The Pines at Placerville Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain room temperature at a comfortable and safe level for four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) out of a census of 88, when: 1. Resident 1 ' s, Resident 2 ' s, Resident 3 ' s, and Resident 4 ' s room temperatures were below 71 degrees Fahrenheit (°F; a unit of measure); and 2. The maintenance department did not provide alternative heat sources after the heating, ventilation, and air conditioning (HVAC) system broke. These failures increased the residents ' potential for discomfort and loss of body heat. Findings: 1. During an observation on 12/10/24 at 9:59 a.m., rooms [ROOM NUMBER] were located in the facility ' s back hallway. The rooms and hallway were cold. During a concurrent observation and interview on 12/10/24 at 11:30 a.m. with the Maintenance Director (MD), room temperatures were checked in rooms 33-35. MD stated the room temperatures were too low for the residents ' comfort 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 store, prepare, and distribute food in accordance with professional standards for food service safety, when: 1. Two dietary staff had facial hair were not covered; 2. Juice machine was not clean; 3. Several various sizes of kitchen utensils were stacked wet stored at the clean and ready-to-use storage areas; 4. The raw shelled eggs were not pasteurized in the walk-in refrigerator; and 5. One dietary aide was not able to demonstrate and verbalize the correct process of manual dishwashing by using three-compartment sink. These failures had the potential to cause food borne illness in a medically vulnerable 88 out of 91 residents who consumed food in the facility. Findings: 1. During the initial tour in the kitchen on 10/21/24 at 8:42 p.m., observed Dietary Aide (DA) with beard but was not covered with any restraint. A follow up observation was conducted at 10:04 a.m., observed Dietary Supervisor (DS) with beard and side burn hair without any restraint. During a concurrent interview with DS, he confirmed DA and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure controlled substance medications (medications that the use and possession of are controlled by the federal government) for four residents (Resident 33, Resident 37, Resident 51, and Resident 73) of a census of 91 were accurately accounted on the Medication Administration Record (MAR) and Controlled Drug Record (CDR). This failure decreased the facility's potential to ensure accurate accountability for residents' controlled medications and prevent its misuse. Findings: A review of an admission record indicated, Resident 33 was admitted to the facility on [DATE] with a diagnosis of chronic pain syndrome. A review of Resident 33's Order Summary Report, dated 10/22/24, indicated an order for hydrocodone-acetaminophen (an opioid medication used to treat pain) 5/325 milligrams (mg; a unit of measurement), two tablets every four hours as needed for severe pain and one tablet every four hours as needed for moderate pain. A review of Resident 33's CDR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (%) for four residents (Resident 3, Resident 38, Resident 55, and Resident 67) of a census of 91, when seven medication errors out of 39 opportunities were observed during medication pass. This failure resulted in medication error rate of 17.95% for the facility. Findings: A review of an admission record indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses including gastro-esophageal reflux disease (GERD-a condition in which stomach acid flows back into the tube connecting the mouth and stomach) and glaucoma (increased eye pressure that can cause blindness). During a medication pass observation on 10/21/24 at 8:24 a.m., Licensed Nurse 1 (LN 1) was observed administering the following medications to Resident 3: 1. One capsule of delayed release omeprazole (a medication used to treat conditions with too much acid in the stomach) 20 milligrams (mg-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 the menu was followed for the therapeutic diet during the lunch meals on 10/21/23 and 10/22/23 when: A. Dining observation on 10/21/24: 1. Two residents (Resident 18 and 58) with consistent or controlled carbohydrate (CCHO) diet (diet for people need to control their blood sugar or to manage diabetes) received one slice of garlic bread instead of half (1/2) slice; 2. Resident 35 with dysphagia mechanical (DM) texture diet (diet for people with trouble chewing, swallowing, or fully breaking down food and usually ground, pressed, or strained to pudding like consistency) with thin liquids (regular liquid consistency) received pudding instead of ice-cream as dessert, and 3. Resident 54 with finger food (FF) diet (diet that provides food in appropriate size and shape to be eaten without utensils but rather with fingers, it allows residents to maintain independence, dignity, and quality of life) received spaghetti instead of bowtie or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodate the food preferences (food items under the standing order) on the meal tickets (tickets including resident's diet, date, allergies, specific food and beverage items, dislikes, likes) for five residents (Resident 1, 2, 4, 8, and 81) out of 88 residents who received meals from the facility's kitchen. These deficient practices had the potential to result in meal dissatisfaction and decreasing meal intake that may lead to further compromising medical and nutrition status and/or weight loss of the residents. Findings: During an observation of lunch meal service distribution with concurrent review of residents' meal tickets on 10/22/24, beginning at 12:21 p.m., it was noted as followed: 1. Resident 1 with Regular diet did not receive cottage cheese when the meal ticket indicated Resident 1 should have received cottage cheese as standing order; 2. Resident 2 with Regular, two grams (g; a unit of measurement) Na (sodium) diet (diet with consumption of limited amount of sodium to 2,000 milligrams (mg; 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 infection control practices were implemented for a census of 91 when: 1. Nursing staff did not sanitize and disinfect medical equipment between resident use and did not change gloves after resident care and when cleaning equipment; 2. Nail care was not provided for Resident 8, Resident 14, Resident 38, Resident 39, and Resident 73; and 3. Certified Nurse Assistant 5 (CNA 5) did not wear the required personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) upon entering Resident 27's room who was on neutropenic precautions (a set of action to take to prevent infection if there's a low count of white blood cell in the blood that helps fight infection). These practices decreased the facility's potential to prevent the spread of infection among residents. Findings: 1. During a medication pass observation on 10/21/24 at 8:40 a.m., Licensed Nurse 1 (LN 1) used a blood pressure (BP) cuff and stethoscope to measure a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 10 resident rooms (Rooms 3, 4, 5, 6, 7, 8, 9, 14, 15, and 16) met the required 80 square feet (sq. ft.) per resident when rooms 3, 4, 5, 6, 7, 8, 9, 15, and 16 were measured as 228.55 sq. ft. for a three residents occupancy or 76.2 sq. ft. per resident; and room [ROOM NUMBER] was measured as 159.38 sq. ft. for a two residents occupancy or 79.7 sq. ft. per resident. This failure had the potential to result in inadequate space for the provision of health care and services for 29 residents residing in these rooms for a census of 91 residents. Findings: The observations were made throughout the survey in rooms 3, 4, 5, 6, 7, 8, 9, 14, 15 and 16. The space was adequate to store assistive devices in the rooms (such as wheelchair and/or walker) and to facilitate provision of care and needs. During a concurrent interview and record review on 10/23/24 at 12:15 p.m. with the Administrator (ADM), the rooms' dimension were reviewed. ADM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an accurate Minimum Data Set (MDS- a federally mandated resident assessment tool) for two of 25 sampled residents (Resident 18 and Resident 48), when: 1. Resident 18's use of narcotic pain medication was not coded in the MDS admission assessment; and 2. Resident 48's pressure ulcers (PUs; localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) were not accurately coded in her admission assessment. This failure decreased the facility's potential to provide residents with appropriate care and interventions. Findings: 1. A review of Resident 18's admission Record, indicated she was admitted to the facility in September 2024 with diagnoses including compression fracture of the vertebra (a break in the bone at the bottom of the spine). A review of Resident 18's Order Summary Report, dated 9/30/24, indicated an order for tramadol hydrochloride (pain killer) 25 milligrams (mg; a unit of measurement) every eight hours as needed for pain. A review of Resident 18's MDS admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise in a timely manner the care plans for one of 25 sampled residents (Resident 30), when: 1. Resident 30's anticoagulant care plan was not revised and updated since 3/23/24; and These failures decreased the facility's potential to provide resident-centered care plans and evaluate its effectiveness. Findings 1. A review of an admission record indicated, Resident 30 was admitted to the facility in November 2022 with a diagnosis of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). A review of Resident 30's clinical record included the following documents: An anticoagulant (medication that prevent or reduce blood clotting) care plan, dated 3/23/24, indicated Resident 30 was receiving rivaroxaban (blood thinner that treats or prevents blood clots). A physician's order listing report indicated rivaroxaban 20 milligrams (mg; a unit of measurement) was discontinued on 9/9/24 and apixaban (blood thinner that treats or prevents blood clots) 10 mg was started on 9/9/24. 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.

