The Ridge Post Acute

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program when two live cock roaches were observed in the social services office by health facilities evaluator nurses, during a recertification survey. This finding had the potential to put residents and staffs' health and safety at risk. Findings: During an observation on 10/24/24, at 2:30 p.m., in the social services office, a live cockroach was observed on the floor under the desk. During an observation on 10/24/24, at 2:47 p.m., in the social services office, a live cockroach was observed on top of the desk. During a concurrent interview and record review, on 10/25/24, at 2:32 p.m., with the administrator (ADM), the facility's policy and procedure (P&P) titled, Pest Control, revised May 2008, was reviewed. The P& P indicated, This facility maintains an effective pest control program so that the facility is free of pests and rodents. ADM acknowledged an effective pest control program was to ensure a pest free environment.

Based on observation, interview and record review, the facility had a medication error rate of 12.12% when four medication errors occurred out of 33 opportunities for four residents (Resident 27, Resident 12, Resident 46, and Resident 154): 1. For Resident 27, the nursing staff did not confirm the exact dose as ordered by the physician for the medicine Lamotrigine (a medicine used for seizure). 2. For Resident 12, the nursing staff administered the medication Metformin (a medicine used to lower the blood sugar) without a meal. 3. For Resident 46, the nursing staff did not administer Lidocaine 5% Patch (used to alleviate pain). 4. For Resident 154, the nursing staff did not administer an inhalation solution in accordance with the facility procedure. These failures resulted in medications not given in accordance to the manufacturer's instructions and/or physician's order and had the potential for residents not receiving the full therapeutic effects of medications. Findings: 1. During a medication pass observation on 10/21/24 at 4:13 p.m., Licensed Vocational Nurse (LVN) B, took out 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.

Based on observation, interview and record review, the facility failed to ensure that the recipe (a set of instructions on how to prepare or make a particular food) for making vegetable puree (smooth, crushed, or blended food that has the consistency of a creamy paste or liquid) was being followed when the lead cook did not follow the recipe for making carrot puree. This failure had the potential to result in decreased palatability that could lead to decrease in food intake for the 6 residents with puree consistency diet order out of the skilled nursing facility census of 48. Findings: During the observation of making vegetable puree with the lead cook (LC), on 10/22/24 at 10:55 a.m., LC was making vegetable puree using carrots, good for 12 servings. LC put 48 ounces (oz, unit of weight) of carrots, 4 oz per serving, good for 12 servings, into the blender, added 2 cups (cooking measure of volume) of milk and then pureed them. LC then checked the consistency of the pureed carrots, added 1 cup of milk, then added food thickener and pureed them again. LC then set aside the pureed…

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 care was provided in accordance with professional standards of quality for one (Resident 13) out of three sampled residents when Resident 13 had an unnecessary and improper blood sugar check done. This failure resulted in a potentially inaccurate blood sugar result and an additional finger prick which can be painful. Findings: During an observation on 10/21/24 at 11:47 a.m. with Licensed Vocational Nurse (LVN) A, LVN A cleaned Resident 13's left ring finger with an alcohol swab and immediately pricked Resident 13's finger. LVN A then placed the blood sugar strip connected to the glucometer (device used to check blood sugar) to the pricked finger to catch the drop of blood for the blood sugar test. After obtaining the blood sugar result of 136 milligram/deciliter (mg/dl, a unit of measurement; normal range is 80-110 mg/dl), LVN A stated I am going to hold her insulin right now. I am going to feed her at 2 p.m. She has a G-tube (a flexible, hollow tube that is inserted into the stomach through 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 observation, interview, and record review, the facility failed to ensure that appropriate care and services were provided to one out of twelve sampled residents, (Resident 8), when the restorative nursing assistant (RNA) totally assisted Resident 8 in feeding instead of set-up help only. This failure had the potential, for the resident, not to maintain or achieve the highest level of self-care or independence in feeding. Findings: During the concurrent dining observation and interview with RNA on 10/21/2024 at 12:20 p.m., RNA was spoon-feeding Resident 8, totally assisting him with feeding. RNA acknowledged for totally assisting Resident 8 in feeding and for not checking the feeding care plan of Resident 8 prior to assisting him. During the interview with the Infection Preventionist (IP), who was overseeing the lunch dining area of the residents, on 10/21/2024 at 12:27 p.m., IP verified that Resident 8 had specialized adaptive utensils to help with grip and would help encourage self-feeding and should not be totally assisted with feeding. During the concurrent record review…

