Providence Holy Cross Med Ctr D/P SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to screen for, offer, and administer the pneumonia vaccine (medication used to prevent serious lung infections caused by streptococcus pneumoniae [types of bacteria]) for one of five sampled residents (Resident 5) reviewed during the Infection Control task. This deficient practice had the potential to result in serious respiratory infection from pneumonia in Resident 5. Findings: During a review of the facility's census (lists typically contain resident names, locations (unit/room), and the dates of admission), the facility's census indicated the facility admitted Resident 5 on 9/7/2025. During a review of Resident 5's History and Physical (H&P), dated 9/8/2025, the H&P indicated the resident had diagnoses including chronic (long-term) respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]),…

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 fully develop and implement an antibiotic (antimicrobial, medicine that inhibits the growth of or destroys microorganisms) stewardship program (ASP- a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics as a part of its overall Infection Prevention and Control Program (IPCP) for one of six sampled residents (Resident 3) reviewed under Infection Control facility task by: a. Failing to establish protocols to identify signs and symptoms of infections among residents to assess whether they met evidence-based national standard criteria for initiating antibiotic treatment b. Failing to identify Resident 3's use of levofloxacin (antibiotic) indicated for urinary tract infection (UTI- an infection in the bladder/urinary tract). These deficient practices had the potential to result in increased risk of inappropriate antibiotic use, potentially leading to adverse outcomes (complications arising from an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care in accordance with professional standards for two of two sampled residents (Residents 35 and 42) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin for Resident 42, and heparin (an anticoagulant) for Resident 35. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and heparin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross Reference F760 Findings: a. During a review of Resident 35's Face Sheet, the Face Sheet 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 observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal tract) received the appropriate care and services to prevent complications for three of three sampled residents (Resident 2, 35, and 41) reviewed under the tube feeding care area by failing to: 1. Change Resident 35's water flush bag according to the manufacturer's guideline. 2. Indicate the date for Resident 2's medication syringe replacement. 3. Ensure Resident 41 the accurate amount of tube feeding formula was delivered to the resident as ordered. These deficient practices had the potential to result in altered nutritional status, such as dehydration and malnutrition, and complications associated with enteral feeding, such as gastrointestinal (GI - relating to stomach and intestines) problems, such as abdominal pain and diarrhea, and for residents to experience unmet nutritional needs and place…

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 three of five sampled residents (Resident 24, Resident 38, and Resident 40) investigated under the respiratory care area oxygen (type of gas our body needs in order to function) therapy equipment was maintained, and standard infection control practices were followed by failing to ensure: 1. Resident 24 and Resident 38's oxygen tubing did not touch the floor. 2. Resident 40's humidification bottle was labeled and changed per the facility established schedule. 3. Resident 38's Yankauer suction tool (long plastic tool used to remove secretions [thick or thin sticky fluids from the mouth and throat]) was labeled with the date when it was opened. These deficient practices had the potential for Resident 24, Resident 38, and Resident 40 to develop complications such as infection. Findings: 1a. During a review of Resident 24's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted the resident on 7/16/2020,…

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 are free of any significant medication errors for two of two sampled residents (Residents 35 and 42) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin and heparin (an anticoagulant) administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and anticoagulants (a substance that is used to prevent and treat blood clots in blood vessels and the heart) such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross Reference F658 Findings: 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 safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1. Ensure towels were stored in clean towel bins, sanitation buckets, or dirty towel bins when not in use. 2. Ensure food items in the walk-in Refrigerators #2 and #5 were labeled according to facility policy. 3. Ensure the personal property of staff was not stored in the kitchen area next to an uncovered serrated knife and food items. 4. Ensure Refrigerator #10 and the Subacute Resident Refrigerator/Freezer temperatures were maintained per facility policy and procedure. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (the process by which bacteria, microorganisms, or chemicals are unintentionally transferred from one substance or object to another, with harmful effect) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 10 of 45 medically compromised residents who received…

