Gold Country Health Center

Based on observation, interview, and record review, the facility failed to maintain privacy for one of 26 sampled residents (Resident 82), when Resident 82's urinary catheter (a tube left in the bladder to continuously drain urine into a collection bag) collection bag had no privacy cover. This failure decreased the facility's potential to maintain Resident 82's dignity.Findings:A review of Resident 82's admission Record, indicated she was admitted to the facility in August 2025 with diagnoses including acute cystitis (bladder infection) and neuromuscular dysfunction of the bladder (a condition in which the nerves controlling the bladder and urinary sphincter are damaged, leading to problems with urine storage and emptying).A review of Resident 82's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/3/25, indicated her Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was 12 out of 15 with moderate memory impairment.A review of Resident 82's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately assess one of 26 sampled residents (Resident 5), when the Minimum Data Set (MDS, a federally mandated assessment tool) inaccurately indicated Resident 5 had no pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence).This failure had the potential to incorrectly recognize Resident 5's care needs.Findings:A review of an admission record indicated Resident 5 was admitted to the facility in November 2023 with a diagnosis of pressure ulcers. During an observation on 9/7/25 at 9:44 a.m. inside Resident 5's room, a wound vacuum assisted closure device (wound VAC, a negative pressure wound treatment that uses suction to help hard to heal wounds heal faster) was observed at the side of Resident 5's bed in continuous operation.A review of Resident 5's Order Summary Report, dated 7/10/25, indicated Resident 5 had treatment orders for two stage four pressure ulcers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodate the needs of one of 26 sampled residents (Resident 76), when Resident 76 was not given a shower as scheduled.This failure decreased the facility's potential to provide comfort to residents.Findings:A review of an admission record indicated Resident 76 was admitted to the facility in September 2025 with a diagnosis of right femur (thigh bone) and vertebra (backbone) fracture.During an interview on 9/7/25 at 9:24 a.m. with Resident 76, Resident 76 stated she felt uncomfortable because she had not taken a shower since her admission to the facility.A review of the facility's Skilled Nursing Shower Assignment, updated on 8/18/25, indicated Resident 76 was scheduled to have morning showers on Monday, Wednesday and Friday.During an interview on 9/10/25 at 9:45 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated residents were assisted with showers in the morning per their schedule. CNA 2 further stated CNAs must complete a shower tracking sheet and document it in the computer to let the Licensed Nurse (LN)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care of respiratory equipment was consistent with the facility's policy and professional standards of practice for one of 26 sampled residents (Resident 10), when Resident 10's nebulizer tubing and nasal cannula (a thin, flexible tube that goes around your head and into the nose and gives additional oxygen through the nose) were not changed after seven days.This failure decreased the facility's potential to provide safe respiratory care for Resident 10.Findings:A review of an admission record indicated Resident 10 was admitted to the facility in February 2024 with a diagnosis of respiratory failure with hypoxia (insufficient amount of oxygen in the body's tissues).A review of Resident 10's Order Summary Report, dated 7/30/25, indicated an order for oxygen via nasal cannula to keep oxygen saturation at 92 percent.During a concurrent observation and interview on 9/7/25 at 9:32 a.m. with Licensed Nurse 1 (LN 1) in Resident 10's room, a nebulizer machine with tubing/mouthpiece (a machine that turns…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promote dignity for one of three sampled residents (Resident 2), when the resident was not provided shower for five days. This failure had the potential to result in Resident 2 ' s not attaining her feelings of self-worth and self-esteem. Findings: Resident 2 was admitted to the facility in spring 2025 with diagnoses which included spinal stenosis (narrowing of the spine), weakness, gait (walking) and mobility (moving) abnormalities, and lower back pain. During a review of Resident 2 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 6/6/25 , the MDS indicated Resident 2 required assistance with activities of daily living (ADLs), including bathing. During a concurrent observation and interview on 6/12/25 at 9:40 a.m. with Resident 2 in Resident 2 ' s room, Resident 2 was awake, alert and verbally responsive, and stated, I voiced my concern about not getting a shower quite a bit to the CNA ' s (Certified Nursing Assistant). My hair was so matted and dirty it didn ' t make me feel…

