Almond Vista Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. During a concurrent observation and interview on 4/28/25 at 3:08 p.m. with Resident 207 in Resident 207's room, Resident 207 was observed laying in bed wearing a gown and wearing a nasal cannula with oxygen flowing at a rate of 1.5 L/min, no label was observed on the oxygen tubing indicating when it was connected to the concentrator. Resident 207 was unable to answer questions. During a concurrent observation and interview on 4/28/25 at 3:19 p.m. with CNA 10 in Resident 207's room, Resident 207's oxygen tubing was observed to be without a label indicating when it was connected to the oxygen concentrator. CNA 10 stated Resident 207's oxygen tubing was not labeled with the date it was connected. CNA 10 did not know why the tubing needed to be labeled with the date. CNA 10 stated the nurses were responsible for changing and labeling residents' oxygen tubing. During a review of Resident 207's AR, dated 5/2/25, the AR indicated Resident 207 was admitted to the facility from an acute care hospital on 4/26/25 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 During a concurrent observation and interview on 4/29/25 at 9:50 a.m. with Resident 74 in Resident 74's room, Resident 74 was observed sitting in bed wearing a gown. Resident 74 stated she had been at the facility for one week. Resident 74 stated the facility was a non-smoking facility, so she used a vape pen. Resident 74 stated there were a group of smokers who used to smoke cigarettes, but now used vape pens. A vape pen was observed on Resident 74's bedside table and a box of cigarettes was observed inside her bedside drawer. Resident 74 stated she did not have matches. Resident 74 stated she went with a group to vape with no supervision from staff. During a review of Resident 74's AR, dated 5/2/25, the AR indicated Resident 74 was re-admitted to the facility from an acute care hospital on 4/25/25 with an original admission on [DATE]. Resident 74 had diagnoses of encephalopathy (damage or disease that affects the brain), tubulointerstitial nephritis (a kidney condition that causes inflammation and swelling…

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 medication error rate was less than five percent when the facility ' s medication error rate was 7.41 percent. There were 27 opportunities for errors and two medication errors occurred with two of five sampled residents (Resident 134 and Resident 26) when: 1.Resident 134 was administered the incorrect dose of K2 Plus D3 (potassium vitamin and vitamin D) Oral Tablet [PHONE NUMBER] MCG [microgram]-UNIT This failure resulted in Resident 134 receiving the incorrect dose of medication. 2.Licensed Vocational Nurse (1) did not follow the order for Lidocaine External Patch 4 % (topical anesthetic that numbs pain by blocking the nerve signals to the skin) for Resident 26. This failure had the potential to result in ineffective pain management for Resident 26. Findings: 1. During a medication pass observation on 4/20/25 at 7:40 a.m. with LVN 11 in front of Resident 134 ' s room at the medication cart, LVN 11 removed K2 D3 90 mcg + 125 mcg…

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 appropriately store and label medication for three of eight medication carts and one of four medication storage rooms and had incomplete 41 of 106 Narcotic (substance used to treat moderate to severe pain) medication disposal sheets when: 1. Medication cart on station three had: one of four eye drops (Resident 354) with no open date, two dabigatran (blood thinner medication that can treat and prevent blood clots) bottles (Resident 355 and Resident 356) opened with no open date labeled, one bottle of morphine (narcotic medication used to treat pain) with no patient label for Resident 357, four of 11 inhalers (a handheld medical device used to deliver medication directly into the lungs through inhalation) (Resident 355 and Resident 354) with no open date, and one inhaler (Resident 356) with no patient label and open date. 2. Medication cart on station one had: one of eight resident insulin (a hormone that removes excess sugar from 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, interview and record review, the facility failed to maintain safe food preparation standards when Worcestershire sauce and Dutch Cocoa powder with expired labeled use by (UB) dates were found in the walk-in refrigerator and dry storage. This failure had the potential for 159 of 169 sampled residents to be served food prepared with expired ingredients which could increase the risk of food contamination and the development of food borne illness. Findings: During a concurrent observation and interview on 4/28/25 at 9:48 a.m. with the Registered Dietician (RD) in the kitchen walk-in refrigerator, Worcestershire sauce labeled with a Use by (UB) 3/18/25 and a manufacturer's expiration date of 10/27/26 was observed. The RD stated the correct UB date should be labeled to ensure food was safe to use. The RD stated food used after the UB date could have bacteria. During a concurrent observation and interview on 4/28/25 at 10:02 a.m. with the RD in the dry storage area, a container of Dutch Processed Cocoa labeled with a UB: 3/14/25 and a manufacturer's expiration date:…

