Pelican Ridge Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to ensure the licensed nurses and certified nursing assistants (CNA) had specific competencies and standard of practice skill sets needed to provide the safe and efficient nursing care to the residents as evidenced by: * Resident 10 was admitted on [DATE], with a surgical incision with three sutures that was not assessed, monitored or had care provided from the date of admission until 9/2/25, when the wound was brought to the attention of the facility by the resident's outpatient dialysis clinic. This failure had the potential to put the Resident 10 at risk for care not provided in a safe and competent manner. Findings: Medical record review for Resident 10 was initiated on 9/23/25. Resident 10 was admitted to the facility on [DATE]. Resident 10 had left pleural effusion (a buildup of fluid in the space around the lung) and left chest tube placement (a tube placed into the space around the lung to drain the accumulated fluid) in…

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, medical record review, facility document review, and facility P&P review, the facility failed to follow the physician's order for one of 18 sampled residents (Resident 11). * The facility failed to administer lidocaine patches to Resident 11 per the physician's order. This failure had the potential to negatively impact the resident's well-being.Findings: Review of the facility's P&P titled Medication Orders dated 4/2008 showed medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Review of the facility's P&P titled Preparation and General Guidelines-Medication Administration dated 10/2017 showed the following:a. medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so;b. medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer…

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, medical record review, and facility P&P review, the facility failed to obtain a complete and accurate informed consent (process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention to obtain agreement or permission for care, treatment, or services) for the psychotropic medications for three of 28 sampled residents (Residents 8, 86, and 154). * Resident 8's Informed Consent dated 8/17/25, for duloxetine 40 mg po QD (once a day) for depression had no date next to the physician's signature. * Resident 86's Informed Consent dated 7/25/25, for quetiapine 100 mg one tablet by mouth three times a day for psychosis and trazodone (antidepression medication) 100 mg one tablet by mouth every bedtime for inability to sleep had no resident signature on the informed consent. * Resident 154's informed consent (undated) for the buspirone HCl5 mg tablet two times a day had no physician's signature, resident/resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs for three of 140 residents (Residents 1, 2, and 8). * The facility failed to ensure Resident 1, 2, and 8's call light was within the residents' reach. This failure posed a risk in a delay in providing care to the residents and the potential to negatively impact on the residents' well-being.Findings: 1. Review of the facility's document titled Lesson Plan for Call lights/ Accommodation of Needs (undated) showed the following: - When the residents are placed in a hospital bed, there is one piece of equipment they feel is their lifeline: the call light; - Call lights should be within reach of the resident. Example, if the resident's left arm is not able to move, then place it within reach of the right hand; and - Residents use the call light to communicate with nursing staff. This is one way they can let staff know that they have an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to provide the written Notice of Medicare Non-coverage (NOMNC) form CMS-10123 and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form CMS-10055 for one of three residents reviewed for beneficiary notification (Resident 7). The NOMNC and SNFABN forms are used to inform the residents of their potential financial liability, appeal rights, and protection should they wish to receive care and services that may not be covered by Medicare. This failure had the potential of not allowing Resident 7 and/or their representative to make an informed decision regarding their Medicare services.Findings: Medical record review for Resident 7 was initiated on 8/19/25. Resident 7 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 7's MDS assessment dated [DATE], showed Resident 7 had moderately impaired cognitive skills for daily decision making. Review of the facility'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, medical record review, and facility P&P review, the facility failed to ensure four of six sampled residents (Residents 3, 8, 86, and 154) reviewed for unnecessary medications were free from unnecessary medications. * The facility failed to ensure Resident 3 was monitored for an adverse events such as orthostatic hypotension, and failed to show documented evidence an AIMS assessment was conducted for the use of the Risperdal (antipsychotic medication). * The facility failed to ensure Resident 8's order for lorazepam (antianxiety medication) PRN had a duration for use, failed to show documentation for non-pharmacological interventions for the use of duloxetine (antidepressant medication), and failed to show documentation of the behavior monitoring for the depression. * The facility failed to ensure Resident 86 was monitored for an adverse events such as orthostatic hypotension, and failed to show documented evidence of an AIMS assessment was conducted for the use of the quetiapine fumarate…

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, medical record review, and facility P&P review, the facility failed to develop and implement a comprehensive person-centered care plan to reflect the individual care needs for one of 28 final sampled residents (Residents 138). * The facility failed to develop a care plan problem when Resident 138 developed a DTI (Deep Tissue Injury) in the right heel. This failure posed the risk of not providing appropriate, consistent, and individualized care to Resident 138. Findings: Review of the facility's P&P titled Wound Care Guidelines revised 11/2021 under the Documentation section showed care plans are updated accordingly to reflect the current interventions for the wounds and the long-term interventions to prevent further breakdown as appropriate. Medical record review for Resident 138 was initiated on 8/12/25. Resident 138 was admitted to the facility on [DATE]. Review of Resident 138's H&P examination dated 7/14/25, showed Resident 138 had fluctuating capacity but could make needs known. 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 medical record review, the facility failed to provide the necessary care and services for one of one final sampled resident reviewed for ADL care (Resident 102). * The facility failed to ensure Resident 102's long fingernails were trimmed. This failure had the potential for Resident 102 to experience physical discomfort and skin breakdown due to scratching with long fingernails.Findings: Medical record review for Resident 102 was initiated on 8/12/25. Resident 102 was admitted to the facility on [DATE]. Review of Resident 102's H&P examination dated 3/27/25, showed Resident 102 was partially able to make decisions by themselves. Review of Resident 102's MDS assessment dated [DATE], showed Resident 102 had moderate cognitive impairment and had impairment on both sides of the upper extremities. Review of Resident 102's Care Plan showed the following: - dated 3/27/25, showed Resident 102 was dependent on the staff for his physical needs such as transfer and ADL care.- dated…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure three of six final sampled residents (Residents 2, 96, and 138) and one nonsampled resident (Resident 71) reviewed for pressure injury were provided with the necessary care and services. * The facility failed to provide LAL mattress to Resident 138 per the resident's plan of care for wound management and skin maintenance. In addition, the facility failed to ensure Resident 138's LAL mattress setting was accurate to the resident's weight and was not in static mode while the resident was in bed when the LAL mattress was provided. For Resident 138's DTI in the right heel, the facility failed to monitor Resident 138 every shift for 72 hours after the identification of a DTI in the right heel and develop and implement a comprehensive person-centered care plan when the resident developed a DTI in the right heel. The facility failed to ensure the weekly skin assessment was completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the appropriate care and services for the use of the GT for three of seven final sampled residents (Residents 41, 94, and138) reviewed for the GT feeding. * The facility failed to ensure the physician's order was followed for Resident 41's enteral feeding. * The facility failed to ensure the HOB (head of the bed) was elevated at a minimum 30-degree angle when the enteral feeding was infusing via GT to reduce the risk of aspiration (entry of food, liquid or foreign material into the airway) for Residents 94 and 138. These failures posed the risk of complications related to the use of GT.Findings: Medical record review for Resident 41 was initiated on 8/12/25. Resident 41 was admitted to the facility on [DATE]. Review of Residents 41's H&P examination dated 9/21/24, showed Resident 41 had no capacity to understand and make decisions. Review of Resident 41's Order Summary Report showed the following physician orders: - dated…

