Town & Country

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 five final sampled residents (Resident 32) reviewed for unnecessary medications was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 32's physician's orders were appropriate and properly clarified. This failure resulted in the prescriber's orders not being transcribed correctly in the resident's medical record and could have potentially lead to missed medication. Findings: Review of the facility's P&P titled Medication Orders revised 8/29/23, showed the nurse will transcribe handwritten physician's orders into the resident's electronic medical record. If necessary, the order should be clarified before the physician leaves the nursing station whenever possible. Medical record review for Resident 32 was initiated on 9/22/25. Resident 32 was admitted to the facility on [DATE]. Review of Resident 32's Order Summary Report showed a physician's order dated 9/15/25, to resume…

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 provide the necessary pharmacy services to ensure the proper storage and disposal of the drugs and biologicals. * The facility failed to ensure safe storage of the medications when LVN 9 left medications on Resident 3's bedside table during medication administration observation. * The facility failed to ensure the bubble packs containing the gabapentin (anticonvulsant) tablets for Resident 3 and zolpidem (sedative medication) tablets for Resident 21 remained intact and free from tears inside Medication Cart B. * The facility failed to ensure safe storage of the medications when LVN 3 left medications on Resident 15's bedside table during the medication administration observation. * The facility failed to ensure the opened medication package was stored properly and an expired medication was disposed of in Medication Cart C. * The facility failed to ensure the temperature for the refrigerator containing intravenous and other medications requiring refrigeration was within 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, facility document review, and facility P&P review, the facility failed to provide only food in a form designed to meet the individual needs for one of 11 residents (Resident 45) receiving soft and bite sized diet (food that are soft, tender and moist throughout but with no separate thin liquid). *Resident 45 was served breakfast with Cheerios cereal added to the resident's meal tray. This failure had the potential to result in difficulty in swallowing, chewing, decrease in food and nutrient intake, resulting in possible unintended (not planned) weight loss and choking (when food gets stuck in the airway, blocking the flow of air to the lungs).Findings: Review of the International Dysphagia Diet Standardization Initiative (IDDSI) A global initiative that developed standardized terminology and definitions for texture-modified foods and thickened liquids used for individuals with dysphagia (difficulty swallowing) and chewing) guideline website titled IDDSI dated 7/2019 the IDDSI guideline showed, Level 6 Soft and Bite Sized is eaten with a fork, spoon…

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 food preferences were honored for one nonsampled resident (Resident 17) who received food prepared in the kitchen. * The facility served pork to Resident 17 during lunch when there was a physician's order for no pork, and resident's religious preference for no pork. This failure had the potential to negatively impact the resident's food intake and well-being. Findings: Review of the facility's P&P titled Resident Dining Profile and Food Preferences revised 1/2025 showed individual food and dining preferences incorporating religious, cultural, ethics, and portion sizes are obtained from residents and/or a resident representative(s) on a regular basis. Food and dining preferences will be obtained as soon as possible but not exceeding 72 hours after admission.Resident preferences include:- dining preferences;- dislikes;- allergies;- cultural, religious, and ethnic preferences;- mealtime preferences;-…

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 residents had the ability to store and reheat food brought from outside the facility. * There was no microwave or refrigerator available to use for the residents' food brought from outside the facility to be stored or reheat. This failure had the potential to negatively impact the resident's well-being.Findings: Review of the facility's P&P titled Use of Food Brought into the Facility revised 10/1/24, showed all the food items that are already prepared by the family or visitor brought in must be for immediate consumption. On 9/23/25 at 1415 hours, an interview was conducted with LVN 9. LVN 9 stated there was no microwave or refrigerator to use for the residents' food brought from outside the facility. LVN 9 stated if a visitor brought in food from outside the facility, it must be consumed right away. The facility did not store food or reheat food. On 9/23/25 at 1430 hours, an interview was conducted with RN 2. RN 2 stated there was no microwave or refrigerator available to use for 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 implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections for one final sampled resident (Resident 7) and one nonsampled resident (Resident 96) reviewed for infection control. * The facility failed to ensure CNA 1 performed proper hand hygiene after providing incontinence and indwelling urinary catheter care to Resident 7. * The facility failed to ensure COTA 1 wore a gown when transferring Resident 96, who was on the EBP from the wheelchair to bed. These failures had the potential for cross-contamination and spread of infectious organisms throughout the facility. Findings: Review of the facility's P&P titled Hand Hygiene revised 4/21/24, showed the following: - Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; - Hand hygiene is…

