The Hills Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide a reasonable accommodation to meet the needs of one of 32 final sampled residents (Resident 54) and one nonsampled resident (Resident 147). * The facility failed to ensure Resident 54 and 147's call light was within the resident's reach. This failure had the potential to negatively impact the residents' psychosocial well-being and cause delays in receiving the needed care.Findings: Review of the facility's P&P titled Call Light/Bell revised 5/2007 showed to leave the resident comfortable. Place the call device within resident's reach before leaving room. If the call light/bell is defective, immediately report this information to the unit supervisor. 1. Medical record review for Resident 54 was initiated on 5/3/26. Resident 54 was admitted to the facility on [DATE]. Review of Resident 54's MDS assessment dated [DATE], showed Resident 54 had a BIMS score of 2 (severe cognitive impairment). Furthermore,…

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 medical record review, the facility failed to maintain a safe, clean, and homelike environment for two of 32 final sampled residents (Residents 26 and 48) and one nonsampled resident (Resident 117). * Resident 26 resided in Room D. The wall behind Resident 26's bed was observed in disrepair with black streak marks on the wall and chipped paint on the wall and wall trimmings. In addition, Resident 26's ceiling was observed with chipped and peeling paint. * Resident 48 resided in Room E. The wall behind Resident 48's head of bed was observed in disrepair with chipped paint and cracked wall trims. * The walls and bathroom door in Resident 117's room were observed in disrepair. These failures had the potential to negatively impact on the residents' quality of life. Findings: 1. Medical record review for Resident 26 was initiated on 5/3/26. Resident 26 was admitted to the facility on [DATE], and readmitted on [DATE]. On 5/3/26 at 0900 hours, Resident 26 was observed lying in bed…

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, medical record review, and facility P&P review, the facility failed to provide a copy of the notification of the transfer/discharge to the Office of the State Long-Term Care Ombudsman for one of the two residents (Resident 7) who were transferred to the acute care hospital. * The facility failed to ensure copy of the transfer discharge notification was sent to the Ombudsman when Resident 7 was transferred to the acute care hospital on 2/24/26. This failure had the potential for the resident to not receive additional protection when the residents was being inappropriately transferred or discharged .Findings: Review of the facility's P&P titled Criteria for Transfer and Discharge revised April 2025 showed the facility shall send a copy of the notice to the State Long-Term Care Ombudsman. The notice shall be made at least 30 days before the resident transferred or discharged or as soon as practicable before transfer or discharge when:- The safety or health of individuals in the facility would be…

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, medical record review, and document review, the facility failed to ensure the PASRR Level 1 screening was accurate for one of four final sampled residents (Resident 94) reviewed for PASRR. * Resident 94 had diagnosis of psychosis, however, the PASRR Level 1 screening showed Resident 94 had no diagnosis of serious mental illness and had no psychotropic medication. This failure had the potential risk for Resident 94 not to receive the necessary care and services due to inaccurate assessment.Findings: Review of PASRR screening background statement showed the Omnibus Budget Reconciliation Act of 1987 (Public Law 100-203) and 42 Code of Federal Regulations Sections 483.100 through-483.138 requires that each individual, including, but not limited to, an applicant and resident, regardless of payment source, applying for admission to, or residing in, a Medicaid-certified Nursing Facility (NF) be screened and evaluated for serious mental illness and intellectual disability, developmental disability…

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, medical record review, and facility P&P review, the facility failed to ensure the comprehensive, person-centered care plan was developed and implemented for four of 32 final sampled residents (Residents 1, 12, 13, and 94). * The facility failed to develop a comprehensive, person- focused care plan addressing Resident 1's noncompliance with the prescribed dietary regimen. * The facility failed to develop the comprehensive, person-centered care plan to address Resident 12's hemodialysis treatments, fluid restrictions, hemodialysis access monitoring, and nutrition status. * The facility failed to develop a care plan to address Resident 13's use of a low air loss mattress (LAL). * The failed to develop a care plan to address and support Resident 94's care needs related the resident's diagnosis of dementia. These failures had the potential to result in inconsistent, inappropriate or non-individualized care for Residents 1, 12, 13, and 94.Findings: Review of the facility's P&P titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plans of care for two of 32 final sampled residents (Residents 53 and 98) was revised to reflect the resident's current care needs and interventions. * Resident 53's care plan was not updated to reflect the resident's care needs and interventions. * Resident 98's plan of care was not revised to reflect resident's care needs and interventions. These failures posed the risk of not providing Residents 53 and 98 with individualized and person-centered care.Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised 8/2019 show it is the policy of this facility that the Interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.- the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and the facility P&P review, the facility failed to ensure the appropriate services needed to maintain the acceptable parameters of nutritional status were provided for one of five final sampled residents (Resident 53) reviewed for nutrition. * The facility failed to ensure the RD and IDT analyzed and implemented the necessary interventions and the physician and resident and/or their representative were notified when Resident 53's had unplanned significant weight loss of 16 lbs. (8.04%) between 4/4 and 5/2/26. In addition, Resident 53's resident-centered care plan was not revised to address Resident 53's severe weight loss of 16 lbs. These failures had the potential for Residents 53 to not receive the necessary intervention to prevent further weight loss.Findings: Review of the facility's P&P titled Nutrition Status Management revised on 4/2025 showed it is the policy of this facility to assess each resident's nutritional status and needs, including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for one of three final sampled residents (Resident 164) reviewed for enteral feeding care. * The facility failed to ensure Residents 164 was administered the total amount of the enteral feeding as ordered by the physician. This failure posed the risk of developing complications related to the enteral feeding.Findings: 1. Review of the facility's P&P titled Enteral Feeding Administration revised 5/2020 showed it is the policy of this facility to administer enteral feeding at a constant controlled infusion rate per physician's order. Intermittent delivery schedules are recommended. Medical record review for Resident 164 was initiated on 5/3/26. Resident 164 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident MDS annual assessment dated [DATE], showed Resident 164's Cognitive Skills for Daily Decision Making severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for one of one final sampled resident (Resident 107) reviewed for IV therapy, consistent with the professional standards of practice. * The facility failed to ensure Resident 107's IV tubing was correctly labeled. In addition, the facility failed to develop a care plan for the use of an IV antibiotic therapy cefepime (medication used to treat serious bacterial infection including urinary tract infection). These failures posed the risk for the resident to develop complications related to the IV therapy.Findings: 1. Review of the facility's P&P titled Antibiotic Infusion Guideline (undated) showed closely observe and monitor the resident during the first and second doses for any sign of allergic reactions. Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised 8/2019 showed the baseline care plan will include…

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, facility document review, and facility P&P review, the facility failed to ensure safe and effective pharmaceutical services was provided for one of four residents (Resident 85) observed for medication pass and the proper accounting procedures of controlled substances was provided for two residents (Residents 90 and 193) reviewed for controlled substances reconciliation. * The facility failed to ensure medication for Resident 85 was administered in accordance with the prescriber's orders. This failure resulted in a medication error and had the potential to negatively affect the resident's health conditions. * The facility failed to ensure the RX Number was documented on the Controlled Substances Log for the bottles of morphine sulfate liquid solutions for Residents 90 and 193 which were stored in Medication Cart B. This failure had the potential for the facility to be unable to trace the movement of the scheduled drugs and identify discrepancies, prevent diversion, and ensure compliance with government regulations. Findings: 1. Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review and facility document review, the facility failed to ensure the Pharmacy Consultant's recommendation was acted upon for one of five residents (Resident 3) reviewed for unnecessary meds. * The facility failed to ensure Resident 3's continued use of the trazodone(antidepressant) and escitalopram (antidepressant) medications had a clinical rationale as per the Pharmacy Consultant recommendation. This failure had the potential to put Resident 3 at risk for adverse consequences related to the medications.Findings: Review of the facility's P&P titled Medication Drug Regimen Review dated 4/2025 showed if there is no change in the resident's medication during medication regimen review, the attending physician will document the rationale on the resident's medical record.Review of Resident 3's Note To Attending Physician/Prescriber dated 4/4/26, showed Resident 3 was currently prescribed with trazodone and escitalopram medications.to consider managing the resident's depression…

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, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 7) reviewed for unnecessary medication was free from the unnecessary medications. * The facility failed to ensure Resident 7's heart rate was monitored for the use of the amiodarone (medication to treat irregular or fast heartbeats) as ordered by the physician. This failure had the potential for the resident to receive unnecessary medication and put the resident at risk for adverse side effects. Findings: Review of the facility's P&P titled Guidelines for Medication Administration (undated) showed to observed the resident for immediate reaction and any reactions that occur during the hours following administration and record relevant and required information on the appropriate documentation record. Medical record review for Resident 7 was initiated on 5/5/26. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's H&P examination dated 3/4/26,…

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 facility document review, the facility failed to ensure food prepared in the facility kitchen was appealing and palatable when three of 153 residents (Residents 6, 12, and 94) expressed dissatisfaction with the taste of the food served. * The facility failed to ensure the potatoes served on the test tray was palatability. This failure posed the risk of the residents not receiving palatable and appetizing meals from the facility kitchen.Findings: Review of the facility's document titled Spring Cycle Menus dated 5/4/26, showed the regular menu for lunch menu included tarragon chicken with sauce, oven roasted potatoes, green beans with red peppers, broccoli salad, and tropical fruit mold. On 5/3/26 at 0923 hours, during the initial tour of the facility, Resident 12 stated the food does not taste good. On 5/3/26 at 1200 hours, during dining observation, Resident 6 stated the food was a bit bland. On 5/3/26 at 1324 hours, during dining observation, Resident 94 stated food tastes very old. On 5/4/26 at 1328 hours, an interview and concurrent test tray…

