Carmel Mountain Rehabilitation & Healthcare Center

Based on observation, interview and record review, the facility failed to maintain proper food sanitation procedures when expired food was identified in the kitchen refrigerators, and in the nursing unit refrigerator. These failures had the potential to cause foodborne illness to the residents who received food from the kitchen and/or nursing unit refrigerator. Findings: A concurrent kitchen tour and interview with the Dietary Services Supervisor (DSS) was conducted on 4/21/25 at 8:23 A.M. In the walk-in refrigerator, a bag containing approximately eight ounces of shredded parmesan cheese was found to have a Use By Date of 4/17/25. A reach-in refrigerator contained six small plastic containers of peaches, with a Use By Date of 4/20/25. The DSS stated both foods should have been disposed of on the Use By Date. The DSS stated expired food had the potential to cause foodborne illness to the residents. A concurrent observation of nursing unit refrigerators and an interview with a Nurse Manager (NM 1) was conducted on 4/24/25 at 10:45 A.M. Three containers of expired yogurt was…

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's Quality Assessment and Assurance Committee (QAA-facility group that monitors concerning trends in a facility) failed to identify and include in the facility's Quality Assurance Performance Improvement plan (QAPI-plan developed by QAA to help improve conditions in the facility) deficient trends found by surveyors during the recertification survey concerning call light response and the lack of homelike environment for the residents. This failure had the potential for the facility to overlook trends in resident care that might have affected residents' health and quality of life. Cross Reference: F558, F584 Findings: On 4/24/25 at 2:18 P.M., a concurrent interview with the Administrators (ADM 1 and ADM 2), the Director of Nursing (DON) and a review of QAPI program was conducted. The ADMs stated that the main areas that the QAPI team were monitoring were falls, pressure ulcer reduction, weights and urinary tract infection prevention. During the recertification survey, deficient trends in call light response and the lack of homelike…

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 did not follow infection control practices when: 1) Staff did not don (put on) and doff (remove) Personal Protective Equipment (PPE- gown, gloves, mask) or perform hand hygiene when providing care to a resident on Enhanced Barrier Precautions (EBP, use of PPE when providing high contact resident care to reduce the spread of bacteria), and, 2) Two ice scoops were not stored in a sanitary manner. As a result, there was the potential for cross contamination, affecting the health of residents. Findings: 1a. According to the admission Record, Resident 316 was admitted on [DATE] with diagnoses which included fractures (broken bones) of the vertebra (spinal column), and muscle weakness. During an observation on 4/21/25 at 7:54 A.M., a sign was observed outside Resident 316's room which indicated EBP. A blue sticker was observed next to Resident 316's name, outside the room. A container filled with PPE was observed outside the room. On 4/21/25 at 7:54…

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 showers consistently for one of one sampled resident (Resident 24), reviewed for choices related to personal care. As a result, Resident 214's preferences and choices were not honored and respected. Findings: Resident 24 was readmitted to the facility on [DATE] with diagnoses which included muscle weakness, per the facility's admission Record. Resident 24's history and physical, dated 3/31/25, indicated Resident 24 had the capacity to understand and make decisions. A record review was conducted of Resident 24. Resident 24's minimum data set (MDS - a federally mandated resident assessment tool), dated 4/1/25, indicated Resident 24's brief interview for mental status (BIMS, ability to recall) score was 15/15 (a score of 13 to 15 suggests the patient is cognitively [process of acquiring knowledge and understanding] intact). On 4/21/25 at 9:39 A.M., an observation and an interview of Resident 24 was conducted in her room. Resident 24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement individual care plans for two of five resident's (Resident 214 and Resident 220), reviewed for care plans. This failure resulted in Resident 214 experiencing pain, when a care plan was not developed for constipation and Resident 220's plan of care was not implemented as ordered by the physician, to wear bilateral foam boots (both feet), to protect and prevent future skin injuries to the heels. Findings: 1. Resident 214 was admitted to the facility on [DATE], with diagnoses which included orthopedic aftercare related to cervical disc disorder (neck region), per the facility's admission Record. An observation and interview was conducted with Resident 214 on 4/22/25 at 8:41 A.M., as he laid in bed. Resident 214 was rubbing his abdomen, stating he felt discomfort and bloating. Resident 214 stated he had not had a bowel movement in several days and they gave him a suppository last night, but nothing has happened yet. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 97), reviewed for closed record, when: 1. Staff failed to follow physician's order related to intravenous (IV, within a vein) antibiotics (anti-infective medications) therapy for Resident 97, and, 2. Consistently provide Resident 97's peripherally inserted central catheter (PICC, a long, thin tube inserted through a vein in the arm) care. These failures placed Resident 97 at risk for delayed healing and PICC line associated complications. Findings: Resident 97 was readmitted to the facility on [DATE] with diagnoses which included sepsis (a life-threatening blood infection), and urinary tract infection (UTI), per the facility's admission Record. A review of Resident 97's clinical record was conducted. Resident 97's physician's order dated 4/1/25, indicated, Resident 97 was to receive two antibiotic medications…