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, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for five of five final sampled (Resident 1, 19, 86, 124, and 135) and two non-sampled residents (Resident 40 and 60) reviewed for respiratory care. * The facility failed to ensure the administration of oxygen to Resident 1 was documented. * The facility failed to ensure Resident 19's nasal cannula tubing was labeled and dated. * The facility failed to ensure Resident 40 was administered oxygen per the physician's order. In addition, the facility failed to ensure the humidifier bottle was changed and not left empty for Resident 40. * The facility failed to ensure the nasal cannulas for Resident 60 were stored properly when not in use. * The facility failed to ensure Resident 86's nebulizer storage bag was changed weekly. * The facility failed to ensure a physician's order was obtained prior to the administration of Resident 124's oxygen therapy. In addition, 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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary dialysis care for four of five final sampled residents (Residents 1, 9, 41, and 116) reviewed for dialysis. * The facility failed to monitor Resident 1's fluid intake and specify the fluid restriction per the physician's order. In addition, the facility failed to ensure Resident 1's dialysis access assessments pre- and post-dialysis were accurate and complete, and Resident 1's BP (blood pressure) was not taken on the right upper extremity. Furthermore, the facility failed to ensure the medications scheduled to be administered to Resident 1 on the days the resident had dialysis treatments had a physician's order to be held or were rescheduled. * The facility failed to ensure Resident 9's Dialysis Communication Forms were completed on multiples dates. * The facility failed to ensure Resident 41's BP access site was accurately documented in the resident's medical…

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 medical record review, the facility failed to ensure three of 28 final sampled residents (Resident 2, 5, and 138) were free from the unnecessary drugs. * Resident 2 was administered metoprolol (medication to treat high blood pressure) on numerous occasions when Resident 2's BP (blood pressure) was below the parameter prescribed by the physician. In addition, Resident 2 was administered midodrine (medication to treat low blood pressure) on numerous occasions when Resident 2's BP was above the parameter prescribed by the physician. Furthermore, the facility failed to ensure Resident 2's antibiotic was held when an adverse side effects were documented. * The facility failed to ensure Resident 5's anticoagulant was held when an adverse side effects were documented. * The facility failed to monitor Resident 138 for the signs and symptoms of bleeding related to the use of apixaban (medication used to treat or prevent blood clots). In addition, the facility failed to ensure 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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5% during medication pass observation. The facility's medication error rate was 6.9%. One of four licensed nurses (LVN 7) was found to have made errors during the medication administration. * Resident 138 had a physician's order for Nystatin Suspension (antifungal medication) 100000 unit/ml give 5 ml by mouth four times a day for oral thrush, swish and swallow. LVN 7 instructed Resident 138 to swish and spit, rather than swish and swallow, and did not follow the bold writing instructions on the label on the medication bottle to shake the Nystatin Suspension prior to the administration of the medication. * Resident 138 had a physician's order for Lansoprazole capsule (a medication used to treat acid reflux and heartburn) delayed release 30 mg give one capsule through the GT two times a day. LVN 7 did not administer the medication as ordered by the physician. These…

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 medical record review, the facility failed to ensure Resident 1 was free from significant medication errors for one of 28 final sampled residents (Resident 1). * The facility failed to ensure the vancomycin (antibiotic medication), apixaban (anticoagulant medication), and metoprolol (antihypertensive medication) medications scheduled to be administered to Resident 1 on the days the resident had dialysis treatments had a physician's order to be held or were rescheduled. In addition, the facility failed to notify the physician when these medications were not administered to Resident 1. This failure placed Resident 1 at risk for significant side effects and medical complications.Findings: According to dailymed.com (an online reference for clinical drug information):- For the vancomycin (antibiotic) medication, under the Patient Counseling Information section, although it is common to feel better early in the course of therapy, the medication should be taken exactly as directed. Skipping doses…

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 facility P&P review, the facility failed to provide the necessary pharmacy services to ensure medications were stored as per the facility's P&P and outdated medications and medical supplies were not available for residents' use. * The facility failed to ensure orally administered medications were kept separate from externally used medications in Medication Rooms A and B, and Medication Cart A. * The facility failed to ensure the expired medications and medical supplies were not available for resident use in Medication Carts B and C. * The facility failed to ensure for safe storage of the medications observed at the bedside for Residents 2, 23, 25, 97, and 138. These failures had the potential to result in unsafe medication administration and negatively impact the residents' well-being.Findings: Review of the facility's P&P titled Storage of Medications, revised January 2025 showed orally administered medications are kept separate from externally used medications, such as…

