Montrose Springs Skilled Nursing & Wellness Center

Based on observation, interview and record review, the facility failed to follow the facility's policy and procedure on Dry Goods Storage Guidelines to ensure safe and sanitary food storage in the kitchen where several food items were stored in the dry storage area with no opened date. In addition, one bag of dried cheese powder, dated 3/28/2025, exceeded storage period and was stored in the dry storage area. This deficient practice had the potential to result in harmful bacteria growth that could lead to foodborne illness (any illness resulting from the consumption of contaminated food or beverages) in 113 out of 117 residents who receive food from the kitchen. Findings: During a concurrent observation and interview on 7/1/2025 at 10:15 AM with the Registered Dietitian (RD) in the dry storage area, there was one medium plastic storage bin labeled with powder cheese dated 4/1/2025. Inside the storage bin, there was one open bag of powdered cheese dated 3/28/2025. The RD stated, 4/1/2025 was the delivery/received date for the cheese with opened bag and was old and should already be…

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 one of eight (8) sampled residents (Resident 56) with respect and dignity during mealtime, when Certified Nurse Assistant (CNA) 3 was observed standing over Resident 56 while providing feeding assistance. This failure had the potential to result in negatively affecting Resident 56's self-esteem and self-worth. Findings: During a review of Resident 56's admission Record (AR), the AR indicated the facility admitted Resident 56 on 8/19/2019 and readmitted Resident 56 on 6/29/2021 with diagnoses that included contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of Resident 56's left and right hands, dysphagia (difficulty swallowing), and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 56's Minimum Data Set (MDS, a resident assessment tool), dated 3/25/2025, the MDS indicated Resident 56 had modified independence (some difficulty in new situations only) when making decisions regarding tasks of daily life. The MDS…

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 obtain an informed consent (a process of communication between a person and the health care provider that often leads to agreement or permission for care, treatment, or services) for psychotropic/psychotherapeutic (any drug that affects behavior, mood, thoughts, or perception) drug for one of two sampled resident (Resident 52) who was prescribed Ativan (a psychotropic medication used for anxiety). This deficient practice violated Resident 52's rights to be informed when choosing the type of care or treatment to be received, making decisions on alternative measures that the resident or responsible party preferred, which can negatively affect Resident 52's quality of life. Findings: During a review of Resident 52’s admission Record [AR], the AR indicated Resident 52 was originally admitted to the facility on [DATE], with diagnoses that included dementia (the loss of thinking, remembering and reasoning) and anxiety disorder (feeling of fear as a reaction…

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 prompt efforts to resolve grievances for one of two sampled residents (Resident 107) who voiced to the facility during the Resident Council Meetings to provide a follow-up or a resolution for Wi-Fi extenders (a device that helped extend the range of your existing Wi-Fi network) because it was for the resident's phone and television to work correctly. This deficient practice resulted in unresolved grievance for Resident 107 that affects the residents the resident's quality of life. Findings: During a review of Resident 107's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (CHF, a heart disorder which caused the heart to not pump the blood efficiently, sometimes resulting in leg swelling), hypertension (HTN, high blood pressure), and anemia (a condition where the body did not have enough healthy red blood cells). During a review of Resident 107's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Advance Directives Acknowledgement Form (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) and Physician Orders for Life-Sustaining Treatment (POLST, medical order forms that tell medical staff what to do if you have a medical emergency and are unable to speak for yourself) were obtained and readily accessible in the residents' hard copy medical records for one of three sampled residents (Resident 34). These deficient practices had the potential for residents' medical treatment provisions to not be carried out, according to the resident's wishes during emergency situations and/or when a resident was incapacitated (the clinical state in which a patient is unable to participate in a meaningful way in medical decisions). Findings: During a review of Resident 34’s admission Record [AR], the AR indicated Resident 34 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual for two of four sample residents (Resident 43 and 27) by failing to: 1. Develop a care plan to address interventions for Resident 43's abdominal pain on 3/25/2025. 2. Develop a care plan for Resident 27's to address interventions for medication side effects and behavior monitoring for poor impulse control which was prescribed Depakote (an antiepileptic medication used to reduce excessive electrical activity in the brain believed to cause mood fluctuations in bipolar disorder [sometimes called manic-depressive disordered; mood swings that range from the lows of depression to elevated periods of emotional highs]). These deficient practices had the potential to result in Resident 43 not receiving individualized and necessary care and treatment for pain control and had the potential to result in Resident 27 receiving a…

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

Based on observation, interview, and record review, the facility failed to provide pillows or wedges for body support to help one of four sampled residents (Resident 54) who was quadriplegic (complete immobility due to severe disability from injury to the brain or spinal cord) to achieve the desired comfort and position as indicated in the resident's care plan and the facility's policy and procedures. These deficient practices had the potential for Resident 54 to develop pain, discomfort and contracture (a permanent tightening of muscles, tendons, skin, or other tissues, causing joints to shorten and become stiff, thus limiting normal movement) negatively affect the residents' physical comfort and psychosocial well-being. Findings: During a review of Resident 54's admission Records (AR), the AR indicated that the facility admitted Resident 54 on 6/12/2020, with diagnoses including multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), gastrostomy status (presence of a G-tube, a surgical opening fitted with a device…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the facility's policies and procedures (P&P) titled, Fall Management Program and Fall Prevention and Management Program for two of four sampled residents (Resident 106 and Resident 27) by: 1. Failing to provide appropriate and sufficient supervision for Resident 106 by failing to: a. Implement Resident 106's Risk for Falls Care Plan interventions to not leave Resident 106 unattended when toileting. b. Update Resident 106's Fall Risk after falling on 6/24/2025 as indicated in the facility's P&P titled, Fall Prevention and Management Program. c. Document interventions recommended by the Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together toward the goal of the resident) after Resident 106's fall on 6/24/2025. 2. Failing to ensure that the IDT team met after Resident 27 sustained a fall on 5/2/2025 as indicated in the facility's P&P titled, Fall Management Program. As 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 provide appropriate care and services to prevent urinary tract infections (UTI- an infection in the bladder [a hollow, stretchy organ in the lower part of your abdomen that stores urine before it leaves your body]/urinary tract) by assessing the urine for cloudiness, color, sediments (the matter that settles to the bottom of a liquid), blood, odor, and amount of urine output for one of three sampled residents (Resident 2) with foley catheter (an indwelling device that drains urine from urinary bladder into a collection bag outside of body). This deficient practice had the potential for Resident 2 to develop UTI and receive delayed or no treatment for could lead to a decline in the resident's well-being. Findings: During a review of Resident 2's admission Record (AR), the AR indicated that the facility originally admitted Resident 2 on 8/21/2024 and readmitted on [DATE], with diagnoses including encephalopathy (term that refers to a…

