Desert Springs Healthcare & Wellness Centre

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an appropriate orthostatic (standing upright) blood pressure (BP - measurement of the force of blood pushing against the blood walls) monitoring were conducted, for one of three residents reviewed (Resident 6). This failure had the potential for Resident 6 to experience complications related to orthostatic blood pressure. Findings: On March 6, 2025, at 8:50 a.m., an unannounced visit was conducted at the facility to investigate a quality care issue. On March 6, 2025, Resident 6's record was reviewed. Resident 6 was admitted to the facility on [DATE], with diagnoses which included Alzheimer ' s disease (memory loss) and osteoporosis (bone disease). A review of Resident 6 ' s Minimum Data Set (MDS - a tool for assessment), dated January 18, 2025, indicated Resident 6 had a moderately impaired and poor decisions regarding tasks of daily life. A review of Resident 6 ' s care plan goal, dated February 3, 2025, indicated Resident 6 will be free 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 assess the interventions for revisions to address multiple incidents of falls for two of three sampled residents (Residents 7 and 8). This failure had the potential to result in unmet needs and a potential for falls with possible injury. Findings: On December 26, 2024, at 9:13 a.m., an unannounced visit was conducted at the facility to investigate nursing services and accidents issue. A review of Resident 7's admission record indicated Resident 7 was admitted to the facility on [DATE]. Resident 7 was admitted with diagnoses which included cellulitis (bacterial skin infection) of left lower limb, hypertension (force of blood against the artery walls is too high), anxiety disorder (a mental health disorder of worry, or fear that are strong enough to interfere with one's daily activities), difficultly walking and dementia (a group of conditions with impairment of at least two brain functions, such as memory loss and judgement). A review of Resident 7'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 record review, the facility failed to ensure residents' mail or packages were not opened without prior consent from the resident, for two of five residents sampled (Residents B and C). This failure resulted in Resident B and C's rights not being respected. Findings: On August 16, 2024, at 8:30 a.m., an announced visit to the facility was conducted to investigate a complaint of quality of care. On August 16, 2024, Resident B's medical record was reviewed. Resident B was admitted to the facility on [DATE], with diagnoses which included heart failure and prostate (a male reproductive gland) cancer. A review of Resident B's Minimum Data Set (MDS - an assessment tool), dated April 24, 2024, indicated Resident B had a BIMS (Brief Interview of Mental Status) score of 13 (cognitively intact). On August 20, 2024, at 11:30 a.m., during an interview with Resident B, Resident B stated he did not like when the staff opened his packages, he thought it was a violation of his rights, and he did not give…

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 pharmaceutical services were provided to meet the needs of a resident, for one of five residents reviewed (Resident A), when medications (pain medications and Nictoine patch [medication for smoking cessation]) were not acquired by the facility timely. This failure resulted in a delay in the care and treatment of Resident A's overall health condition. In addition, this failure had the potential for other residents to have a delay in the care and treatment. Findings: On Augsut 16, 2024, at 8:45 a.m., an unannounced visit was conducted at the facility to investigate an allegation of quality of care. On August 16, 2024, at 9:15 a.m., during an interview with the Director of Nursing (DON), the DON stated Resident A was admitted to the facility on [DATE], after 3 p.m., after a spine surgery. The DON stated Resident A was prescribed pain medications such as Fentanly (narcotic pain medication), Methadone (narcotic pain medication), and Percocet…

