West Hollywood Healthcare & Wellness Centre, LP

Based on interview and record review, the facility failed to provide intravenous catheter (IV -a thin, flexible tube inserted into the vein to deliver fluids, medications, or other treatments directly into the blood stream) treatment in accordance with professional standards for one of one sampled resident (Resident 6) by failing to remove Resident 6's IV catheter on 6/8/2025 when ordered IV hydration was completed. This deficient practice had the potential to result in infection and possible hospitalization for Resident 6. Findings: During a record review, Resident 6's admission Record indicated the facility admitted Resident 6 on 6/16/2020 and readmitted Resident 6 on 5/6/2025 with diagnoses including hypertension (elevated blood pressure), chronic kidney disease (when kidneys, that filter waste from the blood become damaged and don't work as well as they should), and diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing. During a record review, Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 5/13/2025, 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 observations, interviews, and record reviews, the facility failed to provide necessary respiratory care services for one of one sampled resident (Resident 19), by failing to: 1. Ensure Resident 19's oxygen tubing was changed weekly in accordance with the facility's policy and procedures (P&P) titled Oxygen Therapy revised 1/27/2025. 2. Ensure a physician's order for oxygen was complete and accurate in accordance with the facility's P&P titled Physician Orders revised 1/27/2025. This deficient practice had the potential to result in infection, medication error and possibly hospitalization for Resident 19. Findings: During a record review, Resident 19's admission Record indicated the facility admitted Resident 19 on 11/27/2018 and readmitted Resident 19 on 12/2/2024 with diagnoses including congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Acute respiratory failure with hypoxia (when the lungs are having a hard time getting enough oxygen into the blood and body), and diabetes (DM-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 record review and interview the facility failed to ensure one of three sampled residents (Resident 59) who required dialysis (a medical treatment that cleans the blood when the kidneys are unable to do so) received services consistent with professional standards. By failing to assess the resident's current vital signs (body temperature, blood pressure, pulse [heart rate], and breathing rate to help assess the general physical health of a person) prior to transporting the resident to the dialysis center. This deficient practice had the potential for Resident 59 to experience adverse complications that would not be identified by facility staff in a timely manner. Findings: During a record review, Resident 59's admission record indicated the facility admitted the resident on 2/3/2025 and readmitted the resident on 5//52025 with diagnoses including but not limited to ESRD (End Stage Renal Disease-irreversible kidney failure), dependence on renal dialysis and kidney transplant failure. During a record review, Resident 59's Minimum Data Stet (MDS - a 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 interview and record review, the facility failed to ensure residents were informed, offered or followed up regarding Advance Directive (ACHD - 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) in a timely manner for four of 18 sampled residents (Residents 48, 43, 3, and 58). This deficient practice had the potential to cause conflict with resident's wishes regarding health care. Findings: 1. A review of Resident 43's admission Record indicated Resident 43 was admitted to the facility on [DATE] with diagnosis including urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder or urethra), sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), and paroxysmal atrial fibrillation (afib- a sudden irregular and very rapid heart rhythm that and can lead to blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician when the resident continued to refuse to take her medications for one of two sampled residents (Resident 58). This deficient practice had the potential to result in delayed provision of necessary care, treatment and services. Cross Reference F656 Findings: A review of Resident 58's admission Record indicated resident was admitted to the facility on [DATE] with diagnosis including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), hypertension (HTN - elevated blood pressure), history of falling and muscle weakness. A review of Resident 58's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 4/21/2024, indicated Resident 58's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning…

