Alta View Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure that one of six sample residents (Resident 46) who was assessed at risk for weight loss, and were provided with timely nutritional intervention to prevent continuous significant weight loss, including: 1.Failure to follow Registered Dietitian (RD) interventions for Resident 46 to have dental evaluation. 2.Failure to have interdisciplinary (IDT-team-a coordinated group of experts from several different fields) meeting to strive to prevent, monitor, and intervene Resident 46's undesirable weight loss as indicated in the facility's policy and procedure on Nutrition (Impaired) Unplanned Weight Loss-Clinical Protocol revised on July 2025. 3.Failure to implement the RD interventions nutritional plan of care by not notifying the attending physician regarding Resident 46's significant weight loss and by not providing the resident with double protein with meals, and multi-vitamin as recommended by RD. 4. Failure to ensure IDT revised plan of care 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 observe infection control measures by failing to wear appropriate personal protective equipment (PPE) while feeding residents on enhanced barrier precautions (EBP- infection control measures that require targeted use of gowns and gloves during high-contact resident care activities along with strict hand hygiene) for three of four sampled residents (Resident 39, Resident 44, and Resident 81)This failure had the potential to spread disease and infection among residents and staff. 1. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was initially admitted to the facility on [DATE] with diagnoses including Candidiasis (C. auris- a multidrug resistant fungus that causes life-threatening infections) and cerebral infarction (stroke- loss of blood flow to part of the brain). During a review of Resident 39's Minimum Data Set (MDS- a resident assessment tool) dated 5/22/2025, the MDS indicated Resident 39…

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 offer COVID-19 vaccines for three of three residents sampled for immunizations (Resident 4, resident 62, and Resident 96). This deficient practice had the potential to result in Resident 4, Resident 62, and Resident 96 contracting, transmitting, and experiencing complications related to COVID-19 such as acute respiratory distress syndrome (ARDS- life-threatening lung injury), pneumonia (an infection/inflammation in the lungs), respiratory failure requiring oxygen, and sepsis (overwhelming infection spreading throughout the body).1. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted on [DATE] with diagnoses including anxiety, depression, psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality), delusional disorders (having false or unrealistic beliefs), and auditory hallucinations (false perceptions of sound, such as hearing voices or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodations for one of 20 sampled residents (Resident 15) by not ensuring Resident 15's call light (a device used by residents to call for assistance) was within reach. This deficient practice had the potential to cause a delay in staff meeting Resident 15's needs for assistance further resulting in falls and accidents.During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke- loss of blood flow to a part of the brain) and needing assistance with personal care. During a review of Resident 15's Minimum Data Set (MDS- a resident assessment tool) dated 5/10/2025, the MDS indicated Resident 15 had severely impaired cognition (significant difficulty with memory, decision-making, and understanding) and was dependent for help (helper does all of the effort) with toileting hygiene,…

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 inform and consult with resident's physician when there was a significant change in the resident's physical status for one of six sample residents (Resident 46) regarding 7.2 pounds weight loss in 14 days. This deficient practice delayed the Medical Doctor (MD) being notified and the resident not being reassessed for the 7.2 pounds weight loss. Findings: During a review of Resident 46's admission Record dated 6/25/2025, the admission record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] to the facility with diagnoses of, but not limited to, Unspecified protein-calorie malnutrition (a nutritional disorder resulting from a lack of adequate protein and caloric intake). Dysphagia (difficulty swallowing), Pneumonitis due to inhalation of food and vomit (inflammation of the lung's air sacs caused by an inhaled substance). Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor…