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, facility documents review, and facility P&P review, the facility failed to ensure two nonsampled residents (Resident 175 and 194) out of 153 residents receiving a lunch tray were provided meals in accordance with the residents documented food preferences. * The facility failed to ensure Resident 175 did not receive vegetables on her lunch tray, as per the resident's documented preference. * The facility failed to ensure Resident 194 did not receive apple juice on her lunch tray, as per the resident's documented preference. These failures had the potential to affect the residents not receiving meals consistent with their preferences. Findings: Review of the facility document titled Diet Type Report revised on 5/4/26, showed 153 residents received food from the kitchen. Review of the facility's P&P titled Nutrition Status Management revised 4/2025 showed diet evaluations will include determining ideal body weight range, usual body weight, current diet order, percentage of food eaten, possible dental problems, current illness, resident likes 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, document review, and facility P&P review, the facility failed to ensure the staff followed the facility's P&P on Foods Brought by Family or Visitor and failed to ensure staff were educated on safe food handling of outside food. * The facility failed to ensure food items in the residents' refrigerator were labeled with the resident name, location, and date as per the facility's P&P. * The facility failed to ensure the staff who receive the food from the residents' family and/or visitors were educated on the safe and proper food handling of outside food. These failures had the potential to cause foodborne illnesses in the medically vulnerable resident population who consumed food brought from outside sources.Findings: 1. Review of the facility's P&P titled Foods Brought by Family or Visitor (undated) showed food(s) brought to a resident by family and/or visitors must be accepted by the resident; inspected before facility storage; and stored and served in accordance with food safety professional standards. The use of outside foods is a possible…

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, medical record, facility record review, and facility P&P review, the facility failed to ensure the medical records were accurate and complete for two of 32 final sampled residents (Residents 48 and 129). * The facility failed to ensure Resident 129's Hospice Visit Communication completed forms had the resident identifier for 6/1/25 to 5/5/26. In addition, the facility failed to ensure Resident 129's Hospice Team Visit Calendar was accurately initialed. * The facility failed to ensure the elopement re-evaluation and documentation for Resident 48's exit-seeking behavior was documented in the medical records. These failures had the potential for the residents' care needs to not be met as their medical information was inaccurate and incomplete.Findings: 1. Review of the facility's P&P titled End of life Care, Hospice and /or Palliative Care dated 4/2025 showed hospice services will be offered as appropriate and as ordered by the physician. These services will be integrated into 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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of three final sampled residents (Resident 52) reviewed for hospice services. * The facility failed to ensure Resident 52's medical record contained the visit notes by the Chaplain and Certified Home Health Aide (CHHA), failed to ensure the monthly hospice visitation calendar for May 2026 was available in the resident's medical record, and failed to show the day Resident 52 would be visited by the Skilled Nurse for the week of 4/26/26. These failures posed the risk of delayed communication and uncoordinated medical care between the facility and the hospice provider, which could negatively affect Residents 52's care.Findings: Review of the facility's P&P titled End of Life; Hospice and/or Palliative Care reviewed 2/2025 showed hospice services will be offered as appropriate and as ordered by the physician. These services will be integrated into 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, interviews, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for five of six final sampled residents (Residents 24, 125, 139, 145, and 816) reviewed for the IV care. * The facility failed to ensure the dressing change was completed weekly, the arm circumference and external catheter length of the PICC line were measured, and the care plan was developed timely for Resident 24's PICC line use . * The facility failed to ensure the dressing change was completed weekly, the arm circumference and external catheter length for midline were measured, and the care plan was developed for Resident 125's midline IV catheter use. * The facility failed to obtain a physician's order for the care and maintenance of the IV line and developed a plan of care for Resident 139's IV use. * The facility failed to ensure the arm circumference and external catheter length were measured on admission and during the PICC line…

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, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the chest freezer had a thermometer to monitor the temperature of the freezer. * The facility failed to ensure the cold beverage were maintained within the acceptable temperature range. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared in the facility's kitchen. Findings: Review of the facility's Diet Type Report dated 3/17/25, showed 151 of 160 residents consumed 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 and interview, the facility failed to maintain the comfortable and homelike environment for one of 33 final sampled residents (Resident 70) and four nonsampled residents (Residents 6, 40, 48, and 56) as evidenced by: * The facility failed to provide the environment with comfortable sound levels for Residents 6, 40, 48, and 56 . * The wall adjacent to Resident 70's bed was observed in disrepair, with scratches and chipped paint. These failures had the potential to result in negatively impact the residents' quality of life. Findings: Review of the facility's P&P titled Noise Control revised 2/2022 showed it is the policy of this facility to maintain a comfortable sound levels that enhance privacy when privacy is desired; as with any health care facility, the atmosphere should be calm, organized, and as quiet as possible. Employees should refrain from making loud noises or talking in a loud voice. 1. Medical record review for Resident 6 was initiated on 3/18/25. Resident 6 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 interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was revised for two of 33 final sampled residents (Residents 15 and 70). * The facility failed to ensure Resident 15's comprehensive care plan was revised to reflect a physician's order for the prescribed amount of fluid to be provided to Resident 15 with meals. The care plan showed to provide Resident 15 with 240 ml of fluid with meals; however, the physician had ordered Resident 15 to receive 360 ml of fluid with meals. * The facility failed to ensure Resident 70's comprehensive care plan was revised when there was a change of the behavior manifestation for Resident 70's use of Seroquel (antipsychotic) medication. These failures placed the residents at risk for not being provided with the appropriate, consistent, and individualized care. Findings: 1. Medical record review for Resident 15 was initiated on 3/17/25. Resident 15 was admitted to the facility on [DATE]. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 2) reviewed for ADL care received the adequate personal hygiene care. * The facility failed to provide the nail care for Resident 2 which caused self-inflicted scratches. This failure had the potential to not meet the personal care needs of the dependent residents in the facility. Findings: Review of the facility's P&P titled Activities of Daily Living revised 7/2015 showed the resident's abilities in ADL do not diminish unless circumstances on the individual's clinical condition demonstrate that diminution was unavoidable. This includes the resident's ability to bathe, dress, groom, transfer, ambulate, toilet, eat, and use speech, language, or other functional communication systems. Grooming is defined as how the resident maintains personal hygiene, including preparatory activities, combing hair, brushing teeth, shaving, nail care, applying make-up,…

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 medical record review, the facility failed to provide the prescribed amount of fluids with meals, for one of 33 final sampled residents (Resident 15). * Resident 15's physician had ordered for Resident 15 to receive 360 ml of fluids with meals (breakfast, lunch, and dinner). However, Resident 15 only received 240 ml of fluids with meals. This failure had the potential to compromise Resident 15's hydration status and posed the risk for negative health outcomes. Findings: Medical record review for Resident 15 was initiated on 3/17/25. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's H&P examination dated 1/14/25, showed Resident 15 had a diagnosis of End-Stage Renal Disease and required hemodialysis three times per week. Review of Resident 15's Order Listing Report showed a physician's order dated 2/22/24, to monitor Resident 15's fluid intake and output every shift. Resident 15's physician ordered a fluid restriction of 2000 ml per 24 hours. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the respiratory services in a safe and sanitary manner in accordance with the facility's P&P for three of three residents (final sampled resident, Residents 123 and 614; and nonsampled resident, Resident 815) reviewed for the respiratory care. * Resident 123 received oxygen therapy without a physician's order and Resident 123's oxygen tubing and nasal cannula were not maintained in a sanitary manner. * The facility failed to ensure the oxygen tubing was labeled and stored in sanitary manner for Resident 815. * The facility failed to ensure Resident 614's oxygen tubing and humidifier bottle were labeled with the date when they were last changed, in accordance with the facility's P&P. These failures had the potential for negative health outcomes for a highly vulnerable resident population related to poor infection control practices and the administration of the oxygen therapy without a physician's order.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical, well-being for two of 33 final sampled residents (Residents 162 and 816). * Resident 162 had scheduled dialysis treatments three times per week at a dialysis center. On the days Resident 162 was scheduled at dialysis, the resident's blood pressure medications were not held as ordered by the physician. This failure posed the risk for Resident 162 not being provided with appropriate care and treatment and possible medical complications. * The facility failed to ensure Resident 816's dialysis access site was assessed and monitored appropriately and consistently. This failure had the potential for Resident 816 not being provided with the appropriate care and medical complications related to the resident's dialysis access site. Findings: 1. Medical Record Review for Resident 162 was initiated on 3/18/25. Resident 162 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, facility record review, and facility P&P review, the facility failed to ensure proper accounting and safeguarding of the controlled medications to prevent loss, diversion, or accidental exposure; and failed to ensure proper administration of eye drop medication for one nonsampled resident (Resident 71). * The facility failed to ensure the incoming and outgoing licensed nurses assigned to Medication Carts 2 and Cart 3 consistently signed the narcotic binder titled Controlled Substance Log. This failure posed the risk for loss or diversion of controlled medications in the facility. * The facility failed to ensure the eye drop medication was administered properly to Resident 71. This failure posed the risk of not receiving the eye drop as ordered to maintain the resident's well being. Findings: Review of the facility's P&P titled Pharmacy Services, Controlled Medications revised 12/2019 showed it is the policy of this facility to provide separately locked, permanently affixed…

