Cypress Ridge Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete the discharge Minimum Data Set (MDS, an assessment tool) for one of three residents (Resident 92). Failure to accurately assess Resident 92's discharge status resulted in an inaccurate record. Findings: Review of Resident 92's discharge summary report indicated he was discharged home with home health services on 2/20/25. Review of Resident 92's discharge MDS, dated [DATE], indicated he was discharged to the acute hospital. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 5/14/25 at 10:18 a.m., the MDSC confirmed Resident 92 was discharged to his home on 2/20/25. The MDSC verified that Resident 92's discharge MDS was incorrectly coded and stated that Resident 92 was discharged home, not to the acute hospital as was coded on Resident 92's 2/20/25 discharge MDS. Review of the Centers for Medicare and Medicaid Services (CMS) 10/2019 Resident Assessment Instrument 3.0 User's Manual (RAI…

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, resident-centered care plan for one out of five residents investigated for their activities, (Resident 51), when Resident 51 did not have a care plan for her activities. This failure had the potential for the resident to not receive the appropriate interventions necessary to maintain her highest level of well-being. Findings: During a concurrent observation and interview of Resident 51 during the resident council meeting (gathering where residents of a facility come together to discuss issues) on 5/13/25 at 11:00 a.m., Resident 51 was in her wheelchair in the activity room, alert, oriented, verbally responsive and participating actively in the resident council meeting discussion. Resident 51 stated that she's the current resident council president and she attends the meetings regularly. Review of the admission record (document created when a resident is admitted to a healthcare facility, containing…

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 and services in accordance with professional standards of practice for two of 25 sampled residents (Residents 59 and 301) when: 1. The facility failed to follow the physician's order for Resident 59 by not applying the prescribed wound care dressing and offloading boots while the resident was in bed. 2. For Resident 301, the licensed nurse incorrectly transcribed the physician's order for Chlorhexidine Gluconate mouth rinse. These failures had the potential to compromise the residents' health and well-being. Findings: 1. A review of Resident 59's clinical record indicated Resident 59 was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness, presence of a left artificial knee joint, and bilateral primary osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) of the knee. A review of Resident 59's physician's order dated 3/26/2025 indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the adequate provision of pharmaceutical services when: 1. Chlorhexidine Gluconate mouth rinse was unavailable for administration for five consecutive days for one of 25 sampled residents (Resident 301). 2. The pharmacy linked the different medications and incorrect administration instructions for one of the 25 sampled residents (Resident 36). This link resulted in the licensed nurse administering the wrong medication to Resident 36. These failure had the potential to worsen the resident's condition or lead to complications. Findings: 1. During a medication administration observation on 5/12/2025 at 10:00 a.m. in Resident 301's room, Licensed Vocational Nurse (LVN) A was observed administering the resident's morning medications. The Chlorhexidine Gluconate Oral Rinse was not administered. During an interview with LVN A on 5/12/2025 at 10:20 a.m., LVN A confirmed that she did not administer the Chlorhexidine Gluconate Oral Rinse 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.

