Palomar Vista Healthcare Center

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 (Resident 85 and Resident 25) minimum data set (MDS - a federally mandated resident assessment tool) was coded accurately when:1. Resident 85's Hospice status was not coded.2. Resident 28's unstageable pressure ulcer was not coded as present on admission.As a result Resident 85 and Resident 28's MDS were sent to the federal database with inaccurate information. Findings: 1. A review of Resident 85's admission Record indicated Resident 85 was admitted to the facility on [DATE] with diagnoses which included history of Cerebral Infarction (stroke- disrupted blood flow to the brain). A record review of Resident 85's MDS dated [DATE] indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of six points out of 15 possible points which indicated Resident 85 had severe cognitive (pertaining to memory, judgement and reasoning ability)…

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 refer a resident with a new mental disorder to the state designated authority for evaluation for one of three sampled residents (10).As a result, the facility may not have been providing necessary services to Resident 10.Findings:Per the facility's admission Record, Resident 10 was admitted to the facility on [DATE], and had a diagnosis of major depressive disorder (depression - a serious mental illness) dated 7/31/24.Per the facility's Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated 6/6/24, Resident 10 was negative for serious mental illness, and the case was closed.On 9/11/25 at 11:26 A.M., an interview and record review was conducted with the MDS Coordinator (MDSC). The MDSC stated, if a resident had a new diagnosis of a serious mental illness such as major depressive disorder, then the facility should have done a new resident review and updated the PASRR.On 9/11/25 at 3:36 P.M., an interview and record review 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 accurately screen newly admitted residents for a mental disorder for two of three sampled residents (9, 11).As a result, the facility may not have been providing necessary services to Resident 9 and Resident 11.Findings:1. Per the facility's admission Record, Resident 9 was admitted to the facility on [DATE] with diagnoses to include Huntington's disease (a disorder that effects movement, thinking, and behavior), post-traumatic stress disorder (PTSD - a mental illness caused by a traumatic event), and major depressive disorder (depression - a mental illness).Per the facility's Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated 10/17/24, Resident 9 did not have a diagnosed mental disorder such as depressive disorder or mood disturbance, and did not require a level 2 mental health evaluation.On 9/12/25 at 8:18 A.M., an interview and record review was conducted with the Admissions Director (AD). The AD stated, the latest PASRR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop a person-centered comprehensive care plan that identified a language preference for one of seven residents (Resident 61) sampled. This deficient practice placed Resident 61at risk for having care provided that did not reflect their individual goals, needs, and choices, that could negatively impact communication, dignity, and quality of care.Findings:A review of Resident 61's admission Record indicated Resident 61 was admitted to the facility on [DATE] with diagnoses which included history of Respiratory Failure (inability of the respiratory system to maintain an adequate blood oxygen level).A record review of Resident 61's minimum data set (MDS - a federally mandated resident assessment tool) dated 8/26/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 11 points out of 15 possible points which indicated Resident 61 had moderate cognitive…

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 an activities program that met the interests and needs for one of seven sampled residents (Resident 42).As a result, Resident 42 was not invited to group social activities (movie social, manicures, social coffee, arts and crafts and any social games such as BINGO) that did not support Resident 42's right to participate in activities of choice and placed Resident 42 at risk for social isolation, boredom, and decreased quality of life.Findings:A review of Resident 42's admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses which included history of Major Depressive Disorder (MDD- a mood disorder that causes a persistent feeling of sadness and loss of interest).A record review of Resident 42's minimum data set (MDS - a federally mandated resident assessment tool) dated 6/10/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician's (MD) orders for tube feeding for one of one resident (Resident 100) reviewed with enteral (refers to any method of feeding that uses the stomach to deliver nutrition and calories) nutrition.As a result Resident 100 did not receive enteral feeding at scheduled time as per MD order and potential risk for malnutrition. Findings:A review of Resident 100's admission Record indicated Resident 100 was re-admitted to the facility on [DATE] with diagnoses which included history of Malignant Neoplasm of Prostate (prostate cancer- an abnormal tumor located below the bladder in males).A record review of Resident 100's minimum data set (MDS - a federally mandated resident assessment tool) dated 5/31/24 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 100 had no cognitive…

