Desert Mountain Care Center

Based on observation, interview, and document review, the facility failed to ensure medications were labeled with the name of the resident for whom they were intended to be administered. This failure had the potential for medications to be shared by multiple residents. Findings: On June 23, 2025, at 2:25 p.m., during an inspection of Medication Cart Rx 2 with LVN 1, there was one Saline Nasal Spray, not labeled with the name or room number of the resident. In a concurrent interview with LVN 1, LVN 1 confirmed there was no name or room number on the spray bottle or the spray bottle's manufacturer box. LVN 1 stated the spray bottle needed to be labeled with the resident's name. LVN 1 stated she would not know who the medication was for without the name on the medication box. The facility's policy and procedure titled, Labeling and Storage, last revised, February 2025, was reviewed, and indicated, .Each prescription medication label includes .Resident's name . The facility's polity and procedure titled, Medication Administration - General Guidelines, updated November 2021, was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow up the dental needs of a resident, for one resident reviewed for dental services (Residents 15) . This failure has the potential to place Resident 15 at high risk for complications related to dental and nutritional needs due to the delay in providing dental services. Findings: On June 24, 2025, at 9:15 a.m., during a concurrent observation and interview with Resident 15 in her room, Resident 15 was observed with missing partial upper teeth. Resident 15 stated she wanted to have dentures so she requested to be seen by the facility dentist, but no one updated her if she would receive the dental service or not. On June 24, 2025, Resident 15's record was reviewed. Resident 15 was admitted to the facility on [DATE], with diagnoses which included tracheostomy status (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs). A review of Resident 15's Initial admission Record, 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 2. On June 23, 2025, at 12:10 p.m., Resident 64 was observed eating lunch in his room. Resident 64 was eating one of two burritos served on a separate plate from the main entree, which contained a piece of meat, parslied rice, and braised cabbage. When asked if he did not like the main dish served for lunch, Resident 64 stated, I don't like pork, so he asked for burritos instead. Resident 64 further stated he disliked pork, but I get it always. Resident 64's meal ticket was reviewed, which indicated, LCS (low calorie sweeteners) Diet .Regular Consistency .GARLIC HERB PORK CHOP 1-EACH .Dislikes: PORK . On June 23, 2025, at 12:30 p.m., Licensed Vocational Nurse (LVN) 2 was interviewed. LVN 2 stated Resident 64 should not have been served pork since that was his dislike, and kitchen staff should follow what it says on the diet slip. A review of Resident 64's record indicated Resident 64 was admitted to the facility on [DATE], with diagnoses which included end-stage renal disease (a condition in which kidneys cannot…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented, when: 1. For Resident 47, a black stand fan in the resident's room was observed with dust accumulated on the front and back guard covers; and 2. For Resident 287, one used plastic urinal was found inside the resident's personal belonging's storage closet. These failures had the potential to increase the spread of pathogens (germs) and infections to residents which could lead to serious illness. Findings: 1. On June 23, 2025, at 10:55 a.m., during a concurrent observation and interview with Certified Nursing Assistant (CNA) 1 in Resident 47's room, a black stand fan was observed with black and gray debris accumulated on the front and back guard covers. CNA 1 stated it was dust, and the fan should have been cleaned. On June 25, 2025, Resident 47's record was reviewed. Resident 47 was admitted to the facility on [DATE], with diagnoses which included respiratory failure with tracheostomy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident's wheelchairs were maintained in a safe operating condition, for two of 15 residents (Residents 45 and 70). These failures had the potential to result in injury to the residents. Findings: 1. On June 24, 2025, at 1 p.m., a record review for Resident 45 was admitted to the facility on [DATE], with diagnoses which included spinal stenosis (the spaces inside the bone become too small), aftercare following joint replacement surgery and diabetic neuropathy (type of nerve damage that occurs with diabetes). A review of Resident 45's Minimum Data Set (MDS - a resident assessment tool), dated June 3, 2025, included a Brief Interview for Mental Status (BIMS) score of 15 (cognitive intact). On June 24, 2025, at 1:58 p.m., an interview and concurrent observation with Resident 45 was conducted. Resident 45 stated the wheelchair he was using was broken including the left-hand break which does not lock up, the left-hand armrest was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care and treatment was provided timely, for one of