The Gardens Healthcare Center

Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards and implement interventions to prevent accidents when Licensed Vocational Nurse 1 (LVN 1) left a bottle of Vitamin C unattended and easily accessible to other residents on top of the medication cart while LVN 1 was inside Resident 30`s room to administer Resident 30's medications. This deficient practice placed other residents at risk to gain access to Vitamin C without staff knowledge resulting in the accidental ingestion possibly causing harm to the residents. Findings: During a review of Resident 30's admission Record (face sheet), the admission Record indicated that the facility admitted the resident on 4/11/2025, with diagnoses including type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure), and Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 30's Minimum Data Set (MDS…

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

Based on interview and record review, the facility failed to follow a physician's order by failing to conduct a weekly weight for one of one sampled resident (Resident 24). This deficient practice had the potential for a delay in care and services and undetected weight loss. Findings: During a review of Resident 24's admission Record, the admission Record indicated the facility admitted Resident 24 initially on 3/26/2025 and readmitted the resident on 4/21/2025 with diagnoses that included but not limited to type two (2) diabetes (a chronic condition that affects the way the body processes blood glucose [sugar]), muscle weakness, and metabolic encephalopathy (the loss of brain function due to a chemical imbalance in the blood). During a review of Resident 24's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 4/24/2025, the H&P indicated Resident 24 did not have the capacity to understand make decisions. During a review of Resident 24's Minimum Data Set (MDS - a resident…

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

Based on interview and record review the facility failed to provide care and services that meet professional standards of quality by failing to assess the continued need for a peripheral intravenous (IV-into or within the vein, a small tub is inserted) catheter (a thin, flexible tube that is inserted into a vein to draw blood and give treatments including IV fluids, drugs, or blood transfusions) if not being used for IV fluids or medications for one of one sampled resident (Resident 198). This deficient practice had the potential for Resident 198 to develop an infection from a prolonged IV that she did not need. Findings: During a review of Resident 198's admission Record, the admission Record indicated the facility admitted Resident 185 on 5/8/2025 with diagnoses that included, but not limited to muscle weakness, fusion of the spine (a procedure that permanently joins two or more vertebrae [the individual bones that make up the spinal column, also known as the spine] in the spine to eliminate movement between them), spinal stenosis (a condition where the spaces in the spine become…

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

Based on observation, interview, and record review, the facility failed to ensure residents receive necessary respiratory care and services that is in accordance with professional standards of practice for one of two sampled residents (Resident 4) investigated under the respiratory care area when Resident 4's nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen levels) oxygen tubing was touching the floor and the tubing cannula (a small flexible tube with two prongs that fit inside the nostrils, used to deliver extra oxygen) was not attached to the resident. This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 4/23/2025 with diagnoses including fracture of right femur (a break of thighbone), aphasia (a condition that makes it hard for a person to speak, understand, read or write language), 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.

Based on observation interview, and record review the facility failed to: 1. Ensure the disposal of medications in a manner that was not retrievable, in one of one inspected Medication Rooms (Medication Room Station 1.) 2. Include three disposed medications with verifying signatures of two licensed nurses on the Medication Disposition Record/Pass Log. As a result, control and accountability of discontinued medications and medications awaiting final disposition (process of returning and/or destroying unused medications) did not follow federal regulations and facility policy and procedures. These deficient practices increased the opportunity for medication diversion (the transfer of a medication from a lawful to an unlawful channel of distribution or use,) and increased the risk that residents in the facility could have accidental exposure to harmful medications and delayed medication treatment during emergencies possibly leading to physical and psychosocial harm, and hospitalization. Findings: During a concurrent observation and interview on 05/11/25 08:32 am, with Registered Nurse…

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 proper sanitation and food handling practices to prevent the outbreak of foodborne illnesses (also called food poisoning, illness caused by eating contaminated food) when one of five sampled residents (Resident 147) had leftover food that was not removed from the resident's bedside after four hours. These deficient practices had the potential for Resident 147 to ingest (consume) contaminated leftover food and lead to foodborne illness. Findings: During a review of Resident 147's admission Record, the admission Record indicated the facility admitted Resident 147 to the facility on 4/7/2025 and readmitted the resident on 5/3/2025, with diagnoses including normal pressure hydrocephalus (a build-up of fluid in the cavities deep within the brain), type two (2) diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and major depressive disorder (a serious mental illness that can cause a persistent low mood, loss of interest, and other symptoms that…

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

Based on interview and record review, the facility failed to ensure the Responsible Party (RP) or the Resident Representative (RR) of one of three sampled residents (Resident 1), who had a history of dementia (a progressive state of decline in mental abilities), with moderately impaired cognition for daily decision making, and had no capacity to make medical decisions, signed Resident 1's consent forms for the administration of the following: 1. Citalopram (medication used to treat depression [a common mental health condition characterized by persistent feelings of sadness, loss of interest, and changes in behavior and cognitive function]), 2. Influenza vaccine (also known as the flu shot, protects against the flu [respiratory illness that infect the nose, throat, and sometimes the lungs]), 3. Coronavirus Disease 2019 (COVID-19- respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) vaccine. These deficient practices placed Resident 1 at risk for making health care decisions because 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 record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a history of dementia (a progressive state of decline in mental abilities), assessed as high risk for fall, had a wandering (moving around without any clear purpose or direction) behavior and had a history of fall, was provided supervision and kept free from accidents by failing to reassess Resident 1 for Elopement Screening (a safety assessment that evaluates a resident's risk of leaving a safe environment without permission) after Resident 1 had triggered (activated) the exit door alarm twice on 12/31/2024 and had a wandering behavior on 1/1/2025. On 1/2/2025, Resident 1 was able to walk two steps outside the facility's exit door (located at the side of the facility equipped with a door alarm that is activated when it is opened and held open for a certain period of time) without staff assistance and without an assistive device (walker- [a mobility aid that helps provide stability and balance…