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 a clean environment for one of six sample residents (Resident 31). This deficient practice had the potential for an unsafe and unclean resident's environment with the potential for the spread of infection and to place the resident at risk for physical discomfort. During a record review of Resident 31's admission Record dated 6/27/2025, the admission record indicated the resident was admitted to the facility on [DATE], with diagnoses of, but not limited to Gastrostomy-tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), Delayed Milestone in Childhood (a situation where a child does not reach a particular developmental milestone at the expected age). During a review of Resident's 31 Minimum Data Set (MDS-a resident assessment tool) dated 7/4/2025, the MDS indicated Resident 31 is dependent (helper does all the effort) from staff 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 Minimum Data Set (MDS, a resident assessment tool) assessment for entry and discharge from the facility were completed within the required time frame for one of three sampled residents (Resident 94).This failure had the potential to result in Resident 94 receiving a delay in care and services at the facility.Findings:During a review of Resident 94's admission Record, the admission Record indicated the facility initially admitted the resident on 6/24/2025 with diagnoses that included chronic respiratory failure (a gradual, long-term condition where the lungs can't effectively exchange oxygen and carbon dioxide, leading to symptoms like shortness of breath, fatigue, and confusion), muscle weakness, seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), encephalopathy (permanent brain damage that causes severe confusion and forgetfulness), glaucoma (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 the assessment entry on the Minimum Data Set (MDS- an assessment and care screening tool) related to weight loss was accurately coded to reflect the resident's weight loss of five percent in a month for one of six sampled residents (Resident 46). This deficient practice resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and services for Resident 46. During a review of Resident 46's admission Record dated 6/25/2025, the admission record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] to the facility with diagnoses of, but not limited to, Unspecified protein-calorie malnutrition (a nutritional disorder resulting from a lack of adequate protein and caloric intake). Dysphagia (difficulty swallowing), Pneumonitis due to inhalation of food and vomit (inflammation of the lung's air sacs caused by an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop a plan of care for one of six sample residents (Resident 46), who had lost 7.2 pounds (5.9 percent) in 14 days after admission. This deficient practice had the potential for delayed provision of necessary care and services. During a review of Resident 46's admission Record dated 6/25/2025, the admission record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] to the facility with diagnoses of, but not limited to, Unspecified-Calorie Malnutrition (a nutritional disorder resulting from a lack of adequate protein and caloric intake). dysphagia (difficulty swallowing), pneumonitis due to inhalation of food and vomit (inflammation of the lung's air sacs caused by an inhaled substance). During a review of Resident 46's Minimum Data Set (MDS-a resident assessment tool) dated 7/15/2025, the MDS indicated Resident 46's cognition (thought process) was moderately impaired. Please add ADL's for eating 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.

Based on observation, interview, and record review, the facility failed to explain medications that were administered to one of nine sampled residents (Resident 35) observed during medication pass, as indicated in the facility's policy and procedure (P&P), titled Medication Administration - General Guidelines, dated 10/2017 and Charge Nurse/Nurse Supervisor Competency Assessment, dated 10/2020. This deficient practice failed to provide information to Resident 35 regarding his medications before Licensed Vocational Nurse 1 (LVN1) administered the medications.Findings:During a review of Resident 35's admission Record (a document containing demographic and diagnostic information), dated 8/21/2025, the admission Record indicated the facility admitted Resident 35 on 11/27/2024 with diagnoses that included but not limited to moderate protein-calorie malnutrition, muscle weakness, pressure ulcer, rhabdomyolysis (severe muscle damage leading to kidney failure), depression (a mood disorder characterized by persistent feelings of sadness or loss of interest), schizophrenia (a mental illness…

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:1. Ensure to inform the facility nursing staff (in general) to maintain the medication refrigerator's temperature with the correct reference range of 36-to-46 degrees Fahrenheit ([ F] is a unit of temperature) (2-to-8 degrees Celsius ([ C] is a unit of temperature) in accordance with the regulatory standards, manufacturer's specifications and the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated 1/2025, for the storage and monitoring of refrigerated medications for one of one inspected medication room (Medication Room). 2. Ensure Resident 84's empty, punctured, opened vial of single-use Epogen ([generic name - epoetin alfa] a medication used to treat anemia [low red blood cell count]) was discarded in accordance with facility's P&P titled, Medication Storage in the Facility, dated 1/2025, in one of one inspected medication room (Medication Room). These failures had the potential to result in medication errors, and for the residents to receive medications that were…

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 implement their protocol for Antibiotic (medicine that kill or stop the growth of bacteria) Stewardship for one of three sampled residents (Resident 62) by failing to complete an Infection Surveillance Outcome form (a tool used in healthcare to document and analyze infections and monitor antibiotic use in a facility) for Resident 62. This deficient practice had the potential to increase antibiotic resistance and provide antibiotics without justification for Resident 62. During a review of Resident 62's admission Record, the admission Record indicated Resident 62 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty breathing), skin cancer (uncontrolled growth of abnormal skin cells), and surgery of the scalp (the skin covering the top of the skull).During a review of Resident 62's Minimum Data Set (MDS- a resident assessment tool) dated 7/31/2025, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the pneumococcal vaccine (PVC 20) was administered to one of three residents sampled for immunizations (Resident 62) after Resident 62 consented to receive the vaccine.This failure had the potential to result in Resident 62 contracting, transmitting, and experiencing complications related to pneumococcal diseases such as pneumonia (an infection in the lungs), meningitis (inflammation of brain and spinal cord membranes), and sepsis (a life-threatening blood infection).During a review of Resident 62's admission Record, the admission Record indicated Resident 62 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty breathing), skin cancer (uncontrolled growth of abnormal skin cells), and surgery of the scalp (the skin covering the top of the skull).During a review of Resident 62's Minimum Data Set (MDS- a resident assessment tool), the MDS 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.