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

Based on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. The microwave in the kitchen was not clean; 2. Several various sizes of metal sheet pans were stacked wet stored at the clean and ready-to-use storage areas; 3. Produce items were not fresh and not discarded; and, 4. One dishwasher was not able to verbalize the procedure for the manual dishwashing with 3-compartment sinks correctly. These failures had potential to cause food-borne illness in a highly susceptible population of 59 out of 59 residents who received food from the kitchen. 1.During a concurrent observation and interview with Dietary Supervisor (DS) on 9/23/24 at 8:48 a.m. at the kitchen's initial tour, the microwave was observed to have dry liquid splashes on the interior top of the microwave. The DS confirmed the microwave was dirty and stated the dry food splashes and dry food debris should be cleaned. During a review of a facility document titled, Section 8- Sanitation, 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 observation and interview, the facility was unable to provide a clean environment for the residents and visitors when three of three garbage dumpsters, located outside the facility, was not closed securely due to deformed dumpster lids. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During a concurrent observation and interview with Dietary Supervisor (DS) on 9/23/24 at 8:38 a.m outside, three out of three dumpsters were covered with bent and deformed lids with bags of trash inside the bins. There were gaps between the deformed lids and the bins because the lids lacked integrity to securely cover the bins. DS confirmed the condition of the dumpster lids and agreed that the facility needed to order new trash bins. The DS further acknowledged that the lids needed to be closed tightly to prevent pest issues. During a review of facility policy and procedure titled, Miscellaneous Areas, last revised 2023, indicated, 1. All food waste must be placed 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 observation, interview, and record review, the facility failed to ensure the menu was being followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) for lunch meals on 9/23/24 and 9/24/24 when: 1. Resident 257 with dysphagia (difficulty swallowing) mechanical texture diet (a diet that consist of foods that are moist, mechanically altered, easily mashed) who: a. Received puree zucchini instead of chopped and mashable zucchini on 9/23/24 lunch meal b. Received puree apple bread pudding instead of bread pudding chopped into half inch (1/2) and soak in milk on 9/24/24 lunch meal 2. Resident 21 with CCHO (controlled carbohydrate) diet (a diet to control blood sugar level) received one slice of garlic breadstick instead of one half of garlic breadstick on 9/23/24 lunch meal. 3. Resident 20 with finger food diet (a diet that provides food in appropriate size and shape to be eaten without utensils) who received regular…

