Canyon Springs Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. A review of Resident 591's medical record indicated an admission Date of 4/17/25. Resident 591's diagnoses included cognitive communication deficit (trouble communicating because of problems with their thinking and processing abilities, not just their language skills), and dysphagia, oral phase (difficulty with the first stage of swallowing, which happens in the mouth). A review of Resident 591's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 591's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 13 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During a concurrent observation and interview on 5/5/25 at 8:56 a.m. inside Resident 591's room, Restorative Nurse Assistant (RNA) K was standing at bedside while feeding Resident 591. Resident 591 was sitting on the bed. RNA K stated it was okay…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement comprehensive care plans that included target symptoms, measurable objectives, and interventions for one of 35 sampled residents (Resident 16) when there were no care plan developed for schizophrenia (chronic brain disorder that affects how a person thinks, feels, and behaves). The failure had the potential for the residents not attaining their highest practicable physical, mental, and psychosocial well-being. Finding: During a review of Resident 16's clinical record indicated Resident 16 was admitted to the facility on [DATE] with diagnosis including schizophrenia. During a review of Resident 16's physician's order indicated an order dated 4/24/25 Aripiprazole (Antipsychotic It can treat schizophrenia) 15 mg (milligram, unit of measure) give one tablet by mouth in the morning for schizophrenia . During a review of Resident 16's clinical record indicated there was no comprehensive care plan developed for the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure administration of enteral feeding (the delivery of nutrients through a feeding tube directly into the stomach) was consistent with and followed Physician's Order for one (Resident 51) out of three sampled residents when insufficient amount was administered, and oral care was not done. These failures had the potential to put Resident 51 at risk for dehydration, weight loss and infection. Findings: A review of Resident 51's clinical record indicated diagnoses of dysphagia following nontraumatic intracerebral hemorrhage (difficulty of swallowing after a stroke), hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side (complete paralysis and weakness on right side of the body after a stroke), aphasia following nontraumatic intracerebral hemorrhage (difficulty to speak, understand and write language after a stroke), and type 2 diabetes mellitus without complications (high levels of blood…

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

Based on observation, interview and record review, the facility failed to ensure that a proper treatment services for oxygen (O2, a colorless, odorless gas) therapy was provided for one of four sampled residents (residents on oxygen therapy) when Resident 139 did not receive the correct flow of oxygen administration. This deficient practice had the potential for Resident 139 to have complication related to improper treatment while receiving O2 therapy. Findings: During an observation on 5/5/2025 at 8:24 a.m., inside Resident 139's room, Resident 139 was observed having breakfast in bed and with O2 therapy at 1.5 liters per minute (lpm) thru (via) a nasal cannula (NC - a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). During a concurrent observation and interview with licensed vocational nurse B (LVN B) on 5/6/2025 at 3:57 p.m., inside Resident 139's room, Resident 139 was observed in bed with O2 therapy at 1.5 lpm via NC. LVN B confirmed the oxygen flow was at 1.5 lpm. During a concurrent interview with LVN B and 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 observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for one of 35 sampled residents (Resident 57) resident who used side or bed rails when there was no physician's order for bilateral (both) quarter upper bed rails prior to installing the bed rails, the care plan for bilateral quarter upper bed rails was not developed in a timely manner, and the informed consent for bilateral quarter upper bed rails was not obtained prior to installing the bed rails. These failures had the potential risk for injuries to the Resident 57. During an observation in Resident 57's room on 5/5/25 at 9:44 a.m., Resident 57's bed observed with bilateral quarter upper bed rails were up. During a review of Resident 57's clinical record indicated Resident 57 was admitted to the facility on [DATE] with diagnosis including Alzheimer's disease (a progressive disease that destroys memory and mental functions). During a review…

