Alta Gardens Care Center

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 three final sampled residents (Residents 18 and 25) reviewed for falls remained free of accident hazards. * The facility failed to ensure the bedside table was not placed on top of the floormat for Resident 18. * The facility failed to ensure the post fall assessment and IDT (Interdisciplinary Team) assessment were conducted after Resident 25 sustained a fall. These failures had the potential to put Residents 18 and 25 at risk for serious injuries. Findings: Review of facility's P&P titled Falls Clinical Protocol revision dated 3/2018, showed the staff and practitioner will review each resident's risk factors for falling and documented in the medical record; for an individual who has fallen, the staff and practitioner will begin to try to identify possible cause within 24 hours of the fall. 1. Medical record review for Resident 18 was initiated on 2/17/26. Resident 18 was admitted to the facility on [DATE], 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 interview, medical record review, and facility P&P review, the facility failed to ensure the nutritional recommendations from the RD were followed for one of five final sampled residents (Resident 48) reviewed for nutrition. * The facility failed to follow the RD's recommendation for an appetite stimulant for Resident 48. This failure 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 Interdepartmental Notification of Diet (Including Changes and Report) revised 10/2017 showed the nursing services shall notify the physician and dietitian when a nutritional problem (e.g., weight loss, pressure ulcer, eating problem, etc.) has been identified and shall collaborate with the dietitian and physician to initiate an appropriate process of clinical review for causes of the nutritional problem. Physician notification will also include Registered Dietician's diet or nutritional recommendations for approval as…

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 IV (intravenous-through the vein) access for one of one final sampled resident (Resident 48) reviewed for IV care. * The facility failed to label Resident 48's IV site with the date, time, and initials of the licensed nurse when the IV was inserted. This failure posed the potential risk for infection or phlebitis (inflammation of a vein) for Resident 48. Findings: Review of the facility's P&P titled Peripheral Venous Catheter Insertion dated 3/2023 showed under the procedure section, after inserting the peripheral IV then write date, time, and initials on the dressing label. On 2/11/26 at 0940 hours, Resident 48 was observed lying in bed with a peripheral IV line on the right hand. The IV site was not labeled with the date, time, and initials of the licensed nurse. On 2/11/26 at 0945 hours, RN 4 was summoned to Resident 48's room. An observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate pain management were provided for two of two final sampled residents (Residents 18 and 28) reviewed for pain management. * The facility failed to ensure the nonpharmacological interventions for pain management were provided before the administration of the pain medication for Resident 28. In addition, the facility failed to ensure the pain medication was administered according to the physician's order for Resident 28. * The facility failed to ensure the pain medication was administered as ordered by the physician for Resident 18. These failures placed Residents 18 and 28 at risk for ineffective pain management. Findings: Review of the facility P&P titled Pain Management dated 8/25/21, showed to provide pain management that is consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences are provided to residents who…

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, facility document review, medical record review, and facility P&P review, the facility failed to ensure the proper monitoring and documentation of the ongoing assessments before, during, and after dialysis treatments were conducted for one of one final sampled resident (Resident 108) reviewed for dialysis services. * The facility failed to ensure Resident 108's Hemodialysis Communication Records were complete. In addition, the facility failed to ensure Resident 108's AV (arteriovenous) hemodialysis site assessments were consistent as per the physician's order. These failures had the potential to delay the identification and response to complications related to the hemodialysis site, and delay of care and treatment for Resident 108.Findings: Review of the facility's P&P titled Dialysis Care dated 8/25/21, showed the facility will arrange transportation to and from the dialysis provider, as well as for meals (if necessary), medication administration, and a method of communication between 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 pharmaceutical services to ensure the accurate administration of the medication to one of one final sampled resident (Resident 28) and one nonsampled resident (Resident 97) observed for medication administration. * The facility failed to ensure the correct medication was administered to Resident 97. LVN 7 administered sodium bicarbonate (alkalinizing agent) 650 mg oral tablet instead of sodium chloride (electrolyte replenisher) oral tablet 1 gram as ordered by Resident 97's physician. * LVN 7 administered lactobacillus acidophilus (probiotic) oral capsule instead of lactobacillus rhamnosus GG (probiotic) oral capsule as ordered by Resident 97's physician. * The facility failed to ensure the administration of the controlled medication for Resident 28 was documented on the MAR. These failures had the potential to negatively affect the residents' health condition for possible complications.Findings:…