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 maintain essential equipment in safe operating condition. * The facility failed to ensure two of two glucometers (a device which measures the amount of sugar in the blood) currently used and stored in Medication Carts A and B were properly calibrated. This posed the risk for inaccurate blood glucose test results used to determine the residents' insulin doses which could lead to inappropriate treatments and negatively affect the well-being of the residents. Findings: 1. Review of the EvenCare G2 Blood Glucose Monitoring System User's Guide dated 2017 showed the following: - Under Control Solution Testing section showed the purpose of the control solution testing is to make sure the EvenCare G2 meter and the EvenCare G2 test strips are working properly; - The Step 3 in performing a control solution test showed a ctl icon will appear next to the test strip and L1 will appear on the meter display screen; and - Under the Viewing Your Meter's Memory section showed control test results are flagged by ctl…

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 call light system (a communication system which are utilized by the residents to call for staff assistance) for two of two nurses stations (Nurse Stations A and B) were fully functional. * The facility failed to ensure the call light system panel console had an audible sound heard from Nurse Stations A and B. These failures had the potential for the residents in the facility not to receive assistance from the staff in a timely manner. Findings: Review of the facility's P&P titled Call lights revised 3/26/23, showed the purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow the residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Ensure the call systems alerts staff members directly or goes to a centralized staff work area. Staff members who see or hear an activated call light are responsible for responding.…

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 three sampled residents (Resident 1) was initiated upon admission. * The facility failed to ensure Resident 1's baseline care plan included the necessary information to properly care for the resident with ileostomy (a surgery that lets stool pass from your body without going through your colon or anus) and the necessary nutritional interventions to maintain or prevent weight loss of the resident. This failure had the potential for Resident 1 to not receive the necessary resident-centered care.Findings: Review of the facility's P&P titled admission of a Resident revised on 8/23/23, showed the admission process is intended to obtain all possible information regarding the resident for the development of the comprehensive plan of care, and to assist the resident in becoming comfortable in the facility. The residents are admitted to the facility under orders of the attending physician.…

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 plan was developed for one of three sampled residents (Resident 1) who had a change in condition. * The facility failed to develop a care plan when Resident 1 had nausea, vomiting, poor meal intake, and weight loss. This failure had the potential for Resident 1 to not receive the necessary care and services.Findings: Review facility's P&P titled Resident Change of Condition revised on 5/22/24, showed it is the policy of this facility that all changes in resident condition will be communicated to the physician. The nurse in charge is responsible for the notification of the physician prior to end of the assigned shift when a change in a resident's condition is noted. To document the resident change of condition and response in Nursing Progress Notes, on Twenty-Four Hour Report and update resident care plan as indicated. Closed medical record review for Resident 1 was initiated on 7/22/25. Resident 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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained the highest practicable physical well-being. The facility failed to to notify Resident 1's physician regarding the discharge instructions from the acute care hospital to provide specific fluid amount and type to the resident, and to monitor the resident's intake and output. In addition, the facility failed to notify the physician regarding the resident's weight loss of 17 pounds timely. This failure posed the risk for Resident 1 to not receive the necessary care and services timely to maintain the resident's highest physical well-being.Findings: a. Review of the facility's P&P titled admission of a Resident revised on 8/23/23, showed the admission process is intended to obtain all the possible information regarding the resident for the development of the comprehensive plan of care, and to assist 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, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen. * The facility failed to ensure the ice machine was properly cleaned. * The facility failed to ensure the ice scoopers were properly stored. * The facility failed to ensure the food items were discarded on or before the best by date. * The facility failed to ensure the food preparation utensils and equipment were in good, sanitary, and cleanable working conditions. * The facility failed to ensure the kitchen staff wore hair and beard restraint. * The facility failed to ensure the blender was free of water prior to use. * The facility failed to ensure the water liners were covered during transportation in the hallway. * The facility failed to ensure the kitchen staff performed hand hygiene. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the facility document titled Diet Type Report…