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 implement and maintain an infection control program by failing to ensure Registered Nurse (RN) 9, accompanied by the Nurse Practitioner (NP) and Medical Doctor (MD), implemented Contact Precautions (an infection control measure aimed to prevent spread of infection by direct or indirect contact by the use of personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments]) during rounding in the residents room for one of five sampled residents (Resident 39) reviewed under the Infection Control task area. This deficient practice had the potential to result in the spread of infectious microorganisms amongst staff, residents, and visitors. Findings: During a review of Resident 39's History and Physical (H&P), dated 3/27/2025, the H&P indicated the resident was re-admitted to the facility on [DATE] with diagnoses that included prostate (a gland in the male…

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 resident's right to dignity and privacy was honored for one of one sampled resident (Resident 38) using indwelling urinary catheter (flexible tube inserted in the bladder through the urethra to drain urine), when Resident 38's indwelling urinary catheter drainage bag was not covered to ensure privacy. This deficient practice had the potential for Resident 38 to be embarrassed and affect their self-esteem. Findings: During a review of Resident 38's admission Record (Face Sheet), the Face Sheet indicated the facility admitted Resident 38 on 11/25/2024 with diagnosis including respiratory failure (lungs are not working well causing difficult breathing). During a review of Resident 38's History and Physical (H&P), dated 11/26/2024, the H&P indicated Resident 38 had a medical history of cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), hypertension (HTN-high blood pressure), and urinary bladder neurogenic dysfunction (loss of bladder control due to brain, spinal cord, or…

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

Based on interview and record review, the facility failed to ensure to obtained informed consent (voluntary agreement to accept treatment or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of five sampled resident (Resident 25) reviewed for informed consent, prior to increasing the dose of Seroquel (medication used to help relax someone who is restless [unable to stay calm or still] or agitated [irritated]) from 50 milligrams (mg - a unit of measure) nightly dose to 75 mg. This failure had the potential to prevent Resident 25 and his responsible party from exercising their right to decline increasing the dose of Seroquel and could have increased the risk that Resident 25 could experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to psychotropic medications (medication that affect brain activities associated with mental processes and behavior.) Findings: During a review of Resident 25's admission Record (Face Sheet), dated 1/2/2024, the facility admitted Resident 25 on 1/2/2024…

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 reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one (1) of 1 sampled resident (Resident 35) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to call for assistance. Findings: During a review of Resident 35's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted the resident on 11/27/2023 and readmitted in the facility on 7/10/2024 with diagnoses including craniotomy (type of brain surgery where the surgeon will remove and replace part of the skull to access and treat a problem within the brain), hypertension (HTN - high blood pressure), and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide…

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 residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) for two (2) of four (4) sampled residents (Residents 24 and 42) reviewed for restraints by: 1. Failing to complete a restraint assessment prior to application of peek-a-boo mitten (a padded mitten restraint used to prevent patients from pulling out tubes, lines, or other medical devices) on the right hand for Resident 24. 2. Failing to complete a restraint assessment and attempt least restrictive interventions prior to application of bilateral soft wrist restraint and peek-a-boo mitten on both hands for Resident 42. These deficient practices had the potential to result in the…

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

Based on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (also known as an indwelling catheter, a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI - an infection in the bladder/urinary tract) for one (1) of 1 sampled resident (Resident 2) reviewed for urinary catheter or UTI by failing to ensure Resident 2's urinary catheter tubing did not have a loop while hanging on the side the bed. This deficient practice had the potential for the resident's urine not to flow freely which may lead to development of UTI. Findings: During a review of Resident 2's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 6/7/2022 and readmitted in the facility on 1/30/2025 with diagnoses including gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), neurogenic bladder (lack of bladder control due to brain, 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.

Based on interview and record review, the facility failed to specify an indication (the reason) for the use of a hypoglycemic medication (lowers blood sugar) for one of five sampled residents (Resident 41) during a review of unnecessary medications when insulin (a hormone that removes excess sugar from the blood) lispro (fast-acting insulin) did not have an indication. This deficient practice had the potential to result in not medically necessary treatments potentially leading to ineffective diabetes management. Findings: During a review of Resident 41's Face Sheet, the Face Sheet indicated the facility admitted the resident on 12/11/2024 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 41's Minimum Data Set (MDS-a resident assessment tool), dated 2/25/2025, the MDS indicated the resident had no speech, hearing was highly impaired, rarely/never made self understood, and rarely/never…