Based on observation, interview, and record review, the facility failed to provide respiratory care services according to professional standards of quality for two of 25 sampled residents (Resident 19 and Resident 40), when: 1. Resident 19's administered oxygen was not consistent with the physician's order; and 2. Resident 40 missed nebulizer (a liquid medication turned into a mist by a machine and inhaled through a mask used to treat lung diseases) treatments on 10/4/24 and 10/15/24. These failures decreased the facility's potential to safely follow the physician's order when providing respiratory services. Findings: 1. A review of Resident 19's admission Order, indicated she was admitted to the facility in February 2024 with a diagnosis of chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing). During a concurrent observation and interview on 10/21/24 at 8:45 a.m. with Resident 19, Resident 19 was observed in bed holding her oxygen tubing and not using it. Resident 19 stated she only used oxygen at night when sleeping with her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 25 sampled residents (Resident 11) received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care and services consistent with professional standards of practice, when Resident 11's order for fluid restriction was not followed as per physician's order. This failure increased Resident 11's risk to develop fluid overload. Findings: A review of Resident 11's admission Record, indicated he was admitted in January 2017 with a diagnosis of stage four chronic kidney disease. During an observation on 10/21/24 at 9:40 a.m. inside Resident 11's room, three water pitchers were placed on Resident 11's bedside table. A review of Resident 11's Order Summary Report (OSR), dated 5/31/24, indicated an order for fluid restriction of 1000 milliliters per day (ml/day; a unit of measurement), 700 ml/day for dietary and 300 ml/day for nursing. A review of Resident 11's OSR, dated 8/16/24, indicated Resident 11 had an order for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequately monitor behaviors for quetiapine (a drug that treats mental health disorders) administration to one resident (Resident 35) of a census of 91. This failure had the risk for residents' ineffective medication management and inadequate decision-making for medications' gradual dose reduction (GDR). Findings: A review of an admission record indicated, Resident 35 was admitted to the facility on [DATE] with a diagnosis of dementia (a progressive state of decline in mental abilities) with behavioral disturbance. A review of Resident 35's hospitalization record titled, History and Physical: Orders, dated 9/11/24, indicated Resident 35 was admitted on [DATE] for dementia with agitation and combativeness and was prescribed quetiapine 25 milligrams (mg-a unit of measurement) at bedtime. A review of Resident 35's Order Summary Report, dated 10/22/24, indicated nursing staff were to monitor Resident 35's behaviors of agitation and combativeness every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two medications in a medication cart were properly labeled with open dates (dates residents start using a product) for a census of 91. This failure increased the facility's potential to administer expired medications to residents. Findings: During a concurrent observation and interview on 10/21/24 at 12:15 p.m. with Licensed Nurse 3 (LN 3), LN 3 confirmed two respiratory treatment medications were found unsealed without open dates in medication cart three: 1. An opened and undated foil pouch of budesonide (a medicine for asthma, a long-term lung disease) nebulization (a method of delivering medication into the lungs by turning liquid medicine into a mist that is inhaled through a mouthpiece or mask) suspension. LN 3 stated nursing staff were expected to write open dates on pouches containing respiratory medications. LN 3 also stated when she first opened a drug foil packet, she would write the date on the packet, and 2. A box, dated 9/17/24, with Advair Diskus (a medication used to prevent asthma…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assistance was provided to one of 25 sampled residents (Resident 48), when Resident 48 who had impaired vision was not assisted with eating as ordered. This failure decreased the facility's potential to meet Resident 48's nutritional needs. Findings: A review of Resident 48's admission Record, indicated she was admitted to the facility in September 2024 with a diagnosis of dysphagia (difficulty swallowing) with no memory problem. During a concurrent observation and interview on 10/21/24 at 12:56 p.m. with Resident 48 during lunch in the dining room, Resident 48 was observed not eating after the tray was served to her. Resident 48 stated she needed help because she could not see what was on her tray. During an interview on 10/22/24 at 8:32 a.m. with Resident 48, Resident 48 stated breakfast was already done but she was not able to eat properly. Resident 48 added staff did not assist her whenever she ate, but she was told by one of the therapists that she should always be assisted when eating because she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records review, the facility failed to ensure one Resident's (of four sampled residents) right to be free from abuse when staff witnessed Resident 1 punch Resident 2. This failure resulted in Resident 1 having experienced physical abuse by Resident 2. Findings: A review