Empress Care Center, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the effective use of medications for one of 13 residents (28) when Resident 28 received ferrous sulfate (iron, used for prevention/treatment of iron deficiency) and Calcium (a medication used to prevent or treat low blood calcium levels) at the same time. This failure had the potential for the residents to not receive the amount of prescribed iron supplements. Findings: Review of Resident 28's admission Record indicated she was admitted to the facility on [DATE] with anemia (a condition that develops when the blood produces a lower-than-normal amount of healthy red blood cells) diagnosis. Review of Resident 28's clinical record indicated, she had physician orders for ferrous sulfate 325 milligrams (mg, a metric unit of mass) every day for anemia at 9 a.m., started on 8/25/22, and for Calcium 500 mg every day at 9 a.m., started on 7/26/24. Thus, since 7/26/24, ferrous sulfate and Calcium were given at the same time at 9 a.m. every day. 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 interview and record review, the facility failed to ensure the pharmacy consultant (PC: a licensed pharmacist provides expert clinical advice and guidance on medication use) identified and reported drug irregularities to the facility during the monthly medication regimen review (MRR: a thorough evaluation of resident's medications) for one of three sampled resident (Resident 31); and facility failed to follow up MRR recommendations for one of thirteen sampled resident (Resident 2). These failures resulted in Resident 31 received more than therapeutic (safety of medication with regard to risk of overdose) dose of medication for over ten months; and Resident 2 received medication for over one month. Findings: 1. Review of Resident 31's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 31 was admitted to facility on 4/19/2024. Review of Resident 31's FS indicated Resident 31's diagnoses including left femur neck fracture (broken left hip upper part of the…

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

Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications (medications capable of affecting the minds, emotions, and behaviors) for three of four sampled residents (Resident 14, 31, and 249) when: 1. There was no documented evidence of non-pharmacological (treatments and strategies that mange health conditions without using medications) approaches attempted before administered medication quetiapine (used to treat mental health condition) for Resident 14. 2. There was no documented evidence of non-pharmacological approaches attempted before administered medication olanzapine (used to treat mental health conditions) for Resident 31 and 249. This failure had the potential to place sampled residents at risk to receive unnecessary psychotropic medication. Findings: 1. Review of Resident 14's face sheet (FS: a document that gives a resident's information at a glance) indicated Resident 14 was admitted to facility on 2/20/2020. Review of Resident 14's diagnoses included schizoaffective disorder (a serious mental…

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

Based on interview and record review, the facility failed to ensure an alleged violation involving abuse was reported immediately to administrator or other officials in accordance with State law for one (Resident 1) out of three residents. This failure had the potential to cause further psychosocial and/or physical harm to the residents. Findings: A review of Resident 1's medical records indicated diagnoses including dementia (loss of mental functioning such as thinking, remembering, and reasoning), weakness and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a concurrent record review and interview on 10/14/24 at 10:38 a.m. with the Director of Staff Development (DSD), DSD stated that on 10/6/24, Certified Nurse Aide (CNA) A reported an alleged abuse on 10/4/24 to Resident 1 from CNA B. DSD also stated that according to CNA A's report, CNA A witnessed CNA B shove graham crackers to Resident 1's mouth and pulled Resident 1's right ear. DSD stated that when CNA A was asked why it was not reported immediately, CNA A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 7. Review of Resident 18's clinical records indicated, Resident 18 was an [AGE] year-old female, initially admitted to the facility on [DATE], with diagnoses including recurrent (occurring often) enterocolitis (inflammation that occurs throughout the intestines) due to clostridium difficile (a germ that causes diarrhea and inflammation of the colon), hemiplegia (paralysis of one side of the body) and dysphagia (difficulty swallowing). Resident 18 did not have advance directive and her POLST forms' section D, which indicate if an advance directive is available, dated 8/10/22 and 12/9/23, were left blank. During an interview with the social services director (SSD) on 12/21/23 at 2:57 p.m., SSD verified, Resident 18 did not have advance directive. SSD further verified, Resident 18's POLST forms' section D, which indicate if an advance directive is available, dated 8/10/22 and 12/9/23, were left blank and these sections, should have been filled out. During an interview with medical recorder (MR) on 12/20/23 at 11:45…