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, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the clear plastic trays were air dried prior to storing and stacking. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the food prepared in the facility's kitchen.Findings: Review of the facility's Diet Type Report dated 8/12/25, showed 88 of 140 residents consumed the food prepared in the kitchen. 1. Review of the facility's P&P titled Hoods and Filters revised date 8/31/18, showed the hoods must 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain proper infection control practices. * The facility failed to accurately identify HAI in the monthly surveillance report. * The facility failed to ensure the residents' clothing and blankets from the laundry were handled in a sanitary manner. The spring lift inside a blue basket truck was observed with ripped edges, and when lifted, the bottom of the basket was pieces of paper, dryer sheets, towel and a sock. In addition, the AC filters of the AC in the clean area, and the AC near the folding area were observed dusty * The facility failed to ensure CNA 7 did not use the same pair of gloves and gown when providing care to Resident 1 on EBP (Enhanced Barrier Precaution) and then to Resident 159 who was not on EBP. * The facility failed to ensure CNA 2 practiced EBP when CNA 2 failed to don (put on) a gown prior to assisting Resident 111 with repositioning. * The facility failed…

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, medical record review, and facility P&P review, the facility failed to protect the resident's rights to be free from the physical abuse when Resident 2 pushed a table hitting Resident 1 in the head resulting in a small movable mass with minimal redness and flaky skin located on the top right side of Resident 1's head. * The facility failed to ensure the concern was addressed when Resident 2 verbalized he was unhappy with his roommate on 3/19/25. Additionally, the facility failed to ensure Residents 1 and 2 were separated when the nurse noticed both residents were using verbal aggression towards each other and Resident 2 stated I will hurt you on 3/23/25. This failure had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Prevention, Reporting, and Correction of Inappropriate Conduct Including Abuse, Neglect, and Mistreatment of Residents and Investigations of Injuries of Unknown Origin revised 10/2021, showed while the investigation is…

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, facility document review, and facility P&P review, the facility failed to thoroughly investigate the allegation of abuse for Residents1 and 2. * The facility failed to interview Residents 1 and 2's roommate after Residents 1 and 2 had had the verbal and physical altercation in their room. This failure had the potential for the abuse allegation to not be thoroughly investigated. Findings: Review of the facility's P&P titled Prevention, Reporting, and Correction of Inappropriate Conduct Including Abuse, Neglect, and Mistreatment of Residents and Investigations of Injuries of Unknown Origin revised 10/2021 showed every report of inappropriate conduct or an injury of an unknown source will be investigated thoroughly under the coordinated supervision of the Administrator. Based on the evaluation of the facts of the allegation and all related circumstances by the Administrator and/or Compliance Officer, the investigation may include interviewing some or all of the following steps as deemed appropriate based on a case-by-case analysis: - Any individual who reported 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, medical record review, facility document review, and facility P&P review, the facility failed to implement the systematic approach to ensure the effective monitoring of the acceptable parameters of nutrition status for two sampled residents (Residents3 and 4). * The facility failed to ensure Resident 3 was assessed and monitored by the IDT when Resident 3 had a severe weight loss of 51 lbs. (-23.29%) in the last six months, 14 lbs. (6.39%) in one month from 9/12 - 10/16/24, and 30 lbs. (14%) from 1/3 - 2/16/25. In addition, the facility failed to initiate a COC for Resident 3 when there was a severe weight loss, including notifying the physician, and legal representative. * The facility failed to ensure Resident 4 was assessed and monitored by the IDT when Resident 4 had a severe weight loss of 17 lbs. (12.14%) in one month. In addition, the facility failed to initiate a COC for Resident 4 when there was a severe weight loss, including notifying the physician and legal…

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, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services to prevent the UTI for two of three sampled residents (Residents1 and 2) reviewed for the use of the indwelling urinary catheters. * The facility failed to ensure Resident 1's indwelling urinary catheter drainage bag was not laying on the floor. * The facility failed to ensure the physician was notified when Resident 2 had a change in condition due to frequent leakage of the indwelling urinary catheter and clarify the size of the indwelling urinary catheter prior to be inserted. These failures had the potential for not providing the necessary care and services and posed a risk for adverse complications related to the indwelling urinary catheter use. Findings: 1. Review of the CDC's guidelines titled Catheter-Associated Urinary Tract Infections (CAUTI) Prevention Guideline dated 4/2024, showed urinary tract infections are the most common type of healthcare associated…

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, medical record review, and facility P&P review, the facility failed to ensure the POLST was followed for one of four sampled residents (Resident 1). This failure resulted in Resident 1 receiving CPR when found unresponsive despite the resident's request for resuscitative measures to not be followed as indicated in Resident 1's signed POLST. Findings: Review of the facility's P&P titled Advanced Directives reviewed 10/2024, showed under the procedures section, upon admission or as soon as practicable thereafter, the resident and/or his/her legal representative or surrogate decision maker will be provided with information regarding preferred intensity of care or advance directives. The resident or his/her legal representative or surrogate shall complete this form as he/she desires which may include a POLST form. If there is an individual healthcare instruction documented by a healthcare worker, then this information shall be placed in the clinical record when provided by the resident or their…

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, facility P&P, and facility document review, the facility failed to ensure the nutritive content of the pureed food for the American menu was preserved and the food served was palatable as evidenced by: * The pureed vegetables were cooked and held in a hot oven more than one hour prior to the meal service. * The bread was hard and crusty in texture. These failures had the potential to not meet the nutritional needs for the residents consuming food prepared in the kitchen. Findings: 1. Review of the facility's Diet Type Report dated 7/18/24, showed 10 of 134 residents residing in the facility received pureed food prepared in the kitchen. Review of the reference titled How Cooking Affects the Nutrient Content of Foods dated 11/7/19, showed the following nutrients are often reduced during cooking: water-soluble vitamins: vitamin C and the B vitamins - thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), folic acid (B9), and cobalamin (B12).…

