University Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent an accumulation of old food and beverage items at the bedside of one resident, Resident 2, sampled for infection prevention. The facility also failed to provide regular showers or bed baths and clean clothing to Resident 2 who had open sores on his arms and face. As a result, Resident 2 was at risk for foodborne illness and infection of his open wounds. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses that included depression (a mental health condition that involves a persistent feeling of sadness), severe protein-calorie malnutrition (a condition that occurs when the body doesn't get enough protein, calories and other nutrients), mood disorder (a mental health condition that involves persistent changes in a person's emotional state), malignant neoplasm of bronchus and lung (a type of tumor in the lower airways and lung), and homelessness. On 11 /13/24 an unannounced visit was made to the facility. On…

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

Based on observation, interview, and record review, the facility failed to provide documented evidences that the maintenance department was proactive in documenting weekly maintence checks for room and facility temperatures during extreme temperature changes. As a result, the facility was unable to show documented evidence the facility and room temperatures were safe and comfortable over the past year. Findings: On 6/27/24, an unannounced visit was made to the facility, regarding a complaint of the buildings' air conditioner not functioning in the east hallway. On 6/27/24 at 1:25 P.M., an observation was conducted of the east hallway which consisted of resident rooms 10-29. All the rooms had one or more fans in them, and a small air conditioner unit was in one room. Seven ceiling fans ran the length of the hallway and were all functioning. On 6/27/24 at 1:28 P.M., an interview was conducted with Resident 3. Resident 3 stated her room was hot and had been like that for, Several days. Resident 3 stated she was told the air conditioner was broken and they were waiting for a part to fix…

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 an interview and record review, the facility failed to ensure that pressure injuries (also known as pressure ulcers or bed sores, which are areas of skin and tissue damage caused by prolonged or intense pressure) were documented in the medical record every week per the facility's policy for one of three sampled residents (Resident 1). As a result, Resident 1's progression or deterioration of the pressure injury could not be accurately assessed. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body), per the facility's admission Record. A review of Resident 1's medical record was conducted. Per the Progress Notes dated 3/22/24, Licensed Nurse (LN) 1 documented that Resident 1 had a stage 1 (no skin break) pressure injury to the sacral (tailbone) area and was red. Per the undated Plan of Care, under Focus (Problem Area), Resident 1 had impaired skin integrity related to a stage 1 reddened sacral area. One intervention was 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 observations, interviews and record review, the facility failed to ensure dignity was provided to the residents when a staff member did not knock or announce herself before entering two residents' rooms (Resident 1 and unsampled residents). This failure had the potential to make residents feel disrespected and may have resulted in diminished quality of life and lower self-esteem. Findings: On 3/14/24, an unannounced onsite was conducted to the facility related to a complaint of resident abuse. a. Resident 1 was readmitted to the facility on [DATE] with diagnoses which included dementia (loss of cognitive function like thinking, remembering, and reasoning) with psychotic (loss of contact with reality) disturbance, per the facility ' s admission Record. A review of Resident 1 ' s minimum data set (MDS, an assessment tool), dated 2/16/24, indicated Resident 1 ' s brief interview for mental status (BIMS, ability to recall) score was six, which indicated Resident 1 ' s cognitive function was severely…

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 follow the plan of care for monitoring a recently placed suprapubic catheter (a surgically inserted flexible tube that drains urine from the bladder into an external drainage bag), for one of three residents (Resident 1), reviewed for comprehensive care plans and following the physician ' s order. As a result, there was the potential for Resident 1 ' s suprapubic catheter to develop an infection or become dislodged when unmonitored routinely by staff. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included cancer of the prostate, per the facility ' s admission Record. On 11/27/23, Resident 1 ' s clinical record was reviewed: According to the admission Minimum Data Set (a clinical assessment tool) Resident 1 had a cognitive score of 15, indicating cognition was intact. According to the facility ' s Progress Note dated, 11/15/23 at 11:39 A.M., Resident 1 returned to the facility following an outpatient surgery of 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 provide pain relief in a reasonable amount of time, following a recently placed suprapubic catheter (a surgically inserted flexible tube that drains urine from the bladder into an external drainage bag), for one of three residents (Resident 1), reviewed for pain management. As a result, Resident 1 had no pain relief for 6.5 hours, delaying his comfort and healing process. Findings: On 11/27/23 an unannounced visit was made to the facility regarding a complaint which involved pain management. Resident 1 was admitted to the facility on [DATE], with diagnoses which included cancer of the prostate, per the facility ' s admission Record. On 11/27/23, Resident 1 ' s clinical record was reviewed: According to the admission Minimum Data Set (a clinical assessment tool) Resident 1 had a cognitive score of 15, indicating cognition was intact. According to the facility ' s Progress Note dated, 11/15/23 at 11:39 A.M., Resident 1 returned to the facility following…