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, for one of five residents sampled (Resident A) had equipment to use was being maintained in a safe and operable condition when the left brakes of the wheelchair was not working. This failure had the potential to cause injury to Resident A when she was using a wheelchair. Findings: On August 16, 2024, at 8:30 a.m., an announced visit to the facility was conducted to investigate a complaint of quality of care. On August 16, 2024, at 10:30 a.m., an observation and concurrent interview was conducted with Resident A. Resident A was lying in bed on her right side facing the wall. Resident A stated she was not doing okay and wants out of the facility. Resident A stated when she wants to get up and go to the bathroom, she presses her call light, but the staff do not show up, and she had to try to take herself to the bathroom. Resident A stated the wheelchair was broken, and it was difficult for her to transfer herself to the wheelchair 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 interview and record review the facility failed to ensure sufficient licensed nurses with the appropriate competencies and skill sets necessary to care for one (Resident A) of six sampled residents' needs, as identified through resident assessments, and described in the plan of care. This failure has the potential to affect the provision of care for Resident A and other residents at the facility. Findings: On September 11, 2024, at 12:30 p.m., an announced visit to the facility was conducted to investigate a complaint for quality of care. On September 16, 2024, at 11 a.m., Resident A ' s admission Record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke-loss of blood flow to a part of the brain), epilepsy (a disorder in which nerve cells in the brain are disturbed, causing seizures), and aphasia (a disorder that makes it difficult to speak). A review of Resident A ' s Order Summary Report indicated: - July 15, 2024, Observe 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 interview and record review the facility failed to ensure one (Resident A) of six sampled residents was consistently assessed and was provided treatment and care in accordance with the professional standards of practice, when Resident A had a fall and her vital signs became abnormal after the fall incident. These failures increased the risk for the current health condition of the resident to worsen due to delayed assessment and delayed provision of appropriate care. Findings: On September 11, 2024, at 12:30 p.m., an announced visit to the facility was conducted to investigate a complaint for quality of care. On September 16, 2024, at 11:00 a.m., Resident A ' s admission Record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke-loss of blood flow to a part of the brain), epilepsy (a disorder in which nerve cells in the brain are disturbed, causing seizures), and aphasia (a disorder that makes it difficult to speak). A 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 interview and record review, the facility failed to ensure a safe environment was provided, for one of three resients reviewed (Resident 1), when the otuside patio had an open sunken area of dirt, approximately 2 inches below the level of surrounding concrete pavement. This failure resulted in Resident 1 being stuck in the dirt between a tree and the edge of the concrete pavement. Findings: On August 7, 2024, at 1:37 p.m. an unannounced visit was conducted at the facility to investigate two complaints. A request for facility policies and procedures, including those regarding Accidents and/or Accident Prevention was made. The Director of Nursing (DON) stated per her consultant, the facility did not have any, unless it pertained to a specific incident or condition that involved an accident. Resident 1' s record was reviewed. The resident was admitted to the facility on [DATE], with diagnoses which included right femur fracture, history of falling, high blood pressure, and muscle wasting and atrophy…