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 medical records were complete and accurately documented for one of five sampled residents (Resident 2) by failing to: a. Ensure Resident 2 ' s physician ' s order for surgical wound treatment was documented in the resident ' s clinical record before the surgical wound treatment was performed. b. Ensure Resident 2 ' s physician ' s order to change the resident ' s indwelling urinary catheter (a flexible plastic tube inserted into the bladder [a hallow organ that stores urine] to provide continuous urinary drainage) drainage bag was documented in the resident ' s clinical record before the drainage bag was changed. c. Ensure surgical wound treatments and urinary catheter drainage bag changes provided to Resident 2 were documented in the resident ' s Treatment Administration Record (TAR). These deficient practices resulted in inaccurate information on Resident 2 ' s clinical record and had the potential for delayed and inaccurate medical interventions for Resident 2. Findings: During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive, person-centered care plan (contains relevant information about a resident ' s health conditions, goals of treatment, specific actions that must be performed, and a plan for evaluation) with measurable objectives and interventions for two of five sampled residents (Resident 1 and Resident 2) by failing to: a. Indicate the frequency of Resident 1 ' s neuro-checks after the resident ' s unwitnessed fall. b. Address Resident 2 ' s urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) care. These deficient practices placed Resident 1 and Resident 2 at risk for not receiving the necessary services and assistance that can result in infection and injury. Findings: a. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 6/10/2024 with diagnoses including Parkinson ' s disease (a…

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

Based on observation, interview, and record review, the facility failed to ensure that a resident with indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) received proper care and services that included to anchor (secure) the urinary catheter tubing to the resident ' s thigh for one of five sampled residents (Resident 2). This deficient practice had the potential to result in urinary catheter dislodgement (forcefully pulled out of a secure position) causing urethral (the tube through which urine leaves the body) tearing that may result in pain, bleeding, and infection. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted the resident on 8/30/2024 with diagnoses including fusion of spine (a surgery to connect two or more bones in any part of the spine) in the lumbar region, muscle weakness, and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a review of Resident 2 ' s Physician Orders,…

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

Based on observation, interview and record review, the facility failed to follow infection control procedures for one of five sampled residents (Resident 2) by failing to ensure Registered Nurse 1 (RN 1) changed gloves after touching unclean surfaces while performing wound treatments and changing an indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) drainage bag. Resident 2 was on enhanced barrier precaution (EBP – an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities). This deficient practice placed Resident 2 at risk for exposure and contracting infections. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted the resident on 8/30/2024 with diagnoses including fusion of spine (a surgery to connect two or more bones in any part of the spine) in the lumbar region, muscle weakness, and essential hypertension (an abnormally high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. A review of Resident 5's admission Record indicated the facility admitted Resident 5 on 1/25/2021 with diagnoses including, but not limited to, type two diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and transient cerebral ischemic attack (a brief episode of neurological [relating to the brain] dysfunction resulting from an interruption in the blood supply to the brain or the eye). A review of Resident 5's MDS, dated [DATE], indicated Resident 5 had moderate cognitive impairment (difficulty understanding and making decisions), required supervision with eating, and required maximal assistance or was dependent on facility staff for other activities of daily living, including hygiene, toileting, and surface to surface transfers. A review of Resident 5's Order Summary Report, dated 10/25/2023, indicated Resident 5 was ordered rivaroxaban (also known as Xarelto, medication that thins the blood) oral tablet 2.5 mg, give one tablet by mouth…

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.

b. A review of Resident 11's admission Record indicated the facility admitted the resident on 4/5/2024, with diagnoses including atrial fibrillation (an irregular and often very rapid heart rhythm), heart failure (occurs when the heart muscle does not pump blood as well as it should), and gastritis (inflammation of the lining of the stomach). A review of Resident 11's History and Physical (H&P), dated 4/8/2024, indicated the resident was receiving heparin every 8 hours for deep vein thrombosis (DVT, a blood clot that develops within a deep vein in the body, usually in the leg) prophylaxis (PPX, preventive). The H&P also indicated the resident had the capacity to make needs known but unable to make medical decisions. A review of Resident 11's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/8/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had moderately impaired cognition (a range of mental processes relating to the acquisition, storage, manipulation, and retrieval of…

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

Based on observation, interview and record review, the facility failed to provide routine drugs to its residents and establish a system of records of receipt and disposition of all controlled drugs (substances that have an accepted medical use, have a potential for abuse, and may also lead to physical or psychological dependence) in sufficient detail to enable an accurate reconciliation when: 1. The facility failed to ensure licensed nursing staff completed documentation indicating reconciliation (a system of recordkeeping that ensures an accurate inventory of medications that have been received, dispensed, and administered) of controlled medications at every change of shift on the Controlled Substance / MAR (Medication Administration Record) Change of Shift Audit form for one of one medication carts (Medication Cart 2) reviewed during the Medication Storage task. 2. The facility failed to administer medication to one of seven sampled residents reviewed during the medication administration task (Resident 249). These deficient practices had the potential for inaccurate reconciliation…

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.

b. A review of Resident 11's admission Record indicated the facility admitted the resident on 4/5/2024, with diagnoses including atrial fibrillation (an irregular and often very rapid heart rhythm), heart failure (occurs when the heart muscle does not pump blood as well as it should), and gastritis (inflammation of the lining of the stomach). A review of Resident 11's History and Physical (H&P), dated 4/8/2024, indicated the resident received heparin every 8 hours for deep vein thrombosis (DVT, a blood clot that develops within a deep vein in the body, usually in the leg) prophylaxis (PPX, preventive). The H&P indicated the resident had the capacity to make needs known but unable to make medical decisions. A review of Resident 11's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/8/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had moderately impaired cognition (a range of mental processes relating to the acquisition, storage, manipulation, and retrieval of information) 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.