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

Based on observation, interview, and record review, the facility failed to ensure that one of 35 sampled residents (Resident 160) received the planned menu meal or the food alternative, as indicated on the posted menu and consistent with the resident's preferences. As a result, Resident 160 did not receive the correct food items on multiple occasions. Findings: A review of Resident 160's Minimum Data Set (MDS, a resident assessment and care screening) dated 4/2/25, indicated a Brief Interview for Mental Status (BIMS, a brief screening tool used to assess thinking and memory) score of 15. A BIMS score of 13-15 indicates intact cognition (suggests no significant impairment in thinking, reasoning, memory, and problem solving). During a dining observation and concurrent interview on 5/5/25 at 1:23 p.m. in Resident 160's room, the resident's meal tray contained a beef patty and salad. Resident 160 confirmed the food items and stated he had received the same meal the day before. Resident 160's tray ticket documented a dislike of all pork. Resident 160 also reported that, several days…

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 call light (a visible and audible alarm activated by a call button) for two of 35 sampled residents (Resident 55 and Resident 148) was within reach. This deficient practice had the potential to result in a delay in meeting Resident 55 and Resident 148's needs for toileting and activities of daily living. Findings: 1. During an observation inside Resident 55's room on 5/5/25 at 9:38 a.m., Resident 55 was observed lying in bed, the call light was not in Resident 55's bed. During a concurrent observation and interview inside Resident 55's room on 5/5/25 at 3:00 p.m., with Certified Nursing Assistant F (CNA F), CNA F looked for the call light button and found it hanging on the feeding tube pole (a device used to support and secure feeding bags or feeding pumps during tube feeding). CNA F confirmed the call light was not within the reach of Resident 55. CNA F further stated Resident 55's call light should not be hanging in the feeding tube pole. During a review of Resident 55's clinical record indicated…

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 lab results were communicated to the physician for one of three sampled residents (Resident 1). This failure had the potential to delay treatments and interventions that Resident 1 may have needed. Findings: Review of Resident 1's medical record indicated he was admitted on [DATE] and had a history of pneumonia (an infection of the lungs) and urinary tract infection. Review of Resident 1's situation, background, assessment, recommendation (SBAR, a communication tool), dated 4/12/25, indicated he had an episode of vomiting. The SBAR also indicated Resident 1 had decreased appetite, fluid intake, and urine output. Review of Resident 1's Order Summary Report indicated he had a physician's order, dated 4/12/25, for a repeat CBC (complete blood count, a blood test that evaluates the number and types of blood cells) and CMP (comprehensive metabolic panel, a blood test that provides an overview of the body's chemical balance). Review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented in four out of six shower rooms when: 1. Shower room [ROOM NUMBER] had a brown substance on the floor; 2. Shower room [ROOM NUMBER] had cotton swabs and a shaver cover on the floor drain; 3. Shower room [ROOM NUMBER] had a used white towel on the shower handlebar, and 4. Shower room [ROOM NUMBER] had a used shaver, toilet tissue, wheelchair footrests, and socks in the bathtub. These failures could result in the spread of infection and cross-contamination that could affect staff, visitors, and the 194 residents who reside in the facility. Findings: 1. During a concurrent observation and interview on 12/4/2024 at 10:12 a.m., with the Maintenance Director (MD), there was a brown substance on the floor in shower room [ROOM NUMBER]. The MD confirmed the brown substance was feces (bodily waste discharged from the bowels after food has been digested). The MD further stated staff should 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.

Based on interview and record review the facility failed to notify a responsible party (RP, person who makes healthcare decisions on behalf of a resident) regarding change in condition (clinically important change of a person's health status) when a resident sustained an injury to his left elbow for one of three sampled residents (Resident 1). This failure resulted in the RP not being informed. Findings: Review of Resident 1's clinical record indicated a physician's order was obtained on 1/20/23 at 3 p.m. to treat the resident's left elbow injury. The clinical record lacked documentation the RP was notified of the wound. During an interview on 6/4/24 at 1:38 p.m., the director of nurses (DON) reviewed Resident 1's clinical record and stated the elbow wound was a change in condition (new wound). The DON stated could not find documentation of RP notification in Resident 1's clinical record. Review of the facility's Change in a Resident's Condition or Status policy, dated February 2021, indicated a nurse was to notify the resident's representative when there was a significant change 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 ensure staff provided treatment and care in accordance with professional standards of practice when Resident 1's: 1. physician's orders were obtained late for wound treatments, and these orders were then implemented late, 2. physician's order for the right third toe was not obtained, 3. change of condition (clinically important change of a person ' s health status) was not documented regarding a (3a.) a STAT (urgent) lab that was ordered and (3b.) elbow wound, 4. clinical record lacked documentation relevant to an elbow wound. These failures placed the resident's health at risk. Findings: Review of Resident 1's clinical record indicated he was admitted [DATE] with diagnoses including diabetes mellitus (chronic condition in which a person's body has trouble controlling blood sugar) and malnutrition. Resident 1 was at risk for dehydration. Resident 1 also tested positive for COVID-19 on 1/14/23. Review of Resident 1's Minimum Data Set (MDS, an assessment…