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

Based on observation, interview, and record review the facility failed to provide a homelike environment for one of 15 sampled residents (Resident 42), when the chain that is used to turn on Resident 42's overhead light was broken and unreachable. This failure had the potential to result in Resident 42 not experiencing a homelike environment which can negatively impact his psychosocial well-being. Findings: A review of Resident 42's admission Record, indicated he was admitted in early September 2024 with diagnoses including depression. During a concurrent observation and interview on 9/24/24 at 8:49 a.m., in Resident 42's room, the chain attached to the overhead light to turn it on and off was broken, approximately three inches long. Resident 42 stated the chain had been broken since admission, which prevented him from turning the light on or off and limited him to do simple things on his own. During a concurrent observation and interview on 9/25/24 at 9:24 a.m. with Licensed Nurse 1 (LN 1) in Resident 42's room, LN 1 acknowledged the chain was too short for Resident 42 to reach 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 a Significant Change in Status Assessment (SCSA, an assessment that indicates a major decline or improvement in the resident's status) was completed for one of 15 sampled residents (Resident 45), when Resident 45 developed a stage four pressure ulcer (PU, deep wound reaching the muscles, ligaments, and bones) to the left sacrum (triangular bone, back portion of the pelvis). This failure decreased the facility's potential to provide appropriate care and services to Resident 45 based on her status. Findings: A review of Resident 45's admission Record, indicated she was admitted to the facility in August 2024 with diagnoses including morbid obesity and diabetes (chronic disease when the body can't produce insulin to control blood sugar). During an observation on 9/23/24 at 8:50 a.m., Resident 45 was observed with a wound vacuum (a device that uses suction to help wounds heal) attached to her lower back. A review of Resident 45's Change in Condition note, dated 7/5/24, indicated Resident 45 developed a stage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Minimum Data Set (MDS, an assessment tool used for care) accurately reflected the status of one of 15 sampled residents (Resident 45), when Resident 45's pressure ulcer (PU, an injury that breaks down the skin and underlying tissue) was not coded accordingly. This failure had the potential for Resident 45 to receive inadequate wound care management. Findings: A review of Resident 45's admission Record, indicated Resident 45 was admitted in August 2024 with diagnoses including morbid obesity and diabetes (chronic disease when the body can not produce insulin to control blood sugar). A review of the facility's census, indicated Resident 45 was sent to the hospital on 8/23/24 for an infection and was readmitted back to the facility on 8/29/24. A review of Resident 45's MDS Discharge Assessment, dated 8/23/24, indicated she had a stage four PU to the left sacrum (triangular bone at the back of pelvis). A review of Resident 45's Skin Observation Sheet, conducted on 8/29/24 upon readmission to the facility, 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 observation, interview, and record review the facility failed to develop a comprehensive person-centered care plan for one of 15 sampled residents (Resident 208), when Resident 208's care plan did not address the use of a leg immobilizer. This failure had the potential for Resident 208's order to be missed and not implemented. Findings: A review of Resident 208's admission Record, indicated she was admitted in September 2024 with diagnoses including pathological fracture of the right distal femur (lower end of right thigh bone). During an observation on 9/23/24 at 1 p.m., Resident 208 was observed seated in the wheelchair wearing a right leg immobilizer. During a concurrent interview and record review on 9/25/24 at 11:30 a.m. with Licensed Nurse 1 (LN 1), Resident 208's care plan was reviewed. LN 1 stated she could not find a care plan that addressed Resident 208's use of a leg immobilizer. During an interview on 9/25/24 at 2:10 p.m. with the Director of Nursing (DON), DON acknowledged that a care plan was not developed for Resident 208's use of a leg immobilizer. DON…

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

Based on observation, interview, and record review the facility failed to provide services which meet professional standards of quality for one of 15 sampled residents (Resident 208), when Resident 208 was allowed to use a right knee/leg immobilizer without a physician's order. This failure increased Resident 208's potential to use a knee/leg immobilizer without a physician order. Findings: A review of Resident 208's admission Record, indicated she was admitted in September 2024 with diagnoses including pathological fracture of the right distal femur (lower end of right thigh bone). During an observation on 9/23/24 at 1 p.m., Resident 208 was observed seated in the wheelchair wearing a right knee/leg immobilizer. During a concurrent observation and interview on 9/23/24 at 4:18 p.m. with Treatment Nurse 1 (TN 1), TN 1 confirmed Resident 208 had been using the right knee/leg immobilizer since her admission. During a concurrent interview and record review on 9/25/24 at 11:30 a.m., with Licensed Nurse 1 (LN 1), Resident 208's Order Summary Report was reviewed. LN 1 stated Resident 208…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an ancillary service was provided to one of 15 sampled residents (Resident 42), when Resident 42 was not assisted to use his hearing aids (HAs) daily as ordered. This failure increased Resident 42's inability to hear clearly and communicate properly. Findings: A review of Resident 42's admission Record, indicated Resident 42 was admitted to the facility in September 2024 with diagnoses including weakness of upper extremities and cerebral infarction (stroke, blood flow to the brain is blocked). During a concurrent observation and interview on 9/23/24 at 3:12 p.m. with Resident 42, a morning routine instruction was posted near Resident 42's bed which included assisting Resident 42 put on his HAs daily. Resident 42 was observed not wearing his HAs. Resident 42 stated staff did not help him and he was not able to put the HAs on his own due to weakness. A review of Resident 42's Order Summary Report, dated 9/21/24, indicated Resident 42 was to wear HAs in the morning and take them off at night. During 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.

