The Redwoods, A Community Of Seniors

Based on observation, interview and record review, the facility failed to ensure one resident (Resident 28) of eight sampled residents remained free of significant medication errors when licensed nurses administered prescribed Parkinson's medications up to two hours late.This failure decreased the facility's potential to ensure medication was administered as ordered by the physician. Findings:A review of Resident 48's admission record indicated admission on 5/15 26 with a primary diagnosis of Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity and slow, imprecise movements) without dyskinesia (uncontrolled, involuntary muscle movements) or without mention of fluctuations. A review of Resident 48's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 5/19/26, indicated he had no memory impairment.In an interview on 5/19/26 at 9:58 a.m. with Resident 48, Resident 48 stated, My [Parkinson's] medications are late. Over an hour the other day. A record review of Resident 48's Medication Administration Record (MAR)…

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

Based on interview, and record review, the facility failed to ensure professional standards of practice were met for one of three sampled residents (Resident 1) when neurological (neuro, relating to the nervous system, includes: brain, spinal cord, and nerves) assessments and vital signs (blood pressure, temperature, pulse, respirations, and oxygen saturation [a measurement of how much oxygen is being carried by red blood cells]) were not conducted, monitored, or documented after a witnessed fall, in Resident 1's medical record per facility policy and protocol.These failures decreased the facility's potential to recognize a change in condition for Resident 1, which could have led to a delay in treatment with other negative outcomes.A review of Resident 1's admission record indicated she was initially admitted to the facility in July 2024 with medical diagnosis which included collapsed vertebra (when the bones in the spine collapse or break due to injury or weakening) and repeated falls. A review of Resident 1's Minimum Data Set (MDS-a federally mandated 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 interviews and record reviews, the facility failed to ensure the Minimum Data Set (MDS, a federally mandated resident assessment tool) assessment was accurate for one resident (Resident 1), when Resident 1's Physician Orders for Life-Sustaining Treatment (POLST, a set of medical orders, based on a patient's preferences, that guide medical care for individuals with serious illnesses) form information was different from the information documented on Resident 1's MDS assessment.This failure could result in inappropriate care and treatment.Findings:A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date of April2025 and she was her own responsible party (RP, a person who is designated in making decisions about health care and financial matters).A review of Resident 1s MDS assessment, dated [DATE], indicated Resident 1 was admitted to the facility with a medically complex condition (a broad category 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 interviews and record reviews, the facility failed to ensure one resident (Resident 1) received treatment and care in accordance with the facility's Infection Control policy for influenza (flu- an illness caused by a virus [a germ] that is spread from person to person) when: Licensed Nurses (LNs) did not notify Resident 1's doctor (MD) that Resident 1 had symptoms of the flu and a report of Resident 1had been exposed to a family member who tested positive for flu; LNs did not notify the MD the facility ran out of flu tests; LNs did not place Resident 1 on droplet precautions (measures implemented to prevent the spread of infection when a person who is infected with a pathogen [germs that cause disease] coughs, sneezes, or talks);These failures resulted in Resident 1's hospitalization from 4/27/25 up to 5/6/25 where she was diagnosed with Influenza A and Acute Hypoxemic Respiratory Failure (AHRF, a serious condition where the respiratory system can't maintain adequate oxygen levels in the 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.

Based on observation, interviews and record reviews, the facility failed to provide written notice of transfer to the Long-Term Care Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) for two out of two sampled residents (Resident 1 and Resident 2), when they were transferred to the hospital in March of 2025 without the Ombudsman being notified. These failures could result in loss of residents ' advocacy and protection and prevent innapropriate transfers and discharges. Findings: During an interview on 4/23/25 at 3:14 p.m., the Director of Staff Development (DSD) stated she was not sure if the nurses were completing a written notice of transfer when residents were discharged or transferred to the hospital. The DSD also stated she was not sure whether the Ombudsman needed to be notified when residents were transferred to the hospital. During an interview on 4/23/25 at 3:30 p.m., the Administrator (Admin) stated she was not sure if the facility had to complete a written notice of transfer and notify the Ombudsman when…

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 did not have a system to track staff compliance in required trainings, when: 1. Two of four sampled employees had mandatory trainings that were overdue (Licensed Staff K and Unlicensed Staff L). This finding had the potential to result in inadequate staff competency to care for the residents within professional standards or practice, poor quality of care, and harm to the residents of the facility. 2. The facility failed to provide a competent DSD to enforce training and verify competencies for Nursing staff when Unlicensed Staff F's (BLS) Basic Life Support Certification (CPR Cardiopulmonary Resuscitation the act of performing chest compressions and artificial respirations) was expired for 4.5 months while working in the facility. This failure had the potential to result in 30 out of 36 sampled residents needing CPR but not having access to a Certified CPR staff member to perform CPR. Findings: 1. During an interview on [DATE] at 11:00 a.m., with the Director 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.

