Hollenbeck Palms

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to measure the external catheter length (insertion site to hub) for Peripherally Inserted Central Catheter (PICC, a thin, flexible tube inserted into a small arm vein and guided to a large central vein near the heart) line for one of 28 sampled residents (Resident 24), in accordance with Facility's policy and procedure (P&P) titled PICC Dressing Change. This failure had the potential to put Resident 28 at risk for PICC line dislodgement (the act of being forced or moved from a secure, fixed) and developing complications like thrombosis (the formation of a blood clot [clump of blood] inside a blood vessel [vein or artery] that blocks or slows blood flow), and infection (when harmful germs invade the body).Findings: During a review of Resident 24's admission Record, it indicated the resident was admitted to the facility on [DATE], admitting diagnoses of malnutrition, weight loss and encounter for adjustment and management of vascular access…

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 facility staff donned (put on) proper personal protective equipment (PPE; clothing and equipment that is worn or used to protect against hazardous substances and/or environments) prior to entering a contact isolation (a transmission based precaution used to stop germs from spreading through direct touch with a resident or indirect touch with contaminated objects in their environment) room for two (2) of nine (9) sampled residents (Residents 28 and 45) in accordance with the facility's policy and procedure (P&P) This failure had the potential to result in the spread of infection to other residents in the facility.Findings:1. During a review of Resident 28's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of cerebral ischemia (when blood flow to the brain is reduced, cutting off oxygen and nutrients, which can damage or kill brain…

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 as indicated on the facility policy when facility failed to: 1. Ensure staff wear Personal Protective Equipment (PPE, protective clothing such as gown, gloves, goggles, mask) before administering medication to Resident 35 via gastrostomy tube (G-tube, a surgically inserted tube that provides a way to deliver nutrition, fluids, and medications directly to the stomach) on 10/24/2024. This deficient practice had the potential to result in Resident 35 developing an infection and spread of infection among staff and residents. 2. Ensure the Legionella (a type of bacteria spread through small droplets of water that can cause legionellosis [Legionnaires' Disease, a serious and potentially deadly lung infection]) Water Management Program policy and procedure was implemented when Facility lost water supply due to water main break outside the facility on 10/23/2024. This deficient practice had the potential to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure three of six sampled resident's (Resident 37, 6, and 10) environment was free from accidental hazards (a source of danger that has the potential to cause harm) when hot water temperatures inside the resident's bathrooms were measured to be above 120 degrees Fahrenheit (F- unit of measurement for temperature). This deficient practice placed Residents 37, 6 and 10 at risk for scalding (very hot) and burns (injury related to exposure to heat or flame) related to hot water temperatures. Findings: 1. During a review of Resident 37's admission record, the admission record indicated the resident was initially admitted to the facility on [DATE] and re admitted on [DATE] with a diagnosis of aphasia (language disorder that makes it difficult to communicate with others) following cerebral infarction (a serious condition that occurs when an area of the brain tissue dies due to a lack of blood flow), difficulty in walking, hemiplegia (total 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 Cross reference: F755 Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Nine (9) medication errors out of 27 total opportunities for error, to yield an overall medication error rate of 33.3 % for one (1) of five (5) residents observed for medication administration (Residents 35). Licensed Vocational Nurse 1 (LVN 1) failed to administer Resident 35's medications within 60 minutes of scheduled time of 8 AM on 10/24/2024. This deficient practice had the potential to result in Resident 35 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Resident 35'ss health and well-being to be negatively impacted. Findings: During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was originally admitted to the facility on [DATE]. Resident 35's diagnoses included hemiplegia (total paralysis of the arm,…

