Alta Vista Healthcare & Wellness Centre

Based on observation, interview, record review, and facility policy review, the facility failed to ensure care of a peripheral intravenous (IV) access site was provided and documented in accordance with accepted standards of nursing practice and facility policy for 1 (Resident #55) of 1 sampled resident reviewed for IV site care. Specifically, the facility failed to obtain physician's orders for IV flushes and dressing changes, failed to conduct and document assessments of the IV site, and failed to ensure the IV site was discontinued promptly when not needed for IV therapy. Findings included: A facility policy titled, Organizational Aspects of IV Therapy, effective 07/2013, specified, General Rules of IV Documentation 1. Document per facility policy - usually every shift if resident has an infusion catheter in place, or whenever and infusion treatment is given and 5. The shift note should include the following information: a. Date, time; signature and title of Nurse. b. Location and objective description of insertion site. The policy also indicated Nursing Responsibilities in…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure splints were applied as ordered for 2 (Resident #18 and Resident #46) of 3 sampled residents reviewed for positioning and mobility. Findings included: A facility policy titled, Restorative Nursing Program Guidelines, revised 09/19/2019, indicated the restorative nursing program may include, G. Splinting and brace application. The policy also indicated, VII. The RNA [restorative nurse aide] carries out the restorative program according on [sic] the Care Plan. The RNA documents the frequency of the program, the amount of time the resident spent in the activity and their tolerance to the program. In addition, the RNA completes a written weekly summary for all residents on a Restorative Nursing Program. The Restorative Nursing Program Coordinator co-signs the weekly progress note. 1. An admission Record indicated the facility most recently admitted Resident #18 on 02/18/2022. According to the admission Record, the resident had a medical history that included diagnoses of muscle…

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

Based on interviews, record review, and facility policy review, the facility failed to ensure an as-needed (PRN) psychotropic medication order was limited to 14 days unless there was documented rationale for the extended use and a specific duration of the order. This affected 1 (Resident #27) of 5 residents reviewed for unnecessary medications. Resident #27 had a PRN order for Ativan (a benzodiazepine) with no stop date or documented rationale for the continued use. Findings included: A facility policy titled, Behavior/Psychoactive Drug Management, revised 11/2018, specified, Any Psychoactive Medication ordered on a prn basis, must be ordered not to exceed 14 days. If the physician feels the medication needs to be continued, he/she must document the reason(s) for the continued usage and write the order for the medication; not to exceed the 14-day time frame. An admission Record indicated the facility admitted Resident #27 on 05/01/2021. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia, bipolar disorder, anxiety disorder,…

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

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a glucometer (device used to check blood glucose levels) was cleaned and disinfected between use to prevent the potential spread of infection for 2 (Resident #7 and Resident #26) of 4 residents observed receiving blood glucose checks. Findings included: A facility policy titled, Cleaning & [and] Disinfection of Resident Care Equipment, revised 01/01/2012, specified, Resident-care equipment, including reusable items and durable medical equipment is cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standard. The policy also indicated the following: - II. Reusable items are cleaned and disinfected or sterilized between residents. - VI. Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturer's instructions. Observations on 05/22/2024 at 4:12 PM revealed Licensed…

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 one of three residents, (Resident 3), was assisted with his meal in a dignified manner when the Certified Nursing Assistant (CNA 2), stood over the resident. This failure caused Resident 3 to feel rushed and had the potential for compromised dignity. Findings: On November 29, 2023, at 11:48 a.m., an unannounced visit to the facility on a complaint investigation was initiated. On November 29, 2023, at 1:15 p.m., observed Resident 3 sitting in a wheelchair in the hallway. Resident 3's lunch tray was on the over-bed table in front of Resident 3. CNA 2 was standing beside Resident 3 as he was feeding Resident 3. On November 29, 2023, at 1:34 p.m., an interview was conducted with Resident 3. Resident 3 stated he needed assistance with eating his lunch. Resident 3 stated he felt rushed while CNA 2 was assisting him with lunch. On November 29, 2023, at 1:58 p.m., an interview was conducted with CNA 2. CNA 2 stated that he should have been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure basic accommodations of needs were met when one of three residents, (Resident 1) ' s call light was not within reach. This failure had the potential for Resident 1 to have unmet needs and unable to call for assistance. Findings: On November 29, 2023, at 11:48 a.m., an unannounced visit to the facility on a complaint investigation was initiated. On November 29, 2023, at 12:54 p.m., observed Resident 1 sitting on the right side of his bed in a wheelchair. His over-bed table was in front of him, and his call light was on the left side of the bed on the floor, outside of Resident 1 ' s reach. On November 29, 2023, at 12:54 p.m., an interview was conducted with Resident 1. Resident 1 stated he used his call light to call for assistance. Resident 1 stated he would not be able to reach his call light and was concerned that he could not call for assistance. On November 29, 2023, at 1:19 p.m., an interview was conducted with the Certified…