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 information regarding formulating an Advance Directives (AD- a written document that indicates a resident's medical wishes,) was provided to the resident or resident representative (RR), for three of six residents reviewed for AD, (Residents 6, 29, and 52). This failure had the potential for the resident/resident representative's current wishes for medical care not to be honored. Findings: 1. On July 15, 2024, Resident 29's record was reviewed. Resident 29 was initially admitted to the facility on [DATE], with diagnoses which included end stage renal failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), cognitive communications deficit (problems with a person's ability to think, learn, remember, use judgement, and make decisions), and dementia (condition characterized by progressive or persistent loss of intellectual functioning especially with impairment of memory and abstract thinking). A 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 interview and record review, the facility failed to ensure a comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was initiated for the use of apixaban (brand name Eliquis, an anti-coagulant, or blood thinning medication), for one of five residents reviewed for unnecessary medications (Resident 6). This failure had the potential to result in the delay in the care and treatment for Resident 6. Findings: On July 17, 2024, Resident 6's record was reviewed. Resident 6 was admitted on [DATE], with diagnoses which included atrial fibrillation (an irregular and often very rapid heart rhythm). A review of the Resident 6's telephone order, dated June 25, 2024, indicated, .Apixaban Oral Tablet 2.5 mg (mg - milligram, a unit of measurement) Give 1 (one) tablet by mouth two times a day for atrial fibrillation. In further review of Resident 6's record, there was no documented evidence a care plan was developed to address Resident 6's risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during monthly medication regimen review (MRR), four of five residents reviewed for unnecessary medications (Residents 9, 6, 40, and 52), when: and three residents (Resident 6, 40, 52) on anticoagulation (medications also referred to as blood thinners) did not have monitoring for signs of bleeding: 1. Resident 9 was administered aripiprazole (an anti-psychotic medication for schizophrenia and bipolar depression) without adequate behavioral monitoring documented during use of aripiprazole; and 2. Residents 6, 40, and 52 were not monitored for signs and symptoms of adverse effects related to the use of anti-coagulants (blood thinners). These failures had the potential for medications not being optimized for the best possible health outcome, and unnecessary or prolonged use of medications which could lead to medication adverse effects for the residents. Findings 1. During 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 interview and record review, the facility failed to ensure three of four sampled residents (Residents 6, 40 and 52) were free from unnecessary medications when: 1. Resident 6 received apixaban (brand name Eliquis, an anti-coagulant, or blood thinning medication) without monitoring for signs and symptoms of adverse effects related to the use of apixaban; 2. Resident 40 received apixaban without monitoring for signs and symptoms of adverse effects related to the use of apixaban; and 3. Resident 52 received enoxaparin (brand name Lovenox, an anti-coagulant, or blood thinning medication) without monitoring for signs and symptoms of adverse effects related to the use of enoxaparin. These failures had the potential to result in unnecessary use of medications for Residents 6, 40 and 52 and had the potential for side effects of this medication (such as bleeding, excessive bruising, etc.) to go undetected or recognized for timely intervention. Findings 1. During a review of Resident 6's admission Record, it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the menu during tray line (food preparation and assembly at the steam table) observation on July 17, 2024, for three of 68 residents who consumed food in the facility (Residents 9, 45 and 35). This failure had the potential to negatively impact the residents' nutritional status and further compromise the residents' medical status. Findings: On July 17, 2024, at 9:15 a.m., the facility's Summer Menu for Week 3, Wednesday, was reviewed. The document indicated the lunch menu for the day included: - Taco Casserole - Seasoned Fresh Zucchini - Fiesta Salad; and - Tangy Glazed Fresh Fruit. On July 17, 2024, beginning at 11:35 a.m., a tray line observation was conducted. The following were observed: a. Resident 9's tray was assembled first due to a dialysis (removal of waste products and excess body fluids from the body via the blood due to kidney failure) appointment after lunch. Resident 9's diet, as written on the Order Listing Report…

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 properly implemented when: 1. The direct care staff were not aware which patients were on Enhanced Barrier Precautions (EBP- a type of infection prevention measure requiring the use of gowns and gloves during high contact resident care); 2. Certified Nursing Assistant (CNA) 1 observed EBP while feeding Resident 40. Resident 40 was not on the list for EBP; 3. Cohorting (placing residents in the same room) guidelines for EBP were not observed for Residents 6 and 117. These failures had the potential to spread infection throughout the facility. Findings: 1. On July 16, 2024, at 10:22 a.m., signs for EBP were observed posted on the door of room [ROOM NUMBER], where Residents 117 and 6 were roomed. On July 16, 2024, at 10:32 a.m., Certified Nursing Assistant (CNA) 1 was interviewed and stated the EBP was for Resident 117 when she had her IV (intravenous- access through the vein 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 treat two of four sampled residents, with dignity and respect when the Certified Nursing Assistants (CNA) did not sit at eye level while feeding the residents (Residents 40 and 43). This failure did not promote resident's dignity, did not allow social interaction, and had the potential promote more serious negative outcomes. Findings: On July 15, 2024, at 12:16 p.m., CNA 1 was observed wearing gloves, gown, and mask, and feeding Resident 40 while standing up. In a concurrent interview, CNA 1 stated he should be sitting down while feeding Resident 40. On July 15, 2024, at 12:23 p.m., during an interview with the Director of Staff Development (DSD), the DSD stated the CNA should been sitting down while feeding the resident. On July 15, 2024, at 12:34 p.m., the Restorative Nurse Assistant (RNA) was observed wearing a gown and gloves, and feeding Resident 43 while standing up. In a concurrent interview, the RNA stated she should be sitting…