five residents reviewed (Resident 1), when Resident 1 had an elevated pulse rate (heart beat per minute {BPM}) and decreased oxygen saturation ({O2 Sat} - the amount of hemoglobin carrying oxygen within the blood). The failure had the potential for a delay in the care and treatment and affect the resident's overall health condition of Resident 1. Findings: On May 22, 2025, at 1210 p.m., an unannounced visit was conducted to the facility to investigate a complaint regarding quality of care. A review of Resident 1 ' s medical records titled, Resident Information, dated May 23, 2025, indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis of respiratory failure (respiratory system is unable to adequately provide oxygen to the body) with hypoxia (low blood oxygen). A review of Resident 1 ' s Progress Notes, dated December 26, 2024, at 1:48 a.m., by Licensed Vocational Nurse…

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 an observation, interview, and record review, the facility failed to ensure trained staff were utilized to provide one on one (1:1) supervision of a resident with wandering behavior, for one of four sampled residents (Resident 4). This failure resulted to untrained staff providing 1:1 supervision to Resident 4 and had the potential for wandering residents to experience physical and psychosocial harm due to lack of training to handle residents with wandering behavior. Findings: On April 22, 2025, at 9:35 a.m., an unannounced visit to the facility was conducted to investigate complaints regarding quality of care. On April 22, 2025, at 12:15 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated the housekeeping staff began to be utilized to provide 1:1 supervision to Resident 4 in April 2025. CNA 3 further stated she believe the housekeeping staff did not have training how to handle at-risk residents or provide 1:1 supervision (sitter) or residents. CNA 3 further 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one on one (1:1) supervision was provided according to the physician's order and plan of care, for one of four residents reviewed (Resident 4) when there was no assigned sitter (staff to supervise the resident's whereabouts) to monitor Resident 4's wandering behavior. This failure had the potential to result in Resident 4 wandering out of the facility, leading to potential physical or psychosocial harm. Findings: On April 22, 2025, at 9:35 a.m., an unannounced visit to the facility was conducted to investigate complaints regarding quality of care. On April 22, 2025, at 12 p.m., during an interview with Certified Nursing Assistant (CNA) 2, CNA 2 stated there were situations where there was not a sitter for Resident 4 which was reflected as blank in the assignment sheet. CNA 2 further stated administration would ask staff to keep an eye on Resident 4 until someone was able to come in and sit with Resident 4. CNA 2 stated keep an eye on a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were implemented when Certified Nursing Assistant (CNA) 1 did not perform hand hygiene after provision of care to a resident and after touching the linen cart. These failures had the potential to spread infection among the vulnerable residents of the facility. Findings: On April 22, 2025, at 9:35 a.m. an unannounced visit was conducted to investigate a infectious disease outbreak. On April 22, 2025, at 9:50 a.m. CNA 1 was observed exiting room [ROOM NUMBER] (resident's room). CNA 1 was observed to remove her gloves outside of room [ROOM NUMBER], then touched the linen cart in the hallway outside of room [ROOM NUMBER]. CNA 1 did not perform hand hygiene when she exited the resident's room. CNA 1 entered room [ROOM NUMBER] again without performing hand hygiene. In a concurrent interview, CNA 1 stated, Sorry, I should have used the hand sanitizer to prevent spreading germs. On April 22, 2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure physician's orders were followed, for one out of four residents (Resident 4) when Resident 4's blood sugar of 403 mg/dl (milligram/decilitier - unit of measurement) was not reported to the physician according to Resident 4's physician's order. This failure had the potential for Resident 4 to have abnormal blood sugar not controlled or managed and could affect the resident's overlal health condittion. Findings: On March 3, 2025, at 11 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care. On March 3, 2025, at 1 p.m., Resident 4 was observed sitting on the edge of the bed. In a concurrent interview with Resident 4, he stated he was unhappy with his care. On March 3, 2025, at 1:05 p.m., Resident 4's record was reviewed. indicated Resident 4's admission Record, indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal…

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

