City Creek Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet professional standards of quality for one of 3 sampled residents (Resident 1) when nursing staff did not follow the physician's order to manually irrigate (unplug) the foley catheter (a soft rubber tubing inserted into the bladder to drain the urine) every shift. This failure resulted in Resident 1 having persistent hematuria (blood in urine) and had the potential to cause complications. Findings: A review of Resident 1's 'admission Record,' indicated Resident 1 was admitted to the facility from the hospital on [DATE], with multiple diagnoses including enlarged prostate (a walnut shaped male gland that causes urination difficulty when enlarged), urinary tract infection and hematuria. Resident 1's clinical record was reviewed as follows: Hospital documentation titled, 'SNF [ Skilled Nursing Facility] orders,' dated 12/27/23, indicated, Foley/Urinary Care orders .Please manually irrigate Foley every shift (q [every] 8 hours) or as needed .…

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

Based on observation, interview and record review, the facility failed to ensure the guidelines and procedures for infection prevention and control were maintained for one of three sampled residents (Resident 3), when the oxygen tubing was not dated or labeled. This failure had the potential to result in lung infection. Findings: Resident 3 was admitted to the facility in early 2024 with diagnoses which included COPD (Chronic Obstructive Pulmonary Disease, a lung disease) and lung failure. During a review of Resident 3's Order Summary Report (OSR), dated 1/26/24, the OSR indicated, Oxygen [O2] @ [at] 2 Liters/Min [liters/minute, a measurement of oxygen flow] Via Nasal Cannula [oxygen tubing] . Patient has shortness of breath/breathing discomfort. During a concurrent observation and interview on 1/30/24 at 12:21 p.m. in Resident 3's room, Resident 3 sat in bed, and at the bedside was a O2 concentrator turned on with an O2 nasal cannula connected to Resident 3 with no label or date. Resident 3 was awake and responded in his own language with signs and gestures when spoken to. During 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 interview and record review, the facility failed to suspend two staff members, an Occupational Therapist (OT) and Physical Therapist (PT), after an allegation of sexual abuse was made against them. This failure decreased the facility's potential to protect residents from potential abuse and mistreatment for a census of 96 residents. Findings: A review of Resident 1's admission record, dated 9/12/23, indicated Resident 1 was initially admitted to the facility in Winter of 2021 with diagnoses which included severe obesity, anxiety disorder, major depressive disorder (a mental health disorder characterized by a persistently depressed mood, or loss of interest in activities impairing daily life), and cognitive communication deficit (difficulty with thinking and how someone uses language). In a phone interview on 9/13/23 at 9:29 a.m. with the Marketing Director (MD), the MD stated she visited Resident 1 at the hospital on 9/7/23, when Resident 1 alleged OT and PT staff members sexually abused her during her previous stay at the facility. The MD stated she notified 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.

Based on observation, interview and record review, the facility failed to ensure sufficient staff with competent skills to carry out functions of the food and nutrition service for 87 residents, when: 1. The Dietary Manager (DM) did not meet the education qualification requirements as required to carry out the functions of the food and nutrition services; and 2. The facility failed to ensure a full-time Registered Dietitian (RD) provided frequently scheduled consultation to the DM on food safety and sanitation, food preparation, meal service and food storage for residents receiving meals from the kitchen. These failures had the potential to result in lapses in the delivery of food and nutrition services associated with meal distribution accuracy, and unsafe food handling and sanitation for food service operations. Findings: During the kitchen observation from July 10 to July 14, 2023, multiple issues surrounding the delivery of dietetic services were identified which included: 1. The menu/recipe were not followed, and the portion size of food items were not served correctly; 2. The…

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

Based on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for a census of 89 when: 1. A facility ice machine located in the kitchen was found soiled with a significant amount of black, brown, green, and yellow slimy substances on the inner surfaces where the ice was produced. The dining room ice dispenser (uses the ice from the facility ice machine) was found with an orange slimy substance at the dispenser opening; 2. Food items were found with incorrect or no labeling for received, opened, and use-by dates in the freezer; 3. Expired food items were available for use in the dry storage area and refrigerator; 4. Food items were opened and not contained properly in the dry storage area; 5. Spoiled produce was found in the dry storage area and the refrigerator; 6. The facility did not have a proper thawing process for the frozen nutritional supplement drinks (drinks that provide additional calories and nutrients); and 7. A box of thawing bacon was found in the refrigerator…