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 treatment and care in accordance with professional standards of practice for one of seven sampled residents (Resident 57) when Resident 57 toenails were not cut for more than eight months. This failure resulted in result in resident 57's toenails to become long which had the potential to result in Resident 57 toenails to become painful, ingrown or to break off causing infection. Findings: During a concurrent observation and interview on 4/29/25 at 11:35 a.m. in Resident 57's room, License Vocation nurse (LVN) 1 stated Resident 57 had long toenails. During an interview on 04/29/25 at 11:35 a.m. in Resident 57's room, Resident 57 stated, he requested to have his toenails cut. Resident 57 stated he was worried about getting an infection and scratching staff members from having long toenails. Resident 57 stated he did not remember when the last time he had an appointment with the Podiatrist (foot physician). Resident 57 stated he had…

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 2. During a review of Resident 132's admission Record (AR- document containing resident personal information), dated 5/6/25, the AR indicated, Resident 132 was admitted to the facility on [DATE], with diagnoses which in included dementia (gradual decline in cognitive abilities), anxiety (feelings of worry, unease, and anticipation of potential danger) and palliative care (medical care focused on providing relief from symptoms of condition). During a review of Resident 132's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 2/20/25, the MDS assessment indicated Resident 132's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 12 out of 15 which indicated Resident 132 had moderate cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). During a review of Resident 132's Order Summary Report (OSR), dated 5/6/25, the OSR…

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 had a means to contact caregiver for two of the 22 sampled residents (Resident 206 and Resident 253) when call lights were not within reach of Resident 206 and Resident 253. This failure did not allow Resident 206 and 253 to call for assistance and put Resident 206 and 253 at risk of not having their needs met and falls. Findings: During a review of Resident 253 s admission Record (AR) (document containing resident demographic information and medical diagnosis) dated [DATE] , the AR indicated Resident 253 was admitted to the facility on [DATE] with diagnoses of cellulitis (a bacterial infection of the skin and underlying tissues) of lower limbs, asthma (a chronic lung disease that causes inflammation and narrowing of the airways, making it difficult to breathe), atrial fibrillation (a common heart rhythm disorder where the heart's upper chambers (atria) beat irregularly and too quickly), hyperlipidemia (an elevated level…

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 review, revise, and implement a person-centered comprehensive care plan for two of three sampled residents (Resident 1 and Resident 2) when: 1. Resident 1 had a left hip hemiarthroplasty (a surgical procedure where only one half of a joint is replaced, typically the ball portion of the hip joint, while the socket remains intact) on [DATE] and the care plan did not indicate how often Resident 1's left hip dressing should be changed, how Resident 1 should bathe, and if Resident 1 can bear weight on the left leg. This failure placed Resident 1 at an increased risk to develop a surgical site infection to the left hip, further injury to the left hip, and had the potential to result in Resident 1's care needs to go unmet. 2. Resident 2 experienced a fall on [DATE] and sustained a one-inch laceration (a cut or open wound, typically caused by tearing of the skin or soft tissue) to the left eyebrow and the care plan did not indicate how to provide…

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 facility assessment reviews, the facility failed to create and implement a comprehensive Facility Assessment to determine what resources the facility needs to meet the needs of its residents which had the potential to affect 161 residents residing in the facility. Findings include: Review of the ''SNF/NF [Skilled Nursing Facility/Nursing Facility] Capabilities List'' dated 07/2021 was not a comprehensive Facility Assessment. Review of the ''Facility Assessment Tool'' provided by the facility and updated 07/30/24. During an interview on 08/02/24 at 6:04 PM with the Administrator confirmed that the current ''Facility Assessment'' dated 07/30/24 was updated and created after the surveyors entered the facility on 07/30/24. Additionally, the Administrator provided ''SNF/NF [Skilled Nursing Facility/Nursing Facility] Capabilities List,'' dated 07/2021, which he stated was a ''snapshot'' of what the facility was able to provide. The Administrator was unable to provide annual ''Facility Assessments'' for 2020, 2021, 2022, and 2023.

Based on interview, review of facility documents, and facility policy review, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was developed and implemented to drive quality assurance (QA) measures. This failure had the potential to affect all 161 residents who currently live in the facility. Findings included: Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program'' revised 04/2014 included, ''. Establishing a QAPI Plan that guides quality efforts and serves as the main document that supports the QAPI implementation . Providing frequent leadership and staff training on the QAPI plan and its underlying principles, including the concept that systems of care and business practices must support quality care or be changed .'' Review of facility documents revealed the facility did not have a QAPI Plan. During an interview on 08/02/24 at 6:04 PM, the Administrator confirmed the facility did not have a QAPI Plan.