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 care plan related to skin integrity for one of one resident with a rash (Resident 2). Failure to develop a care plan related to skin integrity had the potential for residents to not receive appropriate care and treatment. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with hyperglycemia (too much sugar circulating in the blood) according to the facility ' s admission Record. During an interview on 10/17/23, at 1:10 P.M with LN 1, LN 1 stated Resident 2 had a treatment order for a medication to be applied on Resident 2 ' s left under breast. LN 1 stated the treatment was started two days ago. During an interview on 10/17/23, at 1:15 P.M. with Resident 2, Resident 2 stated both under breast areas were sore because of a rash. A review of Resident 2 ' s physician ' s order titled Order Summary Report, dated 10/17/23, the physician ' s order indicated, .Nystatin External…

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 appropriate respiratory (relating to breathing) care and services were given to four residents when: 1. The physician's order for oxygen therapy was not followed for three residents. (Resident 3, Resident 4, and Resident 6) 2. There was no Oxygen in use sign on the doors for two residents (Resident 2 and Resident 4) and, 3. A resident ' s BIPAP (machine used as breathing support and administered through a face mask or nasal mask) nasal mask was exposed and not stored correctly. In addition, staff did not know when and how to clean the BIPAP ' s tubing and nasal mask. (Resident 2) This failure had the potential for residents to have further respiratory problems, and infection from an unclean respiratory equipment. In addition, residents, staff, and visitors were not aware of the safety risk regarding the use of oxygen in residents ' rooms. Findings: 1. Resident 3 was admitted to the facility on [DATE] with the diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide behavioral health care and services for two residents when: (Resident 1 and Resident 3) 1. Residents 1 and 3 both had a history of substance abuse were not referred to an addiction treatment program or for drug counseling services, 2. Residents 1 and 3 did not have a specific resident centered care plans (an approach to care that places a patient's needs and desires first) regarding substance abuse interventions. As a result, Resident 1 was transferred to the hospital and was diagnosed with Fentanyl (a highly addictive pain medication) overdose, and an unknown white powdery substance was found in Resident 3's room. Findings: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses including psychoactive substance (drugs that affect the brain) abuse according to the facility's admission Record. During an interview on 9/1/23, at 10:18 A.M., with the Minimum Data Set (MDS-an assessment tool) nurse, the MDS nurse stated Resident 1 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 resident (Resident 1) was kept safe from injury when Resident 1 walked to the bathroom unsupervised. As a result, Resident 1 fell and sustained a left hip fracture (break in a bone). Findings: Resident 1 was admitted to the facility on [DATE] with diagnosis of generalized muscle weakness and history of falling. Resident 1's admission assessment, dated 6/5/23, indicated Resident 1 had fallen within the month prior to admission. Resident 1's brief interview for mental status (BIMS, an assessment tool) indicated Resident 1 had a mild cognitive impairment with a score of 12. A record review of the facility's fall report document ndicated Resident 1 had an unwitnessed fall and was found on the floor on 6/16/23 at 5:15 P.M. On 7/13/23 at 1:17 P.M., an observation of call light response was conducted in the facilities North Hallway. A call light for room [ROOM NUMBER] went on at 1:20 P.M. A staff member was observed responding to the call…

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 4. Resident 14 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing foods or liquids) and dementia (a disease that affects the brain's ability to think, remember and reason) per the facility's admission Record. A review of Resident 14's nutritional risk assessment on admission, dated 10/10/22, indicated Resident 14 had chewing and swallowing problems and was at high risk for aspiration (when food or liquid enters the airway and lungs). A review of Resident 14's speech therapy evaluation (STE), dated 10/10/22 indicated the resident wore dentures. A review of Resident 14's diet orders, dated 2/17/23, indicated Resident 14 had was on a regular diet, mechanical soft (easy to chew) with ground meat texture and thickened liquids. On 2/16/23 at 11:37 A.M., an observation and interview with Resident 14 was conducted in her room. Resident 14 stated she was served fried eggs and potatoes for breakfast. Resident 14 stated she had difficulty chewing the potatoes and had to suck the soft…