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 residents for the risk of bedrail entrapment (getting caught between the bed and the bedrail), review the risks and benefits of bedrails, and obtain informed consent prior to installing bedrails for two of three sampled residents (11, 98).As a result, Resident 11 and Resident 98 were placed at an increased risk of entrapment related injury.Findings:1. Per the facility's admission Record, Resident 11 was admitted to the facility on [DATE] with diagnoses to include muscle weakness.On 9/10/25 a review was conducted of Resident 11's medical record.The facility's LN(Licensed Nurse)-Restraint/Enabling Device/Safety Device Evaluation - V2, dated 1/28/25 was not filled out, and had all sections blank including the sections on consent and risks and benefits.The facility's LN-Restraint/Enabling Device/Safety Device Evaluation - V2, dated 2/24/25 was not filled out, and had all sections blank including the sections on consent and risks 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 accurately acquire, receive, and account for one of 21 sampled residents (30) personal chemotherapy medication.This failure had the potential for harm to Resident 30 related to missing ordered chemotherapy medications.Cross reference F658Findings:Review of admission Record for Resident 30 indicated that resident was admitted on [DATE] for diagnoses which included: Joint replacement surgery, Muscle Weakness, Recurrent Dislocation (when the normal position of a joint or other part of the body is disturbed) of Left Hip, Malignant Neoplasm (an abnormal growth of cells that have the potential to invade and spread to other parts of the body) of Breast, Major Depressive Disorder(a serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities).Review of Minimum Data Set (MDS-standardized assessment done in nursing homes) Section C-Cognitive (thinking) Patterns, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly store intravenous (IV-a plastic tubing inserted through the vein) supplies for one of 21 residents (Resident 42) when an opened IV flush syringe (device used to inject fluids a water solution through an IV that prevents clogs) and a green IV cap cover was left unattended and stored improperly.This deficient practice placed Resident 42 at risk for contamination, infection and unsafe administration of IV medications and supplies.Findings:A review of Resident 42's admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses which included history of Irritable Bowel Syndrome (IBS-uncomfortable or painful abdominal symptoms).A record review of Resident 42's minimum data set (MDS - a federally mandated resident assessment tool) dated 6/10/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15…