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

Based on observation, interview and record review, the facility failed to ensure equipment is in safe operating condition for four (Residents 8, 23, 26 and 38) out of eight sampled residents when a commode with noticeable rust was found in their shared toilet. This failure had the potential to put residents at risk for harm during their usage of the rest room. Findings: During a concurrent observation and interview on 10/20/24 at 2:19 p.m. with LVN E, a commode with noticeable rust was positioned over the toilet bowl in the rest room shared by Resident 8, Resident 23, Resident 26, and Resident 38. LVN E stated we should have checked the commode before placing it in the resident's toilet. During an interview with the Maintenance Director/ Environment Services Supervisor (EVSS) on 10/23/24 at 1:49 p.m., EVSS stated that there is no log to monitor commodes. EVS also stated that nurses do the log for the commode maintenance and not the maintenance department. During a concurrent interview and record review on 10/23/24 at 1:55 p.m. with the Infection Preventionist (IP), the IP verified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for two of three sampled residents (Residents 2 and 1) when: 1. Licensed nurses did not start to monitor Resident 2's whereabouts after the incident with Resident 3 on 1/15/2023; 2. Licensed nurses did not monitor Resident 2's whereabouts until the 6/15/2023's incident with Resident 1 and had some missing documentations on Resident 2's implementation of Elopement Risk/Wanderer care plan dated 6/15/2023; 3. Licensed nurses did not complete Resident 1's admission Assessment in a timely manner, who was admitted on [DATE]; the admission Assessment was only completed on 6/16/23; and 4. Licensed nurses did not complete Resident 2's follow-up assessment after the 6/15/2023 incident in a timely manner and the interdisciplinary team's (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) note was initiated three…

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 appropriate social services (SS) support for two of three residents (Residents 2 and 3) when: 1) There was no SS support following Resident 2 and Resident 3's altercation (a heated or angry dispute) on 1/15/23; and 2) There was no SS support following an abuse allegation against Resident 2 and no documentation on SS follow up to address Resident 2's psychosocial needs and behaviors. These failures resulted in a lack of timely social services interventions for Resident 2 and Resident 3. These failures had potential not to address Resident 2, Resident 3 and other residents' mental distress. Findings: 1. Review of Resident 2's admission Record dated 3/6/2024 indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses including catatonic schizophrenia (a mental illness when the patient may not respond to what's happening around them, or they could have periods of high activity, where they could act violently), major depressive…

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 report an abuse allegation incident for one of one sampled resident (Resident 1, female) when the facility staffs found Resident 2 (male) on Resident 1 ' s bed. This failure had left the public agencies with jurisdiction over the facilities unaware of the event. Findings: Review of Resident 1 ' s facesheet (a document that gives a resident's information at a quick glance, including contact details and a brief medical history), indicated Resident 1 was admitted on [DATE], with diagnoses of status post left hip replacement surgery due to left femur neck fracture, major depressive disorder. During an interview on 7/24/23 at 3:30 p.m. with Licensed Vocational Nurse (LVN) A, she stated, on 6/15/23 at around 9:30 p.m., two Certified Nursing Assistants (CNA) from Station 1 told her Resident 2 was found sitting on the foot of Resident 1 ' s bed. LVN A stated Resident 1 told her I'm ok after the incident; however, Resident 1 appeared fearful. LVN A stated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure five of 16 sampled residents (91, 29, 93, 94, and 30 ) were provided care in a manner that maintained the resident's dignity and respect when : 1. Resident 91's urine collection bag for the indwelling catheter (sterile tube inserted into the bladder to drain urine), was not covered; 2. Resident 29's incontinent pad was exposed to public view while walking in the hallway; 3. Staff did not greet, communicate with Resident 93,and spoke in his native language (non-English language); and 4. Staff spoke in their native language (non-English language ) during resident care, around other residents, in the hallways within resident's hearing distance, for Residents 94, 91, 30 . These failures had the potential to negatively affect the residents' emotional and psychosocial well-being. Findings : 1.Review of Resident 91's admission assessment, dated 4/8/23 indicated he was admitted with an indwelling catheter, and he was alert and oriented 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 provide an ongoing activity program that meet the residents' needs, interests and preferences for four of 16 sampled residents (Residents 30, 23, 37 and 3), when: 1. Resident 30's activity care plan was not updated and followed; 2. Staff provided activities to Resident 23 without having an activity initial assessment and a care plan was not developed timely; 3. Staff provided activities to Resident 37 without having an activity initial assessment and care plan; and 4. Resident 3's activity was not provided. These failures had the potential to affect the residents' physical, mental, psychosocial well-being and self-worth. Findings: 1. During an initial observation of Resident 30 on 4/17/23 at 9:17 a.m., Resident 30 was lying in bed, sleeping and did not have any activities. Review of Resident 30's clinical records indicated, Resident 30 was a [AGE] year-old female with diagnoses including dementia (memory loss) without behavioral…

