Garden Park Care Center

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 provide the necessary care and services to prevent accidents for one of two residents reviewed for smoking (final sampled resident, Resident 50). In addition, the facility failed to assess following multiple unwitnessed falls for one of one final sampled resident (Resident 21) reviewed for falls. * The facility failed to complete the neurological assessments following unwitnessed falls on 3/27, 4/25 and 5/1/25, for Resident 21. * The facility failed to ensure the safe smoking practices were followed for Residents 50 when the resident was permitted to keep the cigarettes with his possession after being assessed as requiring supervision while smoking. These failures posed the risk of injuries from fire and serious injuries to the residents who smoked and to the other residents who resided in the facility. Furthermore, these failures had the potential to delay the detection and response…

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 one final sampled resident (Resident 75) reviewed for catheter care received the appropriate care and services for an indwelling urinary catheter. This failure had the potential for the resident to develop complications associated with the use of the indwelling urinary catheter. Findings: Review of the facility's P&P titled Urinary Catheter Use revised 12/19/22, showed the following: - If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to ongoing monitoring for changes in condition related to potential catheter-associated urinary tract infections, recognizing, reporting and addressing such changes. Review of the facility's P&P titled Notification of Changes revised on 12/19/22, showed the facility must inform 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 respiratory care and services for three of 23 final sampled residents (Residents 84, 96, and 915) and one nonsampled resident (Resident 71) reviewed for oxygen therapy. * The facility failed to follow the physician's order for Residents 84 and 96's oxygen therapy. * The facility failed to ensure the oxygen tubing for Resident 71 was labeled with the date. * The facility failed to ensure the administration of oxygen to Resident 915 was documented in the TAR. In addition, the facility failed to monitor Resident 915 for SOB or wheezing as an indication of the use of oxygen as per the physician's order. These failures had the potential for the residents to not receive the appropriate care and may negatively impact on the residents' medical conditions. Findings: Review of the facility's P&P titled Oxygen Administration date revised 5/20/24, showed oxygen is administered to residents who need…

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 competency of four of six licensed nurses (LVN 1, RN 1, DSD, and DON) observed in performing a control solution check with the glucometer. LVN 1, RN 1, the DSD, and DON were unable to demonstrate the competency in the quality control of the glucometer. This failure had the potential of not providing care to the residents in a safe and competent manner. Findings: Review of the glucometer manufacturer's information sheet titled Assure Platinum Blood Glucose Monitoring System Quality Assurance/Quality Control Reference Manual (undated) under the Quality Checks section showed the following: - To perform a control solution test, before testing with the Assure Platinum System for the first time, when a new bottle of test strips was opened, whenever meter or test strips may not be functioning properly, if the test results appear to be abnormally high or low, or are not consistent, when the test strip bottle has been left open or exposed to temperatures below 39 degrees F or above 86 degrees F,…

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 pharmaceutical services were provided when: * The facility failed to ensure the complete documentation for the destruction of medications. * The facility failed to ensure LVN 7 administered the medications to Resident 86 via the correct route. LVN 7 administered the medications to Resident 86 via GT, and not orally as per the physician's order. These failures had the potential for drug diversion and to cause ineffective treatment and complications from the medications administered. Findings: Review of the facility's P&P titled Destruction of Unused Drugs revised [DATE], showed all the unused, contaminated, or expired prescription drugs shall be disposed of in accordance with the state laws and regulations. The section titled Policy Explanation and Compliance Guidelines showed the following: - The actual destruction of drugs conducted by our facility must be witnessed by the consultant pharmacist…

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 two final sampled residents (Residents 86 and 914) and two nonsampled residents (Residents 41 and 916) were free from the unnecessary medications. * The facility failed to ensure Resident 41 was not administered the metoprolol (antihypertensive) and amiodarone (antiarrythmic) medications without parameters when to hold or administer the medications. * The facility failed to ensure Resident 914 was not administered the carvedilol (antihypertensive medication) without monitoring the resident's blood pressure and heart rate as per the physician's order. * The facility failed to ensure Resident 916 was not administered the hydralazine (antihypertensive medication) when the SBP less than 160 mmHg as per the physician's order. * The facility failed to ensure the monitoring for signs and symptoms of bleeding was completed related to use of enoxaparin sodium medication (anticoagulant medication, use to prevent…

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 medication error rate was below 5%. The facility's medication error rate was 54.29%. Two of the two licensed nurses (LVNs 7 and 8) who were observed during medication administration were found to have errors. * LVN 7 failed to administer the Eliquis (anticoagulant medication) medication to Resident 41. * LVN 7 failed to ensure the medications were not administered together when administering medications via the GT to Resident 86, and to flush the GT in between the medications and after the administration of the medications. * LVN 7 failed to administer the artificial tears to Resident 86. * LVN 8 failed to ensure Resident 6 received the correct amount of prescribed eye medication. * LVN 8 failed to ensure the GT was properly flushed in between the medication administration for Resident 99. These failures created the risk for the residents to have potential side effects 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 observation, interview, medical record review, facility documentation review, and facility P&P review, the facility failed to ensure the removal of the discontinued medications from one of six medication carts (Medication Cart 4) inspected. This failure had the potential to result in drug diversion of controlled medications and the administration of medication without a physician's order. Findings: Review of the facility's P&P titled Disposal of Medications and Medication-Related Supplies IE3: Discontinued Medications revised 1/2025 showed when the medications are expired, discontinued by a prescriber .the medications are marked as discontinued or stored in a separate location and later destroyed. The procedure for discontinued medications was described as follows: A. If a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified and shall be stored in a separate location designed solely for this purpose. B. Medications are…