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 to follow their policy and procedure (P&P) for bed side rails (adjustable metal or rigid plastic bars that attach to the bed) for six of six sampled residents (Resident 5, 11, 36, 37, 40, and 48). This failure had the potential to place sampled residents at risk for accidents, entrapment, and unsafe environment. Findings: 1. Review of Resident 5's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 5 was admitted to facility on 10/22/2022. Review of Resident 5's physician orders indicated there was no physician order to use side rails for Resident 5's bed. Review of Resident 5's clinical record indicated there were no documentations for physical restraint assessment and informed consent for use of side rails for his bed. Review of Resident 5's care plans indicated there was no care plan for use of bed side rails. During an observation on 12/19/2023 at 12:15 p.m., noted left side bed rail up while Resident 5 was in bed. During an interview with certified…

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: 1. For Residents 23 and 35, the nurse did not perform hand hygiene between glove changes, 2. For Resident 45, the nurse did not perform hand hygiene after medication administration, 3. Staff's face mask below nose 4. Staff did not perform hand hygiene 5. Nursing staff did not use required PPE 6. Urine drain bag on floor for Resident 5 These failures could result in the spread of infection and cross-contamination that could affect the 49 residents residing in the facility. Findings: 1. During a medication pass observation on 12/19/23 at 11:55 a.m., Registered Nurse B (RN B) did not perform hand hygiene between glove changes after insulin injection to Resident 23. During a medication pass observation on 12/19/23 at 12:08 p.m., RN B did not perform hand hygiene between glove changes after insulin injection to Resident 35. During an interview with RN B on 12/19/23 at 12:10 p.m., RN B…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR, screening for residents with a mental disorder and residents with intellectual disability) screening document was accurately completed for one out of two residents (Resident 36). This failure had the potential for mentally ill Resident 36 not to receive benefit from specialized mental health care and services. Findings: Review of Resident 36's face sheet (a document that gives a resident's information at a quick glance) indicated, Resident 36 was admitted to the facility on [DATE] with diagnoses including Psychosis (a serious mental disorder characterized by a disconnect from reality) and anxiety (a disorder that involves more than temporary worry or fear that can be mild or severe). Review of Resident 36's readmission PASRR level 1 screening for serious mental illness dated 10/14/2022, indicated, he was noted to have no diagnosed mental illness. During a concurrent 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 develop and implement comprehensive, person-centered, care plans for four out of fifteen sampled residents, (Residents 3, 18, 30 and 35), when: 1. for Residents 3, 18 and 30, their activity care plans were not comprehensive and person-centered and 2. for Resident 35, no comprehensive and person-centered care plan for his hearing aids. These failures had the potential to result in the residents, not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. a. Review of Resident 3's clinical records indicated, Resident 3 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis (degenerative vessel wall disease that results in narrowing of the blood vessels in the brain), chronic diastolic congestive heart failure (comes on slowly with age and occurs if the left ventricle muscle becomes stiff or thickened, hence the heart is not pumping blood, as…

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 residents received the necessary care and services for seven out of nineteen residents investigated, (Residents 18, 30, 41, 23, 35, 39 and 48), when: 1. for Resident 18, the physician was not notified of her weight loss and weight gain of more than 5 pounds (lbs, unit for measuring weight) and there were no alert charting by nurses for 72 hours of her weight loss and weight gain; 2. for Resident 30, there were no alert charting by nurses for 72 hours of her weight loss of more than 5 lbs; 3. for Resident 23, 35 and 39, the nurses used alcohol wipes to wipe the blood after the needle punctures; 4. for Resident 41, the physician orders for blood pressure (BP) medications without holding parameters and 5. for Resident 48, management for his diabetes, not being followed. These failures had the potential to affect the residents' care and could jeopardize their health and well-being. Findings: 1. Review of Resident 18's face sheet…