Based on observation, interview, and record review, the facility had a medication error rate of 7.14 % when two medication errors were observed out of 28 opportunities during medication administration for two out of six residents (Residents 301 and 36). 1. Chlorhexidine mouth rinse was not administered as ordered for Resident 301, 2. Insulin was not administered as ordered for Resident 36 before lunch. These failures resulted in residents not receiving medications as prescribed, which had the potential to result in residents not receiving the full therapeutic benefit of their medications and/or experiencing negative health outcomes. Findings: 1. During a medication administration observation on 5/12/2025 at 10:00 a.m. in Resident 301's room, Licensed Vocational Nurse (LVN) A was observed administering Resident 301's morning medications. The Chlorhexidine Gluconate Oral Rinse was not administered. During an interview with LVN A on 5/12/2025 at 10:20 a.m., she confirmed that the Chlorhexidine Gluconate Oral Rinse was not administered because it had not been available since the order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident's right to be treated with dignity was rendered for one of two residents (Resident 1) when Resident 1's request not to move to another room was not followed. This failure had the potential to cause emotional distress and a feeling of less self-worth for Resident 1. Findings: Review of Resident 1's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included encephalopathy (disorder or damage that affect the brain's structure or function), and psychotic disorder (a mental disorder that affects a person's ability to think and perceive reality) with delusions (having false and unrealistic beliefs). Review of Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 11/2/24 indicated her cognition (the mental process of thinking, learning, remembering, being aware of surroundings, and using judgement) was severely impaired but had a clear speech, made herself to be understood, 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 the residents' pressure ulcers (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) had weekly assessment for four of seven residents (1, 2, 3, and 4). This failure resulted in undetermined wound status and had the potential to negatively affect the healing of the wounds and/or to cause the deterioration of the wounds. Findings: Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including severe obesity, muscle weakness, and cognitive communication deficit. Review of Resident 1's clinical record indicated she had a pressure ulcer stage 2 (a partial-thickness skin loss that appears as a shallow, open wound with a red or pink wound bed) on her sacrum (a large, triangular bone at the base of the spine), but her sacral pressure ulcer was not assessed from 11/8/24 to 12/2/24. Review of Resident 2's admission Record indicated he was admitted…

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 implement infection control practices when: 1. Certified nursing assistant A (CNA A) did not sanitize/wash her hands after removing the gloves which she wore during working with Resident 5; 2. CNA B walked out of Resident 6's room with gloves on and did not sanitize/wash her hands; and 3. CNA C walked out of Resident 7's room with gloves on. These failures had the potential to spread infection in the facility. Findings: During an observation on 12/2/24, at 4:05 p.m., CNA A was working with Resident 5 in his room. She removed and discarded her gloves and walked out of Resident 5's room and in the hallway without sanitizing/washing her hands. During an interview with CNA A on 12/2/24, at 4:10 p.m., she stated she was preparing Resident 5 and transferring him for shower in his room. CNA A stated she should sanitize/wash her hands when she walked out of Resident 5's room and in the hallway. During an observation on 12/2/24, at 4:20 p.m., CNA B was working with Resident 6 in his room. She walked out of Resident…

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

Based on observation, interview, and policy review, the facility failed to ensure proper medication storage when an unlocked medication cart was left unattended. This failure had the potential for residents, unauthorized staff, and visitors to access the medications. Findings: During an observation and interview with registered nurse A (RN A) on 7/9/24, at 1:45 p.m., RN A was in Resident 1's room and her medication cart was facing out in the hallway and not locked. RN A stated she was checking on Resident 1's knee in his room. RN A acknowledged that she should lock her medication cart before going to Resident 1's room to check his knee. During an interview with the director of nursing (DON) on 7/9/24, at 4:05 p.m., he stated the unattended medication cart should be locked. Review of the facility's policy, Storage of Medication, dated 8/2014, indicated Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.