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 implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections for one final sampled resident (Resident 6) and one nonsampled resident (Resident 99) observed for medication administration, and one final sampled resident (Resident 75) observed for personal hygiene. * LVN 8 failed to perform hand hygiene prior to administering the eye medication to Resident 6 after touching the privacy curtain. * LVN 8 failed to perform hand hygiene and change gloves before administering the medication via GT after touching the enteral feeding pump to Resident 99. In addition, hand hygiene was not performed prior to donning new gloves after cleaning the medication tray and overbed table. * The facility failed to ensure CNA 1 performed hand hygiene when providing care to Resident 75. In addition, CNA 2 failed to perform…

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 themedical records were complete and accurately maintained for two of ten sampled residents (Residents 9 and 10). * Residents 9 and 10's medical records failed to show the monitoring of the residents' locations was completed on 3/9, 3/10, and 3/12/25. These failures had the potential for the residents' care needs to not be met as their medical information was inaccurate and incomplete. Findings: Review of the facility's P&P titled Falling Star Program dated 8/1/18,showed the resident safety committee/interdisciplinary team will determine placement of the residents into the Falling Star Program to reduce the incidence of falls/injury for each resident in the program. Nursing staff will do every hour monitoring as followed and log completion. 1. Medical record review for Resident 9 was initiated on 3/13/25. Resident 9 was readmitted to the facility on [DATE]. Review of Resident 9's MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to administer the medications as ordered by the physician for one of four sampled residents (Resident 3). * Resident 3 had a physician's order for insulin glargine (a medication used to treat diabetes) to be given at bedtime, with parameters to hold if the blood sugar levels were less than 120 mg/dl. There was no documented evidence the blood sugar level was checked to determine whether to administer or hold the insulin as ordered. This failure put Resident 3 at risk of complications. Findings: Medical record review for Resident 3 was initiated on 1/2/24. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's Order Summary Report showed an order dated 12/26/23, for insulin glargine 100 unit/ml 6 units subcutaneously (under the skin) at bedtime for DM and to hold if the blood sugar levels were less than 120 mg/dl. Review of Resident 3's Medication Administration Record showed Resident 3 received insulin…

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 kitchen staff were competent in the position related duties when: 1. Two of four cooks (Cooks 1 and 4) failed to perform the following: a. Failed to prevent cross contamination, b. Failed to perform proper hand hygiene during food preparation, c. Failed to sanitize food preparation equipment when washed manually, d. Failed to sanitize food preparation surfaces, and e. Failed to follow the recipes. 2. One of four cooks (Cook 1) failed to know the final cooking temperature of chicken. 3. One of seven DA (DA 1) failed to know the manual dish washing procedure. 4. One of seven DA (DA 2) failed to follow the resident menu. These failures had the potential to cause food borne illness and not meet the resident's nutritional needs for the 115 residents who received food prepared in the kitchen. Findings: 1.a. Review of the facility's P&P titled Food Storage revised 4/6/23, showed in part, Dry Storage 7. Any opened products should be placed in seamless plastic or glass…

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 P&P review, the facility failed to ensure the professional standards for food safety and sanitation guidelines were followed when: 1. Potential for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) was not prevented. A scoop was stored in the instant mash potato container and the kitchen staff did not use proper color coded cutting board when cutting raw chicken and vegetable. 2. Time Temperature Control for Safety (TCS) Foods (food that require time and temperature controls to limit the growth of illness causing bacteria) were not handled safely as no cooling down log for the leftover chicken and turkey cooked on the previous day. 3. Proper hand hygiene was not performed by the kitchen staff. 4. Food preparation equipment was not sanitized when washed manually. 5. Kitchen surfaces were not sanitized. 6. Refrigerated and frozen foods were not stored safely. 7. Hair restraints were not worn appropriately…