Based on observation, interview, and record review the facility failed to ensure proper infection prevention and control standards were followed, when three direct care staff members were noted to have artificial nails. This failure had the potential to result in the transmission of healthcare-associated infections to the vulnerable immunocompromised residents. Findings: On January 7, 2025, at 9:30 a.m., an unannounced visit was made to the facility to investigate a complaint of quality of care and infection control and one facility reported incident of gastrointestinal outbreak. On January 7, 2025, at 1:10 p.m., a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 was observed coming out of a resident's room and had long decorative artificial nails. CNA 1 stated the staff were not allowed to have long artificial nails. CNA 1 stated she should not wear artificial nails because of infection control reasons. On January 7, 2025, at 1:15 p.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an environment free of accident hazard was provided, for one of three residents (Resident 1) reviewed for elopement (resident leaves the facility without authorization or supervision necessary for his safety) when the door alarm was not activated. This failure had the potential for Resident 1 to be able to leave the facility undetected, which could lead to repeated elopement and have subsequently result in accidents, injuries or even death to the resident. Findings: On November 5, 2024, at 9 a.m., an unannounced visit was conducted at the facility to investigate an incident of elopement. On November 5, 2024, at 9:30 a.m., during a concurrent observation and interview with the Director of Staff Development (DSD) in hallway 200, the exit door was observed with a red alarm equipment attached to the inner side of the door. The door alarm was tested by opening the door and did not hear any alarm sound come off. The DSD stated the door…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comfortable and home like environment was provided when: 1. The room and hallway temperatures exceeded 81degrees Fahrenheit (F), for five of seven sampled resident (Resident 1, 2, 3, 4, and 7). In addition, the facility failed to report an unusual occurrence of disruption of services when the facility's airconditioning unit was not working. This failure resulted in discomfort and had the potential to for the resident to experience dehydration (loss of body fluids), heat stress (condition where the body is under stress from overheating), and heat stroke (when the body cannot control its temperature); and 2. The carpets in the resident's hallways and through-out the facility were observed to be dirty with multiple areas of dark black circular stains. This failure had to potential to affect resident's physical and emotional condition. Findings: On July 25, 2024, at 2:20 p.m., an unannounced visit was conducted to investigate 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 record review, the facility failed to provide incontinent care, for two of twelve residents reviewed, (Residents 11 and 12), when the residents was left in their soiled diaper for a long period of time. This failure resulted in a delay of care needs and had the potential of a negative impact on their self-esteem. Findings: On July 26, 2024, at 10:55 a.m., a concurrent observation and interview with Resident 11 was conducted. Resident 11 was observed lying in bed watching television. Resident 11 stated she had been at the facility for two weeks and she was left wet for over 10 minutes last week until someone finally came to assist her. Resident 11's facility medical record was reviewed. Resident 11 was admitted on [DATE], with diagnoses which included myocardial infarction (blockage of blood flow to the heart), pneumonia (infection that inflames the air sacs of the lungs), cirrhosis of the liver (chronic liver damage), hear failure (chronic condition which the heart don't pump…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain environmental conditions that could keep insects from entering the building, as evidenced by one window screen was missing, other screens were observed to have tears and gaps, and the entrance and exit doors also had gaps large enough for a fly or other insect to enter the facility. This failure could result in insects coming in to the resident's rooms and other areas of the facility frequented by the residents which could potentially cause health problems to vulnerable residents. Findings: On June 3, 2024, at 8:15 a.m., an unannounced visit was made to the facility for a Quality-of-care issue. On June 3, 2024, at 11:00 a.m., an interview was conducted with the Maintenance Supervisor (MS), the MS stated he tours the outside of the facility once a month, to ensure all doors latch and close entirely with no visible gaps or openings. On June 3, 2024, at 11:05 a.m., a concurrent observation of the front door, and interview with the MS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure treatments were provided upon admission for one of three sampled residents' (Resident 1) wounds located on the right lower extremity (back of the right leg) and left achilles. This failure has the potential to result in worsening of the wounds, which could negatively affect the health status of Resident 1. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], and discharged on March 18, 2024, with diagnoses that included non-traumatic intracerebral hemorrhage (bleeding in the brain), diabetes mellitus (inability to control blood sugars), and end stage renal disease. A review of Resident 1's admission skin assessment dated [DATE], indicated under the section labeled Skin Integrity, (signed by Wound Nurse 2 on March 16, 2024), Patient admitted into facility with the following: -Unstageable pressure injury to sacrococcyx (tail bone) 13.0x10.0xUTD (measurements). Light serosanguineous (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 record review, the facility failed to ensure the following: 1. A multidose bottle of oxycodone (controlled narcotic medication) was dispensed in a readily accountable container. This failure increased the risk for diversion of a controlled medication. 2. A routine fentanyl patch (medication used in the management and treatment of chronic pain) was made available for one of three sampled residents (Resident 2). This failure has the potential to negatively affect the resident's pain management. Findings: 1. On January 16, 2024, at 10:55 a.m., during a concurrent observation and interview with Licensed Vocational Nurse (LVN1), at the medication cart for the subacute unit, observed a multidose bottle of oxycodone (a controlled narcotic pain medication) liquid solution 100mg (milligram- a unit of measure)/5ml (milliliters- a unit of measure) with an expiration date of March 2026. The bottle was nontransparent with no graduations noted on the sides of the bottle to verify amount…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medications to treat scabies (contagious skin infestation caused by an itch mite) were administered according to the physician's orders, for two of eight residents (Residents 1 and 2), when: 1. The oral medication Ivermectin (medication given by mouth to treat scabies) was not administered to Resident 1 on December 18 and 19, 2023; and 2. The medication Elimite topical cream (brand name for permethrin- medication applied to the skin to treat scabies) was not administered timely for Resident 2. These failures had the potential to result in insufficient and/or ineffective treatment of scabies for Residents 1 and 2. Findings: 1. On January 2, 2024, at 10:42 a.m., an unannounced visit was conducted at the facility for a facility reported incident regarding a scabies outbreak. On January 2, 2024, beginning at 10:57 a.m., the infection Preventionist (IP) was interviewed. The IP stated Resident 1 had a rash in October 2023 and received treatments 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, and record review, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency (CDPH-California Department of Public Health) within two hours or immediately after the facility was aware of the abuse allegation, for one of three sampled residents (Resident 1). This failure had the potential to delay the identification and implementation of appropriate actions and place Resident 1 at risk for further injury. Findings: On October 13, 2023, at 10:00 a.m., an unannounced visit was conducted to the facility to investigate an allegation of abuse. On October 13, 2023, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which includes anxiety disorder (persistent and excessive worry that interferes with daily activities), schizophrenia (a mental health condition), bipolar disorder (unusual shifts in a person ' s mood, energy and concentration), and major depressive disorder (loss of interest in activities).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a final report for investigation of an injury of an unknown origin was provided to the California Department of Public Health (CDPH), within five working days from the time injury was identified, for one of three residents (Resident A) reviewed for abuse. This failure had the potential to result in a delay of the implementation of the appropriate action and the provision of protection to the residents of the facility and placed Resident A at risk for further abuse. Findings: On August 7, 2023, at 1 p.m., an unannounced visit to the facility was conducted to investigate a facility reported incident of an injury of unknown origin. On August 7, 2023, at 1:10 p.m., an interview was conducted with the Director of Nursing (DON). She stated a facility staff observed Resident A with swelling to her left ankle and reported it to the licensed nurse on July 19, 2023. She stated an x-ray (a digital picture taken inside the body) was ordered by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. On August 23, 2021, at 3:37 p.m., Resident 1 was observed lying in bed, not verbally responsive. Resident 1 was observed to have contractures on his right hand. On August 26, 2021, the record of Resident 1 was reviewed. Resident 1 was readmitted to the facility on [DATE], with diagnoses which included quadriplegia (weakness of arms and legs). The MDS, dated March 15, 2021, indicated, .Functional Limitation in Range of Motion .Impairment of both sides .Upper extremity (shoulder, elbow, wrist, hand) .Lower extremity (hip, knee, ankle, foot) . The quarterly MDS, dated [DATE], indicated, .Functional Limitation in Range of Motion .Impairment on both sides . A physician's order dated, August 28, 2020, indicated, .Continue gentle ROM . A document titled, IDT (Interdisciplinary Team) Care Plan Conference, dated June 22, 2021, indicated, .No RNA (restorative nursing assistant) at this time, will refer to therapy for eval (evaluation) and splint recommendations . There was no documented evidence the physician was…

