The Pavilion At Sunny Hills

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 8) was provided with the necessary care in the manner which promoted dignity and respect. * The facility staff failed to knock and request for permission before entering Resident 8's room. This failure resulted in the resident feeling exposed and disrespected. Findings: Review of the facility's P&P titled Dignity And Respect effective June 2018 showed each resident shall be cared for in a manner that promotes dignity and respect, and staff will knock and request permission before entering the residents' rooms. Medical record review for Resident 8 was initiated on 4/21/25. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's MDS assessment dated [DATE], showed the resident was cognitively intact. On 4/23/25 at 1518 hours, an interview was conducted with Resident 8. Resident 8 stated she had concerns with her privacy being respected as the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to determine and clarify whether two of four final sampled residents (Residents 123 and 785) reviewed for advanced directives had formulated an advance directive for healthcare. * Resident 123's medical record showed conflicting documentation as to whether the resident had formulated an advance directive. * The facility failed to determine if Resident 785 had formulated an advanced directive. These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advanced Directive revised 1/2025 showed the residents have the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Advance care planning is an integral aspect of the facility's comprehensive care planning process and assures re-evaluation 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, medical record review, and facility P&P review, the facility failed to ensure the Level I PASRR contained accurate information for two of two final sampled residents (Residents 92 and 135) reviewed for PASRR screening. * Resident 135 had a diagnosis of unspecified psychosis (a symptom or feature of mental illness typically characterized by radical changes in personality, impaired functioning, and a distorted or nonexistent sense of objective reality) and major depressive disorder (a mental disorder characterized by persistent feelings of sadness, loss of interest or pleasure in activities, and other symptoms that significantly impair daily functioning) and was prescribed olanzapine (an antipsychotic medication); however the Level I PASRR showed Resident 135 had no serious mental illness and was not prescribed any psychotropic medications. * Resident 92 had a diagnosis of major depressive disorder and was prescribed citalopram (an antidepressant medication); however, the Level I PASRR showed…

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, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plans were developed or implemented for three of 35 final sampled residents (Residents 13, 80, and 143). * The facility failed to implement Resident 143's care plan specific to the PICC line management. * The facility failed to develop a care plan problem to address Resident 13's use of an e-cigarette and safe smoking practices. * The facility failed to develop a care plan problem addressing Resident 80's LUA midline catheter use. These failures placed the residents at risk for not being provided appropriate, consistent, and individualized care. Findings: Review of the facility's P&P titled Comprehensive Care Plans-Timing revised 1/2025 showed each resident has a person-centered, comprehensive care plan, developed, reviewed, and revised by the facility interdisciplinary team including the resident and resident representative. 1. Medical record review for Resident 143 was initiated…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest physical well-being for two of 35 final sampled residents (Residents 44 and 77). * The facility failed to ensure the TLSO brace was applied to Resident 44 as per the physician's order. * The facility failed to ensure Resident 77's physician was notified when the resident had the blood sugar levels between 351- 400 mg/dL as ordered. These failures had the potential to affect Resident 44 and 77's well-being. Findings: 1. On 4/21/25 at 1034 hours, Resident 44 was observed lying in her bed and sleeping. There was a TLSO brace observed on her wheelchair. Medical record review for Resident 44 was initiated on 4/21/25. Resident 44 was admitted to the facility on [DATE]. Review of Resident 44's Order Summary Report dated 4/24/25, showed a physician's order dated 4/9/25, to apply the TLSO brace while up on the wheelchair; and may remove when in bed 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, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 13) and one nonsampled resident (Resident 40) remained free from accidents and hazards. * Resident 40's room had items cluttered on multiple surfaces of her room, including the floor. This failure had the potential for injury related to resident care and obstacles when a quick and safe evacuation of the resident was needed in an emergency. * The facility failed to ensure Resident 13 was evaluated to determined if the resident required supervision and could safely store their own e-cigarette. These failures had the potential to put the residents at an increased risk for serious injuries and negative health outcomes. Findings: 1. Review of the facility's P&P titled Free of Accident Hazards/Supervision/Devices revised January 2025 showed the following: - The facility will provide an environment free from accident hazards including in the resident's environment…

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, medical record review, and facility P&P review, the facility failed to ensure the nursing staff provided the necessary care for one of three final sampled residents (Resident 985) reviewed for indwelling urinary catheter (a flexible tube that drains urine from the bladder) use. * The facility failed to ensure Resident 985's suprapubic indwelling urinary catheter bag was placed below the bladder and covered with a privacy bag. This failure had the potential to result in inadequate care and risk for adverse complications for the residents with an indwelling urinary catheter. Findings: Review of the facility's P&P titled Urinary Catheter Care revised 12/24 showed urinary drainage bags should be maintained in a position to avoid contact with the floor to reduce the risk of developing a urinary tract infection to the extend possible. Urinary drainage bags should be placed in a privacy bag to preserve resident dignity. Medical record review for Resident 985 was initiated on 4/21/25.…

