Creekside Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the safety for one of two residents (Resident 1) when: 1. The Certified Nursing Assistant A (CNA A) did not position Resident 1 properly in wheelchair before doing another task, 2. CNA A did not notify the Licensed Nurse (LN) immediately to assess Resident 1 for possible injury after the fall prior to transferring back Resident 1 to wheelchair and 3. The facility failed to document the correct information on how the fall incident happened for Resident 1 on 8/5/24. These failures put Resident 1's safety at risk. Findings: Review of Resident 1's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD, an illness at its final stage where kidneys are permanently damage and can no longer function properly) and dependence on renal dialysis (a process that involve a machine that removes excess water, solutes and toxins from the blood in people whose kidneys can no longer perform…

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 implement their policy and procedure related to staff screening procedures for hiring direct access employee (means any individual who has access to a resident or patient of a long term care (LTC) facility) when the criminal background check (used to check for any convictions or claims of crime, including abuse) was not done prior to re-employment for Certified Nursing Assistant A (CNA A). This failure had the potential to put the residents' safety at risk. Findings: During a concurrent interview and record review with the Director of Staff Development (DSD) on 8/9/24 at 1:28 p.m., revealed CNA A went on vacation on 1/14/23 but did not come back after 90 days. The facility re-hired CNA A on 10/17/23 and started working with the residents the next day on 10/18/23. Further review of CNA A's employees file indicated the criminal background check was done on 8/5/24 (more than nine months after the CNA A was re-hired by the facility on 10/17/23). The DSD confirmed the criminal background check was done more than nine months…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care and services for one of three residents (Resident 1) when: 1. Resident 1's physician was not notified regarding her multiple refusal in participating in the Restorative Nursing Assistant program (RNA, a program that helps residents to gain an improved quality of life by increasing their level of strength and mobility) in a timely manner. 2. Resident 1's frequent refusal of RNA programs was not care planned. These failures had the potential to result in resident's decline in range of motion and mobility. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] with diagnoses that included peripheral vascular disease (PVD, narrowing of blood vessels that cause poor blood flow to the legs and feet), osteoarthritis (a disorder due to aging that caused wear and tear on a joint) of bilateral knee, muscle weakness and abnormalities of gait and mobility. Review of Resident 1's Minimum Data Set (MDS, a comprehensive…

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 1) was free from unwanted touching of her perineal area when one staff (receptionist E) found Resident 2 was inside Resident 1's room with his hands seen to be inside Resident 1's diaper between her legs, and when the facility did not complete Resident 2 whereabout monitoring to help prevent this incident of sexual allegation to happen. Failure to protect Resident 1's rights to be free from sexual abuse could result in psychological harm to her. Findings: Review of Resident 1's admission record indicated she was admitted to the facility on [DATE] with diagnoses including late onset Alzheimer's disease (a progressive disease that affects memory and other mental functions begins after age [AGE]) and hemiplegia (paralysis of partial or total body function on one side of the body ) and hemiparesis (is characterized by one?sided weakness, but without complete paralysis) following cerebral…

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 obtain routine medications for two of three residents (1 and 2) when Resident 1's and Resident 2's routine medications were not available for administration. This failure resulted in Resident 1's and Resident 2's needs were not met. Findings: Review of Resident 1's admission Nursing Assessment, dated 12/18/23, indicated Resident 1 was admitted to the facility on [DATE] at 7:45 p.m. Review of the facility's pharmacy delivery window indicated Resident 1's medications should be delivered on 12/19/23 between 10:50 a.m. and 1:50 p.m. Review of Resident 1's Medication Administration Record (MAR), dated 12/2023, indicated ceftazidime(used to treat infections) 2 grams (gm, a metric unit of mass) intravenous (IV, administered into a vein or veins) solution due on 12/18/23 at 10 p.m. and valproic acid (used to treat seizures) 2.5 milliliter (ml, a metric unit of volume) of 250 milligrams (mg, a metric unit of mass)/5 ml oral solution due on 12/19/23 at 6 p.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents received the treatment and care in accordance with professional standards of practice related to pain management for one of three sampled residents (Resident 1) when the licensed nurses did not follow the doctor's order to administer PRN (as needed) pain medication as ordered.The Acetaminophen (pain medication0 500 mg 2 tablets was ordered for mild pain but it was adminsitered when Resdient 1 complained of moderate and severe pain.This failure resulted in Resident 1's pain remained uncontrolled affecting his quality of life. Findings: 1. A review of Resident 1's facesheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including aftercare following explanation of hip joint prosthesis, unspecified dislocation of left hip, unspecified organism sepsis (a life-threatening complication of an infection), trigeminal neuralgia (a chronic pain condition affecting the trigeminal nerve in the face),…