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, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of the medications. * One vial of Lidocaine (anasthetic, numbing medication) 1% removed from Medication room [ROOM NUMBER]'s IV e-kit was not documented in the Emergency Kit Usage Log. This failure has the potential for the medication in the emergency kit to be lost and/or not be replaced. * The facility failed to ensure the expired Santyl ointments were removed from Treatment Cart 2. This failure had to potential for using of the expired medications. Findings: 1. Review of the facility's P&P titled Pharmacy Services, Emergency Drug Supply revised 11/2007 showed it is the policy of this facility to establish a method of providing residents with emergency medications prior to the receipt of filled prescriptions for that medication. A physician's order is required to justify the use of any drug from the emergency drug…

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 medical record review, the facility failed to ensure the special eating equipment was provided during the mealtime for one of 33 final sampled residents (Resident 27). This failure posed the risk for Resident 27 not maintaining or improving his independence in self-feeding skills when consuming meals and snacks. Findings: Medical record review of Resident 27 was initiated on 3/17/25. Resident 27 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 27's Nutrition Evaluation and RD Nutritionist Review dated 10/8/24, showed the resident was to have a magic cup for lunch and dinner. Review of Resident 27's Order Summary Report dated 3/20/25, showed a physician order dated 2/7/25, may benefit from a sippy cup to promote independence with self-feeding. Review of Resident 27's Diet Card dated 3/20/25, showed for breakfast, lunch, and dinner to include the adaptive equipment: sippy cup. On 3/17/25 at 1220 hours, an observation of Resident 27 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, medical record review, facility document review, and the facility P&P review, the facility failed to ensure the medical records were complete and accurately maintained for three of 33 final sampled residents (Residents 15, 20, and 123). * Resident 123's MAR failed to show the Protonix (treats conditions that cause too much stomach acid) and humalog insulin (antidiabetic) per sliding scale were administered on 3/3/25 at 0630 hours. The MAR failed to show the tuberculin test was completed on 3/18/25. In addition, the MAR failed to show the hours of sleep monitoring, non-pharmacological interventions, monitoring of side effects of hypnotics, monitoring of signs and symptoms of bleeding related to anticoagulant use, and monitoring of pain level were completed on 3/2/25 for night shift. * Resident 20's POLST dated 9/25/24, under Section D Information and Signatures, showed the physician's name, telephone number, license number, and signature were left blank and undated for six months. * 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 facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * Resident 139's urinal was placed next to a water pitcher and two cups of juice on the bedside table. * The facility failed to ensure a hand hygiene was performed before touching the GT. * The facility failed to ensure the staff practiced EBP when rendering GT care for one of 33 sampled residents (Resident 24). These failures posed the risk for transmission of disease-causing microorganisms. Findings: 1. On 3/17/25 at 0720 hours, during an observation, Resident 139's urinal was stored on the bedside table next to a water pitcher and two cups of juice. On 3/17/25 at 1030 hours, an observation in Resident 139's room and concurrent interview was conducted with the MDS Coordinator. The MDS Coordinator verified Resident 139's urinal contained…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the appropriate dietary texture was provided for one of four sampled residents (Resident 1) as ordered by the physician. * The facility failed to ensure Resident 1 was provided with the appropriate food texture as per the physician's diet orders. This failure had put Resident 1 at risk for choking. Findings: Review of the facility's document titled Regular Pureed Diet dated 2020 showed the pureed diet is a regular diet that has been designed for the residents who have difficulty chewing and/or swallowing. The texture should be of a smooth and moist consistency and able to hold its shape. Foods such as cakes, cookies, pancakes, and breads may be soaked in milk syrup or slurries until the proper consistency is achieved. Additionally, the document showed the breads may be soaked in liquids such as milk, soup, broth or gelatin water or pureed; and under the miscellaneous section to avoid showed…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to safeguard the controlled medications for nine of 11 sampled residents (Residents 3, 4, 5, 6, 7, 8, 9, 10, and 11) as evidenced by: * 116 tablets of tramadol (a controlled pain medication used to treat moderate to severe pain) 50 mg for Resident 3 were missing from the medication cart's locked narcotic drawer. * 39 tablets of hydrocodone-acetaminophen (a controlled pain medication made up of an opioid and a mild analgesic) 5 mg/325 mg for Resident 4 were missing from the medication cart's locked narcotic drawer. * 60 tablets of tramadol 50 mg for Resident 5 were missing from the medication cart's locked narcotic drawer. * 15 tables of Oxycontin (generic name is oxycodone, a controlled pain medication used to treat severe ongoing pain) 10 mg for Resident 6 were missing from the medication cart's locked narcotic drawer. * 87 tables 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, medical record review, and facility P&P review, the facility failed to ensure the medical records for three of eight sampled residents (Residents 2, 3, and 8) were complete and accurate. * The facility failed to ensure the licensed nurse documented the blood sugar levels and medications administered to Resident 2 in the MAR. * The facility failed to ensure the licensed nurse documented the blood sugar levelsand insulin medication administered to Resident 3 in the MAR. * The facility failed to ensure the licensed nurse documented the initials in the MAR when Resident 8's medications were administered. These failures had the potential for the residents' care needs not being met as their medical information were inaccurate and incomplete. Findings: Review of the facility's P&P titled Specific Medication Administration Procedures dated 10/2019, showed to obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration; and after 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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of four sampledresidents (Resident 1). * The facility failed to ensure Resident 1's oxycodone medications (narcotic/pain medications) were stored properly that resulted in the missing medications. * The facility failed to ensure Resident 1's Controlled Drug record and the MAR documentation for oxycodone matched. * The facility failed to ensure the proper inventory of all narcotics during the incoming and outgoing shift changes for the licensed nurses assigned to Medication Carts 1, 2, 3, and 5. These failures had the potential for diversion of the controlled medications and possible health complications due to not administering the medications as prescribed. Findings: Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy revised 9/2019 showed only the licensed personnel may receive the controlled substances…

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, medical record review, and facility P&P review, the facility failed to ensure the staff implemented the proper storage, labeling, and disposal of medications in a safe manner as evidenced by: * The facility failed to ensure Resident 12's opened stool softener and fish oil were properly labeled and dated in Medication Cart 5. * The facility failed to dispose of the Ozempic pen after 28 days of the open date for Resident 12 in Medication Cart 4. * The facility failed to dispose the single use opened wound care treatments and expired wound care treatments in Medication Cart 4. * The facility failed to ensure a working thermometer was in place inside the refrigerator containing medications for Medication room [ROOM NUMBER]. * The facility failed to dispose expired COVID-19 testing kit in Medication Cart 3. * The facility failed to ensure opened eyedrop medications in Medication Cart 1 were dated. * The facility failed to ensure the refrigerated medications was properly stored. * 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, medical record review, and facility P&P review, the facility failed to ensure the proper infection control as evidenced by: * The facility failed to perform infection surveillance for 23 of 23 residents (Resident 7, 13, 14, 20, 21, 24, 31, 42, 46, 59, 78, 90, 92, 97, 110, 132, 134, 135, 136, 762, 763, 1012, and 1013) during their COVID-19 outbreak. * The facility failed to ensure the infection control practices were maintained in the facility's laundry room area when Laundry Aide 1 was observed picking linen from the floor and then putting it in a clean laundry bin with other clean laundry. Additionally, the soiled linen carts were kept in the clean linen area touching the cover of a clean linen cart and the clean laundry bin was not covered. * Rooms A, B, and C had posted signage outside of the rooms for contact/droplet/respiratory precaution. The facility failed to ensure the doors for Rooms A, B, and C were closed. * The facility failed to ensure the staff practiced 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 interview, medical record review, and facility P&P review, the facility failed to provide the antibiotic stewardship for the residents as evidenced by: * The facility failed to monitor antibiotic use for 33 of 33 residents who were ordered antibiotics in January 2024. * The facility failed to identify Residents 20 and 100's antibiotic use did not meet McGeer's criteria to notify the physician to evaluation of the prescribed antibiotics. These failures had the potential to expose the residents to the adverse effects of unnecessary antibiotic use. Findings: Review of the facility's P&P titled Antibiotic Stewardship revised 1/2022 showed the facility must assess residents for any infection using McGeer's criteria. 1. Review of the facility's Order Listing Report for January 2024 showed 33 residents were prescribed with antibiotics and anti-infective agents. On 2/7/24 at 1309 hours, an interview was conducted with the DSD/IP. When asked how the facility provided antibiotic stewardship, the DSD/IP stated 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 interview, medical record review, and facility P&P review, the facility failed to ensure four of 33 final sampled residents (Residents 49, 61, 107, and 122) were informed in advance regarding their proposed treatments. * The facility failed to ensure the informed consent was obtained from Resident 107 before administering lorazepam (antianxiety medication) to Resident 107. * The facility failed to ensure the informed consent was obtained from Resident 49 before administering sertraline (antidepressant medication) to Resident 49. * The facility failed to ensure Resident 122's informed consent for mirtazapine (antidepressant medication) was obtained. * The facility failed to ensure Resident 61's informed consent for nortriptyline (antidepressant medication) was obtained prior to medication administration. These failures had the potential to compromise the rights of the residents or their responsible party (person designated to make decisions on behalf of the resident) to be fully informed regarding 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, medical record review, and facility P&P review, the facility failed to ensure one of 33 final sampled residents (Resident 24) was assessed to safely self-administer the medications prior to performing the self-administration of medications. This failure had the potential to negatively impact the resident's physiological well-being and could administer the medications inaccurately. Findings: Review of the facility's P&P titled Care and Treatment, Self Administration of Medications revised 5/2019 showed the purpose of the policy is to determine the ability of alert residents to participate in self-administration of medication and maintain the safety and accuracy of medication administration. The policy also showed if a resident desires to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on change in the resident's status with the LN-Self Administration of Medication UDA. During the initial tour 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to provide privacy to six of 33 final sampled residents (Residents 1, 12, 61, 128, 131, and 133) and one nonsampled resident (Resident 963). * The facility failed to provide privacy by closing the curtains while applying the topical medication patch to Resident 12's right hip. * The facility failed to provide privacy by closing the curtains while administering the medications via GT for Resident 61. * The facility failed to provide privacy when providing wound care to Resident 128. * The facility failed to ensure Residents 1, 131, and 133 were provided a dignity bag for their indwelling urinary catheter drainage bag as per the facility's P&P. * The facility failed to ensure Resident 963's laboratory results were safeguarded to protect the resident's confidential health information. These failures had the potential for the residents to be exposed to the public view and negatively impact the residents' psychosocial wellbeing, right 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, medical record review, facility document review, and facility P&P review, the facility failed to maintain a clean, sanitary, and homelike environment for five of 33 final sampled residents (Residents 19, 61, 116, 122, and 128) and one nonsampled resident (Resident 74). * Resident 61's window was missing four blind slats and had three broken blind slats * Resident 122's room was observed with cracks and paint peeling on the ceiling * The facility failed to assess Resident 128's living condition for sanitary and homelike environment, as the bathtub and showerhead were observed with presence of rusty stain and calcium deposits. * The facility failed to ensure there were adequate washcloths to be used for Resident 19 in the facility during care. * The facility failed to ensure the resident's restroom was clean and free from bodily fluids on the bathroom floor for Resident 74. * The facility failed to ensure Resident 116 had adequate towels. These failures placed the residents at risk…