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, medical record review and facility P&P review, the facility failed to timely respond and follow up on the weight loss for one of four final sampled residents (Resident 169) reviewed for nutrition. In addition, the facility failed to review the resident's nutritional status during the weekly weight management IDT meetings. These failures had the potential for adverse nutritional outcomes and to negatively affect the resident's well-being. Findings: Review of the facility's P&P titled Weight Management revised December 2024 showed the weight management committee, consisting of the key members of the IDT, meets weekly and will include residents who have lost five lbs since their last recorded weight, and a lost of 5% or more of their body weight in the last month. Medical record review for Resident 169 was initiated on 4/22/25. Resident 169 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 169's Order Summary Report showed a physician's order dated 4/21/25, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the PICC line assessments were performed and documented for two of two final sampled residents (Residents 80 and 143) reviewed for IV management. * The facility failed to ensure the nurse obtained measurements of Resident 143's arm circumference and PICC line external catheter length in accordance with the physician's orders and the facility's P&P. * The facility failed to ensure the arm circumference and external catheter length measurements were measured on admission and during the PICC line change for Resident 80's PICC line. These failures posed the risk for the residents developing complications related to the use of the PICC line. Findings: Review of the facility's P&P titled Assessment of the Patient Receiving IV Therapy dated 2011 showed to measure the external length of the central venous access device and compare to the length documented at insertion, during each dressing change and when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of four sampled residents (final sampled residents, Residents 109, 143, and 155) reviewed for respiratory care were provided with the appropriate respiratory care and services when: * The facility failed to ensure Resident 109 received the continuous oxygen therapy via the nasal cannula (flexible tube to deliver oxygen into the nose) as per the physician's order. In addition, the facility failed to ensure the nasal cannula oxygen tubing was not touching the floor mat on the ground. * Resident 143's nebulizer oxygen tubing was improperly stored, having been found lying on top of a sock on the resident's end table. * The facility failed to ensure a physician's order was obtained for Resident 155's use of oral suctioning equipment. Additionally, the facility failed to ensure Resident 155's oral suctioning equipment was labeled when changed. These failures had the potential to affect the respiratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for two of two final sampled residents (Residents 18 and 69) reviewed for pain management. * The facility failed to accurately document the monitoring of pain for Residents 18 and 69 and administer the pain medications according to the physician's order. In addition, the facility failed to ensure the non-pharmacological interventions for pain were provided to Residents 18 and 69 prior to the administration of the pain medications as per the physician's order. These failures had the potential to put Residents 18 and 69 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication. Findings: Review of the facility's P&P titled Pain Assessment and Management revised 1/2025 showed the facility provides pain management to residents who require such services, consistent with the professional standards of practice, the comprehensive…

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, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs for one of 35 sampled residents (Resident 60) and two nonsampled residents (Residents 73 and 685). * The facility failed to ensure Resident 73's omeprazole (acid reflux medication) medication bottle was shaken well prior to administering the medication as per the instruction on the bottle. * The facility failed to ensure the narcotic medication for Residents 60 and 685 were accurately signed out and documented as per the facility's P&P. These failures had the risk for negative health outcomes to the residents and the potential to result in medication diversion (the illegal use or distribution of a prescription medication that was not originally intended by the prescriber) and unsafe handling of the narcotic medications. Findings: Review of the facility's P&P titled Administering Medications revised 3/2023 showed the medications must 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 81) was free from the unnecessary medications. * The facility failed to follow the physician's order to hold the amlodipine, metoprolol, and hydralazine (antihypertensive medications) medications when Residents 81's systolic blood pressure (the top number in a blood pressure measurement) was less than 110 mmHg. This failure had the potential for Resident 81 to develop significant side effects. Findings: Review of the facility's P&P titled Administering Medications revised 3/2023 showed the medications must be administered in accordance with the orders. Medical record review for Resident 81 was initiated on 4/21/25. Resident 81 was admitted to the facility on [DATE]. Review of Resident 81's physician's order dated 11/3/24, showed to administer amlodipine 10 mg via GT once a day for hypertension and to hold the medication for a systolic blood pressure less than 110 mmHg.…

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, medical record review, and facility P&P review, the facility failed to ensure six of seven final sampled residents (Residents 9, 56, 69, 135, 155, and 985) reviewed for the unnecessary medications were free from the unnecessary psychotropic drugs. * The facility failed to ensure Resident 69's orthostatic blood pressure was monitored for the use of the quetiapine (antipsychotic) medication as per the care plan. In addition, the facility failed to implement the non-pharmacological interventions for Resident 69's observed behaviors for the use of the quetiapine and sertraline (antidepressant) medications. * The facility failed to ensure Resident 135's orthostatic blood pressure was accurately monitored as ordered by the physician and per the care plan, for the use of the olanzapine (antipsychotic) medication. In addition, the facility failed to implement the non-pharmacological interventions for Resident 135's use of the olanzapine, lorazepam (antianxiety), and citalopram (antidepressant)…

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, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage and disposal of the medications as evidence by the following: * The facility failed to ensure the oral and suppository medications in Medication Cart D were stored separately. * The facility failed to ensure the opened and expired medications and medical supplies in Medication Cart E were properly disposed. * The facility failed to ensure the expired medical supplies were removed from Medication Room B. * The facility failed to ensure Resident 81 and 95's latanoprost 0.005% (glaucoma medication) eye drops were labeled with the opened date; and failed to discard Resident 95's latanoprost 0.005% eyedrop after the beyond-use by date in Medication Cart C. * The facility failed to ensure the opened collagen powder and opened hydrofera blue (antibacterial foam) dressing were discarded after opening in Medication Cart F. * The facility failed to…