Based on interview and record review the facility failed to ensure each resident's medication regimen was managed and monitored to promote the resident's highest practicable mental, physical, and psychosocial well-being to four out of four sampled residents (Resident 39, 29, 23, and 148)) selected for unnecessary medications review by failing to: 1.a. Ensure the order for (PRN) lorazepam (a psychotropic medication that affects the mind, emotions, and behavior) was limited to a 14-day duration unless longer timeframe was deemed appropriate by the attending physician for Resident 39. 1.b. Identify and define specific measurable target behaviors (behavior that is targeted for change) related to the use of lorazepam for Resident 39. 2. Complete and document monitoring for behavioral manifestations for the use of buspirone (an anxiolytic, a medication used to treat feelings of fear, dread, uneasiness that may occur as a reaction to stress) for Resident 29. 3.a. Ensure the physician's orders include the appropriate indication, indicate specific target behaviors and specific adverse…

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.

b. A review of Resident 5's admission Record indicated the facility admitted Resident 5 on 1/25/2021 with diagnoses including, but not limited to, type two diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and transient cerebral ischemic attack (a brief episode of neurological [relating to the brain] dysfunction resulting from an interruption in the blood supply to the brain or the eye). A review of Resident 5's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/13/2024, indicated Resident 5 had moderate cognitive impairment (difficulty understanding and making decisions), required supervision with eating, and required maximal assistance or was dependent on facility staff for other activities of daily living, including hygiene, toileting, and surface to surface transfers. The MDS further indicated Resident 5 was at risk for pressure ulcers and received treatments, including pressure reducing device for the bed. A review of Resident 5's Order Summary Report indicated Resident 5 was…

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

Based on observation, interview, and record review, the facility failed to ensure: 1. The staff followed the dress code in the kitchen 2. Food was labeled with a date, stored correctly, and disposed of when contaminated. 3. Kitchen equipment and utensils were kept clean. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (an illness caused by food contaminated with bacteria, viruses, and other toxins) in 42 of 44 medically compromised and vulnerable residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 6/4/2024 at 8:10 a.m., with Dietary Aide (DA) 2 in the kitchen, DA 2 was preparing the drinks and shared open condiments of strawberry preserve, lemons, and drinks for the resident's meal trays. DA 2 was wearing a long dangling necklace and watch that was not covered to avoid exposure to food. DA 2 stated she was never advised that she could not wear jewelry while…

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 5.a. A review of Resident 13's admission Record indicated the facility admitted the resident on 8/29/2023, and was readmitted on [DATE], with the diagnoses that included, but not limited to chronic obstructive pulmonary disease (COPD - long term lung disease making it hard to breathe), emphysema (a type of COPD that affects the air sac of the lungs), and dependence on supplemental oxygen (a machine that provides oxygen). A review of Resident 13's History and Physical (H&P), dated 5/20/2024, it indicated the resident was readmitted to facility on 5/17/2024 from a general acute care hospital (GACH) for sepsis (a serious condition when the body overreacts to an infection) caused by pneumonia (PNA - an infection that affects one or both lungs). The H&P indicated the resident has the capacity to understand and make decisions. A review of Resident 13's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/23/2024, it indicated Resident 13 had the ability to make self-understood and had…

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

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for one of two sampled residents (Resident 249) when Resident 249's urinary catheter bag (device used to collect urine drained from the bladder via a urinary catheter [a tube inserted into the bladder through the urethra (duct that lets urine leave the bladder and body) to allow urine to drain]) was not covered with a privacy bag (also known as a dignity bag - device used to cover the contents or a urinary catheter bag). This deficient practice had the potential to negatively affect the resident's psychosocial wellbeing and loss of dignity. Findings: A review of Resident 249's admission Record indicated the facility admitted the resident on 5/31/2024, with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest task), acute kidney failure (abrupt decrease in kidney function), 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.

Based on interview and record review, the facility failed to offer the resident or their resident representative assistance with formulating an Advance Directive (AD - a legal document telling the doctor one's wishes about their healthcare in the event they cannot make the decision for themselves) upon admission to one out of two sampled residents (Resident 34) investigated during review of advance directive care area. This deficient practice violated the resident and/or their representative the right to be fully informed of the option to formulate an AD and had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences. Findings: A review of Resident 34's admission Record indicated the facility admitted the resident on 3/5/2024 with diagnoses including type 2 diabetes mellitus (a condition in which the body has trouble controlling blood sugar and using it for energy with hyperglycemia (a condition that happens when there is too much sugar in the blood). A review of Resident 34's History 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.

Based on observation, interview, and record review, the facility failed to ensure residents receive care to prevent pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one of one sampled residents investigated under the pressure ulcer care area (Resident 5) when Resident 5's low air loss mattress (LALM - a pressure reducing device) was not set according to the manufacturer's guidelines. This deficient practice had the potential for the resident to develop pressure ulcers. Findings: A review of Resident 5's admission Record indicated the facility admitted Resident 5 on 1/25/2021 with diagnoses including, but not limited to, type two diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and transient cerebral ischemic attack (a brief episode of neurological [relating to the brain] dysfunction resulting from an interruption in the blood supply to the brain or the eye). A review of Resident 5's Minimum Data Set (MDS - a…

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

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents by failing to ensure medications were not left unattended and readily available for one of four sampled residents (Resident 196) reviewed under the Accidents care area. This deficient practice had the potential to result in residents obtaining medication without staff knowledge resulting in accidental ingestion causing harm to residents. Findings: A review of Resident 196's admission Record indicated the facility admitted the resident on 4/23/2024 with diagnoses that included fracture (broken bone) of the sacrum (region at the bottom of the spine), hypertension (high blood pressure), immunodeficiency (decreased ability of the body to fight infections and other diseases) and need for assistance with personal care. A review of Resident 196's Minimum Data Set (MDS - an assessment and care screening tool) dated 4/26/2024, indicated the resident usually was able to understand others and usually was able to make herself understood. The MDS further…