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 and record review, the facility failed to ensure a physician's order for a PRN (as needed) psychotropic medication (medication capable of affecting the mind, emotions, and behavior) was limited to 14 days of use, for one of 15 sampled residents (Resident 101). This failure had the potential to lead to the administration of unnecessary medication to the resident. Findings: A review of Resident 101's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations) and major depressive disorder. Further review of Resident 101's clinical record indicated a physician's order, dated 12/18/23, for Lorazepam 0.5 milligram (mg., a unit of measure) every 8 hours as needed (PRN) without a stop date. During a concurrent interview and record review with Registered Nurse (RN) B on 12/21/23 at 3:54 p.m., RN B reviewed the physician's order and stated there should be a 14-day limit to…

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

Based on observation, interview and record review, the facility had a medication error rate of 7.41 % when two medication errors occurred out of 27 opportunities during the medication administration for two residents (Residents 45 and 24). The failure resulted in medications not being given according to the manufacturer's specifications and physician's order and had the potential to affect residents' health and well-being in the facility. Findings: 1. During a medication pass observation on 12/20/23 at 8:05 a.m., the Licensed Vocational Nurse E (LVN E) was observed administering the chewable aspirin 81 mg (mg, a unit of measure) to Resident 45. A review of Resident 45's physician's order, dated 11/01/2023, indicated administering enteric coated Aspirin low dose delayed releases oral tablet 81mg by mouth once a day related to cerebral infraction. During an interview with LVN E on 12/20/23 at 2:20 p.m., LVN E confirmed that she administered chewable Aspirin 81 mg to resident 45 instead of enteric-coated. She further stated that she should have followed the physician's order to…

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

Based on observation, interview, and record review, the facility failed to appropriately label the lubricant eye drops bottle for 2 out of 15 sampled residents (Residents 24 and 43). This deficient practice resulted in the nurse administering the wrong eye drops and had the potential to affect residents' health and well-being in the facility. Findings: During a medication pass observation on 12/20/23 at 4:20 p.m., Licensed Vocational Nurse F (LVN F) administered lubricant eye drops to Resident 24 using a bottle, not labelled with resident identification information. During an inspection of Medication Cart 1 on 12/20/23 at 04:22 p.m., with LVN F, two opened bottle of lubricant eye drops were inside Medication Cart 1 for Residents 24 and 43 without residents' identification information and open date. During an interview with LVN F on 12/20/23 at 4:25 p.m., LVN F confirmed that the eye drops bottle she used with Resident 24 was Resident 43's eye drops bottle. LVN F acknowledged that she should have labeled each bottle with resident identification information to prevent administering…

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 accommodate food preferences for two out of six sample residents (Residents 35 and 40). This failure had the potential for decreased meal intake, negative effect on health and well-being for sample residents. Findings: Review of Resident 40's lunch tray card dated 12/18/2023 indicated, Dislikes: Tomato Products, Spinach. Review of facility's lunch menu dated 12/18/2023 indicated, Fish with Tarragon, Cajun Country Rice, Creamed Spinach, Sweet Corn Salad, Fruit Bavarian Cream. During lunch observation on 12/18/2023 at 12:54 p.m., noted Resident 40's lunch meal tray was served with creamed spinach, and carrots along with other food items from lunch menu. During an interview with certified nursing assistant A (CNA A) on 12/18/2023 at 12:57 p.m., CNA A confirmed Resident 40's lunch tray card dated 12/18/2023 indicated, Resident 40 does not like spinach and tomato products. CNA A also confirmed Resident 40 was served creamed spinach, and carrots during lunch on 12/18/2023. CNA A stated dietary staff should not have…