of an admission record indicated Resident 1 was admitted to the facility in early 2024 with multiple diagnoses which included paranoid schizophrenia (feeling afraid and unable to trust others), bipolar disorder (intense mood, energy, and activity changes), and psychological and behavioral factors with disorders. Resident 1's Minimum Data Set (MDS, a comprehensive assessment tool), dated 3/29/24, indicated he had a very severe cognitive (the mental process of obtaining knowledge and understanding through thought, experience, and the senses) decline. A review of Resident 1's Order Summary Report, dated 5/4/24 indicated, risperiDONE [antipsychotic] ORAL Tablet 1MG (milligram, dose) .for PARANOID SCHIZOPHRENIA AEB…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) were treated with dignity and respect when: 1. Resident 1 had to wait three hours on a bedpan for assistance; and, 2. Resident 2's call light was not accessible when she was up in her wheelchair. These failures decreased the facility's potential to ensure residents received the care they needed and were treated with dignity and respect. Findings: 1. A review of an admission record indicated Resident 1 was admitted to the facility in April 2019 with diagnoses including difficulty walking, contracture (occurs when a muscle, joint or other tissues tighten or shorten causing a deformity) of right and left wrist, morbid obesity (chronic complex disease defined by excessive fat deposits that can impair health) and osteoarthritis (a degenerative joint disease causing joint stiffness, pain, and swollen joints) of right and left shoulder. A review of Resident 1's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent an avoidable accident for one of 90 residents (Resident 1), when: 1. Resident 1 eloped from the facility, fell, sustained injuries, was found by police and transferred to a hospital, 2. Three out of four main entrance/exit doors had a non-functional or semi-functional wanderer monitoring system; and 3. Resident 1's wander guard physician order and elopement care plan were not followed. These failures decreased the facility's potential to maintain residents' safety. Findings: A review of an admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including traumatic subdural hemorrhage (bleeding between brain and skull) with loss of consciousness, cerebral infarction (disrupted blood flow to the brain), cognitive communication deficit, surgery on the nervous system, major depressive disorder, delirium (an altered state of consciousness characterized by episodes of confusion), alcohol dependence,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications for one of three sampled residents (Resident 1) when the resident's prescription medications were not refilled in a timely manner. This failure resulted in Resident 1 having withdrawal symptoms including unbearable pain, anxiety, and insomnia. Findings: Review of Resident 1's admission Record indicated the resident was a long-term resident in the facility with multiple diagnoses that included rheumatoid arthritis (RA, a chronic autoimmune disease that causes inflammation in the joints), low back pain and sideways curvature of the spine. In a concurrent observation and interview on 3/25/24 at 10:26 a.m., Resident 1 was sitting upright in her bed and stated she had RA. The resident's wrists were observed to be deformed and have healed surgical incisions over both wrists. Resident 1 voiced she did not receive her routine medications because somebody forgot to fill in her prescriptions and it caused her having gone through withdrawal for four days. The resident reported that she 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 interview and record review, the facility failed to ensure a comprehensive resident centered care plan was developed for one of three sampled residents (Resident 1), when Resident 1's at risk for falls care plan did not list safety measures for the resident's gait and balance problem. In addition, Resident 1's risk for altered ADLs (activities for daily living) care plan did not have the resident's specific interventions addressing the needs for assistance with ambulation. This failure had the potential to have contributed to Resident 1's recent fall and placed her at risk for more falls. Findings: A review of the admission record for Resident 1 indicated she was admitted to the facility in 2023 with diagnoses which included muscle weakness, difficulty in walking, and dementia (a chronic disorder characterized by memory loss and impaired reasoning). A review of Resident 1's 'Fall care plan,' dated 1/15/23, indicated the resident was at risk for falls related to altered mental status, visual impairment, unsteady gait, altered balance while standing and/or walking, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of four sampled residents (Resident 4) when: 1. Resident 4's care plan intervention to prevent Resident 4 from entering other residents ' room was not properly implemented; and, 2. Resident 4's care plan for an allegation of hitting another resident on the private area on 11/27/23 was not developed. These failures placed Resident 4 and other residents in the facility at increased risk for physical and/or psychosocial harm. Findings: 1. A review of Resident 4's clinical record indicated Resident 4 was originally admitted December of 2021 and had diagnoses that included mood disorder due to known physiological condition with depressive