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 1d. A review of Resident 44's admission Record indicated Resident 44 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including injury of head, dementia (loss of cognitive functioning-thinking, remembering, and reasoning), generalized weakness, history of falling and epilepsy (a disorder in which a nerve cell activity in the brain is disturbed causing seizure [a sudden, uncontrolled electrical disturbance in the brain]). A review of Resident 44's MDS dated [DATE], indicated Resident 44's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was moderately impaired and requiring maximal assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use). A review of Resident 44's physician order summary report (POSR), as of 5/27/2024, POSR indicated no orders for side rails. A review of Resident 44's care plan, indicated Resident 44 was at risk for fall related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement individualized (resident-specific) comprehensive care plans (plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) for 12 out of 12 sampled residents (Residents 36, 40, 227, 277, 278, 48, 43, 50, 3, 178, 330 and 44) by: 1. Failing to develop and implement care plans for bilateral upper bed side rails as mobility enabler (assist in turning and transferring in and out of bed) for residents 36, 40, 277, and 278. 2. Failing to develop and implement a care plan for Resident 277's Venofer (iron sucrose - an IV iron medication) intravenous (IV, medical technique that administers fluids, medications, and nutrients directly into a person's vein) solution 100 milligrams (mg) intravenously in the evening for iron deficiency. 3. Failing to implement a care plan for transmission-based precautions (a set of infection control measures used in addition to standard precautions 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 provide the necessary care and services to attain or maintain the highest practical emotional/physical well-being and pain management for two of two sampled residents (Resident 9 and Resident 58), by: 1. Failing to administer Resident 9's Lidocaine External Patch 5 percent (% - unit of measurement)- apply to affected area topically one time a day for pain management leave on for only 12 hours only within a 24-hour period at the scheduled time (9:00 a.m.). 2. Failing to remove Resident 9's lidocaine patch (a prescription-only topical local anesthetic) 12 hours after application as per physician's order and timely administered medications per physician's order. 3. Failing to ensure Resident 58's lidocaine patch was labeled according to facility's policy and procedure, titled Transdermal Drug Delivery System (Patch) Application reviewed on 1/29/2024. This deficient practice placed Resident 9 and Resident 58 at risk for experiencing untreated…

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 sufficient staffing to accommodate resident needs by not answering call lights (device(s) with a button or touch pad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) in a timely manner for four of five sampled residents (Resident 8, 18, 50 and 53). This deficient practice resulted in Resident 8, 18, 50 and 53 not receiving needed services timely and efficiently and had the potential to affect the quality of life and treatment given to all 72 facility residents. Findings: A review of Resident 8's admission Record indicated Resident 8 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including obesity (a disorder involving excessive body fat that increases the risk of health problems), osteoarthritis (inflammation of the bone) and generalized muscle weakness. A review of Resident 8's Minimum Data Set (MDS - a comprehensive assessment…

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 facility staff possessed the appropriate competencies to provide nursing and related services to assure resident safety four of nine sampled nursing staff (Registered Nurse 1-RN 1, Infection Prevention Nurse 1-IPN 1, Certified Nursing Assistant 4-CNA 4 and Certified Nursing Assistant 7-CNA 7) had the specific competencies and skills sets necessary to care for the residents. This deficient practice had the potential to lead to inadequate care and a delay resident's care. Findings: During a concurrent interview and record review of employee files on 5/27/2024 at 4:35 p.m., the Director of Staff and Development (DSD) reviewed nine sampled nursing staff files and confirmed by stating there were missing skills competencies (verification of the ability to perform a task with the necessary knowledge, skills, and abilities to provide safe and effective care to residents) for RN 1, IPN 1, CNA 4 and CNA 7. The DSD stated nursing skills competencies were required to be verified upon hire, yearly, and as needed. 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 ensure pharmaceutical services included procedures to ensure the emergency kit (e-kit - secured container or secured electronic system containing drugs which are used for either immediate administration to residents or in an emergency or as a starter dose) was securely sealed and medciation used from the E-kit was reordered. By failing to: 1. Ensure the Intravenous (IV, insertion of a cannula or catheter into a vein to provide access to the bloodstream) E-kit located in one of one sampled medication storage closet (medication storage closet 1) was properly resealed, had an open date documented, and medication used was reordered. 2. Ensure the narcotic (any psychoactive compound with numbing or paralyzing properties) E-kit located in one of two sampled medication carts (medication cart 1B) was properly resealed and medication used was reordered. This deficient practice had the potential for harm to residents due to a lack of availability of medications leading to delays in the timely administration 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 pharmaceutical services to meet the needs of residents in the facility by failing to: 1. Ensure proper disposal of an open sterile central line (a small, soft tube called a catheter is put in a vein that leads to your heart, used for delivering fluids or medications for a longer period of time) dressing kit, and expired sterile (completely clean and free from germs) needles, alcohol pads (small gauze pads saturated with alcohol used as an disinfectant), and saliva collection kit (syringe used to collect saliva for a lab test). 2. Ensure opened medication bottles/containers for acidophilus (prebiotic medication) and bismuth subsalicylate (medication that relieves symptoms of upset stomach) were dated when opened. 3. Ensure ipratropium Bromide and albuterol sulfate solution (medication being given via inhalation [inhaling medication in the form of gas or vapor] used to treat or prevent bronchospasm [when muscles that line the airways…