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 facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure proper labeling and dating of the opened food in the freezer. * The facility failed to ensure the food preparation equipment were properly air dried prior to storage. * The facility failed to ensure the food preparation equipment were in good condition. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen. Findings: Review of the facility's Diet Type Report dated 7/18/24, showed 82 of 134 residents received diet with regular texture and 10 of 134 residents received pureed food prepared in the kitchen. 1. Review of the facility's P&P titled Food Safety and Food Storage revised 10/2023 under Refrigerated Storage, showed the following: - Labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so its use-by date, or frozen (where applicable)/discarded;…

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, medical record review, and facility P&P review, the facility failed to conduct the regular inspection of the residents' beds and assess for areas of risk for entrapment for four sampled residents (Residents 16, 32, 34, and 95) and four nonsampled (Residents 18, 49, 77, and 96) reviewed for the use of siderails. * The facility failed to conduct a routine bed inspection for all the facility beds. In Addition, the facility failed to ensure the entrapment assessments were properly conducted to identify areas of possible entrapment with the use of side rails and the facility failed to conduct the routine bed inspection for Residents 16, 18, 32, 34, 49, 77, 95, and 96. These failures had the potential for entrapments for these residents using the side rails. Findings: According to the FDA.gov there are seven zones that are tested on a bed system with bed rails to help reduce life-threatening entrapments associated with bed systems and bed rails. Review of the facility's P&P titled Bed…

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 facility P&P review, the facility failed to ensure the audible sound and visual light could be heard and seen from the call light panel at the nurse's stations for 16 of 63 rooms. * Room N's restroom call light did not light at the door and did not sound at the Nursing Station B's call panel. * Room O's restroom call light did not light at the door and did not light and sound at the Nursing Station B's call panel. * Resident 16's call light had a dim light above the door and was not audible. * The facility failed to ensure the call light system for Rooms A to M had an audible sound in the call light panel at the Nursing Station A. These failures had the potential for the staff not to hear and see the call light resulting in delayed provision of assistance to the residents. Findings: Review of the facility's P&P titled Call Light, Use Of revised 11/2021 showed: - Promptly report any defective light to the Maintenance/Engineering Department and/or charge nurse; - 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, medical record review, and facility P&P review, the facility failed to properly obtain the informed consents (permission granted in the knowledge of the possible consequences) for the use of psychotropic medications (medications affecting brain activity) and treatments from the responsible party (person designated to make decisions on behalf of the residents) for one of five final sampled residents (Residents 64) reviewed for unnecessary medications. This failure posed the risk for Residents 64 and his responsible party to not be informed of Resident 64's medications and the potential side effects. Findings: According to AFL 24-7 titled Assembly [NAME] (AB) 48 - Nursing Facility Resident Informed Consent Protection Act of 2023 dated 2/28/24, with an effective date of 1/1/24, the facilities must obtain a resident's written informed consent for treatment using psychotherapeutic drugs, and must renew the written informed consent every six months. At that time, the facility must provide 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 medical record review, the facility failed to provide the reasonable accommodations to meet the needs two nonsampled residents (Residents 38 and 124) observed during the initial tour. * The facility failed to ensure Residents 38 and 124's call lights were within the residents' reach. This failure had the potential to negatively impact the residents' psychosocial well-being or result in a delay to receive care. Findings: 1. On 7/16/24 at 0837 hours, during the initial tour, Resident 124 was observed in bed with call light not within reach. The call light was observed clipped to the call light panel on the wall. Resident 124 complained of legs hurting. On 7/16/24 at 0844 hours, an interview with the IP was conducted. The IP verified the call light was clipped to the wall call light panel and not within Resident 124's reach. The IP stated Resident 124 was able to use call light. Medical record review for Resident 124 was initiated on 7/16/24. Resident 124 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to clearly identify the current code status to obtain a copy of an advance directive and provide the written information regarding the rights to formulate the advance directives for three of 26 final sampled residents (Residents 24, 48, and 99) reviewed for advance directives. * The facility failed to clarify and honor Resident 99's desire not to prolong life in case of incapacity. Resident 99's advance directive showed the resident did not wish to prolong life in case of incapacity, while Resident 99's POLST showed to attempt CPR. * The facility failed to ensure the copy of Resident 48's advance directive for healthcare was obtained and maintained in the resident's medical record. * The facility failed to ensure Resident 24 was offered information on how to formulate an advanced directive. These failures had the potential to not provide care in accordance with Resident 24, 48, and 99's treatment wishes. Findings: 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 interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive care plans to reflect the individual care needs for four of 26 final sampled residents (Residents 46, 116, 120, and 374). * The facility failed to develop a care plan problem to address Resident 116's left heel pressure injury. * The facility failed to develop a care plan to address Resident 120's need for fluid restriction and the use of ertapenem sodium injection solution (an antibiotic used to treat infections caused by bacteria) intravenously (into or by means of a vein or veins) for treatment of empyema of pleura (an infection that spreads directly from the lung that leads to a buildup of pus in the pleural space (thin space inside the chest wall). * The facility failed to develop a care plan problem to address Resident 46's left air pain and ear treatments. * The facility failed to develop a care plan problem to address droplet isolation precaution for Resident 374. These failures posed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to provide the necessary ADL care and services for two of two residents (Residents 48 and 374) investigated for ADL care. * Resident 48 was provided with only two showers on 7/15 and 7/18/24, instead of twice a week since his admission on [DATE]. * Resident 374 was provided with only one shower on 7/14/24, instead of twice a week since her admission on [DATE]. These failures posed the risk of the residents not being provided with the appropriate care which could negatively impact their psychosocial well-being. Findings: 1. On 7/16/24 at 0857 hours, during the initial tour of the facility, Resident 48 was observed lying in bed. Resident 48 was observed wearing a gown, and his hair was unkempt. Resident 48 was observed not on any isolation precautions. Medical record review for Resident 48 was initiated on 7/16/24. Resident 48 was admitted to the facility on [DATE]. Review of Resident 48's H&P examination dated 7/3/24,…