Based on interview, review of facility documentation, and review of facility policy, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure the required members of the committee attended the quarterly meetings. This failure had the potential to affect all 161 residents who currently live in the facility. Findings include: Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program'' revised 04/2014 and provided by the facility did not include QAPI attendance expectations. Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program- Analysis and Action'' revised 03/2020 and provided by the facility did not include QAPI attendance expectations. During an interview on 08/02/24 at 6:04 PM, the Administrator confirmed that QAPI meetings were held at a minimum every quarter and that all meetings should include an Administrator, DON, Infection Preventionist (IP), and Medical Director (MD). The Administrator confirmed that for the third and fourth quarters of 2023 the MD did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of R68's undated ''admission Record'' located in the EMR under the ''Profile'' tab included an original admission date of 05/28/23 and most recent readmission on [DATE]. Review of R68's ''Clinical Census'' located in the EMR under the ''Census'' tab indicated on 08/10/23 a hospital leave with readmission on [DATE]. Review of R68's ''Progress Note,'' located in the EMR under the ''Progress Note'' tab and dated 08/10/23, included transfer to the Emergency Department (ED) for foley catheter evaluation and possible obstruction/malfunction with bleeding. No documentation was located in the EMR indicating a transfer/discharge notice was provided to the resident or representative. During an interview on 08/01/24 at 3:15 PM, the Director of Nursing (DON) confirmed that R68's hospitalization from 08/10/23-08/13/23 did not a include a transfer/discharge notification to the resident or RP; or Ombudsman notification. 4. Review of R102's ''admission Record'' located in the EMR under the ''Profile'' tab included 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, record review, and policy review, the facility failed to ensure five out of five sampled residents who were reviewed for hospitalization (Residents (R)126, R151, R99, R69, R102) were provided with a bed hold notice within 24 hours of emergent transfer to the hospital. This failure increased the potential that residents would not know to request a bed hold and may be unable to return to the facility. Findings include: 1. Review of the undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R99 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), heart failure, and chronic kidney disease (CKD). R99 was her own responsible party (RP). Review of R99's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/07/24, located in the EMR under the MDS tab, revealed R99 was unimpaired in cognition with a Brief Interview for Mental Status (BIMS) score of 14 out of a total of 15.…

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, review of facility documents, and facility policy review, the facility failed to ensure bed hold audits were completed per the performance improvement project. This failure had the potential to affect residents who were emergently sent out to the hospital. Findings included: Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program'' revised 04/2014 included, ''. Performance improvement projects (PIPs) are initiated when problems are identified . Prioritizing identified quality issues based on risk of harm and frequency of occurrence, and determining which will become the focus of PIPs . Planning, conducting and documenting PIPs .Taking systematic action targeted at the root causes of identified problems. This encompasses the utilization of corrective actions that provide significant and meaningful steps to improve processes and do not depend on staff to simply 'do the right thing'.'' Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program- Analysis and Action'' dated 03/2020…

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.

Based on interview, record review, and facility policy review, the facility failed to correctly issue Medicare Part A beneficiaries CMS-10055 (Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) when the residents completed therapy or skilled nursing services for two of three residents (Residents (R) 76, and R102) reviewed for beneficiary notices. This failure had the potential of a resident or responsible party to make an informed decision related to continuing to receive Medicare A services, by having the facility continue services and bill Medicare A, continue the services, and bill the resident, or no receive the services. Findings include: 1. Review of the facility completed SNF Beneficiary Protection Notification Review form revealed R76 was admitted for a Medicare A stay on 07/15/24 after a short stay in a hospital. Her last covered date (LCD) was 07/27/24. R76 received a SNFABN on 07/27/24 with financial liability to begin on 07/28/24. Review of R76's, facility provided, SNFABN was revealed in the section titled Care facility staff documented You no longer require…

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, record review, and policy review, the facility failed to ensure two out of two residents (Resident (R) 78 and R203) reviewed for restraints out of total of 32 sampled residents were free from physical restraints. R78 was positioned in bed in a manner to prevent him from getting out of bed as a fall intervention. R203 was observed with his hand to mid forearm wrapped with a bandage with a sock worn over it on his left hand/arm that he was not able to remove. Unnecessary physical restraints created the potential for psychological distress to R78 and R203. Findings include: 1. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R78 was admitted to the facility on [DATE]; current diagnoses included chronic obstructive pulmonary disease (COPD), chronic pain, major depressive disorder, psychotic disorder with delusions, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 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, record review, and facility policy review, the facility failed to ensure one of two residents (Resident (R) 95) reviewed for ''Pre-admission Screening and Resident Review (PASARR)'' had a level two assessment completed. Specifically, the facility failed to re-submit a positive PASSAR Level I screening, after a PASARR Level II was not able to be conducted. This failure placed the resident at risk for unmet care needs and not receiving appropriate mental health support/services as needed. Findings include: Review of R95's ''admission Record,'' located in the electronic medical record (EMR) under the ''Profile'' tab, showed a facility admission date of 03/29/21 and re-admission on [DATE]. R95's primary medical diagnoses included schizoaffective disorder and bipolar disorder. Review of R95's admission ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 05/03/24, located in the EMR under the ''MDS'' tab, included a ''Brief Interview for Mental Status (BIMS)'' score of 12 out 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 2. Review of R253's undated admission Record, located in the EMR Profile tab, revealed R253 was admitted on [DATE] with diagnoses including secondary malignant neoplasm of unspecified ovary and cutaneous abscess of the abdominal wall with hospice services. Review of the EMR revealed a POLST (Physician Order for Life Saving Treatment) completed by R253 on 07/21/24 located in the Documents tab of the EMR which documented R253 did not want resuscitation. Review of the Orders tab of the EMR revealed a physician order for DNR (Do Not Resuscitate), dated 07/21/24. Review of the care plan, dated 07/22/24 and located in the EMR Care Plan tab, revealed there was not a care plan for advance directives or her code status. During an interview on 08/02/24 at 4:00 PM, the MDS Director confirmed a care plan for code status should have been initiated when R253 was admitted . Review of facility policy titled, ''Care Plans-Baseline,'' revised 03/2022, revealed, ''A baseline plan of care to meet the resident's immediate health 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 interview and record review, the facility failed to ensure one out of one residents (Resident (R) 204) reviewed for bowel and bladder out of a total sample of 32 residents received timely care for constipation. The bowel protocol was not initiated until R204 failed to have a bowel movement for five days. R204 went a total of ten days without having a bowel movement putting him at risk for a fecal impaction. Findings include: Review of the undated admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R204 was admitted to the facility on [DATE] with diagnoses including COVID 19, type two diabetes mellitus, and acute kidney failure. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/24, located in the EMR under the MDS tab, revealed R204 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. R204 was continent of bowel and did not have constipation. Review of the Order Summary…

