Rancho Mirage Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a fall prevention intervention for one of three sampled residents (Resident 1), by not ensuring the tab monitor was attached while the resident was in a wheelchair, as sspecified in the resident's care plan. This failure had the potential to place Resident 1 at risk for further falls and potential injury. Findings: A review of Resident 1's medical record titled, Personal Information, indicated, the resident was admitted to the facility on [DATE], with a diagnosis of a fracture (broken bone) to lower back, and muscle weakness. A review of Resident 1's care plan dated February 8, 2025, indicated, .Resident is at risk for falls r/t (related to) impaired mobility, hx (history) of falls .Intervention .apply tabs monitor in w/c (wheelchair) to remind resident to get assistance for ambulation (walking) and transfers . A review of Resident 1's, Brief Interview of Mental Status (a cognitive assessment), dated February 11, 2025, 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 ensure proper disposal of garbage when three dumpsters' lids were not closed, and the surrounding area was littered with trash. This failure had the potential to attract pests and rodents which could lead to contamination and food borne illness among residents. Findings: On February 3, 2025, at 9:40 a.m., during an observation of the dumpster storage outside the facility, three out of three dumpster lids were not closed, and trash was scattered around the dumpsters. On February 3, 2025, at 10:50 a.m., during a concurrent observation and interview with the Dietary Supervisor (DS) regarding the three dumpsters, the DS stated, the lids were open and trash was surrounding the area. The DS stated, the dumpsters should have been closed and free of trash to prevent pest infestations. On February 5, 2025, at 10:15 a.m., during a concurrent observation and interview with the Maintenance Supervisor (MS), he stated he was responsible for keeping the dumpster lids closed and making sure the surrounding area was clean.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to ensure medications were properly labeled consistent with the policies and procedures and stored at appropriate temperature consistent with the drug manufacturer's instructions when: 1. Bisacodyl (medication to relieve constipation) 10 mg (milligram; unit of measurement) suppositories were stored in the medication room and the medication cart without proper pharmacy labels; 2. Multi-dose medications were not properly labeled with open dates; 3. One liquid medication bottle did not have a legible expiration date on the manufacturer's label; and 4. The room temperature in the Nursing Station 2 Medication Room was not maintained below the drug manufacturer's instruction for storage at room temperature. These failures had the potential for residents to received ineffective medication treatment. Findings: 1. During an inspection of the medication room located in Nursing Station 3 on February 3, 2025, at 11:30 a.m. with LVN 3, there were 13 bisacodyl 10 mg suppositories inside a plastic bag that did not have 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 safe and sanitary food preparation and storage practices in the kitchen when: 1. Food resident was found on the puree blender. 2. Spilled dry oatmeal was observed on the floor inside the dry storage room. 3. Two ovens had grime buildup and food residue. 4. A dietary staff's plastic cup was found on the bottom shelf of the tray line table. 5. The cook's beard and mustache were not covered with a beard net. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) among a vulnerable population of 86 out of 92 residents who received food prepared in the facility's kitchen. Findings: 1. On February 3, 2025, at 9:10 a.m., a concurrent observation and interview inside the walk-in preparation room were conducted with the Dietary Supervisor (DS). The puree blender was found with white and yellow food residue. The DS stated the puree blender had white and yellow food residue and it should be cleaned after each use to prevent cross-contamination.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for one of one resident reviewed (Resident 71), the resident's bathroom had a functioning paper towel dispenser. This failure had the potential to prevent Resident 71 from performing proper hand hygiene, increasing the risk of infection. Findings: On February 6, 2025, at 9:52 a.m., during a concurrent observation and interview inside Resident 71's bathroom with the Maintenance Supervisor (MS) and Resident 71, the MS stated the paper towel dispenser was not dispensing paper towels. Resident 71 stated she had reported the non-functioning towel dispenser to the Case Manager (CM) and the Infection Preventionist (IP) nurse. On February 6, 2025, at 10:01 a.m., during an interview with the IP nurse, the IP nurse stated Resident 71 had informed him on February 4, 2025, about the paper towel dispenser issue. The IP further stated he informed the MS but did not follow up to ensure the issue was resolved. On February 6, 2025, at 10:04 a.m., during an interview with the CM, she stated Resident 71 informed her last…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 copy of the discharge notice to the Office of the State Long-Term Care Ombudsman (LTC