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 comprehensive assessment, treatment and care were provided in accordance with professional standards of practice for one of 25 sampled residents (Resident 593), when the resident's request for side rails to use for mobility was not appropriately evaluated. This failure resulted in the Resident's 593's inability to move around in bed, removing her neck collar frequently due to pain, and had the potential to result in not maintaining her highest practicable well-being. Findings: Resident 593 was admitted in the middle of 2023 with multiple diagnoses which included fracture of the neck and fracture of the right foot. During a review of Resident 539's Order Summary Report (OSR), dated 7/8/23, the OSR indicated, [Neck] collar to be worn at all times every shift. During a review of Resident 593's Nursing Care Plan (NCP), dated 7/8/23, the NCP indicated, [Resident 593] has an ADL [activities of daily living] self-care performance deficit r/t [related to] .Impaired balance, Limited Mobility .C2 [2nd cervical vertebra, neck]…

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 medications requiring refrigeration were kept in the refrigerator as specified by the pharmacy for a census of 89. This failure had the potential for residents to be given expired or deteriorated medications, which could be ineffective in treating their medical conditions. Findings: During an inspection of medication cart 1 on [DATE] at 10:35 a.m., one vial of unopened latanoprost eye drop, a medication used to lower the pressure in the eye, 0.005%, unit of measure, one box of unopened regular human insulin, medication to lower blood sugar level, U-100, unit of measure, were found in room temperature stored in the medication cart. During an interview on [DATE] at 10:35 a.m., with Licensed Nurse 1 (LN 1), LN 1 confirmed both the eye drop vial and insulin box were unopened. LN 1 stated, According to the pharmacy labels, refrigerate before opening .they needed to be in the refrigerator since they were not in use .the NOC [Nocturnal,…

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

Based on observation, interview and record review, the facility failed to ensure the menu was followed for the therapeutic diet (a modification of a regular diet tailored to fit the nutritional needs of a resident, and a part of a treatment or medical condition prescribed by a physician) during the lunch meal for 31 residents in a census of 89, when: 1. Fourteen residents (Resident 3, Resident 9, Resident 11, Resident 13, Resident 15, Resident 18, Resident 36, Resident 38, Resident 43, Resident 52, Resident 62, Resident 67, Resident 73, and Resident 76) received green beans as a substitute for baked fresh zucchini; 2. Three residents (Residents 67, Resident 69, and Resident 590) were provided three ounces (#10 scoop) of polenta (yellow cornmeal) instead of two ounces (#16 scoop) of polenta for residents with small portions as part of their ordered diets; 3. Thirteen residents (Resident 5, Resident 16, Resident 19, Resident 29, Resident 30, Resident 32, Resident 33, Resident 34, Resident 35, Resident 37, Resident 40, Resident 56, and Resident 68) were provided the incorrect puree…

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

Based on observation and interview, the facility failed to ensure essential equipment was working for four of 25 sampled residents (Resident 56, Resident 69, Resident 35, and Resident 38), when their call lights did not turn on. This failure had the potential to result in the residents not being able to ask staff for assistance. Findings: Resident 69 was admitted to the facility in early 2022, with diagnoses which included anxiety, lung disease, and depression. Resident 56 was admitted to the facility in late 2021, with diagnoses which included dementia (loss of memory), anxiety, and depression. Resident 35 was admitted to the facility in late 2016, with diagnoses which included hemiplegia and hemiparesis (loss of functional mobility), anxiety, and schizophrenia (inability to think, feel and behave clearly). Resident 38 was admitted to the facility in mid-2022, with diagnoses which included atrial fibrillation (irregular heartbeat), and heart disease. During an observation on 7/10/23 at 8:45 a.m., in Resident 56, Resident 69, Resident 35, and Resident 38's rooms, the calls lights…