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 provide the necessary pharmacy services to ensure proper storage of medications for one of four medication carts (Medication Cart B) inspected. * The facility failed to ensure the orally administered medications were stored separate from the externally used medications in Medication Cart B. This failure had the potential to negatively impact the residents' well-being, and the potential for the medications to lose stability and effectiveness. Findings: Review of the facility's P&P titled Medication Labeling and Storage revised 2/2023 showed medications for external use, as well as hazardous drugs and biologicals are clearly marked as such and are stored separately from other medications. On 2/13/26 at 1105 hours, a medication cart inspection for Medication Cart B and concurrent interview was conducted with LVN 1. The following was observed: - A bottle of sodium chloride tablet (supplement) for oral use was stored with four boxes of artificial tears lubricant eye drops in a storage compartment in 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, facility document review, and facility P&P review, the facility failed to ensure one of the kitchen employees (Dietary Aide 1) was competent in the position related duties. * Dietary Aide 1 failed to intervene when the low dishwashing machine failed to reach 120 degrees Fahrenheit. This failure had the potential for food preparation equipment, dishware, and utensils not to be cleaned and sanitized correctly. Findings: Review of the facility's P&P titled Warewashing revised 2/2023 showed all dishware, serviceware, and utensils will be cleaned and sanitized after each use. The Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware. All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. Review of the facility's in-service titled Pots and Warewashing dated 7/29/25, showed Dietary Aide 1 attended the in-service. On 2/12/26 at 0845 hours, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu and recipes were followed for one sampled resident (Resident 89) and one nonsampled resident (Resident 87) reviewed for meal observation. * The facility failed to ensure Resident 87 was served the pureed soup and dessert as per the menu. * The facility failed to ensure Resident 39 was served omelet, bread, jelly, and margarine for breakfast, as listed on the meal ticket. These failures posed the risk of negatively impacting the residents' satisfaction and dietary compliance.Findings: Review of the facility's Diet Type Report dated 2/12/26, showed 114 of 118 residents consumed the food prepared in the kitchen. Review of the facility's P&P titled Menus revised 10/2022 showed menus will be planned in advance to meet the nutritional needs of the residents in accordance with established nutritional guidelines. Menus will be served as written, unless a substitution is provided In response 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, facility document review, and facility P&P review, the facility failed to accommodate the drink preferences for two of 114 residents (Residents 55 and 114) who received food prepared in the kitchen. * The facility failed to ensure Resident 114 was served with his juice of choice for his lunch meal. * The facility failed to ensure Resident 55 was served with the preferred beverage as per the meal ticket. These failures had the potential to affect the residents' overall meal intake and nutritional status.Findings: Review of the facility's P&P titled Dining and Food Preferences revised 10/2022 showed individual dining, food, and beverage preferences are identified for all residents. Food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered in the resident's profile in the menu management software program. The individual tray assembly ticket will identify all food items appropriate for the resident based on diet order, allergies, intolerances and…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the food brought from the outside were handled safely. * The facility staff and residents' visitors were not educated on the safe food handling practices when food from the outside was brought to the facility for resident consumption. This failure had the potential for unsafe food handling which could lead to food borne illness in the residents who resided in the facility. Findings: Review of the facility's P&P titled Food Brought in by Visitors revised 3/28/24, showed in part Family members and visitors will be educated to inform nursing staff of their desire to bring food into the facility. Family/visitors are asked to prepare and transport food using safe food handling practices. Review of the facility's in-service lesson plan and attendance record titled Safe Food Handling in a Skilled Nursing Facility dated 6/19/25, showed an in-service was conducted by the DSD. The in-service included implementation which reviewed the safe food handling in the facility; however, the safe food handling…