Ombudsman - an advocate for residents of nursing homes to protect residents' rights and ensure quality care) at the same time the discharge notice was given to the resident, for one of three residents reviewed for closed records (Resident 88). This failure had the potential to delay advocacy and oversight of Resident 88's discharge plan, impacting continuity of care and resident rights. Findings: A review of Resident 88's admission Record, indicated Resident 88 was admitted to the facility on [DATE], with a diagnoses which included fatty liver (a condition that can cause jaundice [yellowing of the skin and eyes]). A review of Resident 88's Minimum Data Set (an assessment tool), dated October 31, 2024, indicated, Resident 88 had Brief Interview of Mental Status (use to assess cognition), score of 15 (cognitively intact). A review of Resident 88's eINTERACT…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to ensure expired medications were not available for use by residents. This failure had the potential for residents to received ineffective medication therapy. Findings: 1. During an inspection of the 8400 Floor Medication Cart located in Nursing Station 3 on February 3, 2025, at 12:10 p.m. with LVN 3, there was one discontinued bubble pack containing hydroxyzine (medication to treat itching) for Resident 3 in the cart along with active medications. In a concurrent interview, LVN 5 stated the medication was discontinued and was change from as needed to routine. LVN 5 stated the bubble pack should have been removed from the cart. In a concurrent interview, LVN 3 also stated the bubble pack should have been removed from the card and placed in the discontinued box in the medication room. 2. During an inspection of Medication Cart 3A located in Nursing Station 3 on February 3, 2025, at 3:20 p.m. with LVN 3, there was one used Humalog (fast-acting insulin to control blood sugar in diabetics) Qwikpen 100 units per…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician's order for oxygen was transcribed into the electronic medical record after the order was received. This failure resulted in an incomplete and inaccurate medical record, which could have led to miscommunication among staff regarding Resident 189's prescribed oxygen therapy, potentially affecting the resident's respiratory care. Findings: On February 3, 2025, at 9:58 a.m., Resident 189 was observed lying in bed receiving oxygen at 2 liters per minute via nasal cannula (a medical device used to deliver supplemental oxygen to resident who has difficulty breathing or require oxygen therapy). A review of Resident 189's admission Record indicated Resident 189 was admitted to the facility on [DATE], with diagnoses which included pneumonia (lung infection) and dementia (memory loss). Resident 189 was under hospice care. A further review of Resident 189's record indicated Resident 189 did not have a physician order for the…

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

Based on interview, and record review the facility failed to ensure one of three staff reviewed for immunization (process of developing immunity [the ability to resist diseases]) (Certified Nurse Assistant [CNA] 1) was provided education regarding the risk and benefits of the COVID-19 vaccine (a medication that helps the body fight diseases caused by COVID-19 [a respiratory illness caused by a virus ). This failure had the potential to leave staff without proper guidance and information regarding the COVID-19 vaccine, potentially affecting their decision-making and increasing the risk of infection transmission within the facility. Findings: A review of Certified Nurse Assistant (CNA) 1 Consent for 2023/2024 updated COVID-19 Vaccine Additional Dose indicated no documented evidence CNA 1 was provided with education and information about COVID-19 immunization. On February 6, 2025, at 2:05 p.m., during a concurrent interview and review of CNA 1's vaccine consent record for 2023/2024 with the Director of Staff Development (DSD), he stated CNA 1's last COVID-19 vaccination (act of…

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

Based on observation & interviews, the facility failed to ensure resident's call light was within reach for one out of three residents (Resident 1). This failure had the potential to result in Resident 1 unable to call nursing staff for assistance. Findings: On December 24, 2024, at 8:30 a.m., an unannounced visit was made to the facility, for a quality of care issue. On December 26, 2024, at 1:10 p.m., a concurrent observation of Resident 1 lying in bed, and interview with resident, was conducted. Resident observed with a contracted right hand, and left hand under the covers. Observed resident's call light out of reach, as it was tied around the bed rail, hanging down the right side of the bed, towards the floor. Resident 1 asked by this writer, How do you call the nurses for help? Resident stated, I usually can't reach my call light, I'll ask my roommate to call the nurses. Resident 1 observed unsuccessfully trying to reach her call light with her right contracted hand. A review of Resident 1's medical records, titled, Resident Information, dated, January 2, 2025, 2:02 p.