visible on the screen. On 3/21/19 at 4:40 P.M., a joint observation, interview and record review was conducted with LN 2 and CNA 1. LN 2 reviewed the wall mounted computer screen and stated the computer screen showed Resident 129's name and photo, a communication board, bowels and bladder, and mood of Resident 129. CNA 1 stated the computer screen was used to input resident health information. CNA 1 stated all CNAs were expected to log-out when they finished entering the information, which would prevent residents, visitors and non-medical staff from accessing confidential 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a home like environment when the shower rooms and residents' rooms were not well maintained. This failure had the potential to affect residents' comfort and quality of life. Findings: On 3/19/19 at 8:56 A.M., an observation was conducted in shower room one, 2 East. The shower stall on the right had a gray and orange substance on the floor along the edges inside the tiled enclosure. The shower stall on the left had three broken tiles on the tiled enclosure. On 3/19/19 at 9:12 A.M., an observation was conducted in shower room two, 2 East. In the shower stall on the left, on the wall above the tiled enclosure, the paint had scratches and bubbles approximately 1 foot by 2 feet in size. Three broken tiles were observed on the far wall of the tiled enclosure. In the shower stall on the right, above the tiled enclosure, there was a rough, cream colored, substance approximately 1.5 feet by 1.5 feet in size. On 3/19/19 at 2:25 P.M., an observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident was free from verbal abuse (harsh and insulting language directed at another person) for one of two sampled residents (115). As a result, Resident 115 did not feel safe in her room and experienced fear. Findings: Resident 115 was admitted to the facility on [DATE], with diagnoses which included a fracture of the right hip, anxiety and depression. Resident 115's medical records were reviewed. The MDS (an assessment tool), dated 2/27/19, indicated Resident 115 had a BIMS score of 15 (a BIMS score of 13-15 indicated a resident was cognitively intact) and Resident 115 required supervision to get out of bed and to walk. On 3/19/19 at 8:12 A.M., an observation was conducted. Resident 101 was observed standing up from her wheelchair, walking across the room, and throwing open the privacy curtain at the bedside of Resident 115. Resident 115 was observed in bed, eating breakfast. Resident 101 stated to Resident 115 . shut up, I…

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 create a plan of care for aggressive behaviors for one of one sampled resident (101). As a result, there were no goals or interventions to address Resident 101's aggressive behavior. Findings: Resident 101 was admitted to the facility on [DATE], with diagnoses which included depression and anxiety, per the facility's Resident Face Sheet. On 3/19/19 at 8:12 A.M., an observation was conducted. Resident 101 was observed yelling at Resident 115 shut up, I will not complain about your TV, I will get in your face. Resident 101 pointed her finger at Resident 115 and stated Shut up, shut the door, and I won't complain about your TV. Have a nice day, you stupid bitch. On 3/19/19 at 5:00 P.M., an interview was conducted with the SSD. The SSD stated Resident 101 had been moved to another room for violating her former roommate's space. On 3/21/19 at 11:14 A.M., an interview and joint record review was conducted with LN 1. LN 1 stated Resident 101…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the care plan related to activities for four of four sampled residents receiving one-to-one visits (16, 131, 72, 97). These failures had the potential to negatively affect the residents' physical, mental and psychosocial well-being. Findings: 1. Resident 16 was admitted to the facility on [DATE] with diagnoses to include tracheostomy (a surgical opening in the neck allowing a person to breathe), and dependence on a ventilator (a machine that supports breathing for people who cannot breathe on their own), per the facility's Resident Face Sheet. On 3/19/19 at 8:44 A.M., Resident 16 was observed lying in bed with his eyes closed, positioned toward the window. The window curtains were closed. There were no sounds in the room other than the ventilator. One photograph was posted on the wall behind Resident 16's bed. On 3/19/19, Resident 16's record was reviewed. The annual MDS (an assessment tool), conducted on 12/4/18, 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 a resident's environment remained free of accidental hazards when staff did not store cigarettes in a secured area for one of four residents (112). As a result, there was a risk to resident's safety from burns and fire. Findings: Resident 112 was admitted to the facility on [DATE] with diagnoses which included nicotine (a constituent of tobacco) dependence per the facility's Resident Face Sheet. On 3/21/19 at 2:17 P.M., an interview was conducted with Resident 112. There were 2 packets of cigarettes observed on top of Resident 112's bedside table. Resident 112 stated he had the cigarettes in his room for three days and the staff was not aware he had them in his room. Resident 112 also stated he was not supposed to have cigarettes in his room. On 3/22/19 at 9:37 A.M., a concurrent observation of Resident 112's room and an interview with CNA 7 was conducted. CNA 7 confirmed there were 2 packets of cigarettes which were clearly visible…

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 monitor specific target behaviors for the use of an antipsychotic medication for one of six residents (18) selected for unnecessary medication review. As a result, this placed the resident at increased risk for receiving unnecessary medication. Findings: 1. Resident 18 was readmitted to the facility on [DATE] with diagnoses which included Parkinson's disease (progressive nerve disease) and Major Depressive disorder with psychotic (hallucinations) symptoms, per the facility's Resident Face Sheet. Resident 18's clinical record was reviewed on 3/22/19. On 2/22/19, the physician ordered Zyprexa (olanzapine-an antipsychotic medication) 5 mg SL (sublingual-under the tongue) twice a day for Major depressive disorder, recurrent, severe with psychotic symptoms. There were no specific target behaviors being monitored for the use of Zyprexa. According to Resident 18's care plan for receiving Zyprexa, Monitor resident's behavior/mood and response to medication.…

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

Based on observation, interview, and record review, the dietary department failed to maintain sanitary conditions in the kitchen in accordance with professional standards when an employee failed to wear a beard restraint (a cover for facial hair). As a result, there was a potential for contamination of the residents' food. Findings: During the initial kitchen tour on 3/19/19 at 7:45 A.M., DS 1 was observed in the resident food plating area without a beard restraint. DS 1 had a full beard and mustache. DS 1 was observed to have a yellow face mask under his chin. The facial hair on the sides of DS1's face was not covered by the face mask. DS 1 stated he wore the face mask when he was in the dishware washing area, but removed it to deliver the meal tray carts to the nursing units. On 3/19/19 at 8:15 A.M., the FSM was interviewed. The FSM stated a beard restraint was not needed in the kitchen when the employee was not cooking or handling the residents' food. According to the United States Public Health Food Code, dated 2017, Chapter 2, subsection 402.11, Food employees shall wear hair…

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.