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, facility document review, and facility P&P review, the facility failed to ensure 45 of 171 residents who received food from the kitchen received the proper diets when the facility's menu was not followed. * The facility failed to ensure 45 residents who were on CCHO diets (diets for diabetics) and three residents who were on renal diets (specialized diet designed to support kidney health) received the homemade barbeque (BBQ) sauce with their oven BBQ beef roast as per the menu and recipe. This failure had the potential for the residents' nutritional needs not being met, which could result in medical complications. Findings: Review of the Diet Order Tally Report dated 4/21/25, showed 171 of 182 residents received food from the kitchen. Review of the Diet Order Tally Report - All Special Diets dated 4/21/25, showed 45 residents were on CCHO diets and three residents were on renal diets. Review of the facility's P&P titled Menus revised 9/2021 showed the facility provides meals to the residents that meet requirements of the Food and Nutrition Board of…

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

Based on interview and facility P&P review, the facility failed to ensure the facility staff responsible for handling food brought for the residents from the outside and family/visitors who brought food for the residents from the outside were educated on safe food handling procedures. This failure posed the risk for food borne illness in residents who consume food from outside sources. Findings: Review of the facility's P&P titled Use and Storage of Food Brought to Resident revised 3/2023 showed the facility has procedures to ensure safe and sanitary storage, handling, and consumption of the foods brought to the residents by the family and other visitors. The facility strives to support each resident's right to safe food storage, handling, and preparation. To ensure safe food practices and the prevention of foodborne illness, the facility shall provide safe and sanitary storage of food brought to the residents by the family and visitors for a period not to exceed 48 hours, and in accordance with the following guidelines. The facility helps the family and visitors to understand safe…

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, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurately maintained for four of 35 final sampled residents (Residents 56, 80, 81, and 163) and one nonsampled resident (Resident 40). * Resident 81 had conflicting orders for holding Resident 81's enteral feeding via GT, specific to the residuals. * The facility failed to ensure the accurate and complete medical record for Resident 56. * The facility failed to ensure the medication routes for Resident 163 with GT were accurate. * The facility failed to ensure the documentation on the IV MAR was completed for Resident 80. * Resident 40's consult psychiatrist's progress note was not part of the resident's medical record. These failures had the potential for not providing necessary care and services due to inaccurate medical records. Findings: 1. Medical record review for Resident 81 was initiated on 4/21/25. Resident 81 was admitted to the facility on [DATE]. Review of 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, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections for two of 35 final sampled residents (Residents 143 and 985) and one nonsampled resident (Resident 37) as evidence by the following: * The facility failed to ensure the EBP was maintained for Resident 143 with a PICC line during an IV medication administration observation. * The facility failed to ensure the visitors wore PPE in a contact isolation room for Resident 985. * During the medication administration observation for Resident 37, LVN 6 failed to perform hand hygiene in between glove use. * The clean laundry room had the facility staff's personal belongings and a Sani-cloth disinfectant wipe container with the clean linen. * Resident 985's did not have a trash bin with a lid in their room, when the resident had a MDRO. These failures had the potential to result…

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 facility document review, the facility failed to ensure the facility equipment was maintained in the safe operating condition. * For Medication Cart C, the glucometer's (a device that measures the amount of sugar in the blood) serial number did not match the serial number for the glucometer tested on the quality control log. In addition, the facility failed to ensure the corrective actions were taken when the quality control results for the glucometer were out of range. * The facility failed to ensure the serial number on the glucometer and on the Quality Control Record matched for Medication Cart B. * The facility failed to ensure the quality control checks were performed for the glucometers in Medication Cart A and B. These failures had the potential risk of inaccuracy for the residents' blood glucose test results. Findings: Review of the Assure Platinum (blood glucose monitoring system), User Instruction Manual (undated) showed to perform control solution tests in accordance with the state regulatory guidelines. To use the Assure Dose Control…

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, medical record review, and the facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well -being for one of two sampled residents (Resident 2). * The facility failed to ensure Resident 2 had a physician's order for suctioning as per the discharge order from the acute care hospital. * The facility failed to weigh daily and provide the Lasix medication to Resident 2 as per the physician's instructions. * The facility failed to notify the physician and responsible party of Resident 2's continued refusals of the medications and supplements. * The facility failed to provide Resident 2's indwelling urinary foley catheter care, and wound care treatments as ordered by the physician. These failures had the potential to negatively affect the resident's well-being as the necessary care and services were not provided. Findings: Closed medical record review for Resident 2 was initiated on 3/5/25. Resident 2 was admitted to the facility 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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of three sampled residents (Resident 1). * The facility failed to follow up with the hospice for the latanoprost eye drop (to treat glaucoma) order for Resident 1. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Hospice Services revised March 2023 showed the nursing home staff may obtain the orders for care from the designated hospice physicians and communicate the necessary changes initiated by the hospice provider to the resident's attending physician/practitioner in a timely manner. The nursing home shall communicate changes in orders provided by the resident's attending physician/practitioner in the facility if he/she is not the resident's designated physician on the hospice team. Review of the facility's Hospice and 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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of four sampled residents (Resident 4). * The licensed nurse failed to prime Resident 4's Tresiba (insulin pen injection) prior to administering the insulin medication as per the manufacturer's instructions for the use of insulin pen medication. This failure posed the risk for complications related to the resident not receiving the correct amount of the prescribed medication. Findings: Review of the facility's P&P titled Insulin Administration effective 2/2024 showed the nursing staff will have access to specific manufacturer's instructions on all forms of insulin delivery system prior to their use. Under the section for Insulin Delivery, the forms of insulin delivery include the pens containing insulin cartridges to deliver insulin subcutaneouslythrough a needle. Review of the Manufacturer's Instruction for Use for Tresiba (insulin degludec) injection revised…