Based on interview and record review, the facility failed to ensure one of three Certified Nursing Assistants (CNA) A had a current CNA certificate during the time of employment working as a CNA while providing resident care from August 2023 to April 2024. This deficient practice had the potential for an unqualified CNA to provide care to the residents. Findings: A review of CNA A's employee file indicated that she applied for the CNA position on 7/19/23 and signed the Team Member Handbook Acknowledgement and at-will Agreement as a CNA on 7/26/23. A further review of CNA A's employee file revealed that there was no documentation that indicated she had obtained her CNA certificate. During an interview with CNA A on 3/29/24 at 1:03 p.m., CNA A confirmed she started working as a CNA and worked with several residents after passing the CNA knowledge portion on 8/13/23 and the skill examinations on 8/5/23 even though she did not received her CNA certificate. A review of the facility's work schedule on 3/29/24 indicated that CNA A worked from 7:00 a.m. to 3:30 p.m. and provided care 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 interview and record review, the facility failed to ensure the residents received the necessary care and services for four of six residents (2, 3, 4, and 5) when their wounds did not receive weekly assessment. This failure resulted in undetermined wound status and could negatively affect the progress of their wound healing. Findings: Review of Resident 2's admission Record indicated he was admitted to the facility on [DATE] and discharged on 1/30/24. Review of Resident 2's 1/2024 Treatment Administration Record (TAR) indicated Resident 2 had a sacrococcygeal (the region at the base of the spine) wound during his stay at the facility. Review of Resident 2's clinical record indicated Resident 2 had only one Comprehensive Skin Evaluation/Assessment done on 1/24/24 and one Skin and Wound Evaluation done on 1/29/24. Review of Resident 3's admission Record indicated she was admitted to the facility on [DATE] and discharged on 2/14/24. Review of Resident 3's 1/2024 and 2/2024 TARs indicated Resident 3 had 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 interview and record review, the facility failed to provide safe discharge to one of three residents (1) when the physician indicated that Resident 1 could not be discharged home for self-care, but Resident 1 was discharged home without a caregiver readily available for her upon her discharge to home. This failure had the potential to jeopardize the resident's health, safety and well-being. Findings: Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE] and discharged from the facility on 2/26/24. Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 2/1/24, indicated her cognition was moderately impaired. Review of Resident 1's Encounter Notes, dated 2/22/24, at 5:45 p.m., the physician indicated that Resident 1 needed a safe placement and could not be discharged home for self-care. Review of Resident 1's clinical record indicated Resident 1 was discharged to home and was given the pamphlets on caregiving services. However, there was no…

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

Based on observation, interview, and record review, the facility failed to follow care plan and physician's order to apply Triamcinolone cream (a corticosteroid used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions) to one of three sampled residents (1). This failure had a potential to delay the improvement and/or resolution of Resident 1's skin problem. Findings: Review of Resident 1's admission record indicated he admitted facility on 1/20/10 and had diagnoses including rash and other nonspecific skin eruption. Review of Resident 1's physician order, dated 11/29/22, indicated physician prescribed, Triamcinolone Acetonide Cream 0.1 % (Triamcinolone Acetonide (Topical)) apply to affected area topically every day and evening shift for general for general body rashes. Apply to legs, arm creases and any areas of rash /redness. Review of Resident 1's plan of care for generalized body rash, dated 9/28/22, indicated to provide treatment per physician's orders. Review of Resident 1's three months' electronic treatment administration record (ETAR)…

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 to outline dysphagia ((difficulty of swallowing) care for one of three sampled residents (2) when she had a newly added diagnosis of dysphagia after her hospital admission. This failure potentially affected Resident 2's quality of care for prevention of aspiration or choking in the facility. Findings: Review of Resident 2's acute hospital Discharge summary, dated [DATE], indicated her baseline was with severe psychiatric issues and refused majority of care for chronic medical conditions. She was found to have altered mental status, decreased responsiveness, oxygen saturation decreased to 83% room air and blood pressure was 90 over 33 upon change of condition on 3/13/24. The hospital course documented that She is at high risk of aspiration pneumonitis. Review of Resident 2's dysphagia progress notes, dated 3/20/24, indicated she had seen Speech and Language Pathologist (SLP)…

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. A review of Resident #298's admission Record, revealed the facility admitted the resident on 01/13/2024, with a diagnosis of benign prostatic hyperplasia. A review of Resident #298's care plan, initiated 01/13/2024, revealed the resident was at risk for complications related to a suprapubic catheter. Interventions directed the staff to provide a privacy cover for the catheter bag to promote the resident's dignity. On 01/22/2024 at 1:13 PM, 01/23/2023 at 12:08 PM, and on 01/23/2024 at 3:37 PM, the surveyor observed that Resident #298's urinary catheter drainage bag did not have a privacy cover. During an interview on 01/24/2024 at 1:14 PM, Certified Nursing Assistant (CNA) #13 stated it was facility policy for a urinary drainage bag to be covered for respect and privacy of the resident. During an interview on 01/24/2024 at 1:35 PM, CNA #14 stated all urinary catheter bags should be covered for privacy. Per CNA #14, CNAs were responsible for providing the privacy bags. CNA #14 confirmed Resident #298 should have a urinary drainage privacy bag. During an interview on 01/24/2024 at…

