Flower Villa, INC

Based on interview and record review the facility failed to employ an Infection Preventionist Nurse (IPN- a healthcare professional who works to prevent the spread of infections in healthcare facilities) at least part time, to oversee the infection prevention and control program outlined in the Facility Assessment Tool (the facility's self-evaluation of its resident population and identification of the resources needed to provide the necessary person-centered care and services the residents require) dated 1/8/2026. This deficient practice had the potential for a delay in implementing and practicing infection prevention and control measures that could lead to increased risk of infection for the residents in the facility.Findings:During a Review of the facility's November 2025 LVN Schedule, the schedule indicated the IPN was only scheduled to work 4 days in the month of November 2025 (11/4/2025, 11/11/2025, 11/18/2025, and 11/25/2025). During a review of the IPNs timecard for November 2025, the timecard indicated the actual hours worked during the entire month of November 2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to assess and notify the physician immediately when the resident had a change of condition with severe weakness, unable to eat, and unable to speak on 12/11/2025 AM shift for one of three sampled residents (Resident 3). This failure resulted in Resident 3 declining further and requiring a transfer to General Acute Care Hospital (GACH) via 911 (a telephone number used to reach emergency medical, fire, and police services) for further evaluation and treatment.During a review of Resident 3's admission Records, the Records indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), hypertensive heart disease (when the heart had to work too hard, making its muscle thicken and stiff leading to problems like chest pain and heart attack), anxiety disorder (a mental health condition…

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 that a Registered Nurse (RN) worked onsite for at least 8 consecutive hours a day, seven days a week. This deficient practice had the potential for the facility's inability to manage and oversee nursing services provided to 31 residents including resident assessments, consulting with physicians, and administering intravenous fluids or medications. Cross Reference F851 Findings: During A review of Center for Medicare and Medicaid Services (CMS) Staffing Data Report, run date 3/4/2025, the PBJ Payroll Based Journal (PBJ- information of the provider's daily staffing hours for the appropriate care of the residents) staffing data report indicated, on 1st fiscal quarter, facility has no RN hours coverage for the following dates: the facility did not have RN coverage onsite on the following days: 12/02/20230, 12/03/2023; 12/09/2023; 12/10/2023, 12/16/2023, 12/17/2023; 12/23/2023; 12/24/2023; 12/25/2023, 12/29/2023, 12/30/2023;…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC - notification of termination of covered care) at least two days prior to the last covered day for three of three selected residents (Residents 7, 11, and 18). This deficient practice had the potential to result in residents losing their right to appeal the decision of termination of covered care. Findings: A review of Resident 7's admission Record indicated the facility originally admitted the resident on 7/8/2021, and re-admitted the resident on 8/7/2024, with diagnoses that included 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) and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of the NOMNC, the facility gave to Resident 7, indicated skilled nursing care services would end on 11/12/2024. 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 maintain a safe, clean, comfortable and home-life environment in three of seven residents' rooms (Rooms 1, 16 and 20). These deficient practices had the potential to negatively impact the quality of life and increased risk for physical discomfort for residents residing in the facility. Findings: During a concurrent interview and observation of residents' Rooms 1, 16 and 20 on 3/8/2025 at 8:46 a.m. with Maintenance Director (MTD), the drawers in the rooms where resident placed their clothes and belongings did not close completely, and the paint are chipped. MTD stated, the drawer's sliders need to be replaced so that it will be in proper condition for residents used. During an interview with Director of Nursing (DON) on 3/9/2025 at 4:59 PM, DON stated, the equipment that are not in proper condition must be replaced as needed. During a review of the facility policy and procedures (P&P), titled, Safe and Homelike Environment, revised on 1/2025, indicated, In accordance with residents' rights, the facility will…

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: 1. Ensure residents' notice of proposed transfer/discharge's notification was sent to the Office of the State Long-Term Care Ombudsman (public advocate) for four of 10 sampled residents, (Resident 35, 11, 19 and 30) 2. Ensure the documentation was completed and recorded the reasons for the transfer or discharge in the resident's medical record for Resident 35 These deficient practices denied the residents additional protections from being inappropriately discharged for and an incomplete documentation of the discharge process. Cross reference with F842 Findings: A. During a review of Resident 35's admission Records indicated Resident 35 was admitted to the facility on [DATE] and was discharged on 1/22/2025 with diagnoses including Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive…