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, medical record review, and facility P&P review, the facility failed to ensure 10 of 35 final sampled residents (Residents 55, 58, 94, 151, 154, 167, 420, 421, 423, and 425) and three nonsampled residents (Residents 146, 160, and 872) were provided with the appropriate respiratory care when: * The facility failed to ensure Resident 154's oxygen nasal cannula (flexible tube to deliver oxygen into the nose) tubing was labeled and dated as per the physician's order. * The facility failed to ensure Resident 425 had a physician's order for administration of oxygen and oxygen nasal cannula tubing was labeled and dated. * The facility failed to ensure Resident 420's nebulizer mask, tubing, and oxygen tubing were labeled and dated. * The facility failed to ensure Resident 421's oxygen nasal cannula tubing and CPAP (continuous positive airway pressure, a machine used to help keep breathing airways open while sleeping) facemask and tubing was labeled and dated. * The facility failed to…

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, medical record review, and facility P&P review, the facility failed to ensure proper labeling and storage of medications according to the facility's P&P and/or manufacturer's specifications when: * Medications were not properly labeled and stored in five of eight inspected medication carts and two of two inspected medication rooms. This deficient practice had the potential for inadequately monitored medications, which could lead to unsafe and ineffective medications for the residents, unsafe and reduced efficacy from being used past their discard date, and medication errors due to medication not being labeled. Findings: Review of the facility's P&P titled Labeling of Biologicals and Storage of Biologicals dated 3/23 showed in part, drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable . For medications designed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen and in patient food storage areas. * The facility failed to ensure food preparation equipment was air dried. * The facility failed to ensure the resident food equipment was stored clean. * The facility failed to ensure the food cutting boards were in good condition. * The facility failed to ensure the resident food in the cold and dry storage areas were labeled and dated. * The facility failed to ensure the resident food in the third floor community refrigerator was labeled and dated. * The facility failed to ensure the food items stored in the residents' personal refrigerator for Residents 146, 160, 520, 870, and 872 were properly labeled and dated. * The facility failed to ensure the temperatore of the personal refrigerators for Residents 96, 160, 870, 871, and 872 were checked and recorded daily. * The facility failed to ensure Resident 160's personal refrigerator 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, medical record review, and facility P&P review, the facility failed to determine if it was safe for four of 35 final sampled residents (Residents 151, 422, 425, and 520) and one nonsampled resident (Resident 110) to self-administer the medication left at the bedside. * Resident 110 was observed with bottles of vitamin B12 (supplement), vitamin E (supplement), fish oil (supplement), vitamin D3 (supplement), and PreserVision (supplement) medications at the bedside. Resident 110 did not have the assessment, physician's order, and care plan problem addressing the resident's self-administration of medication. * A bottle of polymix B sulfate and trimethoprim ophthalmic solution (eye drops antibiotic), a medication cup filled with white cream, and one Dulcolax suppository were observed at Resident 422's bedside table. Resident 422 had self-administered the eye drop antibiotic without being assessed for self-administration of medications. * An albuterol sulfate HFA inhalation aerosol…

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, medical record review, and facility P&P review, the facility failed to obtain and maintain the copy of the advance directive (legal document that stats a person's wishes about receiving medical care if that person is no longer able to make medical decisions) for two of 35 final sampled residents (Residents 91 and 151). This failure had the potential for the resident's decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives revised 2/1/17, showed upon admission, the admission Staff or designee will obtain a copy of a resident's advance directive. A copy of the resident's advance directive will be included in the resident's medical record. 1. Medical record review for Resident 91 was initiated on 12/4/23. Resident 91 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed resident was cognitively intact. Review of Resident 91's POLST dated 8/3/23, showed Resident 91 did not have 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 interview, observation, medical record review, facility document review, and facility P&P review, the facility failed to notify and promptly resolve a written filed grievance for one of 35 final sampled residents (Resident 6). Resident 6 had missing personal photos from her room after she was moved to another room and requested for reprinting he photos; however, no staff had followed up with her regarding reprinting her personal photos. As a result of this failure, Resident 6 stated she felt depressed and angry. Findings: Review of the facility's P&P titled Grievance Policy revised March 2023 showed the facility will make prompt efforts to resolve grievances the resident may have. The Grievance Official will, as necessary, take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated. Review of the facility's P&P Theft Prevention revised 9/1/21, showed upon completion of the investigation, the Administrator or designee is…

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, medical record review, and the facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for five of 35 final sampled residents (Residents 91, 135, 154, 424, and 520). * The facility failed to develop a care plan problem for Resident 154's use of oxygen and Resident 424's use of PICC line (peripherally inserted central catheter - intravenous access used for a prolonged period of time). * The facility failed to ensure Resident 520's care plan was personalized to address safe smoking practice. * The facility failed to develop and implement a person-centered care plan for Resident 91's buspirone. * The facility failed to develop a care plan problem to address Resident 135's use of bilateral 1/4 side rails. These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Develop-Implement Comprehensive Care Plans revised March 2023 showed…