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, facility document review, and facility P&P review, the facility failed to ensure the information on how to file a grievance was provided to one of 33 final sampled residents (Resident 116) and one nonsampled residents (Resident 153). This failure posed the risk for the residents grievances not being addressed and resolved timely. Findings: Review of the facility's P&P titled Grievances revised December 2023 showed the information is made available to the resident and/or representative and posted in designated locations throughout the facility. Information includes the resident or resident representative have the right to file a grievance orally, in writing and/or anonymously, contact information of the facility grievance office to include name, business and email address, phone number, and reasonable expected time frame for completing review of the grievance. Review of the medical records for Residents 116 and 153 was initiated on 2/4/23. The medical records showed the following:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the residents or the residents' representative were provided written or verbal notice of the facility's bed hold (holding or reserving a resident's bed while the resident in the acute care hospital) policy upon transfer to the acute care hospital for one of 33 final sampled residents (Resident 29) and one closed record sample resident (Resident 152). This failure had the potential for the residents and the residents' representative to be unaware of their rights to return to the facility following a hospitalization. Findings: Review of the facility's P&P titled Admission/Discharge/ Transfer, Bed Hold revised 11/2016 showed it is the facility's policy to inform the resident, or the resident's representative, in writing, of the right to exercise the bed hold provision of seven days, upon admission and before transfer to a general acute hospital or before the resident goes on therapeutic leave. 1. Medical 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, and facility P&P review, the facility failed to ensure the recommendations from the Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) level II determination was followed up and incorporated into the resident care for one of 33 final sampled residents (Resident 99). This failure had the potential for Resident 99 not receiving the adequate care that was recommended by PASARR level II determination and evaluation report assessed by a appropriate state-designated authority. Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised January 2022 showed the facility IDT will develop and implement a comprehensive person centered care plan for each resident within seven days of completion of the resident minimum data set and will include resident needs identified in the comprehensive assessment, any specialized…

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, medical record review, and facility P&P review, the facility failed to ensure the baseline care plan for one of 33 final sampled residents (Resident 133) were initiated upon admission. * The facility failed to ensure Resident 133's baseline care plan included the necessary information to properly care for the resident with the history of fluctuating weights, necessary nutritional interventions to maintain or prevent further weight loss, and individualized activity care plan to appropriate for the resident. This failure had the potential for Resident 133 not receiving necessary resident-centered care. Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning dated November 2016 showed within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care. The baseline care plan will include the minimum healthcare information necessary to properly…

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, medical record review, and facility P&P review, the facility failed to ensure the care plans for two of 33 final sampled residents (Residents 133 and 812) were developed to address the residents' activities. * The facility failed to ensure Resident 133 and 812's care plans included the individualized activity care plans to provide the appropriate activities for the residents. This failure posed the risk for Residents 133 and 812 not receiving the necessary resident-centered care. Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning dated November 2016 showed within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care. The baseline care plan will include the minimum healthcare information necessary to properly care for a resident including, but not limited to: a) Initial goals based on admission orders, b) Physician orders, c)…

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, medical record review, and facility P&P review, the facility failed to provide the services to attain or maintain the highest practicable well-being for five of 33 final sampled residents (Residents 12, 31, 107, 105, and 1012) and one nonsampled resident (Resident 39). * The facility failed to ensure the systolic blood pressure and heart rate for Resident 107 were monitored before administering carvedilol (anihypertensive medication) medication as per the physician's order. * The facility failed to ensure the systolic blood pressure and heart rate for Resident 105 were monitored before administering amlodipine (antihypertensive medication) hydralazine (antihypertensive medication) medications as per the physician's order. * The facility failed to ensure the injection sites for lantus (insulin) administration for Resident 12 were rotated as per the physician's order. * The facility failed to ensure a Change in Condition was completed for Residents 31 and 1012 when the residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review the facility failed to provide the necessary care and services related to pressure injury for two of 33 final sampled residents (Residents 61 and 94). * The facility failed to ensure the bilateral heel protectors were provided as ordered by the physician for Residents 61 and 94. This failure posed the risk for skin breakdown for these residents. Findings: Review of the facility's P&P titled Skin and Wound Monitoring and Management revised 12/2023 showed it is the policy of this facility that a resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. 1. Medical record review for Resident 61 was initiated on 2/4/24. Resident 61 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 61's Order Summary Report showed a physician's order dated 5/5/23, for bilateral heel protectors, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure the adequate assistance and supervision were provided for two of 33 sampled residents (Residents 49 and 122). * The facility failed to ensure a portable space heater was not plugged in Resident 49's room at bedside. This failure provide an accident hazard for the resident and the facility in case of malfunction, and fire. * The facility failed to ensure Resident 122's tab alarm was attached to the resident. Furthermore, the facility failed to obtain directions for the use of the tab alarm. These failures had the potential to negatively impact the residents' well-being and increase the risk of the residents for more accidents which may result in further injuries. 1. On 2/4/24 at 0824 hours, during the initial facility tour, an observation and concurrent interview was conducted with Resident 49. A portable space heater was observed plugged directly into an outlet…

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, medical record review, and facility P&P review, the facility failed to ensure one of 33 final sampled residents (Resident 12)'s hydration needs were met. * The facility failed to monitor Resident 12's intake and output as per the physician's order. This failure had the potiential to negatively affect the resident's health and well-being. Findings: Review of the facility's P&P titled Intake and Output Documentation revised 6/2023 showed it is the policy of the facility to maintain a measurement of a resident's intake and output to assess fluid balance when indicated by the resident's clinical condition if ordered by the physician. This shall be reviewed and monitored by the license nurse. Measure and record all liquids taken by the resident on intake and output monitoring. Records of enteral and IV intake may be recorded on the MAR or electronic MAR in lieu of the intake and output record. Medical record review for Resident 12 was initiated on 2/4/24. Resident 12 was readmitted 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, medical record review, and facility P&P review, the facility failed to provide the necessary enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) care and services were provided to two of 33 final sampled residents (Residents 29 and 110). * The facility failed to ensure Resident 29's enteral syringe was labeled and dated. * The facility failed to ensure Resident 110's enteral syringe was changed daily as per the facility's policy. These failures posed the risk for complications related to the use of the enteral feeding for Residents 29 and 110. Findings: Review of the facility's P&P titled Medical Equipment, Storage, Labeling, Cleaning and Disinfecting revised 5/2020 showed it is the facility's policy to provide areas, equipment, and supplies to implement its Infection Control Program. The policy also showed enteral syringes are changed daily and as needed. 1. During the initial tour of the facility on 2/4/24 at 1031 hours, an observation was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one of 33 final sampled residents (Resident 105) and one nonsampled resident (Resident 814). * The facility failed to ensure Resident 105's midline catheter was assessed upon admission and weekly. In addition, Resident 105's midline catheter dressing was unlabeled and undated. * The facility failed to follow the physician's orders for flushing of the intravenous catheter before medication administration for Resident 814. These failures had the potential to delay identification of catheter related complications for the residents, an increased risk of potential drug incompatibility and lacking assessment of IV line patency prior to medication administration. Findings: According to Taylor's Fundamentals of Nursing, seventh edition, midline catheters are inserted peripherally, normally just above or below the antecubital fossa…