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 assess the need for duplicated medication (Depakote-medication for seizure and mood stabilizer for behavior management) to manage behavior for one of five sampled residents (Resident 1). This failure had resulted for Resident 1 to receive two different forms of Depakote for 11 days which could potentially cause drug adverse reaction, complication, and hospitalization. Findings: On August 7, 2023, at 10:25 a.m., an unannounced visit was conducted to investigate quality care issues. On August 7, 2023, Resident 1 ' s record was reviewed. The Physician ' s Order by Licensed Vocational Nurse (LVN) 1, dated 06/27/2023, at 4:54 p.m., indicated an order for, Depakote ER Oral Tablet Extended Release 24 Hour 500 MG (Divalproex Sodium) Give 1 tablet by mouth at bedtime for SCHIZOAFFECTIVE DISORDER (D/O) BIPOLAR TYPE (mental illness that can affect thoughts, mood, and behavior) MANIFESTED BY (M/B) MOOD SWINGS INFORMED CONSENT (I/C) OBTAINED BY MEDICAL DOCTOR (M/D). The resident ' s record further indicated another order from…

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

Based on interview and record review, the facility failed to prevent administration of unnecessary medication to one of five sampled residents (Resident 1), when Resident 1 was administered with Depakote (medication used to treat seizures and bipolar disorder)DR (delayed released -delayed release of drugs in the body) and Depakote ER (extended released-drug is released slowly to provide a prolonged therapeutic effect), at bedtime without adequate indication for duplicated use. The facility failure had resulted in Resident 1 receiving unnecessary medication for 11 days which could potentially cause drug adverse reaction, complications, and unnecessary hospitalization. Findings: On August 7, 2023, at 10:25 a.m., an unannounced visit was conducted to investigate quality care issues. On August 7, 2023, Resident 1 ' s record was reviewed. The Physician ' s Order by Licensed Vocational Nurse (LVN) 1, dated 06/27/2023, at 4:54 p.m., indicated an order for, Depakote ER Oral Tablet Extended Release 24 Hour 500 MG (Divalproex Sodium) Give 1 tablet by mouth at bedtime for SCHIZOAFFECTIVE…

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, for three of five residents reviewed for PASRR (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care): a. The evaluation for PASRR level II (identifies the specialized services required by the resident) was cooordinated with State-Designated Authority (SDA), for Resident 75. This failure may result to the facility's inability to incorporate PASRR Level II evaluation in the resident's care plan. In addition, Resident 75 specialized services were not met, and b. PASRR level I assessment was coded accurately for Residents 51 and 67. This failure had the potential to result in admitting residents that were not appropriate in the facility and for Residents 51 and 67 not to receive the appropriate services. Findings: a. A review of Resident 75's record, indicated she was admitted to the facility on [DATE], with diagnoses which included encephalopathy (brain disease, damage, 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 provide treatment and care in accordance with the professional standards of practice for two of 18 residents reviewed (Residents 67 and 88) when: 1a. The licensed nurse did not clarify the dose of the medication Roxanol (Morphine: opioid medicine used to treat moderate to severe pain) with the physician for Resident 88. This failure had the potential for Resident 88 to receive the wrong dose of Roxanol; 1b. The intake and output was not monitored as ordered by the physician for Resident 88. This failure had the potential to result in fluid overload. 2. Turning and repositioning was not implemented in accordance to the schedule for Resident 67. This failure had the potential to result in skin breakdown for Resident 67. Findings: 1a. Resident 88's record was reviewed. Resident 88 was admitted to the facility on [DATE], with diagnoses which included old cerebrovascular accidents (stroke), ESRD ( End stage renal disease - long standing disease of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide restorative nursing services (nursing interventions that promote quality of life by increasing the resident level of strength and mobility and maintain his or her maximum functional capacity) as ordered by the physician for three of five residents reviewed for limited range of motion (ROM-the full movement potential of joint) (Residents 19, 52, and 67). This failure had the potential to result in the resident's decline in ROM and deterioration in their ability to perform activities of daily living (ADL). Findings: 1. On July 19, 2021, a review of Resident 19's record indicated that Resident 19 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), personal history of traumatic fracture (broken bone), and abnormal posture. A review of Resident 19's Minimum Data Set (an assessment tool) dated April 14, 2021, indicated .Section G .Functional Limitation in Range of Motion .Hip, Knee, Ankle, Foot…