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 medical record review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of two of 35 final sampled residents (Residents 33 and 76). * The facility failed to provide activities for Residents 33 and 76 to meet the residents' identified interests. The facility only provided activity programs to Residents 33 and 76 on 11/9, 11/20, 11/23, and 12/2/23, for November and December 2023. This failure had the potential for the residents to experience feelings of social isolation and frustration. Findings: 1. On 12/5/23 at 1454 hours, 12/6/23 at 1300 hours, and 12/7/23 at 0900 and 0949 hours, Resident 76 was observed in bed and awake. There was no in-room sensory stimulation observed. The TV and radio were turned off. Medical record review for Resident 76 was initiated on 12/4/23. Resident 76 was readmitted to the facility on [DATE]. Review of Resident 76's MDS dated [DATE], showed Resident 76 had a severe cognitive impairment.…

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, medical record review, facility record review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for one of 35 final sampled residents (Resident 10). * Resident 10 was not administered hydralazine (antihypertensive; used to treat high blood pressure) medication when the resident's SBP was more than 150 mmHg as per the physician's order. This failure had the potential for Resident 10 to develop health complication from high blood pressure. Findings: Medical record review for Resident 10 was initiated on 12/4/23. Resident 10 was readmitted to the facility on [DATE]. Review of Resident 10's Order Summary Report showed the following physician's orders dated: - 1/4/23, to administer hydralazine 25 mg every six hours as needed to give if SBP more than 150 mmHg; and - 9/24/23, to monitor blood pressure every six hours. May administer hydralazine if SBP more than 150 mmHg. Review of Resident 10's MAR for November…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the resident was evaluated for safe smoking practices for one of 35 sampled residents (Residents 520). * Residents 520 was not evaluated to determine if the resident required supervision and could safely store their own cigarettes or lighters. This failure posed the risk for unsafe environment. Findings: Review of the facility's P&P titled Smoking Policy - Residents revised 3/2023 showed following: - Facility will recognize the residents' right to smoke; however, this right is strictly in accordance with the interdisciplinary team assessment of a resident's ability to smoke safely, in a designated smoking area; - To promote the safety of the smoking resident, the IDT may require a resident to smoke under the direct supervision. Resident were responsible for proving all smoking material. Such materials will be labeled and maintained in a safe area by the facility staff; - Smoking material (s) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for two of final sampled residents (Residents 3 and 76) and one nonsampled resident (Resident 871). * The facility failed to ensure Resident 76 was positioned safely at least 40 degrees during feeding administration via GT as ordered. * The facility failed to ensure Resident 33 was administered the water flush via GT pump as ordered. *The facility failed to ensure Resident 871's enteral formula container was labeled with the time when it was hung, and the water flush container was labeled and dated when hung. These failures posed the risk for developing complications related to GT. Findings: Review of the facility's P&P titled Enteral Feeding - Pump revised 3/2023 showed to raise the head of the bed at 30 to 45 degrees for feeding, unless medically contraindicated. The P&P also showed to document the initials, date, and time the formula was hung/administered on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one of 35 final sampled residents (Resident 424). The facility failed to ensure the PICC line external catheter and arm circumference measurements were performed and documented in the medical record for Residents 424. This failure had the potential to delay identification of catheter related complications for the resident. Findings: Review of the facility's P&P titled Assessment of the Patient Receiving IV therapy dated September 2022 showed to measure the external length of the midline or central venous access device, and compare to the length documented at insertion, during each dressing change and when catheter dislodgment is suspected. Medical record review for Resident 424 was initiated on 12/5/23. Resident 424 was admitted to the facility on [DATE]. Review of Resident 424's Order Summary Report dated 12/5/23, showed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for three of 35 final sampled residents (Residents 10, 86, and 126). * The facility failed to ensure the physician's order for 1000 ml fluid restriction (a diet which limits the amount of daily fluid consumption) per 24 hours was followed and carried out accordingly for Resident 126. * The facility failed to ensure the water pitcher was not in Resident 126's room when on a fluid restriction as per the facility's P&P. * The facility failed to ensure the dressing on the dialysis access site was removed four hours after dialysis treatment. Resident 86 was observed with a dressing on the left forearm dialysis access two days after dialysis treatment. * The facility failed to ensure Resident 10's pre-dialysis assessment of dialysis access and post-dialysis documentation of return date and time were accurate. These failures had the potential for the residents not being provided…

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, facility P&P, and document review, the facility failed to * Ensure accountability for controlled medications (medications that have some potential for abuse or dependence) for one of 35 sampled Residents (Resident 135), when the controlled medication was signed out of the resident's narcotic record but was not documented as administered. This failure had the potential for exposing residents to ineffective treatment, medication errors, and the potential for diversion of controlled medications. * Ensure used refrigerated emergency medication kit was replaced timely. This failure had the potential for medication not to be available when needed, which may result in poor resident's outcome. Findings: 1. Review of the facility's P&P titled Ordering and Receiving Controlled Medications dated 1/23 showed the pharmacy or the nursing care prepares an individual resident-controlled substance record/receipt/log for each controlled substance medication prescribed for a resident as applicable…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for three of 35 final sampled residents (Resident 91, 92, and 135). * The Pharmacy Consultant's recommendation for a duration of therapy for the prescribed heparin (anticoagulant; used to decrease the clotting ability of the blood) medication for Resident 92 was not acted upon. This failure had the potential to put Resident 92 at risk for adverse consequences related to the medication. * The facility failed to ensure the consultant pharmacist identified the medication-related irregularities during the monthly drug regimen review; when adverse effects of lamotrigine medication used to treat mood swings by Resident 91 was not being monitored and it was not identified by the consultant pharmacist. This failure resulted in inadequate medication monitoring for the resident which has the potential to compromise their health. * The Pharmacy…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure four of 35 final sampled residents (Residents 55, 91, 94, and 425) were free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to monitor the specific behavior manifestation for Resident 94's use of clonazepam (use to treat anxiety). * The facility failed to ensure Resident 55's orthostatic blood pressure (measure the blood pressure while laying down and sitting) was monitored as ordered by the physician related to the use of an antipsychotic medication. * The facility failed to ensure Resident 425's orthostatic blood pressure (measure the blood pressure while laying down and sitting) was monitored as ordered by the physician related to the use of an antipsychotic medication. * The facility failed to implement non-pharmacological intervention for quetiapine, mirtazapine,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the infection control practices were maintained. * The facility failed to ensure the residents' clothing and blankets from the laundry were transported and delivered in a clean and sanitary manner. The facility failed to ensure the residents' clothing and blankets were inside a fully covered linen cart during transportation. * The facility failed to ensure the staff practiced the contact precaution when entering Resident 75's room that had a posted signage outside the room for contact precaution. In addition, the facility failed to ensure the correct special precautions for Resident 75 were posted. * The facility failed to ensure Resident 925's uncovered urinal was not placed next to a drinking water cup. These failures posed the risk of potential transmission of communicable diseases to other residents in the facility. Findings: 1. Review of the facility's P&P titled Laundry Services revised 7/1/15, showed the facility…