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 were provided the necessary level of assistance to meet their activities of daily living needs, for two of two sampled residents (Residents 30 and 29), when: 1. Resident 30 was observed with lunch meal tray set up incomplete, with plastic covering/seal on food items and the milk carton was left unopened. Resident 30 was unable to remove the plastic covering nor able to open the milk carton; and 2. Resident 29 was observed with lunch meal tray set up incomplete, with plastic covering/seal on plated food items. Resident 29 was unable to remove the plastic covering on the plated food or reach her drinking cup. These failures resulted in the residents not receiving direct necessary care and services needed at mealtime and had the potential to compromise the health and wellbeing of the residents. Findings: 1. On July 15, 2024, at 12:14 p.m., Resident 30 was observed with lunch meal tray set up incomplete, with plastic covering/seal on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the abnormal results of the chest x-ray (radiology procedure of the chest) was addressed by the physician timely, for one of three closed record reviewed (Resident 22). In addition, the physician's order for antibiotic to treat the abnormal chest x-ray was not administered timely. These failures resulted in a delay in the care and treatment for Resident 22. Findings: On July 17, 2024, Resident 22's record was reviewed. Resident 22 was admitted to the facility on [DATE], with diagnoses which included aftercare for right femur (hip) fracture (broken bone) and malnutrition. A review of Resident 22's Progress Notes, indicated the following: - May 10,2024, at 3:34 p.m., indicated, .reported to (name of physician) pt (patient) VS (vital signs) 132/70 (blood pressure) 99.8 (temperature) .102HR (heart rate) 40resp (respiratory rate) a minute .refusing to open her eyes and moans to painful stimuli .waiting for advice .; - May 10, 2024, at 4:38 p.m.,…

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 interventions to prevent falls were implemented, for one of two residents (Resident 40) when 1:1 sitter was not provided to address impulsive behavior and falls. This failure had a potential to result in Resident 40 to have falls and sustain injury. Findings: On July 15, 2024, at 11:42 a.m., a concurrent observation and interview was conducted with Resident 40. Resident 40 was observed lying in bed awake. Two bumps were observed on Resident 40's forehead. The right side of her forehead had a nickel-size bump with a dark scab and the left side had a quarter size bump with red bruising. The Resident 40 stated she fell a couple of days ago and could not remember how. Resident 40 stated staff helped her to eat as she was blind. On July 15, 2024, at 3:42 p.m., observed Resident 40 in her room alone, sitting at the edge of her wheelchair trying to get up, Resident 40 almost slipped out of the chair. A Certified Nursing Assistant (CNA) 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 accurate accountability of controlled medications (those with high potential for abuse and addiction) for one of four residents (Resident 62) when a random controlled medication audit did not reconcile. The controlled medication was signed out of the Individual Narcotic Record (a controlled drug record, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate it was administered to Resident 62. This failure resulted in inaccurate accountability of controlled medications, which had the potential for misuse or diversion. Findings: The Individual Narcotic Record for controlled medications for four random residents receiving controlled medications were requested for review during the survey and indicated the following: A review of Resident 62's facility medical record indicated Resident 62 had a physician's order, dated June 19, 2024, for .Norco (hydrocodone-acetaminophen, a potent controlled medication for pain) 5/325…

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 was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications, for one of five residents reviewed for unnecessary medications (Resident 9), when Resident 9 was administered aripiprazole (brand name Abilify, an anti-psychotic medication for schizophrenia and bipolar disorder) without adequate behavioral monitoring documented during use of aripiprazole. This failure had the potential to result in unnecessary use of medications for Resident 9, which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss. Findings: During a review of Resident 9's admission Record indicated, Resident 9 was originally admitted to the facility on [DATE], and readmitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the antibiotics were prescribed and administered to the residents under the guidance of their antibiotic stewardship program, for one of three residents reviewed for closed record (Resident 22), when: - Resident 22's condition did not meet the McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for the use of antibiotic for UTI (Urinary Tract Infection); and - The physician's order to discontinue Macrobid (a medication to treat UTI) was not carried out as ordered. These failures had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria. Findings: On July 17, 2024, Resident 22's record was reviewed. Resident 22 was admitted to the facility on [DATE], with diagnoses which included aftercare for right femur (hip) fracture (broken bone) and malnutrition. A review of Resident 22's Progress Notes, indicated the following: - May…