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

Based on observation, interview, and record review, the facility failed to provide adequate nutritional care and services to one of five (5) sampled residents (Resident 117) based on the comprehensive assessment when Certified Nurse Assistant (CNA) 5 failed to assist Resident 117, who required moderate assistance (helper less than half the effort) during mealtime. This failure had the potential to result in Resident 117 not being provided the proper nutritional care and services consistent with the resident's comprehensive assessment which may lead to decreased appetite and sensation for thirst and could result in unplanned weight loss, dehydration, and the inability to maintain the highest practicable level of well-being. Findings: During a review of Resident 117's admission Records (AR), the AR indicated the facility admitted Resident 117 on 6/9/2025 with diagnoses that included dysphagia (difficulty swallowing), severe protein-calorie malnutrition, and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 117's History and Physical…

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 medically related social service to assist one of four sampled resident (Resident 91), who had no teeth and loose-fitting dentures, by failing to follow up and make an appointment with the dentist. This deficient practice resulted in Resident 91 not utilizing the facility provided dentures and leaving Resident 91 unable to eat well that could lead to weight loss and negatively impacting the resident's quality of life and well-being. Findings: During a review of Resident 91's admission Records (AR), the AR indicated the facility originally admitted Resident 91 on 5/3/2023 and readmitted on [DATE] with diagnoses including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and asthma (a chronic [long term] condition that causes airways to swell, narrow and fill…

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 enforce the facility's policy and procedure on infection control related to a safe, sanitary environment by failing to: 1. Ensure that Certified Nurse Assistant (CNA) 1 performed hand hygiene between contacts with Resident 2 and Resident 79. 2. Ensure that CNA 1 and Registered Nurse (RN) 1 followed Resident 2 and Resident 54's Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of resistant organisms) to prevent spread of infections. This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for the residents. Findings: 1. During a review of Resident 54's admission Records (AR), the AR indicated that the facility admitted Resident 54 on 6/12/2020, with diagnoses including multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), gastrostomy status (presence of a G-tube- 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 provide a call light system (a communication device attached to the bed or on the wall that allows residents to call for assistance from staff when needed) according to the need of two of six residents (Resident 3 and Resident 59) with limited range of motion (ROM) to upper extremities in accordance with the facility's policy and procedure (P&P) titled, P-NP29 Communication - Call System. These deficient practices had the potential to result in a delay in the provision of assistance for all care needs that could lead to accidents for Resident 3 and Resident 59. Findings: a. During a review of Resident 3's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with diagnoses that included dementia (a progressive state of decline in mental abilities), arthritis (a condition that caused inflammation and pain in the joints), and osteochondrodysplasias (a group of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) care plan was initiated to indicate Resident 1 ' s current therapeutic diet (a meal plan that controls the intake of certain foods or nutrients) ordered for nothing by mouth (NPO). This deficient practice had the potential for Resident 1 to not receive specific care and services specific to Resident 1 ' s needs in accordance to the facility ' s policy and procedure titled, Care Plans, Comprehensive Person-Centered Care Planning. Findings: A review of Resident 1 ' s admission Record [AR] indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included adult failure to thrive (a decline in an adult ' s physical and mental state) and Alzheimer ' s disease (a brain disorder that destroys memory and thinking skills). A review of Resident 1 ' s History and Physical Examination (HPE, a comprehensive physician ' s note regarding the assessment of the Patient ' s health…

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 notify CDPH, the Ombudsman, and Law Enforcement within two (2) hours of an allegation of abuse. The allegation of abuse was reported to CDPH via fax on 3/15/2025 at 8:06 PM (around 33 hours later), iin accordance with the facility's policy and procedure titled Abuse - Reporting & Investigations. The facility failed to: 1. Notify the allegation of physical abuse by Certified Nurse Assistant (CNA) 1 for Resident 1 when Responsible Party (RP) 1 observed CNA 1 being rough during Resident 1 ' s peri care (also known as perineal care, refers to the cleaning and maintenance of the genital and anal areas), on 3/14/2025 and informed CNA 1 to be gentler. RP 1 reported to the facility ' s Infection Preventionist (IP) Nurse around 11:00 AM witnessing CNA 1 was rough during Resident 1 ' s peri care and complained of vaginal pain on 3/14/2025. 2. Suspend the CNA on 3/14/2025 in accordnace with the facility's P&P. CNA 1 was assigned back to Resident 1 on 3/15/2025 after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate discharge planning and assistance for resident ' s safe discharge for one of three residents (Resident 1) by not ensuring home health services (medical services being provided at home) and durable medical equipment (DME-reusable medical devices, equipment, or supplies prescribed by a healthcare provider to assist with the treatment, monitoring, or management of a medical condition or disability) is arranged and confirmed for delivery prior to Resident 1 ' s discharge from the facility. This deficiency resulted in Resident 1 did not receive rehabilitation therapy and the durable medical equipment needed for use at home. Findings: During a review of Resident 1 ' s admission Record dated 12/5/24 indicated that initial admission on [DATE] with diagnoses including Parkinson ' s Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Dementia (a progressive…