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 when staff did not wear appropriate Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) as required when working with transmission-based precaution (TBP, the second tier of basic infection control and are to be used in addition to Standard Precautions ) residents who were COVID-19-positive (an infectious disease caused by the SARS-CoV-2 virus). This failure had the potential to result in cross-contamination and spread of infections among residents, staff and visitors. Findings: During a concurrent observation and interview with Registered Nurse (RN) A in the hallway on 2/7/24 at 2:40 p.m., room [ROOM NUMBER] and room [ROOM NUMBER] had transmission-based precaution signs posted by their doors, including droplet (for diseases spread by large particles in the air) and contact (for diseases spread by direct…

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 resident's medical records were complete and readily available for review by an official authorized by law for one of three sampled residents (Resident 1) when the physician's initial admission Note and physician's Progress Notes were not found in Resident 1's medical record during the surveyor's two facility visits. This failure had the potential to cause a delay in the determination of the quality of care rendered to Resident 1. Findings: A review of Resident 1's medical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including aftercare following explanation of hip joint prosthesis, unspecified dislocation of left hip, unspecified organism sepsis (a life-threatening complication of an infection), trigeminal neuralgia (a chronic pain condition affecting the trigeminal nerve in the face), and unspecified abdominal pain. A review of Resident 1's medical record on 2/7/24 at 4:00 p.m., and on 2/14/24 at 3:00 p.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure needs were accommodated for one of three residents (Resident 1) when there was no call device in the facility's designated smoking area. This failure had the potential for a delayed response and not meeting the resident's needs. Findings: Review of Resident 1's clinical record indicated she was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe), hemiplegia (a symptom that involves the loss of the ability to move on one-side of the body)and hemiparesis (one-sided weakness), abnormalities of gait and mobility, muscle weakness, history of falling, major depressive disorder (a mood disorder that causes a feeling of sadness and loss of interest), and anxiety disorder (increased anxiety that interferes with daily life). During a review of Resident 1's minimum data set (MDS, an assessment tool) dated 4/12/23, 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 observation, interview, and record review, the facility failed to ensure needs were accommodated for five residents (72, 13, 3, 36, and 66) when the call light devices were not within reach. This failure had the potential for a delayed response and not meeting the resident needs. Findings: 1. Resident 72's clinical record indicated she was admitted on [DATE] and had the diagnoses of weakness, dementia (a group of condition with impairment of brain function) with behavioral disturbance, hypertension (high blood pressure), depressive disorder (a mood disorder that causes feeling of sadness and loss of interest), obesity (a disorder involving excessive body fat). Review of Resident 72's clinical record indicated she was on observation for cough in a single room since 12/31/21. Review of Resident 72's MDS dated [DATE], indicated she required staff assistance for bed mobility, transfer, dressing, toileting, personal hygiene and had an impairment on one side of the lower extremity. During an observation of…

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

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services, when: 1. There were 12 cracked edge meal trays placed in the food cart. 2. There was ice build-up on the ceiling of the walk-in freezer. 3. There were pieces of undated sandwich bread kept in plastic found in the dry storage area. 4. The cleaning solution in the red bucket was not adequate. These failures had the potential to result in food-borne illness among residents. Findings: 1. During observation on 01/04/22 at 8:45 a.m., there were 12 meal trays placed in the food cart with cracked edges. During interview with the dietary supervisor (DS), on 1/04/22 at 9:00 a.m., DS acknowledged it and she stated that these cracks or crevices are ideal breeding grounds for bacteria that can contaminate food, so they must be replaced. 2. During observation on 1/04/22 at 9:15 a.m., there was ice build-up on the ceiling of the walk-in freezer. During interview with DS on 1/04/22 at 9:16 a.m., DS stated defrosting time takes a while for ice 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 implement infection control practices when: 1. For Resident 66, facility staff did not label and date the resident's nebulizer (drug delivery device used to administer medication in the form of a mist inhaled into the lungs) tubing; 2. Facility staff did not clean and disinfect the resident's shower room promptly; and 3. For Resident 16, facility staff did not put the indwelling urinary catheter drainage bag below the level of the bladder (the organ that stores urine). These failures have the potential to compromise the health and well-being of the residents in the facility. Findings: 1. Review of Resident 66's clinical record indicated with diagnoses of but not limited to cerebral infarction (stroke), altered mental status (change in cognition or level of consciousness), severe sepsis without septic shock (serious complication of an infection), acute respiratory failure with hypoxia (not enough oxygen in the blood), pneumonia (lung…