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 seven of 24 final sampled residents (Residents 52, 54, 60, 67, 85, 99, and 422) were provided with the appropriate respiratory care when: * The facility failed to administer the oxygen therapy as ordered and failed to ensure the titration oxygen order included the parameters as to how to titrate the oxygen flow rate. * The facility failed to ensure Residents 85 and 422 were provided with continuous oxygen therapy per the physician's order. In addition, the facility failed to ensure Resident 422's nebulizer mask was changed weekly and stored properly per the facility's P&P. * The facility failed to ensure Resident 60's oxygen therapy tubing was changed weekly per the facility's P&P. * The facility failed to ensure Resident 52's nebulizer mask was changed weekly per the facility's P&P. * The facility failed to ensure Residents 67 and 99's suction set-up bag showed the date when it was changed. 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.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure an adequate oversight of the kitchen was provided when multiple issues were identified in regard to the kitchen safety and sanitation, following the facility's recipes, and monitoring of the kitchen staff' competency. This failure had the potential to result in food not being served in a safe and sanitary manner which could lead to foodborne illness and resident nutritional needs not being met for the 115 facility residents who received food prepared in the kitchen. Findings: According to the USDA Food Code 2022 Annex 4 Management of Food Practices-Achieving Active Managerial Control of Foodborne Illness Risk Factors showed under section G. Assess Active Managerial Control of Foodborne Illness Risk Factors and Implementation of Food Code Interventions, the Demonstration of Knowledge: it is the responsibility of the person in charge to ensure compliance with the Code. The knowledge and application of Food Code provisions are vital to preventing foodborne illness 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, facility document and P&P review, the facility failed to ensure the resident menu was followed as evidenced by: 1. Puree vegetable recipes were not followed for the American and Vietnamese menus. 2. Puree meat recipes were not followed for the American and Vietnamese menus. 3. Puree cake recipe was not followed for all menus. 4. Puree rice recipe was not followed for the Vietnamese menu. These failures posed the risk for an inconsistent product and to not meet the nutritional needs of the 23 residents who received puree diets. Findings: Review of the facility's P&P titled Cycle Menus revised 9/14/18, menus must be followed as written. Review of the facility's Diet Count by Diet dated 5/17/23, showed there were 23 regular pureed servings. However, the Diet Count sheet did not distinguish between American and Vietnamese menus. Review of the facility's Diet Count by Diet dated 5/18/23, showed there were 24 regular pureed servings. However, the Diet Count sheet did not distinguish between American and Vietnamese menus. 1. Review of the facility's Recipe:…

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 reasonable accommodations to meet the needs of one of 24 final sampled residents (Resident 422). * The facility failed to ensure Resident 422's call light was within the resident's reach. This failure created the potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care. Findings: Review of the facility's P&P titled Call Lights: Accessibility and Timely Response revised 9/2/22 showed the staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light, and staff will ensure the call light is within reach of resident and secured, as needed. On 5/16/23 at 0920 hours, Resident 422 was observed seated in the wheelchair in her room, on the right side of the bed. Resident 422's call light button was observed underneath the pillows on the left side of the bed, which was away from…

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 three of 24 final sampled residents (Residents 20, 54, and 77) had copies of their advance directive (written instruction, recognized under State law, relating to the provision of health care when the individual is incapacitated) in their medical records. This failure had the potential to go against the health care wishes of the Residents 20, 54, and 77. Findings: Review of the facility's P&P titled Advance Directives revised 9/23/20, showed the Social Services staff will place a copy of the completed advance directive in the resident's medical record. 1. Medical record review for Resident 54 was initiated on 5/16/23. Resident 54 was admitted to the facility on [DATE]. Review of Resident 54's H&P Examination dated 1/2/23, showed Resident 54 had the capacity to understand and make decisions. Review of the MDS Quarterly assessment dated [DATE], showed Resident 54 was cognitively intact. Review of the Physician Orders…

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 a significant change of status assessment was completed with 14 days after a significant change in the resident's physical or mental condition had been determined for one of 24 final sampled residents (Resident 101). This had the potential of not providing the appropriate care and services to Resident 101 based on the resident's current status. Findings: According to CMS's RAI 3.0 Manual dated October 2019, Chapter Two: Significant Change in Status Assessment (SCSA), showed the SCSA is a comprehensive assessment for resident that must be completed when the IDT had determined that a resident meets the significant change guidelines for either major improvement or decline. A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered…

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 develop the comprehensive plans of care to reflect the individual care needs for four of 24 final sampled residents (Resident 18, 45, 107, and 422). * The facility failed to develop a care plan problem to address Resident 422's use of apixaban (anticoagulant medication) and Melatonin (medication to aid with sleep). * The facility failed to ensure a care plan problem addressing Resident 422's use of lorazepam (antianxiety medication) was accurate to reflect the resident's behavior manifestation as ordered by the physician. * The facility failed to ensure a care plan problem addressing the dialysis access site was accurate to reflect Resident 18's dialysis access site. * The facility failed to ensure a care plan problem to address the use of foot cradle, the resident's noncompliance, and any alternatives to the use of foot cradle for wound management for Resident 107. * The facility failed to ensure a care plan problem addressing Resident 45'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.