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 safe and sanitary food service operations were carried out according to standards of practice when: 1. dented can was found in the dry storage area, 2. the two-compartment sink did not have air gaps (an unobstructed vertical space between the water outlet and the flood level of a fixture) and 3. the Maintenance Supervisor (MS) did not follow safe sanitary practice in the kitchen. These failures had the potential to cause food contamination and spread food-borne illness to the forty-three residents who received their food from the kitchen. Findings: 1. During an initial kitchen observation on 12/18/23 at 8:57 a.m., with the Dietary Supervisor (DS), there was one large dented can in the dry storage area. The DS took away the dented can and placed it under the designated area. During an interview with DS on 12/19/23 at 3:30 p.m., DS confirmed the above observations and stated, the dented can should have been placed in the designated area. She stated, We put a sign already for dented cans area. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow facility's written policy and procedure (P&P) for pneumococcal (PNA- an serious infection of one or both of the lungs caused by bacteria, viruses, fungi, or chemical irritant) vaccine (a preparation that is used to stimulate the body's immune response against diseases) for four out of five sampled residents (Resident 5, 11, 26, and 36). This failure had the potential for acquiring PNA and its associated health complications for sampled residents. Findings: 1.Review of Resident 5's face sheet (FS: a document that gives a resident's information at a quick glance) indicated, [AGE] years old Resident 5 admitted to facility on 10/22/2022. Review of Resident 5's immunization record indicated, Resident 5 received PCV 13 (PNA vaccine and a conjugate [conjugate: a type of subunit vaccine which combines a weak antigen with a strong antigen as a carrier so that the immune system has stronger response to the weak antigen] vaccine used to protect against…

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

Based on observation, and interview, the facility failed to ensure to install and conduct inspections to identify loose fitting bed side rails (SR adjustable metal or rigid plastic bars those attached on both sides of to the bed) for three out of eight sampled residents (Resident 11, 36, and 40)'s beds. These failures had the potential to place sampled residents at risk for accidents and unsafe environment. Findings: 1. Review of Resident 11's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 11 was readmitted to facility on 8/11/2020. Review of Resident 11's physician order dated 3/5/2021 indicated, may have bilateral ½ side rails for bed mobility/positioning. During an observation on 12/18/2023 at 7:55 a.m., observed Resident 11 bed's bilateral 1/2 SR were up while Resident 11 was in bed. Further observation of SR indicated Resident 11's bed right SR was loose fitted and moving side to side loosely. During a concurrent observation and interview for Resident 11's bed SR with facility's maintenance supervisor (MS), and 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 interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for three of 15 sampled residents (Residents 21, 26, and 30) when: 1. Resident 21's anxiety and antipsychotic care plan was incomplete and not person-centered; 2. For Resident 26, there was no care plan developed for the hearing difficulty and the bleeding precautions related to the use of Rivaroxaban (an anticoagulant or blood thinning medication); and, 3. For Resident 30, there was no care plan for use of antipsychotic medication (Haldol). These failures had the potential for inaccurate development and implementation of personalized and resident-centered care plans that would address the residents' identified concerns and needs. Findings: 1. Review of Resident 21's clinical records indicated she was admitted to the facility on [DATE] with diagnoses of bipolar disorder (mental disorder characterized by periods of elevated mood and depression (mood disorder that causes a persistent feeling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the consultant pharmacist's (CP) medication regimen review (MRR) recommendations were acted upon for three out of 15 sampled residents (Residents 7, 37, and 44). This failure resulted in unnecessary medications due to inadequate monitoring, prolonged medication use, etc. and had the potential for adverse side effects that could negatively impact the residents' physical, mental, and psychosocial well-being. Findings: 1. Resident 7 was admitted to the facility with diagnoses including moderate calorie malnutrition, chronic heart disease, and hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). A review of Resident 7's medical record indicated the resident was receiving: - Furosemide (Lasix, a diuretic) 40 milligrams (mg, unit of measurement), 1 tablet twice daily from 2/19/21 to 8/25/22; and 40 mg daily for high blood pressure since 8/15/22. - Levothyroxine (a thyroid medication) 88 micrograms (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 had a medication error rate of 10.71% when three medication errors occurred out of 28 opportunities during the medication administration for three residents (Residents 30, 37, and 40). The failure resulted in medications not given according to manufacturer's specifications, and had the potential for residents not receiving the full therapeutic effects of medications. Findings: 1. During a medication pass observation on 8/29/22 at 9:05 AM, the nurse supervisor (NS) was observed preparing 3 medications for Resident 40. The medications included the phenytoin (brand name: Dilantin, a medication for seizures) 125 milligrams (mg) per 5 milliliters (mL) oral liquid. He removed the phenytoin bottle from the medication cart and poured 4 mL into a small medication cup without shaking the bottle first. On 8/29/22 at 9:10 AM, the NS was observed administering the phenytoin liquid, along with the other two medications, via the resident's gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition and…