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 safe provision of pharmacy services to meet the needs of the residents by failing to: 1. Remove a discontinued medication from the medication cart for a discharged resident in a timely manner; 2. Label with the time and date of activation (contact between previously separated diluent and medication) of the Mini Bag Plus - piperacillin/tazobactam (antibiotic for injection into vein) vial system before storage in the medication refrigerator; 3. Clarify a physician order to provide pain medication only for moderate pain for one of five residents reviewed (Resident 8); and 4. Correctly administer a pain medication based on the perceived level of pain for one of five residents reviewed (Resident 33). 5. Correctly ensure that medication was stored in the correct location for one of 19 sampled residents (70). These had the potential for administration of ineffective medications and inadequate control of pain. Findings: 1. During…

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 an adequate handwashing sink with soap in the kitchen. This failure had the potential to increase the risk of food-borne illness. Findings: During the initial tour of the kitchen, conducted on 2/14/23 at 8:15 A.M., a sink was observed near the entrance to the kitchen; the soap dispenser was empty. A concurrent observation and interview with the Dietary Services Manager (DSM) was conducted on 2/14/23 at 8:18 A.M. The DSM stated the soap dispenser was empty and, There should be soap available to make sure employees are washing their hands. A review of 2022 US FDA Food Code- Section 2-301.15 Where to Wash, indicated: Effective handwashing is essential for minimizing the likelihood of the hands becoming a vehicle of cross contamination. It is important that handwashing be done only at a properly equipped handwashing facility in order to help ensure that food employees effectively clean their hands. Handwashing sinks are to be conveniently located, always accessible for handwashing, maintained so they…

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 QAPI/QAA (quality assessment performance improvement/quality assessment and assurance) committee failed to identify, develop, and implement action plans related to the residents discharging from the facility against medical advice (AMA). Cross reference F622. This failure had the potential to affect the health and safety of the residents. Findings: On 2/17/23 at 2:02 P.M., a telephone interview was conducted with the medical director (MD) 1 to discuss the facility's discharge and AMA process. MD 1 stated the facility's QAPI/QAA Committee reviewed the facility's discharges, but not specifically AMA discharges. MD 1 stated it was normal for a facility to average about one to two AMA discharges a month. MD 1 stated the facility would need to pay attention to abnormalities such as five or more AMA discharges a month. MD 1 stated having five or more AMA discharges a month would open a can of worms and the root cause of such an occurrence would need to be investigated by the facility's QAPI/QAA. A review of the facility documents titled…

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 one of four residents (18) reviewed for discharge, was permitted to remain in the facility when: 1. The facility initiated Resident 18's discharge as AMA (against medical advice). 2. Licensed nurse (LN) 2 did not verify that Resident 18's order for discharge came from the physician. 3. There was no documentation in Resident 18's clinical record that the AMA discharge was resident-initiated. 4. Facility policies for discharge and leaving AMA were not implemented. In addition, when the facility discharged Resident 18 home on 1/30/23, the resident was unable to use the stairs to access his home, the resident had been sent home with medications/treatments he did not know how to administer to himself, and was not provided with home health services. As a result of this unsafe discharge, Resident 18's health and safety was put at risk. Findings: A review of Resident 18's admission Record indicated the resident was admitted to the facility on [DATE]…

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 notify the responsible party of discharge for one Resident (11). Findings: Resident 11 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (the kidneys no longer function);diabetes mellitus with chronic kidney disease and dependence on renal dialysis (a procedure that removes toxins from the blood in people who have no kidney function) per the facility's admission Record. No observation opportunity of Resident 11 was available as the Resident was no longer residing in the facility. A review of Resident 11's admission Record indicated: . daughter: emergency contact #1 responsible party . A review of Resident 11's medical record was conducted on 2/15/23. A progress note by Social Services, dated 1/3/23 at 4:51 P.M. was reviewed. The progress noted indicated, Resident adamantly requesting to dc (discharge) from facility . resident stated he would be leaving AMA . An interview was conducted with the Social Services…