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. A review of Resident #81's admission Record, revealed the facility admitted the resident on 09/12/2023, with diagnoses that included end stage renal disease and dependence on renal dialysis. A review of Resident #81's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2023, revealed Resident #81 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Per the MDS, Resident #81 did not receive dialysis. A review of Resident #81's care plan, initiated on 09/13/2023, revealed the resident required hemodialysis due to end stage renal failure. Interventions specified the resident received hemodialysis on Mondays, Wednesdays, and Fridays. A review of Resident #81's Order Summary Report, for active orders as of 01/24/2024, revealed an order dated 01/22/2024, for dialysis on Mondays, Wednesdays, and Fridays. During an interview on 01/24/2024 at 11:33 AM with MDS Coordinator #3 and MDS Coordinator #4, MDS Coordinator #4 acknowledged Resident #81 received hemodialysis. MDS Coordinator #4…

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 interviews, record review, and review of facility policy, the facility failed to schedule and complete quarterly care plan reviews and invite the resident and/or the resident representative to the care plan meeting for 1 (Resident #71) of 20 sampled residents. Findings included: A review of an undated facility policy titled, Care Plans, Comprehensive Person-Centered, revealed, 4. Each resident has the right, individually or through a responsible party, to participate in the development and implementation of his or her comprehensive person-centered care plan, including the right to: a. Participate in the planning process. The policy revealed, 5. The resident should be informed of the date of his or her care planning conference(s) and given the opportunity to participate. A review of Resident #71's admission Record, revealed the facility originally admitted the resident on 02/10/2023, with diagnoses that included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting right non-dominant side and aphasia. A review of Resident #71's quarterly…

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

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure a nebulizer mask was cleaned and stored properly after use for 1 (Resident #298) of 3 sampled residents reviewed for respiratory care. The facility also failed to ensure a physician order contained the supplemental oxygen flow rate for 1 (Resident #6) of 3 sampled residents reviewed for respiratory care. Findings included: 1. Review of a facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised in October 2010, revealed, 24. When treatment is complete, turn off nebulizer and disconnect T-piece, mouthpiece, and medication cup. The policy revealed, 27. Rinse and disinfect the nebulizer equipment according to facility protocol, or: a. Wash pieces with warm, soapy water; b. Rinse with hot water; c. Place all pieces in a bowl and cover with isopropyl (rubbing) alcohol. Soak for five minutes); d. Rinse all pieces with sterile water; and e. Allow to air dry on a paper towel. 28. Wash and dry hands. 29. When equipment is completely dry,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to ensure residents receiving hemodialysis (HD, treatment to filter wastes and water from your blood) treatment received services consistent with professional standards of practice for two of three sampled residents (Residents 1 and 2) when: 1. For Resident 1, licensed staff failed to complete the Dialysis Unit Communication Report, and accurately assess the type of HD access site (a way to reach your blood for hemodialysis) resident was using; 2. Facility licensed staff failed to document pertinent (significant) information when the facility's contract transport company did not pick up Resident 1 and Resident 2 on time at the dialysis center on 9/16/23 after their dialysis sessions; and 3. Facility did not conduct a post-incident follow up or investigation as to why Resident 1 and 2 were not picked up by the contracted tranport company on time as per schedule. These failures had resulted in Resident 1 and 2's emotional distress, and had 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 interview and record review, the facility failed to implement their Personal Property policy and procedure or one of 2 sampled residents (Resident 1)when Resident 1's inventory of personal belongings was not completed and documented upon his admission to the facility. This failure had the potential for Resident 1's belongings to be stolen or lost without the resident or family's knowledge. Findings: Review of Resident 1's Intake Information, dated 9/19/23, indicated, .the staff could not find the pt's (patient's) clothes . During an interview with the Medical Records Assistant (MRA) on 12/19/23, at 2:00 p.m., the MRA stated she could not find any record of Resident 1's inventory of personal belongings when Resident 1 was admitted to the facility and throughout resident's stay in the facility. During an interview and concurrent record review with the Director of Nursing (DON), on 12/27/23, at 2:19 p.m., the DON stated he was unable to find any record of Resident 1's inventory of personal belongings. The DON stated the facility staff was supposed to complete the inventory of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents received the necessary care and services for one of three residents (1) when Resident 1 came back from the hospital on [DATE] with wounds, but after the assessment at admission, Resident 1 did not have any skin assessment until 11/13/23 which was almost one month after his admission. Also, Resident 1 did not have any treatment order for the wound on his right lateral lower leg until 10/27/23 which was about 9 days after his admission. These failures had the potential to affect the resident's care and could jeopardize his health and well-being. Findings: Review of Resident 1 ' s admission Record indicated he was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), moderate protein-calorie malnutrition, diabetes (a chronic, metabolic disease characterized by elevated levels of blood sugar), asthma (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 interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and 2) were free from incident of falls when: 1.The facility's contracted transportation driver A (FCTD A) did not perform the correct technique when the FCTD A pulled the wheelchair up the ramp instead of pushing Resident 1's wheelchair up the ramp when Resident 1 was scheduled to go out of the facility for an appointment. This resulted in Resident 1 falling face down on the pavement. 2. The facility failed to follow Resident 1's Minimum Data Set (MDS, an assessment tool) to provide two persons physical assist when Resident 1 went off the unit (when Resident 1 left her room/unit to go out of the facility for her appointment). The facility also failed to provide the designated escort (facility staff to accompany the resident for the appointments) to Resident 1 when Resident 1 fell. These failures had resulted in Resident 1 falling and transferring to the hospital. Resident 1's hospital discharge…