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 services to attain or maintain the highest practicable well-being for one of 24 final sampled residents (Resident 51). * The facility failed to follow the physician's order to record Resident 51's I&O every shift for 30 days. This failure had the potential risk of not providing the appropriate care for Resident 51. Medical record review for Resident 51 was initiated on 5/16/23. Resident 51 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 51's Order Summary Report showed a physician's order dated 4/26/23, to record I&O every shift for 30 days. However, further review of Resident 51's medical record failed to show documented evidence the resident's I&O was recorded as per the physician's order. On 5/23/23 at 1415 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 51 had a physician's order 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 document review, the facility failed to ensure one of 24 final sampled residents (Resident 101) was provided with the appropriate bed to promote the healing of the pressure injury. This failure posed the risk for Resident 101's pressure injury to deteriorate and develop additional pressure injuries. Findings: According to the National Pressure Injury Advisory Panel, Stage 4 pressure injury (ulcer) is defined as full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough (non-viable fibrous yellow tissue) and/or eschar (dead tissue) may be visible and undermining and/or tunneling often occur. Review of the Invacare microAir MA600 Alternating Pressure Low Air Loss (LAL) Mattress System User Manual showed MicroAir MA600 Air Mattress Therapy System is recommended for use in the prevention and treatment of decubitus (pressure) ulcer Stage 1 to 3. For higher risk…

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 two of 24 final sampled residents (Residents 87 and 96) were provided with the necessary indwelling urinary catheter care to prevent UTI. This failure had the potential to put Residents 87 and 96 at risk for UTI. Findings: Review of the facility's P&P titled Catheter Care revised on 12/19/22, showed it is the policy of the facility to ensure that residents with indwelling urinary catheters received appropriate catheter care and maintain their dignity and privacy when indwelling catheter is in use. Catheter care will be preformed every shift and as needed by nursing personnel. The procedure for catheter care are as follows: - Wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap). - Use new part of the cloth or different cloth for each side. - With new moistened cloth, starting at the urinary meatus moving out. - Document care and report any concerns noted to 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 one of the 24 final sampled residents (Resident 99) received the appropriate treatment and services to prevent the occurrences of complications from GT feeding. * The facility failed to ensure Resident 99's head of bed was elevated during GT feeding to reduce the risk of aspiration. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Care and Treatment of Feeding Tubes revised on 9/2/22, showed it is a policy of the facility to utilize feeding tubes in accordance with the current clinical standards of practice, with the interventions to prevent complications to the extent possible. On 5/16/23 at 1606 hours, an observation of CNA 1 performing care to Resident 99 was conducted. CNA 1 was noted to be fixing Resident 99's diaper and bed. However, Resident 99's head of bed was not elevated while the GT feeding was turned on. CNA 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.

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 appropriate pain management was provided to one of 24 final sampled residents (Resident 20). * The licensed nurse failed to clarify with the physician regarding two different orders for pain scale for Resident 20. In addition, the medication prescribed for moderate pain was administered for a severe pain, and there were no documented non-pharmacological interventions provided to Resident 20 prior to the administration of the pain medication. These failures posed the risk of Resident 20's pain not being managed appropriately. Findings: Review of the facility's P&P titled Pain Management revised on 2/2022 showed the following steps for the staff to complete: - Following the implementation of non-pharmacological intervention, the licensed nurse may administer pharmacological interventions as ordered and document medication administered on the MAR; - The licensed nurse will complete the Pain Flow Sheet for residents…

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 licensed nurse coordinated with the physician regarding the sevelamer carbonate (a medication that can lower the amount of phosphorus in the blood of residents receiving kidney dialysis) scheduled at the time when the resident was out to the dialysis center for one of 24 final sampled residents (Resident 18). Resident 18 did not receive the medication as ordered by the physician on the dialysis days. This failure posed the risk for Resident 18 to not be provided with the appropriate care and treatment and sustained possible medical complications that could had been avoided when the physician's order was followed. Findings: Review of the facility's P&P titled Hemodialysis revised on 9/2/22, showed the licensed nurse will communicate to the dialysis facility via telephone communication or written format, such as the used of the dialysis communication record or other forms that will include, but not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical records review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of one of 24 final sampled residents (Resident 5) and three nonsampled residents (Residents 22, 90, and 822). * The facility failed to ensure Resident 22's Lactulose (medication to treat constipation) was administered as ordered. * The facility failed to ensure the Norco (controlled pain medication) for Resident 5 was documented in MAR when administered. * The facility failed to ensure the Norco for Resident 90 was documented in the MAR when administered. * The facility failed to ensure the medications were not left unattended by a licensed nurse during medication administration. * The facility failed to ensure the wasting of controlled medication was performed by two licensed nurses. These failures posed the risk for possible complications, delay in interventions and treatments, and risk for diversion of controlled medication. Findings: Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility P&P review, and facility document review, the Pharmacy Consultant failed to identify and recommend for monitoring of the side effects for enoxaparin (anticoagulant medication which reduces the chance of getting blood clots) for one of 24 final sampled residents (Resident 92). This failure had the potential risk of providing Resident 92 unnecessary medication and the potential for the development of significant side effects. Findings: Review of the facility's P&P titled Consultant Pharmacist Reports IIIA1: Medication Regimen Review (Monthly Report) dated 6/2021 showed the consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimized adverse consequences relation to medication therapy. Resident-specific irregularities and/or clinically…