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

Based on observation, interview, and document review, the facility failed to ensure the planned menu was followed when 11 of 11 residents on mechanical soft diet (texture modified diet that restricts foods that are difficult to chew or swallow) were to be served roast beef. This failure had the potential to result in residents not meeting the nutritional needs thus further compromising the nutritional status of the residents. Findings: Review of the facility titled Cooks Spreadsheet for week 1 Monday lunch (8/29/22) indicated Swedish meatballs for all types of diet. During a concurrent observation and interview with Kitchen Supervisor (KS) on 8/29/22 at 8:30 a.m. in the kitchen, a tray of roast beef was inside the oven. KS confirmed the observation. During a concurrent interview and spreadsheet review with KS on 8/31/22 at 8:31 a.m. in the kitchen, KS stated the roast beef was not on the Monday (8/29/22) menu list. KS verified meatballs are available to be cooked for the day. During an interview with the dietary cook (DC) on 8/29/22 at 8:32 a.m. in the kitchen, the DC stated he…

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

Based on observation, interview and document review, the facility failed to ensure food was stored and prepared under safe and sanitary conditions when: 1. Frozen meatballs were thawed at room temperature. 2. A sanitizing bucket (contains concentration of chemical sanitizer used for cleaning) was placed too near with clean pots. 3. Sanitizing wipes (pre moistened towelettes that contain disinfecting ingredients) were placed next to potholders and liquid seasonings (vinegar, soy sauce). 4. The oven door was broken. 5. The can opener base was not kept in sanitary condition. 6. There were crumbs seen under the microwave oven. 7. Personal items were seen in the food storage and preparation areas. 8. The log sheet for cleaning the ice scooper was recorded incomplete. These failures had the potential to cause food contamination, spread illness to 45 out of 48 residents. Findings: 1. During a concurrent observation and interview with the kitchen supervisor (KS) on 8/29/22 at 8:28 a.m. in the kitchen, two bags of frozen meatballs on a dry container were being thawed in the sink at room…