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 establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections as evidenced by: * The facility failed to ensure the contact and droplet precautions were practiced for Resident 569. * The facility failed to ensure the infection control was maintained in the laundry room. * The facility failed to show consistent and accurate documentation of its testing protocols for Legionella and other opportunistic pathogens in building water systems. These failures had the potential risk for transmission of communicable diseases or organisms to residents in the facility. Findings: 1. Review of the facility's P&P titled Transmission Based Precautions revised 10/31/22, showed the Definitions section includes the following: - Contact precautions refer to measures that are intended to prevent transmission 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 the essential kitchen equipment were in safe operating condition. * The facility failed to ensure two of two ice machines were properly cleaned as per the ice machine cleaning instruction. This failure had the potential for ice served from the kitchen to be unsanitary. Findings: Review of the facility document titled Hoshizaki Instruction Manual revised 11/2018 showed Hoshizaki provides this manual primarily to assist qualified service technicians in the installation, maintenance, and service of the appliance. Further review of the facility document showed the cleaning and sanitizing instructions in the manual included the following: - Cleaning solution: dilute 9.6 fl. oz. (0.29 L) of Hoshizaki Scale Away with 1.6 gal (6.0 L) of warm water. This is a minimum amount. Make more solution if necessary. - Sanitizing solution: dilute 2.5 fl. oz. (75 ml or 5 tbs) of 5.25% sodium hypochlorite solution (chorine bleach) with 5 gallons (19 L) of warm water. This is a minimum…

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 15. On 9/10/24 at 0911 hours, a concurrent observation and interview was conducted with Resident 37. Resident 37 was observed sitting in his wheelchair next his bed, with bilateral side rails elevated. Resident 37 stated he used the side rails to help turning himself in bed and getting out of bed. On 09/11/24 at 0806 hours, a concurrent observation and interview was conducted with Resident 37. Resident 37 stated the bilateral side rails were elevated all the time. Medical record review for Resident 37 was initiated on 9/10/24. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's H&P examination dated 7/28/24, showed Resident 37 had the capacity to understand and make decisions. Review of Resident 37's Bed Rail Assessment and Consent dated 7/26/24, showed the resident and the resident's representative requested the use of the side rails for mobility and transfer assistance and the resident's representative gave consent for the use of the side rails. However, the Bed Rail Assessment 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 one of 18 final sampled residents (Resident 43) reviewed for side rail use and unnecessary medication was provided the right to self-determination regarding the use of psychotropic medication (medications affecting brain activity) and side rails. * The facility failed to obtain the informed consent for side rail from Resident 43's responsible party when Resident 43 was deemed to not have the capacity to make medical decisions. In addition, the facility failed to ensure the informed consent was obtained from the responsible party and signed by the physician before administering alprazolam (antianxiety) medication for Resident 43. These failures posed the risk of Resident 43 and his responsible party not being informed not understanding risks and benefits of the treatments and medications. Findings: Review of the facility's P&P titled Informed Consent revised 3/1/24, showed the following: - 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.

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 obtain and maintain a copy of the advance directives (a legal document stating a person's wishes about receiving medical care if the person is no longer able to make medical decisions) for six of 18 final sampled residents (Residents 8, 37, 43, 44, 320, and 669). * The facility failed to obtain a copy of advance directives for Residents 8, 37, 43, and 669. * The facility failed to obtain a copy of advance directives for Residents 44 and 320. In addition, the facility failed to ensure the POLSTs for Residents 44 and 320 were completed. These failures had the potential for the residents' decisions regarding their healthcare and treatment options to not be honored. Findings: Review of the facility's P&P titled Advanced Directives revised date [DATE], showed in part, the facility will verify and/or modify the presence of advance directives or the resident's wishes with regard to CPR upon admission .each resident will receive…