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 three of 24 final sampled residents (Residents 77, 92, and 422) were free from unnecessary medications. * The facility failed to monitor for signs and symptoms of bleeding related to Residents 422 and 77's use of apixaban (anticoagulant medication used to prevent blood clots). * The facility failed to monitor for signs and symptoms of side effects related to Resident 422's use of Reglan (medication used to treat nausea and vomiting). * The facility failed to monitor for signs and symptoms of bleeding related to Resident 92's use of enoxaparin (anticoagulant medication used to prevent blood clots). * The facility failed to ensure Resident 422's anti-bacterial medication order had a stop date. These failures had the potential for residents to receive unnecessary medications and develop significant adverse effects, and risk of adverse effects from prolonged use of the medication. Findings: 1. According the Lexicomp, Apixaban is 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 the interview, medical record review, and facility P&P review, the facility failed to ensure two of 24 final sampled residents (Residents 77 and 422) were free from unnecessary psychotropic medications (any drug which afftects brain activities associated with mental processes and behavior). * The facility failed to ensure the non-pharmacological interventions were provided to Resident 422 for the use of lorazepam PRN and melatonin. In addition, the facility failed to ensure a rationale was documented for extending the duration of the use of lorazepam for Resident 422. * The facility failed to ensure non-pharmacological interventions were provided to Resident 77 for the use of clonazepam (antianxiety medication). These failures had the potential for residents to develop significant adverse effects from the medications and had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Use of Psychotropic Medication revised on 9/2/22, showed residents are…

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 medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 23.33%. Two of two licensed nurses (LVNs 7 and 8) were found to have made errors during the medication administration. * Resident 22 had the physician's order to mix lanzoprazole (a medication which reduces the amount of acid in the stomach) with apple sauce/apple juice; however, LVN 8 mixed the medication with water instead of apple juice as ordered. * Resident 22 had the physician's order for lactulose (medication to treat constipation); however, LVN 8 did not administer the medication as ordered. * Resident 22 had the physician's order for Oscal and D3 500/200 (supplement); however, LVN 8 did not administer the correct dose as ordered. * Resident 422 had the physician's orders for diltiazem ER (an extended release antihypertensive medication) and potassium chloride ER (an extended release potassium supplement); however LVN 7 crushed these extended release medications to administer to the resident. * Resident 422…

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 provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the expired medications were removed from Treatment Cart A and Medication Room B. * The facility failed to ensure Resident 45's medication requiring refrigeration was stored in the medication refrigerator. * The facility failed to ensure the discontinued eye drop medication was removed from Refrigerator A. * The facility failed to ensure the opened insulin pens and medication vial labeled with open date more than 30 days for Residents 25, 56, and 100) were removed from stock or Medication Cart A. * Two bottles of pain-relieving oil were observed on Resident 53's bedside table. These failures had the potential to negatively impact the residents' well-being; had the potential for the medications to lose the stability and effectiveness; and had the potential for residents, staff, and visitors to have…

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 of 24 final sampled residents (Resident 51) was provided with food prepared in a form to meet the resident's individual need. * The facility failed to ensure Resident 51 was provided with pureed dessert as per the resident's diet order. This failure posed the risk for Resident 51 to develop complications like aspiration (accidental breathing in food or fluid into the lungs) and choking. Findings: Medical record review for Resident 51 was initiated on 5/16/23. Resident 51 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 51's MDS assessment dated [DATE], showed Resident 51 was edentulous (lacking teeth). Review of Resident 51's H&P examination dated 2/23/23, showed Resident 51 had diagnoses of Parkinson's disease, dementia, and dysphagia. Review of Resident 51's Order Summary Report as of 5/18/23, showed a physician's order dated 4/27/23, to provide a regular…

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 residents' family members and visitors were trained on safe food handling practices of food brought to the residents by the family members and other visitors. This failure posed the risk for the residents to have foodborne illness. Findings: Review of the facility's P&P titled Use and Storage of Food Brought in by Family or Visitors (undated) showed prepared food must be consumed by the resident with three days. If not consumed in three days, the food will be thrown away by the facility staff. However, the P&P did not address educating family members on safe food handling practices. On 5/17/23 at 0832 hours, an observation of the resident's food storage refrigerator was conducted. The posted instructions on the refrigerator door showed food will be disposed after 72 hours. On 5/17/23 at 1005 hours, an interview with RN 1 was conducted. When asked about their process on how the family or visitors were educated on safe food handling when food was brought from outside, RN 1 stated they would…

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 maintain the accurate and complete medical records of one of three final closed record sampled residents (Resident 121). * The facility failed to the POLST was voided as per the facility's P&P when Resident 121's family member requested to change the treatment options and failed to ensure one of three copies of Resident 121's POLSTs was in the medical record. This failure has the potential to put the resident at risk for a delay in necessary care and treatment. Findings: Review of the facility's P&P titled Physician Orders for Life Sustaining Treatment (POLST) revised [DATE], showed to void a POLST, a draw line through the entire section A and D and write VOID on large letters across the document, then sign and date it. All voided POLST documents are to be retained in the resident's medical record. Closed medical record review for Resident 121 was initiated on [DATE]. Resident 121 was readmitted in the facility on [DATE],…