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 accurate administration of treatments, as ordered by the physician for Residents 1 & 2. This failure had the potential to delay Resident 1 & 2 ' s wound healing. Findings: On November 20, 2023, at 8:30 a.m., and unannounce visit was made to the facility to investigate a Quality-of-Care issue. 1) Review of Resident 1 ' s admission records, indicated, Resident 1 was admitted to the facility on [DATE], with a diagnosis of surgical aftercare following surgery on the skin and fatty tissue, cutaneous abcess (collection of puss in the skin) of the abdominal wall. Further review indicated Resident 1 had a BIMS (Brief Interview for Mental Status) score of 12 (Moderate cognitive impairment). Review of Resident 1 ' s Physician ' s (Dr ' s) orders, indicated the following: A) October 24, 2023, . Cleanse abdominal wound with normal saline, pat dry apply Cacium alginate with silver to wound bed, apply zinc oxide ointment to peri wound cover . secure .…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment free from verbal abuse, for one of three residents reviewed (Resident 1), when Certified Nursing Assistant (CNA) 1 was heard threatening Resident 1 that she was going to be thrown on the floor during Resident 1's shower if she would not stop yelling. This failure resulted in Resident 1 being subjected to verbal abuse, which could result in emotional and psychological distress. Findings: On November 2, 2023, at 10:57 a.m., an unannounced visit was conducted at the facility to investigate an allegation of abuse. On November 2, 2023, at 11:02 a.m., the Administrator (ADM) was interviewed. The ADM stated an allegation of verbal abuse was reported from the student CNAs and their instructor who witnessed the incident. He stated the student CNAs and the instructor heard CNA 1 telling Resident 1 that she was going to be thrown to the floor during her shower if she would not stop yelling. On November 2, 2023, at 11:12 a.m.…

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 person-centered care plan for dementia (memory loss) was developed, for one of three residents (Resident A) reviewed for dementia care. This failure had the potential for Resident A not to receive the appropriate interventions to manage symptoms of dementia. Findings: On August 7, 2023, at 9:40 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. On August 7, 2023, at 9:46 a.m., an interview was conducted with the Director of Nursing (DON). She stated Resident A was observed to have discolorations on her body on July 23, 2023, at around 9 a.m. The DON stated Resident A claimed that a Certified Nursing Assistant (CNA) from the previous night was rough during care. The DON stated Resident A was screaming and scratching at the CNA while care was being provided. She stated the CNA then grabbed Resident A's both arms and hands to prevent the resident from scratching her. The DON stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the physician for one of three sampled residents' (Resident 1) episode of hypoglycemia (low blood sugar) in accordance with the facility's policy and procedure. This failure had the potential for delayed treatment of hypoglycemia for Resident 1. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (inability to regulate blood sugar) and hypertension (blood pressure that is higher than normal). The document indicated the resident was her own representative. A review of Resident 1's physician orders indicated the following: a.HumaLOG Kwikpen subcutaneous Solution Pen-injector 100 unit/ml (milliliter- a unit of measure) (insulin Lispro) inject as per sliding scale: if 61-150=0 units; 151-200=0 units; 201-250=2 units; 251-300=4 units; 301-350=8 units; 351-400=10 units; > (greater than) 400 md/dl notify MD (Medical Doctor), subcutaneously two…