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 pharmacist failed to report drug irregularities for one of four sampled residents (Resident 1), when Resident 1 received a diuretic (Lasix) with a black box warning (BBW, medications identified by the Food and Drug Administration (FDA) to have serious side effects to alert consumers) label; however, the consultant pharmacist (CP) did not address side effects monitoring for it. This failure left the potential side effects of Lasix to be unmonitored for Resident 1. Findings: Review of Resident 1's physician's medication orders, dated 12/23/22, indicated furosemide (Lasix) 40 milligrams (mg, a metric unit of measurement) twice daily. Resident 1's hospital Discharge summary, dated [DATE], indicated he presented to the hospital on 1/25/23 with hypernatremia (high sodium in blood), confusion more than baseline. Lab results drawn on 1/24/23 indicated a critically high sodium value of 161 mEq/L (milliequivalents per liter, units of measure; normal range is 135 mEq/L to 145…

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 STAT (urgent) laboratory result was obtained timely for one of three sampled residents (Resident 1). Resident 1's STAT laboratory order was not obtained until a day after it was ordered and one test result had a critical value (potentially life-threatening requiring immediate medical attention). This failure resulted in a delay in hospital transfer and placed the resident's health at risk. Findings: Review of Resident 1's care plan, dated 12/23/22, indicated the resident was at risk for dehydration. Review of Resident 1's physician order dated 1/24/23 at 9:44 a.m. indicated STAT lab tests including a comprehensive metabolic panel (CMP, blood test that measures different substances to provide information about a person's chemical balance and metabolism). Review of Resident 1's Nurses Note, dated 1/25/23 at 11:21 a.m., indicated the facility received lab results drawn on 1/24/23 that had a critical high sodium 161 mEq/L (milliequivalents per…

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 promptly notify an abnormal lab result to the physician/nurse practitioner (NP) for one of four sampled residents. This failure resulted in the delay of the resident's change in prescription. Findings: Review of Resident 1's clinical record indicated he was admitted on [DATE] with a diagnosis of diabetes mellitus (long term condition in which the body has trouble controlling blood sugar). Review of Resident 1's clinical record indicated he had a lab drawn on 12/29/22 at 6:25 a.m. with an elevated A1c (a test that measures the average amount of sugar in a person's blood over the past few months) level of 9.1% (desired range is below 5.7%). Review of a Nurse's Note, dated 1/5/23 at 2:33 p.m., indicated the NP made changes to Resident 1's diabetic medications and reordered lab tests. Review of a physician's order, dated 1/10/23, indicated Resident 1's dosage of a diabetic medication was increased and noted his A1c result was 9.1%. Review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded. Specifically, MDS assessments did not reflect the use of oxygen for 1 (Resident #34) of 4 sampled residents reviewed for respiratory care and did not accurately reflect the discharge location for 1 (Resident #183) of 6 sampled residents reviewed for hospitalizations. Findings included: A review of a facility policy titled, Certifying Accuracy of the Resident Assessment, revised in November 2019, revealed, 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for the assessment. 1. A review of an admission Record revealed the facility admitted Resident #34 on 02/07/2013. According to the admission…

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

Based on record review, interviews, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, the facility failed to ensure 1 (Resident #117) of 8 sampled residents reviewed for PASRR requirements was referred for further evaluation after the addition of a new mental illness diagnosis. Findings included: Review of an undated facility policy titled, admission Criteria, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The policy further indicated, b. When/if the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative by the system for the Level II (evaluation and determination) screening process. Review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1…