Based on interview and record review the facility failed to ensure 12 hours required in-service training for one of two sampled Restorative Nursing Assistant (RNA). This deficient practice has a potential to compromise residents safety due to RNA training was insufficient. Findings:During a concurrent interview and record review on 8/21/2025 at 8:19 AM with Interim Director of Staff Development (IDSD)IDSD and RNA 1 employee file out of five sampled employees, the IDSD stated there is no training prior to going on the floor for RNA 1, The employee file packet does not have the required in-service training for RNA 1. IDSD stated employee file was missing a documentation of the required mandatory in-service. IDSD stated that Dementia in-service training hours as of August 2024-August 2025 only showed 1 hour and abuse in-service hours as of August 2024-Agust 2025) showed a total of 9 hours accordingly. IDSD stated that it is not enough trainings before taking care of elderly can put residents at risk to get abused or unable to meet demented resident's needs. During a record 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 one of three sampled residents (Resident 1) received his personal belongings after discharge as indicated in the facility's policy and procedures titled Resident's Personal Belongings. This failure resulted in Resident 1 feeling angry, belittled, and disgusted. A review of Resident 1's admission sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnoses including muscle weakness (lack of physical or muscle strength), and essential hypertension (high blood pressure). A review of Resident 1's History and Physical dated 2/26/25, indicated Resident 1 was a great historian. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/12/2025, indicated the resident was cognitively intact, and required moderate to maximum assistance with Activities of Daily Living (ADL's- activities related to personal care such as toileting, eating, bathing, dressing, etc. ). A review of Resident 1's care plan dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a care plan was developed for Resident 2 ' s Central Venous Catheter (CVC—is a thin, flexible tube that's inserted into a vein to give fluids, blood, and/or medications). This failure had the potential to negatively affect the delivery of care and services. Findings: During a review of Resident 2 ' s admission Record dated 1/13/25, it was indicated that Resident 2 was readmitted . to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), muscle weakness, and pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 2 ' s History and Physical (H&P), dated 10/25/24, indicated the resident can…

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 Resident 2 ' s Central Venous Catheter (CVC, a thin, flexible tube that's inserted into a vein to give fluids, blood, and/or medications) care was documented, indicating it was done in the Intravenous (IV, inside the vein) Administration Record (IVAR). This failure resulted in the documentation not being complete and therefore unable to tell if the care was completed. Findings: During a review of Resident 2 ' s admission Record dated 1/13/25, it was indicated that Resident 2 was readmitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), muscle weakness, and pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony…

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 notify the physician and the next of kin (NOK) when resident had a change in condition for one of three sampled residents (Resident 1). For Resident 1 whose weight was 126 pounds (lbs., unit of measurement) on 10/8/24 and on 11/4/24 Resident 1 weighed 118 lbs., the facility identified Resident 1 had a significant weight loss of eight lbs. in one month. The facility failed to notify Resident 1 ' s physician and Resident 1 ' s NOK in a timely manner. This deficient practice had the potential for delay in providing Resident 1 interventions to prevent further weight loss and the NOK not updated with Resident 1 ' s condition. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 8/22/24 with diagnoses including dementia (progressive state of decline in mental abilities) and chronic kidney disease (CKD, disease characterized by progressive damage and loss of function in the kidneys [two bean shaped organs that filter waste in the blood]). During a review of the Minimum Data Set (MDS,…

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

Based on interview and record review the facility failed to maintain accurate record for one of three sampled residents (Resident 1). For Resident 1, who had a physician order to collect urine sample for urinalysis (UA, test of urine for the presence of infection and other problems), culture and sensitivity (C&S, determine the causative agent of the infection and the best way to treat it) on 10/25/24, the facility failed to ensure the Resident 1 ' s record reflected that the urine sample was not collected and the notification of Resident 1 ' s primary physician. These deficient practices resulted in inaccurate representation of Resident 1 ' s medical record. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 8/22/24 with diagnoses including dementia (progressive state of decline in mental abilities) and chronic kidney disease (CKD, disease characterized by progressive damage and loss of function in the kidneys [two bean shaped organs that filter waste in the blood]). During a review of the Minimum Data Set (MDS, resident assessment tool)…