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 the trash containers were not overfilled and the lids kept securely closed to prevent the potential attraction of pests and vermin (nuisance animals that could spread diseases). This facility failure increased the potential for attracting insects and vermin, which could result in food-borne illnesses in a highly susceptible population of 68 residents. Findings: During an initial kitchen tour on December 4, 2022, at 11:34 a.m., a concurrent observation and interview was conducted with the Dietary Supervisor (DS). There were three garbage bins located outside the kitchen approximately 40 feet away in the alley, by the iron fence in front of the back yard. One extra large white metal bin, identified by the DS as the recycle bin, was uncovered and contained multiple boxes that overfilled the bin. In addition, one of the two lids intended to cover the trash bin, was missing. Approximately 6 feet to the side of the recycle bin was one extra large dark gray Burrtec metal bin, identified by the DS as 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 nutritional care and services were provided, for four of 14 residents reviewed (Residents 3, 5, 27, and 48) for nutrition, when: 1. For Resident 3, there was no follow up evaluations and interventions to address the resident's nutritional status after she had a 3.3% weight loss in a week on September 1, 2022, and continued to refuse to be weighed. In addition, Resident 3's low albumin and Vitamin D level were not referred to the Registered Dietitian (RD) for further evaluation and recommendation. This failure resulted in Resident 3's weight loss of 30 lbs. (pounds)/10% from September 1, 2022 to December 7, 2022 (three months). 2. For Resident 5, there was no follow up evaluation and recommendation by the RD to address Resident 5's weight loss of 14 lbs/7.3% in a month (August 18, 2022 to September 20, 2022). In addition, the RD's recommendation on November 10, 2022, to refer to the physician Resident 5's significant weight 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: 1. The intravenous (IV - given through a vein) medication cart was locked when not in use. This failure had the potential for the IV medication cart to be accessible to residents, unlicensed staff, and visitors; 2. Expired IV medication were removed from the medication cart. This failure had the potential for the residents to receive expired medications with less potency and/or experience serious adverse outcomes; and 3. Three (3) bags of IV medications were removed from the medication cart after the order was completed. This failure had the potential for the medication to be available for use to other residents. Findings: On December 4, 2022, at 9:20 a.m., an unlocked IV medication cart was observed in station one hallway. In a concurrent interview with Licensed Vocational Nurse (LVN) 4, she stated the IV medication cart was left unlocked. She stated it should always be locked when not in use. The IV medication cart 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 store food in accordance with professional standards for food service safety, when several food items were undated or stored beyond their use by dates, readily available for use. This failure had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food in the facility. The facility census was 68. Findings: On December 4, 2022, beginning at 10:14 a.m., a concurrent kitchen inspection and interview was conducted with the Dietary Supervisor (DS - [NAME]). The following were found in the dry storage area, readily available for use: - Three packs (12 pieces per pack = 36 pieces) and seven pieces of hotdog rolls labeled with a use by date of November 12, 2022. The DS stated bread can be on the shelves for seven days from the delivery date and to be discarded after the use by date. The DS acknowledged the hotdog rolls had been on the shelf more than two weeks beyond the use by date and should…

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 conduct and implement a Quality Assurance Performance Improvement (QAPI) program to address the residents' weight loss. This failure had the potential for the facility to not take preventative measures for weight loss. Findings: On December 8, 2022, at 4:03 p.m., the Administrator (ADM) was interviewed. He stated the QAPI programs were initiated and discussed by the QAPI committee monthly. The QAPI committee included but not limited to the ADM, the Director of Nursing (DON), the Medical Director (MD), and the department directors and supervisors. The ADM stated weight management was not included in their monthly QAPI meetings. He stated the QAPI committee was not able to identify resident care issues such as weight loss. Therefore, the QAPI committee was not able to initiate measures to improve weight loss. He stated the facility initiated a QAPI program to address the weight loss on December 8, 2022, after the survey team identified the weight loss at the start of the survey on December 4, 2022. The ADM presented the QAPI…