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

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to accurately determine whether five nonsampled residents (A, 22, 41, 128, and 159) who were prescribed antibiotics had met the McGeer's criteria. As a result, the facility failed to inform the residents' physicians that the residents did not meet McGeer's criteria for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antibiotics. This failure had the potential to result in the adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria. Findings: According to the Centers for Disease Control and Infection, an estimated 70% of nursing home residents receive one or more courses of antibiotics during a year. Studies have shown that 40% to 75% of the antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Frail and older adults are at significant risk of harm from antibiotic overuse including increased adverse drug events, increased drug interactions and infection…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were completed and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed rails for four of 35 sampled residents (Residents 5, 92, 167, and 422). These failures had the potential to negatively impact the residents' well-being. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated March 10, 2006, showed the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head 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, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was free from abuse when the Activity Assistant yelled, held Resident 1's wristdown, and raised her hand in a fist above Resident 1 in a threatening manner. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Abuse Prevention and Prohibition Program revised 10/2022 showed the facility has zero tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, misappropriation of resident property, or deprivation of goods necessary to attain or maintain physical, mental, and psychosocial well-being. Review of the facility's SOC 341 form dated 11/7/23 at 1621 hours, showed CNA 2 overheard Activity Assistant 1 raise their voice and grab the arm of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to protect the rights to be free from misappropriation of property for one of two sampled residents (Resident 1). This failure resulted in Resident 1 experiencing psychological distress after learning she had lost $7,000 cash when the facility was unable to locate and produce the cash money that was arranged to be kept safe within the facility, which had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Abuse Prevention and Prohibition Program revised 10/2022 showed each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. Review of the facility's P&P titled Theft Prevention undated, showed the facility is committed to preventing the misappropriation of resident property and will exercise reasonable care for the protection of the resident's property from theft or loss. 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.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to conduct thecriminal background screening prior to hiring Business Office Manager 1. This failure had the potential of hiring an employee with prior reported incidents of abuse, neglect, misappropriation, or exploitation and put the residents in the facility at risk. Findings: Review of the facility's P&P titled Abuse Prevention and Prohibition Program dated 10/2022 showed the facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, friends, and visitors. Review of the facility's P&P titled Staff Screening dated 2/2023 showed the facility will utilize reasonable and prudent criminal background screening and reference checks for prospective staff, and prior to employment, the facility will verify and document or obtain a copy, if applicable of previous and/or current employer regarding work history…

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 facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure labeling and dating of food items in the refrigerator and open, dry storage area used for resident food. * The facility failed to ensure the clean sippy cups were stored properly and not mixed with dirty sippy cups. * The facility failed to ensure the ice machine was clean. * The facility failed to ensure the ice machine drainpipe had an air gap and not touching the drain. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the form CMS-672 Resident Census and Conditions of Residents completed by the DON dated 11/9/21, showed 131 of 140 residents residing in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Labeling and Dating of Foods dated 2020 showed all food items in the storeroom, refrigerator, and freezer need to be labeled 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 5. On 11/9/21 at 1543 hours, an inspection of Medication Cart B was conducted with LVN 7. A medication cup containing six tablets was observed inside the drawer of Medication Cart B. When asked what the medications were in the medication cup, LVN 7 stated she did not know what they were and for whom. LVN 7 acknowledged the medications were not labeled and should have been discarded. 6. On 11/9/21 at 1605 hours, an inspection of Treatment Cart A was conducted with LVN 6. A medication cup filled with powdered white medication was observed inside the top drawer. When asked what the medication was for, LVN 6 stated she was not sure. When asked who the medication was for, she stated she did not know. LVN 6 stated the unlabeled medication should have been discarded. Based on observation, interview, medical record review, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner for five of 12 Medication Carts (Medication Carts A, B, D, E, and F) and one treatment cart (Treatment…

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.