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 provide evidence that the Annual Certified Nurse Assistant (CNA) Core Clinical Competencies (ACCC, an assessment and training on the CNAs for the ability to perform clinical nursing care) was completed. In addition, the facility failed to provide evidence that there was a system in place to keep track of the CNA's performance evaluation to ensure eight of eight sampled CNAs (CNA 5, 6, 7, 8, 10, 12, 13, 14) were evaluated for their competencies annually and provided training based on the outcome of the review for each of the CNAs. This failure had a potential to result in the facility's resident ' s population based on the Facility Assessment (an assessment to make decisions about direct care staff needs, as well capabilities to provide services to the residents) not to receive quality care services from CNAs with insufficient skills and competencies. Findings: During an interview on 7/12/2024 at 10 AM with the Director of Nurses (DON), the DON stated, the Director of Staff Development (DSD) had an emergency, so she was off.…

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: 1. Ensure to provide the name of medications and their indication (reason for the use of the medication) prior to administration of the medications, affecting one (1) of seven (7) residents observed for medication administration (Resident 23.) 2. Account for six (6) doses of Controlled Substances ([CS]- also known as narcotics are medications which have a potential for abuse and may also lead to physical or psychological dependence) for Residents 13, 45, 57 and 67, in one of two inspected Medication Carts (Station North). These deficient practices violated Resident 23 ' s rights to make decisions regarding their medication regimen, and increased the opportunity for CS diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) and risk that Residents 13, 45, 57 and 67 could have delayed medication treatment and continuity of care due to lack of availability of the CS, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two (2) medication errors out of twenty-four (24) total opportunities contributed to an overall medication error rate of 5.71% affecting two (2) of seven (7) residents observed for medication administration (Resident 20 and 103.) The medication errors were as follows: Resident 20 received a form of calcium (a medication used as a dietary supplement to provide support to bones) that was different than the one ordered by Resident 20's physician. Resident 103 received a form of multivitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements, including magnesium) that was different than the one ordered by Resident 103's physician. These failures had the potential to result in Residents 20 and 103 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have)…

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 remove and discard from facility stock unused and expired medications, in accordance with the manufacturer ' s requirements in one of two inspected Medication Rooms (Medication Room Station 1 South West). The medications included the following: 1. One Aplisol (medication used to diagnose tuberculosis [infection in the lungs]) vial, and 2. 15 expired Afluria (an influenza [also known as flu] vaccine [a substance that provides immunity to an infectious disease] used to provide protection against the flu vaccine for the 2023 -2024 flu season) prefilled (already loaded with the medication) syringes These deficient practices increased the risk for residents in the facility to receive medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization. Findings: During an observation, on 7/10/2024 at 11:54 AM, with Licensed Vocational Nurse (LVN) 4, in Medication Room Station 1 South West, the following medications were found…

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 one of three kitchen staff, Dishwasher (DW) 1 was routinely trained and evaluated for competency related to their duties when: Dishwasher 1 (DW 1) did not know the proper sanitizer test strip to use for the quaternary ammonium (QUAT-a quaternary ammonium-QUAT, a type of sanitizing solution used to sanitize food contact surfaces) sanitizer. DW 1 did not know the procedure for testing strength of the quaternary ammonium sanitizer. This Deficient practice had the potential to result in unsafe and unsanitary food production and can affect residents who were served food from the facility kitchen. Findings: During an observation in the kitchen on 7/9/2024 at 9:10AM, DW 1 was cleaning the counters using a kitchen cloth stored in a red bucket filled with solution. DW 1 stated the red bucket was filled with sanitizer (a solution used to kill germs) and the cloth was used to clean the counters. DW 1 stated he checks the sanitizer ' s effectiveness before starting to clean the counters. During a concurrent…

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 portion sizes for lunch menu was followed on 7/9/2024 when the facility failed to follow the lunch menu and portion sizes as written for residents on Pureed diet and Mechanical soft diet. During the facility ' s observed Tray Line Service, 12 residents on pureed diet received 4 ounces (oz) of chicken oregano instead of 5 and 1/3 oz. 46 residents on mechanical soft diet received 2 and 2/3 ounces of zucchini instead of 4 oz per the food portion and serving guide. These deficient practices had the potential to result in meal dissatisfaction, decreased nutritional intake, weight loss in residents who received food from the kitchen. Findings: According to the facility ' s lunch menu for puree diet on 7/9/2024, the following items will be served: Pureed Oregano Chicken #6 scoop (5 1/3 ounces (oz)); pureed polenta #8 scoop (4oz); Pureed baked fresh zucchini #12 scoop 1/3 cup; fresh green salad; dressing; pureed frosted cake. And for the mechanical soft menu: Ground oregano chicken #10 scoop 3 oz; polenta…

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 dignity and respect for two of three sampled residents (Resident 16 and 80) when: 1. Certified Nursing Assistant (CNA) 1 was observed standing over Resident 16, who was in bed, while feeding resident for breakfast. 2. CNA 3 was observed standing over Resident 80, who was in bed, while feeding resident for breakfast. This deficient practice violated the resident's rights to maintain and enhanced their self-esteem, self-worth, and the right to be treated with dignity and respect. Findings: 1. During a review of Resident 16's, admission Record (AR), dated 7/10/2024, indicated Resident 16 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including metabolic encephalopathy (damage or disease that affects the brain), Parkinsonism (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and muscle wasting (a weakening,…