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 revise a care plan for falls for one Resident (13). This failure had the potential to increase the risk of falls for Resident 13. Findings: Resident 13 was admitted to the facility on [DATE] with diagnoses that included left knee arthritis, muscle weakness and epilepsy (seizures). An observation of Resident 13 was conducted on 2/14/23 at 10 A.M. Resident 13 was reclining in bed and the bed was not at a low position. An observation of Resident 13 was conducted on 2/15/23 at 9 A.M. Resident 13 was reclining in bed and the bed was not at a low position. An observation of Resident 13 was conducted on 2/16/23 at 8:28 A.M. Resident 13 was sitting on the bed and the bed was not at a low position. An interview was conducted with registered nurse (RN)13 on 2/16/23 at 8:37 A.M. RN 13 stated, The resident uses a walker and refuses to have a low bed; he is very independent. An interview and concurrent record review was conducted on 2/16/23 with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a discharge summary for one Resident (11). This failure had the potential to cause a decrease in communication for post-discharge information for the resident and the care-giver. Findings: Resident 11 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (the kidneys no longer function);diabetes mellitus with chronic kidney disease and dependence on renal dialysis (a procedure that removes toxins from the blood in people who have no kidney function) per the facility's admission Record. No observation opportunity of Resident 11 was available as the Resident was no longer residing in the facility. A review of Resident 11's medical record was conducted on 2/15/23. A progress note by Social Services, dated 1/3/23 at 4:51 P.M was reviewed. The progress noted indicated, Resident adamantly requesting to dc (discharge) from facility . resident stated he would be leaving AMA . An interview was conducted 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 provide activities designed to meet the interests of one of one resident (41) reviewed for Activities. This failure had the potential to effect resident 41's physical, mental, and psychosocial well-being. Findings: A review of resident 41's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including a right femur (leg bone) fracture, a sacral pressure ulcer, pneumonia, and depression. Resident 41's Brief Interview for Mental Status (an assessment used to measure and track a resident's cognitive decline or improvement in a long-term care facility) score was 15 (cognitively intact). On 2/14/23 at 3:34 P.M., resident 41 was observed laying in bed, wearing hospital gown and staring at the television. On 2/15/23 at 10:42 A.M., a concurrent observation and interview was conducted with resident 41. Resident 41 was observed laying in bed, wearing hospital gown and staring at the television. Resident 41…

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 Resident (13) was provided proper eyeglasses. This failure had the potential to affect Resident 13's vision. Findings: Resident 13 was admitted to the facility on [DATE] with diagnoses that included Osteroarthritis of the left knee (inflammation of the joint) and epilepsy (seizures) per the facility's admission Record. An observation of Resident 13 was conducted on 2/14/23 at 2:33 P.M. Resident 13 was observed reclining in bed and watching TV. Resident 13 was wearing eyeglasses that were broken; the right side, including frame and lens were missing; the nose bridge was taped. A review of Resident 13's medical record indicated an Eye Doctor Consultation dated 11/2/22. The consultation indicated, .chief complaint: blurry vision; diagnosis: cataracts: context: reading and TV . In addition: initiation of Diagnostic and Treatment Plan: New Glasses recommended:frame and bifocal lenses . A review of the care plan, titled Impaired Visual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 396), had her oxygen therapy monitored and documented accurately. This failure resulted in an over-administration of oxygen and had the potential to slow Resident 396's heart and breathing rate, and cause lung damage. Findings: A record review of Resident 396's medical chart was conducted on 2/14/23. Resident 396 was a [AGE] year-old female admitted to the facility on [DATE] with a Diagnosis that included, but was not limited to, Uterine Cancer (cancer of the womb), complete hysterectomy (a surgery that removed her womb and her ovaries), hypertension (elevated blood pressure) and muscle weakness. The Minimum Data Sheet (MDS), dated [DATE], reported a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. During a review of Resident 396's physician orders, dated 2/10/23, oxygen (O2) was to be administered at 2 Lpm (measurement of liters per minute) per nasal…

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 one medication to treat high blood pressure was not administered in excess of the dose ordered by the physician when one medication order was duplicated and administered twice each day for one of five residents reviewed (Resident 33). This had the potential to significantly lower the blood pressure to cause dizziness, confusion, fainting and a fall. Findings: Review of Resident 33's medical record indicated the resident was admitted on [DATE] with diagnoses that included DM, HTN, and chronic pain. There was a physician order on 1/27/23 for Lisinopril (medication for high blood pressure) 10 mg (milligram; unit of measurement) with the direction to give one tablet by mouth one time a day for HTN (hypertension; high blood pressure) and hold if SBP (systolic blood pressure) less than 100. Also, there was a physician order on 2/8/23 for Lisinopril 10 mg with the direction to give one tablet one time a day for hypertension and hold if SBP less than…

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 use of psychotropic medications for sleep ordered as PRN (as needed) by the physician for residents did not exceed beyond 14 day without being re-ordered by the physician. This had the potential for unnecessary medications to be administered to the resident. Findings: Review of Resident 8's medical record indicated the resident was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus (DM; condition in which the body is not able to control high blood sugar), hypertension (HTN; high blood pressure), and enlarged prostate gland. There was a physician order on 1/10/23 for zolpidem (hypnotic to aid sleep) 10 mg with the direction to give one tablet by mouth every 24 hours as needed for insomnia (inability to sleep) at bedtime. The electronic medication administration record (EMAR) indicated the resident has been treated with this medication for insomnia presently. There was no indication in the resident's medical record there 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 there was an open date written on the insulin pen when it was removed from the medication refrigerator and stored in the medication cart at room temperature. This had the potential for the medication to be less effective, or for an expired medication to be administered to the resident. Findings: During inspection of the East Medication Cart on [DATE], at 3:30 P.M., it was noted there was an insulin injection pen, Insulin Lispro Kwikpen (medication to help control blood sugar), stored in the medication cart at room temperature without an open date or the date it was removed from the refrigerator. In an interview on [DATE], at 4:05 P.M., licensed nurse (LN) 4 was not able to locate the open date on the pen and agreed there was no open date. In an interview on [DATE], at 12 P.M., the Director of Nursing (DON) agreed there should have been an open date on the pen. The manufacturer's prescribing information for Insulin Lispro Kwikpen…