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

Based on observation, interview, and record review, the facility failed to properly store and dispose of refuse (trash, garbage or rubbish) in a sanitary manner when the outside dumpster lids were opened and accessible to pests.This deficient practice placed all 69 residents at risk for pest infestation, foul odors, and the spread of infection.Findings:On 9/10/2025 at 8:48 A.M., an observation and interview was conducted with the Dietary Supervisor (DS), outside of the kitchen back exit. There was two dumpsters outside with one dumpster's lid open. The opened dumpster contained garbage in clear plastic bags and cardboard boxes scattered in the dumpster with a foul odor coming out from the dumpster. The DS stated the dumpster lids needed to be closed to contain the garbage that was inside the dumpster and to prevent pests such as rats, and flies from entering the dumpster and potentially spreading infection.A review of the facility's policy and procedure titled, Miscellaneous Areas dated 2023, indicated .Garbage and trashcans must be inspected daily that no debris is on the ground or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident's belongings were documented in the medical record for one of three sampled residents (24).As a result, there was no way to verify where Resident's 24 belongings went. Findings:Per the facility's admission Record, Resident 24 was admitted to the facility on [DATE] with diagnoses to include generalized anxiety (worry) disorder.On 9/10/25 a review was conducted of Resident 24's medical record. There were no progress notes documenting the incident, and there were no progress notes of any kind documented on 9/6/25.On 9/9/25 at 2:44 P.M., an interview was conducted with Resident 24. Resident 24 stated, she had vitamins in her room which went missing. Resident 24 further stated, she told the administrator and other facility staff about her missing vitamins but they told her they couldn't find them and didn't do anything to help her.On 9/12/25 at 9:16 A.M., an interview was conducted with the Social Worker (SW). The SW stated, they took…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control practices for one of 21 residents sampled (Resident 100) when a Certified Nursing Assistant (CNA) provided mouth care without wearing a gown for a resident on Enhanced Barrier Precautions (EBP-infection control precautions to reduce transmission of multi-drug resistant organisms (MDRO) a bacteria that resists treatment with more than one antibiotic).These deficient practices placed all 21 residents at risk for the spread of infection and cross-contamination.Findings:A review of Resident 100's admission Record indicated Resident 100 was re-admitted to the facility on [DATE] with diagnoses which included history of Malignant Neoplasm of Prostate (prostate cancer- an abnormal tumor located below the bladder in males).A record review of Resident 100's minimum data set (MDS - a federally mandated resident assessment tool) dated 5/31/24 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing 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 provide safety rails in a bathroom that was used by two of four residents (Resident 7 and Resident 11) who had access to the bathroom. This failure had the potential for accidents related to toilet use. Findings: Per the facility's admission Record, Resident 7 (R7) was admitted on [DATE] for Respite Care (short-term relief for primary caregivers, giving them time to rest, travel, or spend time with other family and friends). R7 had diagnoses which included Malignant Neoplasm (a cancerous tumor, which is an abnormal growth of cells that have the potential to spread to other parts of the body) of bladder, Surgery of the Genitourinary (the urinary and genital organs) System, Chronic Respiratory Failure (a long-term condition that prevents the lungs from exchanging enough oxygen and carbon dioxide with the body). Record review of Minimum Data Set (MDS-standardized assessment tool used to comprehensively evaluate the health status of nursing…

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 did not ensure patient centered care plans were developed for one of four residents reviewed for care plans when Resident 1 had diarrhea and purple feet with swelling. This failure resulted in delayed care and a decreased physical well-being for Resident 1. Findings: Resident 1 was 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 cerebrovascular disease (a condition affecting blood flow and blood vessels in the brain) according to the facility ' s admission Record. During an interview and concurrent record review on 8/29/24 at 10:32 A.M. with LN 1, LN 1 stated an open area on Resident 1 ' s coccyx (tailbone) was identified on 8/28/24. LN 1 reviewed Resident 1 ' s bowel movement record and stated Resident 1 had loose bowel movements from 8/16/24 through 8/23/24. During a review of progress notes (PN) titled, Physician…

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 provide a medication for diarrhea for one of four residents (Resident 1) reviewed for services that meet professional standard, according to professional scope of practice. As a result, Resident 1 continued to have diarrhea and had a skin breakdown on the sacro-coccyx (the triangular shaped bone at the base of the back extending to the tailbone) area. In addition, Resident 1 had the potential for increased infection and discomfort. Findings: Resident 1 was 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 cerebrovascular disease (a condition affecting blood flow and blood vessels in the brain) according to the facility ' s admission Record. The MDS (a clinical assessment tool) dated 7/19/24 for Resident 1, listed a cognitive (mental process involved in knowing, learning, and understanding things) score of 14,…

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 did not ensure one of three residents (Resident 1) reviewed for pressure ulcers (bedsores), received the necessary care and services to prevent pressure ulcer formation. This failure resulted in Resident 1 ' s rash to become a deep tissue injury. Findings: Resident 1 was 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 cerebrovascular disease (a condition affecting blood flow and blood vessels in the brain) according to the facility ' s admission Record. During an interview with licensed nurse (LN) 2 on 8/29/24 at 10:03 A.M., LN 2 stated Resident1 was transferred to the hospital on 8/28/24. LN 2 stated Resident 1 was on a low air loss mattress (mattress designed to distribute the resident ' s body weight and help prevent skin breakdown) due to skin problems. LN 2 stated to prevent pressure ulcers, residents should be…