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, three Certified Nursing Assistants (CNA) failed to implement appropriate hand hygiene during passing of meal trays and feeding the residents. This failure had the potential to result in the spread of communicable diseases and infections to residents and other staff members. Findings: On December 4, 2022, at 12:32 p.m., CNA 1 was observed placing a lunch meal tray in front of Resident 6, in room [ROOM NUMBER]. CNA 1 was observed to set up resident's meal tray, removed the lid on the plate, and opened other items for resident to eat and drink. CNA 1 left the resident's room and did not perform hand hygiene. Then CNA 1 proceeded to pour two (2) cups of coffee from the coffee cart and brought them to the resident in another room. On December 4, 2022, at 12:35 p.m., CNA 2 was observed to have picked up meal tray from a resident in room [ROOM NUMBER], after feeding the resident. CNA 2 left the room and placed meal tray onto the meal cart in the hallway. Then CNA 2…

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 a written notification regarding the facility's bed hold policy (holding a bed for up to seven [7] days if a resident is transferred to a general acute hospital or goes on therapeutic leave), was provided to the resident or resident representative, for one of three residents reviewed for hospitalization (Resident 37) when Resident 37 was transferred to the acute care hospital on September 9, 2022, September 16, 2022, and September 27, 2022. This failure had the potential to result in the resident or resident representative losing the opportunity to secure the right to reside in the facility past the bed hold duration policy time frame. Findings: On December 5, 2022, at 12:03 p.m., Resident 37 was interviewed. She stated her recent readmission was her third time back to the facility after she was sent to the acute care hospital. On December 12, 2022, Resident 37's record was reviewed. Resident 37 was initially admitted on [DATE] and readmitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) was completed accurately, for one of one resident reviewed for smoking (Resident 12). This failure had the potential for not identifying the resident as a safety risk to self and other residents in the facility and implement appropriate interventions. Findings: On December 4, 2022, at 3:19 p.m., Resident 12 was observed lying in bed. During a concurrent interview, Resident 12 stated she would smoke once a day at around 1:30 p.m. She stated she was the only smoker at the facility. On December 7, 2022, Resident 12's record was reviewed. Resident 12 was admitted to the facility on [DATE], with diagnoses which included diabetes (abnormal blood sugar). The Minimum Data Set (MDS), dated August 22, 2022, indicated Resident 12 did not use tobacco. On December 7, 2022, at 3:50 p.m., Resident 12's record was reviewed with the MDS Coordinator. She stated she made a mistake by not indicating the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a comprehensive assessment regarding a resident's change of condition, for one of three residents reviewed for closed record (Resident 167). In addition, the facility failed to implement the physician's order for IV (intravenous - through the vein) hydration. This failure resulted in a rapid decline in Resident 167's condition and may have potentially contributed to Resident 167's demise. Findings: On [DATE], at 3:56 p.m., Resident 167's record was reviewed. Resident 167 was admitted to the facility on [DATE] with diagnoses which included fracture of the sacrum (triangular bone in the lower back), falls, anemias (lack of healthy red blood cells), and high blood pressure. The History and Physical, dated [DATE], indicated Resident 167 had the capacity to understand and make decisions. The Physician's Orders for Life-Sustaining Treatment (POLST-a document honoring a resident's wishes for care and treatment), dated [DATE], indicated, .Attempt…

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 a referral to an eye specialist was scheduled, for one of one resident reviewed for vision/hearing (Resident 24). This failure resulted in Resident 24 not receiving the proper evaluation to determine other contributing factors for her vision loss, and had the potential to have a delay in receiving the proper treatment to maintain and/or preserve her remaining vision. Findings: On December 5, 2022, at 10:35 a.m., Resident 24's Significant Other (SO) was interviewed via telephone. The SO stated he was aware that Resident 24 had vision loss but was not sure if the facility addressed the problem with her eyesight. On December 5, 2022, Resident 24's record was reviewed. Resident 24 was admitted to the facility on [DATE] with diagnoses which included diabetes (abnormal blood sugar), hypertension (elevated blood pressure), and legal blindness (occurs when a person has vision that allows them to see straight ahead of them of 20/200 [a person can see at…

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