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 medical director failed to ensure policies and procedures were implemented related to residents leaving/discharging the facility against medical advice (cross reference F622). As a result, there was a potential for residents to be inappropriately discharged from the facility without the necessary care and services, which could potentially result in physical and psychosocial harm to the residents. Findings: During the course of the facility's recertification survey (2/14/23 through 2/17/23), four closed resident records were reviewed. Upon review, Resident 18 had a physician's order dated 1/30/23 to discharge from the facility against medical advice (AMA). In addition, there was no documentation the risks of leaving AMA were evaluated, clearly explained, and discussed with Resident 18. A review of the facility's policy titled Discharging a Resident without a Physician's Approval, revised October 2022, indicated, .A physician's order is obtained for discharges, unless a resident or representative is discharging himself or herself…

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 accurate documentation of medication for two of 18 residents (Resident 70 and 396). This failure had the potential to result in inadequate pain control and oxygen toxicity (damage to the lungs from too much oxygen). Findings: 1). A record review of Resident 70's medical reccord was conducted on 2/14/23. Resident 70 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that included, but not limited to, Heart Failure (declining heart function), heart arrythmia (the heart has an irregular beat), Diabetes (high blood sugar) and psoriatic arthritis (swelling and pain of the joints). The Minimum Data Sheet (MDS), dated [DATE], reported a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. During concurrent observation and interview on 2/14/23, at approximately 10 A.M., Resident 70 was alert sitting in a wheelchair at her bedside. Resident 70 stated that she kept her cream…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement infection prevention controls when oxygen tubing was not changed weekly, per the facilities expected practice, for two of 19 residents (20, 28) reviewed for infection control. As a result, there was a potential for germs to enter the respiratory tract of resident's causing an infection. Findings: A review of resident 20's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including right sided paralysis (the loss of the ability to move) due to cerebrovascular disease (a condition which effects blood flow to the brain). A review of resident 28's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including left sided paralysis due to cerebrovascular disease. On 2/14/23 at 9:32 A.M., resident 20 was observed awake, sitting up in bed. Oxygen was being delivered to the resident through nasal cannula tubing (a device with two small prongs that rest 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 observation, interview, and record review, the facility failed to treat residents with respect and dignity for three of 21 sampled residents and three unsampled residents when: 1. A staff member did not wait for a resident's response before entering and did not introduce themselves upon entering the resident's room (49), 2. Staff did not talk to or sit down with residents (10, 45, 331, 2) who relied on staff for assistance with their meals; and, 3. A staff member did not provide care in a respectful manner for one resident (22). 1. Resident 49 was admitted to the facility on [DATE], per the facility's Resident Face Sheet. On 8/22/19, a review of Resident 49's MDS (health status screening and assessment tool), Section C, dated 7/15/19, indicated Resident 49's BIMS Summary Score (test for cognitive function) was 13 out of 15 (score of 13-15 indicated cognition was intact). On 8/21/19 at 10 A.M., an observation in Resident 49's room was conducted. Resident 49's door to her room was closed. Resident 49'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 food was prepared in accordance with professional standards of food service safety when the food processor was not properly cleaned between preparing puree vegetables and chicken. This failure had the potential for cross-contamination (when germs are unintentionally transferred from one item to another) and the potential for foodborne illness. Findings: During an observation of the puree process, on 8/22/19 at 10:14 A.M., after pureeing peas and carrots, [NAME] 1 took the dirty food processor to the food prep sink. [NAME] 1 was observed to rinse the food processor. At 10:16 A.M., [NAME] 1 brought the rinsed food processor back to the work station and prepared the pureed chicken. During an interview with [NAME] 1 on 8/22/19 at 10:39 A.M., [NAME] 1 stated she was supposed to put the food processor through the dishwasher before she pureed another food item. [NAME] 1 stated, The dishwasher was busy, so I just rinsed it with hot water. During an interview with the Dietary Services Supervisor (DSS) on 8/22/19…

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.