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 follow the physician's order related to pressure ulcer (a localized injury to the skin and underlying tissue caused by prolong pressure), treatment and prevention for one of four residents (Resident 43), reviewed for pressure ulcers. This failure had the potential for worsening or additional pressure ulcers to occur. Findings: Resident 43 was admitted to the facility on [DATE], with diagnoses which included cellulitis (a bacterial infection of the skin and the underlying tissues) of the lower extremities, along with sepsis (a serious condition in which the body responds improperly to an infection), per the facility's admission Record. An observation and interview was conducted with Resident 43 on 4/21/25 at 8:25 A.M., as she sat in bed. Resident 43 had a padded green boot on her left foot and both heels were resting directly on the mattress. Resident 43 stated she got a wound on her left heel, after her legs swelled up from an infection.…

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 supervision during toileting for a resident identified as high risk for falls. In addition a gait belt (a safety device used by caregivers to assist residents with mobility issues), was not utilized during transferring the resident from bed to a bedside commode for one of three residents (Resident 220), reviewed for accidents. These failures could potentially contributed to Resident 220 having an unwitnessed fall in the room. Findings: Resident 220 was admitted to the facility on [DATE], with diagnoses which included displaced fracture of the right tibia (lower leg bone) and right patella (knee), per the facility's admission Record. An observation and interview was conducted with Resident 220 on 4/21/25 at 9:23 A.M. Resident 220 was sitting up in bed with a sling and partial splint on her left forearm. Resident 220 stated she fell four days ago, while using the bedside commode, resulting in a fractured left wrist. A bedside…

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 follow its Bowel and Bladder protocol for two of two residents (Resident 214 and 104) reviewed for Bowel and Bladder when: 1. The constipation bowel regimen was not implemented after three days of no bowel movement for Resident 214; and, 2. The urine output (UO) was not consistently documented for Resident 104, who had a urinary catheter (a tube inserted into the bladder to aid in urine flow). This failure had the potential for increased and unnecessary pain for Resident 214, along with no consistent monitoring of urine output for Resident 104. Findings: 1. Resident 214 was admitted to the facility on [DATE], with diagnoses which included orthopedic aftercare related to cervical (spine in the neck) disc disorder, per the facility's admission Record. An observation and interview was conducted with Resident 214 on 4/22/25 at 8:41 A.M., as he laid in bed. Resident 214 was rubbing his abdomen, stating he felt discomfort and bloating. Resident…