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

Based on observation, interview, and record review the facility failed to ensure residents who were incontinent (lacks voluntary control over urination) of bladder (organ in the pelvis that stores urine) received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) for two out of three sampled residents (Resident 249 and 40) reviewed under the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain) care area by: 1. Failing to keep Resident 249's urinary catheter tubing from coiling and allowing the contents to flow freely into the indwelling urinary catheter bag (container that connects to a urinary catheter and collects urine). 2. Failing to keep Resident 249 and Resident 40's indwelling urinary catheter bag from touching the floor. The deficient practices had the potential for residents to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine 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 record review, the facility failed to label the intravenous (IV - a tube inserted into the vein that delivers medication) medication bag and tubing for one of one sampled resident (Resident 36). This deficient practice had the potential to increase Resident 36's risk for complications from IV medication administration such as bacteria growth in the tubing, wrong rate (how fast to give), wrong amount and wrong time. Findings: A review of Resident 36's admission Record indicated the facility admitted on [DATE], with diagnoses that included, but not limited to malignant neoplasm (cancerous tumor that can spread) of left female breast, secondary malignant neoplasm (cancerous tumor arising from an existing tumor) of bone, chronic kidney failure (when kidneys are damaged over time and can't filter blood correctly) and hypercalcemia (when the calcium level in the blood becomes too high.) A review of Resident 36's History and Physical (H&P), dated 5/9/2024, it indicated the 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, and record review the facility failed to assess the risk of entrapment (an event in which a resident is caught, trapped, or entangled in spaces in or about the bed rail) from side rails (adjustable metal or rigid plastic bars that attach to the bed) and obtain informed consent from the resident or the resident representative prior to installation to two of two sampled residents (Residents 11 and 20) investigated during review of accidents care area. These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment, and death of residents. Findings: 1. A review of Resident 11's admission Record indicated the facility admitted the resident on 4/5/2024, with diagnoses including age-related osteoporosis (bone loss occurs with aging in all adults), dementia (the loss of cognitive functioning, thinking remembering, and reasoning to such an extent that it…

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 that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs for one of five sampled facility staff members reviewed under the sufficient and competent staffing care area (Licensed Vocational Nurse [LVN] 2) when LVN 2 did not flush Resident 249's gastrostomy tube (GT - a tube inserted through the wall of the abdomen directly into the stomach used to provide nutrition, hydration, and or medications) via gravity (method of sending fluids through the GT in a downward direction using the force of gravity) and verbalized using a slow push method (using a syringe and pushing the plunger slowly to administer medications or fluids) when administering medications via the GT instead of administering via gravity. This deficient practice had the potential to cause discomfort for the resident and or cause the GT to dislodge from the resident. Cross-reference F755, F759, F842 Findings: A review of Resident 249's admission Record indicated the facility admitted Resident…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent (%). There were two medication errors out of 25 opportunities resulting in an overall medication error rate of 8% affecting one out of seven sampled residents observed for medication administration (Resident 249) when Resident 249 did not receive cholecalciferol (a medication used to supplement Vitamin D [a nutrient the body needs for building and maintaining healthy bones]) and fluticasone (medication used to relieve seasonal and year-round allergic and non-allergic nasal symptoms) as ordered by the resident's physician. This deficient practice had the potential for the resident's health and well-being to be negatively impacted. Cross-reference F726, F755, F842 Findings: A review of Resident 249's admission Record indicated the facility admitted Resident 249 on 5/31/2024 with diagnoses including, but not limited to, gastrostomy status (creation of an artificial external opening into the stomach for nutritional support) and retention of urine. A review…

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

Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services during the inspection of one of one medication carts (Medication Cart 2) reviewed during the Medication Storage and Labeling task by failing to ensure five unpackaged and unlabeled albuterol (a medication that relaxes muscles in the airways and increases air flow to the lungs) nebules (a plastic container that holds liquid medication) were not stored and readily available for use in Medication Cart 2. This deficient practice had the potential to result in medication being administered to the wrong resident or loss of resident medication. Findings: During a concurrent medication storage observation and interview on 6/4/2024 at 4:13 p.m. with Licensed Vocational Nurse 2 (LVN 2) at Medication Cart 2, observed five unpackaged and unlabeled albuterol nebules in the bottom, right drawer of the medication cart. LVN 2 stated the five albuterol nebules in the drawer were not in a labeled box, not labeled to identify the resident to whom they belonged, and not labeled…

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

Based on interview and record review, the facility failed to maintain clinical records that are complete and accurate for one of seven sampled residents investigated during medication administration (Resident 249) by documenting the administration of cholecalciferol (a medication used to supplement Vitamin D [a nutrient the body needs for building and maintaining healthy bones]) when it was not administered. This deficient practice resulted in inaccurate documentation in Resident 249's medical record. Findings: A review of Resident 249's admission Record indicated the facility admitted the resident on 5/31/2024 with diagnoses including gastrostomy status (creation of an artificial external opening into the stomach for nutritional support) and retention of urine. A review of Resident 249's Order Summary Report, dated 5/31/2024, indicated a physician's order for cholecalciferol oral liquid 125 mcg (micrograms - a unit of measure for mass) per milliliter (ml - a unit of measure for volume), give 125 mcg via gastrostomy tube one time a day for nutritional support. During a concurrent…

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

Based on interview and record review, the facility failed to ensure the arbitration (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) agreement (a written contract in which two or more parties agree to settle a dispute out of court) was explained to residents in a form and manner that the resident understands, and the the resident and/or representative acknowledged that they understand the agreement to two of three sampled residents reviewed under the Arbitration care area (Resident 4 and 246) when: a. Resident 246's representative Family Member 1 (FM1), signed the facility's arbitration agreement without knowing the agreement can be rescinded by written notice within 30 days. b. Residents 4 and 40 signed the facility's arbitration agreement without understanding what they signed and without knowing the agreement can be rescinded by written notice within 30 days. These deficient practices resulted in the residents not knowing or understanding what an arbitration…

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

Based on interview and record review, the facility failed to screen eight of ten sampled visitors and three of ten sampled staff (Certified Nursing Assistant 4 [CNA 4], Licensed Vocational Nurse 4 [LVN 4] and Certified Occupational Therapy Assistant 1 [COTA 1]) for Coronavirus Disease 2019 (COVID-19, highly contagious viral respiratory infection that spreads from person to person through droplets released when an infected person coughs, sneezes or talks) from 4/23/2024 to 4/26/2024 while facility is on COVID-19 outbreak. This deficient practice had the potential to result in the spread of the COVID-19 to all residents and staff. Findings: During an observation on 4/29/2024 at 8:15 a.m., by the facility's front door, observed a signage on COVID-19 Outbreak Notification, dated 4/17/2024 posted on the left side of the door. During an observation on 4/29/2024 at 8:16 a.m., by the front lobby, observed no staff by the front desk, the front table had N95 mask (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide reasonable accommodations for resident needs and preferences for one of three sampled residents (Resident 4) when Family Member 1 (FM 1) requested for room change. This deficient practice had the potential to negatively impact the psychosocial well-being of the resident. Findings: A review of Resident 4's admission Record indicated the facility admitted Resident 4 on 3/26/2024 with diagnoses that included unspecified (unconfirmed) sequelae (after effect) of unspecified cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), pneumonitis (inflammation of lung tissue) due to inhalation of food and vomit and Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). The admission Record indicated Family Member 1 (FM 1) was the responsible party (means an individual, including the patient's relative, health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the narcotic and hypnotic record (accountability record of controlled medications that are considered to have strong potential for abuse) was accurately documented for three out of eight sampled residents (Resident 5, Resident 6, and Resident 7). This deficient practice resulted in inaccurate reconciliation of the controlled medications (tramadol [a strong painkiller from a group of medicines called opiates, or narcotics], hydrocodone-acetaminophen [Norco (a combination opioid medication used to manage pain when non-opioid medications aren't working well enough)], and zolpidem tartrate [used to treat insomnia (trouble sleeping)]) and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use of unintended purposes) of controlled medication for Resident 5, 6, and 7. Findings: a. A review of Resident 5 ' s admission Record indicated 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.