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: 1. Resident 4's and Resident 43's oxygen tubing were not changed every week; 2. Certified Nursing Assistant I (CNA I) did not wash or sanitize her hands before feeding Resident 13; 3. Licensed Vocational Nurse D (LVN D) did not wash her hands and change the gloves before cleansing Resident 42's pressure ulcers; 4. CNA L did not perform hand hygiene between residents; 5. The nurse supervisor (NS) did not wipe the medication tray with the disinfectant wipe after use for each resident. These failures could result in the spread of infection and cross-contamination in the facility. Findings: 1.a. Review of Resident 4's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including asthma (a chronic disease in which the airways in the lungs become narrowed and swollen, making it difficult to breathe) and dependence on supplemental oxygen. 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 interview and record review, the facility failed to notify the Physician for one of two closed sampled selected resident (Resident 49) upon discharge. This deficient practice had the potential for Resident 49 to be discharge home inappropriately. Findings: A review of Resident 49's admission record indicated the resident was admitted to the facility on [DATE] with the diagnosis including Alzheimer's disease (a progressive disease that destroys memory and mental functions) and hypertension (high blood pressure). A review of Resident 49's transfer/discharge report, dated 6/13/22, indicated the resident was discharged home on that day. During a concurrent interview and record review, on 8/31/22 at 10:40 a.m., Medical records (MR) reviewed Resident 49's clinical record and could not provide the physician discharge summary. She further stated there was no physician's order for Resident 49's discharge. During a concurrent interview and record review, on 8/31/22 at 10:44 a.m., the director of nursing (DON)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on an observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) in minimum data set (MDS, an assessment tool) for one of 12 sampled residents (Resident 48). When Resident 48 had significant weight loss, had declined in activities of daily living (ADL, daily self-care tasks, e.g., bathing, toileting, and transferring), incontinency and communication. This failure had the potential to result in Resident 48 unable to achieve or maintain optimal status of health, function and quality of life. Findings: 1.Review of Resident 48's face sheet (summary page of a patient's important information) indicated she was admitted to the facility on [DATE] with diagnoses including muscle weakness, bipolar disorder (mental disorder characterized by periods of elevated mood and depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning, often with poor decision-making) 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 ensure the Minimum Data Set (MDS, an assessment tool) quarterly assessments was transmitted (sent electronically) to the Centers of Medicare and Medicaid Services (CMS, a government agency) for one of 12 residents (Resident 44). This failure could potentially affect the provision of care or services to the resident. Findings: Review of Resident 44's clinical record indicated he was re- admitted to the facility on [DATE] and MDS quarterly assessments, dated 3/15/22, 6/15/22 and 8/15/22, were completed, but were not submitted to CMS. During an interview on 9/2/22 at 2:09 p.m., with registered nurse K (RN K) she confirmed the above record review and stated that the assessment for Resident 44 should have been transmitted within 14 days after they were complete. During a concurrent interview and record review on 9/2/22 at 3:52 p.m., RN K reviewed resident 44's MDS 3.0 final validation report from CMS and confirmed the assessments, dated 3/15/2022,…

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 assess the skin of one of three residents (Resident 22) when the resident's skin abrasion (surface of the skin has been broken) was not monitored. The failure resulted in progression of skin blisters (skin condition where fluid fills a space between layers of skin) and potential for skin infection. Findings:one resident Review of Resident 22's clinical record indicated he was admitted with multiple diagnosis including peripheral venous insufficiency (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), muscle weakness. Review of Resident 22's Minimum Data Set (MDS, a standardized assessment tool), dated 7/9/22, indicated his cognition was intact. During an observation on 8/29/22/ at 9:01 a.m. inside Resident 22's room, his lower left leg was noted to be dark in appearance and had abrasions. During a concurrent interview with Resident 22, he stated he had spoken to the staff about his leg and was waiting for treatment. Review of Resident 22'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 prescribed treatment for pressure ulcer (an area of the skin that breaks down when something keeps rubbing or pressing against the skin) was followed for two of three residents (Residents 43 and 44). This failure had the potential for decreased healing and further injury to the residents' wounds. Findings: 1. Review of Resident 43's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including hemiplegia (a condition caused by brain damage or spinal cord injury that leads to severe or complete loss of strength on one side of the body), pressure ulcer on left buttock, pressure ulcer on right buttock, and dependence on supplemental oxygen. Review of Resident 43's physician order, dated 8/12/22, indicated she had a treatment order for her left and right buttock pressure ulcers to be cleansed with Dakin's solution (used to prevent and treat skin and tissue infections that could result from cuts, scrapes…

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 follow a fall prevention order for one of four sampled residents (Resident 20) when the pad alarm (device that makes a loud noise to alert caregivers if a resident is getting up from bed) was not placed in bed. This failure had the potential for falls and injury to the resident. Findings: Review of Resident 20's clinical record indicated the resident had a diagnosis including dementia (the loss of cognitive functioning) and abnormalities of gait and mobility. Review of Resident 20's Minimum Data Set (MDS, an assessment tool), dated 7/7/22, indicated the resident's Brief Interview for Mental Status score (BIMS score, a test to get a quick snapshot of how well the resident is functioning cognitively at the moment) was seven, which means severely impaired cognition. Review of Resident 20's Fall assessment, dated 7/7/22, indicated 13, high risk. Review of Resident 20's physician order, dated 7/30/21, indicated. Pad alarm while on bed for poor safety awareness every shift. During a concurrent observation 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 observation, interview, and record review, the facility failed to administer oxygen (02) according to professional standards of practice for one of one resident (Resident 3). This failure could affect the resident's health and safety. Findings: Review of Resident 3's clinical record indicated the resident was admitted to the facility on [DATE] and was readmitted on 5/1/ 22 with diagnoses including COPD (Chronic Obstructive Pulmonary Disease, a group of diseases that cause airflow blockage and breathing-related problems) and acute respiratory failure. Review of Resident 3's physician order, dated 8/11/21, indicated to administer oxygen at 2 LPM (liters per minute, the flow of oxygen) via nasal cannula (NC, a device used to deliver supplemental oxygen. The device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils). During an observation on 8/29/22 at 8:39 a.m., Resident 3 was sleeping in the bed with oxygen at 2.5 LPM via NC. There was an oxygen…