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 the observation, interview, and record review, the facility failed to ensure call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for two out of three sampled residents (Resident 357 and Resident 26) as indicated in the facility's policy and procedure. These deficient practices had the potential not to meet the residents' needs, preferences, especially during emergency. Findings: 1. A review of Resident 357's admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included major depression (a common and serious medical illness that negatively affects how the person feels, the way they think and how they act) and aphasia (a language disorder that affects a person ' s ability to communicate), and Parkinsonism (a disorder of the central nervous systems that affects movement). A review of Resident 357's History and Physical Examination…

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 report a significant change in condition to the attending physician (Physician 1) and responsible party for one of three sampled residents (Resident 48), with a redness on both eyes. This failure resulted in a delay in receiving necessary care and treatment to both eyes which could potentially result in worsened eyes condition and/or infection that could lead to blindness. Findings: A review of Resident 48 admission Record indicated Resident 48 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis that included hypertension (high blood pressure), obesity (overweight) , type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood) with diabetic nephropathy [the deterioration of kidney (a pair of organs in the abdomen which remove waste and extra water from the blood) function], and bilateral age-related cataract (a condition in which the lens of the eye becomes cloudy). 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 preserve one of twenty-seven sampled residents (Resident 36), dignity when failing to pull the privacy curtain while a certified nurse assistant was cleaning the resident without clothes inside the resident ' s room. This failure resulted in Resident 36's privacy violated and had the potential to impact the resident's self esteem and feel humiliated on 7/9/2024. Findings: A review of Resident 36's admission Record indicated Resident 36 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included encephalopathy (damage or disease that affects the brain), dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities], Type 2 diabetes mellitus ((DM2 - condition that results in too much sugar circulating in the blood), and hypotension (low blood pressure). A review of Resident 36's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan that address the necessary interventions in management and services for two out of 22 total sample residents (Resident 48 and Resident 99), when: 1. Resident 48 was observed with redness of both eyes on 7/9/2024. 2. Resident 99 did not have a care plan for the clinical management of inguinal hernia (condition in which soft tissue bulges through a weak point in the abdominal muscles, causing discomfort and/or pain). These failures had a potential to result in inadequate and incomplete provision of care and result in the residents' decline in wellbeing. Findings: 1. A review of Resident 48 admission Record indicated Resident 48 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis that included hypertension (high blood pressure), obesity (severely overweight) , type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood) with diabetic…

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 review and revise a resident-centered care plan for one of three sampled residents (Resident 93) to address interventions for occasional bladder incontinence (no control urination) after the removal of the urinary catheter (a flexible tube catheter inserted into the bladder to drain urine from the bladder). As a result of this deficient practice Resident 93 did not receive consitent care and services to regain continence (control) of bladder and prevent urinary tract infection (UTI - an infection in any part of the urinary system, the kidneys, bladder or urethra). Findings: A review of the admission Record dated 12/07/2023 indicated Resident 93 was admitted to the facility with diagnoses that included dementia (conditions characterized by impairment of at least two brain functions), and psychosis (a mental disorder characterized by a disconnection from reality.) A review of Resident 93's Minimum Data Set (MDS - a comprehensive assessment and care tool) dated 6/18/2024 indicated Resident 93 ' s cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement care and services to prevent the development of skin breakdown and/or pressure ulcer (painful wound caused as a result of pressure or friction) for one (1) of three sampled Residents (Resident 15) in accordance with the facility's policy and procedure by failing to ensure the Low Air Loss mattress (LAL, mattress designed to circulate a constant flow of air for the management of pressure ulcer) was based on the resident ' s weight as ordered by the physician. The physician ordered for Resident 15's LAL mattress to be set at #6 (setting for 275 pounds [lbs. unit of mass] body weight), the LAL mattress was observed set at #2 (setting for 150 lbs. body weight) and the mattress was soft. This deficient practice had the potential for the resident to be at risk of developing new pressure ulcer. Findings: A review of Resident 15's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [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.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 63) who had an indwelling catheter (a flexible tube [a catheter] inserted into the bladder that remains (dwells) there for continuous urinary drainage) was provided with care and services to prevent and urinary tract infection (UTI, an infection of the kidney, ureter, bladder, or urethra) by ensuring the urinary indwelling catheter was secured/ anchored and not touching the floor. This deficient practice placed the resident at risk to have potential accidental dislodgement (removal) of the catheter that may result with a trauma to the urethra (a hollow tube that lets urine leave the body) and urinary tract infection. Findings: During a concurrent observation and interview on 7/10/24 at 8:50 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 63 was in the room with the indwelling that was not secured and anchored and the catheter bag touching the floor. In an interview LVN 1 stated the urinary bag should not be touching the floor, even if the bed was kept low…