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, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for six of 33 final sampled residents (Residents 19, 29, 61, 107, 110, and 128) and six nonsampled residents (100, 134, 156, 162, 662, and 762). This failure posed the risk for residents' safety and respiratory related complications including infection. * The facility failed to obtain the physician's order for oxygen therapy for Residents 107 and 128. * The facility failed to ensure Resident 19's BiPap was stored properly and not hanging on the wall. * The facility failed to provide oxygen therapy as per the physician's order for Resident 662. * The faclity failed to ensure the nebulizer machine was not on the floor for Resident 134. * The facility failed to ensure the nebulizer mask and tubing were changed weekly and dated for Residents 29 and 156. * The facility failed to ensure the CPAP was being cleaned, the set up bag was dated, and the CPAP mask with tubing…

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 medical record review, the facility failed to offer or provide adequate and appropriate pain management for one of 33 final sampled residents (Resident 34). * The facility failed to administer pain medication for Resident 34 after a fall on 1/26/24. This failure had the potential to cause the resident unnecessary pain and complications from worsened pain. Findings: On 2/4/24 at 1343 hours, during the initial tour of the facility, an interview was conducted with Resident 34. Resident 34 stated she had not been administered pain medication when she had a fall. When asked to elaborate, Resident 34 stated she had a horrible pain on her left ankle from a slow fall about two weeks ago. Resident 34 stated she was okay now, but it had a psychological effect on her, and she did not want to see the CNA who was assigned to her again. Medical record review for Resident 34 was initiated on 2/4/24. Resident 34 was readmitted to the facility on [DATE]. Review of Resident 34's MDS dated…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to attain the highest physical wellbeing for four of 33 final sampled residents (Residents 42, 107, 128, and 812) who required dialysis. * The facility failed to ensure Residents 812's pre dialysis assessment (access site, vital signs, time of last meal, blood sugar, lung sound assessment, LOC, Covid-19 signs, and symptoms), dialysis center assessment and post dialysis assessment (dressing in place, bleeding on site, SOB, assessment of dialysis site, signs and symptoms of infection to access site, vital signs, and Covid-19 signs and symptoms) were completed. * The facility failed to perform the post dialysis treatment assessment and ensure the dialysis communication forms for Resident 128 were completed. * The facility failed to consistently monitor Resident 107's weight and dialysis access site for pre and post-dialysis. In addition, 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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of 33 final sampled residents (Residents 12 and 89). * The facility failed to obtain the consent for 1/2 side rails for Resident 12 as per the physician's order. In addition, the facility failed to ensure the bed assessment was correct to reflect Resident 12's bariatric bed. These failures had the potential to put the residents at risk for serious injuries from side rail use. Findings: Review of the facility's P&P titled Bed Rails revised 12/2023 showed the following: - After the facility has attempted alternatives to bedrails and determined that these alternatives failed to meet the resident's assessed needs, the facility IDT will assess the resident for risks of entrapment. The risks and benefits regarding the use of bed rails will be considered for each resident; - If the use of bedrails is recommended by the IDT, the facility must obtain informed consent from…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the residents' needs for two of 33 final sampled residents (Residents 24 and 42) and two nonsampled residents (Residents 162 and 814). In addition, the facility failed to ensure the controlled medication was accurately reconciled. * The facility failed to ensure Residents 24 and 42's scheduled medications were administered within 60 minutes of scheduled time per the facility's P&P. * The facility failed to ensure accurate documentation of the controlled medications to one nonsampled resident (Resident 162) for hydrocodone-acetaminophen 5-325 mg (narcotic pain medication). * The facility failed to ensure the prefilled normal saline syringe for Resident 814 was not left unattended on the medication cart. These failures had the potential to negatively affect the residents' health and drug diversion. Findings: Review of the facility's P&P titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for two of 33 final sampled residents (Residents 19 and 107). * The facility failed to follow-up on the Pharmacy Consultant recommendation to place hold parameters for minoxidil (a vasodilator used to treat high blood pressure) medication for Resident 107. * The facility failed to follow-up on the Pharmacy Consultant recommendation to place blood glucose hold parameters for glargine (a synthetic version of human insulin) medication for Resident 19. These failures had the potential to put the residents at risk for adverse consequences related to the medications. Findings: 1. Medical record review for Resident 19 was initiated on 2/4/24. Resident 19 was readmitted to the facility on [DATE]. Review of Resident 19's Order Summary Report showed a physician's orders dated 11/25/22, to administer insulin glargine 18 units subcutaneously two times a day 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 observation, interview, and medical record review, the facility failed to ensure one of 33 final sampled residents (Resident 12) was free from the unnecessary drugs. * Resident 12 was administered midodrine (medication to treat low blood pressure) when Resident 12's blood pressure was above the parameter prescribed by the physicians. This failure had the potential for Resident 12 to develop significant side effects such as hypertension (high blood pressure). Findings: Medical record review for Resident 12 was initiated on 2/4/24. Resident 12 was readmitted to the facility on [DATE]. Review of Resident 12's Order Summary Report showed a physician's order dated 1/4/23, to administer midodrine 10 mg one tablet by mouth three times a day for hypertension, and to hold of systolic blood pressure above 130 mmHg. Review of Resident 12's MARs for January and February 2024 showed Resident 12 was administered the midodrine medication when the resident's systolic blood pressure was above 130 mmHg as follows: - On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure three of 33 final sampled residents (Residents 21, 34, and 49) were free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior) as evidenced by: * The facility failed to ensure the PRN orders for lorazepam (antianxiety) and temazepam (hypnotic) medications were limited to 14 days. There was no documented evidence explaining why the PRN orders were extended beyond the 14 days. This failure had the potential for the resident to have adverse complications from the medications. * The facility failed to ensure the physician's order for Lexapro (antidepressant medication) included a specific behavior manifestation for Resident 34. In addition, the facility failed to complete the psychotropic summary sheets to monitor the number of behavioral episodes related to the use of Lexapro medication for Resident 34. * The facility failed to ensure 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, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 12.82%. Three licensed nurses (LVNs 8, 12, and 17) were found to have made errors during the medication administration for two of 33 final sampled residents (Residents 12 and 61) and one nonsampled resident (Resident 62). * LVN 8 failed to administer the Cholecalciferol Tablet and multivitamin with minerals for Resident 61. * LVN 17 failed to properly administer omeprazole (a medication used to treat gastroesophageal reflux disease (GERD) to suppress stomach acid secretions) for Resident 12. * LVN 12 failed to properly administer the eye drops for Resident 62. These failures had the potential to negatively affect the residents' health conditions. Findings: Review of the facility's P&P titled Preparation and General Guidelines-Medication Administration-General Guidelines dated 10/2019 showed medications are administered in accordance with written orders of the attending physician. 1. 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.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure six of 149 residents who received meals in the facility were provided the correct amount of gravy as directed by the Cook's Spreadsheet. This failure had the potential to provide the residents who received meals in the facility with incorrect nutrients. Findings: Review of the facility's P&P, Menu Planning dated 2023 showed the facility's registered dietitian must sign and date spreadsheets when changes are made. Review of the facility form, Cook's Spreadsheet - Winter Menus dated 2/5/24, showed the lunch meal included one ounce of Cream Gravy to be served over the residents' patty and potatoes. One ounce of Cream Gravy was indicated for regular and therapeutic diets. Review of the facility's Diet Type Report dated 2/6/24, showed 149 residents received meals from the facility. The report showed 36 of 149 residents were on a fortified diet. On 2/5/24 at 1200 hours, an observation of the resident lunch tray line and concurrent interview with the RD was conducted. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to provide the food preference for two of 33 final sampled Residents (Residents 3 and 26). This failure had the potential for inadequate nutrition. Findings: Review of the facility's P&P titled Food Preferences dated 2023 showed the resident's food preferences will be adhered to within reason. Substitutes for all food disliked will be given from the appropriated food group. 1. Medical record review for Resident 3 was initiated on 2/4/24. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 3's care plan dated 12/7/23, addressing nutritional problem or potential nutritional problem showed the interventions included to honor the resident rights to make personal dietary choices and provide dietary education as needed. Review of Resident 3's diet orders dated 2/4/24, for breakfast and 2/6/24, for lunch showed Resident 3 disliked eggs and salads. On 2/4/24 at 0800 hours, a concurrent…

