Villa Health Care Center

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 (Resident A) five residents, residents with a multidrug- resistant organism (MDRO-bacteria and other microorganisms that have developed a resistance to one or more classes of antimicrobial drugs) was placed in a single room or cohorted with other residents with the same MDRO infection, according to the facility's policy and procedure. This failure had the potential to exposed Resident A's two susceptible roommates to acquiring an infection. Findings: On August 5, 2024, at 9 a.m., an unannounced visit was conducted at the facility for the investigations of three complaints. On August 5, 2024, at 10 a.m., two Certified Nursing Assistants (CNAs) were observed caring for a resident in bed one, wearing gloves. A sign outside the room, indicated, Contact Isolation (a set of precautions used in healthcare facilities to prevent the spread of germs from patients with illnesses that can be transmitted through direct or indirect…

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 record reviews, interviews, and facility document and policy review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for 1 (Residents #37) of 5 sampled residents reviewed for unnecessary medications and 1 (Resident #17) of 4 sampled residents reviewed for accidents. Specifically, the facility failed to ensure Resident #37's use of psychotropic medications and Resident #17's fall event was accurately coded on their MDS assessments. Findings included: A review of a facility policy titled Resident Assessments, revised in September 2023, revealed, 8. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 9. All resident assessments completed within the previous 15 months are maintained in the resident's active clinical record. The results of the assessments are used to develop, review, and revise the resident's comprehensive care plan. 1. A review of Resident #37's admission Record indicated the facility admitted the resident on 10/20/2023 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 observations, interviews, record review, and facility policy review, the facility failed to ensure pressure injury interventions ordered by the physician were implemented for 1 (Resident #12) of 1 sampled resident reviewed for pressure injury prevention. Findings included: A review of a facility policy titled, Prevention of Pressure Injuries, revised in September 2023, revealed, Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. A review of an admission Record reveled the facility most recently admitted the resident on 06/19/2023 with diagnoses that included type two diabetes mellitus and hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness affecting one side of the body) following cerebral infarction (stroke). A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/23/2024, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. According to the MDS, 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 observations, interviews, record review, and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%). The facility had 2 medication errors out of 36 opportunities, affecting 1 (Resident #19) of 9 residents reviewed during the medication administration task, resulting in a medication error rate of 5.56%. Findings included: A review of a facility policy titled, Administering Medications, revised in April 2023, revealed, 4. Medications are administered in accordance with prescriber orders, including any required time frame. The policy further indicated, 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. A review of an admission Record revealed the facility admitted Resident #19 on 03/13/2020 with diagnoses that included hypertension (high blood pressure). A review of Resident #19's Order Summary Report, listing active orders as of 04/12/2024, revealed an order dated 11/29/2022 for amlodipine 5 milligrams (mg)…

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 no significant medication errors occurred for 1 (Resident #19) of 9 residents reviewed during the medication administration task. Specifically, staff failed to hold Resident #19's amlodipine when the resident's heart rate was outside the parameters specified by the physician's order. Findings included: A review of a facility policy titled, Administering Medications, revised in April 2023, revealed, 4. Medications are administered in accordance with prescriber order, including any required time frame. The policy further indicated, 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. A review of an admission Record revealed the facility admitted Resident #19 on 03/13/2020 with diagnoses that included hypertension (high blood pressure). A review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/10/2024, revealed Resident #19 had a Brief…