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, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure injury (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of existing pressure ulcer for two of three sampled residents (Residents 103 and 116) reviewed for pressure injury. * The facility failed to ensure Resident 103's wound care was provided in a manner to decrease infection and cross contamination as per the facility's P&P. * The facility failed to ensure Resident 116's bilateral lower extremities were offloaded as per the physician's order. These failures had the potential for deterioration of wound and delay of wound healing for these residents. Findings: 1. Review of the facility's P&P titled Clean Dressing Change revised on April 2024 showed it is the policy of this facility 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 medical record review, the facility failed to ensure two of five residents (Residents 48 and 120) reviewed for nutrition and hydration status maintained their acceptable nutritional and hydration status. * The facility failed to follow the RD's recommendations to provide two Boost VHC (a very high calorie complete nutritional drink which provides 530 calories per eight fluid ounce serving, with 22 grams of protein and 26 vitamins and minerals) every meals and to discontinue health shakes. In addition, the facility to clarify the physician's order whether to provide Boost VHC TID (three times a day) or with meals. * The facility failed to monitor Resident 120's fluid intake while on fluid restriction to assess and maintain proper hydration. These failures had the potential to compromise Resident 48's nutritional status, and Resident 120's hydration status and posed the risk for negative health outcomes. Findings: 1. On 7/16/24 at 0857 hours, during the initial tour of 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, medical record review, and facility's P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one nonsampled residents (Resident 97). In addition, the facility failed to ensure the PICC line external catheter and arm circumference measurements were performed and documented in the medical record. These failures had the potential to delay the identification of catheter related complications for the residents. Findings: Review of the facility's P&P titled Central Venous Catheter Dressing Change dated 6/18 showed an assessment of the venous access site and dressing change should be performed upon admission and every seven days, and as needed; and assess the site for complications and notify the physician if problem exist. On 7/16/24 at 0830 hours, Resident 97 was observed with a PICC line on the right upper arm with a labeled transparent dressing. Medical record review for Resident 97 was initiated on 7/17/24. Resident 97…

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 medical record review, the facility failed to provide the necessary respiratory care for three of three sampled residents (Residents 54, 95, and 374) investigated for respiratory care. * The facility failed to ensure Resident 374's Yankauer suction (an oral suctioning tool used in medical procedures) was stored in a set-up bag when not in use. In addition, the facility failed to ensure Resident 374's oxygen saturation levels and administration of oxygen were documented in the MAR. * The facility failed to ensure Resident 95's oxygen saturation levels and administration of oxygen were documented in the MAR. * The facility failed to ensure Resident 54's nasal cannula tubing was stored in a set up bag when not in use and the nasal canula was observed on the floor and Resident 54's bed. In addition, the facility failed to ensure the administration of oxygen therapy for Resident 54 was documented and followed the physician's order. These failures posed the risk for cross…

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, medical record review, and facility P&P, the facility failed to ensure the accurate documentation of two controlled medications on the Controlled Drug Record for one nonsampled resident (Resident 724). This failure had the potential for medication diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: Review of the facility's P&P titled Controlled Medications dated 8/2024 showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and MAR: 1. Date and time of administration. 2. Amount administered. 3. Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply. 4. Initials of the nurse administering the dose on the MAR after the medication is administered. Review of Resident 724's MAR for June 2024 showed Resident 724 was administered the following controlled medications: - morphine sulfate (narcotic…

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, medical record review, facility P&P review, and facility document review, the facility failed to ensure one of five sampled residents (Residents 64) reviewed for unnecessary medications was free from the unnecessary psychotropic medications (any medication which may affect brain activity associated with mental processes and behavior). * The facility failed to ensure Resident 64's monthly behavior summary was completed for the use of Seroquel (a medication used to treat schizophrenia), and sertraline (a medication used to treat depression). In addition, the facility failed to ensure the behavior manifestation and side effects for the use of antipsychotic medications were monitored. These failures had the potential to place the residents at risk for receiving unnecessary medications and increased risk of serious adverse reactions from the medications. Findings: Review of the FDA black box warning for prescribing quetiapine fumarate showed elderly patients with dementia-related psychosis treated…

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, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 16%. One of four licensed nurses observed (LVN 6), was found to have made errors during the medication administration observation. * LVN 6 failed to ensure Resident 10's HR was taken prior to administering the metoprolol (blood pressure medication) and failed to administer the medications as per the physician's order. These failures had the potential to negatively affect Resident 10's health. Findings: Review of the facility's P&P titled Medication Administration- General Guidelines dated 10/2017 under the section Administration showed medications are administered in accordance with written orders of the attending physician; medications are administered within 60 minutes of scheduled time (one hour before and one hour after); except before or after meal orders, which are administered based on meal times. Unless otherwise…

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, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 10) was free from a significant medication error. *The facility failed to ensure Resident 10's HR was taken prior to administering the metoprolol (blood pressure medication). This failure had the potential to cause Resident 10 to have abnormally slow heart rate and negatively affect the resident's health. Findings: Review of the facility's P&P titled Medication Administration- General Guidelines dated 10/2017, under the section Administration showed medications are administered in accordance with written orders of the attending physician. On 7/18/24 at 0905 hours, a medication administration observation for Resident 10 was conducted with LVN 6. LVN 6 prepared and administered Resident 10's medications including one tablet of metoprolol 75 mg. LVN 6 was observed not obtaining Resident 10's HR prior to administering the metoprolol. Medical record review for Resident 10…