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

Based on observation, interview, and record review, the facility failed to maintain safe food handling practices when: 1. The food products located in the resident's refrigerator were not labeled. 2a. The interior of the microwave oven was observed with dark yellowish substance; and 2b. The convection oven was observed with dust particles and dark brownish material. These failures had the potential to result in foodborne illnesses in the highly susceptible resident population. Findings. 1. On July 23, 2021 at 11:12 a.m., during the inspection of the resident's refrigerator in the Yellow zone with the Infection Preventionist (IP), the following were observed: a. One bag filled with multiple sandwiches was found not labeled with names and date; b. One white plastic bag containing food was not labeled with name and date; c. One brown paper bag with a glass container with food inside, was not labeled with name and date. A concurrent interview was conducted with the IP. The IP stated all food in the resident's refrigerator should be labeled with a name and date. The IP stated the bag of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure for two of eight residents reviewed: 1. An Advance Directive (written instruction, such as a living will or durable power of attorney for healthcare, recognized under State Law, relating to the provision of healthcare when the individual is incapacitated) was discussed with their responsible party, for Resident 43; and This failure had the potential for the residents to not receive their preplanned treatment and services in the event they were incapacitated and/or unable to speak for themselves. 2. The Advance Directive was in the medical chart and easily accessible to the staff for Resident 51. This failure had the potential for Resident 51's Advance Directive to not be readily retrievable by the staff, by the physician, not knowing the wishes of the resident regarding medical treatment. Findings: 1. Resident 43's record was reviewed. Resident 43 was admitted to the facility on [DATE], with diagnosis which included cerebrovascular disease…

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 licensed nurse notified the physician of the resident's change of condition for one of 18 residents reviewed (Resident 88). This failure had the potential for Resident 88 not to receive the appropriate treatment to address his medical needs. Findings: Resident 88's record was reviewed. Resident 88 was admitted to the facility on [DATE], with diagnoses which included old cerebrovascular accidents (stroke), ESRD ( End stage renal disease - long standing disease of the kidneys leading to renal failure) on hemodialysis (medical procedure to remove fluid and waste products from the blood), Hepatitis C (infection caused by a virus that attacks the liver and leads to inflammation). Resident 88's record titled, Physician Order, indicated, DNR (instructs health care providers not to do cardiopulmonary resuscitation [CPR] if a patient's breathing stops or if the patient's heart stops beating). SELECTIVE TREATMENT, HOSPITAL TRANSFER ONLY IF COMFORT…

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 address a concern on room temperature during mealtime, for one of sixteen residents observed (Resident 25). This failure had the potential to result in resident not having the quality of life she deserved. Findings: On July 19, 2021, at 12:02 p.m., during dining observation, Resident 25 while waiting for her lunch tray, the resident complained to the staff that she was freezing cold. There was no response from the staff. On July 19, 2021, at 12:18 p.m., Restorative Nursing Assistant (RNA) 3 was observed beside Resident 25. Resident 25 informed RNA 3, the room was cold. On July 19, 2021, at 12:29 p.m., Resident 25 complained to RNA 3, the room was cold. RNA 3 stated this is the coldest room in the facility. On July 19, 2021, at 12:47 p.m., Resident 25 was observed beside Licensed Vocational Nurse (LVN) 4. Resident 25 stated it's always this cold. LVN 4 stated the room was cold. On July 19, 2021, at 12:50 p.m., Resident 25 stated she did not like it when the room was cold. LVN 4 stated the cold air was directly…