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

Based on interview and record review, the facility failed to provide a registered nurse (RN) coverage eight consecutive hours a day, seven days a week. As a result, there was not consistent oversight by an RN for the coordination, management, and overall delivery of care to the residents. Findings: During a record review of the facility's payroll-based journal (PBJ- report that provides data on staffing levels) data report indicated the facility triggered for low weekend staffing and a 1-star rating (quality of healthcare service) both in 2024. A record review of the facility's daily census (a facility form used to track facility daily census, licensed nurse hours, and certified nursing assistant hours) dated April 2024, May 2024 and June 2024 indicated: 1. Less than eight hours of RN coverage in the facility on 4/11/24, 2. No RN in the facility for eight consecutive hours on 4/11/24, 4/13/24, 4/14/24, 4/27/24,4/28/24 5/11/24, 5/19/24, 6/8/24 and 6/9/24. An interview on 7/1/24 at 3 P.M., with the Staffing Coordinator (SC) was conducted. The SC stated the weekends are challenging,…

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 safe and sanitary environment that mitigated the risk for foodborne illness and cross contamination when: 1. The kitchen walk in refrigerator contained ketchup, soy sauce, and Italian dressing that did not have a use by date, staff's plastic water bottle, and beverage were also in the kitchen refrigerator. In addition, shredded carrots in a plastic bag, pack of hot dogs, tortilla in an opened plastic bag containers and two onions in plastic wrap were not identified and labeled in the refrigerator, 2. A coil above the food shelf in the refrigerator had gray debris covering the entire coil attached to a light fixture. These failures exposed residents to contaminated food and unsanitary practices, which had the potential to place them at risk of developing a foodborne illness. Findings: 1. During a concurrent observation and interview on 6/24/24 at 8 A.M. with the cook, the cook stated a label with OD was the date a food item was opened and a label with UB was the use by date. Inside the kitchen walk 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat one of two residents (59) with dignity and respect when incontinent care was not provided on a timely basis. This failure resulted in Resident 59 feeling upset towards staff. Findings: Resident 59 was admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of the bladder (loss of control of the bladder due to brain, spinal cord, or nerve condition) and muscle weakness according to the facility's admission Record. The Minimum Data Set (MDS- a clinical assessment tool) for Resident 59 dated 5/7/24, listed a cognitive score of 14 (a score of 13 to 15 meant cognitively intact) indicated, cognition was intact. Section GG (functional abilities and goals) of the MDS listed Resident 59 as dependent with toileting hygiene. During an observation and interview on 6/24/24, at 9:15 A.M., Resident 59 was in his wheelchair in the room wearing an incontinent brief and a shirt. Resident 59 stated he was upset because he…

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 Pre-admission Screening and Resident Review Level II (PASRR II - an evaluation of the resident's psychiatric treatment requirements) was followed up and completed for one of one resident reviewed for PASRR. (Resident 10) This failure had the potential for Resident 10 to not receive necessary mental health care services in an appropriate healthcare setting. Findings: Resident 10 was re-admitted to the facility on [DATE] according to the facility's admission Record. A review of Physician's Progress Note (PN), for Resident 10 dated 5/13/24, indicated, .Review of System: unreliable due to cognitive impairment .Schizo-affective d/o (disorder) (a mental health disorder with combination of hallucinations [a perception of having seen, heard, touched, tasted, or ssmelled something that was not actually there] or delusions [a belief or altered reality that is persistently held despite evidence or agreement to the contrary, generally 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not develop patient centered care plans for two of eight residents reviewed for care plans (Resident 169 and 170). These failures had the potential for the residents to not receive care and services specific to the residents' needs. Findings: 1. Resident 169 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (OSA- a problem in which breathing pauses during sleep due to blocked airways) according to the facility's admission Record. The Minimum Data Set (MDS- a clinical assessment tool) for Resident 169 dated 6/20/24, listed a cognitive score of 14 (13 to 15 score meant cognitively intact), indicated cognition was intact. On 6/24/24 at 8:33 A.M., Resident 169 was observed sitting up in bed watching TV with an oxygen cannula (a thin, flexible tube that goes around the head and into the nose to deliver oxygen) on his nose. Resident 169 stated he applied the mask connected to a continuous positive airway pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a CPAP machine was functioning for one of two residents (Resident 169) reviewed for respiratory care. This failure had the potential to adversely affect the health and well-being of the resident. Resident 169 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (OSA- a problem in which breathing pauses during sleep due to blocked airways) according to the facility's admission Record. The Minimum Data Set (MDS- a clinical assessment tool) for Resident 169 dated 6/20/24, listed a cognitive score of 14 (13 to 15 meant cognitively intact), indicated cognition was intact. During an observation and interview on 6/25/24 at 9:02 A.M., Resident 169 was sitting up in bed watching TV. A continuous positive airway pressure machine (CPAP- a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep) was observed on an overbed table next to Resident 169's bed. The mask…