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, record review, and policy review, the facility failed to ensure one out of three residents (Resident (R) 204) reviewed for nutrition/hydration out of 32 sampled residents received sufficient fluids to maintain adequate hydration status. R204 was not assessed timely for fluid requirements even though he was prescribed intravenous (IV) fluids twice within the first ten days of admission due to poor nutritional and fluid intake. R204's care plan goal for fluids was inadequate to meet his fluid needs, and his supplement intake was not monitored. R204 was at risk for dehydration and weight loss. Findings include: Review of the undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R204 was admitted to the facility on [DATE] with diagnoses including COVID 19, type two diabetes mellitus, and acute kidney failure. His stay was projected to be short term. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date…

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, record review, and policy review, the facility failed to ensure one out of five residents (Resident (R)78) reviewed for unnecessary medications out of 32 sampled residents did not receive an as needed antianxiety medication for more than fourteen days without a physician rationale for extending the use and without the stop date specified. This failed practice increased the risk of experiencing adverse reactions to medications which they may not need to treat a clinical condition. Findings include: Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R78 was admitted to the facility on [DATE]; current diagnoses included major depressive disorder, psychotic disorder with delusions, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/24, located in the EMR under the MDS tab, revealed R78 was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) score…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that two of three residents (Resident (R) 81 and R79) reviewed for catheters out of 32 sampled residents received catheter care in a manner to prevent cross-contamination. Nursing staff did not change gloves appropriately while providing catheter care to R81 and the facility failed to ensure R79's catheter bag was kept off the floor. This failure has the potential for staff to spread infections between residents. Findings include: 1. Review of R81's undated admission Record under the ''Profile'' tab in the electronic medical record (EMR) indicated that R81 was re-admitted to the facility on [DATE] with a diagnosis of obstructive and reflux uropathy, unspecified. Review of R81's urinalysis culture, dated 02/04/24 and located under the tab ''Results'' in the EMR, indicated that R81 had a urinary tract infection which had bacteria including Citrobacter freundii (healthcare associated infection). During suprapubic catheter observation…

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 meet professional standards of quality when one of three sampled residents (Resident 1) was not administered his anti-viral medication (medication used to help the body fight off harmful viruses which can ease symptoms and shorten the length of a viral infection) for seven days, as ordered on admission and staff did not follow up with the pharmacy or notify the physician as required according to the facility ' s policy and procedure titled, Unavailable Medications. This failure resulted in increasing the risk of worsening Resident 1 ' s viral infection and possibly cause harm and mental and emotional distress (anger and frustration). Findings: During an interview on 11/28/23 at 1:08 p.m. with Resident 1, Resident 1 stated he was admitted to the facility on [DATE] through 2/27/23. Resident 1 stated, he was not administered his anti-viral medication as ordered from 2/20/23 through 2/27/23. Resident 1 stated he asked staff for the anti-viral 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents remained free of accident hazards for one of three sampled residents (Resident 1), when one Certified Nursing Assistant (CNA) assisted during briefs (adult diaper) change alone, not using two - person assist (two staff members to one resident) as required. This failure resulted in Resident 1 falling out of bed during briefs change and sustained a sprained (soft tissue injury) right ankle. Findings: During a concurrent observation and interview on 3/15/23 at 10:19 a.m. with Resident 1, in Resident 1 ' s room, Resident 1 was in bed with a bruised (skin discoloration) right ankle. Resident 1 stated, she fell off the bed on 2/26/23 during briefs change and injured her right ankle. Resident 1 stated, Certified Nursing Assistant (CNA) 2 was changing her brief and rolled her too far off the bed. Resident 1 stated, she fell off the bed and landed on both knees on the floor. Resident 1 stated, she was supposed to have two CNAs…

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.