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 dignity was provided for two of 25 sampled residents (Resident 19 and Resident 73), when: 1. Resident 19's room was bare and empty and personal belongings were removed; and 2. Resident 73's room was bare and empty. These failures had the potential to negatively impact the residents' quality of life and psychosocial well-being. Findings: 1. Resident 19 was admitted to the facility in the middle of 2018 with diagnoses which included depression and communication deficit. During a review of Resident 19's Minimum Data Set (MDS, an assessment tool), dated 5/18/23, the MDS indicated Resident 19 had severe memory impairment and needed extensive assistance with activities of daily living (ADLs). During an observation on 7/10/23 at 10:38 a.m., Resident 19's room had no personal belongings and the walls were bare and empty. During an interview on 7/10/23 at 10:39 a.m. with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated, I see the side of [Resident 19] is totally bare and the other side has the other…

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

Based on observation, interview and record review, the facility failed to ensure the resident needs were accommodated for one of 25 sampled residents (Resident 73), when the call light button and pitcher of water was not reachable. These failures had the potential to result in Resident 73 not attaining his highest practicable physical and psychosocial well-being. Findings: Resident 73 was admitted to the facility in the middle of 2022 with diagnoses which included memory impairment, anxiety, repeated falls, and post-traumatic stress disorder. During a review of Resident 73's Minimum Data Set (MDS, an assessment tool), dated 6/20/23, the MDS indicated Resident 73 had moderate memory impairment and needed extensive assistance with activities of daily living. During a concurrent observation and interview on 7/10/23 at 10:45 a.m., Resident 73 was lying in bed, awake, alert and verbally responsive. Resident 73's call light button was unreachable and found on the floor, and the bedside table with a water pitcher was at a distant away from the bed. Resident 73 stated, I don't know how to…

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

Based on observation, interview, and record review, the facility failed to ensure a safe, clean and comfortable environment was provided for one of 25 sampled residents (Resident 19), when Resident 19's room was found with scattered food on the floor. This failure had the potential to result in Resident 19's not maintaining her highest practicable quality of life and psychosocial well-being. Findings: Resident 19 was admitted to the facility in the middle of 2018 with diagnoses which included depression and communication deficit. During a review of Resident 19's Minimum Data Set (MDS, an assessment tool), dated 5/18/23, the MDS indicated Resident 19 had severe memory impairment and needed extensive assistance with activities of daily living. During an observation on 7/10/23 at 10:38 a.m., Resident 19's room had several scattered food items on the floor below his bed and was not cleaned. During a concurrent observation and interview on 7/10/23 at 10:40 a.m. with CNA 4, CNA 4 verified the scattered food on the floor of Resident 19's room, and stated, I didn't clean this room out 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.

Based on interview and record review, the facility failed to ensure one of 25 sampled residents (Resident 16) was free from restraints, when several pillows were lined on both sides adjacent to the resident's body. This failure had the potential to limit Resident 16's freedom of movement. Findings: Resident 16 was admitted to the facility in early 2022 with diagnoses which included dementia (memory loss), anxiety, and schizophrenia (inability to think, feel and behave clearly). During a review of Resident 16's Minimum Data Set (MDS, assessment tool) dated 4/26/23, the MDS indicated Resident 16 had severe memory impairment. During a review of Resident 16's Order Summary Report (OSR) dated 7/23, the OSR indicated no restraint order. During an observation on 7/10/23 at 1:41 p.m., Resident 16 was observed lying in bed with several pillows stuffed under the sheets on both sides of her bed. During a concurrent observation and interview on 7/10/23 at 2:06 p.m., with Certified Nursing Assistant 4 (CNA 4) in Resident 16's room, CNA 4 confirmed Resident 16 had pillows tucked under the sheets…

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, staff interview and record review, the facility failed to implement pharmaceutical policies and procedures for one in a census of 89 when Resident 36 received an incorrect probiotic, a medication used for digestive and immune support. This failure had the potential to negatively affect Resident 36's quality of health. Findings: During an observation of medication administration on 7/11/23 at 9:10 a.m., Licensed Nurse 1 (LN 1) was observed preparing and administering Resident 36's morning medications which included a probiotic capsule, saccharomyces, a type of yeast/fungus probiotic. During a reconciliation of the observation of medication administration with Resident 36's current physician orders on 7/11/23, the physician's orders indicated, Lactobacillus [a type of bacterial probiotic] give one capsule by mouth one time a day . During an interview on 7/11/23 at 10:30 a.m., with LN 1, LN 1 stated, The product dispensed, saccharomyces, was not the prescribed product, lactobacillus. The two products were different. During an interview on 7/11/23 at 1:30 a.m.,…