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

Based on observation, interview, and record review the facility failed to ensure medications were properly stored and disposed when: 1. One licensed nurse (LN) was observed disposing the sorbitol liquid medication (medicine to treat constipation) in a regular trash bin inside the resident's room. 2. Multiple non-controlled medications were observed not properly disposed or placed in authorized collection receptacles for proper destruction. These failures had the potential for accidental poisoning or possible environmental contamination to occur. 3. Expired medications were stored in the treatment cart and medication storage room readily available for use. This failure had the potential for residents to receive expired medication with less potency and efficacy. Findings: 1. On August 25, 2021, at 8:32 a.m., during a medication administration observation with Licensed Vocational Nurse (LVN) 3, LVN 3 was observed disposing 30 ml (milliliter- unit of measurement) of sorbitol in the trash can in the resident's room. In a concurrent interview with LVN 3, he verified he disposed 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 2a. On August 23, 2021, at 9:36 a.m., Resident 6 was observed to be awake, lying in bed and not verbally responsive. Resident 6 was observed to have a tracheostomy (surgical opening created at the front of neck to help a person breathe). Resident 6 was observed to be connected to a ventilator (a machine that provides ventilation by moving breathable air into and out of the lungs) through the tracheostomy. A [NAME] tubing of approximately one and a half feet long was observed to be connected to the tracheostomy tube. The bottom end of the suction valve of the [NAME] tubing was observed to not have a protective cap. On August 25, 2021, the record of Resident 6 was reviewed. Resident 6 was admitted to the facility on [DATE], with diagnoses which included respiratory failure (lung failure). The Order Summary Report, for August 2021, included a physician's order, dated March 7, 2018, which indicated, .Suction PRN (as needed) for retained or increased secretions . 2b. On August 24, 2021, at 9:30 a.m., Resident 14 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light was within reach, for one of 23 residents reviewed (Resident 8). This failure had the potential for Resident 8 to not receive timely care and assistance from staff. Findings: On August 24, 2021, at 9:14 a.m., and 11:41 a.m., Resident 8 was observed lying on a geri-chair (large padded chairs with wheeled bases used to assist resident with limited mobility). The geri-chair was observed on the right side of the bed and the call light was observed on the left side of the bed not within Resident 8's reach. On August 24, 2021, at 11:41 a.m., during an interview with Resident 8, she stated she would press the call light button when she needed assistance. When Resident 8 was asked to call for staff assistance, she stated she could not find the call light. On August 24, 2021, Resident 8's record was reviewed. Resident 8 was admitted to the facility on [DATE], with the diagnoses which included history of fall and fracture…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for three of six residents reviewed for Advance Directives (AD - a written instruction regarding the provision of health care when the individual is incapacitated) (Residents 6, 43, and 48), the facility failed ensure: 1. For Resident's 6 and 43, written information regarding formulating an AD were provided to the resident and/or the resident's representative (RR); and 2. For Resident 48, a follow up with the RR was conducted regarding obtaining a copy of the resident's AD. These failures had the potential to result in not determining and/or following the residents' wishes related to the provision of medical treatment and health care services when the residents become unable to make decisions for themselves. Findings: 1a. On August 24, 2021, Resident 43's record was reviewed. Resident 43 was initially admitted to the facility on [DATE], with diagnoses which included atrial fibrillation (an irregular and often rapid heart rate). The Advance Directive/DPAHC (Durable Power 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 interview, and record review, the facility failed to ensure timely coordination with the resident and/or the family member (FM) to obtain the list of home medications upon admission, for one of one resident reviewed (Resident 273). This failure resulted in the delay of Resident 273's administration of her home medications necessary for the continuity of care in the facility. Findings: On August 24, 2021, at 2:43 p.m., an interview with Resident 273 and her FM was conducted. She stated she was admitted to the facility on [DATE]. Resident 273 stated she had not received her home medications since