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 dialysis (the process of cleaning the blood through a machine) access site was properly cared for one of one resident reviewed for dialysis (Resident 87). This deficient practice had the potential for Resident 87's dialysis access to clot. Findings: Resident 87 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (kidney failure), per the admission Record. On 4/21/25 at 10:34 A.M., an observation and an interview were conducted of Resident 87 in her room. Resident 87 was up in her wheelchair. Resident 87 stated she went for dialysis Tuesdays, Thursdays and Saturdays and showed her right arm dialysis access site. On 4/22/25 at 2:37 P.M., an observation of Resident 87 was conducted. Resident 87 arrived at the facility from the dialysis via wheelchair and noted a dressing to right upper dialysis access site. On 4/23/25 at 8:09 A.M., an observation and an interview were conducted of Resident 87…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of 24 sampled residents (Resident 17) received: 1. A physician's explanation for renewal of a PRN (as needed) anti-anxiety medication, 2. Review and monitoring of the behaviors which required the use of an anti-anxiety medication, and, 3. A scheduled Gradual Dose Reduction (GDR, a required attempt to reduce dosage of a medication) for the anti-anxiety medication. These failures had the potential for Resident 17 to receive unnecessary medications, or more medication than necessary to treat anxiety. Findings: Resident 17 was admitted on [DATE] with diagnoses to include anxiety disorder (an intense, excessive and persistent worry and fear about everyday situations), per the facility admission Record. On 4/21/25 at 11:01 A.M., an interview was conducted with Resident 17. Resident 17 stated she was on a medication to treat anxiety, but she did not know if she received it regularly, and she often felt worried about getting staff 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately document the correct extremity involved in their weekly wound evaluation summary for one of four residents (Resident 43), reviewed for wound care. This failure had the potential for confusing and misleading information in Resident 43's clinical record. Findings: Resident 43 was admitted to the facility on [DATE], with diagnoses which included cellulitis (a bacterial infection of the skin and the underlying tissues), in the lower extremities along with sepsis (a serious condition in which the body responds improperly to an infection), per the facility's admission Record. An observation and interview was conducted with Resident 43 on 4/21/25 at 8:25 A.M., as she sat in bed. Resident 43 had a padded green boot on her left foot and both heels were resting directly on the mattress. Resident 43 stated she got a wound on her left heel, after her legs swelled up from an infection. Resident 43's clinical record was reviewed on 4/22/25.…

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 follow the physicians' plan of care related to skin and wound treatments for three of three residents (Residents 1, 2, and 3) reviewed for Comprehensive Care Plans. This failure had the potential for Resident 1, 2, and 3's skin and wound injuries to worsen. Findings: 1. Resident 1 was readmitted to the facility on [DATE], with diagnosis which included Amyotrophic Lateral Sclerosis (ALS-a progressive nervous system disease that affects the brain and spinal cord), resulting in functional quadriplegia (unable to move all four limbs), per the facility's admission Record. Resident 1's clinical record was reviewed on 12/17/24: According to the facility's admission Note, dated 10/25/24, Resident 1 was readmitted from the hospital with documented skin injuries to the right and left scapula (shoulder blades), and right buttocks, all described as deep tissue injuries (a type of pressure ulcer where the underlying soft tissues, like muscles and fat,…

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 fall evaluation tool did not accurately represent the fall risk status of three residents, (Residents 1, 2 and 3), sampled for admission fall risk evaluation. Per the Director of Nursing (DON), the fall evaluation tool did not allow nursing staff to include all medications and medical diagnoses that could increase fall risk, which resulted in artificially low fall risk scores. This failure had the potential to contribute to one or more actual falls for each sampled resident, and a right hip fracture (a break or crack in a bone) for resident 1. Findings: Resident 1 was admitted on [DATE] with diagnoses that included difficulty in walking and generalized muscle weakness, major depressive disorder (a mood disorder that can be treated with antidepressant medication that can increase fall risk), cardiac murmur (a sound caused by improper closing of valves in the heart, a condition that can cause lightheadedness), chronic kidney disease (a condition in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to create an admission fall risk care plan for one resident, (Residents 1), sampled for baseline care plan. This failure had the potential outcome of contribution to two falls for Resident 1 who sustained a fracture (a break or crack in a bone) of her right hip. Findings: On 9/23/24 the State Agency (SA) received a facility reported incident which indicated, Resident fell in her room, sent to hospital, admitted and a diagnosis of right femur (fracture) declared. Resident 1 was admitted on [DATE] with diagnoses that included difficulty in walking and generalized muscle weakness, major depressive disorder (a mood disorder that can be treated with antidepressant medication that can increase fall risk), cardiac murmur (a sound caused by improper closing of valves in the heart, a condition that can cause lightheadedness), chronic kidney disease (a condition in which the kidneys cannot fully eliminate waste from the blood, which can cause confusion), anemia (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, one resident (Resident 1) was served a food item inconsistent with the prescribed therapeutic diet. This failure had the potential to cause Resident 1 difficulty swallowing safely. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (a medical condition that causes partial or total paralysis of one side of the body) following cerebral infarction (a serious condition that causes brain tissue to die) affecting left side, generalized muscle weakness, and dysphagia (swallowing difficulty). On 8/22/24 the State Agency (SA) received a complaint that indicated Resident 1 was served a bowl of soup that was not pureed per the ordered therapeutic diet. On 8/28/24 a telephone interview was conducted with the Ombudsman (an official who investigates concerns and facilitates solutions) prior to facility entrance. The Ombudsman stated on 8/21/24 Resident 1 had an order for pureed (blenderized) food but was served chicken soup…