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, medical record review, and facility P&P review, the facility failed to ensure proper sanitation was maintained for food prepared by the kitchen when: * The Assistant Director of Dietary Services/Cook 2 (Assistant DDS/Cook 2) failed to perform hand hygiene while preparing pureed food from the kitchen. * The facility failed to ensure Resident 762's dessert was stored and prepared under sanitary conditions when their pumpkin dessert was not covered or wrapped on the resident's meal tray while being transported by the staff to the resident's room. * The facility failed to ensure Resident 1's two bags of chips, five bottles of coke and disposable drinking cups were properly stored. These failures had the potential to cause foodborne illnesses and spread of infection. Findings: Review of the facility's P&P titled Food Preparation dated 2023 showed the facility must not use cleaning products or sanitizer in the food preparation areas, including spraying or pouring products near food items during preparation or cooking. Review of the facility's P&P titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure accurate and complete medical records for two sampled residents (Residents 61 and 94) and one closed record sample resident (Resident 152). * Resident 61's physician's order was not consistent with the resident's condition. * The facility failed to ensure the discharge documentation was completed for Resident 152. * The facility failed to ensure the TAR was completed to show the treatment was administered for Resident 94. These failures had the potential to result in medication error and delay of care administration; and potential for lack of follow up. Findings: 1. On /7/24 at 1300 hours, medical record review was intiated for Resident 61. Resident 61 was admitted to the facility on [DATE]. Review of the physician's order dated 1/12/24, and MAR for January and February 2024 showed an order for Nortryptiline HCL oral capsule 10 mg one capsule by mouth one time a day for depression manifested by sad facial expression. However, further…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the coordination of hospice services for one of 33 final sampled residents (Resident 32). * The facility failed to ensure Resident 32 had hospice visitation calendar projection for each month showing the scheduled visits of the hospice's staff. There was no coordination regarding the care plan. This failure had the potential for not providing the timely, appropriate, and consistent care to Resident 32. Findings: Review of the facility's P&P titled End of Life Care: Hospice and/or Palliative Care dated 1/2022 showed a care plan will be developed based on the individualized assessments, the desire of the resident/surrogate decision maker, and the physician's orders. Hospice services will be offered as appropriate and as ordered by the physician. These services will be integrated into the overall individualized, interdisciplinary care plan. Collaboration with the Hospice will include processes…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were completed for two of 33 final sampled residents (Resident 12 and 34). This failure had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are…

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, medical record review, and facility P&P review, the facility failed to ensure the call lights for 10 of 29 sampled residents (Residents 2, 3, 4, 7, 8, 11, 12, 24, 25, and 26) were answered promptly. In addition, the facility failed to ensure Residents 2, 4, and 7 ' s call lights were within the resident ' s reach. These failures had the potential for the residents to not get their needs met timely. Findings: Review of the facility ' s P&P titled Call Light/Bell (undated) showed to answer the light/bell within a reasonable time, respond to the resident ' s request, and leave the resident comfortable. 1. On 1/9/24 at 0919 hours, an interview was conducted with Resident 11. Resident 11 stated the facility seemed understaffed with CNAs and they were given too many residents to take care of. Resident 11 stated every time she turned on her call light, she would have to also call the facility ' s main telephone lineto have someone callfor a CNA to assist her. On 1/9/24 at 1607 hours, 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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure eight of 29 sampled residents (Residents 1, 3, 6, 8, 9, 10, 13, and 22) and one nonsampled resident (Resident B) attained and maintained their highest practicable and physical well-being. * The facility failed to provide the appropriate and necessary nursing services to ensure Resident 13 received daily wound treatments for his diabetic foot ulcer (a wound complication of diabetes which can cause bone infection and amputations) as per the physician's orders. In addition, the facility failed to evaluate Resident 13's skin upon admission and failed to implement weekly skin assessments as per the facility P&P. The facility additionally failed to ensure Resident 13's admission assessments were completed upon his admission to the facility. * The facility failed to ensure Resident B's readmission assessments and admission consents were completed upon her readmission…

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 facility document review, the facility failed to ensure adequate 24-hour staffing was maintained to meet the residents' care needs. This failure had the potential to result in the residents not being provided with care consistent with professional standards of practice and care as outlined in their person-centered plans of care. * The facility failed to have adequate licensed nurses to administer the scheduled medications at 2100 hours on 1/9/24, for Residents 8, 9,and 10. * The facility failed to have adequate licensed nurses to provide the wound care to Residents 13, 14, and 15. * The facility failed to have adequate staff to ensure the care was provided timely to the residents on 1/9/24. These failures placed the residents at risk for adverse outcomes. Findings: Review of the facility's Facility Assessment, Part 3: Facility Resources Needed to Provide Competent Support and Care for out Resident Population Everyday and During Emergencies, showed the following nursing staffing plan: -…

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 medical record review, the facility failed to ensure one of 29 sampled residents (Resident 3) was provided the right to self-determination and communication regarding the changes of Resident 3 ' s Social Security Income (provides monthly payments to people with disabilities and older adults who have little or no income or resources) collection. This failure had the potential to affect Resident 3 ' s quality of life. Findings: Medical record review for Resident 3 was initiated on 1/9/24. Resident 3 was admitted on [DATE], and readmitted to the facility on [DATE]. Review of Resident 3 ' s History and Physical examination dated 10/25/23, showed Resident 3 had the capacity to understand and make decisions. Review of Resident 3 ' s MDS dated [DATE], showed Resident 3 was cognitively intact. On 1/9/24 at 0920 hours, an observation and concurrentinterview were conducted with Resident 3. Resident 3 was observed in her room, awake, lying in her bed. Resident 3 stated she had been…

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, medical record review, and facility P&P review, the facility failed to ensure the Physician Orders for Life Sustaining Treatment (POLST) and advance directives information were accurate for four of 29 sampled residents (Residents 1, 2, 3, and 22) and one nonsampled resident (Resident B). These failures had the potential for the facility to provide treatment and services against the resident's wishes. Findings: Review of the facility's P&P titled Advance Directives revised 11/2019 showed the facility will be utilizing the POLST form for the residents with the capacity to make decisions and legal representatives to communicate their choices of medical interventions and procedures and end-of-life decisions if they wish to formulate an Advance Directive. Should the Resident indicate that he or she has issued advance directives about his/her care and treatment, the facility will require that a copy of such directives be included in the medical record. 1.a. Closed medical record review was…

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

Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the comfortable temperatures for six of 80 resident rooms (Rooms A, B, C, D, E, and F) housing 12 residents (Residents 2, 4, 17, 18, 23, 25, 27, E, F, G, H, and I). This failure had the potential for negatively affect the residents' health and well-being. Findings: Review of the facility's P&P titled Comfortable & Safe Air Temperature Levels revised 1/1/24, showed it is the policy of this facility to monitor, measure ambient air temperature and make sure the ambient temperature is comfortable and at a safe level, to minimize resident's susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailment. It will be the responsibility of the maintenance staff to monitor the ambient temperature of the resident's room and residents occupied area. Any temperatures that record below 71 degrees F (Fahrenheit) or exceed the upper range of 81 degrees F, the HVAC (heating, ventilation, and air conditioning) system will be adjusted to meet 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 interview, medical record review, and facility P&P review, the facility failed to ensure the safe and appropriate discharge when one of 29 sampled residents (Resident 1) was discharged to another skilled nursing facility approximately 36.5 miles away. * The facility failed to ensure Resident 1 met the facility's criteria for discharge according to the facility's P&P. * The facility failed to document Resident 1's transfer information in the medical record. * The facility failed to ensure appropriate information was communicated to SNF 2 prior to the transfer of Resident 1. These failures had the potential of miscommunication of information, unsafe discharge, and not providing necessary care and services to the resident. Findings: Review of the facility's P&P titled Criteria for Transfer and Discharge revised 11/2016 showed it is the policy of this facility that each resident will remain in the facility, and not be transferred or discharged unless the discharge or transfer is appropriate as per 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 interview and medical record review, the facility failed to notify one of 29 sampled residents (Resident 1) and their representative of their transfer/discharge and the reasons for the move in writing. In addition, the facility failed to send a copy of the transfer/discharge to the representative of the Office of the State Long-Term Care Ombudsman (a person who routinely visits the facility and advocated for the residents). These failures resulted in Resident 1 and the representative to be not aware of the discharge. Findings: Closed medical record review was initiated for Resident 1 on 1/9/24. Resident 1 was readmitted to the facility on [DATE], and discharged to SNF 2 on 4/11/23. Review of Resident 1's Order Summary Report, dated 1/9/24, showed a physician's order dated 4/11/23, to transfer to SNF 2 on 4/11/23. Review of Resident 1's Progress Notes (written by RN 7) dated 4/11/23, showed Resident 1 was discharged to another facility (SNF 2) at 1620 hours. The Progress Notes also showed Resident 1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide and document sufficient orientation and preparation to ensure the safe and orderly discharge for one of 29 sampled residents (Resident 1) prior to Resident 1's discharge to another healthcare facility, SNF 2. This failure resulted in Resident 1 and his responsible party of not having the necessary information for a safe and orderly discharge. Findings: Closed medical record review was initiated for Resident 1 on 1/9/24. Resident 1 was readmitted to the facility on [DATE], and discharged to SNF 2 on 4/11/23. Review of Resident 1's Order Summary Report dated 1/9/24, showed a physician's order dated 4/11/23, to transfer to SNF 2 on 4/11/23. Review of Resident 1's Progress Notes (written by RN 7) dated 4/11/23, showed Resident 1 was discharged to another facility (SNF 2) at 1620 hours. The Progress Notes also showed Resident 1 was picked up by transportation and a report was given to a nurse on duty. Further review of Resident 1's closed…