features, recurrent moderate major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and nontraumatic intracerebral hemorrhage (a condition where a pool 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 maintain complete and accurately documented medical records for five residents (Resident 5, Resident 6, Resident 7, Resident 8, and Resident 9) of a census of 85, when the residents' bowel and bladder (B&B) continence data was not documented. This failure decreased the facility's potential to assess and monitor the residents' B&B status. Findings: During an interview on 10/5/23 at 12:06 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated during morning rounds in September he witnessed Resident 5, Resident 6, and Resident 8 were left in soiled and wet briefs by registry CNAs who worked the night shifts. During an interview on 10/5/23 at 12:53 p.m. with CNA 4, CNA 4 stated during morning rounds in September and on a daily basis she witnessed Resident 5, Resident 6, Resident 7, and Resident 9 were left for long periods of time in soiled and wet briefs by registry CNAs who worked the previous night shifts. During an interview on 10/5/23 at 1:10 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated during morning rounds she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dignity was promoted for one of two sampled residents (Resident 1) when Resident 1 was left for 2 and a half hours in the hospital lobby and then in a locked van at the hospital parking lot unattended. This failure resulted in Resident 1 feeling of being treated like a dirt, not respected and getting sick and nauseated. Findings: Resident 1 was admitted to the facility with diagnoses that included fluid accumulation within the abdomen and pelvis area due to liver disease. In an interview on 9/1/23 at 10:50 a.m., the Administrator stated the facility received a phone call from the hospital on 9/1/23 at around 4:30 p.m. that a resident was in the van without a driver. In a concurrent observation and interview on 9/6/23 at 11:30 a.m., Resident 1 was in bed in his room. Resident 1 stated he had a hospital appointment for a procedure to drain out his abdominal fluid a few days ago. Resident 1 stated he had to wait for the facility van driver to pick him up in the hospital for more than two hours…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff was competent for a census of 82 when, 15 of 24 Certified Nursing Assistants (CNA's) had not received annual competency evaluations. This failure had the potential for residents to receive unsafe care. Findings: In a concurrent record review and interview on 11/10/22 at 10:10 a.m., with the Director of Staff Development (DSD) and the HRM (Human Resources Manager), employee files for 25 CNA's were reviewed. DSD and HRM confirmed only 9 Certified Nursing Assistants had received annual competencies and 14 had not. In an interview on 11/10/22 at 10:10 a.m., DSD confirmed she was aware CNA annual competencies had not been completed. She further stated this failure could affect resident care negatively if staff were lacking the skills to care for the residents. A review of facility's policy titled, In-Service Training, Nurse Aide, last revised 8/22, indicated, The facility completes a performance review of nurse aides at least every 12 months.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet resident needs when: 1. Medication was not re-ordered on time to ensure availability for Resident 335. 2. Resident 17 was not appropriately identified before medication administration; 3. An E-Kit (an emergency supply of medication) was accessed without completing required documentation; and 4. Three of four randomly selected controlled drug (medications with a high potential for abuse, misuse and diversion) records did not reconcile with the Medication Administration Record (MAR) for Residents 13, 26, and 54. These failures increased the potential for medication errors. Findings: 1. A review of Resident 335's admission record indicated the resident was admitted to the facility in October 2022 with diagnoses including pneumonia (lung inflammation caused by infection), acute respiratory failure with hypoxia (not enough oxygen in the body) and sepsis (a potentially life-threatening infection in the blood). During a medication pass observation on 11/7/22, at 8:55 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 6.45% error rate when 2 medication errors out of 31 opportunities were observed during a medication pass for 2 out of 6 residents (Resident 5 and Resident 335). These failures had the potential for the residents to not receive the full therapeutic effect of their medications when not given in accordance with the prescriber's order and manufacturer's specifications. Findings: A review of Resident 335's admission record indicated the resident was admitted to the facility in October 2022 with diagnoses including pneumonia (lung inflammation caused by infection), acute respiratory failure with hypoxia (not enough oxygen in the body) and sepsis (a potentially life-threatening infection in the blood). During a medication pass observation on 11/7/22, at 8:55 a.m., with Licensed Nurse 5 (LN 5), LN 5 was observed preparing 11 medications including an Alvesco® inhaler (a steroid medication used to treat asthma). During the same medication pass observation on 11/7/22, at 8:55 a.m., with LN 5, LN 5 handed the Alvesco®…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their medication storage