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 follow its COVID-19 mitigation plan when: 1. front desk staff did not request people who entered the facility to wear a mask during a COVID-19 outbreak (at least three confirmed positive cases within a seven day period). 2. Infection Preventionist (IP) 1 allowed a visitor into the COVID-19 isolation area without an n95 mask (a highly protective respiratory mask). 3. Floor staff did not stop unmasked visitors to ask them to wear a mask while inside the facility. 4. Licensed Nurse (LN) 1 had a mask under her chin when she entered a patient room. 5. A Certified Nursing Assistant (CNA) and a Receptionist were unmasked in a hallway. 6. All but two kitchen staff were unmasked in the kitchen during lunch preparation. These failures had the potential to infect vulnerable residents with COVID-19. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (a medical condition that causes…

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 adequate supervision for one resident, Resident 3, sampled for falls. This failure had the actual outcome of Resident 3 suffering two fractured ribs. Findings: On 8/26/2019 Resident 3 was admitted to the facility with diagnoses that included hemiplegia (total or partial paralysis of one side of the body that results from disease of, or injury to the nervous system) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (disrupted blood flow to the brain which causes part of the brain to die), epilepsy (disorder of the brain characterized by repeated seizures), tremor (a medical condition that includes shaking movement of part of the body), history of falling, fracture of rib on right side 12/29/2015, right clavicle fracture (a bone that connects the breastbone to the shoulder blades, also called collarbone) 4/12/2016, shoulder dislocation (a separation of two bones where they meet at a joint)…

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 staff followed policy and procedure when: 1) opened food items were not labeled and dated properly 2) opened food item was not discarded by use by date and 3) a. knife had food debris on it and b. a kitchen staff did not change gloves after washing a used blender during food preparation. As a result, there was a potential for foodborne illness (illness caused by food contaminated by microorganisms and toxin) and cross-contamination (physical transfer of harmful bacteria). Findings: 1) On 5/7/24 at 7:50 A.M., a tour of the facility's kitchen was conducted. Inside a refrigerator, a plastic container with leftover pineapple slices was noted. There was no date on the container when the pineapple was first opened/prepared or needed to be used by. On 5/7/24 at 8:04 A.M., an observation of a shelf with bread in it was conducted. An opened package of bread buns and an opened package of hot dog rolls had no dates when they were opened or needed to be used by. One of the hot dog rolls was noted to have a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff adhered to proper infection control practices when : 1. a resident's urinary catheter (a tube inserted into the bladder to aide in urine flow) bag and dignity bag (a bag used to cover and conceal contents inside), were laying on the floor on 1 of two residents (Resident 81). 2. the staff did not perform hand hygiene (HH- washing hands with soap and water or use of hand sanitizer to kill microorganisms a) after exit from resident's room and b) before entry to residents' room. 3. the staff did not perform HH in between glove changes a) during wound care and b) after glove removal and before putting on new glove. 4. the staff did not remove personal protective equipment (PPE) before exiting a resident's room on an Enhanced Barrier Precautions (EBP- precautions to prevent spread of infection that require the use of PPE during high-contact resident care activities); placed the basket of phlebotomy (blood draw) supplies on the clean…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dignity was maintained for one out of six residents (Resident 320) when Resident 320's urine collection bag was not concealed from public view. This failure had the potential to negatively affect the resident's psychosocial well-being. Findings: Resident 320's clinical record was reviewed and indicated he was admitted to the facility on [DATE] with muscle weakness, urinary retention (inability to eliminate urine completely) per the facility's admission Record. During an observation conducted on 5/7/24 at 11:08 A.M. in the facility hallway, Resident 320's urine bag was observed hanging on the wheelchair. The collection bag was not covered, and the content was visible. A concurrent observation and interview were conducted with Licensed Nurse (LN) 31 on 5/7/24 at 11:15 A.M. LN 31 stated, Resident 320's urine collection bag was seen by the people passing in the hallway and further stated, the urine collection bag must be covered 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure their policies on medication self-administration (resident takes medication without staff assistance) were implemented for one of one sampled resident (Resident 101) when the facility did not determine the resident was clinically appropriate and safe to self-administer a medication. This failure had the potential to result in unsafe medication administration. Findings: Review of Resident 101's clinical record indicated she was admitted on [DATE] with diagnoses which included hypertension (elevated blood pressure), diabetes mellitus (DM - elevated blood sugar) per the facility's admission Record. An observation and interview were conducted with Resident 101's son on 5/7/24 at 10:05 A.M. inside Resident 101's room. A tube of triamcinolone cream (medication to treat skin condition) was on the bedside table. Resident 101's son stated he applied the medication to Resident 101's itching skin. A joint interview and record review were…

