Double Tree Post Acute Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications of a discharged resident were removed from the nurse's medication cart and mixed with other residents' active medication supplies. This failure had the potential to result in medication errors when the medications were accidentally given by mistake to other residents. During a facility task observation, two medication carts were inspected on [DATE] at 1:21 p.m. Cart #3 was inspected together with Licensed Nurse 3 (LN 3). Inside med cart #3, the lower medication cart drawer contained oral, liquid, and topical medications of active residents. The same lower drawer also contained one box of lidocaine patch which belonged to a resident who was discharged on [DATE]. During a concurrent observation and interview with LN 3 on [DATE] at 1:21 p.m., LN 3 confirmed the resident's name imprinted on the 1 full box of lidocaine patch was already discharged last [DATE]. LN 3 stated medications of discharged residents 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.

Based on observation, interview and record review, the facility Registered Dietitian lacked the skill set to assess a non-English speaking resident (Resident 11) when language interpreter services were not utilized though the resident appeared to have lost 22 pounds during her 3 months at the facility. This failure had the potential of leading to further weight and muscle loss as well as malnutrition for Resident 11.Findings: During a concurrent observation and interview of the lunch meal on 1/20/26 at 12:36 p.m., Resident 11 was in bed, awake and alert. Resident 11 nodded to answer questions, but after a couple of questions Resident 11 stated she did not speak English and reported her preferred language. During a review of Resident 11's electronic medical record on 1/20/26 at 2:17 p.m. a weight variance note from 1/15/26 was observed. This note included the following weight history:Current wt (weight)=88# (pounds) 1/3/26=84#12/1/25=89#11/1/25=99.5#10/11/25=106# During a concurrent observation and interview on 1/21/26 at 8:27 a.m. with Resident 11, Certified Nursing Assistant 4 (CNA…

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 protect the resident's right to be free from abuse for one of seven sampled residents (Resident 1) when Resident 2 hit Resident 1 in the head.This failure resulted in Resident 1 having pain and dizziness and had the potential for Resident 1 to experience physical and/or psychosocial harm.Findings:During a review of Resident 1's clinical record, Resident 1 was admitted [DATE] with diagnosis that included Dementia (a progressive state of decline in mental abilities).During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) the MDS, dated [DATE] indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) BIMS score of 7 out of 15 which indicated Resident 1 had severe cognition impairment. During a review of Resident 2's clinical record, Resident 2 was admitted [DATE] with diagnosis that included chronic pain syndrome (pain that lasts longer than three months),…

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 protect the resident's right to be free from physical abuse for one (Resident 1) out of a census of 108 when Resident 1 was pushed by a visitor during an altercation.This failure resulted in Resident 1 not free from abuse by a visitor.Findings:During a review of Resident 1's admission Record (AR), indicated Resident 1 was admitted [DATE] with diagnosis including Alcohol Induced Psychotic Disorder- Unspecified.During a review of Resident's 1 Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 7/9/25 indicated Resident 1 had intact cognition.During a review of Resident 1's Care Plan (CP), indicated there was no documented evidence of a person-centered care plan, related to the potential risk of aggression. During a review of SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers for changes in residents' conditions) dated 7/1/25, it indicated that Resident 1…