policies and procedures when: 1. Expired medications were found inside Medication Cart 3, and Station 2 Medication Storage Room refrigerator; 2. Inspection of a medication storage room and two medication carts displayed pharmaceutical products that were not properly labeled with open dates, and 19 loose pills; 3. Medication Carts 1 and 4 were left unlocked and unattended and; 4. Medication was not appropriately labeled to alert staff of a dosage change. The deficient practices had the potential for residents to receive discontinued and expired medications with unsafe and reduced potency from being used past their discard date. Findings: 1. During an inspection on 11/7/22, at 10:50 a.m., of the Station 2 Medication Storage Room with the Assistant Director of Nursing (ADON), ADON confirmed a Glucagon solution kit (emergency medication to treat low blood sugar in patients with diabetes), expired on 10/17/22, was available for use inside the medication refrigerator. ADON 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 ensure one of 24 sampled residents (Resident 59) was able to receive a flavorful and nutritious meal when recipes were not followed. This failure has the potential to decrease Resident 59's appetite and could lead to weight loss. Findings: During a concurrent observation and interview on 11/7/22 at 11:05 a.m., Resident 59 stated the food was bland. A review of Resident 59's MDS (Minimum Data Set, an assessment tool), dated 10/18/22, indicated the resident had no memory impairment. The MDS also indicated Resident 59 needed supervision and 1 person assist with eating. A review of an undated facility's document titled, Recipe: Apple Glazed Meatballs, stipulated for staff to, Toss meatballs with sauce to cover. Top with green onions at service. A review of an undated facility's document titled, Recipe: Baked Fish, stipulated, Place fish on greased sheet pan. Mix margarine, salt, pepper, and lemon juice together and spread on top of fish .Garnish with paprika and parsley. During an observation on 11/9/22 at 11:51…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nutritious vegetables for a census of 82 when dietary staff did not follow the recipe when cooking carrots and peas. This failure decreased the potential for residents to receive nutrient-based food values and increased their potential for weight loss. Findings: During a concurrent observation and interview on 11/9/22 at 9:35 a.m., a pot of peas was cooking on the stove with medium heat. [NAME] 1 confirmed he did not know how long to cook the peas; but would do a taste test to see if they were cooked. During an observation on 11/9/22 at 9:49 a.m., two trays of carrots were placed in the steamer to cook. The 2 trays of carrots were taken out of the steamer on 11/9/22 at 11:39 a.m. The carrots were cooked for 1 hour and 50 minutes. During an observation on 11/9/22 at 12 p.m., the pot of peas was still cooking on the stove and was then turned to high heat. During an observation on 11/9/22 at 12:20 p.m., the pot of peas was taken off from the stove and directly placed to the tray line's warmer. There 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 food was safely stored and prepared when: 1. Opened and unlabeled food was stored in the refrigerator; 2. Dietary staff did not wear hair nets and beard guard while in the kitchen; and 3. The Dietary Service Supervisor (DSS) did not wash hands prior to entering the kitchen. These failures decreased the facility's potential to prepare, store, and provide food under sanitary conditions for a census of 82. Findings: 1. During a concurrent observation and interview of the initial kitchen tour on 11/7/22 at 8:54 a.m., the DSS confirmed the following items were opened with expiration date: 1/2 bucket container of vinaigrette with expiration date 11/5/22; approximately 1 quart (qt, a unit of measurement) cut pineapple with expiration date 11/6/22; about 1 qt pudding dessert with expiration date 11/6/22; Less than 1/2 liter (L, a unit of measurement) of tartar Sauce with expiration date 11/4/22; 1 gallon (g, a unit of measurement) of buttermilk ranch dressing with expiration date 8/25/22; 1 g [NAME] Caesar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection prevention measures were implemented for a census of 82 when: 1. Resident 12's bedding was on the floor and numerous flies were on the resident; 2. Two sharps containers were above the fill line; 3. Hand hygiene was not performed prior to entering and exiting resident rooms; 4. Reusable resident equipment was not disinfected between residents; 5. PPE (Personal Protective Equipment, protective clothing donned to protect the wearer from injury or infection) was not changed prior to entering and exiting resident rooms; 6. Clean linen was transported through the soiled linen area; 7. Resident 48's nebulizer tubing and mask were unlabeled; 8. Resident 185's IV (intravenous therapy, tubing that administers medications directly into the vein) dressing was unlabeled; 9. Resident 48's oscillating fan was dirty and covered in dust; and 10. Hand hygiene was not performed prior to pouring medications, entering and exiting 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 an effective pest free environment for a census of 82 when flies were presented throughout the facility. This failure decreased the facility to maintain a sanitary, safe, and infectious free environment for the residents. Findings: During a concurrent observation