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 the menu and provide resident a variety of food options when: 1.One resident (Resident 48) who was on a renal diet (a diet aimed at keeping levels of fluids, electrolytes, and minerals balanced in the body in individuals with kidney disease or who are on dialysis) received chicken jambalaya (mixed rice, chicken, and tomato dish) instead of Baked chicken and rice per menu. 2. Residents who were on vegetarian and vegan diets (Resident 69, Resident 61 and Resident 9) complained that the menu does not have variety of vegetarian options and Resident 61 complained that last week fish sticks were served every day for lunch. This deficient practice had the potential to result in inadequate nutrition status and meal dissatisfaction when the menu is not updated to reflect the needs of the residents. Findings: According to the facility dinner menu for regular diet on 5/24/2024, the following items will be served on the regular diet: Chicken Jambalaya (a casserole type dish with mixed rice, chicken, sausage, tomato…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents were served the food with preferences listed on the lunch meal ticket (physician ordered diet with resident food preferences) and received substitute meal options of similar nutritive value when: 1.One resident (Resident 69) food preferences were not honored by serving fish sticks during lunch, despite Resident 69's diet order indicated Vegan. 2. Two residents (Resident 61 and Resident 9) who are vegetarians and do not eat meat, received 3 fish sticks for alternate protein choice that had lower protein content than the beef paprika (diced beef and spices) and the roasted pork chop that was on the regular menu. This deficient practice had the potential to result in decreased meal satisfaction, decreased nutritive value for the meal, which could lead weight loss and other health issues. Findings: 1. A review of admission Record indicated Resident 69 was admitted to the facility on [DATE] with diagnoses including epidural…

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 when: Food brought to resident from outside of the facility, including leftovers stored in the resident food refrigerator were not dated. There was no monitoring system for the refrigerator temperatures and expired food was not discarded. This deficient practice had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 67 out of 70 residents who received food from facility including the residents who had their food stored in the resident refrigerator. Findings: During an observation in the resident refrigerator located in a room in the common hallway on 5/25/2024 at 11:00 a.m., there was no thermometer inside the freezer, no refrigerator/freezer temperature documentation log. There were three plastic bags containing food with no date. There was one large brown bag with food for a resident with no date. There was one lunch box with no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the facility's Administrator (ADM) who was responsible for providing effective leadership, oversight, safe access to residents, staff, and visitors, policies, and procedures throughout the recertification process-maintained professionalism and appropriate behavior. This deficient practice impeded the completion of an investigation, placing facility residents at risk for the spread of infections, delays in care, and had the potential to make residents, visitors, and staff feel threatened. Findings: A review of Resident 278 admission record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included chronic kidney disease stage 4 (kidneys are moderately or severely damaged and are not working as well as they should to filter waste from your blood. Waste products may build up in your blood and cause other health problems), type 2 diabetes mellitus (DM-a chronic condition that affects the way 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 observation, interview, and record review, the facility failed to maintain an infection prevention and control program to implement their infection control policy and procedures (P&P) for five of 19 by failing to: 1. [NAME] (put on) appropriate personal protective equipment (PPE) when disconnecting Resident 3 from the gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) and while assisting Resident 3. 2. [NAME] appropriate PPE when Certified Nursing Assistant 4 (CNA 4) was assisting Resident 178 during basic care. Enhanced Standard Precaution (ESP-transmission based precaution that refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) signage was not updated in Resident 178's door. 3. Provide education about ESP and offer PPE use to the visitors of Resident 278. 4. Ensure…