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 medical record review, the facility failed to ensure the comprehensive plans of care for two of 29 sampled residents (Residents 1 and 17) were revised to reflect the resident's current care needs and interventions. * Resident 1's plan of care was not updated to include all the fall interventions recommended by the IDT. * Resident 17's plan of care failed to show a care plan problem addressing the use of Seroquel. These failures posed the risk of not providing the residents with individualized and person-centered care. Findings: 1. Review of the facility's P&P titled Fall Management System (undated) showed it is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Review of the fall incident will include investigation to determine probably causal factors considering environmental factors, resident medical condition, resident behavioral manifestations, and medical of assistive…

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 medical record review, the facility failed to develop the discharge plan for one of 29 sampled residents (Resident 1) when Resident 1 was discharged to another healthcare facility, SNF 2. Subsequently, Resident 1 was discharged to another skilled nursing facility approximately 36.5 miles away. This failure had the potential to negatively impact the resident's well-being. Findings: On 1/4/24 at 1538 hours, a telephone interview was conducted with Resident 1's responsible party (Responsible Party 1). Responsible Party 1 stated Resident 1 had lewy body dementia (disease which leads to problems with thinking, movement, behavior, and mood) and stated Resident 1 was an exit seeker and ambulatory. Responsible Party 1 stated the facility did not discuss a plan to indicate Resident 1 was going to another facility with her. Closed medical record review was initiated for Resident 1 on 1/9/24. Resident 1 was readmitted to the facility on [DATE], and discharged to SNF 2 on 4/11/23. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medial record review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure injuries for three of 29 sampled residents (Residents 14, 15, and 24). * The facility failed to provide the appropriate and necessary nursing services to ensure Resident 14 received daily wound treatments for his Stage 4 pressure injury (a wound caused by pressure which results in tissue loss with exposed bone, tendon, or muscle) as per the physician's orders. * The facility failed to ensure Resident 15 received daily wound treatments for his Stage 4 pressure injury as per the physician's orders. * Resident 24 had a physician's order for a low air loss mattress (a special mattress designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown); however, Resident 24 was observed on a regular mattress on multiple occasions. These failures had the potential for the residents to not…

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, medical record review, and facility P&P review, the facility failed to ensure three of 29 sampled residents (Residents 19, 20, and 21) remained free from accident hazards. * The facility failed to update a care plan to address the fall sustained by Resident 20 on 1/6/24, and Resident 21 on 12/15/23. * The facility failed to ensure the IDT had met and discussed the factors that lead to the fall and the intervention on how to prevent further falls for Resident 19 who sustained a fall on 1/6/24, Resident 20 who sustained a fall on 1/6/24, and Resident 21 who sustained a fall on 12/15/23. These failures had the potential for the residents to sustain additional falls and possible injuries. Findings: Review of the facility's P&P titled Nursing Administration, Section Continuum of Care, Subject Fall Prevention revised 8/2020 showed the following: a. Falls are reviewed in clinical stand-up meeting after the fall. b. Residents that will be reviewed by the Fall Interdisciplinary (ID) Team will be…

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 medical record review, the facility failed to ensure the proper indwelling urinary catheter care for one of 29 sampled residents (Resident 17). * Resident 17 was observed with an indwelling urinary catheter bag on the floor and/or attached to a trash can on multiple occasions. This failure put Resident 17 at risk for infection, such as UTI. Findings: According to the CDC guidelines, the proper urinary catheter maintenance includes keeping the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. On 1/9/24 at 1000 hours, Resident 17 was observed in bed with a urinary catheter bag. The urinary drainage bag was observed hooked to the top of Resident 17's trash can and with the drainage bag touching the floor. When asked about the urinary drainage bag, Resident 17 stated he had an operation and a nephrostomy (a drainage tube inserted into the kidney used to drain urine through an opening in the skin). On 1/9/24 at 1014 hours, a concurrent…

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, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain management was provided to two of 29 sampled residents (Residents 10 and 23). * The licensed nurse failed to notify the physician regarding Resident 10's complaint of pain level more than 6 and the resident's prescribed PRN pain medications were only for the pain levels of 1-6. * The facility failed to ensure the pain medication was given as ordered by the physician. Resident 23 waited six hours to receive the next pain medication dose. These failures resulted in the residents not receiving effective pain management. 1. Medical record review for Resident 10 was initiated on 1/10/24. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's H&P examination dated 11/13/23, showed diagnoses of tremors, neuralgia, neuritis, diabetes mellitus, muscle weakness, hypertension, and hyperlipidemia. Review of Resident 10's Order Summary Report for January 2024 showed an order dated…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration, reconciliation, and disposition of all drugs to meet the needs of the residents. * The facility failed to ensure the physical inventory of controlled medications was conducted during shift change as per the facility's P&P, for one of the six medication carts (Medication Cart A). * The facility failed to ensure administration of the medications for Resident 9 and Resident D were accurately documented to ensure accurate reconciliation and prevent medication errors. These failures posed the risk for diversion and medication administration errors. Findings: 1. Review of the facility's P&P titled Controlled Substances Log Blue Book Process (undated) showed for the shift-to-shift count, the controlled medication reconciliation will occur between incoming and outgoing nursing at shift change for the physical inventory…

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, medical record review, and facility P&P review, the facility failed to ensure one of 29 sampled residents' (Resident 17) medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. * Resident 17 had a physician's order for the use of Seroquel (antipsychotic medication) for hallucinations; however, there was no monitoring of the behaviors and side effects in place. This failure had the potential for Resident 17 to receive the unnecessary psychotropic medication and/or the physician to not know the effects of the medication. Findings: Review of the facility's P&P titled Psychotropic Drug Use revised 8/2017 showed the licensed nurse shall review the classification of the drug, the appropriateness of the diagnosis, its indication/behavior monitors and related adverse effects prior to verification of admission orders with the attending physician. The SSD and/or nursing designee will be responsible 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 medical record review, the facility failed to ensure two of 29 sampled residents (Residents 8 and 9) were free from the significant medication errors. The facility failed to administer Residents 8 and 9 their scheduled medications. This failure put the Residents 8 and 9 at risk for medical complications. Findings: Review of the facility's P&P titled Preparation and General Guidelines Medication Administration-General Guidelines dated October 2016 showed the following: - The medications are administered in accordance with written orders of the attending physician. - The medications are administered are administered within (60 minutes) of scheduled time, except before and after meal orders, which are administered (based on mealtimes). Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule of the facility. - If a dose of regularly scheduled medication is withheld, refused, not available, or given at 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 observation, interview, and record review, the facility failed to ensure one of 10 sampled residents (Resident 3) who had limited mobility and ROM received the appropriate treatment and services to maintain or improve their ROM functions and prevent further decline in their ROM functions. * Resident 3 had orders for RNA services to both BUE and BLE;however, Resident 3 was not provided RNA services for the BLE since it was ordered by the OT on 5/2/23. In addition, Resident 3 had physician ' s orders for a hand surgeon consultation due to hand contracture ordered on 8/22/23; however, the order was not addressed until 12/7/23. This failure had the potential for Resident 3 to experience a decline his physical abilities. Findings: Review of the facility ' s P&P titled ROM and Contracture Prevention revised 5/2019 showed it is the policy of this facility to ensure the residents receive services, care, and equipment to assure every resident maintains and/or improves to his/her highest level of ROM 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, medical record review, and facility P&P review, the facility failed to ensure the proper side effect monitoring of blood thinner medications for one of 10sampled residents (Resident 8) and one nonsampled resident (Resident GG); and hemodialysis monitoring for Resident GG while on hemodialysis as evidenced by: * The facility failed to monitor for bleeding or bruising for Resident 8 while on the blood thinner medications. * The facility failed to monitor Resident GG for bleeding or bruising while on a blood thinner medication and hemodialysis monitoring while on hemodialysis. These failures had the potential to cause negative outcomes for the residents. Findings: Review of the facility ' s P&P titled Specific Medication Administration Procedures revised on 10/2019 showed to administer medications in a safe and effective manner and monitor for side effects or adverse drug reactions immediately after administration and throughout each shift. Review of the facility ' s P&P titled Nursing Clinical…