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 oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for two (2) of three (3) sampled residents (Resident 31 and Resident 50) in accordance with the facility's policy and procedure by failing to: 1. Ensure Resident 31 who was using the nasal cannula (a device that delivers extra oxygen through a tube and into your nose) for continuous oxygen therapy was properly placed on her nostrils (two openings in the nose through which air moves when you breathe) and not on the resident's right cheek. This deficient practice had the potential for Resident 31's lung, heart, brain at risk for hypoxemia (low concentration of oxygen in the blood) and can be life-threatening. 2. For Resident 50 with history of pneumonia (a severe lung infection), label Resident 50 ' s nasal cannula (NC- a flexible tubing used to deliver oxygen into the nares) with the date of when the NC was last changed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of twenty-seven sampled residents (Resident 65), who was observed with pain on 7/9/2024 was assessed for pain and reassessed for effectiveness of pain management and relief interventions as indicated in the facility ' s policy and procedure for pain management. This failure resulted Resident 65 in recieving delayed care and services to relieve pain, which can also potentially affect the resident's ability to maintain the highest practicable level of well-being and healing process. Findings: A review of an admission Record indicated Resident 65 was admitted to the facility on [DATE], with diagnosis that included arthritis (the swelling and tenderness of one or more joints [places where two bones meet, such as the elbow or knee]) in multiple sites, muscle wasting and atrophy, primary generalized osteoarthritis (arthritis that occurs when flexible tissue at the ends of bones wears down), and dementia [the loss of cognitive…

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 identify the need for medically related social services for one out of 3 sampled residents (Resident 99) and ensure that these services are provided. For Resident 99, the facility failed to follow up on Resident 99's plan for surgery for the diagnosis of inguinal hernia (a condition in which soft tissue bulges through a weak point in the abdominal muscles, causing discomfort and/or pain). This deficient practice had the potential for Resident 99 to suffer complications of inguinal hernia such as abdominal pain and discomfort. Findings: A review of Resident 99's admission Record indicated Resident 99 was admitted to the facility on [DATE] with diagnoses that included inguinal hernia and weight loss. A review of Resident 99's History and Physical (H&P), dated 3/14/2024, indicated Resident 99 had the capacity to understand and make medical decisions. The H&P indicated Resident 99 had a history of inguinal hernia and abdominal pain. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the facility ' s infection control program to prevent the spread and infections in the facility by failing to: 1. Ensure the shared restroom for Room A had labeled urinal and three rectangle wash basins left on top of the reservoir tank (reserve and hold the correct amount of water require to flush the toilet bowl) of the toilet. 2. Ensure Resident 12 ' s urinal at his bedside table with urine was labeled with the resident ' s name and date on when the urinal was first used. 3. Ensure Resident 20 ' s urinal was observed at his bedside table with urine was labeled with the resident ' s name and date on when the urinal was first used. 4. Ensure staff use the appropriate equipment when Certified Nursing Assistant (CNA) 11 was observed providing care to Resident 102 with a wound on the foot and was not wearing an isolation gown (a disposable down made of paper-like material or plastic that helps in protecting the user ' s clothes).…

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 a functioning call light for one of six sampled residents (Resident 357). This deficient practice had the potential to result in the residents not to receive necessary immediate care specially during emergency or delay receiving care to meet the residents needs for toileting, personal hygiene and activities of daily living. Findings: A review of Resident 357 admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included major depression (a common and serious medical illness that negatively affects how the person feels, the way they think and how they act), aphasia (a language disorder that affects a person ' s ability to communicate), and Parkinsonism (a disorder of the central nervous systems that affects movement). A review of Resident 357 ' s History and Physical Examination (H&P) dated 12/7/2023, indicated Resident 357 did not have the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure treat 2 out of 5 sampled residents (Resident 2 and Resident 3) with respect and dignity, by not honoring their preferences, and choices regarding activities of daily living (ADL: bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) These deficient practices had the potential to negatively impact residents leading to decreased self- worth, fear of not having control over choices and preferences, and even depression. Findings: 1. A review of Resident 2 ' s admission Record indicated the resident was admitted on [DATE] with a diagnosis that included depressive disorder (loss of pleasure or interest in activates) and adult failure to thrive (a state of decline, withdrawn, lonely and depressed). A review of Resident 2 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 3/15/2024, indicated Resident 2 required partial to moderate assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (a button the patient pushes at the bedside that notifies the nursing staff to request assistance) within reach for 1 out of 5 sampled residents (Resident 4). This deficient practice has the potential to delay necessary assistance, not meeting the needs of the resident promptly. Ensuring that the call light is always within reach is crucial for the safety and well – being of resident. Finding: A review of Resident 4 ' s admission Record indicated the resident was originally admitted to the facility on [DATE], with diagnoses the at included Hemiplegia (severe or complete loss of strength or on one side of the body) and Hemiparesis (partial weakness on one side of the body) and Parkinsonism (tremor, slowness, stiffness, and walking and balance problems). A review of Resident 4 ' s History and physical dated 1/4/2024, indicated resident had fluctuating capacity to understand and make decision known. A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician visits included an evaluation of the resident's condition and total program of care and the appropriateness of the resident's current medication regimen for one of three sampled residents (Resident 1) with a diagnosis of Diabetes Mellitus (DM, a chronic disease where a person has sustained high blood sugar levels) with high blood sugar levels while in the General Acute Care Hospital (GACH) had no physician order for blood sugar monitoring. As a result of this deficient practice, Resident 1 blood sugar was not monitored for high blood sugar and not evaluated for the need for administration of insulin from 4/12- 4/19 (a total of 6 days at the facility). On [DATE] at 7:15 PM, Resident 1 was transferred to the GACH via 911 (an emergency number for any police, fire or medic) due to altered level of consciousness and admitted in ER with a blood sugar of 823 mg/dL [milligrams per deciliter] (a normal blood sugar range is 70-100 mg/dL) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodations for a resident ' s needs and preferences for one of three sampled residents (Resident 1), who was by not: 1. Ensuring Resident 1 ' s overhead light cord was within the resident reach. 2. Ensure Resident 1 ' s bed was properly positioned inside the resident ' s room, which resulted in the doorway being obstructed by the foot of the bed and prevents the resident ' s door to fully close. This deficient practice prevented resident 1 from having the ability to turn the light on or off as needed, have adequate lighting, and personal privacy according to the resident ' s preference. Findings: A review of admission information indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which include Glaucoma (eye condition that causes vision loss), Urinary Tract infection, Polyneuropathy (damage of nerves that cause problems with sensation, coordination) , chronic kidney disease (damage to kidney…