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 maintain an accurate medical record for two of 24 final sampled residents (Residents 6 and 10) and one of three residents (Resident 22) reviewed for closed records. * The facility failed to ensure the POLSTs were complete for Residents 6, 10 and 122. This failure had the potential for the residents' care needs to not be met as their medical information was inaccurate.Findings: Review of facility's P&P titled Charting and Documentation revised dated 7/2017 showed documentation in the medical record will be objective (not opiniated or speculative), complete, and accurate. 1. Medical record review for Resident 6 was initiated on 2/12/26. Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 6's POLST dated 12/17/25, showed under Section D - Information and Signatures, the following check boxes were left blank: Advance Directive, Advance directive not…

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

Based on observation and interview, the facility failed to maintain the essential equipment in a safe operating condition for one of three facility water heaters (Water Heater 1). * Water Heater 1 was observed leaking water from the check valve. This failure had the potential to cause water heater component damage, which posed the risk for the residents' water heater to malfunction. Findings: On 2/17/26 at 1010 hours, an observation was conducted of the facility's water heaters. Water Heater 1 was observed leaking water from the check valve. On 2/17/26 at 1500 hours, an interview was conducted with the Director of Maintenance. The Director of Maintenance stated he was aware the check valve on Water Heater 1 was leaking water. The Director of Maintenance stated Water Heater 1 provided water to the resident rooms throughout the facility. The Director of Maintenance stated the check valve functioned to prevent the backflow of water. The Director of Maintenance stated the facility was in the process of repairing the leak.

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 IV accesses for six of six final sampled residents (Residents 60, 83, 110, 716, 816, and 818) reviewed for IV care. * The facility failed to ensure the initial PICC line external catheter measurements were documented in the medical record and confirmed the baseline measurements of the PICC line external catheters and arm circumferences prior to the administration of IV antibiotics for Resident 83. In addition, the facility failed to ensure Resident 83's PICC dressing was labeled with the date and a care plan was developed for the use of Resident 83's right upper arm PICC. * The facility failed to ensure accurate documentation of the monitoring and documentation of Resident 60's right arm midline. In addition, the facility failed to develop a care plan for the use of Resident 60's right upper arm midline. * The facility failed to ensure the midline…

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 the menus were followed as evidenced by: * Residents were served the yellow cake instead of the carrot cake with cream cheese frosting as shown on the posted menu. * Residents 97 and 466 were not served the chocolate ice cream as per the menu. * Resident 66 who was on a renal diet was not provided a renal diet per the menu. In addition, Resident 66 was not served a double portion of the protein per the diet order. These failures had the potential for the residents to not receive an adequate nutrition and appropriate servings to meet the residents' individual needs. Findings: Review of the facility's Diet Type Report dated 2/12/25, showed 107 of 111 residents residing in the facility received foods prepared in the kitchen. On 2/12/25 at 1050 hours, the CDM stated she was unable to provide the Diet Type Report for 2/10/25. Review of the facility's P&P titled Menus revised 10/2022 showed the menus will be served as written, unless a substitution is provided in response 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 provide the necessary care and services to prevent accident hazards for one of three final sampled residents (Resident 4) reviewed for accident hazards. * The facility failed to implement the bilateral floor mats as per the plan of care for Resident 4. This failure had the potential risk for injury to Resident 4. Findings: Review of the facility's P&P titled Care Plan Comprehensive dated 8/25/21, showed the care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. Medical record review for Resident 4 was initiated on 2/11/25. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's plan of care showed a care plan problem dated 7/29/24, addressing Resident 4's risk 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 appropriate care and services related to the use of the GT for three of three final sampled residents (Residents 55, 58, and 74) reviewed for the GT management. * The facility failed to ensure the licensed staff managed the GT feeding for Resident 55. CNA 14 had resumed the GT feeding after providing incontinent care to Resident 55. In addition, the facility failed to ensure Resident 55's enteral feeding formula was labeled with the time and the Kangaroo (enteral feeding pump machine) water bag was labeled with the time and name of contents inside the bag. * The facility failed to ensure LVN 2 auscultated the resident to check the GT placement prior to the administration of the GT medication for Resident 58. In addition, the facility failed to ensure Resident 58's abdominal binder (compression band around the abdomen used to provide support and safety) was applied as per the care plan. * 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 safe respiratory care to the meet the needs for two of two final sampled residents (Residents 55 and 816) reviewed for respiratory care. * The facility failed to administer the oxygen as per the physician's order to Resident 816. * The facility failed to ensure Resident 55's sterile water for the humidifier was labeled with an opened date. These failures had the potential to affect the respiratory health and well-being of the residents in the facility. Findings: 1. Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed under the preparation section, to verify there is a physician's order for this procedure and to review the physician's orders or facility protocol for oxygen administration. During the initial tour of the facility on 2/10/25 at 1057 hours, an observation was conducted in Resident 816's room. Resident 816 was observed lying in bed receiving oxygen by nasal…