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 facility's protocol for Antibiotic Stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients/resident) for three of three sampled residents (Resident 13, 178, and 278). This deficient practice had the potential for Resident 13, 178, and 278, to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use, which could lead to adverse events including allergic reactions. Findings: 1. A review of Resident 178's admission Record indicated Resident 178 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), end stage renal failure (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident's right to be informed were honored and implemented accordingly to her decision on health care treatment for one of five sampled residents (Resident 43). This deficient practice violated resident's right to make an informed decision and resulted to failure in the delivery of necessary care and services. Findings: A review of Resident 43's admission Record indicated Resident 43 was admitted to the facility on [DATE] with diagnosis including urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder or urethra), sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), and paroxysmal atrial fibrillation (afib- a sudden irregular and very rapid heart rhythm that and can lead to blood clots in the heart). A review of Resident 43's Minimum Data Set (MDS - a comprehensive assessment and care 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to enhance a resident's dignity and respect by failing to provide personal hygiene and assistance to one of five sampled residents (Resident 1). This deficient practice had the potential to negatively affect the residents' psychosocial well-being. Findings: A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning), moderate protein-calorie malnutrition (lack of sufficient nutrients in the body), and heart failure (a condition in which the heart does not pump blood as well as it should). A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 5/2/2024, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were 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 Based on interview and record review, the facility failed to provide a safe, comfortable, and homelike environment by failing to ensure residents' rooms were kept with comfortable sound levels maintained for two of five sampled residents (Residents 18 and 53). This deficient practice had the potential to negatively impact the resident's quality of life and placing Residents 18 and 53 an increased level of discomfort and inability to sleep during the night. Findings: 1. A review of Resident 18's admission Record indicated that Resident 18 was admitted to the facility on [DATE] with diagnosis including monoplegia (paralysis limited to a single limb [arm/leg]) of lower leg, spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine) and generalized muscle weakness. A review of Resident 18's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 3/27/2024, MDS indicated Resident 18 has a moderately intact…

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 observations, interview, and record review the facility failed to identify and notify the Medical Director (MD) about a change in condition for Resident 62's noncompliance of not using a humidifier (are devices that add moisture to the air to prevent dryness that can cause irritation in many parts of the body) for his oxygen. This deficient practice had the potential to place Resident 62 at a risk of having dry mucus membranes mucus membranes which could lead to break in skin resulting in bacteria entering through the broken skin. Findings: A review of Resident 62 admission record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included hemiplegia (loss of strength in the arm, leg, and sometimes the face on one side of the body) and hemiparesis (loss of use in the arm, leg, and sometimes the face on one side of the body) following cerebral infarction (stroke), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment free from risks and hazards for one of six sampled residents, (Resident 48) by failing to ensure Resident 48's Desitin cream (used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations [such as diaper rash, skin burns from radiation therapy]) inside the resident's bedside drawer and [NAME] tears eyedrops (used to help relieve dryness of the eyes) were not left on top of the resident's bedside table by facility staff without a proper physician's order and per facility's policy and procedures (P&P) titled Self-Administration of Medications with a review date of 1/29/2024. This deficient practice increased the risk for accidents, under or overdosing, medication diversion (medication used for a purpose or on a person not prescribed for), and jeopardized residents' health and safety. Cross Reference F656 Findings: A review of Resident 48's admission Record indicated resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide intravenous (IV, insertion of a cannula or catheter into a vein to provide access to the bloodstream) access care consistent with professional standards of practice and as per facility policy and procedures (P&P) titled Central Venous Catheter Dressing Changes dated May 2022, for two of two sampled residents (Residents 277 and Resident 278). By failing to ensure: 1. A care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) was developed and implemented for Resident 277's IV therapy. 2. Resident 278's peripherally inserted central catheter (PICC, a thin, soft tube inserted into a vein in the arm, leg, or neck for long-term intravenous antibiotics) was labeled with date and time the dressing was changed and the initials of the staff member changing the dressing. 3. Registered nurse 1 (RN 1) wore the required personal protective equipment (PPE, protective clothing for 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 observation, interview, and record review, the facility failed to provide necessary respiratory care services for two of two sampled residents (Resident 3 and Resident 10) by failing to ensure: 1. Resident 3 received oxygen at 2 liters per minute (l/min - unit of measurement) via nasal cannula (NC - a device used to deliver supplemental oxygen that should be placed directly on the resident's nostrils) to keep oxygen saturation (O2 sat) above 93 percent (% - unit of measurement) every shift for shortness of breath (SOB)/desaturation (the condition of a low blood oxygen concentration) as per physician's order dated 1/17/2024. 2. Resident 10 received oxygen at 2l/min via NC to keep O2 sat above 93 percent every shift for SOB every shift, as per physician's orders dated 8/18/2023. This deficient practice had the potential to deny Resident 3 and Resident 10's the oxygen needed to ensure brain and organ health and function. Cross Reference: F656 Findings: 1. A review of Resident 3's admission Record indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 46) received the care and services consisted with professional standards of practice for hemodialysis (HD-filtering the blood of a person whose kidneys are not working normally) by failing to assess and documented resident 46's condition for complications after hemodialysis treatment. This deficient practice had the potential to allow for unidentified malfunctioning AV shunt, infections and bleeding from the AV shunt site which could all lead to serious harm and/or death. Findings: A review of Resident 46's admission Record indicated Resident 46 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), end stage renal failure (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis),…