2. During a review of the clinical record for Resident 162, the admission Record dated 7/16/19, indicated Resident 162 was discharged home from the facility on 4/30/19. During an interview with the Medical Records Assistant (MRA), on 7/16/19, at 9:54 a.m., the MRA stated Resident 162 was discharged home. The MRA stated she did not know if the Ombudsman was notified for Resident 162's discharge. The MRA reviewed Resident 162's clinical record and stated she could not find notification of discharge to the Ombudsman in the resident's record. During an interview with the Director of Social Services (DSS), on 7/16/19, at 11:02 a.m., the DSS stated a letter of the last covered day needs to be sent to the Ombudsman to notify of the residents' discharge. The DSS stated medical records should have sent a copy to the Ombudsman. The facility policy and procedure titled Transfer and Discharge Notice dated 6/2017, indicated .Other Types of Facility-Initiated discharges: a written notice of discharge must be provided to the resident and resident representative with a copy to the State LTC [long…

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 a comprehensive person-centered care plan for three of three sampled residents (Resident 51, Resident 138, and Resident 15) when: 1. Resident 51 did not have a care plan for the use of an indwelling urinary catheter. This failure resulted in Resident 51's indwelling urinary catheter (a urinary catheter is a thin tube placed in the bladder to drain urine) care not being properly implemented by licensed nurses. 2. Resident 138 did not have a care plan for walking without feet protection. This failure resulted for Resident 138's feet not assessed by licensed nurses for potential injuries and signs infection. 3. Resident 15 Fall care plan failed to address the identify the need to use a mechanical lift for safety during transfers. This failure placed Resident 15's health and safety at risk when the procedure to use a mechanical lift for safe transfers was not included in the care plan. Findings: 1. During an observation…

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 complete a performance review of every nurse aide at least once every 12 months for five of 20 sampled Certified Nursing Assistants (CNAs). These failures had the potential for residents' needs to go unmet by CNAs whose competence had not been determined through annual performance reviews. Findings: During an employee record review with the Director of Staff Development (DSD), the following CNA records indicated: 1. CNA 15 with a hire date (HD) of 5/22/17, was evaluated on 2/20/18 and had no evaluation on or before 2/20/19. 2. CNA 16 with a HD of 12/14/17 was evaluated on 2/15/18 and had no evaluation on or before 2/15/19. 3. CNA 17 with a HD of 3/17/15, was evaluated on 2/14/18 and had no evaluation on or before 3/14/19. 4. CNA 19 with a HD of 1/30/16, was evaluated on 2/23/18 and had no evaluation on or before 2/23/19. 5. CNA 18 with a HD of 8/24/17, was evaluated on 2/22/18 and had no evaluation on or before 2/22/19. During an interview with the DSD on 7/12/19, at 4:35 p.m., the DSD stated the evaluations were completed…

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 store medications and biological in a manner that conforms with state requirement and the standard of practice when: 1. The facility stored and made available for resident use expired medications, medications for external use, medical supplies and medications labeled for individual's use with the over-the counter (OTC) oral medications in the medication storage area in Station 2. 2. The facility stored medications for external use with OTC oral medications in the central supply storage room in Station 3. 3. The facility stored medications for external use with the OTC oral medication in the medication storage in Station 3. 4. The facility stored medications for internal use mixed with oral medications in the medication cart in Station 3. This failure placed the residents' health and safety at risk for residents to receive expired medications, potentially contaminated medications when medications were not safely stored in accordance with the manufacturer's specifications, state requirements and the standard 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 food services staff had appropriate competencies for safely and effectively carrying out the functions of food services when [NAME] 1, 2 and Dietary Aide were unable to verbalize the cool down process and did not follow the cooling down policy and procedure. This failure had the potential for untrained staff to place residents at risk of exposure to foodborne illnesses. Findings: During an interview in the kitchen with [NAME] 1 and Certified Dietary manager (CDM), on 7/11/19, at 10 a.m., regarding cool down food process, [NAME] 1 stated when food cooked temperature (temp) goes down to 140 Fahrenheit (F) she would start the cooling process and log it, then in two - hours (hrs.) after, food should reach 70, then she had 4 hrs. to cool the food to 41degrees F. [NAME] 1 stated the cooling process should reach 70 degrees F at the two - hrs. mark and if food does not reach 70 degrees F, to continue cooling the food in the refrigerator. During an interview in the kitchen with [NAME] 2 and CDM, on 7/11/19,…