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

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported timely within 2 hours for one of four sampled residents (Resident 1), when an allegation of abuse was reported to the department the following day.This failure reduced the potential to ensure resident safety.Findings:A review of a facility document titled, SBAR (Situation, Background, Assessment, Recommendation - a communication tool used by healthcare workers for changes in residents' conditions) note dated 7/1/25 indicated, .Writer [Licensed Nurse (LN) 3] was also approached by this Resident [1] and also got in writers face . Resident [1] got agitated, and pushed the visitor. visitor reacted and pushed back [Resident 1] as he was getting in his face as well with yelling and cursing. Primary Care Clinician notified 7/1/25 at 6:30 p.m.A review of Interdisciplinary Team (IDT) Follow up dated 7/2/25 at 9:48 a.m. indicated, . On 7/1/25, pm shift, res [1] was verbally aggressive to staff in the hallway. Staff asked him to calm down. Res [1] got close to charge nurses' face about 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 interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one of three sampled residents (Resident 2) when facility staff witnessed Resident 1 hit Resident 2. This failure resulted in Resident 2 not being free from abuse and had the potential for Resident 2 to be injured. Findings: Resident 1 was admitted [DATE] with diagnoses which included anxiety disorder and muscle weakness. A review of Minimum Data Set (MDS, an assessment tool), dated 7/30/24, indicated Resident 1 had intact cognition. Resident 2 was admitted [DATE] with diagnoses which included hemiplegia (muscle weakness or partial paralysis on one side of the body) and reduced mobility. A review of the MDS, dated [DATE], indicated Resident 2 had intact cognition. During an interview on 10/24/24, at 11:23 a.m. with the Director of Nursing (DON), the DON stated on the morning of 10/16/24, she was informed by Janitor (JN) that he witnessed Resident 1 and Resident 2 get into a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to verify, document, seal, and replace an opened E-Kit (emergency kit, a limited supply of medications in the facility to use during an emergency or after-hours) for a census of 116 residents. This failure had the potential to have expired pharmaceutical products, contribute to decreased availability of medications in an emergency or increase the risk of drug diversion. Findings: During a concurrent observation and interview on [DATE] at approximately 9:15 a.m. with Licensed Nurse (LN) 3 e-kit # 731 was observed to be kept unsealed in the north station medication storage room. LN 3 stated she did not know when the e-kit # 731 was opened and when the e-kit should have been replaced. LN 3 confirmed the opening of the e-kit # 731 was not logged in the e-kit logbook and the contracted facility pharmacy was never contacted for replacement and both pharmacy white labels were not signed by any pharmacists. During an interview with the Director of…

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

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for two of 28 sampled residents (Resident 31 and 103). 1. For Resident 31, Licensed Nurse (LN) 1 did not administer Resident's Humulin Insulin medication used to lower blood sugar level, in accordance with the Physician Order. 2. For Resident 31, LN 1 did not administer Resident's glipizide, a medication given 30 minutes before breakfast to lower blood sugar level, 5 mg (milligram, unit of measure) in accordance with the Physician Order. 3. For Resident 103, LN 1 administered lactobacillus, a probiotic to aid in digestion, without clarifying the Physician Order. These failures exposed the residents to possible adverse reactions and health complications. Findings: 1. During an observation of medication administration on 9/30/24 at 9:37 a.m., LN 1 was observed to prepare and administer Resident 31's morning medications which did not include Humulin R insulin. During a reconciliation (review of medications observed being administered against the physician…

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

Based on observation, interview, and record review, the facility failed to ensure one of 28 sampled residents, Resident 31 was free from significant medication errors when: 1. For Resident 31, Licensed Nurse (LN) 1 did not administer Resident's Humulin R Insulin, medication used to lower blood sugar level, in accordance with the Physician Order. 2. For Resident 31, LN 1 did not administer Resident's glipizide, medication to be given 30 minutes before breakfast used to lower blood sugar level, 5 mg (milligram, unit of measure), according to the physician order. These failures resulted in Resident 31's elevated blood sugar levels and subsequent signs and symptoms of high blood sugar (headache, dizziness, thirsty, and not feeling well), and had the potential to result in a diabetic coma (a life-threatening condition that occurs when someone with diabetes experiences dangerously high or low blood sugar levels, leading to unconsciousness). Findings: 1. During an observation of medication administration on 9/30/24 at 9:37 a.m., LN 1 was observed to prepare and administer Resident 31's…