Based on interview and record review, the facility failed to notify the physician of a significant change in the resident's physical health for one of six sampled residents (Resident 2) when Resident 2 had a cognition (a term for the mental processes that take place in the brain, including thinking, attention, language, learning, memory and perception) decline noted by the Director of Rehabilitation (DOR). On 1/25/2024 the DOR informed the Responsible Party (RP) of Resident 2's cognition decline requiring laboratory (lab) procedures in order to be discharged . On 1/30/2024, Resident 2 was discharged with no labs being done and no documentation of a change of condition (COC) for Resident 2' cognition decline. This deficient practice resulted in a delay in care. Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 1/1/2024 with the diagnoses that included acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), anemia (a condition in which the body does not have enough healthy red…

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

Based on interview and record review, the facility failed to provide laboratory (lab) services for one of six sampled residents (Resident 2) on 1/25/2024. The Director of Rehab (DOR) informed Resident 2's Responsible Party (RP) that Resident 2 had a cognitive (referring to mental processes that take place in the brain, including thinking, attention, language, learning, memory and perception) decline requiring labs in order to be discharged . On 1/30/2024 Resident 2 was discharged with no labs being done and RP not being notified of labs not being done. This deficient practice had the potential for Resident 2 to receive a delay in care and services. Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 1/1/2024 with the diagnoses that included acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), anemia (a condition in which the body does not have enough healthy red blood cells [A type of blood cell that is made in the bone marrow and found in the blood]), and essential (primary)…

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 confidential personal information for one of six sampled residents (Resident 6) was protected. The clinical records of Resident 6 were left unattended on the receptionist's computer. This deficient practice had the potential to violate Resident 6's rights for privacy and confidentiality of personal and medical records. Findings: A review of Resident 6 ' s admission Record indicated the facility admitted the resident on 12/6/2022 with diagnoses including type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high), chronic kidney disease (a condition in which the kidneys were damaged and cannot filter as well as they should), and muscle weakness. On 1/16/2024 at 3:50 p.m., during a concurrent observation and interview, observed Resident 6 ' s medical records on the computer at the reception area. The reception area is located at the hallway across the nurse station. The Infection Preventionist Nurse (IPN) stated that the computer with Resident 6 ' s medical records should be closed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions for one of six sampled residents (Resident 1). The facility failed to develop and implement individualized care plan interventions addressing Resident 1 ' s wandering and elopement (a person who may present an imminent threat to the person ' s health and safety because the person was deemed too ill or impaired to make a reasoned decision to leave) behavior. As a result, Resident 1 eloped on 1/13/2024. Resident 1 fell at the nearby bus stop and sustained a right rib fracture (broken bone). Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 12/1/2023 with diagnoses that included muscle weakness, anxiety disorder (a persistent and excessive worry that interferes with daily activities), and dementia (the loss of cognitive [conscious mental activities including thinking, reasoning, understanding, learning, 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.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for one of eight facility staff members (Licensed Vocational Nurse 1 [LVN 1]), by failing to ensure LVN 1 wore the N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) properly. This deficient practice placed other residents and staff at risk for exposure and contracting COVID-19. Findings: On 1/16/2024 at 3:58 p.m., during a concurrent observation and interview, observed LVN 1 ' s N95 mask was not worn properly. The elastic straps of LVN 1 ' s N95 mask were both on the lower back of the neck with a space between the N95 mask and LVN 1 ' s face. LVN 1 stated that one of the N95 mask elastic strap should be on top of the head and the other elastic strap should be on the neck area to keep an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 1) when the facility failed to create a care plan related to Resident 1 ' s contact isolation due to clostridium difficile (c-diff - bacteria that causes diarrhea and colitis [an inflammation of the colon]) infection. This deficient practice had the potential to negatively affect the delivery of necessary care and services and potentially spread of infection to other residents and staff. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 12/8/2023 with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood affecting the brain that can lead to personality changes), enterocolitis (an inflammation that occurs throughout the intestines) due to clostridium difficile (c-diff- bacteria that causes diarrhea and colitis [an inflammation of the colon]), muscle…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was receiving enteral nutrition (also known as tube feeding-a way of delivering nutrition directly to the stomach or small intestine) formula had labels indicating the date and time it was started. This deficient practice had the potential to result in increased risk for gastrointestinal (stomach) problems. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 12/8/2023 with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood affecting the brain, it can lead to personality changes), enterocolitis (an inflammation that occurs throughout your intestines) due to clostridium difficile (bacteria that causes diarrhea and colitis [an inflammation of the colon]), muscle weakness, and dysphagia (swallowing difficulties). A review of Resident 1 ' s History and Physical, dated 12/11/2023, indicated the resident can make needs known but cannot make 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.

Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1) who was receiving enteral nutrition (also known as tube feeding-a way of delivering nutrition directly to the stomach or small intestine) and was on antibiotic (medication used to treat infection). This deficient practice had the potential to result in confusion of care and services rendered to Resident 1 and resulted to inaccurate information entered to resident ' s medical record. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 12/8/2023 with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood affecting the brain, it can lead to personality changes), enterocolitis (an inflammation that occurs throughout your intestines) due to clostridium difficile (bacteria that causes diarrhea and colitis [an inflammation of the colon]), muscle weakness, and dysphagia…

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

Based on observation, interview, and record review, the facility failed to implement infection control practices for one of five sampled residents (Resident 1) by: 1. Failing to ensure Certified Nursing Assistant 1 (CNA 1) wore eye protection (face shield or goggles) and tie the back of her isolation gown (provides a barrier to prevent clothes and skin underneath from becoming exposed to body fluid splash) while assisting Resident 1 who tested positive for Coronavirus disease 2019 (COVID-19- highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) in the bathroom. 2. Failing to ensure the Director of Nursing (DON) wore a mask inside the facility during a COVID-19 outbreak. These deficient practices had the potential to result in the spread of infection placing the residents, staff, and visitors at risk to be infected with COVID-19. Findings: a. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 9/6/2023 with diagnoses that included displaced…

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

Based on interview and record review, the facility failed to notify the physician of a significant change in the resident ' s physical health for one out of four sampled residents (Resident 1) when: 1. Resident 1 was noted with diarrhea from 10/13/2023 to 10/16/2023. This deficient practice delayed testing for Clostridium difficile (C-diff: a bacterium that can infect the bowel and cause diarrhea). 2. Resident 1 was noted with a blood pressure (the force of your blood pushing against the walls of your arteries [blood vessels that distribute oxygen-rich blood to your entire body]) and heart rate [the number of times your heart beats per minute]) of 93/61. This deficient practice had the potential for a delay in care. Findings: a. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 9/20/2021 and readmitted the resident on 9/21/2023 with diagnoses including dehydration (occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions), personal history of other…

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

Based on interview and record review, the facility failed to ensure one of four resident (Resident 1) received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by failing to document the blood pressure for metoprolol tartrate (a medication that lowers your blood pressure (the force of your blood pushing against the walls of your arteries [blood vessels that distribute oxygen-rich blood to your entire body]) and heart rate [the number of times your heart beats per minute]) in the Medication Administration Record (MAR- is a report detailing the drugs administered to a patient by a healthcare professional at a treatment facility), from 9/22/2023 to 10/27/2023. This deficient practice placed the resident at risk for hypotension that can negatively affect the resident's health status. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 9/20/2021 and readmitted the resident on 9/21/2023, with diagnosis including dehydration (occurs when you use or lose…

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 designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis (40 hours per week) from 9/7/2023 to 11/16/2023. This deficient practice had the potential to result in the provision of substandard quality of care to the residents. Findings: During an interview on 10/31/2023 at 2:15 p.m. with the Assistant Director of Nursing (ADON), the ADON, who is also the Infection Preventionist (IP), stated the facility does not have a Director of Nursing (DON). The ADON stated not having a full time DON have the potential for the facility to have issues with the quality of care provided to the residents. During an interview on 10/31/2023 at 3:30 p.m. with the Administrator (Adm), the Adm stated the facility does not have a full time DON since August 2023. The Adm stated the facility is actively looking for a DON currently. A review of the facility ' s policies and procedures, titled, Director of Nursing Services, last revised on 8/2006 indicated the Director (DON) is employed full time (40+…

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

Based on interview and record review, the facility failed to provide the resident and the resident representative a written notification for the reason for discharge and the location to which the resident is being transferred or discharged for one of six sampled residents (Resident 1). Resident 1 was transferred to a General Acute Care Hospital (GACH) on 9/14/2023, for evaluation and treatment but was denied the right to return to the facility on the same day, after care at GACH was provided. Upon return from GACH, Resident 1 was considered fully transferred and discharged out of facility displacing Resident 1. This deficient practice prevented Resident 1 the right to return to the facility. Findings A review of Resident 1 ' s admission Record indicated an admission date of 6/10/2023 with diagnoses of encephalopathy (damage or disease affecting the brain), Type ll Diabetes Mellitus (having elevated glucose/sugar levels in the blood), Parkinson ' s disease (brain disorder causing uncontrolled movements such as shaking or difficulty with balance), dysphagia (having difficulty 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.

Based on interview and record review, the facility failed to provide a resident a safe and orderly discharge from the facility by failing to provide the resident and the resident representative a written notification for the reason for discharge and the location to which the resident is being discharged for one of six sampled residents (Resident 1). Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment but was denied the right to return to the facility after care at GACH was provided. Upon return from GACH, Resident 1 was considered fully transferred and discharged out of facility displacing Resident 1. This deficient practice prevented Resident 1 the right to return to the facility. Findings A review of Resident 1 ' s admission Record indicated an admission date of 6/10/2023 with diagnoses of encephalopathy (damage or disease affecting the brain), Type ll Diabetes Mellitus (having elevated glucose/sugar levels in the blood), Parkinson ' s disease (brain disorder causing uncontrolled movements such as shaking or difficulty with balance),…

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

Based on interview and record review, the facility failed to allow a resident to return to the facility after being sent to a General Acute Care Hospital (GACH) for evaluation and treatment for one of ten sampled residents (Resident 1). This deficient practice prevented Resident 1 the right to return to the facility after care at GACH was provided. Findings: A review of Resident 1 ' s admission Record indicated an admission date of 6/10/2023 with diagnoses of encephalopathy (damage or disease affecting the brain), Type ll Diabetes Mellitus (having elevated glucose/sugar levels in the blood), Parkinson ' s disease (brain disorder causing uncontrolled movements such as shaking or difficulty with balance), dysphagia (having difficulty in swallowing), and encounter to for attention to Gastrostomy (a surgically inserted tube, from outside of abdomen directly into the stomach). A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care planning tool) dated 6/14/2023, indicated that Resident 1 was severely impaired with thought process, remembering names 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.