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, medical record review, and facility P&P review, the facility failed to ensure the residents' medications were stored and labeled properly when: * The facility failed to ensure a multi-dose vial for one nonsampled resident (Resident 39) was labeled with the opened date in Medication Room B. This failure posed the potential risk of residents receiving expired medication. * The facility failed to ensure the medications for the discharged residents (Residents 115, 726, and 727) were placed in the designated location for medication destruction in Medication Room A. This failure have the potential for medications to be accidentally administered to residents. * The facility failed to ensure the discontinued medication for one nonsampled resident (Resident 45) was removed from the medication cart; failed to ensure the external medication was kept separate from the orally administered medications; and failed to ensure the inhalation solution vials for one nonsampled resident (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 facility P&P review, the facility failed to implement their P&P on foods bought to the facility by the residents' family members or visitors to ensure the safe food handling practices were followed for one of 26 final sampled residents (Resident 95). * The facility failed to ensure opened food items at Resident 95's bedside were refrigerated when needed to be refrigerated. This failure had the potential for unsafe food handling which could lead to food borne illness. Findings: Review of the facility's P&P titled Use and Storage of Food Brought in by Family or Visitors revised 9/2023 showed the following: - It is the right of the residents of the facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident; and - All food items brought in that are manufactured and does not require refrigeration, may be kept in the resident room inside a lock tight container that is provided by the resident. According to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure the proper infection prevention practices for the facility's Water Management Program in the laundry room and for two of four residents reviewed for antibiotic use (Residents 116 and 120). * The facility did not have documentation to show they followed their Water Management Program. * The facility failed to maintain the clean enviroment in the clean linen area in the laundry room * The facility failed to ensure a physician's order was obtained for Resident 116 for contact isolation precaution related to ESBL in urine. In addition, the facility failed to ensure the CNA observed contact isolation precaution practices while providing care for Resident 116. * The facility failed to ensure the Enhanced Barrier Precaution was followed and practiced by providers, staff, and visitors for Resident 120. These failures had the potential for spread of infection in the facility. Findings:…

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, facility document review, the facility failed to ensure the facility equipment were maintained in a safe operating condition when: * The facility failed to ensure corrective actions were taken when the quality control results for the glucometers (a device that measures the amount of sugar in the blood) were out of range for Medication Carts A and B. This failure had the potential risk of inaccuracy for the blood glucose test results. * The facility failed to ensure there was no ice buildup and brownish stain in the freezer of the medication refrigerator in Medication Room A. This failure had the potential for the equipment to not function in the way it was intended. Findings: 1. Review of the Assure Platinum (blood glucose monitoring system) Manual revised 06/22 showed to use Assure dose control solutions to check if the meter and test strips are working correctly as a system. Under the section Quality Checks, showed to compare the results (of the control solution) to the range printed on the test strip bottle. To make sure the result is within the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of 26 final sampled residents (Resident 48) attained and maintained his highest practicable well-being. * The facility failed to coordinate and follow up for Resident 48's needed medical appointments per the transfer orders from the acute care hospital. Resident 48's scheduled medical appointment to the infectious disease clinic was marked as completed; however, there was no documentation Resident 48 went to the infectious disease clinic. In addition, Resident 48 was supposed to be scheduled for a medical appointment with the oncology clinic, but it was discontinued, and no documentation it was scheduled nor followed up. This failure had the potential for Resident 48 to not receive appropriate medical care and treatments. Findings: Medical record review for Resident 48 was initiated on 7/16/24. Resident 48 was admitted to the facility on [DATE]. Review of Resident 48's acute care hospital…

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 medical record review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained her highest practicable physical well-being. * The facility failed to administer Resident 1's medications as ordered by the physician. This failure had the potential for Resident 1to not receive the appropriate care and services to treat her medical conditions. Findings: On 5/21/24 at 1015 hours, an interview was conducted with Resident 1's family member. Family Member 1 stated Resident 1 was discharged from the facility without aspirin (anti-platelet medication) and Apixaban (blood thinning medication). Medical Record review for Resident 1 was initiated on 5/21/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1's diagnoses included DM, DVT, and May [NAME] Syndrome (a condition where blood vessels in the pelvis are compressed which disrupts blood flow and can lead to DVT). 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 interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) received the medications as prescribed by the physician and failed to inform the physician of the missed medications. This failure created the risk of complications and ineffective therapeutic effects of the medication for Resident 1. Findings: Review of the facility's P&P titled Medication Administration-General Guidelines effective 10/2017 showed under Section B.2, the medications are administered in accordance with the written orders of the attending physician. Closed medical record review for Resident 1 was initiated on 5/6/24. Resident 1 was admitted to the facility on [DATE], with the diagnosis of epileptic seizures. Resident 1 was discharged from the facility on 4/29/24. Review of Resident 1's Order Summary Report showed an order dated 4/19/24, for Carbamazepine 200 mg, give one tablet by mouth four times a day for seizure disorder. Review of Resident 1's MAR and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation and administration of medication for one of 13 sampled residents (Resident 11). * Resident 11's hydrocodone/acetaminophen (narcotic pain medication) tablets were removed and signed out from the controlled medication record; however, they were not documented as administered. This failure had the potential for medication administration errors, inaccurate reconciliation, and drug diversion. Findings: Review of the facility's P&P titled Controlled Medications dated 8/2014 showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record including date and time of administration, amount administered, signature of the nurse administering the dose on the accountability record at the time the medication is removed…

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, medical record review, and facility P&P review, the facility failed to provide the treatment and care in accordance with the professional standards of practice for one of nine sampled residents (Resident 1). * The facility failed to provide Resident 1's wound treatment as ordered by the physician. * The facility failed to provide Resident 1's colostomy belt (use to secure ostomy appliances and provide support) as ordered by the physician. * The facility failed to ensure the weekly wound assessment was completed for Resident 1 as per the facility's P&P. These failures had the potential for Resident 1 not to receive appropriate care and treatment. Findings: Review of the facility's P&P titled Wound Care Guidelines reviewed November 2023 showed the wound should be measured and evaluated weekly for improvement or decline. Wounds and/or dressing shall be inspected daily and documented. Further review of the P&P showed the physician should be notified for changes in the wound…