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 medications were stored correctly, when: 1. Three unopened bottles of latanoprost ophthalmic solution, an eye drop medication used to treat an eye condition, 0.005% (percentage, unit of measure), 2.5 ml (milliliter, unit of measure) were not kept in the medication refrigerator per manufacturer's instructions before opening. 2. An opened glucose test strip bottle was found in the medication cart #1 did not have an open date to determine its expiration date. 3. An opened bottle of insulin lispro, medication used to treat high blood sugar levels, 100 unit/ml (unit per milliliter, unit of measure), was found in the medication cart #1 without an open date to determine its expiration date. 4. Two expired 5 ml multidose vials of Tuberculin purified protein derivative testing agents, a solution used in a skin test to diagnose latent tuberculosis infection, were found in the North Station Medication room's refrigerator. 5. One prescription bottle of polyethylene glycol with electrolytes, a laxative used 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 and interview, the facility failed to maintain the walk-in freezer in safe operating condition in a census of 115 residents who received facility prepared foods, when the walk-in freezer had ice buildup on the walls, ceiling, and boxes of food. This failure had the potential to cause the freezer to not operate efficiently, which would result in possible contamination of food leading to food borne illnesses and decreased food quality. Findings: During a concurrent observation and interview with the Dietary Manager (DM), on 9/30/24, at 8:56 a.m., the walk-in freezer revealed ice buildup on two separate food boxes, on the floor, walls, and ceiling. The DM stated he was aware of the ice buildup in the freezer, and it was caused by the fluctuating temperature from the door opening and closing. During an interview with the Maintenance Supervisor (MS), on 10/1/24, at 8:36 a.m., the MS confirmed he was aware of the ice buildup in the freezer. MS stated the ice buildup was probably due to old equipment and insulation issues. MS stated he was not aware that ice buildup…

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

Based on observation, interview, and record review, the facility failed to ensure two of 25 sampled residents' (Resident 100 and Resident 72) planned meal tray tickets (guidance to staff on what to serve for a meal to a resident) were accurate and followed. This failure had the potential to negatively impact Resident 100's and Resident 72's nutritional status and potentially result in unplanned weight lost. Findings: Resident 100 was admitted to the facility January 2024 with multiple diagnoses which included muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue) and protein-calorie malnutrition. Resident 72 was admitted to the facility February 2024 with multiple diagnoses which included muscle weakness and protein-calorie malnutrition. During a concurrent observation and interview on 9/30/24, at 11:57 a.m., in the Dining Room, Resident 100's supplement drink was observed missing from his meal tray. Resident 100's meal tray ticket indicated, House Supplement. The Dietary Supervisor (DS) acknowledged the supplement drink was missing and stated, Will…

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 four of seven sampled residents (Resident 1, Resident 2, Resident 3 and Resident 4) were free from abuse when: 1. Resident 1 and Resident 2 had an altercation resulting in Resident 2 sustaining a skin tear; and 2. Resident 3 and Resident 4 had an altercation resulting in Resident 3 sustaining a skin tear. These failures had the potential to result in serious physical injury to the residents. Findings: 1. A review of Resident 1's admission record indicated he was admitted in 3/24 with diagnoses including hemiplegia and hemiparesis (paralysis and weakness) following a cerebral infarction (stroke) affecting the right dominant side. A review of a Minimum Data Set (MDS, an assessment tool), dated 2/26/24, indicated Resident 1 had no cognitive impairment. A review of a Situation, Background, Assessment, Recommendation (SBAR) Communication form, dated 4/5/24 and written by Licensed Nurse 1 (LN 1), indicated Resident 1 had been in an altercation 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 review of facility documents, the facility failed to ensure infection control guidelines were followed for 1 of three residents (Resident 3) in a census of 115, when Resident 3's privacy curtain had multiple soiled areas. These failures had the potential to increase the risk for the development and transmission of communicable disease and infections. Findings: Resident 3 was admitted to the facility in mid-2023 with diagnoses which included enterocolitis due to clostridium difficile (C-difficile, germ that causes diarrhea and swollen colon). During a record review, dated 11/7/23, of Resident 3's Brief Interview for Mental Status (BIMS, an assessment of memory) indicated severe memory impairment. During an observation on 11/30/23 at 12 p.m., the signage on the bedroom door for Resident 3 indicated contact precautions for C-difficile. During an interview on 11/30/23 at 12:15 p.m. with Resident 2, Resident 2 stated, I wanted a room change because, there is poop [feces] on the…

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

Based on observation, interview and record review, the facility failed to ensure an effective pest control program was provided for a census of 109, when roaches, ants and flies were found in multiple locations throughout the building. This failure resulted in the presence of pests inside the facility and had the potential to result in the transmission and spread of infection. Findings: During a review of the facility's (Name of Company .PEST MANAGEMENT) Service Summary Report (SSR) dated 4/28/23, the SSR indicated, Services & Findings: Inspected interior rooms 600, 608 and 609 checked monitors for roaches. Minor Turkestan roaches seen at this time. During a review of a facility provided receipt titled, Name of Company .PEST MANAGEMENT, dated 6/10/(23), the receipt indicated, Treated interior of breakroom .Added monitor to rooms 309, 211, 507 for Turkistan (sic) Roaches. During a review of a facility provided receipt titled, Name of Company .PEST MANAGEMENT, dated 7/10/(23), the receipt indicated, Plesed (sic) insect monitor in rooms 610, 511, 403 and main station for Turkestan…