Based on observation, interview and record review, the facility failed to ensure the daily nursing staffing information was posted in a conspicuous place, during one of five days (7/08/24). This finding had the potential to result in inability for residents, visitors, and staff to review the staffing information, advocate for the residents' care, and identify issues with staffing numbers, which could have contributed to decreased quality of care. Findings: During a concurrent observation and interview with the Director of Staff Development (DSD) on 7/08/24 at 9:20 a.m., the posting that included the nursing staffing information, posted on the wall across the nursing station of the facility, had staffing posting information from the previous Friday, 7/05/24. At the time of the observation, there was a lot of activity going on at the facility. More than 10 residents were observed in the dining area involved in recreational activities, and staff were busy with their morning work routines. The DSD confirmed the finding and stated the unit clerk was responsible for posting the nursing…

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

Based on interview and record review, the facility failed to ensure the Pharmacist's Drug Regimen Review (DRR/Medication Regimen Reviews- a monthly summary report of each resident's medication irregularities) report was acted upon with timely responses from Physicians and Medical Director. This failed practice had the potential to affect all residents currently receiving medications (36 of 36 residents) and placed them at risk for negative clinical outcomes due to a potential urgent action not being communicated in a timely fashion. Findings: During a review of the monthly Drug Regimen Review binder on 7/11/24, it was observed that monthly medication reviews conducted by the Consulting Pharmacist for the months of May and June showed no follow-up responses to recommendations made by the Consulting Pharmacist, and no documentation was present in the binder. Previous months (February, March, and April) Pharmacist recommendations for several residents was incomplete and did not show Physician responses or that follow-through was conducted. During an interview on 7/12/24 at 9:30 a.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of fourteen sampled residents (Resident 16) was free of psychotropic drugs (Medications used to treat mental health disorders. These medications have many side and adverse effects) she did not need. This failure had the potential to result in adverse consequences such as medication interactions, depression, confusion, immobility, falls with fractures, and death. Findings: Record review indicated Resident 16 was admitted to the facility on [DATE] with medical diagnoses including Dementia (A condition that affects memory) without Behavioral Disturbance (When a person is presenting signs and symptoms of dementia and has a dementia diagnosis, but they lack any symptoms of behavioral disturbances), and Repeated Falls (History of having suffered falls, which may indicate increased risk for future falls), according to the facility Face Sheet (Facility demographic). Record review of Resident 16's MDS (Minimum Data Sheet-An 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the temperature of one of one medication refrigerators in the medication room of the facility (Medication Refrigerator A), was kept within normal parameters for several months, to store resident medications. The medication room where Medication Refrigerator A was stored, was observed propped open with a stool, unattended, prior to entering the room. In addition, one expired medication was found stored with active medications in one of the two medication carts (Medication Cart B, cart for the south hall), stored with other active medications. This failure had the potential to result in medications that were no longer effective, causing harm to the residents involved, and access to unauthorized personnel to the resident medications. Findings: During a concurrent observation and interview on [DATE] at 7:34 a.m., with the Director of Staff Development (DSD), the medication room door was observed propped open with a small stool, and 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 interview and record review, the facility failed to ensure resident records for 1 of 2 sampled residents that suffered multiple falls at the facility (Resident 190) were accurate. These documents consisted of the fall risk assessments for Resident 190, who suffered three falls at the facility, with two resulting in major injuries. As a result of the inaccurate responses in the fall risk assessments, one of these documents indicated Resident 190 was at low risk for falls, when that was not the case. This failure may have contributed to the lack of care planning and interventions to prevent further falls for Resident 190. It also had the potential to result in inability for staff to identify triggers and patterns necessary for fall prevention measures for Resident 190. Findings: Record review indicated Resident 190 was admitted to the facility on [DATE] with medical diagnoses including History of Falling (History of having suffered falls, which may indicate increased risk for future falls), Alzheimer's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow their Infection Control policy and QAPI (Quality Assurance and Performance Improvement) policy for 36 out of 36 residents when the facility failed to track and surveil data for resident's chronic UTI (Urinary Tract Infections). This failure had the potential to result in residents developing MRDO (multidrug resistant organisms). Findings: During an interview with Licensed Staff A on 7/10/24 at 10:15 a.m., Licensed Staff A was queried for the QAPI documentation for tracking chronic UTI's in the facility. Licensed Staff A stated, I have not been tracking chronic UTI's. Licensed Staff A queried as to what the risks are to the resident population if the chronic UTI's in the building are not being tracked and surveilled. Licensed Staff A stated, the residents taking long term or frequent antibiotics could become resistant to antibiotics due to overuse. Licensed Staff A queried if she has tracked UTI data for QAPI and IDT conferences 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 follow their Enhanced Barrier Precautions policy and their Hand Hygiene Policy's when 1 resident (Resident 31) out of 36 sampled residents had a staff member who did not practice hand hygiene or correct isolation techniques while administering hygiene care to a resident on Enhanced Barrier isolation. Findings: During an observation on 7/8/24 at 9:00 a.m., outside room [ROOM NUMBER], observed an Enhanced Barrier Isolation Cart (a cart that contains gloves, alcohol, masks, and gowns for staff to wear while providing high contact (Hygiene and bathing) activities to residents. Unlicensed Staff F was observed in room [ROOM NUMBER] without a isolation gown providing hygiene care for Resident 31 who was incontinent of stool. Observed Unlicensed Staff F exiting Resident 31's room also without washing his hands or using hand sanitizer after caring for Resident 31. During an interview on 7/8/24 at 9:20 a.m., in the hallway outside room [ROOM NUMBER],…