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 post the federally required daily actual hours worked by the facility staff in an area accessible to the public for one of four days (5/25/2024) for the month of May 2024. As a result, the actual hours worked by the staff was not readily accessible to residents, family, or visitors. And had the potential to cause inadequate staffing. Findings: During an observation of the nurse's station on 5/25/2024 at 9:55 a.m., nurse staffing hours information was observed posted with a date of 5/23/2024. During an interview with on 5/27/2024 at 4:35 p.m., the Director of Staff and Development (DSD) stated since he (DSD) had been in vacation, the facility was not able to update and post the nursing hours. The DSD stated nurse posting was to be done daily. A review of a facility's policy and procedures (P&P) titled Nursing Department-Staffing, Scheduling & Posting reviewed on 1/29/2024, indicated the facility will post the following information on a daily basis: i. Facility name ii. Current date iii. Total number 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 communicate the consultant pharmacist's recommendation, in the Medication Regimen Review (MRR), to the attending physician for two of five sampled residents (Resident 15 and 53). This deficient practice had the potential for unnecessary medication use, resulting in an adverse drug reaction to affect the health and wellbeing of Resident 15 and Resident 53. Findings: A review of Resident 15's admission Record indicated the resident was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including dementia (a chronic or persistent disorder of the mental processes caused by brain disease), osteoarthritis (inflammation of the bone) and anxiety disorder. A review of Resident 15's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 3/28/2024, indicated Resident 15 had moderately intact cognition (mental action or process of acquiring knowledge and understanding) for 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.

Based on observation, interview, and record review, the facility failed to provide fortified diet (diet enhanced to increase caloric content) as ordered by the physician to one of 21 sampled residents (Resident 36) who was on a kosher (food that complies with a strict set of dietary rules in the Jewish religion) and fortified diet. This deficient practice had the potential to result in decreased caloric intake and lead to undesirable weight loss for the resident. Findings: During an observation of lunch service in the kitchen on 5/25/2024 at 12:00 p.m., residents who were kosher diet received prepacked kosher meal. The prepackaged kosher meal was heated for 2 minutes in the microwave and then placed on resident tray. During the same observation and interview in the kitchen with [NAME] 1 and [NAME] 2, [NAME] 2 was communicating the fortified diet orders written on the resident's meal tickets during tray line for lunch service and [NAME] 1 was adding butter on the vegetables for residents on fortified diet. [NAME] 1 stated fortified diet means add butter for more calories. 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 and interview, the facility failed to maintain patient care equipment in safe working condition when one of six sampled residents (Resident 3) had an uncovered overhead light with exposed bulb. This deficient practice had a potential to cause incidental accidents to the resident, which could result in injuries. Findings: A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side, Parkinson's disease (a disorder in the brain that affects movement, often including tremors), dysphagia (difficulty swallowing food or liquid), and Alzheimer's disease (a progressing brain disorder that destroys memory and other important mental function). A review of the Minimum Data Set (MDS - a comprehensive assessment and care…