2. A review of Resident 15's admission Record, indicated Resident 15 was admitted in May 2024 with diagnoses including complete paraplegia (inability to move lower body from waist down), weakness, and presurre ulcer on the sacral region (lower back between hip bones). A review of Resident 15's Minimum Data Set (MDS; an assessment tool), dated 8/30/24, indicated presence of a stage three pressure ulcer on the sacral region. During a concurrent observation and interview on 9/24/24 at 11:28 a.m. with LN 3, Resident 15's room was observed. There was no sign on the door indicating EBP. LN 3 checked the personal protective supplies in the lower drawer of Resident 15's dresser as per facility practice and no supplies were available. LN 3 agreed EBP sign and PPE supplies were missing. During an interview on 9/26/24 at 10:30 a.m. with DON, DON stated staff should have placed EBP sign on the door and supplies in bottom drawer of Resident 15's dresser. DON stated missing EBP sign and protective supplies increased the risk of spreading infection to Resident 15, other residents, and staff.…

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

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of 15 sampled residents (Resident 18). This failure decreased Resident 18's potential to get assistance from staff in a timely manner when needed. Findings: A review of Resident 18's admission Record, indicated Resident 18 was admitted to the facility in February 2023 with diagnoses including dementia (impaired ability to remember, think, or make decisions) and need for assistance with personal care. During a concurrent observation and interview on 9/23/24 at 9:23 a.m. with Certified Nursing Assistant 1 (CNA 1), Resident 18 was observed sitting in a chair next to her bed. Resident 18's call light was clipped to the head side of mattress in bed and behind Resident 18. CNA 1 confirmed Resident 18's call light was out of reach. CNA 1 stated the call light was supposed to be in front of Resident 18 and within her reach. During an interview on 9/26/24 at 10:40 a.m. with Director of Nursing (DON), DON stated the call light placed out of reach for Resident 18 might have…

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

Based on interview and record review the facility failed to follow the professional standards of practice for one of three sampled residents (Resident 1) when required documentation in the resident's chart was not completed timely. This failure decreased the facility's potential to provide complete and accurate nursing care for Resident 1. Findings: According to the Resident 1's face sheet, Resident 1 was admitted in late 2023, with diagnosis that include respiratory failure and coronavirus disease. During a record review on 9/10/24 at 10:36 a.m., progress notes in Resident 1's chart indicated that Resident 1 was transferred to the hospital due to a significant change in condition. Upon further review a COC (change of condition) form, a hospital transfer form and family notification were not found. During an interview on 9/10/24 at 12:44 p.m., with Licensed Nurse (LN), the LN stated that if a resident had a change of condition, she stated I would inform the doctor and family, fill out a COC form ., and transfer to the hospital form. During a concurrent interview and record review on…