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

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 proper infection control practices were followed for two of 24 final sample residents (Residents 72 and 106). * The facility failed to ensure RN 1 performed handwashing during the preparation of parenteral medication. This failure had the potential for Resident 72 getting infected and posed the risk of spreading infection to another resident. * The facility failed to ensure CNA 3 followed the contact precautions when providing care for Resident 106 who was on enhanced standard precaution. This posed the risk for the transmission of disease-causing microorganisms Findings: 1. Review of the facility's P&P titled Preparation and General Guidelines, IIA2 Medication Administration - General Guidelines dated 10/2017 showed hands are washed before and after administration of topical, ophthalmic, otic, parenteral , enteral, rectal, and vaginal medications. On 5/17/23 at 0831 hours, RN 1 was observed 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.

Based on observation, interview, and facility document review, the facility failed to ensure the essential kitchen equipment was maintained in safe operating condition when: 1. The walk-in ceiling fan cover had a brown residue resembling rust. 2. The reach-in freezer had ice build-up. 3. The manual dish machine draining table was not properly attached to the adjoining dish machine draining table. Failure to maintain necessary kitchen equipment in proper working order may result in compromised food safety. Findings: According to the USDA Food Code Section 4-501.11 Good Repair and Proper Adjustment, proper maintenance of equipment to manufacturer's specifications helps ensure it will continue to operate as designed. Review of the facility document titled Maintenance Job Request, undated, showed no entries from 2/18/22 to 5/16/23. Review of the facility document titled Sanitation Audit Report (SAR) completed by the RD on 2/10 and 3/30/23, showed major equipment was in working order. The SAR completed by the RD on 4/28/23, showed the oven was not working. 1. During the initial tour 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, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the proper labeling and dating of foods in the kitchen and refrigerator used for the residents' food brought in by the visitors. * The facility failed to ensure the proper thawing of meats in the refrigerator. * The facility failed to ensure the proper hand hygiene performed by the kitchen's staff. * The facility failed to ensure the proper use of sanitizing solution. * The facility failed to ensure the kitchen equipment and utensils were cleaned. * The facility failed to air dry equipment. 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 CMS 672 Resident Census and Conditions of Residents completed by the facility dated 4/21/21, showed 69 of 109 residents in the facility received food prepared in the kitchen. Review 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, and facility P&P review, the facility failed to ensure the call light system was within reach for one of 23 final sampled residents (Resident 18) and one nonsampled resident (Resident 58). This failure had the potential for the residents to not receive timely care and assistance from the staff. Findings: Review of the facility's P&P titled Answering the Call Light dated 10/21 showed when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 1. On 4/20/21 at 0745 and 0830 hours, during the initial tour of the facility, Resident 18 was observed lying in bed with her call light not within reach. Resident 18's call light was observed hanging on the wall behind the head of bed. Medical record review for Resident 18 was initiated on 4/20/21. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's plan of care showed a care plan problem dated 1/21/21, addressing Resident 18's risk for falls and injuries. 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 maintain a copy of the resident's advance directive in the medical record for one nonsampled resident (Resident 34). This 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 9/23/20, showed when there is an advance directive about a resident's care and treatment, the facility will require that a copy of such directives be included in the medical record. Once the advance directive is received by the facility, it will notify the resident's primary care physician of the resident's advance directive decisions so, if necessary, appropriate orders can be written. Medical record review for Resident 34 was initiated on 4/21/21. Resident 34 was admitted to the facility on [DATE]. Review of Resident 34's MDS dated [DATE], showed Resident 34 had no cognitive impairment. Review of the POLST dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to implement the plan of care to reflect the individual care needs for one of 23 final sampled residents (Resident 79) and two nonsampled residents (Residents 44 and 60). * The facility failed to ensure Resident 79 had bilateral floor mats and foot cradle in place. * The facility failed to ensure Residents 44 and 60 were provided with two-person assist with their ADLs. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents to attain or maintain their highest practicable physical well-being. Findings: 1a. Medical record review for Resident 79 was initiated on 4/20/21. Resident 79 was readmitted to the facility on [DATE]. Review of the History and Physical examination dated 1/22/21, showed Resident 79 had the necrotizing (death of part of the body's soft tissues) toes. Review of Resident 79's plan of care showed a care plan problem dated 3/24/21, addressing Resident 79'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure two of 23 final sampled residents (Residents 16 and 79) attained and maintained their highest practicable physical well-being. * The facility failed to ensure the insulin injection sites for Residents 16 and 79 were rotated. This failure posed the risk of damaging or causing tissue injuries due to repeated injection sites. * Resident 79 was administered fludrocortisone acetate (medication used to help control the amount of sodium and fluids in the body) when the resident's SBP (systolic blood pressure, the top number of blood pressure that measures the amount of pressure exerted on the vessels when the heart is contracting) was above the parameter prescribed by the physician. This failure had the potential for Resident 79 to receive unnecessary medication and develop significant side effects. Findings: 1a. Medical record review for Resident 79 was initiated on 4/20/21. Resident 79 was readmitted…