Based on observation, interview and record review, the facility's governing body failed to ensure a licensed Administrator (ADM) was responsible for management of the facility and present at the premises enough hours to permit adequate attention to the facility. The Administrator in Training (AIT) was performing administrative tasks without the presence of the ADM at the facility. As a result, there was an increased risk of inadequate management of the facility and affect the safety and overall well-being of the residents. Findings: On 9/27/2023 at 7:48 a.m., during an observation of the bulletin board, the ADM's license was posted indicating ADM was the ADM of the facility. Registered Nurse 2 (RN 2), present at the time of the observation, stated the ADM was not in the facility. On 9/27/2023 at 8:44 a.m. during an observation, AIT provided RN 1 with the documents the surveyor had requested. On 9/27/2023 at 9:08 a.m. during an interview, Resident 4, who was oriented to person and place, stated he did not know who the ADM was. On 9/27/2023 at 10:05 a.m. during an interview, AIT 1…

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

Based on observation, interview, and record review, the facility failed to implement its infection prevention and control program by leaving a cart dedicated for clean linen open with the clean linen exposed and containing used and soiled items. The cart contained linen and gowns to be used with multiple residents' beds and residents. This deficient practice increased the risk for cross contamination and the spread of infection among residents. Findings: On 9/27/2023 at 8:14 a.m., during an observation of a Clean Linen cart in front of the Central Supply room and concurrent interview with Certified Nursing Assistant 1 (CNA 1), the Clean Linen cart was noted open (content exposed). The cart had a resident's purple shirt, a used hairbrush with hair on it, and a wet paper towel next to the clean bed linens and resident gowns. CNA 1 stated Clean Linen cart should be kept closed and should only have clean supplies to prevent contamination and the spread of infections to residents. CNA 1 stated the laudry staff gives one Clean Linen cart to each CNA to use with their assigned residents.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices by failing to ensure an Occupational Therapist (OT) entering a contact isolation room (are measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident ' s environment) for Clostridium difficile (C-DIFF- inflammation of the colon caused by the bacteria that can be transmitted from person to person by spores) was wearing disposable gowns and gloves while inside the room and performed handwashing with soap and water before leaving the room. These deficient practices had the potential to result in the spread of diseases and infection. Findings: A review of Resident 1 ' s admission Record (face sheet) indicated the facility admitted the resident on 8/11/2023 with diagnoses including urinary tract infection (infection of the bladder), diabetes type 2 (disease when body doesn ' t use insulin properly)…

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

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program for three of five sampled residents (Residents 2, 3, and 4) by: 1. Failing to ensure that the oxygen tubing (a tubing that connects to an oxygen source providing a steady flow of oxygen) for Resident 4 indicated the date it was last changed and was not touching the floor. 2. Failing to ensure the nebulizer (a small machine that turns liquid medicine into a mist) tubing for Resident 4 was placed properly inside the plastic storage bag when not in use and indicated the date it was last changed. 3. Failing to ensure that the catheter tip syringe (a syringe used to flush or clean a catheter or a gastrostomy tube [a tube inserted through the abdomen and into the stomach to provide nutrition and medication] and are also used to administer medications) for Resident 4 was changed timely. These deficient practices had the potential for contamination of residents ' equipment and placed the residents at risk for infection. 4. Failing to ensure that Certified Nursing…

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

Based on interview and record review, the facility failed to ensure that Registered Nurse 1 (RN 1) documented in the medical records, communicated, and provided the discharge summary or instruction to the receiving facility for one (Resident 1) of five sampled residents per facility policy. This deficient practice resulted in incomplete records for Resident 1 and had the potential for a delay in necessary services the resident needs. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 7/4/2023 with diagnoses including muscle weakness, history of falling Alzheimer ' s Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), and left femur fracture (also known as hip fracture or broken hip). A review of Resident 1 ' s History and Physical dated 7/6/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and screening tool) dated 7/8/2023, indicated…

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

Based on interview and record review, the facility: 1. Failed to notify the State Long-Term Care (LTC) Ombudsman (public advocate) of a resident ' s transfer and discharge to another facility for one of five sampled residents (Resident 1). 2. Failed to ensure a written notice of transfer and discharge was provided to the resident or responsible party as soon as practicable for one of five sampled resident (Resident 1). These deficient practices had the potential to deny Resident 1 ' s protection from being inappropriately discharged and being unaware on how to contact the State Long Term Care Ombudsman and on how to appeal the transfer and discharge if necessary. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 7/4/2023 with diagnoses including muscle weakness, history of falling Alzheimer ' s Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), and left femur fracture (also known as hip fracture or broken hip). A review of Resident 1 ' s History…

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

Based on observation, interview and record review, the facility failed to provide the needed care and services that were resident centered for one of two sampled residents (Resident 17) by: 1. Failing to ensure insulin Lispro (a medication used to control blood sugar) with a hold parameter (specific instructions to not give insulin according to the measured blood sugar level) when the blood sugar (BS) was less than 150 was not administered. 2. Failing to notify the physician when the blood sugar was above 349. 3. Failing to clarify a physician's order with an error in the sliding scale (the progressive increase of the insulin dose based on the measured blood sugar level) that resulted in Resident 17 not receiving insulin coverage for a BS between 260 and 299. These deficient practices had the potential for Resident 17 to experience adverse effects of low and high blood sugar levels including sweating, tremor, increased heart rate, confusion, slurred speech, blurred vision, and prolonged wound healing. Findings: A review of the admission record indicated Resident 17 was admitted to…

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

Based on observation, interview, and record review, the facility failed to ensure licensed nurse staff provided disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, for 19 of 98 shifts. This deficient practice had the potential for the facility's inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: During an inspection of Medication cart #1, on 11/5/2021 at 3:21 p.m., with Licensed Vocational Nurse 2 (LVN 2), the Controlled Substance/MAR Change of Shift Audit form was reviewed. LVN 2 verified there were missing entries on the log. The Controlled Substance/MAR Change of Shift Audit form indicated the following: - On 10/03/2021 at 3 p.m., there was a missing entry indicating if count was correct. - On 10/03/2021 at 11 p.m., there was a missing signature for the oncoming charge nurse and missing entry indicating if count was correct. - On 10/04/2021 at 7 a.m., there was a missing signature for the outgoing charge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of six residents (Resident 14 and 27) reviewed for unnecessary medications were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) by failing to: 1. Ensure Resident 14's physician order for Clonazepam (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) PRN (as needed) had a duration. 2. Ensure Resident 27's physician order for Trazadone (medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) PRN had a duration. These deficient practices had the potential to result in adverse reaction or impairment in the residents' mental or physical condition. Findings: a. A review of admission record indicated Resident 14 was admitted to the facility, on 5/01/2017 with a readmission date of 6/23/2021, with diagnoses that included major depressive disorder (a mood…