2. According to Taylor's Clinical Nursing Skills fifth edition, under the skills checklist titled Removing Medication from a Vial, when removing a medication from a vial, the medication is withdrawn into a syringe in a sterile manner preventing the medication from contamination, and the proper dose is prepared. The procedure included the following: - Remove the metal or plastic cap on the vial that protects the self-sealing stopper. - Scrub the self-sealing stopper top with the antimicrobial swab and allow to dry. On 11/10/21 at 0932 hours, a medication administration observation for Resident 438 was conducted with LVN 8. LVN 8 was observed removing the plastic top of a heparin (medication to prevent clotting) vial. LVN 8 was observed withdrawing the medication from the vial, then administered the medication to Resident 438. LVN 8 did not disinfect the self-sealing stopper top of the vial with an antimicrobial swab. On 11/10/21 at 1010 hours, an interview was conducted with LVN 8. LVN 8 verified the above findings. Based on observation, interview, medical record review, facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to promote dignity, respect, for two of 28 final sampled residents (Residents 58 and 110). The facility failed to ensure the staff were seated at the eye level when providing assistance during meals for Residents 58 and 110. This had the potential to negatively impact the residents feelings of self-worth and well-being Findings: 1. Medical record review of Resident 110 was initiated on 11/9/21. Resident 110 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 110 needed assistance from one staff when eating. On 11/8/21 at 0800 hours, a concurrent observation and interview was conducted with CNA 8. Resident 110 was observed lying in bed with the head of bed elevated. CNA 8 was observed standing over Resident 110 while feeding and assisting during meals. When asked on how the residents were to be assisted during meals, CNA 8 stated she should be at the eye level with Resident 110 when assisting during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to accommodate the needs for two of 28 final sampled residents (Residents 13 and 123). * The facility failed to answer Resident 123's call light in a timely manner, which resulted in Resident 550 urinating on herself. * The facility failed to ensure Resident 13 was assisted back in bed in a timely manner after being placed on the bedside commode. These failures placed the resident at risk for her needs to not be met. Findings Review of the facility's P&P titled Communication Call System revised 1/22/16, showed the nursing staff will answer the call lights promptly in a courteous manner. 1. Medical record review for Resident 123 was initiated on 11/8/21. Resident 123 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 123 was cognitively intact and totally dependent on the staff for toileting which included the use of bedpan. On 11/8/21 at 0957 hours, 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 medical record review, the facility failed to ensure the privacy was maintained during care for one nonsampled resident (Resident 76). * The facility failed to ensure Resident 76 had full visual privacy during care. This posed the risk of exposing the resident's body to other residents, staff, and visitors and had the potential to negatively affect the resident's dignity. Findings: Medical record review for Resident 76 was initiated on 11/10/21. Resident 76 was admitted to the facility on [DATE]. Review of the History and Physical examination dated 7/20/21, showed Resident 76 did not have the capacity to understand and make decisions. On 11/10/21 at 0850 hours, a medication administration observation was conducted with LVN 13 for Resident 76. LVN 13 lifted Resident 13's clothes exposing her abdomen and accessed the GT. After checking for GT placement, LVN 13 administered all of Resident 13's medications via GT. Resident 76's abdomen remained exposed during the entire…

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, medical record review and facility P&P review, the facility failed to develop the comprehensive care plans for two of 28 final sampled residents (Residents 79 and 340). * The facility failed to develop a care plan to address Resident 79's smoking behavior. Resident 79 was assessed as an independent smoker. * The facility failed to implement Resident 340's care plan for the use of oxygen. Resident 340 was not provided a oxygen humidifier while on the oxygen therapy. Resident 340 had episodes of nose bleeds due to the drying effect of oxygen therapy. These failures posed the risks of the residents not receiving the necessary care and services. Findings: 1. Review of the facility's P&P titled Smoking by Residents revised on 1/19 showed a smoking care plan will be created for the residents who smoke. Medical record review for Resident 79 was initiated on 11/9/21. Resident 79 was readmitted to the facility on [DATE]. Review of Resident 79's Smoking Risk assessment dated [DATE], showed…

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, medical record review, and facility P&P review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one of 28 final sampled residents (Resident 88). * The facility failed to ensure the television in Resident 88's room was turned to a program with the resident's primary language. In addition, the facility failed to ensure Resident 88 was provided her preferred religious activities. These failures had the potential to affect the resident's psychosocial well-being. Findings: Medical record review for Resident 88 was initiated on 11/9/21. Resident 88 was admitted to the facility on [DATE]. Review of Resident 88's MDS dated [DATE], showed Resident 88 had a severe cognitive impairment. Resident 88 was able to make herself understood and understand others. Resident 88 needed assistance from one to two staff with her activities of daily living. Review of Resident 88's quarterly Activity Participation Review assessment 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, medical record review, and facility P&P review, the facility failed to provide respiratory care to meet the needs of two of 28 final sampled residents (Residents 28 and 340). * The facility failed to ensure Resident 28 received oxygen as ordered by the physician. This posed the risk of the resident receiving unnecessary oxygen. * The facility failed to ensure an oxygen humidifier was provided for Resident 340 while receiving the oxygen therapy as per Resident 340's care plan. This posed the risk for discomfort associated with a dry airway. Findings: 1. Review of the facility's P&P titled Oxygen Administration revised on 7/15 showed oxygen should be turned on at the prescribed rate. Medical record review for Resident 28 was initiated on 11/9/2021. Resident 28 was readmitted to the facility on [DATE]. Review of Resident 28's Order Summary Report dated 11/10/21, showed a physician's order dated 5/21/21, to administer oxygen at two liters per minute via nasal cannula as needed to…