admission. Resident 273's FM provided the list of home medications for Resident 273. The following were Resident 273's home medications: - Levothyroxine (medication to treat an underactive thyroid) 100 mcg (microgram -unit of measurement); - Oxybutynin chloride (medication to treat symptoms of overactive bladder) 5 mg (milligram -unit of measurement); - Amlodipine 5 mg (medication to treat high blood pressure); -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a plan of care (POC) when the resident (Resident 1) was assessed to have limitations of his lower and upper extremities, for one of six residents reviewed for range of motion (ROM- movement of joints) and restorative nursing care. This failure had the potential for Resident 1 to not receive timely treatment and interventions which could result in further decline with mobility and range of motion. Findings: On August 23, 2021, at 3:37 p.m., Resident 1 was observed lying in bed, not verbally responsive. Resident 1 was observed to have contractures (tightening of the muscles and skin leading to a deformity and rigidity of joints) on the right hand. On August 26, 2021, the record of Resident 1 was reviewed. Resident 1 was readmitted to the facility on [DATE], with diagnoses which included quadriplegia (weakness or paralysis of both arms and legs). The Minimum Data Set (MDS-assessment tool), dated March 15, 2021, indicated, .…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the plan of care (POC) was updated or revised, for one of 23 residents reviewed (Resident 58), when the resident had a physician's order perform range of motion exercises. This failure had the potential to result in a delay of the implementation of appropriate interventions to address the care and treatment for Resident 58. Findings: On August 24, 2021, at 9:49 a.m., Resident 58 was observed in bed in a semi-sitting position and unable to move his right upper and lower extremities. In a concurrent interview with Resident 58, he stated he did not receive any exercises for the weakness in his right side of the body. He stated he wanted to receive exercises for his right-sided body weakness. On August 26, 2021, Resident 58's record was reviewed. Resident 58 was admitted to the facility on [DATE], with diagnoses which included cerebrovascular accident (stroke) with right-sided weakness. The Order Summary Report, dated August 26, 2021,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication was administered as ordered by the physician, for one of four residents reviewed during medication administration observation (Resident 19). This failure had the potential for Resident 19 to not receive the intended therapeutic effect of the medication. Findings: On August 25, 2021, at 8:50 a.m., an observation of medication administration was conducted with Licensed Vocational Nurse (LVN) 1 for Resident 19. LVN 1 was observed administering one tab of Oyster 500 mg (milligram - unit of measurement) to Resident 19. On August 25, 2021, a review of Resident 19's record indicated he was admitted to the facility on [DATE], with diagnoses which included, muscles weakness and vitamin D deficiency (low vitamin D level). The Order Summary Report, dated October 1, 2020, indicated, .Oyster Shell Calcium/Vitamin D Tablet 500-200 MG-UNIT (supplement) .Give 1 tablet by mouth two times a day for /Vitamin D deficiency . On August…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care and treatment per professional standards of practice, for two of 23 residents reviewed (Residents 22 and Resident 5) when: 1. For Resident 22, the multiple discolorations on both hands and forearms were not assessed and monitored. This failure had the potential for a delay in the necessary care and treatment for Resident 22; and 2. For resident 5, there was no consistent blood sugar monitoring when the resident was receiving diabetic medications and had frequent episodes of refusing meals. This failure had the potential for a delay in the identification of abnormal blood sugar levels which could lead to a compromised health condition. Findings: 1. On August 23, 2021, at 11:25 a.m., Resident 22 was observed in the hallway sitting in the wheelchair. Resident 22 was observed to have purplish skin discolorations on top of both hands and forearms. On August 24, 2021, at 10:55 a.m., a concurrent observation and interview was…

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