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

Based on interview and record review, the facility did not provide three of four Unlicensed Staff (Unlicensed Staff N, Unlicensed Staff O & Unlicensed Staff P) with 12 hours of abuse and dementia training annually. This failure had the potential to result in inadequate staff competency to care for the residents within professional standards or practice, poor quality of care, and harm to the residents of the facility. Findings: During an interview with the Director of Staff Development (DSD) on 7/11/24 at 10:00 a.m., she was asked to provide evidence of abuse and dementia training from 7/10/23 to the present for four sampled Certified Nursing Assistants (CNAs-Unlicensed Staff M, Unlicensed Staff N, Unlicensed Staff O & Unlicensed Staff P). During a concurrent interview and record review with the Director of Staff Development on 7/11/24 at 11:30 a.m., the DSD provided the requested documents. The documents provided indicated: 1) Unlicensed Staff M-She was still in orientation taking mandatory trainings. This was confirmed by the DSD during the interview on 7/11/24 at 11:30 a.m. 2)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six sampled resident's (Resident 3) medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information was provided to the resident and/or responsible parties and desire for physician orders for life sustaining treatment (POLST) were reviewed, signed and dated by a physician. This failure had the potential for the resident's wishes not to be honored during a medical emergency. Findings: A review of Resident 3's admission record indicated the resident was admitted on [DATE], with diagnoses that included Pyonephrosis (an infection of the kidney with pus in the upper collecting system which can progress to obstruction), Calculus of the Kidneys (kidney stones), Sepsis of unspecified organism Bacteria, Hypokalemia, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the facility develop a resident-centered, comprehensive care plan for 1 of 14 sampled residents (Resident 18) with a stage 4 pressure ulcer (A pressure ulcer is a wound caused by prolonged pressure on an area of the skin. Stage 4 pressure ulcers are the most severe type of pressure ulcer, and can extend into muscle and/or tendons and bones). This had the potential to result in inability for the wound to heal, decline of Resident 18's medical condition, medical complications including the acquisition of serious infections and death. Findings: Record review indicated Resident 18 was admitted to the facility on [DATE] with medical diagnoses including Pressure Ulcer of Left Heel, and Repeated Falls (History of having suffered falls, which may indicate increased risk for future falls), according to the facility Face Sheet (Facility demographic). During an observation on 7/08/24 at 11:30 a.m., Resident 18 was observed in his wheelchair,…

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 interviews and record reviews, the facility failed to ensure 1. staff knew the correct time frame for reporting abuse allegations and injury of unknown source (source of the injury was not observed by any person; the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury) to the state, the Ombudsman (a person who investigates, reports on, and helps settle complaints) and the local law enforcement. 2. staff knew what injury of unknown source was 3. staff knew who to report abuse allegations and injury of unknown source 4. there was an SOC 341 (a form that documents the information given by the reporting party on the suspected incident of abuse) and 5 day investigative summary report completed for a report on injury of unknown source for one out of three sampled residents (Resident 1) 5. the facility provides in its reports, sufficient information to describe the allegation of abuse for two out of 3…