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

Based on interview and record review the facility failed to ensure physician's orders were implemented for one of five sampled residents (Resident 1) when an order for a topical (used on the skin) cream used for pain was not entered from the hospital orders into Resident 1's medication orders. This failure resulted in Resident 1 not having access to her topical pain cream. Findings: Resident 1 was admitted to the facility late 2023 with diagnoses which included respiratory failure and muscle weakness. During a review of Resident 1's AFTER HOSPITAL CARE, dated 12/13/23, the document indicated, Medication List .MISCELLANEOUS CREAMS TOPI (sic) Apply to the affected area if needed [arthritis pain]. Indications: arthritis pain [brand name of cream, over the counter used for pain]. During a review of Resident 1's Order Summary Report [OSR], dated 12/13/23, the OSR does not have (brand name of cream) listed as an order. During a review of Resident 1's Progress Notes [PN], Type: NURSE PROGRESS NOTE, dated 12/17/23 at 6:02 a.m. the PN indicated, Resident c/o [complains of] pain to neck 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 provide a qualified activities director to direct their activities program for a census of 59. This failure potentially placed the residents at risk for decreased physical, mental, and psychosocial well-being. Findings: During an interview on 2/7/24 at 10:55 a.m., with the Activity Director (AD), the AD stated . started a course in November 2023, but it's a 1-year program . there is no activities director consultant overseeing the program . the administrator oversees the program . During a concurrent record review and interview on 2/7/24 at 11:51 a.m., with the facility Administrator (Admin), a previous Plan of Correction (POC, plan to correct previous deficiency) for intakes(s) CA00870126; CA00870644, regarding allegations of an unqualified AD, were reviewed. The POC, dated 12/18/23, stated Currently we employ a certified activities director for consultation and supervision oversight of the activities director and programs. The Admin stated .the activity director consultant isn't overseeing the program yet and will start…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services according to professional standards of quality for four of seven sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4), when doses of antibiotics (medicine that fights bacterial infection) were missed and/or not administered intravenously (IV; into the vein) on time as indicated in physician's orders. This failure increased the residents' potential to have unmet health needs. Findings: 1. A review of an admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute cystitis (bladder infection) and urinary tract infection (UTI). A review of a record titled, IV Administration, dated 12/23, indicated one gram (a unit of measure) of ertapenem (an antibiotic) to be administered to Resident 1 one time a day for UTI for five days. A review of Resident 1's Location of Administration Report, dated 1/3/24, indicated the 8 a.m. scheduled dose of ertapenem was administered on 12/30/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 qualified activities director for their activities program for a census of 61. This failure potentially placed the residents at risk for decreased physical, mental, and psychosocial well-being. Findings: During an interview on 11/21/23 at 12:56 p.m., with the Activity Director (AD), AD stated . This is my first job as an activities director I don ' t have my state certification . I have not done my training course yet . AD stated that she is aware she needs the state certification and is currently looking into state training courses. During a concurrent record review and interview on 11/21/23 at 2:22 p.m., with the facility Administrator (Admin) and Director of Nursing (DON), the AD 's personnel file was reviewed and no documentation of activity qualifications was seen. Admin stated, I don't know how long she has worked in activities and there is no way for me to check . After reviewing the file the Admin stated . there is no evidence in her file of her experience in activities . During a phone interview on…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, when: 1) One dietary aide did not use appropriate handwashing during food handling; 2) The ice machine was not cleaned and sanitized correctly; 3) Two kitchen staff did not wear hair restraints in the food prep area; 4) Nineteen various size metal pans were found wet or dirty, stacked in the ready to use shelves; 5) Nine dry goods were not sealed or dated in the dry storage area; 6) Eleven cartons of supplement shakes (drinks that provide additional nutrients) were not dated with the correct use by date; and 7) The microwave in the resident's nutrition room was dirty. These failures had the potential to lead to food-borne illnesses. Findings: 1) During the initial kitchen tour on 8/21/23 at 8:52 a.m. Dietary Aide (DA 1) was observed not washing hands in between tasks multiple times when she touched dirty dishes with bare hands, then touched clean dishes, and placed clean gloves on when: a. At 8:52…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and complete a comprehensive person-centered care plan for one out of 19 sampled residents (Resident 19). This failure had the potential for Resident 19 to not receive appropriate care, services, and treatment. Findings: A review of Resident 19's medical record indicated she was admitted to the facility on [DATE] with diagnoses including bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). A review of Resident 19's medical record indicated the following active physician's orders for psychotropic (drugs that affects brain activities associated with mental processes and behaviors) medications: - Lorazepam (a medication to treat anxiety) 0.5 milligrams (mg, a unit of measure): 1 tablet two times a day, dated 5/26/23; - Lorazepam 1 mg: 1 tablet at bedtime, dated 5/26/23; - Lorazepam 0.5 mg: 1 tablet every 12 hours as needed for breakthrough anxiety/agitation related to bipolar disorder,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for two out of two residents (Residents 21 and 303) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents; 2. Have an efficient system in place to accurately document and secure emergency medications (E-Kit) for a census of 52; 3. Store discontinued controlled medications in accordance with facility policy and procedure (P&P); and, 4. Ensure medications were safely administered to two out of four sampled residents (Residents 3 and 13). These failures resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications, the potential…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 19 sampled residents (Resident 19 and Resident 202) were free of unnecessary medications when: 1. Resident 202 was prescribed three psychotropic (a drug that affects behavior, mood, thoughts, or perception) medications without adequate indication and behavior monitoring, a PRN psychotropic had no end date and consent was not obtained prior to its administration; and 2. Resident 19 was prescribed four psychotropic medications without adequate side effect and behavior monitoring. These failures placed the residents at risk for use of unecessary psychotropic medications. Findings: 1. A review of Resident 202's admission record indicated she was admitted in 8/23 with diagnoses including anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities) and depression. A review of Resident 202's clinical record included the following documents: 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 had a 32.26% error rate when ten medication errors out of 31 opportunities were observed during a medication pass for three out of four residents (Residents 3, 13 and 47). This failure resulted in medications not given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions. Findings: During a medication pass observation on 8/21/23 at 8:33 a.m. with Licensed Nurse 2 (LN 2), LN 2 was observed preparing three medications, including metoprolol succinate (a medication to treat high blood pressure) ER (ER, a long acting formulation) 50 milligrams (mg, a unit of measurement), magnesium oxide (a mineral to treat heartburn) 400 mg, and lisinopril (a medication to treat high blood pressure) 10 mg for Resident 47. LN 2 took Resident 47's blood pressure but did not measure the resident's heart rate. A review of Resident 47's medical record indicated the following physician's orders: - Metoprolol succinate ER 50 mg: 1 tablet one time a day for HTN (hypertension, high blood pressure).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: - Medication carts were kept securely locked when left unattended; - Opened biologicals, multi-dose inhalers, and inhalation solutions were dated with an open and discard date to ensure they were not used beyond the discard date; - Medication was appropriately labeled with a pharmacy label or name to correctly identify which resident they were for; and - Expired and discontinued medications were not available for resident use. The deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their discard date or improper storage, and diversion or misuse of medications from not being securely stored in medication carts. Findings: During an observation on [DATE] at 8:29 a.m., the medication cart (med cart) was observed unlocked and unattended facing a resident's room. During a second observation on [DATE] at 8:34 a.m. with Licensed Nurse 2 (LN 2), LN 2 left the med…