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

Based on record review, interviews, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, the facility failed to ensure the accuracy of a Preadmission Screening and Resident Review (PASRR) Level 1 Screening for 1 (Resident #117) of 8 sampled residents reviewed for PASRR requirements. Specifically, the facility failed to ensure Resident #117's PASRR Level 1 Screening reflected the resident's diagnosis of major depressive disorder. Findings included: Review of an undated facility policy titled, admission Criteria, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. Review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, dated 01/12/2023, revealed, Section III-Serious Mental Illness Questions 10-12 This section helps determine…

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

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure 2 (Resident #106 and Resident #128) of 33 sampled residents' care plans reflected the residents' current conditions and needs. Findings included: A review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised in December 2016, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy further indicated, 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Additionally, the policy indicated, 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy further indicated, 13. Assessments of residents…

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 services in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. Licensed nurses did not complete Resident 1's quarterly fall risk assessment; 2. Licensed nurses did not document the assessment and reassessment of skin discolorations that were discovered on Resident 1's body; and 3. Licensed nurses did not accurately complete Resident 1's Nursing Weekly Summaries (weekly assessments of the resident's overall condition). These failures had the potential to compromise the facility's ability to provide resident-centered interventions based on assessment data. Findings: 1. Review of Resident 1's medical record indicated she was admitted on [DATE] and had the diagnoses of muscle weakness and history of falling. The medical record indicated the facility completed a fall risk assessment for Resident 1 on 4/7/22. Further review of the medical record indicated the facility did not complete another…

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 maintain proper infection control practices when: 1. Multiple residents did not wear their face masks properly when they were outside the room; 2. Dirty hamper in the hallway was overflowing with linens; 3. Electric fan on top of the Room J has grayish substance inside and out; 4. Residents 51, 61 and 84's oxygen concentrator filters were dusty; 5. There were no documents that indicated multiple residents refused Coronavirus Disease 2019 vaccine (COVID-19, a respiratory disease spreads from person-to-person through respiratory droplets produced when an infected person coughs, sneezes, or talks); 6. Incomplete Visitor Respiratory Screening Questionnaires for COVID-19; 7. Multiple facility staff did not maintain infection control practices; 8. The facility staff did not maintain droplet precaution practice. These failures have the potential to result in transmission of infection among residents. Findings: 1a. During an observations on 6/7/21…

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 accommodate residents' needs for six of 31 sampled residents (Residents 22, 43, 60, 110, 122, and 563) when: 1. Four residents' call lights (Residents 43, Resident 122, Resident 563 and Resident 60) were not functioning for four consecutive days; 2. Facility staff did not answer Resident 22's call light in a timely manner to assist her with bowel care; 3. Resident 110 was using the small size incontinent brief pad instead of the proper large size; 4. Resident 60 was using a wheelchair that was not fitted for him. These failures had the potential to result in the residents' needs being unmet and affecting residents' well-being. Findings: 1. During multiple observations in room I on 06/07/21, 6/08/21, 6/09/21 and 6/10/21 at 12:06 p.m., four residents' call lights (Resident 43, Resident 60, Resident 122 and Resident 563) were not functioning as there was no light from the outside door (to alert staff to check the resident's needs) and no…

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 baseline care plan for four of 31 sampled residents (Residents 134, 150, 560 and 566). This failure had the potential to result in the facility being unable to identify residents' individualized concerns/needs and outline the care and services required to meet the residents' identified needs. Findings: 1. A review of Resident 134's facesheet (document that summarizes a resident's information) indicated she preferred to speak a language other than English. During observations with certified nursing assistant C (CNA C) on 6/8/21 at 12:01 p.m., and observation with CNA T on 6/11/21 at 8:25 a.m., Resident 134 was observed talking to both CNA C and CNA T in her native language, which neither CNAs understood. Both CNA C and CNA T confirmed Resident 134 had difficulty understanding them during the resident's care. During a telephone interview on 6/09/21 at 11:37 a.m., Resident 134's family member stated Resident 134 could not speak…