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 address resident's needs for one of 29 sampled residents (Resident 316) when the resident's call light (device used to call staff's assistance) was not placed within reach. This failure had the potential for Resident 316's needs not being met. Findings: Review of Resident 316's clinical record indicated he was admitted to the facility on [DATE] with displaced fracture (break in the bone) of right femur (leg), history of falling, difficultly in walking. Resident 316's minimum data set (MDS, an assessment tool), dated 5/9/24 indicated Resident 316 was cognitively intact. During an observation and interview on 5/7/24 at 9:20 A.M. inside Resident 316's room. Resident 316's call light was observed dangling on the headboard. Resident 316 stated I need help and I can't reach my button. Resident 316's son was inside the room and pressed the button for Resident 316. An interview was conducted on 5/7/24 at 11:05 A.M. with Licensed Nurse (LN) 32. LN…

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 Physician Order for Life-Sustaining Treatment (POLST- a written medical order from a healthcare provider based on patient preferences on the type of medical treatment they want to receive during serious illness) was signed by the physician in a timely manner for one of two sampled residents reviewed for advance directives (Resident 62). As a result, the POLST was not valid for a patient who wished to be on Do Not Attempt Resuscitation (DNR- allow natural death) in case of a serious illness. Findings: Resident 62 was admitted to the facility on [DATE] with diagnoses which included heart failure per the facility's admission Record. On 5/8/24 a review of records was conducted. The POLST indicated Resident 62 wanted to be DNR. There was no physician signature on the document. On 5/9/24 at 3:50 P.M., an interview with the Social Services Director (SSD) was conducted. The SSD stated for new admission residents, the nurse, physician and social…

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 staff protected the confidential information of two of 29 sampled residents (Resident 216 and Resident 215) when the computer monitors were left open and unattended. This failure had the potential for the residents' personal and confidential medical information to be visible to unauthorized persons. Findings: Resident 216 was admitted to the facility on [DATE] with a diagnoses which included fracture of sacrum (a large triangular bone at the bottom of the spine) per the facility's admission Record. Resident 215 was admitted to the facility on [DATE] with a diagnoses which included right supracondylar and humeral fracture (right shoulder fracture) per the facility's admission Record. An observation was conducted on 5/7/24 at 9:56 A.M. on the Medication Cart #1's computer monitor in the hallway outside of room [ROOM NUMBER]. The unattended computer monitor was observed open with Resident 216's medical record. An interview was…