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 food were handled, prepared, and stored in a manner that prevents foodborne illness (food poisoning) for 56 of 56 residents receiving food from the facility's kitchen, by failing to ensure: 1. Food items stored in the kitchen refrigerators and freezer (thirty-eight [38] food items), walk-in freezer (eleven [11] food items), dry storage area 1 (where breads and vegetables are stored) (three [3] food items) were labeled with open date and/or use by date (last date recommended for use of the product while at peak quality), and/or expiration date and sealed after opening. 2. Two (2) dented canned products were discarded and one (1) cracked and leaking peanut butter jar was discarded from the dry storage area 2 (where canned products, sugars and jars are stored). In addition, the facility failed to ensure the container with blue lid in the dry storage area 2 was free of dirt, dust, and dead fly. 3. Expired food products were removed and discarded. 4. Temperature logs for the kitchen refrigerators and dry…

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 dispose garbage (mostly decomposable food waste or yard waste) and keep 11 of 11 garbage bin/plastic dumpster/refuse (dry material such as glass, paper, cloth, or wood that does not readily decompose) containers covered and/or not overfilled with trash as indicated on the facility policy. These deficient practices had the potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) that could potentially infiltrate the facility, affect the resident care areas and pose a disease threat to the residents and staff of the facility. Findings: During an observation of the first-floor hallway of the kitchen on 10/22/2024 at 7:59 AM, a garbage bin without a cover was seen next to a metal cart with a plate, two used uncovered pitchers, a washcloth, roll of unused trash bags, and two open boxes of plastic aprons. There was also a rolling cart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect for one of one sampled resident (Resident 1) by failing to ensure facility staff did not stand above Resident 1's eye level while assisting the resident to eat. This deficient practice had the potential to affect Resident 1's self-esteem and self-worth and violates Resident 1's right to be treated with dignity. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted the resident on 6/30/2016 and readmitted on [DATE] with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), polyosteoarthritis (arthritis- inflammation and stiffness of the joints, affects five or more joints at the same time), major depressive disorder (a mood…

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 copy of the advance directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them) was readily available in the residents' medical chart for two of 10 sampled residents (Residents 6 and 108) in accordance with the facility's policy and procedure titled Advance Directives. This failure had the potential to result in nursing staff not knowing if Residents 6 and 108 had specific resident wishes to follow in case of an emergency. Findings: During a review of Resident 6's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die), epilepsy (a sudden, abnormal burst of electrical activity in the brain that causes…

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 one of two sampled resident (Resident 19) was free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body) when the facility failed to conduct an assessment for the use of geriatric chair (Geri chair, a large, padded, and mobile reclining chair that prevents a resident from rising). This deficient practice had the potential to result in limiting Resident 19's mobility and cause injury. This also had the potential for Resident 19 not to be treated with respect and dignity with the use of restraints. Findings: During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was originally admitted to the facility on [DATE]. Resident 19's diagnoses included dementia (a progressive state 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 incontinent care and keep the resident free of foul odors to one of ?? sampled residents (Resident 108) who is dependent (helper does all the effort to complete an activity) on assistant from staff for personal, toileting hygiene, and showers. These deficient practices resulted in the residents feeling frustrated and embarrassed, due to lack of or delay in receiving sufficient services to maintain personal hygiene and incontinent care and had the potential to lead to skin breakdown, social isolation and to negatively impact Resident 108's self-esteem. Findings: During a review of Resident 108's admission record, the admission record indicated the resident was initially admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses cellulitis of left lower limb (a superficial infection of the skin), obesity (abnormal or excessive fat accumulation that presents a risk to health), personal history of urinary tract…

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 one of two sampled residents (Resident 51) who was on continuous oxygen (colorless, odorless, and tasteless gas) therapy received oxygen as ordered in accordance with the facility policy. This deficient practice had the potential to cause complications associated with oxygen therapy and could result in the resident not receiving proper treatment. Findings: During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 51's diagnoses included shortness of breath, dependence on supplemental oxygen, and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 51's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/19/2024, the MDS indicated Resident 51's cognitive (ability to think and reason) skills for daily decision making was severely…

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 Cross reference: F759 Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of five sampled residents (Resident 35) in accordance with the facility policy by failing to administer Resident 35's 8 AM due medications on 10/24/2024 as indicated on the physician's order. This deficient practice had the potential for Resident 35 to experience tachycardia (a fast heartbeat of more than 100 times per minute), high blood pressure (when your blood pressure is consistently higher than normal), and decline in overall health status. Findings: During a review of Resident 35's admission Record, indicated Resident 35 was originally admitted to the facility on [DATE]. Resident 35's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a medical condition that causes weakness or an inability to move on one side of the body) affecting left side, and gastrostomy (a surgical opening fitted…