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 safe and sanitary food storage and preparation practices when: 1. Dishware were not sanitized with adequate amount of sanitizer per manufacture guidelines. Sanitizers and disinfectants are used on food contact surfaces such as pots, pans and dished helps to prevent the growth and spread of germs and the risk of food borne illness. 2. The ice machine was not maintained in a clean manner and the inside compartment of ice machine was dirty. 3. Individual juice cartons with manufactures instruction if frozen, thaw, refrigerate and use within 10 days, were not monitored for the date they were thawed to ensure expired juice were discarded. One large bowl holding 15 individual cartons of orange pineapple flavored juice were stored in the reach in refrigerator with no thaw date. One package of ham was labeled with open dates 8/10/2024 and use by date of 8/17/2024 exceeding the facility policy for food storage. These deficiencies had 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 accurately code the Minimum Data Set (MDS - a standardized assessment and screening tool) for the section relating to Restorative Nursing Program (nursing aide program that helps residents maintain their function and joint mobility) use for one out of the four sampled residents (Resident 34). This deficient practice had the potential to incorrectly reflect Resident 34's plan of care and care and services received by the resident. Findings: During a review of Resident 34's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to, neuralgia (severe, sharp pain that follows the path of a nerve) and neuritis (inflammation of the nerves), muscle weakness and right hand contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity). During a review of Resident 34's Physician Orders, dated 5/2/2022, indicated the…

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

Based on interview and record review, the facility failed to provide chest physiotherapy on 8/10/2024 and 8/12/2024 according to the physician order for one out of the two sampled residents (Resident 42). This deficient practice had the potential to result in Resident 42 becoming short of breath and could negatively impact the resident's health and well-being. Findings: During a review of Resident 42's admission Record indicated the facility admitted the resident on 4/13/2024 with diagnoses including but not limited to, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), aspiration pneumonia, dysphagia (difficulty swallowing), Stage IV pressure ulcer (deep wound reaching the muscles, ligaments, or bones) and Alzheimer's disease (a progressive disease that destroys memory and other important metal functions). During a review of Resident 42's Respiratory Treatments care plan, developed 7/11/2024, indicated the goal was to reduce the frequency of acute exacerbations. The…

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

Based on observation, interview, and record review, the facility failed to accurately account for one dose of a controlled medication (medications with a high potential for abuse) affecting Resident 28 in one of two inspected medication carts (Medication Cart 1.) This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled medications and that Resident 28 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. Findings: During an observation and concurrent interview of Medication Cart 1, on 8/13/2024 at 1:05 PM, with the Licensed Vocational Nurse (LVN 1), the following discrepancies were found between the Controlled Drug Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): 1. Resident 28's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow up the requested dental services for dentures for one of four sampled resident (Resident 25). This deficient practice resulted in a delay of Resident 25 being evaluated for dentures and increased Resident 25's risk for weight loss and loss of muscle mass. Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included anxiety (a feeling of fear, dread, and uneasiness), dorsalgia (back pain), and chronic obstructive pulmonary disease (COPD-a lung diseases that block airflow and make it difficult to breathe). During a review of Resident 25's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 6/8/2023, the MDS indicated that Resident 25 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and 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 develop individualized person-centered care plans (a set of instructions for providing individualized care to a resident for an identified area of concern) to meet the residents need for three of ten sampled residents (Residents 12, 275, and 40). -For Resident 12, the facility failed to develop a care plan with goals and interventions for doxycycline (an antibiotic [medicines that fight infections] used to treat infections). -For Resident 275, the facility failed to create a care plan for the problematic behaviors of angry outbursts and agitation related to the diagnosis of psychosis (a severe mental condition in which thoughts and emotions were so affected that contact was lost with external reality). -For Resident 40 the facility failed to create a care plan for Carbapenem-Resistant Enterobacterales (CRE, a type of bacteria that causes infections in healthcare setting) of the urine, and contact isolation (steps that healthcare facility visitors and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: -Ensure lorazepam (a medication used to treat mental illness) was used for a medical condition as diagnosed and documented in the resident's clinical record between 3/8 and 3/20/2024, for one of five residents sampled for unnecessary medications (Resident 275). -Define resident-specific target behaviors regarding the use of lorazepam for one of five residents sampled for unnecessary medications (Resident 275). -Monitor Lorazepam for adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) and effectiveness between 3/8 and 3/20/2024, for one of five residents sampled for unnecessary medications (Resident 275). -Quantify episodes of angry outbursts due to psychosis, per the physician's order related to the use of quetiapine (a medication used to treat mental illness) to treat psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality) between 3/6 and…