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 kitchen staff failed to ensure the proper storage, preparation, and distribution of food was done under sanitary conditions for 34 of 34 residents by: 1. Failing to ensure opened food items were labeled with the opened date. 2. Failing to discard expired food stored in the refrigerator that was readily accessible for use in preparing meals. These deficient practices had the potential to result in food borne illness of residents causing symptoms of nausea, vomiting, stomach cramps, and diarrhea. Findings: During an initial observation tour of the facility kitchen and interview with the Dietary Aide (DA), on 11/02/2021 at 08:30 a.m., the following was observed: three opened packages of sliced bread and one opened package of bagels with no label indicating the date opened. The DA stated the bread products were not labeled with the opened date. During an initial observation tour of the facility main kitchen and interview with the Dietary Manager (DM) on 11/02/2021 at 09:00 a.m., the following was observed: 1. In the main kitchen…

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

Based on interview and record review, the facility failed to develop and implement a person-centered care plan for the use of Duloxetine (medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]), for one of 16 sampled residents (Resident 14). This deficient practice had the potential for Resident 14 to not receive the necessary care and services. Findings: A review of the admission Record indicated Resident 14 was admitted to the facility, on 5/01/2017 with a readmission date of 6/23/2021, with diagnoses that included major depressive disorder, anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), and paraplegia (loss of muscle function in the lower half of the body, including both legs). A review of the Minimum Data Set (MDS- an assessment and care screening tool), dated 9/16/2021, indicated Resident 14 had the ability to make self understood and to understand others. A review of Resident 14's physician's orders indicated an order for Duloxetine 30 mg (milligrams- unit of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received oxygen with proper connection and airflow as ordered. In addition, the nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) was not labeled and dated, for one of one sampled resident (Resident 1). These deficient practices had the potential to cause oxygen desaturation (the condition of a low blood oxygen concentration, normal oxygen saturation 95-100%) and contamination of the oxygen tubing. Findings: A review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), atrial fibrillation (irregular rapid heart rate), and anemia (blood has a lower than normal number of red blood cells). A review of the Minimum Data Set (MDS- an assessment and care screening tool), dated 11/1/2021, indicated Resident 1 had the ability to make self understood and to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR) was reviewed to identify and clarify residents' medication for safety for two of six sampled residents (Resident 14 and 27), as evidenced by: 1. For Resident 14, the facility failed to act upon the facility's consultant pharmacist's recommendation for Resident 14's Clonazepam (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) PRN (as needed) order. 2. For Resident 27, the facility's consultant pharmacist failed to identify Resident 27's Trazadone (medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) PRN order that did not have a duration and stop date. These deficient practices had the potential to cause adverse side effects from the continued use of these medications. Findings: a. A review of the admission Record indicated Resident 14 was admitted to the facility, on 5/01/2017 with…

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

Based on observation, interview, and record review, the facility failed to ensure drugs were labeled and stored in accordance with accepted professional principles by: 1. Failing to ensure the drug amlodipine (a medication that lowers blood pressure by relaxing the blood vessels) was labeled with the proper indication (the reason for taking a medication) for Resident 135. This deficient practice had the potential to place the resident at risk for adverse effects of high blood pressure including heart failure and stroke. 2. Failing to ensure the temperature of the refrigerator in the medication storage room was kept within range. This deficient practice had the potential to alter medication potency leading to decreased medication effectiveness for residents. Findings: a. A review of the admission record indicated Resident 135 was admitted to the facility, on 10/14/2021, with diagnoses that included fracture of the right femur and essential (primary) hypertension (high blood pressure with no identifiable cause) A review of the MDS (Minimum Data Set - a standardized assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for two of two sampled residents (Resident 13 and Resident 23) by: 1. Failing to ensure Certified Nursing Assistant 2 (CNA 2) performed proper hand hygiene while providing feeding assistance to Resident 13. 2. Failing to ensure Resident 23's indwelling urinary catheter (a tube inserted into the bladder to drain urine) collection bag and tubing did not touch the floor. These deficient practices placed residents at risk for the transition of infectious diseases. Findings: a. A review of the admission record indicated Resident 13 was admitted to the facility, on 04/26/2021 and re-admitted on [DATE], with diagnoses including Alzheimer's disease (a progressive form of dementia that causes loss of memory) and dysphagia (difficulty swallowing). A review of the Physician History and Physical (H&P), 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.

Based on interview and record review, the facility failed to implement Antibiotic Stewardship (coordinated program that promotes the appropriate use of antimicrobials) by failing to ensure two of three sampled residents (Resident 3, and 24) met criteria for antibiotic use. This deficient practice had the potential to cause adverse side effects and risk for resistance associated with the use of inappropriate antibiotic therapy. Findings: a. A review of the admission Record indicated Resident 3 was admitted to the facility, on 7/28/2021 with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), chronic kidney disease (gradual loss of kidney function), and hypertension (high blood pressure). A review of the Minimum Data Set (MDS- an assessment and care screening tool), dated 8/01/2021, indicated Resident 3 had the ability to make self understood and the ability to understand others. During a concurrent interview and record review, on 11/05/2021 at 12:24 p.m., with the Infection Preventionist (IP), Resident 3's Report of…

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

Based on interview and record review, the facility failed to provide dementia (brain disease causing memory problems) care/management training upon hire for Certified Nursing Assistant 1 (CNA 1). This deficient practice had the potential to place elderly residents with dementia at risk for harm due to lack of sufficient staff training. Findings: During an interview, on 11/03/2021 at 02:22 p.m., CNA 1 stated she had been working at the facility for about three months. During a concurrent review of CNA 1's personnel file and interview, on 11/04/2021 at 09:35 a.m., the Director of Staff Development (DSD) stated she was aware that dementia care training must be completed upon hire, but there was no documented evidence that dementia care/management training was completed for CNA 1 when she was hired in 09/2021. During a concurrent review of CNA 1's personnel file and interview, on 11/05/2021 at 10:06 a.m., the Director of Human Resources (DHR) stated dementia care training was done by the DSD. The DHR stated the DSD used a checklist for orientation. The DSD stated the CNA's training…

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.