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

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diets (a modification of a regular diet, to fit the residents nutritional needs) during the lunch meal on 8/22/2023 when nine residents (Residents 9, 18,20,23,31,43,203, 205 and 305) did not receive the correct dessert. These failures had the potential to result in compromising the medical and nutritional status of nine residents for a census of 52. Findings: During an observation of lunch meal service on 8/22/23, beginning at 12:15 p.m., it was noted seven residents (Residents 18,20,23,31,43,203, and 205) received fresh fruit as a substitute for the diet apple square for dessert on the menu. Resident 305 received fresh fruit instead of the regular glazed apple square for dessert. Resident 9 received puree regular apple square instead of puree diet apple square. A review of residents' meal tickets on 8/22/23 for lunch indicated eight residents (Residents 9, 18, 20, 23, 31, 43, 203, and 205) were on therapeutic diets of CCHO (controlled carbohydrate diet, a diet…

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

3. During an observation on 8/21/23 at 8:33 a.m. with Licensed Nurse 2 (LN 2), LN 2 used a blood pressure cuff to measure Resident 47's blood pressure. After the resident's blood pressure was taken, LN 2 removed the cuff and placed it on the top of the medication cart without sanitizing and disinfecting it. LN 2 was observed taking the blood pressure of Resident 3 and Resident 13 without sanitizing or disinfecting in-between uses. 4. During a medication pass observation on 8/21/23 at 9 a.m. with LN 2, LN 2 was observed administering medications to Resident 13. LN 2 placed Resident 13's medication cup on her bedside table then touched her own hair and glasses. LN 2 left the room to prepare applesauce for Resident 13 and returned to the resident without performing hand hygiene. During an interview on 8/21/23 at 12:09 p.m. with LN 2, LN 2 confirmed she did not sanitize and disinfect the blood pressure cuff that was used earlier on multiple residents. When asked if she performed hand hygiene after touching her hair or glasses in the middle of performing direct resident care she stated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reasonably accommodate the needs of two of 19 sampled residents (Resident 22 and Resident 31) when their call lights were not within reach. This failure had the potential to result in residents being unable to request assistance when needed. Findings: In a concurrent observation and interview, on 8/21/23 at 9:49 a.m., Resident 31 was lying asleep in bed and her call light was on the floor approximately three feet away. Certified Nursing Assistant 4 (CNA 4) confirmed the call light was on the floor and out of Resident 31's reach. In a concurrent observation and interview, on 8/21/23 at 10:20 a.m., Resident 22 was asleep in bed and his call light was not seen. When asked where the resident's call light was, CNA 3 stated she did not know and went to the resident's bedside table where she removed a manilla folder and 2 boxes of tissues and found it coiled beneath them. CNA 3 confirmed the call light was not within Resident 22's reach. In an interview, on 8/24/23 at 11:07 a.m., the Director of Nursing (DON) stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST) form for one resident (Resident 29) of 19 sampled residents was valid in the electronic health record (EHR). This failure decreased the staff's potential to safely follow Resident 29's POLST during emergencies. Findings: A review of an admission record indicated Resident 29 was initially admitted to the facility in [DATE] and readmitted in [DATE] with diagnoses including sepsis (blood infection; a life-threatening medical emergency). A review of Resident 29's POLST, dated [DATE], indicated if Resident 29 had no pulse and was not breathing Do Not Attempt Resuscitation/DNR (Allow Natural Death). A review of Resident 29's Order Summary Report, dated [DATE], indicated to attempt cardiopulmonary resuscitation (CPR) for Resident 29. During an interview on [DATE] at 2:36 p.m. with Licensed Nurse 3 (LN 3), LN 3 stated, if a resident had no pulse and was not breathing she would check the EHR's…