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 medical record review, the facility failed to ensure two of 28 final sampled residents (Residents 87 and 340) remained free from accident hazards due to the use of elevated side rails. * The facility failed to ensure Resident 340 was assessed for the risk of entrapment for side rails use. * Resident 87's side rail entrapment assessment showed she did not use side rails and had no recommendations for its use; however, Resident 87 was observed with the bilateral 1/4 side rails elevated while in bed. These failures had the potential to place the residents at risk for entrapment and serious injury. Findings: 1. Review of the FDA issued Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails showed the residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about…

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, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services in maintaining the emergency medication supplies and accurate quality control for one glucose meter. * Two opened emergency kits in Medication Room A were not replaced in a timely manner. Emergency Kit A had one vial of lorazepam (anti-anxiety medication) removed on 9/12/21. Emergency Kit B had one vial of Humulin R (insulin medication to decrease blood sugar) removed on 10/12/21. These failures posed the risk for the medications not be available when needed in an emergency. * The facility failed to ensure the staff documented the correct test strip lot number in the glucometer quality control record. This failure had the potential for inaccurate glucose readings. Findings: 1. According to the facility's P&P titled Medication Ordering and Receiving from Pharmacy dated September 2019 showed Emergency Pharmacy service is available on 24 hours basis. If exchanging the kits, the opened kits are replaced within 72 hours of opening. On 11/9/21 at…

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

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 12%. * LVN 13 failed to administer a water flush in between the GT administration of metoprolol (medication for blood pressure) and gabapentin (medication for seizure/nerve pain) medications for Resident 76. * LVN 10 crushed and mixed together Resident 64's multivitamin and GeriKot tablets. These failures created the risk of complications and ineffective therapeutic effects of the medications. Findings: 1. According to the facility's P&P titled Feeding Tube-Administration Medication revised on 7/01/16, showed to avoid mixing together medications intended for administration through an enteral feeding, given the risk of physical and chemical incompatibilities, tube obstruction, and altered drug response. Medications must be administered separately, flushed with five cc of water between each medication. On 11/10/21 at 0850 hours, a medication administration observation was conducted with LVN 13…

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, medical record review, and facility document review, the facility failed to ensure one nonsampled residents (Resident 588) was provided with the appropriate diet. * Resident 588's lunch plate had an uncut chicken meat when the prescribed diet was mechanical soft and bite size texture. This failure had the potential to result in choking for the resident. Findings: Medical record review for Resident 588 was initiated on 11/9/21. Resident 588 was admitted to the facility on [DATE]. Review of Resident 588's Physician's Orders showed an order dated 11/3/21, for controlled carbohydrate NAS (no added salt) diet, mechanical soft with soft and bite sized texture. Review of the plan of care showed a care plan problem dated 10/29/21, addressing Resident 588's risk for aspiration. An intervention included to provide diet as ordered. Another care plan problem dated 10/29/21, addressed Resident 588's decreased swallow safety and function. Review of Resident 588's Nutritional Risk assessment…

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 facility P&P review, the facility failed to implement their P&P to ensure proper storage of food in the residents' refrigerators. * The facility failed to ensure proper labeling and dating of food items in the refrigerators and cabinet used for the residents' food brought in by visitors and from the residents' trays. In addition, the facility failed to ensure the expired food items were discarded for one of 28 final sampled residents (Resident 136) and seven nonsampled residents (Residents 17, 33, 63, 75, 130, 341, and 439). These failures had the potential to result in foodborne illnesses in a highly susceptible resident population. Findings: Review of the facility's P&P titled Food Brought in by Visitors revised date 6/1/21, showed if the resident desires to have food brought in by visitors, the dietary staff will review the resident's diet with the visitor, and provide education regarding the resident's diet orders and safe food handling. Food from outside sources should be stored in a sealable container with the resident's name and date it…

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, medical record review, and facility P&P review, the facility failed to maintain the accurate medical records for one of 28 final sampled residents (Resident 28) and ensure the resident's personal health information was kept private for one non sampled resident (Resident 64). * The facility failed to ensure the administration of oxygen was recorded for Resident 28. This failure had the potential for the resident's care needs not being met as their medical information was inaccurate. * Resident 64's personal health information was exposed to passerby when LVN 10's computer monitor was facing the hallway while preparing medications for Resident 64. This had the potential to allow unauthorized staff or visitors access to residents' confidential medical or personal information. Findings: Review of the facility's P&P titled Oxygen Administration revised on 7/15 showed to document the following in the patient's record: - Date and time oxygen is being used. - Oxygen flow rate and device…

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 and interview, the facility failed to ensure the residents' refrigerators were maintained in the safe operating condition. * The facility failed to ensure there was no ice buildup in the freezers of the residents' refrigerators for one of 28 final sampled residents (Resident 136) and three nonsampled residents (Residents 17, 63, and 439). This failure had the potential for equipment not functioning in the way they were intended and in turn could cause contamination of food, leading to foodborne illnesses for the residents who received food from the kitchen. Findings: According to the USDA Food Code 2017 Section 4-501.11, equipment shall be maintained in good repair and proper adjustment. 1. On 11/9/21 at 0831 hours, an inspection of Resident 439's refrigerator inside his room was conducted with LVN 7. The freezer compartment of Resident 439's refrigerator was observed with ice buildup. LVN 7 verified the above findings. 2. On 11/9/21 at 0839 hours, an inspection of Resident 17's refrigerator inside her room was conducted with LVN 7. The freezer compartment of…

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