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

Based on observation, interview and record review, the facility failed to store, prepare and serve food safely when: 1. Potentially hazardous foods (PHF) were not cooled down according to the cool down policy and procedures. 2. Several dry foods containers were opened and stored without opened date label. 3. Frozen products in the walk in freezer were removed from the original containers and were not labeled or had used by date. 4. The kitchen staff did not have a red bucket sanitation chemical monitoring process and did not perform red sanitation water buckets testing to ensure the water contained adequate levels of sanitation chemical. 5. Wet Pans were stack on top of each other to air dry. These failures to ensure effective dietetic service operations placed the residents at risk for food borne illness and the growth of microorganisms (bacteria). Findings: 1. During an interview in the kitchen with [NAME] 1 and Certified Dietary manager (CDM), on 7/11/19, at 10 a.m., regarding cool down food process, [NAME] 1 stated when food cooked temperature (temp) goes down to 140 Fahrenheit…

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 conduct a facility wide assessment specific to the facility needs when the facility assessment did not include a water management plan. This practice failed to establish an individualized facility assessment to meet the requirement for a water management plan which had the potential for waterborne bacteria exposure to the residents including Legionella (disease is a severe form of pneumonia - lung inflammation usually caused by infection, caused by bacterium known as legionella, most people get legionnaires' disease from inhaling the bacteria in showers, water faucets, water fountain) in an event of an outbreak. Findings: During an interview with the Administrator (ADM), on 7/17/19, at 9:46 a.m., he stated he was aware of the facility's requirement to establish a water management plan issued by the Centers of Medicare and Medical Services (CMS) in September 17, 2018. The ADM stated the requirement indicated all healthcare facilities were required to develop a plan for water management in an effort to reduce the risk 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 2b. During a concurrent observation in Resident 6's room and interview with Resident 6, on 7/9/19, at 3 p.m., Resident 6 stated she received dialysis service for about 15 years now. Resident 6 stated she went for dialysis treatments three times a week every Monday, Wednesday and Friday at 10:30 a.m. During a review of Resident 6's undated face sheet indicated resident was admitted with diagnoses which included Hypertensive Chronic Kidney Disease (elevated blood pressure caused by kidney disease), End Stage Renal Disease, dependence on Renal Dialysis. During a review of Resident 6's dialysis, 11 (eleven) communication forms dated 6/1/19, 6/3/19, 6/5/19, 6/10/19. 6/12/19, 6/17/19, 6/19/19, 6/21/19, 6/26/19, 6/28/19 and 7/01/19 were missing resident assessment information Vital signs, Labs During Dialysis, Meds during dialysis, Blood Sugar Before Dialysis, Blood Sugar After Dialysis, Diet Change Recommendation, whether these items were done or not applicable. During an interview with the Director of Nursing (DON)…

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 kitchen equipment was safely maintained when excess ice build up was found inside the walk in freezer above the two freezer fans. This failure had the potential to impact the ability of dietary staff to prepare, store, and serve food in a safe and sanitary manner. Findings: During a concurrent observation and interview with the Certified Dietary Manager (CDM), on 7/9/19, at 9 a.m., in the walk in freezer, there was ice build up above the two freezer fans. The CDM stated the Maintenance Supervisor (MS) was aware of the ice build up. The CDM stated the freezer door was recently replaced to try to resolve the ice build up problem but the problem continued. During an interview with the MS, on 7/10/19, at 10 a.m., he stated the CDM notified him about the ice build up in the walk in freezer. The MS stated, When the dietary staff open the freezer door to store food supplies delivered, they leave the door open too long and the heat from the kitchen temperature goes in and the fan start blowing. That starts…

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 promote care for residents in a manner and in an environment that maintained and enhanced each resident's dignity and respect in full recognition of his or her individuality when residents in the dining room were not served meals to all residents at the same table at the same time while residents watched others eating and they sat and waited for their meal affecting eight of 21 residents (Resident 158, 87, 14, 37, 89, 134, 55, and 40). This failure denied Residents 158, 87, 14, 37, 89, 134, 55, and 40 the right to a dignified and pleasant dining experience. Findings: During a lunch observation in dining room [ROOM NUMBER], on 7/9/19, at 12:26 p.m., 21 residents were seated around the dining tables waiting for lunch to be served. The dining room was staffed with one staff member, Restorative Nursing Assistant (RNA) 1. RNA 1 started serving trays to the residents. RNA 1 served meal trays to Resident 17, Resident 87 and Resident 22 who were…