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 offer or provide adequate and appropriate pain management for one of two final sampled residents (Resident 818) reviewed for pain management. The facility failed to ensure Resident 818 was administered pain medication as per the physician's order. Additionally, the facility failed to consistently provide the NPI for pain prior to the administration of a narcotic pain medication to Resident 818. These failures had the potential for not effectively managing the resident's pain. Findings: Review of the facility's P&P titled Pain Management revised 10/2022 showed the staff will continually observe and monitor the residents for comfort and presence of pain and will implement strategies in accordance with professional standards of practice, the patient-centered plan of care, and the patient's choices related to pain management. The nurse will notify the physician as appropriate and obtain treatment orders as…

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 necessary care and services for one of two final sampled residents (Resident 21) reviewed for dialysis care. * The facility failed to ensure Resident 21's scheduled medications on the dialysis days were held as per the physician's order. In addition, the facility failed to ensure Resident 21's AV shunt was assessed after the dialysis treatment and fluid restriction was monitored . These failures had the potential to negatively affect Resident 21's physical well-being, which potentially would result in the resident having an excess of fluid which could lead to negative health consequences. Findings: Review of the facility's P&P titled Hemodialysis Care and assessment dated 2/2025 showed the process for documentation for residents receiving dialysis services should include the following: a. The licensed nurse completes the pre-dialysis form prior to the resident leaving for dialysis. b. Upon return, 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 ensure the pharmaceutical services were provided to meet the needs of two final sampled residents (Residents 50 and 58). * The facility failed to ensure the physician's orders for Resident 58 were accurate. The medication route was ordered to be oral instead of GT. This failure had the potential for the medications to be administered in error. * One of five licensed nurses (LVN 2) who was observed during the medication administration was found to have an error. LVN 2 failed to administer the complete dose of one of Resident 58's medications when significant residual of the multivitamin (supplement) medication was observed in the medication cup after administering the medication via GT to Resident 58. * The facility failed to ensure LVN 1 documented the administration of the sodium chloride (supplement) medication to Resident 50 in the electronic MAR and/or in the resident's progress notes. These failures had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure two of five final sampled residents (Residents 60 and 110) reviewed for unnecessary medication were properly monitored for the signs and symptoms of bleeding related to the use anticoagulant (prevents blood clots) medication. * The facility failed to ensure Resident 110 was monitored for the signs and symptoms of bleeding for the use of enoxaparin (anticoagulant medication) medication. * The facility failed to monitor for signs and symptoms of bleeding related to Resident 60's use of the apixaban (anticoagulant medication) medication. These failures had the potential for the residents to develop significant side effect of bleeding and negatively affect the resident's health condition and well-being. Findings: According to DailyMed, the enoxaparin medication's most common adverse effect was the increased risk of bleeding. 1. Medical record review for Resident 110 was initiated on 2/10/25. Resident 110 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 interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the monitoring for the use of the antipsychotic medications (medications that affect brain activities associated with mental process and behavior) for three of five sampled residents (Residents 4, 41, and 60) reviewed for unnecessary medications were completed when: * The facility failed to ensure Resident 41 was monitored accurately for orthostatic hypotension as ordered by the physician for the use of Seroquel (antipsychotic medication). In addition, the facility failed to ensure Resident 41's informed consent for the use of the Seroquel medication included the indication for its use and the date for the Seroquel medication to be stopped. * The facility failed to ensure Resident 60's informed consent had documentation of the frequency and behavior manifestations for the use of the Risperdal (antipsychotic) medication and to monitor Resident 60 for orthostatic hypotension for the use of…