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 residents and staff knew the complaint and grievance process and posted grievance and complaint information in a manner accessible to all residents. This failure did not ensure residents rights to file a grievance and had the potential to delay the facility's identification and response to residents needs or complaints. Findings: During a resident council meeting on 2/17/22 at 11:00 a.m., the Resident attendees were asked if they knew how to file a grievance. The Residents stated, they did not know there was a grievance process or how to complete a grievance. When questioning the residents, they did not know where the forms were kept. The Resident stated if they have a problem or a complaint, they go to the DON or Social Services Director (SSD) for help. During an observation post Resident Council meeting on 2/17/22 at 12:30 p.m., a bulletin board located outside of the dining room contained resident rights, license certificates, and Ombudsman information. No other signage was posted on the bulletin…

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 a baseline care plan for 5 out of 13 sampled residents (Resident 229, Resident 129, Resident 130, Resident 132, Resident 133) when: 1. Resident 229 had no baseline care plan for Percutaneous Endoscopic Gastrostomy (PEG-a device that allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus) Care Plan. This failure had the potential for Resident 229 not receiving adequate care because of staff not knowing what care to provide. 2. New admissions to the facility, Resident 129, Resident 130, Resident 132, and Resident 133, were all receiving skilled nursing care without an assessment of their care needs. This failure had to potential for needs to go unmet, continued health decline, and a lower quality of care for these residents. Findings: 1. During an observation on 2/14/22 at 3:21 p.m., Resident 229 was in bed, the head of the bed was elevated and a Tube feeding formula 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 develop comprehensive care plans for 3 sampled residents (Resident 14, Resident 20, and Resident 28) that were individualized and updated to show residents specific care related to their medical needs when: a. Resident 20 did not have a care plan for urinary catheterization. b. Resident 28 did not have a care plan for monitoring of antipsychotic medications and dementia behaviors c. Resident 14 did not have a Care Plan for Anti-Subluxation brace/sling (a medical device intended to protect the shoulder joint from partial dislocation cause by caused by paralysis or injury in the shoulder joint capsule). These failures possibly resulted in residents decline in health, harm, and negatively impact the residents' quality of care and services. Findings: a. During an interview on 2/15/22 at 11:13 a.m., Resident 20 stated nurses catheterize him about three times a day. A review of Resident 20's chart indicated there were no care plan with…

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 medications as ordered by the physician to one of six residents sampled for medication administration (Resident 129). This delayed acquisition resulted in Resident 129 to not receive 11 doses and increased his potential to develop complications. Findings: During an observation on 2/16/22 at 3:55 p.m., Staff H marked Resident 129's Alvesco aerosol inhaler (used to treat asthma) and stated, That medication is not available. A review of Resident 129's face sheet indicated he was admitted to the facility on [DATE] for diagnoses that included combined systolic and diastolic heart failure (a condition in which the heart does not pump blood as well as it should), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide). A review of Resident 129's MAR (Medication…

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

Based on interview and record review, the facility failed to develop comprehensive action plans for identification, analysis, correction, and evaluation of systemic care issues, including high-risk, high-volume concerns, and repeat survey deficiencies. This failure had the potential to precent timely recognition and improvement of care services that do not meet standards for quality for all 31 residents. Findings: A review of the facility's CASPER 3 ([Certification and Survey Provider Enhanced Reporting] a report compiled of survey findings that demonstrate the facility's performance) indicated a pattern of repeat deficiencies related to quality of care and falls, from 2018 to 2019. During an interview on 2/18/22 at 2:59 p.m., Staff A stated QAPI meetings were conducted at least quarterly. Staff A stated that while the pandemic and staffing turnovers were a big focus for the facility in the last year, Staff A confirmed falls continue to be part of the facility's QAPI projects. A concurrent review of the binder titled QAPI, indicated attendance sheets and meeting minutes for 2020 and…

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

Based on observation, interview, and record review, the facility failed to ensure medication error rate was lower than 5% when staff made five medication errors out of 27 opportunities. This failure resulted in a medication error rate of 18.5%, which had the potential of unsafe provision of medications to residents. Findings: During an observation on 2/16/22 at 8:32 a.m., after checking Resident 300's vital signs, Staff D dispensed the following medications into a medicine cup: 1. One tablet of Carvedilol (used to treat high blood pressure), 2. One tablet of Methenamine (used to treat or prevent urinary tract infections), 3. One tablet of Aspirin (used to ease pain and/or prevent blood clots), and 4. One tablet of Sodium Chloride (used to treat low sodium levels in the blood). Staff D knocked on the door, entered the room and handed Resident 300 the medicine cup and a glass of water. Staff D looked on as Resident 300 drank the pills, then exited the room. During an observation on 2/16/22 at 9:13 a.m., Staff D dispensed the following medications into a medicine cup: 1. One capsule 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.