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

Based on observation, interview and record review, the facility failed to ensure the infection prevention and control program guidelines and practices were maintained for one of 25 sampled residents (Resident 61), when unlabeled oxygen (O2) tubing and outdated nebulizer mask were found at the bedside and not placed in a bag. This failure had the potential to result in Resident 61 acquiring a lung infection. Findings: 1. Resident 61 was admitted in the middle 2023 with diagnoses which included morbid obesity and asthma (lung inflammation, narrowing and swelling causing difficulty breathing). During a review of Resident 61's Minimum Data Set (MDS, an assessment tool) dated 6/19/23, the MDS indicated Resident 61 had no memory impairment, needed breathing treatment, and required limited assistance with activities of daily living. During a review of Resident 61's Order Summary Report (OSR) dated 6/15/23, the OSR indicated, Albuterol sulfate [medication for asthma] .Nebulization solution inhale the content of 1 vial by mouth via nebulizer every 6 hours as needed for dyspnea [breathing…

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 privacy for two of 24 sampled residents (Resident 2 and Resident 8) when no privacy curtains were installed and available for use during resident care. This failure placed Resident 2 and Resident 8 at risk for humiliation and psychosocial distress. Findings: Resident 2 was admitted to the facility in 2020 with multiple diagnoses which included lack of normal development in childhood and absence of a breast. Review of Resident 2's most recent Minimum Data Set (MDS, an assessment tool), dated 4/9/21, indicated her cognition (referring to the mental processes involved in gaining knowledge and comprehension) was severely impaired. Resident 2 required limited to extensive assistance with her activities of daily living (ADLs). Resident 8 was admitted to the facility in 2016 with multiple diagnoses which included memory impairment. Review of Resident 8's most recent MDS, dated [DATE], indicated her cognition was severely impaired and she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a baseline care plan (BCP) for five of 24 sampled residents (Residents 182, 185, 186, 188 and 196) were completed and a copy provided to the resident or the resident's responsible party (RP). This failure had the potential to leave the residents and the responsible parties with no information summarizing the goals, medications, treatments, diet and discharge plans. Findings: 1. Resident 182 was admitted to the facility in early 2021 with diagnoses which included stroke, difficulty walking, anxiety and depression. A review of Resident 182's clinical record revealed no documented evidence of a completed BCP or a copy provided to the resident. A review of Resident 182's Minimum Data Set (MDS, an assessment tool), dated 4/24/21 indicated Resident 182 had moderate memory impairment and needed limited assistance with activities of daily living (ADLs). During a concurrent observation and interview on 5/3/21 at 9:43 a.m., Resident 182 was tearful, lying…

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 of facility documents, the facility failed to provide resident-centered activities program with a sample of 24 on a census of 89 when five of the newly admitted residents (Residents 186, 188, 189, 190, and 191) did not have a baseline activities assessment. This failure placed Resident 186, Resident 188, Resident 189, Resident 190, and Resident 191 at risk for a decline in physical, mental, and psychosocial well-being. Findings: A review of Resident 186's clinical record indicated admission to the facility in early 2020 with diagnosis of chronic obstructive pulmonary disease (COPD, a type of lung disease characterized by long-term breathing problems and poor airflow). No activities assessment was available in the record. A review of Resident 188's clinical record indicated admission to the facility in early 2020 with the diagnosis of COPD. No activities assessment was available in the record. A review of Resident 189's clinical record indicated admission to the facility in early 2020 with diagnosis of intracerebral hemorrhage (sudden…

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 of facility documents, the facility failed to provide resident-centered activities program with a sample of 24 on a census of 89 when the activities personnel was not qualified to assess the residents. This failure had the potential risk for a decline in the residents' health status and well-being. Findings: During an interview with the Activities Assistant (AA) on 5/3/21 at 9:48 a.m., AA stated, There is no Activities Director [AD] at the moment. During an interview with the AA on 5/4/21 at 3:33 p.m., AA stated, The AD left a week and a half ago and I have been filling in for the position. I plan to take the certificate for the AD position. There is no licensed AD in the facility. During an interview with the AA on 5/5/21 at 10:34 a.m., the AA stated, The previous AD left on 4/15/21. I have been doing the job since 4/26/21. I am learning how to do the assessments. The plan is for me to learn and get the certification. I have been the AA since 1/3/21. During an interview with the Administrator (ADM) on 5/5/21 at 1:22 p.m., ADM…