Based on interview and record review, the facility failed to ensure the emergency kits (e-kit- an emergency storage box containing a small quantity of critical medications used in emergent situations) were replaced within seventy-two hours according to the facility's policy and procedure. This failure had the potential to result in a delay in the administration of medications. Findings: On August 26, 2021, at 9:30 a.m., during the medication room inspection with Registered Nurse (RN) 1, one intramuscular (IM - injection through the muscle) e-kit was observed with red zip ties. The IM e-kit included a document which indicated it was opened on August 21, 2021. In a concurrent interview, RN 1 stated the red zip ties on the e-kit indicated it was opened and medications were removed from the opened e-kit. RN 1 stated the pharmacy should have been notified for a replacement of the opened e-kit as soon as possible. On August 26, 2021, at 10:54 a.m., an interview with the Director of Nursing (DON) was conducted. The DON stated the facility should have called the pharmacy to replace opened…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR - process by which a consultant pharmacist reviews all medications the resident is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy) recommendations were acted upon timely, for one of five residents reviewed for unnecessary medications (Resident 58), when the recommendation to recheck the potassium (electrolyte which helps the nerves to function and muscles to contract) level was not referred to the physician. This failure had the potential to result in the delay with the provision of treatment and the monitoring of the potassium level for Resident 58. Findings: On August 26, 2021, Resident 58's record was reviewed. Resident 58 was admitted to the facility on [DATE], with diagnoses which included hypertension (elevated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure psychotropic medications (medications to manage mood disorders) were necessary in managing mental and mood disorders, for two of five residents reviewed for unnecessary medications (Residents 60 and 8) when: 1. For Resident 60, the physician or psychiatrist (specializes on mental illness) did not evaluate the resident prior to the use of duloxetine (a medication to treat mood disorder). There was no behavior monitoring for the use of duloxetine. In addition, the facility did not follow through with the physician's recommendation for psychiatric evaluation for Resident 60; and 2. For Resident 8, a periodic evaluation for the continued use of sertraline (medication to treat mood disorder) was not completed by a physician or health care practitioner. In addition, there was also no plan of care developed for the use of sertraline. These failures had the potential for Residents 60 and 8 to receive unnecessary psychotropic medications.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician was notified of the abnormal laboratory test results for potassium (electrolyte which helps the nerves to function and muscles to contract) and platelets (blood cells which help form clots to stop bleeding), for one of 23 residents reviewed (Resident 58). This failure had the potential for a delay in the care and treatment for Resident 58. Findings: On August 26, 2021, Resident 58's record was reviewed. Resident 58 was admitted to the facility on [DATE], with diagnoses which included hypertension (elevated blood pressure) and atrial fibrillation (irregular heartbeat). The Order Summary Report, dated August 26, 2021, included the following physician's orders: - Potassium Chloride ER (extended release [medication to treat low potassium level]) Capsule Extended Release 10 MEQ (milliequivalent - unit of measurement) Give 1 (one) capsule by mouth two times a day .; date ordered on March 2, 2021; - Bumetanide (diuretic - medication to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a diagnostic procedure was provided in a timely manner, for one of 23 residents reviewed (Resident 48), when a CT (computer tomography - a radiologic procedure to get detailed images of the body) scan was not completed as ordered by the physician. This failure had the potential for the delay in the treatment and management of Resident 48's pain. Findings: On August 24, 2021, at 9:13 a.m., Resident 48 was observed sitting in a wheelchair. In a concurrent interview with Resident 48, he stated he had pain on his shoulder and neck. Resident 48 was observed to be unable to lift both arms above his shoulders. He stated there was pain and stiffness. On August 25, 2021, at 9:10 a.m., Resident 48 was observed sitting in a wheelchair. In a concurrent interview with Resident 48, he stated both shoulders still hurt. On August 26, 2021, Resident 48's record was reviewed. Resident 48 was admitted to the facility on [DATE], with diagnoses which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the result of an electrocardiogram (EKG/ECG - a test to check the electrical activity of the heart) was reported to the physician, for one of 23 residents reviewed (Resident 48). This failure resulted in the delay in the identification and notification to the physician of an abnormal EKG result. In addition, this failure had the potential for a delay in the initiation of appropriate treatment for Resident 48. Findings: On August 26, 2021, Resident 48's record was reviewed. Resident 48 was admitted to the facility on [DATE], with diagnoses which included hypertension (elevated blood pressure). The physician's progress notes, dated August 17, 2021, indicated, .Doing patient exam today it was noted that he is having ectopic beats (irregular heart beat) in his heart rhythm. Patient denies having any chest pain, will order EKG . The physician's order, dated August 17, 2021, indicated, EKG. The EKG result, dated August 19, 2021, indicated, ABN…

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.