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 facility P&P review, the facility failed to ensure the food safety requirements were met. * The frozen foods stored in the freezer were not maintained at a temperature to keep the frozen food solid. The freezer had no thermometer to monitor food temperatures and functioning of the freezer. * The foods stored in the freezer were not dated. * The freezer was not maintained in a clean and sanitary condition. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population. Findings: Review of the facility ' s P&P titled Resident/Personal Food Storage revised 11/2019 showed food or beverage brought in from outside sources for storage in facility pantries, refrigeration units, or personal/resident room refrigeration units will be monitored by designated facility staff for food safety. Food storage areas shall be clean at all times. Outside foods brought to the residents by visitors will be stored in personal refrigerators or facility refrigerators designated for resident use. All refrigeration units will 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the medical record for two of 10 sampled residents (Residents 1 and 2) were accurate and complete. * Residents 1 and 2 ' s medical recordshad inconsistent documentation on the MAR for checking the placement and functionality of their WanderGuards (a safety bracelet with a sensor which a resident will wear. When the resident approaches a monitored door, the system with alert with a loud noise. WanderGuards are typically utilized for residents who are at risk for wandering and elopement). This failure had the potential for the staff to not have accurate and complete medical information, which could contribute to accidents and hazards associated with malfunctioning of the WanderGuards. Findings: 1. Medical record review for Resident 1 was initiated on 12/6/23. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1 ' s H&P examination, dated 11/22/23, showed Resident 1was often wandering in hallway and confused. 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 medical record review, and facility P&P review, the facility failed to maintain the infection control practiceswhen Resident 9 ' s family member was observed not wearing the PPE while inside a contact isolation room. This failure had the potential to spread the infection to the staff and residents. Findings: Review of the facility ' s P&P titled Infection Prevention – Control of Transmission of Infection revised on 5/2023 showed contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with resident or resident ' s environment. Staff can use gloves and gowns in order to prevent contamination of hands and clothing while performing high-contact resident care activities that pose the highest risk for MDRO transmission. Furthermore, the P&P showed the facility will implement a system to alert staff, residents and visitors that a resident is on transmission-based precautions. Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the care needs for one of five sampled residents (Resident 1). * The facility failed to ensure Resident 1's call light was kept within sight and reach. This failure had the potential to negatively impact Resident 1's psychosocial well-being or result in a delay to provide care and services to the resident. Findings: Review of the facility's P&P titled Policy/Procedure- Nursing Clinical Subject: Call Light/Bell (undated) showed to leave the resident comfortable and place the call device within resident's reach before leaving room. During the initial facility tour on 11/29/23 at 0956 hours, Resident 1 was observed lying in bed. Resident 1's call light was observed on the floor under Resident 1's bed headboard. Resident 1 stated he was not able to see or reach his call light button if the call light button was on the floor. Medical record review for Resident 1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the medical record for one of five sampled residents (Resident 5) was accurate and complete. * The facility's licensed nurse failed to document a summarization of Resident 5's change of condition event, interventions provided after Resident 5 had experienced signs of unresponsiveness, and if the medical information of Resident 5 was reported to the receiving acute care hospital. This failure had the potential for medical information for Resident 5 to be inaccurate and incomplete. Findings: Closed medical record review for Resident 5 was initiated on 11/30/23. The closed medical record showed Resident 5 was admitted to the facility on [DATE], and transferred to the acute care hospital on [DATE]. Review of Resident 5's eInteract Change in Condition Evaluation dated 11/24/23, showed Resident 5's physician recommended to send Resident 5 to the ER for signs of unresponsiveness. Further closed medical record review for Resident 5 did not show…

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, medical record review, and facility document review, the facility failed to ensure the Long-Term Care Ombudsman (a person who routinely visits the facility and advocated for the residents) was notified of the discharge for four of 18 closed record sampled residents (Residents 15, 16, 17, and 18). This failure had the potential of not providing the residents with access to an advocate who could inform them of their options and rights related to discharge. Findings: Review of the facility's document titled Admission/Discharge To/From Reports dated 2/1/23 to 9/29/23, showed the following: - Resident 15 was transferred to the acute care hospital on 6/15/23. - Resident 16 was transferred to the acute care hospital on 3/15/23. - Resident 17 was transferred to the acute care hospital on 3/17/23. - Resident 18 was transferred to the acute care hospital on 8/1/23. 1. Closed medical record review for Resident 15 was initiated on 10/12/23. Resident 15 was admitted to the facility on [DATE], 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, medical record review, and facility P&P review, the facility failed to ensure the resident or the resident's representative was provided written or verbal notice of the facility's bed hold policy upon transfer to the acute care hospital for one of 18 sampled residents (Resident 4). This failure had the potential for the resident or the resident's representative to not being aware of their rights to return to the facility following a hospitalization. Findings: Review of the facility's P&P titled Admission/Discharge/Transfer, Bed Hold revised 11/2016, showed it is the facility's policy to inform the resident, or the resident's representative, in writing, of the right to exercise the bed hold provision of seven days, upon admission and before transfer to a general acute hospital or before the resident goes on therapeutic leave. Further review of the policy showed a copy of this notification shall become a part of the resident's health record at the time of transfer. On 9/2/23 at 1013 hours, 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, medical record review, and facility P&P review, the facility failed to ensure the medications were administered as ordered by the physician for three of 18 sampled residents (Residents1, 2, and 3). * Resident 1's nystatin external cream (antifungal cream) doses were missed and administered six hours later than scheduled. * Resident 2's gabapentin (a medication used to treat nerve pain) doses were not administered as prescribed. * Resident 3's insulin injection (a medication used lower the level of glucose (type of sugar in the blood) doses was not administered as prescribed. These failures had the potential to result in poor health outcomes to the residents. Findings: Review of the facility's P&P titled Specific Medication Administration Procedures . Administration Procedures for all Medications dated 10/2019 showed it was the facility's policy to administer medications in a safe and effective manner. Further review of the policy showed after administration, return to cart, replace medication…

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 medical record review, the facility failed to provide the necessary respiratory care to meet the needs of one of four sampled residents (Resident 3). * The facility failed to ensure Resident 3 was assessed and monitored after Resident 3 had complained of difficulty breathing and shortness of breath (known medically as dyspnea, often described as an intense tightening in the chest, air hunger, difficulty breathing, breathlessness or a feeling of suffocation). * The facility failed to ensure Resident 3 was adequately oxygenated when she was hypoxemic (a low level of oxygen in the blood) and experienced symptoms of hypoxia (low levels of oxygen in the body tissues; symptoms may include confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin). Instead of placing Resident 3 on a high flow of supplemental oxygen when her oxygen saturation level was in the low 60% (normal level of oxygen saturation is usually 95% or higher; some people with chronic lung disease or sleep…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure one LVN (LVN 3) had the specific competencies and skill sets necessary to care for the residents' needs. The facility failed to ensure LVN 3 was competent in the administration of medications via inhalation. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Nursing Staff Competency revised January 2022 showed it is the policy of the facility to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Within 30 days of the date of hire, the nursing staff member shall complete the orientation competency assessment for the appropriate job category to meet the needs of the facility's resident population. The competency in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medicalrecord review, and facility P&P review, the facility failed to ensure one of eight sampled residents (Resident 1) was free from the accidents when the facility failed to investigate and assess Resident 1 ' s fall risk after the fall incidents. This failure put Resident 1 at risk for further accidents and injuries. Findings: Review of the facility ' s P&P titledFall Management System revised June 2028 showed after a fall incident, the facility should complete a Fall Risk Evaluation. The P&P also showed the facility ' s IDT should document the fall investigation and their recommendations. Medical record review for Resident 1 was initiated on 7/25/23. Resident 1 was admitted to the facility on [DATE], with a diagnosis of dementia and a history of falls at the facility. Review of Resident 1 ' s Change of Condition Evaluation Form and Progress Notes showed Resident 1 fell at the facility on 4/30, 5/17, 6/23, and 7/14/23. Review of Resident 1 ' s Fall Risk Assessments dated 4/30, 5/18, 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, medical record review, and facility P&P review, the facility failed to ensure the vascular access device was maintained consistently with professional standards of practice for one of eight sampled residents (Resident 7). The facility failed to perform the PICC dressing change for Resident 7 every seven days asper the facility ' s P&P. This failure posed the risk for the residents to develop complications such as vascular access devices associated complications such as device associated infection. Findings: Review of the facility ' s P&P titled Infection Control .Universal Precautions (undated) showed all central line occlusive dressings shall be changed using sterile technique every seven days or sooner if the integrity of the dressing was compromised. Medical record review for Resident 7 was initiated on 8/14/23. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7 ' s H&P examination dated 7/24/23, showed Resident 7 had the capacity to understand and make…

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 facility document review, the facility failed to implement the pharmaceutical P&P to ensure the accurate documentation when the medications were taken out of the E-Kit according to the facility ' s P&P. This failure had the potential for an E-Kit to have an insufficient amount of an emergency supply of medication available for the facility's residents. Findings: Review of the facility ' s P&P titled Medication Ordering and Receiving from Pharmacy dated September 2019 showed when an emergency or state dose of a medication is needed, the nurse unlocks the container and removes the required medications. After removing the medication, complete the emergency E-Kit slip and reseal the emergency supply. An entry is made in the emergency logbook containing all required information. Medical record review for Resident 7 was initiated on 8/14/23. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7 ' s Order Summary Report showed a physician ' s order dated 8/14/23,…

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, medical record review, and facility P&P review, the facility failed to ensure one of eight sampled residents (Resident 7) was free from the significant medication errors. * The facility failed to administer Resident 7 ' s full dose of cefazolin (medication to treat wide variety of bacterial infection) sodium as ordered by the physician. * The facility failed to ensure three doses of cefazolin sodium were administered as prescribed. These failures had the potential to increase the risk of infection for Resident 7. Findings: Review of the facility ' s P&P titled Specific Medication Administration Procedures .Administration Procedures for all Medications dated October 2019 showed it is the facility ' s policy to administer medications in a safe and effective manner. Further review of the policy showed to document administration of medications in the MAR. Review of the facility ' s P&P titled Medication Guidelines .Antibiotic Infusion Guidelines (undated) showed it is the 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.