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

Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services during the inspection of one (1) of three (3) medication carts (Medication Cart 1) reviewed during the Medication Storage and Labeling task by failing to discard Resident 1's medication in the bubble pack (a packaged container with compartments that can contain medications) with a broken seal and covered with paper tape. This deficient practice had the potential for medication error and contaminate medications stored inside the medication cart. Findings: During a concurrent observation and interview, on 3/26/2025, at 8:33 a.m., during an inspection of Medication Cart 1, in the presence of Registered Nurse (RN) 8, RN 8 confirmed and stated Resident 1's cyanocobalamin (a manufactured version of vitamin B12 used to treat and prevent vitamin B12 deficiency anemia [low levels of this vitamin in the body]) had a broken seal and was stored in Medication Cart 1. RN 8 stated the process prior to dispensing a medication from a bubble pack includes the licensed nurses…

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 fully develop and implement an antibiotic (antimicrobial, medicine that inhibits the growth of or destroys microorganisms) stewardship program (ASP- a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics as a part of its overall Infection Prevention and Control Program (IPCP) for one of six sampled residents (Resident 3) reviewed under Infection Control facility task by: 1. Failing to establish protocols to identify signs and symptoms of infections among residents to assess whether they met evidence-based national standard criteria for initiating antibiotic treatment 2. Failing to identify Resident 3's use of levofloxacin (antibiotic) indicated for urinary tract infection (UTI- an infection in the bladder/urinary tract). These deficient practices had the potential to result in increased risk of inappropriate antibiotic use, potentially leading to adverse outcomes (complications arising from an intervention or condition) such as antibiotic resistance (the acquired…

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 document that pneumococcal vaccine was offered for the resident and education was provided to the family/decision-maker per its pneumococcal vaccine (an injected medicine that can protect against and often prevent pneumococcal [a type of bacteria] infections [when the immune system fights off the bad germs to get better]) policy and procedures (P&P) for one of five sampled residents (Resident 19) reviewed for immunizations under Infection Control facility task. This deficient practice had the potential to result in increased risk for pneumococcal infections which may lead to serious health complications such as pneumonia (an infection that inflames the lungs' air sacs), meningitis (inflammation of brain and spinal cord membranes, typically caused by an infection), and bloodstream infections. Findings: During a review of Resident 19's Face Sheet, the Face Sheet indicated the resident was admitted on [DATE] with diagnoses including respiratory failure (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 the residents were free from any physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) to three out of four sampled residents (Residents 24, 23, and 5) investigated during review of physical restraints care area by: 1. Failing to complete an assessment for risk of entrapment prior to use of four bed siderails (SR) up (raised [up] position on bilateral [two sides] upper [area including arms, shoulders, and head] and bilateral lower [area including legs]). 2. Failing to obtain a physician's order for the use of four bed SR up and bed alarms (warn caregivers when residents leave or attempt to leave their beds). 3. Failing to obtain an informed consent prior to use of four bed SR up while in bed and bed alarms. These deficient practices placed 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: 1. Develop and implement a care plan for bed alarm (device that warns caregivers when residents leave or attempt to leave their beds) use to two of four sampled residents investigated during review of restraints (Residents 23 and 5). 2. Develop and implement a comprehensive person-centered care plan for use of four bed siderails (SR) to three of four sampled residents (Resident 23, 24 and 5) investigated during review of restraints. These deficient practices had the potential for residents to not receive the proper and necessary care regarding SRs and bed alarm use with the potential to result in injury of the resident by failing to provide ongoing assessment, monitoring, and re-evaluation of SRs and restraints. 3. Ensure Resident 37 had a care plan addressing the use of apixaban (Eliquis-a FDA-approved to treat and prevent certain types of dangerous blood clots that can block blood vessels in your body) to one out of two sampled…

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 care consistent with professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) to three of three sampled residents (Residents 23, 27, and 14) being investigated under pressure ulcers by failing to consistently: 1. Assess and follow facility's policy and procedure of taking pictures and documenting the measurement of the stage 4 pressure injury (full thickness tissue loss with exposed bone, tendon, or muscle) of Resident 23 on the sacrum (a triangular bone at the base of the spine) and the occipital area (the back of the head). 2. Assess and follow facility's policy and procedure of taking pictures and documenting the measurement of the stage 4 pressure injury of Resident 27 on the sacrum. 3. Assess and follow facility's policy and procedure of taking pictures and documenting the appearance…