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

Based on interview and record review, the facility failed to timely submit an MDS (Minimum Data Set, an assessment tool) for one of 19 sampled residents (Resident 24) when a discharge MDS from 4/23 had not yet been submitted. This failure had the potential to result in incomplete information being submitted to CMS (Centers for Medicare and Medicaid Services). Findings: A review of Resident 24's admission record indicated she was admitted to the facility in 3/23 and discharged on 4/6/23. In an interview, on 8/24/23 at 10:58 a.m., the Assistant Director of Nursing (ADON) confirmed Resident 24's discharge MDS had not yet been submitted to CMS and was overdue. In an interview, on 8/24/23 at 11:16 a.m., the Director of Nursing (DON) stated she expected staff to follow the required timeframes for MDS submission. A review of the facility's policy titled, MDS Completion and Submission Timeframes, revised 7/17, indicated the facility would conduct and submit resident assessments in accordance with current federal and state submission timeframes as published in the Resident Assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and complete a baseline care plan (BCP) within 48 hours of admission for one resident (Resident 29) of 19 sampled residents. This failure decreased the facility's potential to communicate the initial plan of care with residents, promote their continuity of care, and increase their safety. Findings: A review of an admission record indicated Resident 29 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including sepsis (blood infection; a life-threatening medical emergency). During a concurrent interview and record review on 8/24/23 at 10:25 a.m. with the Director of Nursing (DON), Resident 29's BCPs were reviewed. DON confirmed Resident 29 had no BCP after she was initially admitted on [DATE], and the BCP dated 7/12/23, was incomplete after she was readmitted . DON stated the BCP should have been initiated by the nursing supervisors upon Resident 29's admission, completed by other departments, and 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.