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 respect and dignity was maintained for four residents (Residents 25, 80, 240 and 241) when staff provided feeding assistance while standing. This failure had the potential to affect the emotional and psychosocial well-being of the residents. Findings: 1. Review of Resident 240's minimum data set (MDS, an assessment tool) dated 12/28/21 indicated his cognition was severely impaired and he needed one-person physical assistance for eating. During a lunch meal observation on 1/4/22 at 12:25 p.m., Resident 240 was sitting in his wheelchair in his room. Certified nursing assistant K (CNA K) stood beside him while providing spoon-feeding assistance to Resident 240. During a concurrent interview with CNA K he confirmed he was standing while feeding Resident 240. He stated he should be sitting down and be at eye level when he feeds the residents. 2. Review of Resident 241's MDS dated [DATE] indicated his cognition was severely impaired and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain a copy of an advance directive (a legal document that designates a decision-maker and has written instruction that indicates the medical decisions desired when the individual is not able to make choices) in the resident's medical record for one of 19 residents (Resident 30). This failure had the potential to delay care in accordance with the resident's wishes. Findings: Review of Resident 30's record indicated she was admitted to the facility on [DATE]. Review of Resident 30's Physician Orders for Life-Sustating Treatment (POLST, document that specifies the medical treatments the resident wants to receive during serious illness), dated 1/25/21 indicated the resident had an advance directive, dated 10/9/15. Resident 30's advance directive was not in Resident 30's medical record. During an interview on 1/10/22 at 8:48 a.m., the social service designee (SSD) confirmed there was no advance directive in Resident 30's medical record. The SSD stated…

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 complete the Minimum Data Set (MDS, an assessment tool) for one of 19 sampled residents (Resident 70). Failure to accurately assess the resident had the potential to compromise the facility's ability to provide resident-centered care planning and interventions. Findings: Review of Resident 70's medical record indicated she was admitted on [DATE] and had the diagnoses of dementia (mental disorder caused by brain disease or injury) with behavioral disturbance, chronic kidney disease, Type 2 diabetes (a condition that affects the way the body processes blood sugar), hypertension (high blood pressure), sepsis (life-threatening complication of an infection), Alzheimer's disease (a progressive disease that destroys memory and mental functions), anemia (a condition which the blood does not have enough red blood cells), retention of urine (difficulty urinating and emptying the bladder), depressive disorder (a mood disorder that causes a feeling 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 meet services according to professional standards of quality, for four of eight sampled residents, when: 1. There was no monitoring for volume intake in Resident 4's gastrostomy (GT, opening into the stomach) tube. 2. There was no monitoring for urine volume output to Residents 48 and 52, which had the potential to result in dehydration. 3. Resident 61 had no thromboembolic deterrant hose (TED, compression stockings to reduce the risk of developing blood clot) applied to her right lower leg since the time it was ordered, which had the potential to result to complications. Findings: 1. During review of Resident 4's clinical record, Resident 4 was admitted on [DATE], with diagnoses included protein calorie malnutrition, dysphagia (swallowing difficulty), with gastrostomy and diabetes mellitus (high blood sugar). Review of Resident 4's minimum data set (MDS, resident tool assessment) dated 12/16/21, indicated Resident 4 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 observation, interview, and record review, the facility failed to provide treatment and care in accordance with the professional standards of practice for 2 of 19 sampled residents (Residents 8 and 16) when: 1. For Resident 8, nursing staff did not apply the ace bandage as ordered by the physician; and 2. For Resident 16, no current physician's order for the indwelling urinary catheter (a soft, plastic or rubber tube that is inserted into the bladder to drain the urine). These failures had the potential to compromise the residents' health and well-being. Findings: Review of Resident 8's clinical record indicated he was admitted on [DATE], with diagnoses of heart failure (means the heart cannot pump enough blood), acute on chronic diastolic congestive heart failure (occurs when the left ventricle muscle becomes stiff or thickened), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), essential hypertension (abnormally high blood pressure…