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 homelike environment was provided for two of 29 sampled residents (Resident 50 and Resident 216) when the bedrails' black foam was ripped, torn and in disrepair condition. This failure had the potential to negatively impact the resident's comfort, well-being, and quality of life. Findings: 1. Resident 216 was admitted to the facility on [DATE] with diagnoses which included fracture of sacrum (a large triangular bone at the bottom of the spine) per the facility's admission Record. An observation was conducted on 5/7/24 at 10 A.M. in the room of Resident 216. Resident 216's bedrail was observed with a wrapped black foam on both sides of the bed. Both the right and left bedrails' black foam had multiple ripped and torn areas. An interview was conducted on 5/7/24 at 10:05 A.M. with Resident 216. Resident 216 stated she does not feel being cared for because her bedrail foam coverings were broken. An interview was conducted on 5/7/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plans were developed for: 1) psychotropic (drugs that affect mood, behavior, thoughts and perception) medications and 2) code status (an instruction on what the medical team should do if a resident had a cardiac or respiratory arrest) for two of two sampled residents (Resident 6 and Resident 62): As a result, there was a potential for 1) Resident 6's psychotropic medications were not managed appropriately and 2) Resident 62's code status was not followed. Findings: 1) Resident 6 was re-admitted to the facility on [DATE] with diagnoses which included major depressive disorder (a type of mood disorder) and anxiety disorder (a type of mental health disorder characterized by feelings of worry or fear) per the facility's admission Record. On 5/10/24 a review of records was conducted. The Order Summary Report dated 4/5/24 indicated the physician ordered to administer psychotropic drugs to Resident 6. On 5/10/24 at 3:43 P.M., an interview with 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 personal care was provided for one of three sampled residents (Resident 319) when Resident 319 had white, crusty substance on the inner side of her eyes. This failure had the potential to result in poor personal hygiene and decreased psychosocial well-being. Findings: Review of Resident 319's clinical record indicated she was admitted to the facility on [DATE] with diagnoses which included difficulty in walking, traumatic subdural hemorrhage (injury to the brain) per the facility's admission Record. Resident 319's Minimum Data Set (MDS, an assessment tool) indicated she required maximum assistance with shower/bathing. During an observation on 5/7/24 at 9:35 A.M., inside Resident 319's room, Resident 319's inner eyes were observed with white, crusted substance. A joint observation and interview were conducted with Licensed nurse (LN) 2 on 5/07/24 at 12:05 P.M. LN 2 stated Resident 319 had a white, crusty substance on the inner side…

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 did not ensure staff followed physician's orders when : Resident on daily weight was not weighed daily on 1 of 2 residents (Resident 41) These failures had the potential to result in decreased physical and psychosocial well being for the residents. Resident 41 was admitted to the facility on [DATE] with diagnoses which included Morbid (severe) obesity due to excess calories and Chronic Kidney disease Stage 3 per facility's admission Record. On 5/7/24 at 10:34 A.M. a concurrent observation and interview with Resident 41 was conducted in Resident 41's room. Resident 41 was on a wheelchair waiting for his lunch. Resident 41 stated the facility was supposed to weigh him daily to monitor his weight. Resident 41 stated the facility sometimes were not weighing him everyday. On 5/7/24 at 10:49 A.M. , a review of records was conducted. The physician's order dated 1/11/2022 indicated Daily Weights to be completed, everyday shift. On 5/10/24 at 10:05 A.M. 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 Restorative Nursing Assistance (RNA- care to improve or maintain functional ability) was conducted per the physician's order for one of two sampled residents reviewed for limited range of motion (Resident 6). As a result, there was a potential for development of further contractures (chronic loss of joint mobility) for Resident 6. Findings: Resident 6 was re-admitted to the facility on [DATE] with diagnoses which included contracture of muscle, left upper arm and quadriplegia (paralysis of all four extremities) per the facility's admission Record. On 5/9/24 at 9:49 A.M., an observation of Resident 6 was conducted. Resident 6 was in bed, both upper arms were noted to be contracted. On 5/10/24, a review of records was conducted. The physician order dated 4/5/24 indicated to begin RNA program three times per week for three months on both upper and lower extremities. Resident 6's RNA flowsheet for the month of April 2024 indicated: Week…

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 tube feeding (TF-nutrition in liquid form through a tube) was labeled appropriately per the facility's policy for two of three residents reviewed for TF (Resident 6 and Resident 106). As a result, there was a potential the residents may not receive the adequate amount of TF per physician order. Findings: Resident 6 was re-admitted to the facility on [DATE] with diagnoses which included encounter for attention to gastrostomy (opening in the stomach created surgically) per the facility's admission Record. On 5/9/24 at 9:49 A.M., an observation of Resident 6 in the room was conducted. A TF bag was noted to be dated 5/8/24 and running at 55 milliliters (mls) per hour. There was no time on the TF bag when it was started to be administered to Resident 6. On 5/9/24 at 9:54 A.M., a joint interview and record review with Licensed Nurse (LN) 2 was conducted. The physician order for TF for Resident 6 indicated Resident 6 was to be administered…

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 staff was able to verbalize the accurate steps in administering a tube feeding (TF - nutrition in liquid form through a tube) for one of three residents (Resident 20). This failure had the potential to negatively affect Resident 20's health. Findings: Resident 20 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory (lung) failure, with tracheostomy (an incision in the windpipe made to relieve obstruction to breathing),connected to a ventilator (a device used medically to support the breathing ) per Facility's admission Record. On 5/9/24 at 9:25 A.M., a joint observation, interview and record review with Licensed Nurse (LN) 13 was conducted. Resident 20 was in his room with TF through gastrostomy (an opening into the stomach from the abdominal wall made surgically for introduction of food). The physician order for Resident 20 indicated TF at 50 milliliters (ml) per hour for 20 hours. LN 13…