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 document review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one of one final sampled resident reviewed for activities (Resident 43). * The facility failed to provide activities for Resident 43 to meet the resident's identified interests. The facility only provided activity program to Resident 43 on 8/8, 8/9, and 8/18/24 since his admission on [DATE]. This failure had the potential for the resident to experience feelings of social isolation and frustration. Findings: On 9/10/24 at 0904 hours, during the initial tour of the facility, Resident 43 was observed in bed, awake, and staring at the ceiling. The TV was turned off, and there was no other in-room sensory stimulation observed. On 9/11/24 at 0941 and 1326 hours, and 9/12/24 at 0801, and 1008 hours, Resident 43 was observed in bed and awake. The TV was turned off, and there was no other in-room sensory stimulation observed.…

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 services to attain or maintain the highest practicable well-being for two of 18 final sampled residents (Residents 37 and 52) and one nonsampled resident (Resident 621). * LVN 3 failed to follow the physician's order to give furosemide (medication to treat fluid retention) 30 minutes before spironolactone-hydrochlorothiazide (medication to treat high blood pressure and fluid retention) to Resident 621. * Resident 37's physician's order was not followed when the physician was not notified of Resident 37's weight changes. * The licensed nurse failed to document the resident's BP when administered the as needed BP medication to evaluate the effectiveness of medication. These failures had the potential to compromise the health and safety of these residents. Findings: Review of the facility's P&P titled Medication Administration revised 2/13/17, showed the nurse shall read and follow precautionary or…

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 accurate reconciliation and disposal of medications. * The facility failed to ensure the removed controlled medications for Resident 31 was documented in the controlled drug record. * The facility failed to ensure the discontinued controlled medication for Resident 670 was removed from the current medication supply in Medication Cart B. These failures had the potential for drug diversion of the controlled medications, and potential for medication errors. Findings: According to Taylor's Fundamentals of Nursing, Seventh Edition, under Handling Controlled Substances Safely, a record must be kept for each narcotic that is administered. Healthcare agencies provide forms for keeping such records, and these forms are kept with the narcotics. Although the forms differ, the following information usually is required: name of the resident receiving…

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 two final sampled residents (Residents 2 and 56) reviewed for unnecessary medications were free from unnecessary drugs. * The facility failed to ensure Resident 2's losartan potassium (medication used to lower high blood pressure) was administered as per the physician's ordered parameter. * The facility failed to ensure Resident 56's midodrine hydrochloride (medication used to treat low blood pressure) was administered as per the physician's ordered parameter. These failures had the potential for Residents 2 and 56 to receive unnecessary medications and develop significant side effects arising from errors in administration. Findings: 1. Medical record review for Resident 2 was initiated on 9/11/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's Order Summary Report as of 9/11/24, showed an order dated 6/27/24 to administer losartan potassium 25 mg one tablet by mouth at bedtime…

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 five final sampled residents reviewed for unnecessary medication (Resident 43) was free from unnecessary psychotropic drugs. * The facility failed to ensure the side effects were monitored for Resident 43 related to the use of alprazolam (antianxiety medication). This failure posed the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Use of Psychotropic Drugs revised date 11/13/23, showed the resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. Medical record review for Resident 43 was initiated on 9/10/24. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's Initial H&P evaluation dated 8/8/24, showed Resident 43 had no capacity to understand and make decisions. Review of Resident 43's Order Summary Report 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.

Based on observation, interview, medical record review, 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 medications. * The facility failed to ensure the orally administered medications were stored separate from externally used medications. * The facility failed to ensure disinfectant wipes were stored separately from medications and treatment supplies. * The facility failed to ensure the medication bottle was kept clean and free of sticky residue. These failure posed the risk for cross-contamination of the medications. Findings: Review of the facility's P&P titled Medication Storage dated 11/29/23, showed the following: -It is the policy of the facility to ensure all medications housed on our premises will be stored in the pharmacy and/ or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. -External products: disinfectants and drugs…