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 residents were free from unnecessary psychotropic medications for one of three residents reviewed, when Resident 39's use of divalproex sodium (medication used to treat seizure disorder, manic episodes of bipolar disorder and helps prevent migraine headaches) had lack of monitoring of adverse (harmful) effects. This failure had the potential to result in increased risk of serious complications of drug therapy. Findings: During review of Resident 39's clinical record, Resident 39 was admitted on [DATE], with diagnoses included dementia (memory loss), heart failure, senile degeneration of brain. Review of Resident 39's MDS dated [DATE], indicated Resident 39 was severely cognitively impaired and required total dependence with one-two person physical assistance for her activities of daily living (ADLs). Review of Resident 39's physician order indicated the following: (1) Ordered date: 12/16/20, Divalproex sodium tablet delayed release 250 mg by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored appropriately when: 1. One expired medication was not properly discarded and was stored in the medication cart and, 2. Medications were stored under improper temperature. These deficient practices had the potential for unsafe and ineffective use of medications. Findings: 1. During a concurrent medication cart inspection and interview with the director of nursing (DON) on [DATE] at 12:04 p.m., medication cart 1 had one Combigan (medication for eye disorder) 0.25 - 0.5% solution opened on [DATE]. DON stated the medication expires 60 days after opening, per the facility pharmacy. DON confirmed the medication was expired and stated it should be removed from the medication cart. 2. During a concurrent medication room inspection and interview with DON on [DATE] at 12:36 p.m., the temperature of the medication refrigerator inside medication room [ROOM NUMBER] was 58 degrees Fahrenheit (F, unit of…

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

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food services area when: 1. Open air ceiling vent had dust particles and grease build-up. 2. Expired food items were found in the refrigerator. These failures had the potential to result in cross contamination and food borne illnesses in residents who were on oral diets. Findings: 1. During the kitchen tour with kitchen supervisor Q (KS Q) on 6/2/19 at 8:18 a.m., one open air ceiling vent near the food preparation area was surrounded by dust particles and grease build-up. During a concurrent interview with KS Q, she confirmed the observation and acknowledged the dust particles and grease build-up could potentially contaminate the food in the steam table. She stated the facility maintenance staff conducted regular cleaning of the kitchen air ceiling vents. The KS did not know when the air vent was last cleaned. During an interview with maintenance staff I (MS P) on 6/2/19 at 8:45 a.m., he confirmed the air vent had dust particles and grease build-up 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.

Based on observation, interview and record review, the failed to consistently implement infection control practices when housekeeping staff did not wear personal protective equipment (PPE, specialized equipment or clothing used to protect self and patients from the spread of infection. PPE includes gloves, gowns, goggles, masks and face shields) while sorting and handling soiled linens/dirty laundry. This failure had the potential to result in transmission of infection in the facility. Findings: During an interview with housekeeping staff N (HSK N) on 6/6/19 at 9:21 a.m., she stated when she sorts and handles dirty laundry, she would only wears a mask, pair of gloves and a cloth apron that she wore as part of her uniform. During an observation in the laundry room on 6/6/19 at 9:28 a.m., HKS O went inside the dirty side of the laundry room with a bin of soiled linen. She wore gloves and a mask and sorted dirty laundry. No additional protective clothing was worn. During an interview with the housekeeping supervisor (HS) on 6/6/19 at 9:35 p.m., she stated staff should wear a disposable…

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 residents' dignity and self-worth for five of 32 residents (Residents 29, 5, 47, 67 and 103) when: 1. Certified nursing assistant (CNA) kept her personal belongings inside Resident 29's closet; and 2. CNAs did not provide feeding assistance to Residents 5, 4, 6, and 103 within eye level position. These failures may affect the resident's well-being and quality of life in the facility. Findings: 1. During a patient care observation and concurrent interview on 6/5/19 at 1:43 p.m., CNA B assisted Resident 29 inside the bathroom. CNA B stated I need to get my (eye)glasses to read the amount of urine collected. CNA B left the bathroom, opened Resident 29's closet and took out her eyeglasses from Resident 29's closet. During an interview with CNA B on 6/5/19 at 3:02 p.m., she confirmed the above observation. She stated she kept her purse inside the closet of the Resident 29. She further stated she was not supposed to keep her personal belongings in the resident's space. During an interview with the director…

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 residents rights were reviewed and discussed during monthly group meetings when 7 of 7 residents (Residents 21, 60, 75, 85, 100, 103, and 105) who attended the meeting stated their rights were not reviewed and discussed during the monthly meetings. This failure had the potential for the residents not to be able to fully exercise theirs rights that may affect the quality of life during their stay in the facility. Findings: During a resident council group meeting on 6/3/19 at 11:00 a.m., 7 of 7 residents who attended the meeting stated the facility did not review and discuss their rights in the facility during the past meetings. Review of the previous three months council meeting records from 3/2019 to 5/2019 indicated no evidence of documentation that residents' rights were reviewed and discussed. During an interview on 6/3/19 at 3:17 p.m., the activity director (AD) who helped facilitate the resident council group meeting, confirmed there was no documentation that residents's right were discussed during the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for three of 24 sampled residents (Residents 39, 48 and 108) when: 1. For Resident 39, the facility failed to ensure a lab test was done as ordered; 2. for Resident 48, staff did not implement a wheelchair alarm (device that makes sound to alert staff when the resident attempts to transfer unassisted) as ordered; and 3. for Resident 108, the facility failed to ensure his side rails were padded. These failures had the potential to negatively affect the health and safety of the residents. Findings: 1. Review of Resident 39's clinical record indicated she was admitted on [DATE] and had the diagnosis of diabetes (disease that causes high blood sugar). Review of Resident 39's physician order, dated 7/1/18, indicated she was to have a hemoglobin A1C (HgbA1C, a blood test that measures the average blood sugar over time) lab test done every three months. The order…