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 safe, clean, comfortable and homelike environment was provided for six of 35 sampled residents (Resident 10, Resident 55, Resident 64, Resident 511, Resident 512, Resident 517), when: 1. Broken window blinds were found in Resident 10's room; 2. Flies were observed in Resident 55's room; 3. Walls in Resident 64's room had multiple holes and cracks; 4. A used bandage covered with ants was found in Resident 511's room; 5. Two used urinals in the closet drawers, broken window blinds, and over-bed light cord consisted of two garbage bags tied together were found in Resident 512's room; and 6. Several cockroaches were found in the light fixture and on the floor in Resident 517's room. These failures had the potential to result in the residents not maintaining their mental, physical and psychosocial well-being. Findings: 1. Resident 10 was admitted to the facility in the middle of 2023 with diagnoses which included chronic pain and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement comprehensive care plans for three out of 35 sampled residents (Resident 72, Resident 76, and Resident 78), when no person-centered communication care plans with interventions were in place to address the residents' needs. This failure had the potential to result in the residents not attaining their highest practicable physical, mental and psychosocial well-being. Findings: 1. Resident 72 was admitted to the facility in late 2019 with multiple diagnoses which included anxiety and depression. During a review of Resident 72's Nursing Care Plans (NCPs), there was no care plan developed or implemented for hearing difficulty found. During a review of Resident 72's Order Summary Reports (OSR) dated 4/20/23, the OSR indicated, [Resident 72] has the capacity to make healthcare decisions .Refer to hearing and ear consult. During a review of Resident 72's Minimum Data Set, (MDS, an assessment tool) dated 6/21/23, the Section B of the MDS…

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 pharmacy services were maintained for three residents (Resident 89, Resident 86, and Resident 74) of 35 sampled residents when: 1. Antidiabetic-medication (medicine to control blood sugar) was not ordered and delivered on time resulting in a missed dose for Resident 89, and 2. Controlled medication (medications with a likelihood for physical and mental dependence) drug records had discrepancies for Resident 86 and Resident 74. These failures had the potential to result in poor control of Resident 89's diabetes (a chronic condition that affects the way the body processes blood sugar) and controlled medication diversion (the illegal distribution of prescription drugs not intended by the prescriber). Findings: 1. A review of Resident 89's admission Record, dated 8/17/23, indicated Resident 89 was admitted to the facility in September of 2021 with multiple diagnoses including diabetes with hyperglycemia (high blood sugar which can led to headache, fatigue, and in severe cases, loss of consciousness).…