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 a written Notice of Discharge (a notice informing the resident of their discharge date , and their rights to appeal the discharge) was provided to the resident and/or resident representative prior to the date of discharge from the facility, for two of three residents reviewed (Residents 1 and 2). In addition, the facility failed to ensure the State Long Term Care Ombudsman (Ombudsman) was provided a copy of the written Notice of Discharge for Residents 1 and 2. These failures could have resulted in Residents 1 and 2 not to be aware of their rights to appeal the discharge and the Ombudsman to not be able to inform the residents of their rights and options to appeal prior to the resident being discharged . Findings: On March 13, 2024, at 7:55 a.m., an unannounced visit was conducted with the facility to investigate a quality of care issue. 1. On March 13, 2024, a review of Resident 1's face sheet, indicate the resident was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. The facility failed to notify the California Department of Public Health (CDPH) of an outbreak of COVID-19 (a contagious respiratory infection) and respiratory synctial virus infection (RSV - a contagious respiratory infection) according to the facility's policy and procedure and CDPH guidelines; 2. The facility staff failed to wear the appropriate personal protective equipment (PPE - equipment used to prevent or minimize exposure to infections) while providing care to a COVID-19 positive resident, in accordance with the facility's policy and procedure and Centers for Disease Control and Prevention (CDC) guidelines; and 3. A licensed nurse reported to work without testing for COVID-19 after exposure to COVID-19 positive residents. The licensed nurse developed COVID-19 symptoms and was tested positive for COVID-19. In addition, the facility did not conduct active screening 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 ensure laboratory services were provided as ordered by the physician, for one of three sampled residents (Resident 1). This failure had the potential to delay the care and treatment for Resident 1. Findings: On February 1, 2024, at 11:14 a.m., during an interview with Resident 1's representative (RP), she stated the facility failed to include the resident's laboratory results the physician needed for the appointment. She stated the physician had his office contact the facility and they waited for 20 minutes or so for the results to be faxed over. She stated the facility did not fax the laboratory results, and the physician was upset and told them the visit was a waste because he could not evaluate the effectiveness of the resident's medications on his one kidney. On February 1, 2024, Resident 1's record was reviewed. A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included…

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 residents and resident representatives were notified timely of an outbreak of COVID-19 in the facility in accordance with the facility's policy and procedure. This failure resulted in residents and their representatives not informed of the resident's status and placed the residents and representatives at risk for contracting the communicable diseases. Findings: On January 30, 2024, a review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (the heart not able to pump blood efficiently), hypertension, chronic renal disease, and diabetes mellitus (abnormal blood). The record further indicated the resident ' s family member as the resident ' s representative/emergency contact. On January 30, 2024, at 1:55 p.m., during an interview with the Infection Preventionist (IP), she stated the facility had one symptomatic resident tested positive 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 ensure a safe discharge was provided for one of three sampled residents (Resident 1) when, there was no documented evidence that options for alternative living and resources for home care services were provided upon discharge. This failure had the potential for Resident 1 to not have the care and assistance needed at home, (which placed Resident 1 at risk for not doing ADL's (activities of daily living includes bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet and eating) and increased the risk for Resident 1 to be transferred to the general acute care hospital. Findings: On January 3, 2024, at 8:18 a.m., an unannounced visit was conducted at the facility to investigate a complaint on admission, transfer, and discharge rights issue. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included unspecified fracture (break in continuity)…

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 necessary care and treatment services were provided, for two of 23 residents reviewed (Residents 32 and 10) when: 1. For Resident 32, the uncontrolled blood sugar levels were not evaluated and referred to the physician for appropriate management. This failure had the potential for Resident 32 to be at risk for complications related to diabetes mellitus (abnormal blood sugar); and 2. For Resident 10, a plan of care was not developed and staff failed to monitor and manage the implantable cardiac defibrillator (ICD - a device placed under the skin to monitor heart rhythm and detect irregular heartbeats). This failure had the potential for Resident 10 to not receive appropriate and timely interventions in the care and management of an ICD. Findings: 1. On June 28, 2021, Resident 32's record was reviewed. Resident 32 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus. The plan of care, dated November…