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 reviews, the facility failed to consistently provide dialysis (a procedure to remove waste products from the body when the kidneys stop working properly) access site care and assessment for one of three sampled residents (Resident 13) reviewed for dialysis. As a result, there was the potential for the resident to have complications after receiving dialysis treatment. Findings: 1. Resident 13 was admitted to the facility on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis per the facility's admission Record. A review of Resident 13's MDS (an assessment tool) indicated, the resident's BIMS (Brief Interview of Mental Status) score was 7, indicating mild cognitive impairment. On Monday 6/24/24 at 9:24 A.M., an observation and interview of Resident 13 was conducted. Resident 13 was in bed, wearing a hospital gown. Resident 13 showed his dialysis access site on the right upper arm with a dressing intact. Resident 13 stated his last…

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 current infection control practices were followed for three of three residents reviewed for infection control when: 1. Resident 169's continuous positive airway pressure (CPAP- a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep) mask was left on top of the machine open to air, 2. Resident 170's IV (intravenous- into the vein) tubing did not have a date used and the peripherally inserted central catheter (PICC- a type of long catheter inserted through a vein in the arm into a larger vein in the body) line site did not have a date when the dressing was last changed, 3. Resident 126's CPAP mask and tubing were not stored in sanitary manner. Failure to follow current infection control practices had the potential for the equipment to be contaminated and cause illness to the residents. 1. Resident 169 was admitted to the facility on [DATE] with diagnoses including obstructive sleep…

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 a resident's ability to self-administer medications for one of one resident reviewed for self-administration of medications. (Resident 3). This failure had the potential for Resident 3 to over or under medicate himself. In addition, staff had no knowledge if Resident 3 took the medications. Findings: Resident 3 was 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) according to the facility's admission Record. During observation and interview on 3/21/24, at 12:10 P.M. with Resident 3, Resident 3 stated he had a red rash on his right leg that was not resolving. Resident 3 stated he notified his primary care physician outside the facility and referred him to a dermatologist (skin doctor). Resident 3 stated he went to see the dermatologist…

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 provide one of three sampled residents a written notification of bed hold at transfer to the hospital. This deficient practice resulted on resident (Resident 1) not receiving notification of the right to return to a bed at the facility. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder (a disorder of the brain that affects mood and behavior) per the admission record. A review of the facility census on 3/12/24 indicated Resident 1 was no longer residing at the facility. A review of the facility admission/discharge report indicated Resident 1 was discharged to an acute care hospital on 2/5/24. On 3/12/24 at 11:22 A.M., an interview and review of Resident 1's medical record was conducted with the social service director (SSD). The SSD stated the facility was required to provide all residents with a written notification of the seven-day bed hold policy on admission and transfer to the hospital. The medical…

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

Based on interview and record review, the facility failed to ensure residents received care in a safe setting when nursing staff did not follow the facility ' s drug and alcohol policy. As a result, a Licensed Nurse (LN) administered medications to 18 of 18 residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18) after consuming an alcoholic beverage during break. In addition, the facility did not identify the affected residents until two weeks after the incident. These failures had the potential to negatively affect the health and well-being of the residents. Findings: On 11/1/23 at 11:40 A.M. the Director of Nursing (DON) stated during an interview that LN 2 reported to the DON on 10/15/23 that LN 1 had slurred speech and was not herself after returning from break. The DON then called LN 1 who admitted that she had a drink of beer and sushi on break, so the DON sent her home. The DON stated that LN 2 seemed normal when she spoke with her on the phone. The DON further stated that she was made aware that LN 1 did evening med pass after consuming an alcoholic…