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

Based on observations, interviews, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills for the following: -Two of two staff were not following the manufacturer's guidelines of the test strip, when checking the concentration of the Quat Sanitizer (a chemical use for disinfection) solution used in the two compartment sinks and sanitation of food preparation surfaces. -One of two staff were unable to demonstrate and verbalize proper dish machine temperature checks. -Two of two staff were not following the manufacturer's guidelines of the test strip when checking the concentration of the chlorine (a chemical used for disinfection) solution used in the low temperature dish machine. These failures had the potential to result in cross-contamination (a transfer of bacteria from one object to another), ineffective dish machine, and unsensitized dishes that could lead to food borne illness (an illness caused by contaminated food and beverages) in 68 of 73 medically compromised residents who received food and ice from the…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a.Staff was wearing wristwatches and gold bracelet during food preparation and dishwashing. b.Refrigerator gasket was dusty. c.Freezer had ice crystals, tape residue, and food debris on the bottom shelves. d.Storage racks were not six inches (in., unit of measurement) from the floor. e.Dirt debris on the dry storage floor. f.Three dented cans in the storage area. g.Domes were not air dried before storage. h.Sheet pan storage racks were dusty. i.Two staff were not wearing beard guard in the kitchen. j.Staff did monitor food temperature during food pick up from Facility 2 on the first day the kitchen was closed. k.Sticky dirt build-up in two of the plate lowerators (kitchen equipment to warm and hold plates). l.Coffee dispenser spout had coffee build-up. m.Clean dishes in the drying area were not protected from the splash from the two compartment sink where pots and pans were washed. n.Expired Quat sanitizer test strips.…

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 maintain sanitary conditions in the food services department when cockroaches (a type of insect) were observed in the kitchen. This deficient practice resulted in multiple cockroaches (eleven cockroaches), observed hiding in the cracks at the base of the steam table (assembly area for resident's food), crawling in the kitchen on the sheet pan's storage rack. This deficient practice caused an increased risk in 68 of 73 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food. Findings: During concurrent observation of the facility's kitchen and interview with the Dietary Supervisor (DS) on 3/18/2024, at 10:26 AM, two brown cockroaches one centimeter in size and two baby cockroaches were observed hiding in the cracks at the base of the steam table. The DS stated the steam table area was clean and thought the insects were roaches upon seeing it. During concurrent observation of the crack…

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 provide care in a manner that maintained or enhanced the resident's dignity and respect for one of six sampled residents (Resident 51). The Certified Nursing Assistant stood over Resident 51 while assisting him during a meal. This deficient practice had the potential to affect Resident 51's sense of self-worth, self-esteem, and psychosocial wellbeing. Findings: A review of the admission Record (Face Sheet) indicated the facility originally admitted the Resident 51 on 7/28/2023 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) without dyskinesia (uncontrolled, involuntary muscle movements). A review of the Dietary Profile dated 10/24/2023, indicated Resident 51 required total assistance with eating (one-on-one assistance for direct feeding). A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete the minimum data set assessment (MDS - a comprehensive resident assessment and care planning tool), Section I (active diagnoses) on 3/12/2024, for one of five residents sampled (Resident 275) for unnecessary medications by: -Including a diagnosis of anxiety (feeling of fear, dread, and uneasiness that may occur as a reaction to stress) without evidence to support this as an established diagnoses in the clinical record. -Omitting a diagnosis of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) despite evidence to support this as an established diagnosis in the clinical record. This deficient practice increased the risk that Resident 275 may not have received care planning and treatment according to his needs, possibly leading to a decline in his…

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 one sampled resident (Resident 28) was provided a communication device with the language that the resident was able to understand. On 3/18/2024 Resident 28 repeatedly stated comida in Spanish (food). Sitter 1 stated he did not understand what Resident 28 was saying and ingnored the resident. As a result, Resident 28 appeared distressed and prevented Resident 28 from communicating with the staff, delaying appropriate care / treatment the resident requested. Findings: A review of the admission Record indicated the facility admitted Resident 28 on 6/25/2019, and readmitted the resident on 11/24/2021, with diagnoses including unspecified dementia (decline in mental ability severe enough to interfere with daily functioning/life), generalized muscle weakness (lack of physical or muscle strength and the feeling that extra effort was required to move your arms, legs, or other muscles), and anxiety (feeling of worry and nervousness). A review of Resident 28's Minimum Data Set (MDS - standardized assessment and…