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 four of 23 final sampled residents (Residents 6, 53, 77, and 79) received appropriate care and treatment to prevent and promote the healing of pressure injuries. The facility failed to turn and reposition Residents 6, 53, 77, and 79 every two hours to meet their care needs. This failure had the potential to worsen or prevent the healing of the residents' pressure injuries. Findings: In 2016, the NPUAP (National Pressure Ulcer Advisory Panel) defined a pressure injury (same as ulcer) as a localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The NPUAP also defined Stage 3 pressure injury as full-thickness skin loss in which fat tissue is visible in the ulcer; slough (yellow, tan or dead tissue) and/or eschar (a dry dark dead tissue); may be visible. Stage 4 pressure injury is defined as a full-thickness skin and tissue loss with exposed or directly…

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 restorative device was applied to one of 23 final sampled residents (Resident 77). The facility failed to apply the splint on Resident 77's left arm. This posed the risk for Resident 77's left wrist and hand contracture to worsen. Findings: Medical record for Resident 77 was initiated on 4/21/21, Resident 77 was readmitted to the facility on [DATE]. Review of Resident 77's History and Physical examination dated 3/15/21, showed Resident 77 was in a persistent vegetative state. Review of Resident 77's MDS dated [DATE], showed Resident 77 was totally dependent on the staff for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. The MDS showed Resident 77 had bilateral impairment to the upper and lower extremities. Review of Resident 77's plan of care showed a care plan problem dated 3/26/21, addressing an existing contracture. The approaches included to apply the left wrist and hand splint for one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the facility's P&P titled Smoking revised 8/2017 showed the resident will be assessed by the IDT initially when they verbalize the desire/interest to smoke. The assessment is to determine if the resident is able to smoke safely and not harm themselves or others. The resident's care plan will be updated to address smoking and to include smoking activity and any restrictions, special equipment or instructions required, if any. Residents will not be permitted to keep smoking materials in their possessions unless the interdisciplinary team determines they can manage them safely. Medical record review for Resident 310 was initiated on 4/20/21. Resident 310 was admitted on [DATE]. Review of Resident 310's History and Physical examination dated 4/14/21, showed Resident 310 had the capacity to understand and make decisions. Review of Resident 310's physician's orders dated 4/12/21 at 2029 hours, showed Resident 310 was able to smoke independently in the designated smoking patio. Review of Resident 310'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.

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 provide the necessary care and services for the use of GT for one of 23 final sampled residents (Resident 15). * The facility failed to dispose the outdated tube feeding bag and administration kit for Resident 15. This failure posed a risk for complications related to enteral feedings. Findings: On 4/20/21 at 0950 hours, during the initial tour of the facility, a bag of Isosource formula (enteral nutrition) with a tubing was observed connecting to the enteral feeding pump next to Resident 15's bed. Resident 15's enteral administration tubing was tied in a knot and left exposed to air. Resident 15's Isosource formula and tubing were dated 4/14/21. Medical record review for Resident 15 was initiated on 4/20/21. Resident 15 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 15 needed extensive assistance with her ADL care. Resident 15 was on tube feeding. Review 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 necessary services for respiratory care needs were provided for one of 23 final sampled residents (Resident 20) and one nonsampled resident (Resident 22). * The facility failed to obtain a physician's order for continuous oxygen therapy for Resident 22. Resident 22's continuous oxygen use was not documented in her medical record. * The facility failed to label and date the nasal cannula (thin flexible tube with small prongs inserted into the nostrils) used for oxygen administration for Residents 20 and 22. These failures posed the risk for complications related to respiratory treatment. Findings: According to the facility's P&P titled Oxygen Therapy revised 7/30/18, under the Policy section, showed oxygen will be administered as ordered by the physician. Oxygen is a drug and should be administered only by the licensed nurse/respiratory therapist. Under the Documentation section, showed the following…