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 medication error rate did not exceed 5% for two residents (Resident 57 and Resident 517) of 35 sampled residents when: 1. Resident 57 was administered sodium bicarbonate (medication used to treat heartburn or sour stomach) 325 mg (milligram: a unit of measure) instead of 650 mg as prescribed; and, 2. Resident 517 was administered a crushed potassium chloride (medication to prevent or treat low potassium levels) extended release (ER) tablet and was not administered zinc sulfate (medication to prevent or treat low zinc levels) 220 mg and Vitamin B+C Complex with Folate (medication to prevent or treat low vitamins) as prescribed. These failures resulted in four medication errors identified out of 28 opportunities during an observation of medication administration which then resulted in the facility having a medication error rate of 14.29%. Findings: 1. During a medication pass observation on 8/14/23 at 8:23 a.m. with Licensed Nurse 1 (LN 1), LN 1 prepared one tablet of sodium bicarbonate 325 mg 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 medications were stored correctly for a census of 109 residents, when: 1. Pharmaceutical products were not kept within the required temperature range in the medication refrigerator; 2. Products were opened without open dates labeled in medication cart; 3. Expired medications were available for use in medication cart; 4. Medications and syringes were found behind a drawer of the medication cart; 5. Loose pills were found in the medication carts; 6. The treatment cart had prescription products inside without a lock mechanism; 7. Prescription products were without pharmacy labels in the treatment cart; and, 8. A controlled medication cabinet was not permanently affixed. These failures had the potential for medication misuse, drug diversion and medication ineffectiveness. Findings: 1. During a concurrent observation and interview on 8/14/23 at 9:23 a.m. with the Director of Staff Development (DSD) in the medication room, the DSD looked at the thermometer in the medication refrigerator and stated 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 the nutritive value of meals was not compromised, when: 1. Pureed food was not prepared according to recipe; and 2. Vegetarian meal plan was not developed and/or followed. These failures had the potential to result in malnutrition for the 16 residents eating pureed meals, and the one resident who followed a vegetarian diet. Findings: 1. During an observation on 8/15/23 at approximately 10 a.m., [NAME] 1 (CK 1) began preparing the mechanically altered diets for the lunch meal. He explained that he was pureeing enough chicken for 16 servings. He placed eight cooked chicken breasts into the food processor bowl along with an unmeasured amount of drippings from the cooking pan. He proceeded to blend until smooth. Once done, he checked the consistency and noted it to be too thin. He took a gray handled scoop (1/2 cup per guide posted in kitchen) filled with thickener and added it to the mixture. Finding the mixture still too thin, he…

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 an acceptable amount of time in between dinner and breakfast was provided to 108 residents, when there was more than excess of 14 hours between the dinner meal and breakfast the following day. This failure had the potential to result in abnormal blood sugar levels and/or discomfort to residents who experienced excessive hunger. Findings: During review of the Resident Meal Policy on 8/14/23, the Resident Meal Policy indicated mealtimes for breakfast began at 7:05 a.m., lunch at 11:50 a.m., and dinner at 4:45 p.m. These times were also verified by the Meal Service document (RDs for Healthcare, Inc. 2018). During an interview on 8/16/23 at 11:02 a.m. with the Registered Dietitian (RD), the RD indicated the bedtime snacks were only given to those residents who requested snacks and the residents who had a physician order for snacks. During a concurrent interview and record review on 8/16/23 at 12:02 p.m. with the Dietary Manager (DM), the undated document titled, Meal Times Schedule was reviewed. The DM…

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

Based on observation, interview, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a total of 109 residents who received facility prepared foods, when: 1. A box of chocolate chips was not labeled or dated; 2. Open boxes of graham crackers crumbs and chocolate chips were found with inner bags not closed; 3. A container of tuna salad in the refrigerator was found to be out of safe temperature range; and 4. A refrigerator used for storing resident food was out of safe temperature range. These failures had the potential to result in food-borne illnesses. Findings: 1. During a concurrent observation and interview on 8/14/23 at 8:20 a.m. with the Dietary Manager (DM) in the dry storage room, there was an undated and unlabeled box of chocolate chips. The DM indicated the box should be dated so the staff knew if the box of chocolate chips was still safe to eat. During a review of facility's policy and procedure (P&P) titled, FOOD RECEIVING AND STORAGE OF COLD FOODS, dated 2018, the P&P…