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

Based on observation, interview, 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 11.54%. Three of five licensed nurses (LVNs 1, 2, and 10) were found to have made errors during the medication administration observations. * Resident 50 had a physician's order for zinc (supplement) for wound healing. LVN 1 failed to administer the zinc medication as ordered due to the unavailability of the medication. * LVN 2 failed to check Resident 58's last bowel movement and if Resident 58 had loose stool prior to administering the polyethylene glycol 3350 (laxative medication) medication. * LVN 10 failed to check whether Resident 109 had a bowel movement in the last 72 hours prior to administering the polyethylene glycol medication. These failures had the potential to negatively affect the residents' health. Findings: Review of the facility's P&P titled Medication Administration-General Guidelines dated 10/2017 showed the medications are administered as prescribed in accordance with good…

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 the kitchen staff had the appropriate skill set to safely perform the daily operation of the Food and Nutrition Services Department. * Dietary Aide 1 was unable to correctly demonstrate how to test the chemical concentration of the sanitizing solution used to sanitize the food contact surfaces. * Dietary Aides 1 and 2 were unable to correctly describe how to manually wash the dishes. These failures had the potential to lead to foodborne illnesses in a highly susceptible population of the residents who received food prepared in the kitchen. Findings: Review of the facility's Diet Type Report dated 2/12/25, showed 107 of the 111 residents residing in the facility as of 2/12/25, received foods prepared in the kitchen. On 2/12/25 at 1050 hours, the CDM stated she was unable to provide the Diet Type Report for 2/10/25. Review of the facility's P&P titled Environment revised 9/2017 showed the Dining Services Director will ensure that all the employees are knowledgeable in the…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by: * The facility failed to ensure the labeling and dating of the food items in the freezer used for the residents food. * The facility failed to ensure the maintenance tools were stored properly. 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 facility's Diet Type Report dated 2/12/25, showed 107 of the 111 residents residing in the facility as of 2/12/25 received foods prepared in the kitchen. On 2/12/25 at 1050 hours, the CDM stated she was unable to provide the Diet Type Report for 2/10/25. 1. Review of the facility's P&P titled Food Receiving and Storage undated showed all the foods stored in the refrigerator or freezer are covered, labeled, and dated. During the initial tour of the kitchen conducted with the CDM on 2/10/25 at 0754 hours, the following was observed: - an opened bag 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 education was provided to the staff on safe food handling of outside food. This failure had the potential to cause foodborne illnesses to the medically vulnerable residents population who consumed food brought from the outside sources. Findings: Review of CMS S&C-09-39 dated 5/29/09, showed the residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. The CMS guideline further shows the facility has the responsibility under the food safety regulation to help the visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit. Review of the facility's P&P titled Food Brought in by Family or Visitors revised 3/2024 showed the residents' family members will be educated to inform nursing staff of their desire to bring food into the facility. Family/visitors are asked to prepare and transport food using safe food handling…

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 document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide the safe and sanitary environment were implemented as evidenced by: * The facility failed to record all the residents with infection on the facility's infection surveillance tool. The facility's infection surveillance tool did not include all the residents identified with infections. The facility only documented on the surveillance log the residents who were prescribed with antibiotics were identified as having infection. * The facility failed to ensure the staff used proper PPE upon entering the resident's room for one nonsampled resident (Resident 88) who had Covid. * The facility failed to ensure LVN 7 donned the proper PPE during high-contact care for Resident 616 who was on enhanced barrier precautions. * The facility failed to ensure Resident 55's nasal cannula tubing was not touching the ground and under the trash can. These…

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 two final sampled residents (Resident 2) was provided a floor mat as per the resident's care plan to prevent or minimize the injury in case of a fall. This failure had the potential to place the resident at risk for serious injury. Findings: Review of the facility's P&P titled Falls Management revised 3/15/24, showed the residents will be assessed for risk of falling as part of the nursing assessment process, interventions to reduce risk and minimize injury will be implemented as appropriate and implement and document the resident-centered interventions according to the individual risk factors in the resident's plan of care. On 6/4/24 at 1435 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was observed awake and sitting in her bed with the right side of the bed against the wall. Resident 2 was observed without a floor mat on the floor. Resident 2 stated…