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 medication was administered accurately to one of 29 sampled residents (Resident 17) when the Licensed Nurse (LN) administered a medication without properly identifying the resident. This failure had the potential for residents to be administered with wrong medications. Findings: Resident 17 was admitted to the facility on [DATE] with diagnoses which included diverticulitis (inflammation) of large intestine with perforation (rupture) and abscess (pus) per the facility's admission Record. An observation was conducted during medication administration on 5/10/24 at 8:19 A.M. with LN 14. LN 14 verbalized that she was ready to administer the medication to Resident 17. LN 14 was observed walking to the bedside of Resident 17 with a medication. Resident 17 was observed without a wristband identification (ID). LN 14 did not check for Resident 17's wristband ID and did not ask for Resident 17's identifiers (name and date of birth ). LN 14…

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 all medications were locked for one of seven medication carts (Medication Cart # 1). This failure had the potential for Medication Cart # 1 to be accessed by unauthorized personnel. Findings: An observation was conducted on 5/7/24 at 9:56 A.M. in the hallway outside of room [ROOM NUMBER]. A Medication Cart (#1) was noted to be unlocked and unattended by a Licensed Nurse (LN). A joint observation and interview were conducted on 5/7/24 at 10:03 A.M. with LN 11. LN 11 was observed in room [ROOM NUMBER] with a resident. LN 11 later exited the resident's room and went to Medication Cart # 1. LN 11 stated the medication cart was left unlocked and unattended when she went inside room [ROOM NUMBER]. LN 11 opened the drawers of Medication Cart # 1 without unlocking it with a key. LN 11 stated the key lock button should have been pushed to lock the medication cart. LN 11 stated she should have locked the Medication Cart # 1, when she went…

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 fire extinguishers in the kitchen were inspected in a timely manner. As a result, there was a potential the fire extinguishers were not safe to be used. Findings: On 5/7/24 at 7:50 A.M., a tour of the facility's kitchen was conducted. There were three fire extinguishers noted with March 2024 as the last documented inspection date on the tags. On 5/7/24 at 3:48 P.M., an interview with Maintenance Assistant (MA) 1 was conducted. MA 1 stated he did not record the months of April and May 2024 inspection dates of the fire extinguishers on the tags. On 5/9/24 at 9:15 A.M., an interview with MA 1 was conducted. MA 1 stated the fire extinguishers should be checked monthly. On 5/9/24 at 9:56 A.M., an interview with MA 1 was conducted. MA 1 stated it was important to check the fire extinguishers to make sure they work. MA 1 stated when he checked the fire extinguishers, he would write it down on his notebook and rips the page and put it on the boss' computer or desk. MA 1 stated his boss would log it on 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.

Based on observation, interview, and record review, the facility failed to address resident's needs for one of three sampled residents (Resident 7) when Resident 7's call light (device to call staff for help) was not placed within reach. Review of Resident 7's admission diagnoses dated 11/09/21 included gout (severe pain in the joints) and hypertension (increased blood pressure). An observation and interview was conducted on 7/25/23 at 12:45 P.M. inside Resident 7's room. Resident 7 was observed to be frustrated that he was not able to locate his call light device. Resident 7's call light was observed wrapped around his side rail. Resident 7 stated he could not reach his call light. A concurrent observation and interview was conducted on 7/25/23 at 12:46 P.M. with certified nursing assistant 1 (CNA 1) inside Resident 7's room. CNA 1 stated Resident 7's call light was tied around the side rail. CNA 1 further stated the call light should be placed within the resident's reach. On 7/28/23 at 10:15 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a patient centered care plan related to PTSD (Post-traumatic stress disorder - a disorder that may occur in people who have experienced or witnessed a traumatic event) for one of 21 residents (Resident 72) reviewed for care plans. This failure had the potential risk of not providing appropriate, consistent, and individualized care to Resident 72. Findings: Resident 72 was admitted to the facility on [DATE] with diagnoses that included PTSD according to Resident 72's Face Sheet. During a record review of Resident 72's History and Physical (H&P), dated 3/31/2023, the H&P indicated Resident 72 had a past medical history of PTSD. During a record review of the Minimum Data Set (MDS- an assessment tool)) - Section C, dated 4/4/2023, indicated that Resident 72 had short and long-term memory problem, as well as a problem with memory/recall ability and severely impaired cognitive skills for daily decision making. During a record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure one of eight residents (Resident 72) reviewed for Trauma Informed Care (TIC - an intervention and organization approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health), received care and services in accordance with professional standards when Resident 72's PTSD (Post-traumatic stress disorder - a disorder that may occur in people who have experienced or witnessed a traumatic event) was not identified and addressed by the healthcare providers. This failure resulted in the facility's inability to identify Resident 72's possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience). Findings: Resident 72 was admitted to the facility on [DATE] with diagnoses that included PTSD according to Resident 72's Face Sheet. During a record review of the Resident 72's History 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.