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to initiate a care plan (an individualized, plan of care, specific to resident's healthcare needs) for hard of hearing for one of three residents (Resident 3). This failure had the potential to negatively impact the resident's quality of life, as well as the quality of care and services received for Resident 3. Findings: On December 24, 2024, at 9:10 a.m., during a concurrent observation and interview with Resident 3, Resident 3 stated she was hard of hearing and had to get close to her ear or speak louder. Resident 3 was observed wearing hearing aids. Resident 3 stated she still could not hear well even she had the hearing aids. A review of Resident 3's medical record, titled, Resident Information, dated, December 31, 2024, at 10:25 (a.m.), indicated, resident was admitted to the facility on [DATE], with a diagnosis of, Hemorrhage of Cerebrum (Brain bleed). A review of Resident 3's Brief Interview of Mental Status ({BIMS}-a cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Provide fall prevention interventions for a resident assessed as a fall risk, for one out of three residents (Resident 3). This failure resulted for Resident 3 falling and sustaining a scalp hematoma (localized collection of blood that forms beneath the skin of the scalp due to trauma). 2. Ensure that the bed alarm (a device used as a fall precaution intervention to alert staff when a resident attempts to get out of bed) was properly attached to the resident, for one out of two residents (Resident 2). This failure had the potential to result in injury to Resident 2 if the resident attempted to get out of bed without staff knowledge. Findings: A review of Resident 3 ' s, medical record, titled, Resident Information, dated, December 31, 2024, at 10:25 (a.m.), indicated, resident was admitted to the facility on [DATE], with diagnosis ' which include, fracture of the second cervical vertebra (neck fracture) and muscle weakness. A review of Resident 3 '…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow up with the physician regarding the Registered Dietitian's (RD) recommendation to discontinue the resident 's high protein nourishment (HPN) for one of three sampled residents (Resident 1). This failure had the potential to contribute to the resident's significant weight gain of 29 pound (lbs) (26.6 percent) over 6 months. Findings: On October 3, 2024, an unannounced visit was made to the facility for a quality-of-care issue. A review of Resident 1 ' s medical records titled Face Sheet, indicated, Resident 1 was admitted to the facility on [DATE], with a diagnosis of cerebral infarction ({stroke}-Lack of oxygen to the brain, causing a decrease in brain function). A review of Resident 1's Minimum Data Set (an assessment tool) dated July 7, 2024, indicated, Resident 1 had a Brief Interview for Mental Status (cognitive/memory assessment) score of 15 (cognitively intact). A review of Resident 1 ' s physician orders, dated January 3, 2024, 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 that one of three residents (Resident 1) was monitored following an allegation of physical abuse. This failure had the potential to affect Resident 1 ' s emotional and psychosocial wellbeing. Findings: On September 10, 2024 at 9:00 a.m., an unannounced visit to the facility was conducted to investigate an allegation of physical abuse. On September 10, 2024, Resident 1 ' s medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included left shoulder osteoarthritis (a disease where the tissues [a group of cells] of the joints break down overtime.) A review of Resident 1 ' s History and Physical, dated August 22, 2024, indicated, Resident 1 had mental capacity. A review of Resident 1 ' s Minimum Data Set (MDS - an assessment tool), dated August 26, 2024, indicated Resident 1 had a Brief Interview for Mental Status (tool used to assess a resident's cognitive function) score of 15 (cognitively intact). 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 interview and record review, the facility failed to ensure the correct insulin (medication use to lower blood sugar levels) dose was administered as prescribed by the physician, for one of three residents (Resident 3). This failure has the potential risk of dangerously low blood sugar level for Resident 3, leading to harm and or death. Findings: On [DATE] at 9:30 a.m., an unannounced visit to the facility was conducted to investigate quality care issues. A review of Resident 3's admission RECORD, indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar levels). A review of Resident 3's Minimum data Set (an assessment tool), dated [DATE], indicated a Brief Interview for Mental Status (brief cognitive screening measure that focused on orientation and short-term word recall) score of 14 (intact cognition). A review of Resident 3's Order Summary Report, dated [DATE], indicated, .Lantus (a type of Insulin) Subcutaneous (beneath 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report allegations of sexual abuse to the California Department of Public Health (CDPH) within two hours after the allegation was made for one of three sampled residents (Residents 1). This failure could have resulted in an unsafe living environment for Res 1. Findings: On February 14, 2024, an unannounced visit was made to the facility to investigate an allegation of sexual abuse. A review of Resident 1's admission RECORD, dated February 14, 2024, indicated, Resident 1 was admitted to the facility on [DATE], with a diagnosis of right sided weakness/paralysis, due to a history of stroke. A review of Resident 1's Brief Interview for Mental Status (BIMS- test for cognitive functioning), dated February 3, 2024, indicated, the resident had a score of 7 (Severe cognitive impairment). A review of Resident 1's Progress Notes, dated February 3, 2024, at 2:43 p.m., indicated, .Called and notified pt's (patient's) daughter .from early incident .nurse witnessed .