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 a resident receives mails including packages delivered for one of three sampled residents (Resident 1) through the facility. This deficient practice resulted in the violation of Resident 1's rights to receive mails/packages delivered through the facility. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included urinary tract infection, polyneuropathy (damage of nerves that cause problems with sensation, coordination), chronic kidney disease (damage to kidney making it difficult to filter blood), hydronephrosis (difficulty with urine flow to bladder), hemiplegia ( inability to move one side of body) and hemiparesis ( weakness on one side of body). A review of History and physical dated 2/29/2024, indicated resident 1 has the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS- an assessment and care planning tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out activities of daily living receives the necessary services to maintain the resident ' s functional abilities for one of four sampled residents (Resident 1) by failing to: 1. Ensure Resident 1 was provided with a water pitcher at all times, in accordance to the routine distribution of water pitcher to all the residents in the facility. 2. Ensure Resident 1 was provided with the necessary incontinence care as indicated in Resident ' s 1 care plan to check at least every 2 hours for incontinence to ensure soiled and wet areas wre washed, rinsed, and dry. These deficient practices had the potential for Resident 1 to develop skin breakdown, dehydration and urinary tract infection. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included urinary tract infection, polyneuropathy (damage of nerves that cause…

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 a care plan (document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs) on pressure injury (wound caused when an area of skin is placed under pressure) prevention for one of six sampled residents (Resident 4). This deficient practice had the potential to result in Resident 4 developing a pressure injury. Findings: A review of Resident 4 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dementia (disease that impairs the ability to remember, think, or make decisions) and muscle wasting and atrophy (decrease in size of muscle). A review of Resident 4 ' s history and physical (H&P), dated 3/29/2023, indicated the resident had decreased strength and range of motion (full movement potential of a joint). The H&P also indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 4 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to administer antianxiety medication as orderedby the physician for one of two sampled residents. This deficient practice had the potential to negatively affect the resident ' s physical and psychosocial well-being. Findings: A review of Resident 1 ' s admission Record, indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included hemiplegia (paralysis (unable to move) that affect one side of the body, and hemiparesis(weakness or inability to move one side of the body), anxiety (intense, excessive, and persistent worry and fear about everyday situations. ), and depression(constant feeling of sadness). A review of Resident 1's History and Physical (H&P), dated 11/3/23, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 1/23/24, indicated the resident ' s cognition was moderately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement fall (to move in a downward direction) interventions for one (1) of four (4) sampled residents (Resident 1) who was identified as high risk for falls. 1. The facility did not place Resident 1 close to the nurse ' s station after the resident sustained a fall on 2/7/2024. 2. The facility did not follow Resident 1's fall care plan titled Falling Star Program approaches to have R1 within line of sight. These deficient practices resulted in Resident 1 sustaining an injury above the left eyebrow with swelling after falling on 2/7/2024. Findings: A review of Resident 1 ' s Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of metabolic encephalopathy (damage or disease that affects the brain), bipolar disorder (a mental illness that causes unusual shifts in a person ' s mood, energy, activity levels, and concentration) and type 2 diabetes mellitus (a disease 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 interview and record review the facility failed to develop a fall risk care plan for one of three sampled residents (Resident 1) who was identified as at risk for falls, in accordance with Resident 1 ' s Fall Risk Evaluation completed on 3/7/2023. This deficient practice resulted in Resident 1 sustaining a fall on 11/16/23 and a repeated fall on 11/17/23 resulting in a hematoma (injury to the wall of a blood vessel, prompting blood to seep out of the blood vessel into the surrounding tissues) to the forehead and swelling around the right and left orbital (the bony cavity that contains the eyeball) eye sockets. Findings: A review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of metabolic encephalopathy (damage or disease that affects the brain), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and type 2 diabetes mellitus (a…

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

Based on observation, interview and record review the facility failed to follow menu consistency guidelines for residents on mechanical soft diet (foods that are physically soft for people who have trouble chewing and swallowing). For the lunch menu the bread crust was not removed prior to the preparation of the mechanical soft plates. This deficient practice had the potential for the residents to choke while eating their food. Findings: During the tray line observation, on 3/23/17 starting at 11:51 a.m., Kitchen staff on the tray line were observed placing sliced garlic bread cut in four with crust still on for mechanical soft diets. A review of the facility's menu indicated to remove bread crust for residents on mechanical soft diet. During an interview on 3/23/22 at 12:32 p.m., the Registered Dietician (RD) verified the mechanical soft diet plates were being served with bread crust. RD reviewed the menu and stated will notified staff to remove the bread crust and monitor residents. A review of the facility's policy and procedure titled, Regular Mechanical Soft diet-2020 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to enhance a Resident's dignity and respect by failing to provide hygiene timely for one of three sampled residents (Resident 15). This deficient practice had the potential to negatively affect the residents' psychosocial wellbeing. Findings: A review of the admission Record indicated Resident 15 was admitted to the facility on [DATE], with diagnoses of Parkinson's disease (nervous system disorder that affects movement), and hemiplegia (paralysis of one side of the body). A review of the Minimum Data Set (MDS-an assessment tool) dated 12/22/21, indicated Resident 15 had severely impaired cognition. The MDS indicated Resident 15 required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with bed mobility and personal hygiene, extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfers, required supervision…