Based on observation, interview, and record review, the facility failed to timely administer prescriber's ordered medications to one of five sampled residents (Resident 264). This failure had the potential to cause delay and compromise resident's medical health. Findings: Review of Resident 264's Physician's orders indicated she was to receive Bumex (Water pill) 1 mg twice a day and Alphagan (eye drop for elevated eye pressure) 1 drop in both eyes three times a day. During a concurrent observation and interview on 7/25/23 at 11:45 A.M. inside Resident 264's room, Resident 264 was observed upset. Resident 264 stated she had not received her scheduled 9 A.M. medications. An interview and record review was conducted on 7/25/23 at 12:05 P.M. with Licensed Nurse (LN 1). LN 1 stated she was late giving Resident 264's scheduled medications for 9 A.M. LN 1 further stated that medications should be given one hour early or one hour late of the scheduled time. During an interview on 7/27/23 at 9:13 A.M. with the Pharmacy Consultant (PC). The PC stated prescribed medications should be given 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 two of 3 sampled residents (Resident 407 and Resident 25) reviewed for psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication were free from unnecessary use of medication when: 1. Resident 407 did not have behavior monitoring for the four psychotropic medications (psychoactive drugs taken to exert an effect on the chemical makeup of the brain and nervous system). 2. Resident 25's Ativan (medication to treat anxiety, which act on the brain and nerves) ordered to be given as needed, did not have a stop date. This failure had the potential for healthcare providers to not determine the effectiveness of Resident 407's psychotropic medications. In addition, Resident 25 had the potential to be expose to unnecessary side effects of the medications. Findings: 1) A review of Resident 407's admission Record indicated that the resident was…

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 had a medication error rate of 6.9% when two medication errors occurred out of 29 opportunities during medication administration for one of five residents (Resident 9). These failures resulted in the resident not receiving the full therapeutic effects of the medication. Findings: 1. A review of Resident 9's Physician order dated 3/7/20, indicated Docusate Sodium (DSS, stool softener) 250 milligrams (mg, unit of measurement) via Gastric tube (G tube, tube inserted to the abdominal wall) three times a day for bowel management. A med pass observation and interview on 7/26/23 at 9:27 A.M. with licensed nurse (LN 2) inside Resident 9's room. LN 2 took a DSS capsule, placed it in a cup and LN 2 poured water into the cup. LN 2 stated he was going to wait for the capsule to dissolve. During a concurrent observation and interview on 7/26/23 at 9:31 A.M. with LN 2, he verified a liquid form of DSS was in the medication cart. He also stated that the liquid medication should have been prepared instead of the capsule. On 7/28/23 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.

The facility failed to discard four expired cans of food of 20 cans reviewed. This failure put residents at risk of consuming spoiled food. Findings: On 7/25/23 at 7:40 A.M., an observation was conducted of the dry food storage room. Four cans of beef ravioli had a use by date of 7/6/23, and there was a sticky note above the cans which directed staff to use by 7/6/23. On 7/25/23 at 8 A.M., an interview was conducted with the Dietary Supervisor (DS). The DS stated, the facility should have removed the expired food, but the person responsible for removing the expired items was on leave, so it was missed. Per the facility's policy titled, Storage of Food and Supplies, dated 2022, .No food will be kept longer than the expiration date on the product .