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. During observation and record review of Resident 7's face sheet on 6/8/21 at 8:50 a.m., Resident 7 was awake and resting in bed. Resident 7 has a BIMS score of 14. Resident 7 has a history of heart failure (heart struggles to work properly), asthma (respiratory condition making breathing more difficult), chronic obstructive pulmonary disease (respiratory condition making breathing more difficult), and chronic bronchitis (respiratory condition making breathing more difficult). During an observation, interview, and record review with licensed vocational nurse H (LVN H) on 6/8/21 at 8:50 a.m., LVN H gave Resident 7 the Spiriva inhaler and gave no instruction on administration. Resident 7 inhaled the medication and immediately exhaled. LVN H confirmed the order for Spiriva 18mcg daily at 0800. LVN H confirmed the observation that the resident inhaled and immediately exhaled the medication. LVN H stated she should have instructed the resident regarding inhaler administration and should have asked the resident 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 develop, revise, and update an individualized and comprehensive person-centered care plan with measurable objectives, goals and person-centered interventions for four of nine sampled residents who had falls or risk for falls (Residents 3, 41,102 and 143) These failures had the potential to put the residents at risk of sustaining injuries and falls. Findings: 1. During multiple observations on 6/7/21 at 9:32 a.m., and 6/9/21 at 11:21 a.m., Resident 3 was lying in bed with a floor mat on the floor next to her bed and the bed was in a low position. Resident 3 had difficulty communicating. Review of Resident 3's clinical record indicated Resident 3 was readmitted to the facility on [DATE] with diagnosis including difficulty in walking, muscle weakness (decrease in strength in one or more muscles), lack of coordination, repeated falls and Dementia (decline in mental capacity affecting thinking and social abilities interfering with daily…

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 orders regarding gastrostomy tube (GT, a soft tube surgically inserted from the abdomen area into stomach for medication and nutrition use) feeding for three of seven residents (Residents 52, 77 and 114). This failure had the potential to result in complications of tube feeding. Findings: 1. A review of Resident 52's clinical record indicated Resident 52 was admitted on [DATE] with diagnoses included hemiplegia (paralysis of one side of the body), dysphagia (difficulty in swallowing) and dementia (memory loss). Review of Resident 52's Minimum Data Set (MDS, an assessment tool) dated 4/12/21 indicated Resident 52 had severe cognitive impairment and required total dependence with one-person assist in activity daily living (ADL, like walking, eating, dressing, toileting and personal hygiene). During observation on 06/9/21 at 11:30 a.m., Resident 52 was connected to one liter of Jevity 1.2 (feeding solution) with 800…

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 peripherally inserted central catheter (PICC, a thin flexible tube inserted into a vein in the upper arm and guided into a large vein above the right side of the heart to obtain intravenous access for medication administration) line care for three of four residents (Residents 150, 555 and 566) were done per professional standards of practice when: 1. Registered nurses (RNs) did not follow the physician's orders of the PICC line flushing for two of four residents (Residents 555 and 566). 2. Licensed nurse did not notify MD (doctor of medicine) when Resident 555's PICC line was pulled out and the IV antibiotics were not administered on time. 3. Registered nurses did not change the PICC line dressing as ordered for two of four residents (Residents 150 and 555). 4. Registered nurse did not follow the correct procedure during PICC line dressing change observation. 5. Registered nurses did not develop PICC line care plans, document…