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 actual nursing hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift were posted for three of three sampled days (3/7/2025, 3/8/2025 and 3/9/2025). This deficient practice resulted in the actual staffing information not being readily accessible and available to residents and visitors and had the potential to cause inadequate staffing. Findings: During an observation of the facility on 3/7/2025 at 6:18 PM., observed Direct Care Services Hours Per Patient Day (DHPPD) posted on the wall with only the projected hours posted. No actual hours were posted and no calculation of unlicensed nursing staffing directly responsible for resident care in the DHPPD posting, there was no DHPPD posted for the previous day (3/6/2025). During an observation of the facility on 3/8/2025 at 10:18 PM, observed DHPPD posted on the wall with only the projected hours. No actual hours were posted and no calculation of unlicensed nursing staffing directly responsible for…

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

Based on observation, interview, and record review the facility failed to follow food safety, labeling, and kitchen sanitation policies and procedures. These deficient practices had the potential to result in compromised food qualities, harmful bacteria growth could lead to foodborne illness in medically compromised residents living in the facility. Findings: During an observation on 3/7/2025 at 5:22 PM in the facility's dry food storage room, dirt and debris were noted under the dry storage racks in the corners of the room (picture taken). During an observation on 3/7/2025 at 5:27 PM in the facility's kitchen some drips of grease were noted on the sides of the range oven (picture taken). During a concurrent observation and interview on 3/8/2025 at 9:20 AM with [NAME] (CK) 1 the open food containers and all food in the fridge were reviewed for labeling of open on date and use by date. Containers of tuna salad, salsa, shredded cheese, mayonnaise and soy milk were noted with no use by dates. CK confirmed the findings and stated they must have forgotten to put the use by date. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed ensure the medical record for four of five residents (Residents 11, 19, 27 and 30) was accurate and compete for: 1. Resident 27's Physician Orders for Life Sustaining Life (POLST- a portable medical order that communicates a patient's wishes for end-of-life care and treatment interventions, particularly during a medical emergency, and is intended for people with serious illnesses) and Advance Directive were filled out accurately, 2. Residents 11, 19 & 30's Notice of Proposed Transfer / Discharge form was signed by the residents or representative. This failure resulted in an inaccurate and incomplete forms in the medical record and had the potential to affect the delivery of care. Cross reference with F623 Findings: 1. During a review of Resident 27's admission Record dated 11/13/2024 indicated the resident was admitted to the facility on [DATE] with diagnoses including: dementia (a progressive state of decline in mental abilities), Vitamin D deficiency…

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 their Payroll Based Journal (PBJ - information of the provider's daily staffing hours for the appropriate care of the residents) complete and accurate data had been submitted to the Center for Medicare and Medicaid Services (CMS) for three of four required quarters (1st fiscal quarter: 10/2023 - 12/2023, 2nd fiscal quarter: 1/2024 - 3/31/2024, and 4th fiscal quarter: 7/2024 - 9/2024) in 2024. This deficient practice had the potential to place 41 facility residents (bed capacity) as risk for delay in care, treatment, and services necessary to maintain physical and emotional wellbeing. Findings: During a review of the facility Certification and Survey Provider Enhanced Reporting system (CASPER: Shows the facility percentage and how the facility compares with other facilities in their state and in the nation) revealed there were no Registered Nurse (RN) coverage and no licensed nursing (LVN) coverage for 4th fiscal quarter, 2nd fiscal quarter and 1st fiscal quarter. During a review of CMS' website Staffing Data PBJ…

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

Based on observation and interview, the facility failed to ensure one of one Hoyer Lift (a mechanical device used to lift and/or transfer a person from place to place) was properly maintained for a safe and effective operation with safety regulations. This deficient practice has a potential to cause incidental accidents to the residents while using the equipment. Findings: During a concurrent observation of the facility's Hoyer Lift and interview with Maintenance Director (MTD) on 3/8/2025 at 8:52 AM, the Hoyer Lift was observed with no stickers of the date when the last manufacturer's inspection. The Hoyer Lift was also observed with rusty color and paints were chipped. MTD stated, the Hoyer Lift are not being inspected by the manufacturer annually. MTD stated, if the Hoyer Lift is broken, he replaces the broken parts if needed. MTD stated, he does not have a certification from the Manufacturer to service the Hoyer Lift. During a review of facility policy and procedures (P&P) titled, Hoyer Lift Maintenance Policy, revised on 1/2025, the P&P indicated, In accordance with residents'…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to create a care plan (a document outlining a detailed approach to care customized to an individual resident's need) for psychotropic (a medication that affects behavior, mood, thoughts, or perception) medication and the resident's anxiety for one of five residents (Resident 16). This deficient practice had the potential for Resident 16 to not receive the appropriate care and experience adverse (harmful) side effects which could result in injury. Findings: A review of Resident 16's admission record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included but not limited to schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily…