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 a clean and sanitary environment for one of 19 sample selected residents (Resident 75 ). For Resident 75, the room drapes had yellowish/brownish dry stains on it, windowsills had dust and windows had dry water stains as well as dust. This facility failure had a potential to compromise the health and safety of the residents. Findings: During an interview, on 3/21/22 at 12:15 p.m., with Resident 75'sfamily member, he stated that he was very concerned about his mother's health due to the dusty windowsills and stained drapes. He further stated that he had brought up these concerns with the facility staff including the Director of Nursing (DON) and feels frustrated because his concerns have not been addressed even though he had reported it multiple times. During an observation, on 03/23/22 at 08:56 a.m, Certified Nursing Assistant 12 CNA 12) stated the windowsill and the drapes were dirty. CNA 12 further stated it had been almost three months the drapes and windowsill had been in that condition and 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 Based on observation, interview, and record review, the facility failed to obtain a Preadmission Screening and Resident Review (PASRR; responsible for determining if individuals with serious mental illness (SMI) and/or intellectual/developmental disability (ID/DD) or related conditions (RC) require: Nursing facility services, considering the least restrictive setting and/or Specialized services) Level II evaluation for one of three sampled residents (Resident 78). This deficient practice had the potential for Resident 78 to not receive necessary care services related to mental disorder. Findings: A review of the admission Record indicated Resident 78 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves) and major depressive disorder (persistent feeling of sadness and loss of interest). A review of the Minimum Data Set (MDS-an assessment tool), dated 02/17/22, indicated Resident 78's…

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

Based on interview and record review, facility failed to develop a person-centered care plan for two of three sampled residents (Resident 411 and Resident 60) in accordance to the facility's policy and procedures by: 1. No baseline care plan developed for Resident 411's diagnosis for depression (mental health condition that involves a low mood and a low interest in activities) and psychotropic medications (drug that affects brain activities associated with mental processes and behavior) 2. No baseline care plan developed for Resident 60's anticoagulant (help prevent blood clots) medications within 48 hours of admission. This deficient practice of not identifying individualized goals had the potential to negatively affect Resident 411 and 60's ability to achieve their highest practicable physical, mental and psychosocial well-being and their continuity of care. Findings: A review of Resident 411's Face Sheet (admission record) indicated the facility admitted the resident on 3/16/22 with diagnoses of dementia (group of thinking and social symptoms that interferes with daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a specific and individualized care plan for one out of four sampled residents (Resident 12) by failing to initiate a care plan for Resident 12's use of oxygen therapy (treatment that delivers oxygen for you to breathe). This deficient practice had the potential to result in lack of or delay in delivery of oxygen therapy for Resident 12 which can lead to serious harm, injury or death. Findings: A review of the admission record indicated Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 12's History and Physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records reviews, the facility failed to revise, reassess and update care plans (a formal process that correctly identifies existing needs and recognizes potential needs or risks) for five of five sampled Residents (Resident 36, Resident 91, Resident 19, Resident 69, and Resident 23): 1. Resident 36's Care Plan did not indicate a revised diet plan for oral meals intake 2. Resident 91's Care Plan did not indicate the location of the dialysis port (a catheter used for exchanging blood to and from a hemodialysis machine and a patient) after the previous dialysis access port was removed. Resident 91's Care Plan did not indicate a revision of Resident 91's scheduled dialysis days. 3. Resident 19's care plan was not updated to reflect current care as the resident is no longer in insulin 4. Resident 69's Care plan did not reflect restorative nursing assistant (RNA) services discontinuation. This deficient practice had the potential for facility staff to not monitor the progression…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure for two of two sampled residents (Resident 69 and Resident 36) received appropriate care and services, according to current standards of practice in accordance to plan of care and facility's policy and procedure when: practice when: 1.Resident 69's active restorative nursing program (person-centered nursing care designed to improve or maintain the functional ability of residents, so they can achieve the highest level of well-being possible) order was not being followed as ordered by resident's primary physician. 2. Resident 36's Medication Administration Record (MAR) for 3/2022, indicated that G-tube bolus feeding was provided three times a day (8 AM, 12 PM, and 5 PM). However, licensed staff interviews indicated Resident 36 had not received G-tube feeding for approximately two to three months now. 3. Failure to ensure that Licensed Nurse (LVN) 3 verified GT placement, checked gastric residual volume (GRV, the amount of liquid…

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 pressure ulcers (PU [also known as pressure sores or bedsores] are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) was continuously monitored for one of two sampled residents (Resident 42) who was at risk in developing pressure ulcers This deficient practice had the potential to result in a new onset or deterioration of Resident 42's pressure ulcers. Findings: A review of Resident 42's admission Record indicated an initial admission to the facility on 6/24/16, and readmission on [DATE] with diagnoses of pneumonia (an infection that inflames the air sacs in one or both lungs), pressure induced deep tissue damage of right ankle, and candidiasis (a fungal infection typically on the skin or mucous membranes caused by candida). A review of Resident 42's History and Physical, dated 12/29/21, indicated Resident 42 did not have the capacity to understand and make decisions. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that one of three sampled residents (Resident 36) with gastrostomy tube ([G-tube] tube inserted through the belly that brings nutrition directly to the stomach) feeding was: 1. Reassessed for the medical necessity of the continued use of G-tube via bolus feeding (type of feeding where a syringe is used to administer formula through the feeding tube) after Resident 36's oral intake had increased since 2/7/22 to regular small portion diet, pureed texture, regular thin consistency. 2. Checked for G-tube placement and ensure the head of bed was positioned above 30 degrees prior to administering G-tube bolus feeding, as indicated in the care plan and facility's policy. During an observation, the facility's Licensed Vocational Nurse (LVN) 3 did not checked for G-tube placement and ensure the head of bed was positioned above 30 degrees prior to administering G-tube bolus feeding. These deficient practices had the potential to result in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide respiratory care and treatment consistent with professional standards of practice for two of three sampled residents (Residents 3 and 6) who required oxygen administration by failing to ensure facility staff monitored Resident 6's oxygen saturation (refers to the amount of oxygen in the bloodstream) consistently to titrate (adjust based on oxygen need) the oxygen flow rate from 2 liters per minute (L/min) to 5 L/min via nasal cannula (NC; a lightweight tubing with prongs placed in the nose) to maintain the resident's oxygen saturation above 92% continuously as ordered by the physician. This deficient practice had the potential to result in inconsistencies in providing the appropriate care and treatment for Resident 3 and 6 and placed Resident 3 and 6 at risk for respiratory complications such as hypoxia (lack of oxygen in the tissues to sustain bodily functions) or oxygen toxicity (lung damage that happens from breathing in too…