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 dialysis services consistent with professional standards and to ensure staff had coordinated a resident's care with the dialysis facility for one of nine sampled residents (Resident 32) who received hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte, i.e. salts and mineral imbalances by using a machine and an artificial kidney) when: 1. Communication with the dialysis facility center was not properly coordinated when dialysis communication records (DCR) were not completed; 2. Staff was not trained on emergency care for residents with renal diseases, dialysis care and there was no emergency dialysis kit available, and; 3. The dialysis care plan was not resident-centered. These failures may affect the quality of dialysis care being provided to the residents. Findings: 1. Review of Resident 32's clinical record indicated he was readmitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure accurate accountability and storage of controlled substance (CS) medications (drugs with high potential for abuse or addiction); and the security of medications stored in the automated drug dispensing system (ADDS, a mechanical system that performs operations or activities, other than compounding or administration, relative to the storage, dispensing, or distribution of drugs) according to the facility policy and procedures, when: 1. The amount of oxycodone (a potent CS medication for pain) liquid for Resident 30 was inaccurate; 2. A CS medication for a discharged resident was transferred from the pharmacy's original packaging and without any identifiers; 3. Transactions of activities (includes user access of, and all drugs added to or removed) from the ADDS were not maintained in the facility since implementation in October 2019; and 4. Two of two employees, who were no longer employed by the facility, were on the active user…

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.

2. During concurrent observation and interview with licensed vocational nurse H (LVN H) on 6/8/21 at 8:56 a.m., LVN H applied a nitroglycerin transdermal patch to Resident 7's left upper arm. LVN H failed to check Resident 7's skin to make sure the previous nitroglycerin patch had been removed prior to the application of the new patch. Shortly after the medication administration, LVN H stated another shift was responsible for removal of the patch. LVN H stated she should have checked prior to putting it on and confirmed the failure to remove it, and the application of an additional patch can result in extra medication being delivered by the medication patch. LVN H then checked Resident 7's left upper arm, found another undated nitroglycerin patch on Resident 7's upper left arm, and removed the older nitroglycerin patch. Review of Resident 7's physician's order, dated 12/22/2018, indicated nitroglycerin 0.1 mg/hour 1 patch to be applied once daily at 8 a.m. Another physician's order, dated 12/22/2018, indicated the nitroglycerin patch was to be removed daily at 8:00 p.m. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of three medication refrigerators (Refrigerators #1 and #2) were within the accepted range of 36 to 46 degrees Fahrenheit (ºF). Also, the staff failed to take appropriate actions, such as notification to the director of nursing or maintenance, when the temperature was out of range. This failure had the potential for medications to lose their potency and effectiveness when administered to the residents. Findings: During a concurrent observation, interview, and record review, on 6/7/21 at 10:32 a.m., with licensed vocational nurse D (LVN D) in Medication room [ROOM NUMBER], LVN D stated there were two medication refrigerators with Refrigerator #1 on top of Refrigerator #2. LVN D stated the temperatures of both refrigerators were checked by staff twice daily. Refrigerator #2 was observed to contain various types of insulin (medication to control high blood sugar) pens and vials, PPD (purified protein derivative; used in a skin…

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

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when: 1. Four dietary staff did not cover their hair completely with a hairnet; 2. One pair of used gloves was on top of the kitchen cart; 3. Dietary staff did not do hand hygiene after touching his hairnet and face shield; 4. Dietary staff dropped his face shield on top of the kitchen table and did not disinfect the food preparation table and 5. Two out of four chopping boards had multiple deep cuts. These failures had the potential to cause food-borne illness for residents. Findings: 1. During an initial kitchen tour with the director of dietary services (DDS) on 6/7/21 at 8:45 a.m., DSS, registered dietitian (RD), worked to supervise and check kitchen staff within the food preparation areas. Their hair on the sides and back were not completely covered with a hairnet. During puree preparation observation with dietary cook (DC) on 6/7/21 at 11:10 a.m., DC's left side burn was sticking out and not completely covered with a hairnet. During a concurrent observation…

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 treat Resident 68 with dignity and respect when staff did not ask permission and provide privacy when requested to show Resident 68's right hip wound. This failure had the potential to cause emotional distress to the resident. Findings: During an observation on 6/9/21 at 10:14 a.m., when certified nursing assistant C (CNA C) was requested to show Resident 68's right hip wound, CNA C unfastened Resident 68's incontinent pad without asking the resident's permission. CNA C also did not draw the privacy curtain while the door was wide open, and exposed Resident 68's genitals to the public view. The resident immediately pulled back his incontinent pad to cover himself. Resident 68 was hesitant to show his right hip when he noticed people could see him from the outside of the room. CNA C was apologetic to Resident 68 that she did not provide him privacy or asked permission before doing what she did. During a concurrent interview with CNA C, she stated she should have provided privacy to Resident 68 and informed him…