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

Based on observation, interview, and record review, the facility failed to ensure that it was free of medication error rates of five percent or greater for a census of 89 when, the facility medication error rate was 17.86%. This failure had the potential to result in a negative outcome. Findings: During a medication administration observation on 5/4/21, at 7:36 a.m., Licensed Nurse 3 (LN 3) was preparing medications for Resident 4, including: 1. 2 tablets of Aspirin 81 mg (milligram, a unit of measurement) 2. 1 tablet of Finasteride (medication to treat enlarged prostate) 5 mg 3. 1/2 tab of Metoprolol (medication to treat high blood pressure) 50 mg 4. 1 tab of Renavite (dietary supplement) no dosage on the bottle, order was 0.8 mg. 5. 1 tablet of Norco (pain medication) 10-325 mg. During an observation on 5/4/21, at 8 a.m., LN 3 combined and crushed all medications together in a small plastic pouch. LN 3 administered the medications all at once via g-tube (gastrostomy tube, a surgically placed device used to give direct access to the stomach). When asked about the process, LN 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.

Based on observation, interview, and record review, the facility failed to appropriately label and store drugs and biologicals for a census of 89 when, 1. An expired antibiotic medication was stored and available for use; and, 2. An accessed multi-vial dose vial was not labeled with opened date. These failures had the potential to result in unsafe administration of medication and contamination of biologicals. Findings: 1. During a concurrent observation and interview on 5/4/21, at 9:56 a.m., with the Acting Director of Nursing (ADON), in the medication storage room, an intravenous (IV - administered directly into a vein) medication was observed inside the medication refrigerator on a plastic box. The IV bag was filled with Cefepime (an antibiotic) 2 gm (grams - dose) prescribed for Resident 56. The IV medication had an expiration date of 4/23/21 and was stored together with other un-expired IV antibiotic medications. The ADON confirmed, the medication was expired and discontinued. The ADON acknowledged the expired IV antibiotic medication was stored with other non-expired IV…

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 review of facility documents, the facility failed to ensure access to the clinical record was readily available for one of 24 sampled residents (Resident 30) when physician progress notes were unavailable for reference in the electronic record for over one year. This failure increased the risk critical information would not be readily available to all departments. Findings: Resident 30 was admitted to the facility in 2016 with multiple diagnoses which included heart and lung disease, anxiety and depression, memory impairment and mental illness. Review of Resident 30's most recent MDS (Minimum Data Set, an assessment tool), dated 2/24/21, indicated her memory was severely impaired and needed limited to extensive assistance with most activities of daily living (ADLs). Review of Resident 30's physician progress notes revealed no physician documentation from 4/3/20 to 5/6/21 in the electronic or paper record. During an interview with the MDS Coordinator (MDSC) on 5/6/21 at 10:15 a.m., the MDSC checked the electronic record for physician progress notes, verified…

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 of facility documents, the facility failed to implement infection control and prevention practices in a census of 89 when: 1. A glucometer (a device used to measure blood sugar levels) with blood visible on the test strip, and a lancet (a small device used to puncture the skin to obtain a blood sample) were found on the bedside table of Resident 4. 2. Two windows with thick residues were observed in the clean side of the laundry area. 3. An electric fan covered with dust was found in the kitchen. 4. A licensed nurse entered an isolation room with no gloves. These failures increased the potential risk for the transmission of infectious diseases to the residents. Findings: 1. During a concurrent observation and interview with Licensed Nurse 3 (LN 3) on 5/4/21 at 8:20 a.m., a glucometer with blood visible on the test strip, and a lancet were observed on the bedside table of Resident 4. LN 3 indicated the lancet and test strip should have been disposed of and the glucometer should have been sanitized after use. During an interview on…