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 create a comprehensive care plan (a resident-specific plan with defined clinical goals and interventions used to manage identified medical issues or other areas of concern) to meet the needs of three of 16 sampled residents (Resident 26, Resident 28, and Resident 48) by failing to: -Develop a plan of care for Resident 26 who was using oxygen for shortness of breath. -Develop a plan of care with individualized approaches for Resident 28 who had diagnoses for bipolar disorder (a mental illness associated with mood swings ranging from depressive lows to manic highs), major depressive disorder ([MDD] a mental illness characterized by depressed mood, loss of appetite, lack of energy or interest in doing usually enjoyable activities), and schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly). -Develop a plan of care with individualized approaches for Resident 48 who had diagnoses of major…

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 the use of four doses of controlled substances (medications with a high potential for abuse) for four residents (Residents 23, 27, 57, and 213) in two of two inspected medication carts (Medication Carts 2A and 2B). This deficient practice increased the risk that Residents 23, 27, 57 and 213 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 of Medication Cart 2B, on 5/10/22 at 11:01 AM, with the Licensed Vocation Nurse (LVN 1), the following discrepancy was found between the Narcotic and Hypnotic 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): -Resident 27's Narcotic and Hypnotic Record for hydrocodone/acetaminophen (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two medications were labeled with an open date per the manufacturer's requirements in one of two inspected medication carts (Medication Cart 2A) affecting Residents 48 and 214, and the facility failed to remove one expired medication from one of two inspected medication carts (Medication Cart 2A) affecting Resident 57. These deficient practices increased the risk that Residents 48, 57, and 214 could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death. Findings: During an observation on [DATE] at 11:17 AM, of Medication Cart 2A with the Licensed Vocational Nurse (LVN 2), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: -One open vial…

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, staff interviews, record review, the facility failed to ensure safe and sanitary food storage and food preparation practices when: -Raw chicken stored on top of beef brisket and next to raw fish in the reach in refrigerator. -Ice machine ice dispenser and spout internal compartment was dirty. -Dishwahser staff did not wash hands or change gloves when removing the clean and sanitized dishes form the dish machine. -Food brought to residents from outside of the facility, including leftovers, stored in the resident refrigerator were not labeled. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 66 of 67 residents who received food and ice from the facility. Findings: a. During an observation of the kitchen on 5/10/2022 at 9:30 AM, a large bowl of raw chicken was stored on top of raw beef brisket and on the same shelf as the raw fish. The raw chicken was in a stainless-steel bowl and loosely covered with plastic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an indwelling catheter (a tube left in the bladder that drains urine) drainage bag was placed in a dignity bag (a concealment device used to block the view of the contents of a urinary catheter bag, a collection bag connected to a tube inserted into the body to collect urine) to provide privacy for one of three sampled residents (Resident 17). This deficient practice had the potential for resulting to psychosocial harm and violating Resident 17's right to be treated with dignity. Findings: During an initial tour of the facility on 5/10/2022 at 9:45 A. M., Resident 17 was observed lying in bed with the urinary catheter bag anchored to the side of the bed without a privacy bag cover in place. A review of Resident 17's admission record, dated 5/24/2021, indicated the resident was admitted to the facility on [DATE], with diagnoses that included but were not limited to Multiple sclerosis (a disease that can affect the brain and spinal…

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 have the call light (device used to alert the facility staff that a resident requires assistance) within reach in the resident's room for two of 17 sampled residents (Resident 35 and 48). This deficient practice had the potential to result in the delay of provision of services and not allow the resident to call for help when needed or emergencies which could lead to harm to Resident 35 and 48. Findings: a. A review of Resident 35's Facesheet (admission record) indicated the facility admitted the resident on 2/15/2022, with diagnoses that included cerebral infarction (damage to brain tissues caused by lack of oxygen to the area), epilepsy (a seizure disorder) and a cognitive communication deficit (a disorder resulting in difficulty with thinking and how someone uses language). A review of Resident 35's Minimum Data Set (MDS - a standardized assessment and care -screening tool), dated 2/22/2022, indicated Resident 35 cognitive skills 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 the residents' medical records were updated to show documentation clarifying if a resident had an advanced directive (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) or not for two of three sampled resident (Residents 5 and 22) Findings: a. A review of the admission Record indicated Resident 5 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, unsteadiness on feet, and anxiety. A review of the Minimum Data Set (MDS - a standardized assessment and screening tool), dated 4/15/2022, indicated Resident 5 had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). A review of Resident 5's Advance Healthcare Directive Acknowledgement Form,…