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 care plan to address impairment in communication was implemented, when the language communication board was not accessible for the staff to use when providing care for one of five residents reviewed (Resident 62). This failure has the potential for the resident not to be able to effectively communicate his needs to the staff which could result in unmet needs. Findings: On July 19, 2021, at 11 a.m., Resident 62 was observed in the room, with eyes closed, not responsive, to greetings. On July 19, 2021, at 1:08 p.m., in an interview with Certified Nurse Assistant (CNA) 1, she stated Resident 62 understands only Spanish. She stated the resident responds with gestures. On July 19, 2021, at 3:25 p.m., CNA 1 was observed talking in Spanish to Resident 62. Resident 62 was observed staring at her, with no response. In a review of Resident 62's record, the record indicated the resident was admitted to the facility on [DATE], 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 observation, interview, and record review, the facility failed to ensure physician orders were followed in accordance with the professional standards of practice, for one of five residents (Resident 2), when Zinc (supplement) was not transcribed correctly and was not administered according to the physicians order for Resident 2. These failures had the potential for residents to experience unmet healthcare needs . Findings: 1. On July 21, 2021, at 10:20 a.m., an observation of medication administration (med pass) was conducted with Licensed Vocational Nurse (LVN) 5 for Resident 2. LVN 5 confirmed the order on the medication administration record (MAR) was for Resident 2. LVN 5 administered Zinc 220 mg (a unit of measure) one tab PO (by mouth). On July 21, 2021, at 3:30 p.m., in a concurrent interview and record review with LVN 2, she confirmed the telephone order (TO). LVN 2 stated the over the counter zinc supplement is only stocked in 220 mg. LVN 2 stated the licensed nurses should have called 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 an environment free of accident hazard, when a floor mat on the right side of the bed was not provided in accordance to the plan of care for one of four residents reviewed (Resident 19). This failure had the potential for Resident 19 to sustain injuries from a fall. Findings: On July 19, 2021, at 10:38 a.m., and on July 20, 2021, at 11:35 a.m., Resident 19 was observed lying in bed,with one floor mat on the left side of the bed. There was no floor mat observed on the right side of the bed. A review of Resident 19 record indicated the resident was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), personal history of traumatic fracture (broken bone), impulse disorder (condition in which a person has trouble controlling emotions or behaviors). The facility document titled, Morse Fall Risk Assessment, dated April 16, 2021, indicated, .Resident is High Risk. Implement high risk fall prevention…

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 address the pharmacy recommendation on Ativan (lorazepam- used to treat anxiety) use, for one of five residents reviewed for unnecessary medications (Resident 4). This failure had the potential for Resident 4 to receive Ativan unnecessarily. In addition, Resident 4 was not reevaluated by the physician prior to continuing the use of Ativan. Findings: A review of Resident 4's record indicated, she was admitted to the facility on [DATE], with diagnoses which included depression, and anxiety disorder (feeling of worry, nervousness). Resident 4's history and physical examination, dated January 2, 2021, indicated she has the capacity to understand and make decisions. Resident 4s Pharmacist recommendation April 5, 2021, indicated Ativan (Lorazepam) 0.5 mg Daily PRN (date ordered- 3/16/2021) Suggest discontinue the current order for PRN anxiolytic (anti-anxiety drugs). PRN anxiolytics should be initially ordered up to 14 days only. After 14 days, the order should…

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 expired and outdated medications were not stored and readily available for use. This failure could expose residents to expired medications with questionable potency and efficacy. Findings. On July 21, 2021, at 11:15 a.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 2, during a medication storage inspection in the designated yellow zone. One unopened box labeled; Geri-care Ear drops (carbamide peroxide 6.5% Ear wax removal solution) with expiration date of June 21, 2021, was observed stored in the top shelf of the medication storage cabinet. On July 21, 2021, at 11:20 a.m., LVN 2 stated the Geri-care Ear drops for ear wax removal should not have been in the cabinet past the expiration date. LVN 2 stated the medication was expired and should be disposed of according to the standards of the facility. On July 22, 2021, at 4:31 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated if any medication is noticed to be expired it would…