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

Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the menu was followed as evidenced by: * Residents were served the canned sliced peaches instead of peach shortcake as shown on the posted menu. These failures had the potential for the 91 residents receiving food prepared in the kitchen to not meet their nutritional needs which might lead to nutritional related health complications. Findings: Review of the facility's CMS 672 form dated 9/13/22, showed 91 of 108 residents were served food from the kitchen. Review of the facility's P&P titled Menu Substitutions revised 10/27/19, showed the director of dining services or designees revised the day's menu program components (Week-At-A-Glance, Display Menu, Selective Menu, Diet Guide and Production Sheet) to reflect the change. The policy also showed substitutions are communicated to the residents and other department employees, as appropriate. Review of the facility's Diet Guide Sheet for Tuesday (Day 10) Lunch showed all residents were to be served peach shortcake for…

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

Based on observation and interview, the facility failed to follow the proper sanitation and food storage practices. * The facility failed to ensure the prepared food items were properly dated and labeled. *The facility failed to ensure the resident and staff's personal food items were not stored in the walk-in refrigerator. * The facility failed to ensure the personal belongings were stored away from the kitchen preparation area. * The facility failed to ensure the food items in the resident's refrigerator were properly labeled and dated. These failures had the potential to cause the foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the facility's CMS 672 form dated 9/13/22, showed 91 of 108 residents were served food from the kitchen. 1. During the initial tour of the kitchen on 9/13/22 at 0730 hours, with the Dietary Manager, the following items were found in the walk-in refrigerator: - an undated white paper bag labeled with a resident's room number and last name containing prepared soup; - a box of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the dignity was maintained for one of 22 final sampled residents (Resident 89). * The facility's staff was standing over Resident 89 when assisting the resident with the house supplement. This failure created the potential to affect the resident's well-being. Findings: Review of the facility's P&P titled Feeding a Resident revised date 6/1/21, showed to sit in chair at eye level with the resident. On 9/13/22 at 1250 hours, during dining observation, Resident 89 was observed in bed with the head of the bed elevated, and the bed was in a low position. CNA 7 was observed standing over Resident 89 while assisting Resident 89 with her nutritious juice drink (a house supplement to increase calories and protein in the diet). Resident 89's head was at the level of CNA 7's chest. On 9/13/22 at 1254 hours, a concurrent observation and interview was conducted with CNA 7. CNA 7 was observed tapping Resident 89's shoulder and instructing…

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 assess two of 22 final sampled residents (Residents 55 and 745) for their ability to self-administer the medications. * Resident 745 had a bottle of over-the-counter analgesic cream at the bedside and LVN 6 took it out from the drawer and gave to the resident to self-administer. Resident 745 did not have the assessment and physician's order for the self-administration of medications. * Resident 55 had a packet of A&D ointment (skin protective barrier) at bedside which was provided to self-administer by a facility staff member. Resident 55 did not have the assessment and physician's order to self-administer the A&D ointment. These failures had the potential for poor health outcomes to these residents. Findings: 1. Review of the facility's P&P titled Medications: Self-administration revised 3/1/22, showed it is the facility's policy to provide a safe, effective process for patient self-administration 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 ensure the appropriate care and services related to GT were provied to one of 22 final sampled residents (Resident 46) and one of 11 nonsampled residents (Resident 91). * Resident 91's enteral water bag was unlabeled and undated. * The facility failed to ensure Resident 46's GT syringe was rinsed and dried prior to storing as per the facility's P&P. These failures posed the risk for complications related to the GT for the residents. Findings: 1. Review of the facility's P&P titled Enteral Feeding: Administration by Pump revised date 6/15/22, showed to label administration bag and tubing with the resident's name, room number, date, start time, and flow rate. Medical record review for Resident 91 was initiated on 9/13/22. Resident 91 was readmitted to the facility on [DATE]. Review of the Order Summary Report showed an enteral feed order dated 7/19/22, to flush GT with water 40 milliliters per hour for 20 hours.…