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 Beneficiary Protection and Notification forms were given to one of three sampled residents (Resident 3). This deficient practice had the potential to result in Resident 3 incurring an unknown financial liability to the facility or Resident 3 not being able to exercise his right to an appeal. Findings: A review of Resident 3's admission Record indicated the facility originally admitted the resident on 7/18/2018 and he was readmitted on [DATE]. A review of the Notice of Medicare Non-coverage (NOMNC) form indicated Resident 3's coverage for Medicare Part A Skilled Services would end on 2/15/2022. A further review of the form indicated that on page two of the NOMNC, the section, additional information, where one can document speaking to a resident representative, was blank and where the resident's signature/RP signature could go, unable to sign was written. A review of Resident 3's Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage…

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 review and revise care plan for one of five sampled resident (Resident 28) who was receiving furosemide (Laxis - a medication used to treat fluid retention (holding) by increasing the amount of urine voided by the body). This deficient practice had the potential for Resident 28 not to receive the appropriate care treatment and/or services. Findings: A review of Resident 28's Facesheet (admission Record), dated 5/12/2022, indicated Resident 28 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included but were not limited to Stage III chronic kidney disease (mild to moderate damage to the kidneys that causes the kidneys not to work as well as they should to filter waste and extra fluid out of the blood) and heart failure (a chronic condition in which the heart does not pump blood as well as it should and can cause symptoms such as shortness of breath and/or swollen legs). A review of 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, for a resident who had an indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage), the indwelling catherter bag was anchored (secure) below the resident's bladder for one of two sampled residents (Resident 6). This deficient practice had the potential to result in recurrence of urinary tract infection (UTI-an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney) and had a potential to lead to urosepsis (a potentially life-threatening complication of urinary tract infection) or harm to the resident. Findings: A review of Resident 6's admission record indicated the resident was admitted to the facility on [DATE], and readmitted to on 3/21/2022, with diagnoses that included but were not limitted to Urinary Tract Infection and Type II Diabetes (High blood sugar). A review of Resident 6's care plan for Indwelling…

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 through on one recommendation from the consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report irregularities) from February 2022 to consider a gradual dosage reduction (GDR - a periodic attempt to lower the dosage of a medication to the lowest effective dose) on Depakote (a medication used to treat mental illness) in one of five sampled residents (Resident 48.) The deficient practice could have resulted in Resident 48 experiencing preventable complications from her medication therapy, possibly leading to a diminished quality of life. Findings: A review of Resident 48's admission Record dated 5/12/22, indicated she was readmitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental illness associated with mood swings ranging from depressive lows to manic highs). A review of the consultant pharmacist's Medication Regimen Review, dated 2/25/22,…

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 appropriate monitoring of Heparin (a medication used to prevent blood from clotting in the heart or blood vessels) for one of five sampled residents (Resident 35). This deficient practice had the potential to result in complications from the use of heparin such as bruising and bleeding to Resident 35. Findings: A review of Resident 35's admission Record indicated the facility admitted the resident on 2/15/2022 with a medical history including cerebral infarction (damage to brain tissues caused by lack of oxygen to the area), epilepsy (a seizure disorder) and a cognitive communication deficit (a disorder resulting in difficulty with thinking and how someone uses language). A review of the Physician's Order, dated 2/15/2022, indicated Resident 35 was to receive Heparin Sodium 5000 units per one (1) milliliter (ml) solution subcutaneously (applied under the skin) every eight hours for deep vein thrombosis (DVT - a blood clot in a deep vein, usually in the legs) prophylaxis (action taken to prevent…

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 control practices were followed for two of 16 sampled residents (Residents 26 and 36) by: -Failing to ensure Resident 26's oxygen nasal cannula tubing (nc - a device used to deliver supplemental oxygen placed directly on a resident's nostrils) and humidification bottle was dated. -Failing to ensure Resident 36's gastric drainage tubing and the attached cannister were off the floor. These deficient practices caused an increased risk in contamination with the potential for infections for Residents 26 and 36. Findings: a. A review of admission Record indicated Resident 26 was readmitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia (a condition when one does not have enough oxygen in their blood), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin-a protein responsible for transporting oxygen in the blood) and heart failure (condition in…

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.