and interview on 11/7/22 at 10:28 a.m., the Assistant Director of Nursing (ADON) confirmed more than 10-12 flies in resident room [ROOM NUMBER]. During a concurrent observation and interview on 11/7/22 at 1:28 p.m., there were 2 flies present on Resident 9's arm while his was eating lunch. Resident 9 stated, I am bothered by it .nothing I can do . [I am] not comfortable. During a concurrent observation and interview on 11/8/22 at 10:02 a.m., there was 1 fly observed in the kitchen while the staff were cleaning and washing the dishes. The Dietary Services Supervisor (DSS) confirmed there was a fly issue in the kitchen. During an interview on 11/9/22 at 2:33 p.m., the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Resident 30 and 67) were able to maintain dignity when: 1. Resident 30's urinary catheter (a tube that collects urine from the bladder and leads to a drainage bag) was not covered with a privacy bag; and 2. Resident 67 urinated himself while waiting for the call light for 1 hour. These failures increased the potential to negatively impact the residents' self-esteem and self-worth. Findings: 1. According to Resident 30's Face Sheet, Resident 1 was admitted to the facility in mid-2021 with diagnoses including acute cystitis (inflammation of the urinary bladder), kidney failure and benign prostatic hyperplasia (prostate gland enlargement that can cause urination difficulty). A review of Resident 30's clinical record included the following documents: A Minimum Data Set (MDS, an assessment tool), dated 10/20/22, indicated Resident 1 had severe memory impairment. In a concurrent observation and interview 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 interview and record review, the facility failed to notify one of 24 sampled residents' (Resident 58) emergency contacts when there was a dosage increase in their psychotropic medication (medications that affect a person's mental state). This failure deprived the resident of his emergency contact's involvement in his care. Findings: According to Resident face sheet, Resident 58 was admitted in the middle 2022, with diagnoses including alcohol induced persisting dementia (a group of thinking and social symptoms that interferes with daily functioning) and psychotic disorder with hallucinations due to a known physiological condition. A review of Resident 58's clinical record included the following documents: An MDS (Minimum Data set, an assessment tool), dated 9/19/22, indicated Resident 58 had severe memory impairment. A physician's order, dated 9/26/22 to 10/26/22, indicated to administer Risperdal® (a medicine used to treat mental /mood disorders) tablet 0.25 mg (milligrams, a unit of measurement) at bedtime only for Psychosis (a mental disorder characterized by 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 one of 24 sampled residents (Resident 17) was able to maintain privacy during ADLs (Activities of Daily Living, fundamental skills required to care for oneself) when, there were three missing horizontal window blinds. This failure decreased Resident 17's feeling of self-worth and self-esteem. Findings: During a concurrent observation and interview on 11/7/22 at 11:06 a.m., there were three missing window blinds by Resident 17's bed. Resident 17 stated, I don't like getting dressed while others can see me .I still have to get dressed. During an interview on 11/10/22 at 2:50 p.m., the Assistant Director of Nursing (ADON) confirmed when residents have to get dressed with missing window blinds, they could feel embarrassed and exposed. The ADON stated the blinds should have been replaced by maintenance. A review of the facility's policy titled, Dignity, dated 2/21, stipulated, Resident's private space and property are respected at all times .Staff promote, maintain and protect resident privacy, including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of 24 sampled residents (Resident 12, Resident 79 and Resident 9) were provided a comfortable and homelike environment when; 1. Resident 12 had numerous flies on her bed linens, her tray table was dirty, and the drywall of the exterior room was damaged; 2. Resident 79's bathroom had water leaking from bathroom sink and a puddle of water was on the floor and; 3. Resident 9 had 2 flies on his arm while eating lunch. These failures had the potential to negatively impact the residents' comfort and create an environment that was not homelike. Findings: 1. In an observation, on 11/7/22 at 10:04 a.m., Resident 12 was lying in her bed completely covered by her bed linens with some of the linens lying on the floor. 10- 12 flies were observed on her comforter and flying around the area. The tray table was sticky and had crumbs all over it. The exterior wall had an area approximately 4 ft. (feet, a unit of measurement) in length with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of 24 sampled residents' (Resident 54 and Resident 30) care plans were developed and implemented when, 1. Resident 54 was not turned and repositioned every 2 hours and; 2. A care plan was not developed for Resident 30. These failures placed the residents at risk for skin deterioration and developing urinary tract infections (UTI). 