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 appropriate treatment and services to prevent complications of enteral feeding (EF - a form of nutrition that is delivered into the digestive system as a liquid) for three of three sampled residents (Residents 24, 26, and 191) investigated under the tube feeding care area by: 1. Failing to ensure Resident 24's EF bottle indicated the correct date and time the current bottle was started, and the water flush bag indicated the date and time started and the rate prescribed by the physician. 2. Failing to ensure Resident 26's and 191's EF bottle indicated the rate as prescribed by the physician. 3. Failing to ensure Resident 26' and 191's water flush bag indicated the date and time started and the rate prescribed by the physician. These deficient practices had the potential to place Residents 24, 26, and 191 at risk for complications of enteral feeding such as diarrhea (loose, watery stools when you poop) or vomiting which may lead 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 ensure the safe and appropriate use of four (4) bed side rails (SR) for three of four sampled residents (Resident 24, 23, and 5) investigated during review of physical restraints by: 1. Failing to conduct an assessment including the risk for entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) from side rails. 2. Failing to review the risk and benefits of side rails with the resident or resident representative and obtain informed consent (process in which residents or resident representatives are given important information, including possible risks and benefits, about a procedure or treatment). These deficient practices had the potential to result in psychosocial harm and physical harm from entrapment and death of residents. Cross Reference F604 Findings: 1. A review of Resident 24's Face Sheet indicated the facility originally admitted the resident on 7/16/2020 and readmitted the…

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

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by: 1. Failing to ensure food service attendant wore a hair restraint while working in the food production line. 2. Failing to ensure food items not in their original package were labeled and dated. 3. Failing to ensure an open food product that is in its original packaging was labeled and dated. These deficient practices had the potential to place six out of 43 residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). 1.During an initial observation of the kitchen on 4/13/2023 at 8:14 a.m., observed a Food Service Attendant (FSA) working in the food production line placing food on meal trays, not wearing a hair restraint. During an observation and concurrent interview with the FSA on 4/13/2024 at 8:16 a.m., the FSA stated that he was not wearing a hair restraint. When asked when he is supposed to wear a hair restraint, the FSA stated that once he clocks in for work at 5:00 a.m. and upon…

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 implement its policy and procedures for antimicrobial stewardship (AMS- a coordinated program that promotes the appropriate use of antimicrobials [including antibiotics, drugs used to treat infections caused by bacteria and other microorganisms], improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms) for one of six sampled residents (Resident 2) when clindamycin (an antibiotic) was ordered on 1/29/2024 as indefinite and the facility failed to monitor the antibiotic use for 77 days. This deficient practice had the potential for the resident to receive an inappropriate antibiotic and develop antibiotic resistance (when bacteria/germs change in some way that reduces or eliminates the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections). Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 12/28/2023. Resident 2's diagnoses included history of multidrug resistant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide care in a manner that honor the resident's right to a dignified existence to two of two sampled residents (Resident 23 and 238) investigated during review of dignity care area by: 1. Failing to ensure Resident 23's indwelling urinary catheter (flexible tube inserted in the bladder through the urethra to drain urine) drainage bag was covered with a dignity bag (a bag used to cover the urinary catheter drainage bag, so it is not visible). 2. Failing to ensure Certified Nursing Assistant 1 (CNA 1) was not standing over Resident 238 while assisting the resident with feeding. These deficient practices had the potential to affect the residents' self-esteem and self-worth. Findings: 1. A review of Resident 23's Face Sheet indicated the facility admitted the resident on 3/13/2024, with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 23's History and Physical (H&P),…

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 resident receive care and services for the provision of parenteral fluids (medicines or fluids that go directly into the vein) consistent with professional standards of practice to two out of two sampled residents (Residents 21 and 238) investigated during random observations of residents receiving parenteral/intravenous (IV, within a vein) fluids by failing to label the peripheral IV (indwelling single-lumen plastic conduits that allow fluids, medications and other therapies such as blood products to be introduced directly into a peripheral vein) dressing with the date of when the IV was inserted or when the dressing was changed and the licensed nurse's initials who inserted the IV or changed the dressing. The deficient practice had the potential for complications related to intravenous fluid administration such as infiltration, bruising, phlebitis (inflammation of a vein), and infections. Findings: 1. A review of Resident 21's Face Sheet indicated the facility admitted the resident on…