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 document the monitoring of dialysis site and provide a sack lunch (a lunch carried, to be eaten at a destination) during dialysis services for one of two sampled residents (Resident 91). These deficient practices had the potential to result in occlusion or infection of the dialysis site of Resident 1 and potentially lead to electrolyte imbalance and hypoglycemia. Findings: A review of Resident 91's admission Record indicated an initial admission to the facility on 5/30/18, and readmission on [DATE] with diagnoses of end stage renal disease (ESR: a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), renal dialysis (dialysis is the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), and hypertensive heart disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the administration of a controlled (narcotic) medication was documented in the narcotic count sheet (Individual Narcotic Record) for one of two medication carts inspected. This deficient practice had the potential to affect residents receiving controlled medications that may increase the risk for drug diversion, misuse, and had the potential for residents to not receive the dosage amount of controlled medication as ordered by the physician. Findings: A review of the admission Record dated 3/24/22, indicated Resident 77 was admitted on [DATE], with the diagnoses including type 2 diabetes mellitus (high blood sugar), major depressive disorder (persistent feeling of sadness and loss of interest), and schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves). A review of Resident 77's Minimum Data Set (MDS-an assessment tool) dated 2/14/22, indicated Resident 77 had moderately impaired…

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 error rates were not greater than five percent (%), for two of six randomly selected residents (Resident 35 and Resident 70). During observation of the medication pass, there were two errors out of 26 medication observation opportunities, resulting in a 7.4 % medication error rate. These deficient practices had a potential to place residents at risk for receiving less medication than was ordered by the physician and receiving the wrong medications. Findings: 1. A review of the admission Record dated 3/24/22, indicated Resident 35 was admitted to the facility on [DATE] and readmitted on [DATE], with the diagnoses including pneumonia (infection of lungs) and dysphagia (difficulty swallowing). A review of the Minimum Data Set (MDS-an assessment tool) dated 1/14/22, indicated Resident 35 had severely impaired cognition. A review of Resident 35's Order Summary Report, dated 3/01/22, timed at 08:04:26, indicated a physician…

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 label evaporated milk with correct used by date in the dry storage for 10 of 10 cans. These failures had the potential to result in food-borne illnesses to the residents who consume the facility's food. Findings: During a concurrent interview and observation in the kitchen on 03/23/2022 at 11:13 a.m., evaporated milk cans were labeled use by 12/22/22, manufacturer's expiration date was 9/22. The Registered Dietician (RD) stated once food items were received, they need to be labeled with the date received and use by date which is supposed to be a date prior to the manufacturer's expiration date. During an interview on 03/23/2022 at 11:13 a.m., the RD stated the evaporated milk needed to be relabeled with a use by date that is prior the manufacturer's expiration date. A review of the 2017 U.S. Food and Drug Administration Food Code indicated, Time/Temperature control for safety food should be marked by date or day or preparation, with a procedure to discard the food on or before the last date or day by which 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 document and maintain a monthly tracking surveillance log for residents with signs and symptoms of infection but did not receive antibiotics to help identify patterns, rates and possible outbreaks in the facility and implement the facility's infection control program designed to prevent the development and transmission of disease and infection, This deficient practice had the potential to result in the transmission of disease and infection to all residents and staff in the facility. Findings: During a concurrent interview with Infection Preventionist (IP) on 03/24/22 at 11:32 AM and review of the facility's infection surveillance dated 02/22, IP stated the facility's current list did not indicate and include residents with signs and symptoms of possible infections that may lead to an outbreak. The IP stated, the facility's current practice was to have Certified Nurse Assistants (CNAs) monitor and report any signs or symptoms of infection to the Director of Nursing (DON) and assigned charge nurse, who would then document…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document a clinical justification for the use of antibiotic for two of three residents (Residents 87 and 91) reviewed for the facility's Antibiotic Stewardship Program. This deficient practice had the potential for the development of antibiotic resistance due to the lack of screening. Findings: 1. A review of Resident 87's admission Record indicated an admission on [DATE], with diagnoses including, cerebral infarction (stroke), depression and urinary retention. A review of Resident 87's Physicians Orders dated 02/26/2022, indicated Resident 87 was started on Levaquin (medication used to treat infection) 500 milligrams (mg) for 7 days for a urinary tract infection. A review of Resident 87's antibiotic review done on 02/26/22 by the Treatment Nurse (TXN) and reviewed by the Infection Preventionist (IP) did not indicate the type of infection or the signs and symptoms indicated for antibiotic use. During an interview on 3/24/22 at 11:32 a.m. with the IP,…

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.