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 care and services were provided in accordance with professional standards of practice for 8 of 16 sampled residents (Resident 32, 5, 95, 2, 23, 3, 15, and 19) when: 1. A licensed nurse did not implement the facility's policy for Resident 32 with a gastrostomy tube (G-tube, inserted through the wall of the abdomen directly into the stomach and can be used to give drugs and liquids, including liquid food) during medication administration 2. A licensed nurse did not follow the manufacturer's recommendation in taking blood pressure for Residents 32 and 5 3. A licensed nurse did not properly give instructions during eye drop administration for Resident 95. 4. A liciensed nurse did not follow a physician order for administration of inhalers for Resident 2 5. For Resident 23' oxygen (a colorless and odorless gas that people need to breathe) order, the amount to be given did not specify the parameter Resident 23 should be receiving 6. 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.

Based on observation, interview and record review, the facility failed to employ a full-time registered dietitian (RD) or designate a kitchen supervisor or certified dietary manager to carry out the functions of the food and nutrition service based on resident assessments and individual plans of care. This failure had the potential to compromise the nutritional status of the 46 residents residing in the facility. Findings: During the initial kitchen tour observation on 4/17/23 at 7:10 a.m., two kitchen staffs were around, one cook and one dietary assistant. There was no kitchen supervisor or dietary manager. During an interview with the RD on 4/19/23 at 9:25 a.m., the RD verified that she was only working part-time at the facility. She further verified that she only comes to the facility every Mondays and Thursdays and working 16 hours per week or as requested. the RD also stated that the facility does not have a kitchen supervisor or dietary manager and the facility should have one. During the interview with the Administrator Designee (ADMD) on 4/19/23 at 9:30 a.m., the ADMD…

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

Based on observation, interview and record review, the facility failed to ensure food was stored, monitored and served in accordance with professional standards for food safety when: 1. foods in the dry food storage room and freezer in the kitchen, had no received and use by dates, 2. missing temperature logs for the dry food storage room, refrigerator and freezer in the kitchen, and 3. certified nursing assistant M (CNA M), did not perform hand hygiene prior to Resident 30's lunch meal set-up. These failures had the potential to cause the growth of microorganisms which could cause foodborne illness (illness caused by food or water contaminated with bacteria, viruses, parasites or toxins) or cross contaminate (cross contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness) food for the 45 of 46 residents, getting their meals from the facility kitchen. Findings: 1. During the facility kitchen tour observation on 4/17/23 at 7:20 a.m., the following were observed in the dry food storage room and in the freezer: a. three…