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

Based on observation, interview, and record review the facility failed to provide residents with necessary respiratory care and services that is in accordance with professional standards of practice to one out of one sampled resident (Resident 34) investigated during review of respiratory care by failing to connect the trach collar (used to hold a tracheostomy tube [a tube constructed of polyvinyl chloride that is placed between the vocal cords through the wind pipe] in place) to the oxygen humidifier (medical devices used to humidify supplemental oxygen) and oxygen regulator to ensure delivery of oxygen required to keep the resident's oxygen saturation (O2 sat, measures what percentage of the blood is saturated with oxygen) above 92%. The deficient practice had a potential to cause Resident 34 hypoxia (absence of enough oxygen in the tissues to sustain bodily functions) resulting in respiratory problems. Findings: A review of Resident 34's Face Sheet indicated the facility admitted the resident on 11/8/2023, with diagnose including respiratory failure (a serious condition that…

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: 1.Failed to ensure licensed nurse did not leave an insulin pen (an injection device that you can use to deliver preloaded insulin [controls the amount of sugar in the blood by moving it into the cells, where it can be used by the body for energy]) unattended on top of a computer on wheels (WOW). This deficient practice had the potential to result in unwanted serious side effects if placed in undesired hands which can lead to harm. 2.Failed to ensure licensed nurses' account of a controlled drug record (accountability record of medications that are considered to have a strong potential for abuse) was accurately documented per facility policy for one of two sampled residents. This deficient practice had the potential for medication errors. Findings: a. During an observation on 4/13/2024 at 12:09 p.m., observed Licensed Vocational Nurse 3 (LVN 3) place an insulin pen on top of a computer on wheels (wow). Observed LVN 3 walked away from the wow entering a resident's room, leaving the insulin pen unattended. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure if needed (PRN) orders for psychotropic medications (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, and behavior) were only used when the medication was necessary and PRN use was only limited to two of five residents (Residents 23 and 5) selected for unnecessary medications review. The deficient practice had the potential to result in the use of unnecessary psychotropic drugs for residents and can lead to side effect and adverse (unwanted) consequence such as a decline in quality of life and functional capacity. Findings: 1. A review of Resident 23's Face Sheet (admission Record) indicated the facility admitted the resident on 3/13/2024, with a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 23's History and Physical (H&P), dated 4/3/2024, indicated the resident had a history of post traumatic cervical-spine…

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 staff failed to implement its infection control program to two out of 23 sampled residents (Residents 5 and 3) during resident screening by failing to ensure: 1. The suction canister (a temporary storage container for secretions or fluids removed from the body) of Resident 5, labeled 4/5/2024 was discarded and replaced per facility policy. 2. The urinal bottle (frequently used in healthcare for residents who find it impossible or difficult to get out of bed) was labeled with the name, date, and room number of Resident 3. These deficient practices had to potential to spread infection among residents. Findings: 1. A review of Resident 5's Face Sheet indicated the facility admitted the resident on 8/28/2021, with a diagnosis of gastrointestinal (GI, relating to, or including both the stomach and intestine) bleed. A review of Resident 5's History and Physical (H&P), dated 8/18/2023, indicated the resident had a history of coronary artery bypass graft…

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 for one sampled resident (Resident 1), Resident 1's oxygen delivery via tubing was secured and maintained. This deficient practice had the potential to result in Resident 1 suffering from hypoxemia (low level of oxygen in the blood) and may lead to the resident's deterioration of medical condition. Findings: A review of Resident 1's History and Physical (H&P), dated [DATE], indicated Resident 1 was found down by family members. Cardiopulmonary Resuscitation ([CPR] is an emergency lifesaving procedure performed when the heart stops beating) was initiated prior to Emergency Medical Services ([EMS] is a system that responds to emergencies in need of highly skilled pre-hospital clinicians) arrival. The patient was intubated (a tube has been placed inside a patient's trachea through the mouth to keep airways open in an emergency setting) for airway protection. In addition the H&P indicated Resident 1's Computed Tomography ([CT] scan is an imaging…

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.