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 one of five (5) sampled residents (Resident 35) was free from significant medication error (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications [not recommendations] regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services) by administering Amlodipine (a medication used to treat high blood pressure), Carvedilol (a medication that slows down the heart rate making it easier for the heart to pump blood around the body) and Losartan (a medication used to treat high blood pressure) to Resident 35 outside of physician ordered parameters. This deficient practice increased the risk for Resident 35 to may have experience serious medical complications such as bradycardia (a condition where the heart beats…

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 one (1) of two (2) sampled residents (Resident 1) was free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure Resident 1 had a specific target behavior for the use of Lorazepam ( medication used to treat anxiety [persistent and excessive worry that interferes with daily activities]). This deficient practice had the potential to place Resident 1 at risk for significant adverse (harmful) consequences from the use of unnecessary psychotropic drug, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status. Findings: During a review of Resident 1's admission Record, the admission Record indicated an initial admission to the facility on 4/6/2024, and readmission on [DATE]. Resident 1's diagnoses included anxiety disorder, dementia (a brain…

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 one of two (2) sampled residents (Resident 1) was free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body) by failing to conduct an assessment for the use of seatbelt (an arrangement of straps designed to hold a person steady in a seat). This deficient practice had the potential to negatively affect Resident 1's physical and psychological wellbeing and quality of life. Findings: During a review of Resident 1's admission Record, the admission Record indicated an initial admission to the facility on 4/6/2024, and readmission on [DATE]. Resident 1's diagnoses included anxiety disorder (persistent and excessive worry that interferes with daily activities), dementia (a brain disorder that results in memory loss,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility failed to develop a comprehensive resident-centered fall care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) for one of two sampled residents (Resident 1) per facility policy. This deficient practice had a potential for Resident 1's increased risk for further falls. Findings: During a review of Resident 1's admission Record, the admission Record indicated an initial admission to the facility on 4/6/2024, and readmission on [DATE]. Resident 1's diagnoses included anxiety disorder (persistent and excessive worry that interferes with daily activities), dementia (a brain disorder that results in memory loss, poor judgment, and confusion), and repeated falls. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 7/15/2024, 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 observation, interview, and record review, the facility failed to ensure two (2) of 2 sampled residents (Residents 19 and 31) had their low air loss (LAL, operates using a blower based pump that is designed to circulate a constant flow of air through the mattress, commonly used to heal pressure ulcers [wound that occurs as a result of prolonged pressure on a specific area of the body]) mattresses set according to the resident's in accordance to the manual for Med-Aire Essential 8-inch Alternating Pressure and Low Air Loss Mattress System. 1. Resident 19, who weighed 82 pounds (lbs.), was observed with the LAL mattress set at 440 lbs. 2. Resident 31, who weighed 137 lbs., was observed with LAL mattress set at the highest setting at 350 lbs. This deficient practice placed Resident 19 at risk for development of new pressure ulcer and placed Resident 31 at risk for progression of pressure ulcer. Findings: 1. A review of Resident 19's admission Record, indicated the resident was admitted to the facility on…

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

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety and as indicated in the facility policy by failing to: 1) Label multiple food items in the kitchen refrigerator and dry food storage with the opened and prepared date, food item names, and received date and expiration date. 2) Discard expired food. 3) Follow infection control measures in the kitchen when an empty water bottle and soda can were found on the storage rack in the dry storage room. These deficient practices have a potential to contaminate food items and can place the residents at risk for infection. These deficient practices have the potential to result in food borne illnesses (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) to the residents. Findings: 1. During an observation in the kitchen on 11/17/23 at 6 p.m., two (2) large plastic containers of food items without labels indicating the date when food was prepared were found…