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 respiratory care and services for two of 22 final sampled residents (Residents 693 and 743). * The facility failed to ensure a physician's order for supplemental oxygen therapy was obtained prior to the oxygen administration for Resident 693. This failure had the potential for Resident 693 receiving unnecessary oxygen. * The facility failed to ensure Resident 743's nasal cannula tubing was dated as per the facility's P&P. This had the potential for increased risks of infection. Findings: 1. Review of the facility's P&P titled Oxygen: Nasal Cannula (medical device to provide supplemental oxygen therapy) revised 6/15/22, showed to verify order. Review of the facility's P&P titled Oxygen: Concentrator revised 6/15/22, showed to verify order. On 9/13/22 at 0759 and 1102 hours, Resident 693 was observed in bed receiving oxygen via nasal cannula at 1.5 liters per minute. Medical record review…

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 one of 11 nonsampled residents (Resident 78) was administered the medication at the correct time as ordered. * LVN 1 was observed administering the medication to Resident 78 after a meal instead of before meals as ordered. Failure to administer the medication at the right time posed the risk of poor health outcome for this resident. Findings: Review of the facility's P&P titled General Dose Preparation and Medication Administration revised 4/1/22, showed to verify each time a medication is administered at the correct time among others. On 9/15/22 at 0748 hours, a medication pass observation was conducted with LVN 1. Empty meal trays were observed being placed back in the meal carts. LVN 1 was observed administering Insulin Aspart FlexPen (a short acting insulin that to help control blood glucose spikes that happen when eating) 5 units subcutaneously (beneath or under all the layers of skin) to Resident 78. Review of Resident 78's Order Summary Report showed a physician's…

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. Review of the facility's P&P titled LTC Facility's Pharmacy Services and Procedures Manual - Storage and Expiration Dating of Medications, Biologicals revised 7/21/22, showed the facility should ensure the medications and biologicals that have an expired date on the label are stored separate from other medications until destroyed or returned to the pharmacy or supplier. a. On 9/15/22 at 1200 hours, an observation and concurrent interview was conducted with the Central Supply Clerk in the Central Supply Room. Medications were observed in the locked cabinets including three eight ounce bottles of pink bismuth regular strength. The expiration date on the three bottles was 6/22. The bottles were observed in the same area as the non-expired medications. The Central Supply Clerk stated he must have missed those expired medications when he last checked the medications. Based on observation, interview, and facility document review, the facility failed to follow their controlled medication destruction P&P. This failure posed the risk of drug diversion. Findings: Review of the facility's…

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, LVN 1 failed to follow the facility's P&P on hand hygiene practices and infection prevention during contact with two residents (Residents 46 and 78). * LVN 1 did not perform hand hygiene during Resident 78's medication administration. * LVN 1 did not perform hand hygiene before GT medication administration for Resident 46. These failures had the potential to spread infectious organisms to the residents. Findings: Review of the facility's P&P titled General Dose Preparation and Medication Administration revised date 4/1/22, showed prior to preparing or administering medications, authorized and competent facility staff should follow the facility's infection control program (for example handwashing). Review of the facility's P&P titled Hand Hygiene revised date 11/28/17, showed to perform hand hygiene before resident care, after resident care, and after contact with the resident's environment among others. 1. On 9/15/22 at 0812 hours, a medication administration observation was conducted with LVN 1. LVN 1…

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 patient care equipment was maintained in a safe operating condition when two of five glucometers were not checked for quality control. This failure put the residents at risk for inaccurate blood sugar readings. Findings: Review of the Assure Platinum Blood Glucose Monitoring System User Instruction Manual showed to use Assure dose control solutions to check if the meter and test strips are working correctly as a system, and ensure you are testing correctly. Perform a control solution test before testing with the Assure Platinum system for the first time, when you open a new bottle of test strips, to check your technique, and each time the batteries are changed. a. On 9/15/22 at 1218 hours, an observation, interview, and concurrent facility document review was conducted with RN 3. The Assure Platinum blood glucose monitor with the serial number 1040-4057618 was observed in Medication Cart A. RN 3 was asked to show documentation of the quality control check using the control solution 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.