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 administer to one of three sampled residents (Resident 1) the prescribed antibiotics (medications to treat infections) as ordered and scheduled when these medications were available in the facility's Electronic Medication Cabinet (EMC, emergency medication kit). This had the potential for worsening of Resident 1's left knee and skin infections. Findings: Review of Resident 1's clinical record, the clinical record indicated Resident 1 was admitted on [DATE], with multiple diagnoses including infection and inflammatory reaction due to internal left knee prosthesis (artificial knee joint, infection in the area around the internal left knee prosthesis), Cellulitis (skin infection caused by bacteria) of left lower limb. Review of Resident 1's Physician's order, dated 7/11/2023, indicated Resident 1 was admitted on [DATE] with an order for Cefazolin (used to treat bacterial infections) 2 grams (gm, unit of measurement of weight)…

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 to follow their policy and procedure (P&P) for person-centered care plan for discharge plans for six of six residents (Resident 1,2,3,4,5, and 6) and follow physician order to provide medications when discharged resident home for one of six residents (Resident 6) when: 1.There was no discharge care plans for Resident 1,2,3,4,5, and 6; 2. Facility did not follow the physician order to provide Resident 6 for the 3-Day supply of medications when Resident 6 was discharged home. These failures had potential to violate the six of six residents' (Resident 1,2,3,4,5, and 6)'s transfer and discharge rights. Findings: 1a.Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated, Resident 1 admitted to facility (refers as transferring SNF: SNF: skilled nursing facility- a nursing facility which provides 24-hours skilled nursing care for the residents who reside in the facility for a long term) on 1/18/2023 with diagnoses including parkinson's disease (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medication and biologicals were stored and labeled appropriately when expired prescription and over the counter medications were found in the medication room; internal and external medications not stored separately; unlabeled and undated medications; incomplete medication refrigerator log and discontinued medications in the medication carts. These failures had the potential for residents to receive expired, incorrect and unsafe medications. Findings: 1. During the medication room observation with the assistant director of nursing (ADON) on 5/17/21 at 9:20 a.m. the following items were found: a. Medication room [ROOM NUMBER] - Incomplete medication refrigerator temperature log and expired intravenous (IV, a medical technique that delivers fluid, medication and nutrition directly into a person's vein) antibiotic. b. Medication room [ROOM NUMBER] - Earwax removal drops and rectal suppositories (solid forms of medication that are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two out of 18 sampled residents' (Residents 108 and 322) needs were met when their call lights were not within reach. This failure puts these two residents at risk for safety. Findings: 1. The clinical record of Resident 322 was reviewed; he was first admitted on [DATE], readmitted on [DATE] with diagnoses including difficulty walking, muscle weakness, history of falling and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). His minimum data set (MDS, an assessment tool) cognitive skills assessment as of 4/25/21, for daily decision-making indicated he was severely impaired. During an observation on 5/18/21 at 1:53 p.m., Resident 322 was observed in bed without a reachable call light. Certified nursing assistant C (CNA C) was called to the room. CNA C found the flat call light on top of the wall light fixture above Resident 322's bed. CNA C stated, I…