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 two (2) of three (3) sampled residents (Residents 19 and 29) under hospice care (provides medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness) services had coordinated care between the facility and the hospice agency. Resident 19 did not have a certification of illness documented in the active records to receive hospice services. This deficient practice had the potential for Residents 19 and 29 to not receive the appropriate care and/or services from the facility and the hospice agency. Findings: 1. A review of Resident 19's admission Record indicated the resident was admitted to the facility on [DATE] and was re-admitted [DATE] with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a resident's daily functioning) and adult failure to thrive (unintentional weight loss, a decline in functional…

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 standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure when: 1. Resident 15's double lumen (a small soft tubing) peripherally inserted central catheter (PICC, used to give medications, fluid and nutrition directly to the vein near the heart) access dressing was not changed every seven (7) days as indicated on the PICC dressing change policy. 2. Licensed Vocational Nurse 3 (LVN 3) failed to practice hand hygiene after administering: a. Resident 50's gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach) medication and nasal spray b. Resident 30's G-tube medication and eye drops c. Resident 26's oral medications and eye drops 3. A soiled diaper was left on top of the toilet tank of Resident 5 and Resident 37's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST, a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency, taking the patient's current medical condition into consideration) coincides with the advance directives (written statement of a person's wishes regarding medical treatment which were made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for one (1) of 1 sampled resident (Resident 37) when the POLST indicating Do not Resuscitate (DNR, medical order that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest) was placed in the residents chart without the signature of the attending physician. This deficient practice had the potential to cause conflict in carrying out Resident 37's wishes for medical treatment and resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the licensed nursing staff failed to notify the physician when there was a change in condition for one of 15 sampled residents (Resident 17) in accordance with the facility policy. This deficient practice had the potential to result in delayed provision of necessary care and services. Findings: A review of the admission record indicated Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE] with cerebral ischemia (a condition in which a blockage in an artery restricts the delivery of oxygen-rich blood to the brain resulting in damage to brain tissue.), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), candidiasis (skin infection may cause rashes, scaling, itching, and swelling) of skin and nail. A review of the History and Physical report completed on 2/20/23, indicated Resident 17 did not have the capacity to understand and make decisions. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to implement their Abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) Prevention, management, and Reporting Policies by not reporting and investigating an injury of unknown origin that may be a result abuse or neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) for one out of 15 residents (Resident 16). This deficiency has resulted a delay of the delivery of care to Resident 16 who had suffered a fracture (a partial or complete break in the bone) of left shoulder. Findings: a. A review of Resident 16's admission Record indicated the resident was admitted to the facility on [DATE]. Resident 16's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing…

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 one (1) of 1 sampled resident (Resident 17) was provided care and services to maintain good grooming and personal hygiene in accordance with the facility policy. This deficient practice had the potential to result in a negative impact on Resident 17's quality of life and self-esteem. Findings: A review of the admission record indicated Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE] with Cerebral ischemia (Cerebral ischemia- a condition in which a blockage in an artery restricts the delivery of oxygen-rich blood to the brain resulting in damage to brain tissue.), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Candidiasis (skin infection may cause rashes, scaling, itching, and swelling) of skin and nail. A review of Resident 17's Minimum Data Set (MDS, a comprehensive standardized assessment and screening…

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 provision of pharmaceutical services when one (1) of two (2) medication carts was left unlocked before licensed vocational nurse (LVN) entered a resident's room to administer medications. This deficient practice had the potential for non-authorized staff or residents to access the medication cart, which can result to drug diversion (prescription medications are obtained and or used illegally by healthcare providers) or may cause serious injury/harm in the event that the medications are ingested by the residents. Findings: During a medication pass observation on 11/19/23 at 4:13 p.m., the LVN 3 forgot to lock the medication cart before going to Resident 15's room to administer resident's medications. Five (5) Residents were observed sitting on a wheelchair, across the room in the hallway, where the medication cart was located. During an interview on 11/19/23 at 4:20 p.m., LVN 3 verified she forgot to lock the medication cart and stated the cart always had to be locked because the residents might…

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.