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 the safe and sanitary storage, handling, and consumption of food was provided for a census of 109, when staff did not understand and did not follow the facility's policy and procedures for outside food brought in for residents. This failure had the potential to result in the residents' limited food options and enjoyment of outside meals. Findings: During an interview on 8/15/23 at 10:40 a.m. with Licensed Nurse (LN 2), LN 2 indicated they were told approximately six months ago that they could no longer store food from outside sources. LN 2 indicated residents can get outside food, but any food that is not eaten right away would be discarded rather than stored. During an interview on 8/15/23 at 1:23 p.m. with LN 3, LN 3 indicated food can be kept for two days in the resident nourishment refrigerator as long as it's not leftovers. During an interview on 8/16/23 at 9:12 a.m. with LN 7, LN 7 indicated food was not kept if the food had been eaten from and food was thrown out after 24 hours in the refrigerator. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the infection prevention and control program guidelines and practices were maintained for a census of 109, when: 1. Expired hand sanitizers were used by staff and residents; 2. Three urinals with no label and date were found in Resident 87's room; 3. Three wheelchair armrests had sharp pointy edges sticking through the padding for Resident 3, Resident 20, and Resident 64; and 4. Intravenous (IV, plastic tube within a vein for medication administration) tubing was not labeled for Resident 406. These failures had the potential to result in the spread of infection to a vulnerable population. Findings: 1. During a concurrent observation and interview on [DATE] at 1:09 p.m. with the Infection Preventionist (IP), the storage closet contained nine boxes of expired hand sanitizer (Brand Name, Sanitizer Plus Gel), dated [DATE]. The IP verified the expiration date and stated it was expired and should not be used. The IP further stated, 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 maintain resident care equipment in safe operating condition for 108 residents who received food from the kitchen, when an ice build-up was found in walk-in freezer. This failure had the potential to result in the freezer not maintaining the appropriate temperatures and decreasing food quality and safety leading to food-borne illnesses. Findings: During a concurrent observation and interview on 8/14/23 at 8:45 a.m. with the Dietary Manager (DM) in the freezer, an ice build-up was found on the walls, around the light, around the pipes, ceiling, freezer racks, and covering the floor. The freezer door gasket appeared misshapen as well as the metal in the upper corners of the door frame. The DM concurred that the gasket looked unusual. During a concurrent observation and interview on 8/14/23 at 9 a.m. with the Maintenance Director (MD) in the freezer, the MD confirmed that the gasket was misshapen, and there was ice build-up in the freezer, condensation on the ceiling and wet, icy floors. The MD stated, It is 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 record review, the facility failed to provide a safe, sanitary, functional and comfortable environment for a census of 109, when: 1. Flies were found in Resident 55's room; 2. Resident 78 had a nightstand with a broken drawer; 3. Resident 10's meal tray had a fly in his food while having lunch in the dining room; 4. A cockroach was found in the dining room; 5. Resident 3, Resident 20, and Resident 64 had torn wheelchair arm rests; and 6. Several cockroaches were found in light fixture and on the floor in Resident 517's room. These failures had the potential to result in the residents not attaining their highest practicable physical, mental and psychosocial well-being. Findings: 1. During an observation on 8/14/23 at 9:24 a.m. Resident 55 was found lying in bed, awake and alert, appeared uncomfortable in bed, with a splint worn on the left hand and arm. Observed flying on Resident 55's face were two flies. Resident 55 tried to wave away the flies, but could hardly move her hands and attempted to shake her head to drive the flies away. 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 observation, interview, and record review, the facility failed to ensure dignity was provided for one of 34 sampled residents (Resident 78), when Resident 78 was found alone in the bathroom wearing a dirty shirt, had no communication binder at bedside, and the room was disorganized with a piece of furniture in disrepair. This failure had the potential to negatively impact Resident 78's quality of life and psychosocial well-being. Findings: 1. Resident 78 was admitted to the facility in early 2020 with diagnoses which included dementia (memory impairment), restlessness and agitation, and depression. During a review of Resident 78's Nursing Care Plan (NCP), dated 1/22/20 and revised 8/4/23, the NCP indicated, [Resident 76] primary language is Vietnamese .Resident will be provided with a communication binder by her bedside . During a review of Resident 78's NCP, dated 1/23/20 and revised 11/3/22, the NCP indicated, Cognitive Impairment .Severely impaired .Dementia .Staff to produce total assistance while ensuring comfort and dignity. During a review of Resident 78's Minimum…

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 respect the rights of one resident (Resident 517) out of 35 sampled residents, when Resident 517 refused to take a laxative (a medication that helps have bowel movements) and the Licensed Nurse (LN) administered the laxative anyway. This failure contributed to the resident's diarrhea and had the potential to have led to dehydration. Findings: During a review of Resident 517's admission Record, dated 8/17/2023, the admission Record indicated Resident 517 was admitted to the facility in the middle of 2023 with multiple diagnoses which included generalized infection. During an observation on 8/14/23 at 8:50 a.m. of LN 2, LN 2 prepared medications for Resident 517 which included polyethylene glycol (a laxative) mixed with 120 ml (milliliter, a unit of measure) water in a cup. LN 2 entered Resident 517's room with the prepared medications and placed the cup with polyethylene glycol on the bedside table. There were no beverages on the bedside table or in reach of Resident 517, and LN 2 did not offer the resident any…