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

Based on observation, interview, and record review, the facility failed to accurately account for one dose of a controlled medication (has a high potential for abuse) affecting Resident 69 in one of two inspected medication carts (Medication Cart 3). This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations and that Resident 69 could have received too much or too little medication due to lack of documentation, possibly resulting in serious health complications requiring hospitalization. Findings: During an observation and concurrent interview of Medication Cart 3, on 3/20/2024 at 1:51 PM, with Licensed Vocational Nurse (LVN) 1, the following discrepancies were found between the Controlled Drug Record (a log signed by the nurse with the date and time each time a controlled substance was given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): -Resident 69's Controlled Drug Record 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 follow up on a recommendation from the facility consultant pharmacist, concerning adding instructions for how to treat moderate pain, in one of five sampled residents for unnecessary medications (Resident 46). This deficient practice increased the risk that Resident 46 could have experienced pain that was not adequately treated with medications available, causing a decline in Resident 46's quality of life. Findings: A review of Resident 46's admission Record indicated the resident was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including hemiplegia (severe or complete paralysis of one side of the body) and hemiparesis (slight muscle weakness or partial paralysis of one side of the body) following cerebral infarction affecting the left non-dominant side (left-side paralysis due to stroke). A review of the History and Physical dated 4/9/2023, indicated Resident 46 did not have the capacity to understand and…

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

Based on observation, interview, and record review, the facility failed to ensure the appropriate transmission-based precaution (TBP, the second tier of basic infection control that is used in addition to Standard Precautions [the minimum infection prevention practices that apply to all patient care] for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission) signage was posted for one of six sampled residents (Resident 40). This deficient practice had the potential to cause the spread of infection to staff, other residents, and the community. Findings: A review of Resident 40's admission Record indicated the facility re-admitted the resident on on 1/11/2024 with diagnoses that included candidiasis (a fungal infection caused by a yeast), osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), neuromuscular dysfunction of the…

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

Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from misappropriation of the resident's property (the willful misplacement or wrongful temporary or permanent use of a resident's belongings or money) by the staff. The Certified Nursing Assistant (CNA) received money from Resident 1. This deficient practice resulted in the misappropriation of Resident 1's money while under the care of the facility. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 4/20/2023 with a readmission date of 1/4/2024. Resident 1's diagnoses included fracture of the right femur (a break in the uppermost part of the thighbone, next to the hip joint), Type II diabetes (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and heart failure (heart muscle cannot pump enough blood to meet the body's needs). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 10/31/2023,…

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.

Repeat Deficiency from the Recertification Survey 10/2023. Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with accepted professional principles for two of two medication carts. An open bottle of Morphine Sulfate and an open bottle of Ondansetron were open without labeled dates of opening. This deficient practice caused an increased risk of residents to receive potentially ineffective or toxic medication due to improper storage. Findings: A review of the Recertifciation Survey Plan of Correction approved on 11/30/2023, indicated the Pharmacy Consultant was to check all medication carts during the monthly visit and report the findings on the labeling and storage of the medications to the Director of Nursing (DON). During an observation of Medication Cart #1 with Licensed Vocation Nurse (LVN) 1, on 12/20/2023 at 9:13 AM, there was an opened bottle of Morphine Sulfate 100 mg/5 ml oral solution for Resident 63 without a labeled open date. During a concurrent review of the manufacturer's product labeling,…

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 implement their policy and procedure for infection control to prevent an infectious disease outbreak (a sudden rise in the number of cases of an infectious disease) by staff failing to perform hand hygiene when entering and exiting resident rooms, and after touching residents' surroundings in 21 of 36 rooms. This failure had the potential to cause or prolong an infectious disease outbreak, affecting all residents and staff in the facility. Findings: During an interview on 12/19/2023 at 8:44 AM, the Maintenance Director (MDIR) stated he checked all the call lights in the residents' rooms weekly. During an observation on 12/19/2023 at 9:04 AM, the facility's weekly call light check was conducted with the MDIR and the MDIR did not perform hand hygiene after touching the call lights in residents' rooms A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, and U. The MDIR did not perform hand hygiene when entering and exiting rooms A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, and U. During an…

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