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 infection control practices were implemented when: 1. An unlabeled urinal (a plastic container used to collect urine) and unlabeled specimen collection hat (SCH- a wide brimmed hat shape basin placed inside a toilet used to collect urine samples) were on top of the commode; 2. Resident 192's feeding pump (a medical device, pumps the feeding formula from container to feeding tube [FT - a tube that is inserted into the stomach to give medication and liquid food]) had some dry brown stains; 3. Resident 19's room air oxygen concentrator (RAOC-an electronic medical device that provides oxygen to the patients by concentrating room air into pure oxygen) had whitish, grayish buildup substance; 4. Resident 192's FT irrigation syringe (a syringe used to flush with water, feeding formula, and medications via GT) was not labeled and Resident 32's FT irrigation syringe was dated 4/16/2023; 5. Resident 192's bathroom had an unknown odor; 6. Licensed vocational nurse B (LVN B) did not clean the portable 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 one of three sampled residents (Resident 98 ) discharged from Medicare Part A services received a Notice of Medicare Non-Coverage (NOMNC, a form given to Medicare recipients notifying that Part A coverage is being terminated and providing information on how to file an appeal of that decision) letter in a timely manner. This failure had the potential to prevent the resident from filing a timely appeal of the decision to discharge from Medicare Part A services. Finding: 1. Review of Resident 98's clinical record indicated he was admitted to the facility on [DATE] with a diagnosis of chronic kidney disease. Review of Resident 98's NOMNC letter indicated Medicare coverage ended on 9/30/22. The letter was signed on 9/29/22, which was one day before the coverage would end. During an interview and concurrent record review with the case manager (CM) on 4/20/23 at 2:17 p.m. she verified Resident 98's NOMNC should have been completed two days prior 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 develop and implement individualized, resident-centered care plans for two of 16 sampled residents (Resident 3 and 33) when care plans for: 1.the use of ankle foot orthosis (AFO, is used for people with cerebral palsy [a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth] for positioning, deformity management, or to improve standing or walking.) boot was not developed for Resident 3; 2. Resident 3's activity care plan was not implemented; and 3. the use of eyeglasses was not developed for Resident 33. The failure to develope and to follow care plans had the potential to not meet the care needs of residents. Findings: 1.Review of Resident 3's admission record, indicated Resident 3 was admitted to the facility with diagnoses including cerebral palsy, dementia (decline in mental capacity affecting daily function), contractures (a condition of permanent tightening of the muscles, tendons, skin, and nearby tissues that causes 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 observation, interview and record review, the facility failed to ensure residents received foot care and treatment in accordance with professional standards of practice for one out of three Residents (Resident 19). This failure had the potential for podiatric complications for Resident 19. Findings: Clinical record review of Resident 19 indicated, Resident 19 admitted to facility on 1/19/21 with diagnoses including diabetes mellitus 2 (a chronic disease characterized by high levels of sugar in the blood), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During an interview with Resident 19 on 4/17/23 at 10:35 a.m., the Resident 19 stated her toenails were long, and had not been trimmed recently. Resident 19 further stated nobody trimmed her toenails in the facility. During a concurrent observation, and interview with certified nursing assistant F (CNA F) on 4/17/23 at 10:45 a.m., CNA F confirmed Resident 19's toenails were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 32) was accurately assessed, and received services to prevent further decrease in range of motion (ROM- how far a person can move or stretch a part of the body, such as a joint or a muscle) of Resident 32's left upper extremity (LUE - left upper arm) and left lower extremity (LLE - left lower leg). This failure had the potential for further decline of ROM and contractures of Resident 32's LUE and LLE. Findings: Review of Resident 32's admission record indicated Resident 32 was admitted to the facility with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left side (a severe or complete loss of strength in the arm, leg, and sometimes face on left side of the body following (occurs as result of disrupted blood flow to the brain), diabetes type 2 (a disease of high sugar level in blood), and adult failure to thrive (a state of decline that is multifactorial and may…

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 implement interventions for free of accident hazards and to prevent avoidable accidents for three of 16 sampled residents (Resident 19, 93, and 3) when: 1. Resident 19's bed was not in the lowest position as ordered; 2. Resident 93's television cord was dangling through the sink unsecured; and 3. the Oxygen in use sign was not placed at the room entrance of Resident 3. These failures had the potential to result in accidents and injury to Resident 19, Resident 93, and Resident 3. Findings: 1. Clinical record review of Resident 19's admission record, indicated Resident 19 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe),respiratory failure (a serious condition that makes it difficult to breathe) diabetes (a condition of high sugar levels in the blood), anemia (a condition in which the blood does not have enough healthy red blood cells), congestive heart failure (a chronic condition…

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 intravenous (IV,within a vein ) solution from emergency kits (e-kits) was replaced in a timely manner. This failure had the potential to result in medications not being available during emergency situations. Findings: During an observation and concurrent interview with the director of nursing (DON) on 4/17/23 at 7:30 a.m., all e-kits were sealed and not used , except for the IV e-kit .The DON looked at the emergency log binder and verified the IV e-kit was opened on 4/14/23 . The DON stated all e-kits should be replaced same day . Review of facility's policy, Emergency Medications, dated 04/2007, indicated Medication kit must be replaced upon the next routine drug order.

Based on interview, and record review, the facility failed to ensure one of 7 residents (Resident 192) was free from unnecessary drugs when Resident 192 was not monitored for specific target behaviors for use of mirtazapine (a medication to treat symptoms of depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]). This failure had the potential to affect Resident 192's medical condition. Findings: Clinical record review of Resident 192's admission record indicated, Resident 192 was admitted to facility with diagnoses including depression, anxiety (a mental health disorder with intense, excessive, and persistent worry and fear about everyday situation), and adult failure to thrive (a syndrome characterized by unexplained weight loss, malnutrition, and disability). Review of Resident 192's physician orders dated 3/10/23 indicated, Remeron Tablet 15MG [milligram - unit of weight] (Mirtazapine) Give 0.5 tablet via G-Tube (GT- gastrostomy tube is a tube inserted through the belly that brings nutrition, medications, and water directly to the stomach)…