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 current condition for one of 35 sampled residents (Resident 72), when the hearing status was coded incorrectly. This failure resulted in Resident 72's MDS data submitted to CMS (Centers for Medicare-Medicaid Services) inaccurately and had the potential for Resident 72 to not receive appropriate treatment and care to attain her highest practicable quality of life. Findings: Resident 72 was admitted to the facility in late 2019 with multiple diagnoses which included anxiety and depression. During a review of Resident 72's Order Summary Reports (OSR), dated 4/20/23, the OSR indicated, Resident 72 has the capacity to make healthcare decisions .Refer to hearing and ear consult. During a review of Resident 72's MDS, dated [DATE], Section B of the MDS indicated, Adequate Hearing .No hearing aid or other hearing appliances used. During a review of Resident 72's…

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 review and revise the comprehensive care plan for one of 35 sampled residents (Resident 76), when the care plan did not reflect the resident's current health status and needs. This failure had the potential to result in Resident 76 receiving outdated care and placing the resident at risk for not meeting her highest practicable well-being. Findings: Resident 76 was admitted to the facility in early 2020 with diagnoses which included depression, anxiety, and memory impairment. During a review of Resident 76's Nursing Care Plan (NCP), dated 2/1/23, the NCP indicated, [Resident 76] needs motivation to join and participate in group activities .Resident is non English speaking .Resident on hospice. During a review of Resident 76's Order Summary Report (OSR), dated 2/1/23, the OSR indicated, Family/caregivers in agreement with the change of plan of care. During a review of Resident 76's OSR dated 6/19/23, the OSR indicated, [Resident 76]…

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 care and services were provided according to professional standards for two of 35 sampled residents (Resident 516 and Resident 519) receiving dialysis (removal of extra fluid and waste products when the kidneys are not able to) when: 1. Monitoring was not ordered for Resident 516's dialysis access site (entrance way into the bloodstream that lies beneath the surface of the skin and monitor for bleeding); and 2. Physician's orders for daily weights were not followed for Resident 519. These failures had the potential to result in undetected complications such as bleeding in Resident 516 and increased fluid retention in Resident 519. Findings: 1. Resident 516 was admitted in the middle of 2023 with diagnoses which included end stage renal disease (ESRD, when kidneys can no longer support the body's needs), dependence on renal (kidney, organ that filters waste material out of the blood) dialysis. During a concurrent interview and record review on 8/17/23 at 9:28 a.m. with the Director of Nursing (DON), when asked what…

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 act on a previously reported medication irregularity (use of medication that is inconsistent with accepted pharmaceutical services standards of practice) identified during a Medication Regimen Review (MRR) in June and July of 2023 for one resident (Resident 52) of 35 sampled residents. This failure resulted in Resident 52 receiving an antipsychotic medication (a drug prescribed to affect the mind, emotions or behavior) without an adequate indication (valid reason to take a medication). Findings: Resident 52 was admitted to the facility in the middle of 2022 with diagnoses which included schizoaffective disorder (an illness that can affect thoughts, mood, and behavior) and recurrent depressive disorder (an illness that can cause low mood and loss of interest). A review of Resident 52's Order Summary Report (OSR), dated 8/17/23, indicated, .olanzapine [an antipsychotic medication to treat mental illness] Tablet 20 mg [milligram: a unit of measure] Give 1 tablet by mouth at bedtime for schizoaffective disorder M/B [manifested…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two residents (Resident 52 and Resident 55) of 35 sampled residents were free from unnecessary psychotropic medication when: 1. Resident 52 was prescribed antipsychotic medication (medication to treat psychiatric illness) without documented behavioral symptoms that presented a danger to himself or others; and 2. Resident 55 was prescribed antipsychotic medication for an inadequate indication (valid reason to take a medication). These failures increased the potential for Resident 52 and Resident 55 to experience side effects from these medications such as frequent falls, sedation, and abnormal involuntary movements. Findings: 1. Resident 52 was admitted in the middle of 2022 with diagnoses which included schizoaffective disorder (an illness that can affect thoughts, mood, and behavior) and recurrent depressive disorder (an illness that can cause low mood and loss of interest). A review of Resident 52's Minimum Data Sets (MDS, an…

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