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, interviews, and record review, the facility did not ensure adequate supervision and safe environment was provided for one sampled resident (1), when the resident wheeled herself out the facility unattended by staff. This failure put Resident 1 at risk for injury and the potential to affect Resident 1's psychosocial well - being. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). On 5/22/23 at 2:50 P.M., an interview with the Social Services Director (SSD) was conducted. SSD stated Resident 1 was not in the building on 4/23/22 when a family member came to visit. SSD further stated that Resident 1 was wearing a WanderGuard bracelet (monitoring device) for wandering behavior or elopement. On 5/22/23 at 3 P.M., an interview with the certified nurse assistant (CNA) 1 was conducted. CNA1 stated that Resident 1 was alert but…

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 appropriately administer resident's medication, and ensure a system of storage, reconciliation, and disposition of Controlled Substances (CS- a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) were established and implemented when: 1. The facility did not appropriately store Resident 801's-controlled medications: hydrocodone/acetaminophen 10/325 mg (milligram- unit of measure) and lorazepam 0.5 mg tablets (drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence), log Resident 13's controlled medication carisoprodol 350 mg tablets (pain medication) for disposition, and did not have a system in place in sufficient detail to periodically reconcile controlled drugs; 2. Licensed Nurse (LN) 43 did not appropriately administer Resident 124's Diclofenac gel 1% (pain medication). These failures increased the risk for loss and/or diversion (the illegal distribution or abuse of prescription drugs…

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

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were stored and/or labeled in accordance with current accepted professional principles and facility policies and procedures, for seven sampled residents (Residents 801, 59, 44, 40, 59, 124, 14) when: 1. In the facility's medication room, Resident 801's hydrocodone/acetaminophen 10/325 mg and 20.5 tablets of lorazepam 0.5 mg tablets were stored in an unlocked cabinet. 2. In the facility's medication room, Resident 59's discontinued amoxicillin/clavulanate (antibiotic) 500 mg (milligram- unit of measurement) medication was found in the medication cabinet not separated from medications that were in use for facility residents. 3. In medication cart 2, Resident 44's discontinued lorazepam (medication for anxiety) 0.5 mg medication card of 15 tablets was found not separated from medications that were in use for facility residents. 4. In treatment cart 1, Resident 40's discontinued nystatin powder (antifungal), Resident 69's nystatin powder, Resident 124's Clindamycin…

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 all food items were labeled and dated. In addition, the facility did not ensure that there were no expired food items. Findings: An initial tour/observation of the facility's kitchen was conducted on 5/15/23 at 9 A.M. with the facility's Registered Dietician (RD). In the refrigerator, there was a tray of assorted juices and iced tea. The juices and iced tea were not labeled or dated, nor was the tray. In addition, there were two packages of sliced cheddar cheese, uncovered and were not labeled or dated. In the dry storage/emergency food area, a one gallon container of mayonnaise was dated use by 5/8/23; four bags of corn flakes were dated use by 5/8/23; four packages of vanilla wafers expired 5/8/23; and two packages of graham crackers expired 4/10/23. An interview was conducted with the RD on 5/15/23 at 9:30 A.M. The RD stated, They should be dated, because, if outdated, they can cause stomach trouble for the residents. Things (food items) need to be labeled and dated. On 5/15/23 at 3:51 P.M., an…

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 practices when two out of two nursing staff (Licensed Nurse (LN) 44, and 45) in two out of two nursing stations did not properly disinfect shared glucometers (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to the manufacturer's instructions and accepted professional standards of practice. In addition, one LN (42) did not perform hand hygiene during wound care and handled a wound dressing in an unsanitary manner for one (Resident 374). These failures had the potential for widespread transmission of bloodborne diseases (such as Hepatitis B [a serious liver infection caused by the hepatitis B virus that is most commonly spread by exposure to infected body fluids), Hepatitis C, and HIV (human immunodeficiency virus, is a virus that attacks the body's immune system) among residents. Also, there was a potential to spread infection to other residents, staff, and…