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 implement proper storage and timely disposal of medications when: 1. Discontinued medications were stored in the medication cart and readily available for use. This failure had the potential for the resident to receive discontinued medication and/or medication administration error to occur; 2. Medications requiring refrigeration, as per the manufacturer's recommendations, were not stored in the refrigerator. This failure had the potential for the residents to receive medications with decreased efficacy; and 3. Medications of discharged residents were not disposed timely and were still stored in the medication room and readily available for use. This failure had the potential for the medications to be administered to other residents. Findings: On June 30, 2021, at 3:11 p.m., Medication Cart 1 was inspected with Licensed Vocational Nurse (LVN) 3. The following medications were found stored inside the medication cart, readily available 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.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services and food were stored in accordance with professional standards for food service safety when: 1. Two apple sauce cups were stored in the refrigerator past the use-by-date and readily available for use; 2. 12 gelatin cups were stored in the refrigerator past the use-by-date and readily available for use; 3. 36 cans of cranberry cocktail juice were stored past the use-by-date; and 4. One opened container of chlorine water test strips was observed to be expired. These failures had the potential for the growth of harmful microorganisms which may result in food-borne illnesses in a medically-vulnerable population. Findings: On June 28, 2021, at 9 a.m., an initial kitchen tour was conducted with the Dietary [NAME] (DC). Two apple sauce cups and 12 gelatin cups were observed in a plastic bin, in the refrigerator. The two apple sauce cups and the 12 gelatin cups had a use-by-date of June 26, 2021, readily available for use. In a concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: a. The oxygen tubing was changed every seven days as per the facility's policy and procedure, for one of one resident reviewed for respiratory care (Resident 256); This failure had the potential for the growth of harmful microorganisms and for the resident to develop respiratory infection. b. The staff was wearing the appropriate personal protective equipment (PPE) when she was in the resident's room (Resident 252), who was on required transmission-based precautions for Covid-19 (contagious respiratory infection); c. The resident (Resident 17) was transferred to a non-isolation room after completing the 14 days of quarantine (practice of separating individuals who have had possible close contact with someone with a contagious disease) and multiple negative test results for Covid 19; These failures had the potential for the spread of Covid infection to residents and staff. d. The peripheral IV (intravenous line - catheter inserted…

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 Minimum Data Set (MDS-an assessment tool) accurately reflected the resident's status, when the order for hemodialysis (process of cleansing the blood of a person whose kidneys are not working normally) was not coded in the MDS, for one of 23 residents reviewed (Resident 37). This failure had the potential to result in delayed care/treatment or unmet needs for Resident 37. Findings: On July 1, 2021, Resident 37's record was reviewed. Resident 37 was admitted to the facility on [DATE], with diagnoses which included end stage renal (kidney) disease. The Order Summary Report, dated June 23, 2021, indicated, Hemodialysis 3x a week on Tuesday-Thursday-Saturday with chair time of 1:45 pm to 5:15 pm . On July 1, 2021, at 2:22 p.m., an interview and concurrent record review was conducted with the MDS Coordinator. She stated Resident 37 was admitted on [DATE], and had an order for hemodialysis. The MDS admission assessment, dated May 29, 2021,…

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 identify and document the mental illness in the Preadmission Screening and Resident Review (PASARR - a federal requirement to ensure individuals are not inappropriately placed in nursing homes for long term care) prior to the resident's admission to the facility, for one of two residents reviewed for PASARR (Resident 26). This failure had the potential for Resident 26 to not receive appropriate care and services in the facility. Findings: On July 2, 2021, Resident 26's record was reviewed. Resident 26 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and major depressive disorder (mood disorder). Resident 26's record indicated a PASARR Level 1 screen was conducted on May 30, 2021. Resident 26's PASARR Level 1 screening Section V did not indicate a diagnosis of mental illness such as depression. Resident 26's Minimum Data Set (MDS- a resident assessment tool), dated June 9, 2021 indicated a diagnosis 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 develop a plan of care (POC), for one of one resident reviewed for respiratory care (Resident 256), when the resident was placed on oxygen (supplemental air administered through a tubing) for shortness of breath (SOB). This failure had the potential for Resident 256 to not receive the appropriate respiratory treatment needed. Findings: On June 28, 2021, at 10:10 a.m., Resident 256 was observed awake and lying in bed, using an oxygen via NC (nasal cannula - device used to administer supplemental air through the nostrils) at two liters per minute. An undated plastic bag was observed hanging on the oxygen concentrator (machine which delivers supplemental air). On June 29, 2021, at 4:50 p.m., Resident 256's record was reviewed with the Licensed Vocational Nurse (LVN) 1. There was no documented evidence a POC was developed for respiratory care and for the use of oxygen for Resident 256. In a concurrent interview with LVN 1, she stated there…