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 resident's right to be informed of treatment for one of two sampled resident (Resident 80) when Resident 80 did not have a medication informed consent for an antipsychotic medication (affecting mental activity, behaviors, and perceptions). This failure resulted in Resident 80 or legal representative not being fully informed of the risks and benefits of the antipsychotic medication. Findings: During a review of the clinical record for Resident 80, the admission Record (document with resident demographic information) dated 7/16/19, indicated Resident 80 was admitted with medical diagnosis which included hallucinations (perception of having seen, heard, touched, tasted or smelled something that was not there). A review of Resident 80's physician orders dated 7/2019, indicated a medication order dated 2/28/19 for Risperidone (medication used to treat mental/mood disorders) 0.25 mg (milligrams-unit of dose) for psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost 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.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodations for one of seven sampled residents, Resident 133 when Resident 133's call light (a device used to alert staff when a resident needs assistance) was found on the floor and out of Resident 133's reach. This failure had the potential for Resident 133 not to receive assistance when needed and in case of an emergency. Findings: During a concurrent observation in the Resident 113's room and interview with Resident 133, on 7/9/19, at 9:18 a.m., Resident 133 laid in bed and the call light was on the ground out of reach. Resident 133 stated, I call the staff for help with my remote control, can you get it [call light] for me . it's on the ground. During a review of the clinical record for Resident 133's Minimum Data Set (MD'S) assessment (an evaluation of a resident's cognitive and functional status) dated 6/16/19, indicated a Brief Interview for Mental Status (BIMS- assessment of cognitive status) score of 8 of 15 points which indicated Resident 133 had moderate cognitive impairment.…

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 a clean, sanitary, and comfortable environment for one of three sampled residents (Resident 3) when dried feces was found in Resident 3's bathroom on the toilet seat and inside of the toilet. This failure caused Resident 3 to be exposed to an unsanitary and none homelike environment with a potential to cause infection. Findings: During an interview with the Housekeeping Assistant (HA), on 5/22/19, at 1:00 p.m., she stated her shift began at 6:30 a.m. and ended 2:30 p.m. The HA stated bathrooms were cleaned daily and whenever needed after initial cleaning. The HA stated there was no housekeeping staff after 2:30 p.m. and at night and Certified Nurse Assistants (CNA)s were responsible for cleaning the bathrooms of the rooms they were assigned to. During an observation of Resident 3's bathroom and interview with Director of Nursing (DON) and CNA 3, on 5/22/19, at 4:10 p.m., dried stool was observed on the toilet seat and inside of the toilet. The DON and CNA 3 validated upon observation that stool…

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 their abuse reporting policy and procedure for one of one sampled resident, (Resident 9), when the facility failed to report Resident 9's injury of unknown origin to the State Survey Agency in accordance with State law. This failure led to the delayed of immediate investigation of the cause of Resident 9's fracture (broken) rib bone to rule out the potential for abuse. Findings: During a concurrent observation and interview with Resident 9, on 7/9/19, at 9:30 a.m., Resident 9 was lying in bed and stated she had an X-ray (an imaging machine that creates pictures inside of the human body) done yesterday. Resident 9 stated the X-ray results came back showing that her left rib was broken. Resident 9 stated I don't know how it happened, I did not fall. Resident 9 stated that she had had been complaining of shoulder pain for a couple of days and that is why the doctor ordered an X-ray. During a review of the clinical record for Resident 9, the Progress Notes dated 7/8/19, at 12:46 p.m., indicated MD…

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 complete a quarterly Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status) once every 3 months for two of two sampled residents (Resident 2 and Resident 3). This failure had the potential to delay the development of a comprehensive care plan necessary to provide the appropriate individualized care and services for Resident 2 and Resident 3. Findings: During a review of the clinical record for Resident 2, the admission Record dated 7/17/19, at 9:20 a.m., indicated Resident 2 was admitted to the facility with diagnosis which included cutaneous abscess of right upper limb (a localized collection of pus in the skin that may occur on any skin surface). A review of Resident 2's MDS assessment dated [DATE], indicated the most recent quarterly assessment was completed on 1/14/19. During a review of the clinical record for Resident 3, the admission Record dated 7/11/19, indicated Resident 3 was admitted to 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 accurately conduct and document resident Minimum Data Set (MDS-patient assessment tool) assessments for two of three sampled residents (Resident 3 and Resident 137) when: 1. Resident 3's MDS assessment section C, Brief Interview of Mental Status (BIMS assessment) was inaccurately assessed. This deficient practice resulted in the documentation of an inaccurate BIMs assessment and had the potential to cause inaccuracy in identifying resident strengths to maintain and improve medical, functional, and psychosocial status. 2. Resident 137's dental assessment did not reflect the resident's actual dental status. This failure resulted in the delay in meeting Resident 137's dental need that would improve Resident 137's quality of life. Findings: 1. During a review of Resident 3's MDS dated [DATE], the BIMS cognitive assessment score indicated 8 moderately cognitive impairment. During a concurrent interview and clinical record review for Resident 3 with 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 develop and implement a baseline care plan for smoking within 48 hours of the resident's admission for one of one sampled residents (Resident 160). This failure placed Resident 160's health and safety at risk for potential burn or safety when Resident 160 smoking needs were not care planed. Findings: During a concurrent observation in Resident 160's room and interview with Resident 160, on 7/9/19, at 10 a.m., Resident 160 stated he smoked and pulled out a pack of half-full cigarette from his pocket. Resident 160 stated he got a supply of his cigarettes from his girlfriend. During a concurrent interview with the Minimum Data Set Coordinator (MDSC) 2 and review of the clinical record for Resident 160, the undated admission Record indicated Resident 160 was admitted on [DATE]. The MDSC 2 was unable to find documented evidence a baseline care plan was developed for Resident 160 since admission. MDSC 2 stated a smoking baseline care plan should have been…