Based on interview and record review, the facility failed to revise care plans at least quarterly for one of 19 sampled residents (Resident 31) when her risk for pressure ulcer and risk for incontinence care plans had not been revised since 4/19/23. This failure had the potential to result in unmet nursing needs for Resident 31. Findings: A review of Resident 31's admission record indicated she was admitted in 1/23 with diagnoses including Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar) and unspecified urinary incontinence (lack of voluntary control over urination). A review of Resident 31's clinical record included the following documents: A Prevention of Pressure Ulcer Risk Care Plan, initiated 1/19/23, was last revised 4/19/23. A Risk for Incontinence Care Plan, initiated 1/19/23, was last revised 4/19/23. In an interview, on 8/23/23 at 9:30 a.m., the Assistant Director of Nursing (ADON) stated resident care plans were updated at least quarterly and confirmed Resident 31's incontinence and risk for pressure ulcer care plans had not been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide baths/showers as scheduled for two out of 19 sampled residents (Resident 16 and Resident 13) when Resident 16 and Resident 13 did not have a shower as scheduled. These failures had the potential to decrease cleanliness and comfort for the residents. Findings: During a review of the admission Record, Resident 16 was first admitted to the facility on [DATE], with diagnoses including lower spine fracture and abnormal gait and mobility (the pattern and way a resident walks). A review of a Minimum Data Set (MDS, a standardized assessment tool) dated 8/23/23, indicated Resident 16 required extensive assistance with bathing. A review of the Census List, Resident 16 was in the facility on 7/6/23 to 8/14/23, and was readmitted on [DATE] to present date. During a review the Shower Schedule, Resident 16 was on a Wednesday and Saturday day-time shower schedule. During an interview on 8/21/23 at 10:03 a.m., Resident 16 stated she would like…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 honor food preferences during the lunch meal on 8/22/23 for two sampled residents (Resident 12 and Resident 8) out of a census of 53 when; 1. Resident 12 was served a whole slice of turkey even though ground meats was documented on Resident 12's meal card; and, 2. Resident 8 was served fresh fruit as a dessert instead of the regular dessert which was documented on Resident 8's meal card. This failure increased the potential for Resident 12 and Resident 8 to have an unpleasant dining experience and had the potential to result in altered nutrition. Findings: A review of Resident 12's admission Record indicated, Resident 12 was admitted in Summer 2023 with multiple diagnoses which included dysphagia (difficulty swallowing). An observation of lunch tray line, Resident 12 was served a whole slice of turkey by the dietary aide (DA 1). DA 1 was then observed plating the next resident's tray. A review of Resident 12's meal ticket (a ticket including resident's diet, date, allergies, specific food and beverage items,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document and communicate the necessary information for a hospital transfer for one resident (Resident 29) of 19 sampled residents, when Resident 29's Interact SBAR [Situation-Background-Assessment-Recommendation] Communication Form was not completed. This failure decreased the facility's potential to prevent delayed care for transferred residents. Findings: A review of an admission record indicated Resident 29 was initially admitted to the facility on [DATE], transferred to the hospital on 7/6/23, and was readmitted to the facility on [DATE] with diagnoses including sepsis (blood infection; a life-threatening medical emergency), hypotension (low blood pressure), pneumonitis (lung inflammation) due to inhalation of food and vomit, acute kidney failure, and urinary tract infection (UTI). A review of Resident 29's Minimum Data Set (MDS; an assessment tool), dated 7/18/23, indicated the Brief Interview of Mental Status (BIMS) score was 10 with some memory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a pneumococcal vaccine (a vaccine to prevent infection of one or both lungs) for one of 19 sampled residents (Resident 32) when Resident 32 did not receive a pneumococcal vaccine when it was due. This failure had the potential to increase the chance of Resident 32 getting a lung infection. Findings: Review of the admission Record, Resident 32 was over [AGE] years old and admitted to facility on 2/13/23, with diagnoses including pneumonia (infection of the lung) and respiratory failure. During a concurrent interview and record review on 8/23/23 at 1:42 p.m., the Infection Preventionist (IP) confirmed Resident 32 gotten a previous pneumococcal in 2020 and stated the next dose is due. The IP further stated the family member verbally consented for the vaccination and confirmed there was no documentation requesting an order from the physician. Review of the facility's document titled, Pneumococcal and Annual Vaccine Information and Request, 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 provide education regarding risks and benefits associated with COVID-19 (Coronavirus Disease, an infection affecting the lungs) vaccination for one of 19 sampled residents (Resident 35) when Resident 35 did not receive the risks and benefits education upon refusal of a COVID-19 vaccination. This failure had the potential to decrease the chance of Resident 35 getting a COVID-19 vaccination. Findings: On review of the admission Record, Resident 35 was admitted to facility on 3/28/23, with diagnoses including COVID-19. During a concurrent interview and record review on 8/23/23 at 1:59 p.m., the Infection Preventionist (IP) confirmed there was no documentation of education on the risks and benefits of COVID-19 when Resident 35 refused the vaccination. There was no documentation of COVID-19 consent upon request from the IP. Review of the facility's policy titled, Coronavirus Disease (COVID-19) - Vaccination of Residents, dated 11/2021, indicated, .The resident is provided with education regarding the benefits, risks, 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.