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

Based on observation, interview, and record review, facility failed to provide privacy for one of four residents (Resident 42) reviewed for dignity. As a result, Resident 42 felt embarrassed during personal care and not treated with dignity. Findings: On 5/15/23 at 11:10 A.M., an observation of Resident 42 was conducted. Resident 42 was sitting in a shower chair, wrapped in shower blankets, with both legs exposed from the knee down, and bare feet. Resident 42 was visible from the hallway, waved, and stated she had just came from the shower. On 5/15/23 at 11:12 A.M., an observation of Certified Nursing Assistant (CNA) 23 was conducted. CNA 23 entered the room and moved Resident 42 aside without asking permission. On 5/16/23 at 2:20 P.M., an observation and interview of Resident 42 was conducted. Resident 42 was lying down on bed and stated she was waiting to be changed. Resident 42 stated that another CNA (unable to identify) said she would get some things and be back, but the never came back. On 5/16/23 at 2:28 P.M., an observation of CNA 21 was conducted. CNA 21 came inside…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately code a discharge disposition for one resident (Resident 73). This failure had the potential to cause delays in services needed after discharge and inaccurate transmission via Minimum Data Set (MDS- an assessment tool). Findings: Resident 73 was admitted to the facility on [DATE] with diagnoses which included alcoholic cirrhosis of the liver, per the facility's admission Record. Resident 73 was discharged on 2/28/23. A review of Resident 73's medical record was conducted on 3/18/23 at 11 A.M. The Minimum Data Set (MDS-an assessment tool), Section A, Discharge Status, indicated Resident 73 had been discharged to an acute hospital. A physician order dated 2/28/23 indicated, Discharge home . An interview with the MDS nurse was conducted on 5/18/23 at 11:25 A.M. The MDS Nurse stated, Yes, it was a mistake. This Resident was discharged home, not to an acute hospital. If a mistake is made, it could affect post discharge services. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify and accurately coded the PASRR (Preadmission Screening and Resident Review, a federally required document to ensure residents are appropriately placed and/or for services) evaluation for three of 19 residents (Resident 22, 49 and 52) when: 1. Resident 22's PASRR was not coded for a neurocognitive disorder (decreased in mental function due to a medical disease), 2. Resident 49's PASRR was not accurately assessed for mental illness, and, 3. Resident 52's PASRR was not accurately assessed for mental illness and completed for Level 1 screening. These failures had the potential for Residents 22, 49, and 52, to not receive the care and necessary services in the most appropriate setting. Findings: 1. A review of the clinical record for Resident 22 was conducted. The admission record indicated, Resident 22 was re-admitted to the facility on [DATE] with diagnoses which included, traumatic brain injury (happens when a sudden, external, physical assault…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to implement a baseline care plan within the 48-hour time frame as required and included the physician orders for one of one sampled residents (Resident 374). This failure had the potential for Resident 374 having incorrect care provided. Findings: Resident 374 was admitted to the facility on [DATE], with diagnoses which included acute (sudden) respiratory failure, muscle weakness, chronic pain, pressure ulcer (an open area of the skin caused by immobility) of the sacral region (the sacrum is at the end of the spine, and is an inverted triangle between the hips, at the level of the buttock crease), per the facility's admission Record. Resident 374's clinical record was reviewed. Five care plan areas were created after the 48-hour window. Resident 374 was admitted to the facility on [DATE] with physician orders for oxygen. The care plan area of Oxygen Therapy r/t (related to) Respiratory Illness was not created until 5/16/23. The approach Oxygen as ordered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. A review of Resident 724's admission Record indicated, the resident was admitted to the facility on [DATE], with diagnoses that include displaced comminuted fracture of the right patella (a broken bone in two or more pieces), person injured in unspecified motor-vehicle accident. On 5/15/23 at 1:10 P.M., an observation of Resident 724 was conducted. Resident 724 was in his bed with his eyes open. Resident 724 spoke Spanish during an attempted interview. There was no translation line information posted on the wall and no communication tools were visible in the room. On 5/15/23 at 1:20 P.M., a record review of Resident 724's admission record was conducted. The admission record indicated, Resident 724's primary language was Spanish. On 5/15/23 at 1:28 P.M., an interview and a joint record review was conducted with licensed nurse (LN) 44. LN 44 stated she was unable to independently communicate with Resident 724. LN 44 stated there was no language line information posted on the wall and no communication tools…