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 staff interview and record review, the facility failed to revise a care plan on Falls that address the identified need for a safe mechanical lift transfer for one of two sampled residents, Resident 562. This failure placed Resident 562's health and safety at risk when the care plan did not include two person assistance with the use of a mechanical lift. Findings: During a concurrent interview and record review with MDS Coordinator (MDSC 2), on 7/15/19, at 10:35 a.m., MDSC 2 reviewed Resident 562's clinical record and stated Resident 562's Minimum Data Set (MDS) assessment (an evaluation of a resident's functional status) dated 2/3/19 under section G transfers was coded 4 and 3 which indicated Resident 562 required two person assistance during transfers. After a review of Resident 562's revised care plan, MDSC 2 stated Resident 562's care plan did not include interventions that specified the need for two person physical assistance with the use of mechanical lift [A portable lift devise used to lift, move residents]. MDSC 2 stated it is the responsibility of the nurses 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 provide services which meet professional standards of quality for 44 of 46 sampled residents (Residents 1, 3, 5, 7, 10, 11, 15, 16, 20, 26, 33, 34, 36, 41, 42, 44, 47, 49, 57, 58, 65, 73, 76, 89, 92, 93, 94, 99, 107, 122, 125, 135, 137, 141, 564, 565, 566, 567, 568, 569, 570, 571, 572 and 573) when: 1. Registered Nurse (RN) 1 used non-intended syringe with needle to withdraw insulin from an insulin flex pen (a dial-a-dose device, pre-filled insulin pen for discreet insulin medication [for the treatment of diabetes - a disease that causes high blood sugar levels] administration). RN 1 did not use the indicated needle attachment made for use with Insulin Flex Pens, and instead, withdrew insulin out of the pen using a non-intended syringe with needle and administered the insulin to Resident's 141, 564 and 567. This failure placed the residents at risk for dosing errors or subcutaneous (under the skin) injection of air. 2. When five of five…

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 proper maintenance and care for residents with an indwelling urinary catheter (a urinary catheter is a thin tube placed in the bladder to drain urine) for two of 12 sampled residents (Resident 33 and Resident 51) when: 1. Resident 33 and Resident 51's indwelling urinary catheter was not placed below the bladder. This failure had the potential for urine backflow that could lead to urinary tract infection (an infection in the bladder). 2. Nursing staff did not document Resident 51's indwelling urinary catheter urine output in the intake and output log. This failure had the potential for Resident 51's urine output to go unmonitored and placed resident at risk for dehydration. Findings: 1. During a concurrent observation in Resident 33's room and interview with Resident 33, on 7/9/19, at 11:37 a.m., there was a urinary catheter bag on Resident 33's left side of his hip on the wheelchair. Resident 33 stated he keeps the urinary bag 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 ensure Psychotropic Drug (medications that affects brain activities associated with mental processes and behavior) as needed prescriptions were limited to 14 days for one of three sampled residents (Resident 38) when Resident 38's Xanax (anxiety medication) This deficient practice had the potential to expose Resident 38 to unnecessary medications. Findings: During a concurrent observation and interview with Resident 38, on 7/9/19, at 10:30 a.m., Resident 38 was lying in bed and spoke with slow, slurred and unclear speech. During a review of the clinical record for Resident 38, the admission record (a document containing resident profile information) undated, indicated Resident 38 was admitted to the facility with diagnoses which included anxiety disorder (characterized by a sudden feeling of panic and fear, restlessness, and uneasiness) and aphasia (impairment of language, affecting the production or comprehension of speech and the ability to read or write). During a review of the clinical record for 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.

Based on observation, interview and record review, the facility failed to provide food that meets resident's daily nutritional dietary needs and preference for one of one sampled resident (Resident 137) when the physician's diet order was not followed. This failure placed Resident 137 at risk for unplanned weight loss and unmet nutritional dietary needs. Findings: During a lunch observation in Resident 137's room, on 7/9/19 at 12:30 p.m., Resident 137's meal ticket indicated, Diet: NCS (no concentrated sugar) diet- No Meats (Fish Ok) Consistency: Regular 1 oz. (ounce) extra protein with meals- Chef salad with meals and dinner. Resident 137 was served a Cheese sandwich as a substitute, meat and a small bowl of shredded lettuce. During an interview with the Registered Dietician (RD) on 7/10/19 at 3 p.m., the RD stated the 1 oz. of protein ordered by the physician was the serving of chef salad as preferred by Resident 137. The RD stated a chef salad included cheese, eggs and tomatoes and therefore Resident137 receive the 1 oz. of protein ordered by the physician. The RD stated 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.