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 records review, the facility failed to check the residual (gastric content or volume of fluid remaining in the stomach) from a gastrostomy tube (GT, a small tube inserted through the abdomen that delivers nutrition and medication directly to the stomach) for one of 18 sampled residents (63) prior to medication administration. This failure had the potential to result in abdominal distention, pain and aspiration pneumonia. Findings: During a medication pass observation and concurrent interview with licensed vocational nurse D (LVN D) on 5/19/21 at 8:44 a.m., she did not check the residual prior to administering medication through the GT. LVN D confirmed the observation and stated she forgot to check the residual prior to the medication administration. She acknowledged the importance of checking the residual in order to reduce the risk of aspiration pneumonia. Review of Resident 63's clinical record indicated she had diagnoses of cerebral infarction (also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen 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.

Based on observation, interview and record review, the facility failed to ensure the environment was free of accident hazards for one of five sampled residents (Resident 8) when staff did not keep the bed in the lowest position as indicated in Resident 8's plan of care. This failure had the potential to increase the resident's risk for injury in the event of a fall. Findings: Review of Resident 8's clinical record indicated he had the diagnoses of dementia (mental disorder caused by brain disease or injury), hemiplegia (one side of the body is paralyzed), psychosis (a severe mental disorder characterized by a disconnection from reality), difficulty in walking, and repeated falls. Review of Resident 8's document titled Safety Events -- Falls/Found on Floor, dated 9/27/2020, indicated staff found Resident 8 on the floor beside his bed. The document further indicated, When asked what [Resident 8] was doing prior to the fall, he said the bed sheets were slippery and he slid while trying to move his legs and trying to grab onto the footboard. During an observation on 5/19/21 at 11:16…

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 adequate monitoring for one of 12 sample residents (Resident 98) when licensed nurses did not monitor Resident 98 for adverse effects of an anticoagulant medication (medication that thins the blood). This failure had the potential to negatively affect the resident's health and well-being. Findings: Review of Resident 98's clinical record indicated he had a history of deep vein thrombosis (DVT, a blood clot in the deep veins, usually in the legs). Review of Resident 98's Physician Order Report indicated he had a physician's order, dated 4/20/21, for Eliquis (anticoagulant medication) 5 milligrams (mg, unit of dose measurement) orally twice a day for DVT prophylaxis (prevention). There was no order to monitor Resident 98 for adverse effects of Eliquis. Review of Resident 98's May 2021 medication administration record (MAR) and treatment administration record (TAR) indicated there was no documentation that licensed nurses were monitoring him for adverse effects of Eliquis. Review of Resident 98's May 2021 Progress…

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 residents were free from unnecessary psychotropic medications (medications that are capable of affecting the mind, emotions, and behavior) for two of 12 sampled residents (Residents 87 and 26) when: 1. Resident 87 had no physician's rationale for continued psychotropic medication therapy beyond 14 days; and 2. Resident 26 did not have a documented clinical rationale for not receiving a gradual dose reduction (GDR, stepwise tapering of a medication to determine if symptoms can be managed with a lower dose or if the medication can be discontinued altogether) for an antipsychotic medication. These failures had the potential to increase the residents' risk for experiencing adverse effects from psychotropic medications. Findings: 1. A review of Resident 87's active physician orders indicated an order dated 4/28/21 for Ativan (lorazepam, a benzodiazepine, an antianxiety medication) 0.5 milligram (mg, a unit of measurement) every 8 hours PRN (pro re nata, as needed) for anxiety manifested by verbalization of nervousness.…

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.