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 appropriate pain management was provided to one of 23 final sampled residents (Resident 84) and one nonsampled resident (Resident 3). * The facility failed to clarify with the physician when there were two different orders for pain scale for Residents 3 and 84. This failure posed the risk of the residents' pain not being managed appropriately. Findings: Review of the facility's P&P titled Pain Management revised October 2017, under the Procedure section, showed all pain scales will be converted to a 0-10 numeric scale for the purpose of documenting pain. Under the Management section, the licensed nurse will administer pharmacological interventions as ordered . based on the highest pain level that occurred on that shift. 1. Review of Resident 3's medical record was initiated on 4/21/21. Resident 3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 3 had severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to develop and implement the procedures for the provision of pharmaceutical services to meet the needs of the residents as evidenced by: * The facility failed to ensure the controlled medications for Residents 3, 56, and 84 were accurately documented and reconciled in the Medication Administration Record. This posed the risk for diversion of controlled medications and medication administration errors. * The facility failed to replace the facility's emergency kit within 72 hours of opening as per the facility's P&P. This deficient practice posed the potential of an unavailable emergency medication supply. * The facility failed to administer Resident 20's scheduled pain medication as ordered by the physician due to the medication being not available. In addition, Resident 20's prescribed pain medication administration time was changed without clarifying the order with the physician.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of six unnecessary medication sampled residents (Residents 41 and 23) were not receiving unnecessary medications. * The facility failed to ensure the behavior manifestation and adverse side effects were monitored for Resident 41 related to the use of lorazepam (antianxiety medication). * The facility failed to ensure the adverse side effects were monitored for Resident 23 related to the use of citalopram (antidepressant medication). These failures had the potential for these residents to have adverse complications from their medications. Findings: Review of the facility's P&P titled General Guidelines for the Use of Psychoactive Medications revised 10/17 showed the facility staff should document episodes of behavior, the impact of the medication on behavior and the presence or absence of side effects for residents on psychoactive medications. Unnecessary drugs include any drugs used without adequate monitoring…

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 23.33%. Two of two licensed nurses (LVN 2 and RN 4) were found to make the medication errors during the medication administration observation. * LVN 2 failed to administer the correct form of vitamin C and multivitamin to Resident 57 as ordered by the physician. * LVN 2 failed to administer the correct dose of selexipag to Resident 20. In addition, LVN 2 failed to administer multivitamins to Resident 20 as ordered by the physician. * RN 4 administered the wrong calcium medication to Resident 78. In addition, RN 4 failed to administer vitamins D2 and D3 to Resident 78 as ordered by the physician. These failures created the risk for the residents to have reduced therapeutic benefits, potential side effects, or complications related to the medications. Findings: Review of the facility's P&P titled Medication Administration Times revised 5/1/10, showed the residents' medications should be…

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

Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the medications were stored as per the facility's P&P. * The opened Tuberculin PPD vial (purified protein derivative, a multi-dose injectable solution used to determine if a patient has tuberculosis) was not labeled with the open date and was stored in Medication Room A. * The opened Tuberculin PPD vial with an open date past 30 days was stored in Medication Room B. * An emergency kit containing multiple expired medications was stored in Medication Room A. These failures posed the risk of the test not showing an accurate result when determining if a resident had tuberculosis and the potential to result in unsafe administration of medications to the residents. Findings: Review of the facility's P&P titled Medication Storage in the Facility revised August 2019 showed outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, and disposed of according to procedures. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to ensure coordination of hospice services for one of 23 final sampled residents (Resident 32). * The facility failed to show documentation of the current hospice plan of care and certification for Resident 32. In addition, the facility failed to maintain complete documentation of hospice staff visits and services provided for Resident 32. * The facility failed to ensure staff were aware of the individual designated as the facility's hospice coordinator for Resident 32. These failures had the potential to put the resident on hospice services at risk of uncoordinated medical care between the facility and hospice agency. Findings: Review of Hospice Provider A's Nursing Facility Services Agreement dated [DATE], showed the following: - The Responsibilities of Facility/Coordination of Care section showed the hospice and the facility shall communicate with one another regularly and each party is responsible for documenting…

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 appropriate infection control practices designed to help prevent the development and transmission of infections were implemented for one of 23 final sampled residents (Resident 16) and for visitors entering the facility. * The facility failed to don the appropriate PPE prior to entering an isolation room and failed to don clean gloves during wound care treatment. * The facility failed to properly screen the visitors for signs and symptoms of COVID-19 prior to entering the facility. These failures posed the risk for transmission of COVID-19 and other disease-causing microorganisms in the facility. Findings: 1. In 2016, the NPUAP (National Pressure Ulcer Advisory Panel) defined a pressure injury (same as ulcer) as a localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Stage 4 pressure injury is defined as a full-thickness skin and tissue loss…

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 provide a sanitary and comfortable homelike environment for the residents and staff. * Resident 20's bathroom was observed with orange brownish stains on the walls and brownish sediments on the floor. * Dead cockroaches and black-colored droppings were observed in Medication Room A. Findings: 1. On 4/20/21 at 0735 hours, during the initial tour of the facility, Resident 20's bathroom was observed to have orange brownish stains on the walls behind the toilet seat and on the sides of the wall; and brownish sediments were observed on the floor by the toilet. On 4/20/21 at 1006 hours, an interview and concurrent observation was conducted with Maintenance Director. The Maintenance Director acknowledged the orange stained walls and brownish sediment on the floor surrounding the toilet in Resident 20's restroom. 2. On 4/20/21 at 1042 hours, an inspection of Medication Room A was conducted with LVN 1. Two large dead cockroaches were found under the sink by the medication refrigerator. Another dead (third) cockroach was found under…

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.