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 timely and accurate assessment, related to pressure ulcers for one of one resident (Resident 374). In addition, the facility failed to ensure the care plan for one of three hospice (a type of healthcare focusing on symptom management in the final six months of life) residents (Resident 44) was developed collaboratively with hospice. These failures had the potential for Resident 374 not receiving the care and treatment for a pressure ulcer, and the potential for Resident 44 to experience duplication or omission of services. Findings: 1. Resident 374 was admitted to the facility on [DATE]with diagnoses which included, acute (sudden) respiratory failure, muscle weakness, other chronic pain, and pressure ulcer (a wound caused by immobility) of sacral region (the sacrum is at the end of the spine, and is an inverted triangle between the hips, at the level of the buttock crease). Resident 374's history and physical, dated 3/7/23…

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 identify and provide care and treatment to one of one sampled resident (Resident 374) admitted with a pressure ulcer (a wound caused by immobility). This failure caused Resident 374 a delay in treatment of her wound and a delay in care required to prevent further skin problems. Findings: In a Record Review conducted on 5/15/23, at 11:35 AM, Resident 374 was admitted to the facility on [DATE]. Her admitting diagnosis included: Acute Respiratory Failure; Muscle Weakness; Other Chronic Pain; Pressure Ulcer of Sacral Region. A hospital wound consultation note, dated 5/5/23, indicated an open wound on the sacrum with granular/partial thickness ulceration .(The sacrum is at the end of the spine, and is an inverted triangle between the hips, at the level of the buttock crease.) Orders for wound care and offloading pressure (frequent turning and repositioning) were written, and subsequently transcribed to the discharge orders of 5/12/23. 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 observations, interviews and record reviews, the facility failed to consistently provide dialysis (treatment to remove waste from the body) access care, including removal of dressing and assessment of the site, for three of three sampled residents (3, 59, 126), reviewed for dialysis. As a result, there was the potential for complications after dialysis. Findings: 1. Resident 3 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (irreversible kidney damage) and dependence on dialysis, per the facility's admission Record. A review of Resident 3's history and physical (H & P), dated 6/21/22, indicated Resident 3 was alert and oriented to person, time, and place. On 5/15/23 at 10:37 A.M., an observation and an interview of Resident 3 was conducted. Resident 3 was walking in the hallway with dressings on her left upper arm. Resident 3 showed her dialysis access site on her left upper arm and stated she came back from dialysis. On 5/15/23 at 4:10 P.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, interviews, and record review, the facility failed to ensure that the conditions set forth in the Hospice Services Agreement were followed. This failure has the potential for the duplication or the omission of services, the potential for harm, and/or the potential for duplicate billing (see F-tag 684). Findings: Resident 44 was admitted to the facility on [DATE], with diagnoses that included Malignant neoplasm of prostate (Prostate cancer). A review of Resident 44's physician orders, dated 2/22/23, indicated that Resident 44 was admitted to Hospice on 2/22/23. A review of Resident 44's hospice records was conducted. Resident 44's hospice care plan, dated 2/22/23, addressed Resident 44's Durable Medical Equipment and Medication Ordering of Hospice Covered Medications but did not address updated interventions related to hospice care. The record did not indicate a coordinated care plan between the facility and hospice. There was no hospice aide care plan, no calendar that showed discipline…

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.