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 plan of care (POC) was updated or revised, for one of 23 residents reviewed (Resident 32), when the resident required a fall alarm in the wheelchair to prevent falls or injuries. This failure had the potential to result in a delay of the implementation of appropriate interventions to address the care and treatment for Resident 32. In addition, this failure had the potential to place Resident 32 at risk for recurrent falls and/or injuries. Findings: On June 28, 2021, at 3:39 p.m., Resident 32 was observed wheeling inside the facility with a fall alarm placed behind his wheelchair. On July 1, 2021, Resident 32's record was reviewed. Resident 32 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss). The SBAR (Situation Background Assessment Record) Communication Form and progress note, dated May 18, 2021, indicated, .RESIDENT FELL FROM WHEEL CHAIR . The Progress Notes, dated May 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure metformin (medication used to treat high blood sugar levels) was administered with food, as ordered by the physician and according to current professional standards of practice, for one of five residents reviewed (Resident 27). This failure had the potential for the resident to experience medication adverse effects. Findings: On July 1, 2021, at 9:28 a.m., a medication administration observation with Licensed Vocational Nurse (LVN) 2 was conducted for Resident 27. Resident 27's medications included one tablet of metformin ER (extended release) 1000 mg (milligram - unit of measurement). LVN 2 was observed to dispense a medication from a bubble pack labeled, Metformin ER .Give with meals. LVN 2 was observed entering Resident 27's room and administered the ordered medications, including metformin, to Resident 27. Resident 27 swallowed all medications individually, taking medications with water. LVN 2 did not administer metformin 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 implement safety interventions in the prevention of falls and accidents, for one of five residents reviewed for falls (Resident 32), when a fall alarm was not provided to Resident 32 while in the wheelchair, as ordered by the physician. This failure resulted in the occurrence of another fall incident for Resident 32. In addition, this failure had the potential for Resident 32 to have recurrent falls. Findings: On June 28, 2021, at 3:39 p.m., Resident 32 was observed wheeling inside the facility with a fall alarm placed behind his wheelchair. On June 29, 2021, at 11:11 a.m., Resident 32 was observed standing at the nursing station with the wheelchair against the wall, approximately six to eight feet from the resident. The fall alarm was observed in the wheelchair but did not make an alarm sound. The Administrative Assistant (AA) was observed to redirect Resident 32 back to his wheelchair and attached the fall alarm to him. On July 1, 2021,…

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 care and treatment services to manage dementia (memory loss) related mood and behaviors were provided, for two of two residents reviewed (Residents 32 and 26) when: 1. For Resident 32, the psychiatrist's (physician treating mood & mental disorders) order for Depakote (medication to treat mood disorder) was not implemented as ordered. In addition, the Depakote level ordered by the psychiatrist was not referred back to him for appropriate treatment management. This failure had the potential for Resident 32's behavior to not be managed appropriately; and 2. For Resident 26, a plan of care to address dementia was not developed. This failure had the potential for the facility staff to not be aware of interventions to implement in managing behaviors related to dementia. Findings: 1. On June 28, 2021, at 10:36 a.m., Resident 32 was observed sitting in the wheelchair and was trying to exit through the front door. On June 28, 2021, at 3:38…

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 licensed nurses (LN) implemented the facility's policy and procedure on narcotic drug reconciliation and proper documentation in the narcotic count sheet, for one of 23 residents reviewed (Resident 32), when the narcotic count sheet for lorazepam (medication to treat anxiety [mood disorder]) injectable was not countersigned by another licensed nurse each time the medication was wasted. This failure had the potential for narcotic drug diversion (transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) to occur. Findings: On June 30, 2021, at 3:11 p.m., Medication Cart 1 was inspected with Licensed Vocational Nurse (LVN) 3. The narcotic box was inspected and observed to have four vials of lorazepam injectable with a label which indicated 2 mg (milligram - unit of measurement) / ml (milliliter - unit of measurement) for Resident 32. The LIQUID MEDICATION COUNT SHEET, 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 ensure PRN (as needed) orders for psychotropic medications (medications to treat mood and mental disorders) were limited to 14 days, unless the prescribing practitioner provided rationale to extend the medication, for one of two residents reviewed for psychotropic medication use (Resident 32). This failure had the potential to place Resident 32 at risk for receiving unnecessary psychotropic medication. Findings: On June 28, 2021, Resident 32's record was reviewed. Resident 32 was admitted to the facility on [DATE], with diagnoses which included anxiety disorder (mood disorder). The Minimum Data Set (MDS - an assessment tool), dated May 16, 2021, indicated Resident 32 had a BIMS (Brief Interview for Mental Status) score of four (severely impaired cognitive status). The physician's order, dated May 8, 2021, indicated, .Ativan (medication to treat anxiety) Solution (LORazepam) Inject 0.5 mg (milligram - unit of measurement) intramuscularly (injected…

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.