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

Based on observation, interview and review of facility documents, the facility failed to ensure one of 24 sampled residents (Resident 42) was treated with dignity when his catheter bag was not covered. This failure increased the potential risk for humiliation and psychosocial distress. Findings: Resident 42 was admitted to the facility in 2020 with multiple diagnoses which included bladder obstruction, kidney failure, a pressure ulcer and memory impairment. Review of Resident 42's physician orders, dated 6/23/20, indicated [name of] Catheter .Change Q [every] month and PRN [as needed] . Review of Resident 42's most recent Minimum Data Set (MDS, an assessment tool), dated 2/18/21, indicated he was alert and oriented and able to make his needs known. He required limited to extensive assistance with his activities of daily living (ADLs). Review of Resident 42's care plan titled, Presence of indwelling catheter ., revised 7/15/20, did not address the dignity issue or covering the catheter with a privacy bag. Review of Resident 42's, Monitoring Administration Record, dated 5/21, did not…

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 review of facility documents, the facility failed to ensure essential equipment was working for one of 24 sampled residents (Resident 36) when Resident 36's call light was not consistently available to use, and Resident 36 relied on her roommate to call for help. This failure placed Resident 36 at risk of not being able to ask staff for assistance. Findings: Resident 36 was admitted to the facility in 2020 with multiple diagnoses which included respiratory failure, diabetes (the condition in which the body cannot regulate sugar levels), incontinence (inability to control bladder), difficulty swallowing, and a mental illness. Review of Resident 36's most recent MDS (Minimum Data Set, an assessment tool), dated 2/22/21, indicated she had moderate cognitive (process of gaining knowledge and comprehension) impairment and required limited to extensive assistance with her activities of daily living (ADLs). During an initial tour observation and interview with Resident 36 on 5/3/21 at 10:50 a.m., Resident 36 indicated she had to yell for help from staff…

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

Based on observation, interview, and record review, the facility failed to develop an individualized comprehensive care plan for one of 24 sampled residents (Resident 73) when Resident 73's front tooth was broken. This failure had the potential to result in Resident 73 not receiving the necessary care and services to meet her highest practicable well-being. Findings: Resident 73 was admitted to the facility in middle 2020 with multiple diagnoses which included epilepsy (seizure) and dysphagia (difficulty swallowing). During a review of Resident 73's most recent quarterly Minimum Data Set (MDS, an assessment tool), dated 4/2/21, the MDS indicated Resident 73's cognition (process of gaining knowledge and comprehension) was moderately impaired. During a concurrent observation and interview on 5/3/21, at 9:24 a.m., Resident 73 was observed to have a broken front tooth. Resident 73 stated, I broke my front tooth when I had a seizure. During a review of Resident 73's Nurse's Progress Notes (PN), dated 4/8/21, at 10:23 a.m., the PN indicated, Resident 73 refused to go to the dental…

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

Based on observation, interview and record review, the facility failed to ensure a low air loss (LAL) mattress (mattress used for prevention of skin breakdown) was working for one of 24 sampled residents (Resident 2) when the LAL was unplugged. This failure increased the the potential risk for Resident 2 to experience skin breakdown. Findings: Resident 2 was admitted to the facility in 2020 with diagnoses which included low back pain, communication deficit, abnormality of gait (walking) and mobility, muscle weakness, and curvature of the spine. Review of Resident 2's care plan titled, Resident at risk for development of pressure ulcer/skin breakdown ., dated 7/4/20, included the intervention, LAL mattress for skin integrity. Review of Resident 2's Minimum Data Set (MDS, an assessment tool), dated 4/9/21, indicated Resident 2 had severe memory impairment, and required limited to extensive assistance with her activities of daily living (ADLs). Review of the Treatment Administration Record (TAR), dated 5/1/21 through 5/3/21, indicated Resident 2 had no monitoring of the LAL mattress.…

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 adequate pain management consistent with professional standards of practice was provided for one of 24 sampled residents (Resident 182), when the resident complained of pain and there was no documented evidence of pain medication administered on the electronic medication administration record (eMAR). This failure had the potential to negatively affect the resident's highest practicable physical, mental and psychosocial well-being. Findings: Resident 182 was admitted to the facility in early 2021 with diagnoses which included stroke, difficulty walking, muscle weakness, and depression. A review of Resident 182's physician's order, dated 4/18/21, indicated Acetaminophen [pain reliever] tablet 325 MG [milligram, a unit of measurement] Give 2 tablet by mouth every 8 hours as needed for Generalized Pain . A review of Resident 182's Physician's Order, dated 4/19/21, indicated Tramadol HCL [hydrochloride, a medication for moderate to severe pain] Tablet 50 MG Give 1 tablet by mouth every 8 hours as needed 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.