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 1 of 15 sampled residents (Resident 7) was free from unnecessary medications when Resident 7 received long-term diuretic (medication that remove water from the body which can affect the electrolyte levels in the body) without routine electrolyte (such as potassium, calcium, magnesium) monitoring; and levothyroxine (thyroid medication) without periodic lab work for its use. The failure had the potential to result in electrolyte imbalance and inadequate thyroid response, that can cause serious medical conditions such as irregular heartbeats, fatigue, confusion, etc. for the resident. Findings: Resident 7 was admitted to the facility with diagnoses including moderate calorie malnutrition, chronic heart disease, and hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone). A review of Resident 7's medical record indicated the resident was receiving: - Furosemide (a diuretic) 40 milligrams (mg, unit of measurement), 1 tablet twice daily from 2/19/21 to 8/25/22; and 40 mg daily 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of 9 residents (36 and 44) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 36 received Abilify for schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood), and the electrocardiogram (ECG, a test that measures the electrical activity of the heartbeat) was not done as ordered; and 2. Resident 44 received Latuda for schizoaffective disorder and haloperidol for schizophrenia (a mental disorder in which people interpret reality abnormally), and the liver function tests (LFTs, blood tests used to help diagnose and monitor liver disease or damage) was not done as ordered. These failures resulted in unnecessary medications for the residents, which had the potential for increased risks associated with psychotropic medication use that include, but not limited to, sedation, respiratory…

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

Based on observation, interview, and record review, the facility failed to store and ensure food were under sanitary conditions for one of three residents (Resident 6) when the resident's food brought from outside was not properly stored, labeled, and dated. This failure had the potential for food borne illness and food contamination. Findings: During an concurrent observation and interview on 8/29/22, at 9:22 a.m., in Resident 6's room, an unlabeled and undated bottle of Nutella was found at his bedside. Resident 6 stated, it was brought outside by my son. During a follow up observation on 8/30/22, at 8:30 a.m., in Resident 6's room, a bottled of unlabeled and undated peanut butter was found at his bedside. During an interview on 9/01/22, at 10: 56 a.m., certified nursing assistant E (CNA E)confirmed the peanut butter was unlabeled and undated at bedside. CNA E stated, CNA should check the food at bedside and informed the nurse. During an interview with Dietary Manager (DM), on 9/1/22 at 10:51 a.m., she stated that every resident is allowed to bring food from outside. Facility…

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 a safe and functional environment for one of 12 sampled residents (Resident 21) when Resident 21's bathroom sink was clogged and the toilet bowl had a leak with water spilled on the floor. The facility must provide a safe, functional, sanitary, and comfortable environment for residents and staff. Findings: During an initial tour of the facility on 8/29/2022 at 8:46 a.m., Resident 21's toilet bowl was leaking with water spilled on the floor and a wet white bath towel was observed underneath. During a concurrent observation and interview with Resident 21 on 8/29/2022 at 8:48 a.m., she stated the toilet bowl had a water leak with water spilled on the floor since she had been admitted on [DATE]. Resident 21 stated the facility staff was aware of leaking toilet bowl and that was why a white bath towel was put underneath to absorb water. During an interview, on 8/30/2022 at 11:50 a.m., with the licensed vocational nurse D (LVN D), 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.