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, medical record review, and facility P&P review, the facility failed to ensure the medication, carbamazepine (an antimanic/antiseizure medication) was refilled (reordered) in a timely manner to ensure the medication was available to be administered as scheduled to one of two sampled residents (Resident 1). This failure resulted in Resident 1 not receiving carbamazepine as ordered for his nerve pain, which had the potential to negatively impact the resident's well-being. Findings: Review of the facility's contracted pharmacy's P&P titled Ordering and Receiving Medications from the Dispensing Pharmacy dated 4/2008showed to reorder the medications five days in advance of need to assure an adequate supply on hand. During an interview with Resident 1 in his room on 8/17/23 at 0953 hours, Resident 1 stated he was always in pain because of his open wounds on his legs. Resident 1 statedthe pain medication he received at the facility took about 40 minutes to be effective and only lasted to about two…

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

Based on observation, interview, and record review, the facility failed to ensure the food safety and sanitation requirements were met in accordance with professional standards for food service as evidenced by: * The facility failed to ensure the kitchen equipment was clean and free of food particles. * The facility failed to ensure proper back-flow prevention by having air gaps for the drain pipes from the sink, ice machine, and dishwasher. * The facility failed to ensure the kitchen staff used facial hair covering properly. * The facility failed to ensure the temperature of the nourishment refrigerator used to store resident food was maintained at the acceptable range. * The facility failed to ensure the resident silverware was handled in a sanitary manner. * The facility failed to ensure the kitchen utensils were covered. * The facility failed to ensure the cleaning supply was stored properly. These failures posed the risk of negatively impacting safe food handling for the residents. Findings: Review of the CMS 672 Resident Census and Conditions of Residents form completed by 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 medical record review, the facility failed to provide the reasonable accommodation to meet the care needs for one of 21 final sampled residents (Resident 64). * The facility failed to ensure Resident 64's call light was within the resident's reach. This failure had the potential to negatively impact the resident's psychosocial well-being or result in delayed provision of care. Findings: On 7/5/22 at 1128 hours, Resident 64 was observed lying in bed. Resident 64's call light was observed wrapped around the side of the bed, almost touching the floor. The call light was not within the resident's reach. Medical record review for Resident 64 was initiated on 7/5/22. Resident 64 was admitted to the facility on [DATE]. Review of the History and Physical examination dated 6/2/22, showed Resident 64 was capable of making decisions. On 7/6/22 at 1025 hours, Resident 64 was observed lying in bed with his call light clipped on the right side of the pillow under his head. On 7/6/22 at…

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

Based on interview and facility document review, the facility failed address the grievances presented by the residents during the resident council meetings (an organized group of residents meeting on a regular basis to discuss facility concerns and areas for improvement). This failure had the potential for a delay in provision of care of the residents. Findings: Review of the Resident Council Meeting Minutes dated 3/7/22, showed the residents complained about the call lights not being answered in a timely manner and loud noise in the facility. Review of the Resident Council Concert Follow-up Form showed Resident 98 stated the call lights were not answered after dinner and bedtime. However, the section for action taken was left blank. There was no documented evidence Resident 98's concerns were addressed or resolved. Review of the Resident Council Meeting Minutes dated 4/4 and 5/2/22, showed the residents continued to have concerns with call lights not answered in a timely manner and loud noise in the facility. However, there was no documented evidence the residents' grievances 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 interview, medical record review, and facility P&P review, the facility failed to offer assistance to formulate an advance directive, and/or maintain a copy of the resident's advance directive in the medical records for seven of 21 final sampled residents (Residents 36, 59, 60, 64, 72, 85, and 95 ). This failure put the residents at risk of not having their wishes for treatment known and the potential for the residents' decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives revised date 11/21 showed the facility will provide written information to the residents and/or their representative on formulation of an advance directive. If there is an advance directive or individual healthcare instructions documented by a healthcare worker, then this information shall be placed in the clinical record. 1. Medical record review for Resident 59 was initiated on 7/8/22. Resident 59 was admitted to the facility on [DATE]. 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 interview and medical record review, the facility failed to ensure the RD's recommendation was implemented for one nonsampled resident (Resident 8). This failure had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 8 was initiated on 7/8/22. Resident 8 was admitted to the facility on [DATE]. Review of the Nutritional assessment dated [DATE], showed Resident 8 was evaluated by the RD due to a recent weight change (weight loss). The documentation showed the RD had recommended to discontinue the Prostat (supplement) as Resident 8 had no pressure injury. Review of the medical record failed to show documented evidence the RD's recommendation to discontinue Prostat was addressed with the physician. Review of the MAR for the month of July 2022 showed Resident 8 was administered Prostat 30 ml two times a day from 7/1 to 7/8/22. On 7/8/22 at 1356 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 was asked to explain…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services related to a PICC for one of 21 final sampled residents (Resident 30). The facility failed to follow their P&P to obtain the measurement of the external length of the catheter upon admission and during dressing changes. This failure posed the risk for the resident to develop complications such as catheter migration and dislodgement. Findings: Review of the facility's P&P titled PICC Dressing Change dated 06/2018 showed the length of the external catheter is obtained upon admission and during dressing changes. The external length of catheter will be measured from the insertion site to the hub. Documentation in the medical record includes the length of the external catheter. Medical record review for Resident 30 was initiated on 7/5/22. Resident 30 was readmitted to the facility on [DATE]. On 7/6/22 at 1031 hours, Resident 30 was observed with a PICC line on the left upper…