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 licensed staff or interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) assessed and developed care plans for two of 31 sampled residents (Residents 97 and 150) regarding their abilities to self-administer of their own medications. These failures had the potential for improper medication administration and not addressing their clinical conditions. Findings: During an initial facility tour on 6/7/21 at 9:44 a.m., Resident 97 was in his bed awake, a bottle of Phenylephrine nasal spray (medication to relieve nasal discomfort caused by colds, allergies, and hay fever) was seen at his bedside table. Resident 97 stated he self-administered this nasal spray. During an interview with licensed vocational nurse D (LVN D) on 6/7/21 at 9:48 a.m., LVN D stated, no resident should have meds at bedside. A review of Resident 97's clinical record indicated there was no documented evidence that IDT did self-admministration medication assessment for…

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

Based on observation, interview and record review, the facility failed to ensure a sanitary, orderly and comfortable environment for six of 31 sampled residents (Residents 27, 34, 95, 110, 117, and 563), when: 1. Toilet seat and tanks were not securely installed for Rooms G, H and I. 2. Television (TV) reception was blurred for Residents 110 and 117. 3. There was no adequate bedroom space for Resident 563. 4. The walls of Room E and Room F were unmaintained. These failures had the potential to result in affecting the residents' safety, emotions, and well-being. Findings: 1. During an observation on 06/07/21 at 10:51 a.m., the toilet seat in room H was not securely installed with screws on the floor. The toilet seat moved when touched or seated. Also, the toilet tanks in room G and I wiggled as if they were not properly mounted. During an interview with Resident 34 on 06/07/21 at 12:31 p.m., Resident 34 stated he felt dismayed that he already told the maintenance staff about the concerns but the toilet seat and tanks were not fixed. During an interview with maintenance staff (MS) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool) Section N (Medications) for one of 31 sampled residents (Resident 568). This failure had the potential to result in unmet care needs for Resident 568. Findings: During a review of Resident 568's clinical record, it indicated she was admitted to the facility on [DATE] with a physician order that included Lovenox (Enoxaparin, anticoagulant) 40 mg. (milligrams, unit of measurement) subcutaneous daily for DVT (deep vein thrombosis, blood clot) prophylaxis. Resident 568 was not on insulin (medication to lower blood sugar). A review of Resident 568's initial MDS dated [DATE], Section N Anticoagulant indicated 0 (zero, the resident did not receive the medication during the last 7 days since admission) and the Insulin injections were coded 3 (number of days insulin was received during the last 7 days since admission). During the record review and concurrent interview with the assistant director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update and revise the individualized and comprehensive care plans to meet individual needs for three of five reviewed residents (Residents 68, 88 and 136). This failure had the potential to result in not meeting the resident's needs. Findings: 1. During multiple observations on 6/7/21 at 9:40 a.m., 10:05 a.m., 11:08 a.m., and 6/8/21 at 11:30 a.m., Resident 136 was propelling himself in the hallway with his contracture right hand with no splint or device applied. During a review of Resident 136's clinical records, it indicated Resident 136 was admitted to the facility on [DATE] with diagnosis including hemiplegia (paralysis that affects one side) and hemiparesis (weakness on half of the body) , cerebrovascular disease cerebrovascular accident (CVA/stroke, a condition resulting from a lack of oxygen in the brain potentially causing a loss of sensory and motor function), type 2 diabetes mellitus (chronic condition that affects the way 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 appropriate care and treatment for one of 31 sampled residents (Resident 68) when the treatment nurse (TX) did not follow the physician's order for the right hip pressure ulcer (PU, skin injury caused by unrelieved pressure resulting in full thickness tissue loss with exposed bone, tendon or muscles) treatment, and staff did not apply the heel protector/bootee (a device to help prevent pressure injury per Resident 68's care plan. These failures could compromise Resident 68's PU wound healing and possible recurrence of his healed right heel PU. Findings: Review of Resident 68's clinical record indicated Resident 68 was admitted to the facility on [DATE]. The physician's updated order dated 6/8/21 indicated to do daily treatment to Stage 4 PU on the right hip as: cleanse site with NS (normal saline), pat dry, apply santly (wound debridement), apply gentamicin (antibiotic) ointment to wound bed, apply calcium alginate (absorb…