1. According to the Resident Face Sheet, Resident 54 was admitted in the summer of 2021 with diagnoses including rheumatoid arthritis (a chronic inflammatory disorder affecting many joints) and unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 54's clinical record included the following documents: A MDS (Minimum Data Set, an assessment tool), dated 9/30/22, indicated the resident had severe memory impairment. The MDS also indicated the resident was at risk for the development of pressure ulcers (injury to skin and underlying tissue resulting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a safe discharge for one of 24 sampled residents (Resident 84) when, the resident left AMA (Against Medical Advice) and was not provided with medications, durable medical equipment (DME) and follow up services. This failure had the potential to result in a preventable readmission. Findings: According to the Resident Face Sheet, Resident 84 was admitted in the summer of 2022 with diagnoses including fractures of the left tibia (shin bone) and right foot. A review of Resident 84's clinical record included the following documents: A MDS (Minimum Data Set, an assessment tool), dated 8/16/22, indicated the resident had no memory impairment. A SNF (Skilled Nursing Facility) ST (Short-term) Care Plan, initiated 8/16/22, indicated the resident preferred to return home alone. Interventions included arranging for necessary home modifications as indicated and coordinating DME, pharmacy/medications and in-home support services. A progress note, dated 8/16/22 and written by Licensed Nurse 8 (LN 8) at 4:23 p.m., 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of 24 sampled residents (Resident 47 and Resident 54) received adequate assistance with ADLs (Activities of Daily Living, self-care activities) when, showers were not given as scheduled. This failure placed the residents at risk for uncleanliness, body odor and discomfort. Findings: According to the Resident Face Sheet, Resident 47 was admitted in the fall of 2022 with diagnoses including fracture of the left femur (thigh bone) and unspecified osteoarthritis (occurs when the flexible tissue at the ends of bones wears down causing joint pain). A review of Resident 47's clinical record included the following documents: A MDS (Minimum Data Set, an assessment tool), dated 8/23/22, indicated the resident had no memory impairment and was totally dependent on care for bathing. An ADL care plan, initiated 9/7/22, indicated Resident 47 had a problem with ADLs and the goal was to have her ADL needs met. An approach listed was to shower/bathe the…

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

Based on observation, interview, and record review, the facility failed to ensure a licensed nurse had appropriate skills and competencies to provide care for residents based on their identified needs for a census of 82. This failure had the potential to place residents at risk for insufficient care when Licensed Nurse (LN) skills were not demonstrated. Findings: During a medication pass observation on 11/7/22, at 9:57 a.m., LN 6 stated she was a registry nurse (a licensed nurse employed by an agency to work on an as-needed basis). During an interview on 11/7/22, at 10:03 a.m., with LN 6, LN 6 stated she did not receive any training from the facility prior to working and was not aware of any of the facility's policy and procedure in preparing and administering medications. LN 6 stated, Some places [facilities] do provide training, a mandatory 8-hours, but not here. On 11/7/22, at 10:17 a.m., LN 6 was observed preparing to administer medications to Resident 17. LN 6 stated, [Resident's assumed name], and administered the medications to Resident 17, who was not wearing 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.

Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 76) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: Resident 76 received as-needed (PRN) Ativan® (an anti-anxiety medication) without an adequate indication for use and clinical justification for its continued use beyond 14 days. The failure had the potential for unnecessary medication for the resident, and exposure to unwanted side effects associated with psychotropic medication use that include, but are not limited to: sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss. A review of an admission record indicated Resident 76 was admitted in July 2022 with diagnosis including left femur fracture, generalized anxiety disorder and cognitive communication deficit. A review of Resident 76's medication record indicated a physician's order, dated 10/18/22, for Ativan® 0.5 milligram (mg, unit of measure) one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure 10 resident rooms (Rooms 3, 4, 5, 6, 7, 8, 9, 14, 15, and 16) met the required 80 square feet (sq. ft.) per resident when rooms 3, 4, 5, 6, 7, 8, 9, 15, and 16 were measured as 228.55 sq. ft. for a three resident occupancy or 76.2 sq. ft. per resident; and room [ROOM NUMBER] was measured as 159.38 sq. ft. for a two resident occupancy or 79.7 sq. ft. per resident. This failure had the potential to result in inadequate space for the provision of health care and services for 25 residents residing in these rooms for a census of 82 residents. Findings: Observations were made throughout the survey in rooms 3, 4, 5, 6, 7, 8, 9, 14, 15 and 16. The space was adequate to store assistive devices in the room (such as wheelchair and/or walker) and to facilitate provision of care and needs. Interviews were conducted with available residents currently residing in the affected rooms. The residents verbalized the space was adequate for the provision of care. The…

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