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 restorative nursing services (a program that helps residents maintain and promote maximum functional capacity) consistently per physician's order for 6 of 13 residents (Residents 20, 29, 64,73, 94, and 103) when: 1. For Residents 73 and 103, passive range of motion (PROM, exercises that require assistance, usually provided by a caregiver or a therapist) exercises were not done consistently by the restorative nursing assistant (RNA, is a type of nursing assistant trained to help nurses in restoring mobility to residents) three to five times per week as per physicians order, 2. For Residents 20, 29, and 94 ambulations (walk) were not done consistently by an RNA three to five times per week as per physician's order, and 3. For Resident 64 ambulation on bars was not done consistently by an RNA five times a week as per physician's order. This failure had the potential to result in residents' decline in range of motion and ability to ambulate.…

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

Based on observation, interview, and record review, the facility failed to timely receive medications from the provider pharmacy for two of six residents (Residents 30 and 24) when two routine medications were not available during the 5 p.m. medication passing. This failure had the potential to cause delay in treatment and compromised residents' medical health. Findings: 1. A review of Resident 30's physician order indicated prescription levetiracetam solution (medication used for seizure-control) two times a day. The medication was scheduled to be administered at 5:00 p.m. During an observation on 6/2/19 at 4:05 p.m., licensed vocational nurse D (LVN D) administered scheduled medications to Resident 30. She did not administer the above-mentioned medication. During a concurrent interview with LVN D, she confirmed she did not administer levetiracetam solution because the medication was not available in the medication cart. 2. A review of Resident 24's physician order indicated Ipratropium-Albuterol solution (an inhalation medication that relax muscles in the airways and increase air…

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 10 residents (Residents 39 and 9) were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions and behavior) when: 1. For Resident 39, licensed nurses failed to accurately assess and monitor for psychotropic medication side effects; and 2. for Resident 9, licensed nurses failed to monitor specific behaviors for the use of sertraline hydrochloride (HCL) (medication used to treat depression and anxiety). These failures put the residents at risk for experiencing adverse medication side effects and receiving psychotropic medication without the appropriate indication. Findings: 1. Review of Resident 39's clinical record indicated she was admitted on [DATE] and had the diagnoses of major depressive disorder (mood disorder that causes persistent sadness and loss of interest) and anxiety . Review of Resident 39's record indicated she had a physician order, dated 11/9/18, for cymbalta…

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

Based on observation, interview, and record review, the facility had 11.54% medication error rate when three medication errors out of 26 opportunities were observed during medication passes for two of six residents (Residents 30 and 24). This failure had the potential to compromise residents' medical health. Findings: 1. A review of Resident 30's physician order indicated the following: a) prescription eye drops brimonidine tartrate solution (medication used to decrease eye pressure and protect the optic nerve), to be instilled to right eye, three times a day; and b) levetiracetam solution (medication used for seizure-control) two times a day. These medications were scheduled to be administered at 5:00 p.m. During an observation on 6/2/19 at 4:05 p.m., licensed vocational nurse D (LVN D) administered scheduled medications to Resident 30. LVN D did not administer the above mentioned medications. During a concurrent interview with LVN D, she confirmed she did not administer levetiracetam solution because the medication was not available in the medication cart. LVN D also acknowledged…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored appropriately when one of four medication carts and one of three medication rooms had expired and unlabeled prescription medications. The deficient practice had the potential to place residents at risk for receiving expired and/or wrong medications. Findings: 1. During the medication room inspection with minimum data set coordinator E (MDSC E) on 6/2/19 at 10:24 a.m., the medication refrigerator inside medication room [ROOM NUMBER] had the following: a) One unlabeled vial of Procrit (medication used for the treatment of anemia due to chronic kidney disease). b) Two open multidose vials of Aplisol Tuberculin Purified Protein Derivative (TPPD, used for skin test to aid in the diagnosis of active or latent tuberculosis) solution. The label indicated vial 1's open date 4/27/19, expiry date: 5/25/19; and vial 2's open date 4/29/19, expiring date: blank. During a concurrent interview with MDSC E, she…

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