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 bladder care was provided for one of two residents (Resident 30) who had an indwelling urinary catheter (hollow tube that is inserted into the bladder to drain urine) when Resident 30's urinary collection bag was not emptied on the day shift. This failure had the potential to cause the resident's urinary tract infection (when bacteria gets into urine and travels up to the bladder). Findings: A review of Resident 30's clinical record indicated Resident 30 was admitted on [DATE] with diagnoses included COVID-19 (highly contagious respiratory disease), asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe) and neuromuscular bladder dysfunction (leaking of urine that a person cannot control). A review of Resident 30's Minimum Data Set (MDS, an assessment tool) dated 3/15/21 indicated Resident 30 was cognitively alert and required supervision with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure effective pain management for one of 31 sampled residents (Resident 120) when the attending physician was not informed when the resident's pain was not relieved after the PRN (as needed) pain medication was administered, and there was no pain management care plan developed. These failures could result in Resident 120 having ineffective pain management. Findings: During an observation and interview on 6/8/21 at 1:30 p.m., Resident 120 was in bed and stated she was still having pain and the pain comes and go because of the fracture. A review of Resident 120's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses that included fracture (break in the continuity of the bone) of upper end of left tibia (stronger, longer and anterior (frontal) of the two bones in the leg), wedge compression fracture of first lumbar vertebrae (a common fracture of the spine resulting from crush or injury), fracture 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 interview and record review, the facility failed to provide medically-related social services for one of three randomly reviewed discharged residents (Resident 14) when social services (a department aiming to promote welfare of the residents in a facility) failed to: 1. Initiate a discharge care plan; 2. Include in the discharge process the responsible party (RP) and the interdisciplinary team (IDT, leaders from different departments to discuss the resident's care) in discharge planning; 3. Follow the physician's orders regarding the discharge; 4. Pursue other options outside of family, shelter, or street for discharge; 5. Arrange for necessary supplies and after care/follow-up for Resident 14. These failures resulted in the facility unsafely discharging Resident 14 to a local street corner at two streets with a walker on 6/7/21. The facility did not verify where the resident was discharged and left the resident alone on the street. One day after the facility discharged Resident 14 to the street,…

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

Based on interview and record review, the facility failed to ensure two of 12 residents (Residents 11 and 14) were free from unnecessary medications when behaviors were not monitored correctly for Seroquel and behavior monitoring for Geodon was not updated when the Geodon dosage was increased. This failure had the potential of an incorrect dosage being administered and the residents received unnecessary medications. Findings: 1. During an interview and subsequent document review on 6/14/21at 1:10 p.m. with the director of nursing (DON), DON reviewed Resident 14's Behavior Monitoring Administration History (BMAH) for 3/2021, 4/2021, 5/2021, and 6/1/21to 6/14/2021. DON stated Resident 14's administration of Risperdal was monitored by episodes. Resident 14 had episodes of striking out, yelling, and demanding attention. DON stated all of the episodes were counted together. DON state if all three episodes occurred at the same time, it was counted and documented. If only one or two of the episodes occurred, then it was not counted/documented. 2. A review of Resident 11's facesheet…

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 five residents (Resident 79) were offered and/or received influenza vaccination. This failure had the potential to place the resident at risk of becoming infected with influenza. Findings: Review of Resident 79's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 79's medical record indicated Resident 79 did not receive influenza vaccination for the year 2020 - 2021. During an interview with the infection preventionist (IP) on 6/14/21 at 10:25 a.m., she stated Resident 79 refused the influenza vaccine. However, IP was unable to provide the informed consent (a process in which residents were given important information, including possible risks and benefits, about a medical procedure or treatment; this was to help the residents decide if they wanted to be treated) of Resident 79's refusal and the document that Resident 79's health care responsible party was informed of her refusal, and that the risks…

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.