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for two of three employees reviewed, to ensure the infection control policy and procedures were followed when Certified Nursing Assistant (CNA) 1 and Physical Therapist (PT) failed to wear an eye protection (goggles or a face shield that covers the front and sides of the face) as required while entering and providing care for a resident who was infected with the Covid-19 virus (a highly infectious respiratory virus). This failure had the potential to increase staff and resident exposure and transmission of Covid-19 virus resulting in illness. Findings 1. On October 31, 2023, at 12:50 p.m., an observation with a concurrent interview was conducted with CNA 1. CNA 1 was observed exiting the room of a Covid (+ positive Covid test) resident without an eye protection. An isolation sign was observed outside the room which stated, STOP- Everyone must clean their hands, including before entering and when leaving the room, make sure their eyes, nose, mouth are fully covered before room entry. In a concurrent interview,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policy review, the facility failed to ensure food was labeled, dated, and stored properly for 75 of 77 residents who received food from the kitchen. The facility further failed to ensure all food transported from the kitchen to residents' rooms was covered the entire time for residents who resided on two (200 Hall and 300 Hall) of 3 halls in the facility. Findings included: 1. Review of facility a policy titled, Food Receiving and Storage, revised in July 2014, revealed Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices. Per the policy, 6. Food in designated dry storage areas shall be kept off the floor and clear of sprinkler heads, sewage/waste disposal pipes and vents. The policy indicated, 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). The policy revealed, 10. Refrigerated food will be stored in such a way that promotes adequate air circulation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, record review, and facility policy review, the facility failed to ensure an assessment was conducted prior to bolster mattress use for 1 (Resident #15) of 1 sampled resident reviewed for physical restraints. Findings included: Review of a facility policy titled, Bed Safety and Bed Rails, revised in August 2022, revealed, 2. Physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. a. The definition of restraints is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint. A review of Resident #15's admission Record revealed the facility admitted the resident on 04/07/2016, with diagnoses that included Alzheimer's disease and polyneuropathy. Review of Resident #15's quarterly 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 interviews, record reviews, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for 3 (Residents #53, #63, and #88) of 19 sampled residents. Findings included: Review of a facility policy titled, Resident Assessment, revised in March 2022, revealed, 8. All persons who have completed any portion of the MDS [Minimum Data Set] resident assessment form must sign the document attesting to the accuracy of such information. 1. A review of Resident #53's admission Record revealed the facility admitted Resident #53 on 10/06/2023 with diagnoses that chronic obstructive pulmonary disease, muscle weakness, and need for assistance with personal care. A review of Resident #53's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/11/2023, revealed Resident #53 did not use tobacco. A review of Resident #53's care plan initiated on 05/05/2023 and revised on 11/05/2023, revealed Resident #53 preferred to keep their cigarettes in their room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, record review, and facility policy review, the facility failed to refer 1 (Resident #26) of 6 sampled residents to the appropriate state-designated authority for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination after the resident received a new mental illness diagnosis. Findings included: A review of an undated document provided by the facility titled, PASRR [preadmission screening resident review] General Overview, revealed, PASRR ensures that individuals being admitted to, or residing in a NF [nursing facility], receive services or supports that address their PASRR condition, including services linked to that condition, i.e. [a Latin term that meant in other words], specialized services. A review of Resident #26's admission Record, indicated the facility admitted Resident #26 on 06/15/2016, with diagnoses that included mental disorder. Per the admission Record, on 02/09/2022, the resident received a diagnosis of unspecified psychosis. A review of Resident #26's quarterly Minimum Data Set (MDS), with an 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.