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 pureed recipes were followed for three of 77 residents who received pureed food from the kitchen. * The facility failed to ensure the puree recipes for biscuit and rice were followed. This failure had a potential for not providing nutritional meals to meet the residents' needs. Findings: Review of the facility's census on 9/10/24, showed there were 77 residents at the facility. The facility document titled Diet Type Report for September 2024 showed the kitchen provided the diets to 75 residents in the facility. Further review of the Diet Type Report showed three of 75 residents receiving food prepared from the kitchen were on pureed diet. Review of the facility's P&P titled Meal/Tray Assembly Procedures revised 1/2024 showed meal service is prompt and accurate to ensure temperatures and nutrient content of food is preserved. Procedures showed to ensure current diet spreadsheet is available and followed at each meal period, checks meals for accuracy, and tastes 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 ensure four of 75 residents (Residents 17, 26, 39, and 65) who received food from the kitchen were palatable. * The facility failed to ensure Residents 17, 26, 39, and 65 received palatable green beans during dining observation. This failure had a potential for the residents not consuming the food and may experience weight loss. Findings: Review of the facility's P&P titled Modified Texture Foods revised 1/2024 showed a standardized process for modified texture foods to meet community-approved diet guidelines and to assure palatability, flavor, texture, and nutritional value. Review of the facility's recipe titled [NAME] Beans Seasoned (Seasoned [NAME] Beans), undated, showed to steam vegetables until tender. Review of the International Dysphagia Diet Standardization Initiative (IDDSI) dated 7/2019, showed easy to chew texture is described as normal, everyday foods of soft/tender…

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 facility's P&P titled Use of Food Brought Into the Facility was updated to address the use and storage of foods brought to the residents by the family or visitors. In addition, the facility failed to ensure the visitors were educated on safe food handling of outside food. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consume food brought from outside sources. Findings: 1. Review of the CMS S&C-09-39 dated 5/29/09, showed the residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. Review of the State regulations dated 2/3/23, showed the facility must have a policy regarding use and storage of foods brought to the residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Review of the facility's P&P titled Use of Food Brought Into the Facility revised 7/2023 showed it is 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, facility document review and facility P&P review, the facility failed to remove a staff (CNA 1) from resident care areas pending an alleged violation of abuse for one of two sampled residents (Resident 1) as per the facility's P&P. This failure had the potential to expose Resident 1 to abuse. Findings: Review of the facility's P&P titled Reporting Allegations of Abuse/Neglect/Exploitation revised 10/21/22, showed under the Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation section, when thereports of abuse/neglect/exploitation occur, the following procedure will be initiated: 1. The Licensed Nurse will: a. Respond to the needs of the resident and protect him/her from further incident. b. Remove the accused employee from resident care areas. 2. The Administrator or designee will: c. Suspend the accused employee pending completion of the investigation. Review of the facility's SOC 341 (a form to report suspected abuse) dated 4/8/24, showed 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 an environment free from accident hazards for one of 17 final sampled residents (Resident 10). * The facility failed to ensure safe smoking practice for Resident 10 who smoked in the facility. Resident 10 had her smoking materials in her possession when her care plan for safe smoking included the intervention for the activity staff to keep her lighter and the facility's smoking policy showed the smoking materials were to be maintained by staff. This failure posed the risk of fire and injury to the residents and staff in the facility. Findings: Review of the facility's P&P titled Resident Smoking Policy revised 3/27/17, showed the smoking materials of residents will be maintained by staff. Review of Resident 10's medical record was initiated on 11/5/21. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 10 was cognitively intact…