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 medical record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical well-being for one of 21 final sampled residents (Resident 408). The facility failed to ensure Resident 408's dialysis access site was assessed accurately. This failure had the potential to not provide the appropriate care and treatment to the resident. Findings: Medical record review for Resident 408 was initiated on 7/5/22. Resident 408 was admitted to the facility on [DATE]. Review of the physician's order dated 7/2/22, showed Resident 408 was to receive dialysis every Tuesday, Thursday, and Saturday at a dialysis center. Review of Resident 408's plan of care showed a care plan problem dated 7/2/22, addressing the need for hemodialysis. The interventions/tasks included to leave the AV fistula/graft dressing in place for 48 hours or as indicated by the dialysis center after dialysis treatment, unless soiled or if bleeding has…

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, medical record review, and facility P&P review, the facility failed ensure accurate reconciliation of the controlled medication for one nonsampled residents (Resident 8) and failed to implement the facility's P&P on disposed of the discontinued controlled medications. These failures had the potential for drug diversion. Findings: 1. On 7/8/22 at 1115 hours, an inspection of Medication Cart 3 was conducted with LVN 3. Review of Resident 8's Antibiotic or Controlled Medication sheet for hydrocodone/APAP (narcotic pain medication) 10-325 mg showed two tablets were removed from the controlled medication supply on 6/10/22 at 0100 hours, and 6/12/22 at 2000 hours. However, review of Resident 8's MAR failed to show documented evidence the two tablets of hydrocodone/APAP were administered to Resident 8 on those dates and times when they were removed. LVN 3 stated it should be documented on the MAR when administered. 2. Review of the facility's P&P titled Controlled Medication Storage dated August 2014 showed controlled medications remaining in the facility…

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 medical record review, the facility failed to ensure two of 21 final sampled residents (Residents 30 and 408) were free from unnecessary medications. * Resident 30 was administered stool softeners on multiple days even though the resident was documented as having loose stools. * Resident 408 was administered midodrine (blood pressure medication) when the resident's blood pressure was above the parameter prescribed by the physician. These failures posed the potential of complications related to unnecessary medications. Findings: 1. Medical record review for Resident 30 was initiated on 7/5/22. Resident 30 was readmitted to the facility on [DATE]. On 7/6/22 at 1055 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 30 was incontinent of bowel. CNA 2 stated Resident 30 had loose stools and she changed the resident's incontinence brief three times already since the start of her shift this morning due to loose stools. CNA 2 stated she informed the licensed nurse and was told…

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 medical record review, the facility failed to ensure one of 21 final sampled residents (Resident 60) was monitored for adverse effects of psychotropic medication. This failure had the potential for the resident to experience adverse effects of the psychotropic medication. Findings: According to Lexicomp (a reference guide for healthcare professionals), significant adverse reactions for use of risperidone (antipsychotic medication) included orthostatic hypotension. Risk factors for developing orthostatic hypotension related to antipsychotic use included concomitant medications that also cause or exacerbate orthostatic hypotension (e.g., antihypertensive medications) and older adults. Medical record review for Resident 60 was initiated on 7/5/22. Resident 60 was admitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE], showed Resident 60 required extensive assistance with ambulation and transfers, and limited assistance with locomotion on and off the unit.…

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 facility document review, the facility failed to ensure the medications were properly stored. This failure posed the risk for administering the expired and/or discontinued medications. Findings: Review of the facility's P&P titled Medication Storage In the Facility, dated April 2008 showed the outdated medication are immediately removed from stock and disposed of. 1. On 7/8/22 at 0848 hours, inspection of the medication refrigerator in Station 2 was conducted with LVN 2. In the refrigerator, an IV bag labeled with daptomycin (antibiotic medication) 400 mg dose had an expiration date of 7/6/22. LVN 1 verified the medication had expired. On 7/8/22 at 0916 hours, an interview and concurrent medical record review were conducted with LVN 1. Review of Resident 30's physician orders showed an active order dated 6/29/22, to administer daptomycin solution reconstituted 400 mg via IV one time a day until 7/12/22. LVN verified the order. On 7/8/22 at 0902 hours, an interview was conducted with RN 1. RN 1 stated the expired medications should be removed from…

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 medical record review, the facility failed to maintain accurate medical records for three of 21 final sampled residents (Residents 26, 87, and 408). This failure put the residents at risk for not receiving appropriate care due to inaccurate medical records. Findings: 1. Medical record review for Resident 26 was initiated on 7/5/22. Resident 26 was admitted to the facility on [DATE]. Review of the Order Summary Report showed an order dated 7/7/22, to monitor right chest permacath used as a dialysis access. Review of the Dialysis Communication Record showed the following: - On 6/3, 6/11, and 7/2/22, the pre-assessment, first and second four hours assessments showed bruit and thrill as present. - On 6/30 and 7/7/22, the second four hours assessment showed bruit and thrill as present. - On 7/2/22, the pre-assessment, first and second four hours assessments showed bruit and thrill as present. - On 6/5, 6/12, 6/17, and 6/18/22, the first and second four hours assessments showed…

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 medical record review, the facility failed to follow the infection control practices for one of 21 final sampled residents (Resident 30). * Resident 30's urinary catheter drainage bag was observed directly touching the floor. This failure placed the resident at risk for urinary tract infection. Findings: Medical record review for Resident 30 was initiated on 7/5/22. Resident 30 was readmitted to the facility on [DATE]. On 7/6/22 at 1031 hours, Resident 30 was observed lying in bed with an indwelling urinary catheter attached to a drainage bag. The drainage bag was observed directly touching the floor. Review of the Order Summary Report showed a physician's order dated 7/6/22, to administer macrodantin (antibiotic) 100 mg one capsule via GT two times a day for ESBL (extended-spectrum beta-lactamase, an enzyme made by some bacteria which prevents certain antibiotics from being able to kill the bacteria; the bacteria then become resistant to the antibiotics.) in urine times…

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.