Based on interview and record review, the facility failed to develop and implement clinical criteria protocols, infection surveillance protocols, and antibiotic use protocols that promoted antibiotic stewardship. These failures had the potential for inconsistent and ineffective antibiotic stewardship (a coordinated program that promotes the appropriate use of antimicrobials [including antibiotics], improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms) services for all residents in the facility. Findings: During an interview on 2/18/22, at 10:40 a.m., with Staff W, she confirmed she was the facility Infection Preventionist. Staff W stated she worked as a floor nurse 3 shifts a week. Staff W stated the other 2 days her priority was infection control. Staff W stated she was working on the facility's infection surveillance for December. Staff W stated she had not had time to complete January's surveillance. Staff W stated she would be verbally informed by the Director of Nurses (DON) if there was a new…

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

Based on interview and record review the facility failed to ensure 3 out of 5 sampled residents (Resident 133 Resident 129 and Resident 28) immunization status was assessed and accurately documented in their medical record. These failures had the potential to result in higher risk for infection due to lack of immunization or side effects from an additional dose of vaccine been given. Findings: During a review of the Electronic Medical Record (EMR) for Resident 133, the pneumonia immunization status was blank. The EMR had no indication to show the facility had offered the vaccine. The EMR had no indication if Resident 133 was already vaccinated or had refused. During a review of the Electronic Medical Record (EMR) for Resident 28, the pneumonia immunization status was blank. The EMR had no indication to show the facility had offered the vaccine. The EMR had no indication if Resident 28 was already vaccinated or had refused. During a concurrent interview and record review, on 2/18/2,2 at 11:12 a.m., with Staff W, she reviewed Resident 28's immunization status and stated the pneumonia…

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 assistive devices for vision was provided for one resident (Resident 26). This failure resulted in the resident not having vision assistance to read (an activity the resident enjoys) and could contribute to his increased incidents of falls. Findings: During an observation and concurrent interview on 2/14/2022 at 10:00 a.m., Resident 26 was resting in bed. When speaking with the resident, he did not respond to questions asked, but said, Thank-you when the Surveyor was leaving the room. During an interview on 2/14/2022 at 11:00 a.m., Staff G was asked about Resident 26 condition. Staff G stated Resident 26 speaks mostly Russian and very little English. The staff watches him closely because he has had an increased number of falls. Resident 26 was observed in his wheelchair motoring around the hallway. During an interview on 2/16/2022 at 1:35 p.m., Resident (26's) daughter stated her father had an ophthalmology visit last year and the Ophthalmologist told her he needed glasses due to a decline in his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor, re-evaluate, and document clinical rationale for continued use of a psychotropic drug for one of five sampled residents for medication regimen review (Resident 13) despite the resident not exhibiting behaviors the medication was originally prescribed for. This failure placed Resident 13 at a higher risk for adverse side effects associated with psychotropic medications. Findings: During an observation on 2/14/22 at 11:13 a.m., Resident 13 was asleep in bed. During an interview on 2/14/22 at 11:15 a.m., Private Staff stated he was Resident 13's private caregiver for a few months now and provides care and companionship for four hours during the day, five days a week. When queried about Resident 13's condition, Private Staff stated, He has dementia. He's very nice, just very confused. A review of Resident 13's face sheet indicated he was last admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (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 safe medication storage when: 1. Expired medications, including an eye drop belonging to one unsampled resident (Resident 2) were found in medication storage, and 2. Temperature logs were not maintained in the medication refrigerator. These failures had the potential for contamination and altered integrity of stored medications. Findings: During an observation on 2/15/22 at 3:29 p.m., an opened, multi-dose bottle of Latanoprost (a medication used to lower high eye pressure) belonging to Resident 2 was found inside a drawer of Medication Cart 2. The eye drop bottle, dated 12/26, had an affixed label that read, *DISCARD 6 WEEKS AFTER OPENING*. During an interview with Staff B and Staff G on 2/15/22 at 3:44 p.m., Staff C stated 12/26 was the date when the medication was opened. Staff C confirmed the discard instructions and stated, This [bottle] should have been discarded last week. Staff B then proceeded to dispose of the bottle.…

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.