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 respiratory care services for one out of 23 sample residents (Resident 13) by failing to auscultate (listen to) lung sound after nebulized medication Albuterol/Ipratropium inhalation solution (aka Duoneb - a medication used to treat breathing problems) treatment per the physicians' order. This deficient practice had the potential for Resident 13 to not have effective respiratory therapy care. Findings: A review of Resident 13's admission Record indicated the facility originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic/ongoing lung disease causing difficulty in breathing), transient ischemic attack (TIA - a temporary blockage of blood flow to the brain) and anemia (a condition where the body does not have enough healthy red blood cells. A review of Resident 13's Need of Oxygen care plan, initiated 2/2/2025, indicated the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure to label an open date of ipratropium-albuterol inhalation solution (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness) inhalation solution for one of five residents (Resident 13) that can expire once opened with an open date according to manufacturer guidelines. This deficient practice had the potential to compromise the therapeutic effectiveness of the stored medications and unintended complications related to the management of medications. Findings: During a review of Resident 13's admission Record indicated Resident 19 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertensive heart disease (includes a number of complications of high blood pressure that affect the heart), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure) and chronic obstructive pulmonary disease (COPD - 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 facility verify informed consent (a principle in medical ethics and medical law that a patient should have sufficient information before making their own free decisions about their medical care) form was given to the physician prior to administering the psychotropic medication Seroquel (a potentially life-threatening medication that treats psychosis) for one of five sampled residents (Resident 16). This deficient practice had the potential for Resident 16 to not be able to exercise his right to know what medications the facility is administering to the resident. Findings: A review of Resident 16's admission record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included but were not limited to schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a medication error rate below 5% (percent-unit of measurement). This failure resulted in three medication errors observed for one of three sampled residents (Resident 27). There was a total of 28 medication opportunities out of which three were observed given incorrectly, which resulted in a medication error rate of 10.71%. Cross reference with F760 Findings: During a review of Resident 27's admission Record dated 11/13/2024 indicated the resident was admitted to the facility on [DATE] with diagnoses including: dementia (a progressive state of decline in mental abilities), Vitamin D deficiency (condition where the body does not have enough Vitamin D, paranoid schizophrenia (a mental illness that is characterized by disturbances in thought, where there is distrust and suspicion), anxiety disorder (excessive fear or worry), encephalopathy (broad term for any brain disease that alters brain function or structure), and hypotension…

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 administer medications without error to one of five sampled residents (Resident 27). This failure resulted in three medications being crushed and administered together, which had the potential to result in therapeutic failure, and unpredictable chemical and physical interactions of the medications. Cross reference with F759 Findings: During a review of Resident 27's admission Record dated 11/13/2024 indicated the resident was admitted to the facility on [DATE] with diagnoses including: dementia (a progressive state of decline in mental abilities), Vitamin D deficiency (condition where the body does not have enough Vitamin D, paranoid schizophrenia (a mental illness that is characterized by disturbances in thought, where there is distrust and suspicion), anxiety disorder (excessive fear or worry), encephalopathy (broad term for any brain disease that alters brain function or structure), and hypotension (low blood pressure). During 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 observation, interview, and record review, the facility failed to provide a routine dental visit to one of five residents (Resident 15). This failure had the potential to affect the resident's self-esteem and quality of life. Findings: During a review of Resident 15's admission Record dated 3/9/2025 indicated the resident was admitted to the facility on [DATE], with diagnosis including; chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and bipolar disorder (sometimes called manic-depressive disorder, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 15's MDS dated [DATE], indicated the resident had moderately impaired cognition. The same MDS further indicated Resident 15 required supervision or touching assistance with eating,…

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 that a Registered Nurse (RN), worked onsite for at least 8 consecutive hours a day seven days a week. This deficient practice had the potential for the facility not to manage and oversee nursing services provided to 35 residents including resident assessments, consulting with physicians, and administering intravenous fluids or medications. Findings: A review of the facility's Daily Staffing Nursing Record dated 1/1/2024 to 2 27/2024, indicated the facility did not have RN coverage onsite on the following days: 1/1/2024 1/6/2024 1/7/2024 1/13/2024 1/14/2024 1/20/2024 1/21/2024 1/27/2024 1/28/2024 2/3/2024 2/4/2024 2/5/2024 2/8/2024 2/9/2024 2/10/2024 2/11/2024 2/12/2024 2/17/2024 2/18/2024 2/24/2024 2/25/2024 During an interview with Registered Nurse 1 (RN 1) on 2/28/2024 at 11:00 AM, RN 1 stated there was no Registered Nurse in the facility on the weekends. RN 1 stated it is a small facility and there was no need for a Registered Nurse onsite…