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 11.54 % when three medication errors occurred out of 26 opportunities during the medication administration for three residents (Residents 32,19, and 5). The failure resulted in medication not given as scheduled and according to physician orders or/the manufacturer's specifications, and had the potential for the residents not receiving the full therapeutic effects of medications. Findings: 1.During a medication administration on 4/17/23 at 9:00 a.m., licensed vocational nurse B (LVN B) was observed preparing five medications for Resident 32 including Clopidogrel Bisulfate (blood thinner) , Aspirin (blood thinner) , Losartan Potassium ( to treat high blood pressure) , Vitamin D , and Multi Vitamin liquid. LVN B administered these medications through Resident 32's gastrostomy tube (G-ttube, inserted through the wall of the abdomen directly into the stomach and can be used to give drugs and liquids, including liquid food ). During a record review on 4/17/23 at 10:15 a.m., Resident 32'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 medications were stored in a safe manner when when eye drops were expired and insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood ) bottles were not properly labeled in the medication carts. These failures had the potential for the medications to be used beyond the date they were safe and effective for use. Findings : During an observation and concurrent interview with licensed vocational nurse B (LVN B) on [DATE] at 11:00 a.m., medication cart 1 has latanoprost eye drop opened date of [DATE] and an instruction to discard after 42 days in the box . LVN B stated the medication had expired, beyond 42 days, and should not be kept in the medication cart . During an observation and concurrent interview with LVN A on [DATE] at 12:15 p.m., medication cart 2 has insulin glargine opened date [DATE] in the box and lantus opened date [DATE] in the box . Both medications did not have an open date indicated in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow the food preferences for two of 16 sampled residents (Residents 24 and 37) when: 1. Resident 24's choice of food was not followed; and 2. Resident 37's food preference was not provided. This deficient practice could affect the food intake and nutritional status of these residents. Findings: 1. During the initial observation and concurrent interview with Resident 24 on 4/17/23 at 9:22 a.m., Resident 24 appears alert, oriented and very responsive when asked. Resident 24 stated that he had a hard time making food request or choice. He further stated that his concern about his food preference was not followed up. Review of Resident 24's clinical records indicated, Resident 24 was a [AGE] year-old male, with diagnoses including, chronic obstructive pulmonary disease (COPD, chronic inflammatory lung disease that causes obstructed airflow from the lungs), generalized muscle weakness and difficulty in walking. He was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide palatable and appetizing foods and also to ensure, the palatability of cooked foods were maintained when: 1. for Resident 24, he stated that his food lack in taste, 2. the regular and pureed vegetable samples in the test tray were not palatable, and 3. the recipe for making pureed foods were not followed. These failures had the potential to result in decreased food consumption leading to decreased nutrient intake for the 45 of 46 residents, getting their meals from the facility kitchen. Findings: 1. During the initial observation and concurrent interview with Resident 24 on 4/19/23 at 9:15 a.m., Resident 24 appears alert, oriented and very responsive to questions. Resident 24 complained that his food lacked in taste and said that it was still not followed up. Review of Resident 24's clinical records indicated, Resident 24 was a [AGE] year-old male, with diagnoses including, chronic obstructive pulmonary disease (COPD, chronic…

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 follow their written policy and procedure (P&P) for influenza (flu- a common viral infection affects lungs, nose, and throat), and pneumococcal (PNA- a serious infection of one or both of the lungs caused by bacteria, viruses, fungi, or chemical irritant) vaccines (a preparation that is used to stimulate the body's immune response against diseases) for three out of five sampled residents (Resident 19, Resident 29, and Resident 192) when: 1. Facility failed to provide risks versus benefits education to resident or resident's responsible party (RP) when flu vaccine was refused; 2. Facility failed to provide risks versus benefits education to resident or resident's RP when PNA vaccine was refused. These failures exposed Residents 19, 29, and 192 to the risk of contracting flu, and PNA along with their associated complications. Findings: 1. Record review of flu vaccine consent for Resident 19 indicated Resident 19 refused flu vaccination on 10/1/22. There was no documented evidence of education for risks versus benefits of flu…

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 follow its policy and procedure (P&P) for staff Covid-19 (a contagious respiratory disease caused by SARS [severe acute respiratory syndrome]-COV-2 [coronavirus disease] virus) vaccination, and medical exemption requirements for one of one sampled staff. This failure could expose the residents and staff in the facility to the risk of exposure and transmission of Covid-19. Findings: Review of facility's staff Covid-19 vaccination log indicated total staff 59. 58 staff members were completely vaccinated, which equals to 98.31%. Activity assistant L (AA L) was granted medial exemption. Review of declination of Covid-19 vaccination form for AA L, signed and dated on 3/31/22 by AA L., indicated, AA L declined coronavirus vaccination for allergic to tetanus vaccine, vaccines + toxoids. There was no documented evidence of physician signed statement for medical exemption based on AA L's clinical contraindications for Covid-19 vaccination. During an interview with the infection preventionist (IP) on 4/21/23 at 9:51 a.m., the IP…

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.