Based on interviews, record review, and facility policy review, the facility failed to include a resident's ability to perform their activity of daily living (ADL) and the assistance required on the comprehensive care plan for 1 (Resident #39) of 24 sampled residents. Findings included: A review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed, 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. A review of Resident #39's admission Record revealed the facility admitted Resident #39 on 05/05/2022 with diagnoses that included heart failure, polyneuropathy, dementia, and compression fracture of the first lumbar vertebrae. A review of Resident #39's quarterly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, record review, and facility policy review, the facility failed to ensure a root cause analysis of a fall was conducted for 1 (Resident #15) of 5 sampled residents reviewed for accidents. Findings included: Review of a facility policy titled, Accidents and Incidents - Investigating and Reporting, revised in July 2017, revealed, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The policy specified, 7. Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. A review of Resident #15's admission Record revealed the facility admitted the resident on 04/07/2016, with diagnoses that included Alzheimer's disease and polyneuropathy. Review of Resident #15's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/19/2023, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 4,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, record reviews, interviews, and facility policy review, the facility failed to ensure oxygen was administered as ordered by the physician for 2 (Resident #63 and Resident #243) of 2 sampled residents reviewed for respiratory care. Findings included: A review of the facility policy titled, Oxygen Administration, revised in October 2010, revealed The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 1. A review of Resident #63's admission Record revealed the facility admitted Resident #63 on 01/09/2023 with diagnoses that included dementia and heart failure. A review of Resident #63's significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/19/2023, revealed Resident #63 was severely impaired in cognitive skills for daily decision making with long and short-term memory problems. A review of Resident #63's care plan initiated 10/19/2023,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, record reviews, interviews, and facility policy review, the facility failed to ensure their medication error rate less was than 5%. The facility had two medication errors out of 28 opportunities, which yielded a medication error rate of 7.14% for 2 (Resident #10 and Resident #16) of 4 residents observed for medication administration. Findings included: A review of the facility policy titled, Administering Medications, revised in April 2019 revealed, Medications are administered in a safe and timely manner, and as prescribed. The policy indicated, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 1. A review of Resident #10's Order Summary Report, with active orders as of 11/08/2023, revealed an order dated 11/07/2023, for folic acid 400 micrograms (mcg) give two tablets by mouth one time a day. During medication administration observation on 11/07/2023 at 8:46 AM, Licensed Vocational…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and facility policy review, the facility failed to ensure medication labels on 1 (3A medication cart) of 4 medication carts were legible. Findings included: A review of the facility policy titled, Medication Labeling and Storage, revised February 2023, revealed, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Per the policy, If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. During an inspection of the 3A medication cart with Licensed Vocational Nurse (LVN) #7 on 11/07/2023 at 2:23 PM, the surveyor observed a bottle of fluticasone. The label on the bottle of fluticasone that contained the resident's name, date filled, and opened date was unable to be read. LVN #7 stated new bottles of medications were ordered the previous day, but someone forgot to remove the old bottles. She stated it…

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

Based on interview and record review the facility failed to administer medications according to the facility's policy and procedure for one of three sampled residents (Resident 1) when the facility left the wrong medication unattended for Resident 1. This failure had the potential cause Resident 1 to consume the wrong medication and experiencing an adverse effect. Findings: A review of Resident Resident 1's admission record indicated the resident was admitted to the facility August 1, 2019, with diagnoses which included Bechet's disease (an auto-inflammatory systemic inflammation of the blood vessels of unknown etiology), post-traumatic stress disorder (an anxiety disorder caused by very stressful, frightening or distressing events), and sleep terrors (episodes of screaming, intense fear and flailing while still asleep). The record further indicated the resident was self-responsible. A review of Resident 1's Brief Interview for Mental Status (BIMS) dated August 5, 2023, indicated the resident had a score of 15 (no cognitive impairment). On October 2, 2023, at 1:39 p.m., 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.