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' medical records were updated to show accurate documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were provided to the residents and/or responsible parties for two of five sampled residents (Resident 2 and Resident 10 ). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care for Resident 2 and Resident 10. Findings: A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with medical history including major depressive disorder (a mood disorder that causes persistent feelings of sadness), type 2 diabetes (elevated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to immediately notify a physician regarding a left eye infection for one (1) of five (5) sample residents (Resident 8). This deficient practice could have resulted in a delay of care and treatment for Resident 8. Croos Reference F684 Findings: A review of Resident 8's admission Record, indicated the resident was admitted on [DATE] with diagnoses including type 2 diabetes (elevated blood sugar), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anemia (low red blood cells), dementia (memory loss), and entropion (a condition in which the eyelid is rolled inward against the eyeball) of left lower eyelid. A review of Resident 8's Minimum Data Set (a standardized care screening and assessment tool) dated 1/27/2024, indicated the resident's cognition (thought process relating to thinking, reasoning, and remembering) was severely impaired. Resident 8 required moderate assistance with eating, oral…

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 residents' Minimum Data Set (MDS- standardized assessment and care screening tool) assessments were transmitted to Centers for Medicare and Medicaid Services within 14 days after completion for four out of four sampled residents (Residents 2, 5, 27, and 33). This deficient practice resulted in 14 days delayed transmission of MDS assessments for Residents 2, 5, 27, and 33. Findings: During an interview and record review with MDS Licensed Vocational Nurse (MDS LVN) on 2/29/2024 at 8:22 AM, Residents 2, 5, 27, and 33 admission records were reviewed. MDS LVN identified the following MDS assessments completed however documents were not transmitted within 14 days to the Centers for Medicare and Medicaid (provides healthcare coverage to people through Medicare and Medicaid) as follows: a. Resident 2 Annual MDS (ARD 5/15/2019) completed 1/3/2023, was not transmitted. b. Resident 5 Quarterly MDS (ARD: 8/28/2023) completed 1/24/2024, was not transmitted. c. Resident 27 Annual MDS (ARD: 3/27/2023) completed 1/4/2024, was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions for a left eye infection for one out five sampled residents (Resident 8). These deficient practices had the potential to negatively affect the delivery of necessary care and services for Resident 8. Findings: A review of Resident 8's admission Record, indicated the resident was admitted on [DATE] with medical history including type 2 diabetes (elevated blood sugar), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anemia (low red blood cells), dementia (memory loss), and entropion (an inversion or inward turning of the left eyelid margin) of left lower eyelid. A review of Resident 8's Minimum Data Set (MDS - a standardized tool and assessment form) dated 1/27/2024, indicated the resident's cognition was severely impaired. Resident 8 required moderate assistance with eating, oral…

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 resident received treatment and care in accordance with professional standards of practice for one (1) of five (5) sample residents (Resident 8) by: Failing to follow facility's policy on Resident Change of Condition for Resident 8's left eye infection. This deficient practice could have resulted in a delay of care and treatment for Resident 8. Cross Reference F580 Findings: A review of Resident 8's admission Record, indicated the resident was admitted on [DATE] with diagnoses including type 2 diabetes (elevated blood sugar), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anemia (low red blood cells), dementia (memory loss), and entropion (a condition in which the eyelid is rolled inward against the eyeball) of left lower eyelid. A review of Resident 8's Minimum Data Set (a standardized care screening and assessment tool) dated 1/27/2024, indicated the resident's cognition (thought…

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 an antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics), for antibiotic use protocol to ensure that residents received the right antibiotic for the right indication, dose, and duration for one of two sampled residents (Resident 22) in 1/2024. This deficient practice had the potential not to optimize the treatment of infections while reducing the adverse events associated with antibiotic use for Resident 22. Findings: A review of Resident 22's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with medical diagnoses including chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow), type 2 diabetes (high blood sugar), hyperlipidemia (elevated cholesterol), hypothyroidism (low thyroid function), dementia (loss of memory), and osteoarthritis of the knee (a degenerative…

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 failed to ensure Licensed Vocational Nurse 1 (LVN 1) wore appropriate personal protective equipment (not limited gown, mask, gloves, eye protection) before entering a transmission based airborne precaution isolation (used to help stop the spread of germs from one person with known or suspected infection to another) room for three of three residents (Residents 1, 2, and 3) in accordance with the facility's policies and procedures titled, Infection prevention and control programs, Covid-19, and Personal Protective Equipment-Using gowns. Residents 1, 2, and 3 tested positive for COVID-19 (an acute disease caused by coronavirus characterized by fever and cough and is capable of progressing to severe symptoms and in some cases death). This deficient practice increased the risk of spreading COVID-19 among residents, staff, and guests in the facility. Findings: A review of Resident 1's Face Sheet indicated the facility originally admitted Resident 1 on 10/9/2012 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.