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 the use of a GT for one of 17 final sampled residents (Resident 37). * The facility failed to ensure Resident 37 received the accurate amount of enteral feeding as ordered by the physician. In addition, the facility failed to accurately document Resident 37's amount of enteral feeding and water flushed via enteral pump. These failures had the potential for not meeting the resident's nutritional and hydration needs. Findings: According to the facility's P&P titled Tube Feeding,Naso-Gastric, Gastrostomy, Jejunostomy, via Enteral Pump revised on 7/8/21, showed it is the policy of the facility to properly monitor Naso-Gastric, Gastrostomy, Jejunostomy feedings to provide nourishment, administer medication, and to maintain hydration. Medical record review for Resident 37 was initiated on 11/15/21. Resident 37 was admitted to the facility on [DATE]. Review if the 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, and facility P&P review, the facility failed to provide the respiratory care needs to two of 17 final sampled residents (Residents 30 and 44). * The facility failed to ensure Resident 44's oxygen therapy titration (adjusting oxygen level) based on her oxygen saturation level (percentage of oxygen in the blood with normal levels of 95% and higher) was monitored and documented in the medical record. * The facility failed to ensure Resident 30's oxygen was administered as ordered by the physician. These failures had the potential to put the residents at risk for adverse effects of the improper care and administration of oxygen. Findings: According to the facility's P&P titled Oxygen Therapy [NAME] Oxygen revised on 5/8/2017, showed oxygen therapy is administered as ordered by the physician. The licensed nurses will set the oxygen flow rate as ordered. Documentation will include the date and time of oxygen in use, oxygen flow rate and device being use, 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, facility document review, and facility P&P review, the facility failed to ensure the licensed nurses had the specific competencies and skill sets needed to care for the residents. * The facility failed to ensure a program was in place to check the competencies and skill sets of the licensed nurses at the facility upon hiring and ongoing basis. The DSD/IP 1, IP 2, LVNs 1, and 4 failed to demonstrate how to obtain the history of the volume of feeding and water flush via the enteral pump for Resident 37. This failure had the potential to put the residents at risk for care not provided in a safe and competent manner. Findings: According to the facility's P&P titled Competency Evaluation dated 4/1/19, showed it is the policy of the facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents. Initial competency is evaluated during the orientation process. An employee remains on orientation until all competencies are verified. Subsequent and/or annual competency…

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 safe medication storage was observed in two of eight medication carts (Treatment Cart 1 and IV Cart 1). * An expired central line (catheter that is placed into a large vein) dressing kit was observed in IV (intravenous) Cart 1. * An expired tube of Remedy cream (moisture barrier cream) was observed in Treatment Cart 1. These failures had the potential for the residents to be exposed to the expired medications. Findings: According to the facility's P&P titled Storage and Expiration dating of Medications, Biologicals, Syringes and Needles, the facility should ensure that medication and biological that have expired date on the label are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 1. On 11/17/2021, at 0828 hours, during the inspection of IV Cart 1 with IP 2, a central line dressing kit with an expiration date of 10/31/21 was found in the middle drawer of the IV Cart 1. IP 2 verified the findings and stated the central line dressing kit should 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 observation, interview, and facility P&P review, the facility failed to ensure the proper infection control measures were implemented as evidenced by: * LVN 1 did not perform hand hygiene when preparing Resident 207's medications. * The facility failed to ensure aseptic technique was observed during the preparation of Resident 207's heparin (medication to prevent the formation of the blood clot) medication. LVN 1 did not disinfect the self-sealing rubber topper of the medication vial with an antimicrobial swab each time she attempted to withdraw the heparin medication. LVN 1 used the same needle and syringe multiple times to withdraw the medication from the heparin vial. These failures had the potential to result in the transmission of infection for the resident. Findings: 1. Review of the facility's P&P titled Hand Hygiene revised on 04/27/21, showed the staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. On 10/16/21 at 0853 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 interview, medical record review, and facility P&P review, the facility failed to ensure the risks and benefits of influenza vaccination were reviewed with the resident for one of 17 final sampled residents (Resident 52) when Resident 52 refused the influenza vaccine. This failure had the potential for the resident not being informed of the benefits and risks of influenza vaccination to make an informed decision. Findings: Medical record review for Resident 52 was initiated on 11/17/21. Resident 52 was admitted to the facility on [DATE]. Review of the History and Physical Examination dated 10/25/21, showed Resident 52 had the capacity to understand and make decision. Review of the Nursing admission assessment dated [DATE], showed Resident 52 refused the influenza vaccine. Further review of the medical record failed to show any documentation Resident 52 was provided education on the risks and benefits of influenza vaccine. On 11/17/21 at 1012 hours, a concurrent interview and 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.