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, for two of 18 residents reviewed (Residents 49 and 79), the following: a. The routine A1C (blood test that measures blood sugar level over the past three months), CMP (comprehensive metabolic panel blood test often used to evaluate liver function, kidney function, and nutrient levels) and lipid panel (the amount of specific fat molecules called lipids in the blood) was obtained, as ordered by the physician for Resident 49. This failure resulted for the routine laboratory to not be completed as ordered which could result in the delay in Resident 49's care and treatment; and b. The urine analysis was reported to the physician promptly for Resident 79. This failure had the potential to result in the delay of care and treatment for Resident 79 medical condition. Findings: a. A review of Resident 49's record indicated Resident 49 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (condition that affects…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide specialized rehabilitative (rehab) services, as ordered by the physician, for one of two residents reviewed for rehab (Resident 59), when PT and OT did not evaluate and treat Resident 59. This failure had the potential to result in Resident 59's difficulty in attaining and maintaining her highest practicable level of physical, mental, functional, and psycho-social well-being. Findings: On July 19, 2021, at 4:17 p.m., Resident 59 was observed in bed. In a concurrent interview, Resident 59 stated she was admitted to the facility for neuropathy (a disease that causes weakness, numbness, and pain from nerve damage, usually in the hands and feet), and was supposed to get rehab services (PT and OT). Resident 59 stated she did not receive PT and OT evaluation and treatment. Resident 59's record was reviewed. Resident 59 was admitted to the facility on [DATE], with diagnoses which included: dry beriberi (a disease that causes neuropathy,…

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, for one of 18 residents reviewed (Resident 79), an adequate indication for the use of Macrobid (antibiotic to treat urinary tract infection ) . This failure had the potential to result in emergence of antibiotic resistant organisms. Findings: Resident 79's record was reviewed. Resident 79 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar level). Resident 79's document titled, Laboratory Report, dated July 14, 2021, indicated .UA (urine analysis) C.S (culture sensitivity) IF IND (if indicated) .CULTURE, URINE .Final .<10,000 cfu/ml (colony forming unit per milliliter) . No sensitivities required .Abnormal Summary .CHARACTER .slightly-Cloudy .PROTEIN .100 .GLUCOSE .>=500 .LEUKOESTERASE (presence of white blood cells in the urine) .Trace .WBC (white blood cells) .8 .BACTERIA .Small .MUCUS .Few . Resident 79's progress notes dated July 19, 2021, indicated, Received U/A result…

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, for two of five residents reviewed: a. Education was provided to Resident 65 when the resident refused the influenza vaccine. This failure did not honor the resident right to be notified in order to make an informed choice for Resident 65 regarding the vaccine. b. Education was provided to the resident's responsible party about pneumococcal vaccine (prevents infection by Streptococcus [bacterium that causes one of the most common and severe forms of pneumonia] [pneumonia-lung inflammation]), benefits and potential side effects. This failure did not honor the responsible party's right to be notified in order to make an informed choice for Resident 75 regarding the vaccine. Findings: a. A review of Resident 65's record indicated he was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (ESRD- inability of the kidney to make urine and remove waste from the blood) and heart failure (chronic, progressive…

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 accommodate the request for COVID 19 (Corona virus disease 2019- a respiratory disease caused by a virus that can be transmitted from person to person) vaccine for one of five residents reviewed for immunization for COVID 19 (Resident 78). This failure had the potential to result in Resident 78 not getting the protection from the virus. Findings: On July 19, 2021, at 8:56 a.m., during an interview with Resident 78, she stated she had a flu like symptom in the past that is why she requested to have the vaccine in the facility. Resident 78 requested the COVID 19 vaccine from the facility a month ago and she did not received it yet. During a review of Resident 78's record, she was admitted to the facility on [DATE], with diagnoses which included, fracture of the right tibia (larger bone of the leg) and post motor vehicular accident. Resident 78's history and physical exam dated June 19, 2021, indicated she was alert, and cooperative. On July 19, 2021, at…

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