Park View Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a resident centered care plan for one resident (Resident 1) out of four sampled residents when licensed nurse staff did not develop a care plan for Resident 1's use of a Bilevel Positive Airway Pressure (BIPAP- therapy for assisted breathing by delivering pressurized air through a mask). This failure decreased the facility's potential to provide resident centered care and ensure safety for Resident 1. Findings: A review of a facility document titled admission Record indicated Resident 1 was admitted to the facility on [DATE] with a diagnoses of Acute and Chronic Respiratory Failure with Hypercapnia (a severe condition in which the body struggles to remove carbon dioxide from the blood, leading to lung diseases), Sleep Apnea (a sleep disorder where the upper airway collapses, causing pauses with breathing) and Morbid Obesity (a severe disorder which involves too much body fat with co-existing health issues such as Sleep Apnea). A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care and services in accordance with professional standards of care for one resident (Resident 1) out of four sampled residents when: 1. A Licensed Nurse (LN) failed to notify the physician when Resident 1's Bilevel Positive Airway Pressure (BIPAP- therapy for assisted breathing by delivering pressurized air through a mask) machine became inoperable; and, 2. An LN did not notify the physician when Resident 1 was not administered an ordered medication. These failures had the potential to cause Resident 1's condition to deteriorate and complicate his clinical condition. Findings: 1. A review of a facility document titled admission Record indicated Resident 1 was admitted to the facility on [DATE] with a diagnoses of Acute and Chronic Respiratory Failure with Hypercapnia (a severe condition in which the body struggles to remove carbon dioxide from the blood, leading to lung diseases), Type 2 Diabetes (a chronic condition in which the body does 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 record review the facility failed to ensure residents were free of medication errors when one of three sampled residents (Resident 3) was not given the correct dosage of a medication, Uptravi (generic name selexipag) a medication used to treat pulmonary hypertension (high blood pressure in the arteries that carry blood from the heart to the lungs). This failure had the potential for Resident 3 to have a drug overdose causing physical problems ranging from pain, rashes, weakness, organ failure, (when organs in the body such as the heart, lungs, kidneys or liver are unable to perform their critical functions), seizures or even death. Findings: During an interview on [DATE] at 11:55 a.m., Family member of Resident 3 (Family) complained that Resident 3 was given the wrong dose of her medication several times. Family stated they gave the facility a month supply of her medication from home because the medication was not available at all pharmacies. Family stated, I found out that…

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 interviews and record reviews, the facility failed to ensure one of two sampled residents (Resident 1) received care in accordance with professional standards of practice when: 1. Resident 1 did not receive her six of her scheduled medications. 2. The physician was not notified when Resident 1 did not receive their scheduled medications. These failures could lead to worsening of condition, hospitalization, seizure (sudden burst of electrical activity in the brain) or even death. Findings: A review of Resident 1 ' s face sheet (demographics) indicated an admission date of 7/26/24 with a diagnosis of Epilepsy (a brain condition that causes recurring seizures) and Restless Leg Syndrome (RLS, a condition that causes a very strong urge to move the legs). A review of Resident 1 ' s electronic medication administration record (EMAR, electronic documentation of medications administered to a resident) with corresponding progress note dated 7/26/24 indicated the following medications where not administered as ordered because it was still awaiting for arrival: Atorvastatin (used 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, interviews and record review, the facility failed to ensure the contact enteric precaution (used when caring for residents with a suspected or confirmed infection caused by bacteria that spreads through fecal-oral transmission) on room [ROOM NUMBER] was followed when a speech therapist: 1.Did not perform hand hygiene (HH, washing hands with soap and water or using an alcohol-based hand sanitizer to prevent the spread of germs) prior to entering room [ROOM NUMBER], 2.Did not put on gloves prior to entering room [ROOM NUMBER], 3.Did not put on gown prior to entering room [ROOM NUMBER], 4.Did not wash hand with soap and water upon leaving room [ROOM NUMBER]. These failures could result to spread of infection between residents. Findings: A review of Resident 3's face sheet (demographics) indicated an admission date of 1/7/25. A review of Resident 3's Physician's Order's Summary (POS) indicated a diagnoses of Anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry…

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, and record reviews, the facility failed to ensure the rights of five (5) unsampled residents (Resident 20, Resident 55, Resident 69, Resident 76 & Resident 63) and three (3) of 24 sampled residents (Resident 3, Resident 51 & Resident 42) were honored and respected, when: 1) facility staff did not answer or respond to call lights or call for assistance, making residents wait for 20 minutes or more; 2) the facility did not follow its Smoking Policy, when Resident 42 wheeled himself across the facility's parking lot to smoke without staff supervision, and; 3) facility staff entered and exited the building using the slider doors in the residents' rooms that opened to the back patio. These failures: 1) caused Resident 20 to feel terrible after she urinated in her bed while waiting, Resident 55 to fear for the safety of his spouse/room mate when she attempted to get out of bed after waiting for a long time, Resident 69 feeling bad after soiling his bed/linen while waiting, Resident 76…

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

Based on interview and record review, the facility failed to ensure the survey binder was updated for three years, with the results of complaint and facility-reported incident investigations, and failed to ensure the residents were notified of its location. This failure resulted in the facility's residents not having access to the results of the most recent investigations completed by the Department. Findings: During a record review and concurrent interview on 5/14/24 at 2:02 p.m., review of the survey binder in the hallway outside the Administrator's office revealed there were no complaint or facility-reported incident investigation results or plans of correction added to the binder since 2021. When queried, the Director of Nursing verified there were no investigation results added to the binder since 2021. The DON stated the reason was the facility had not had any deficiencies from the Department since the survey in 2021. During a confidential Resident Council interview on 5/14/24 at 2:32 p.m., 12 out of 12 residents did not know where to find the binder with the Department'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 interview and record review, the facility did not ensure four of twenty-four sampled residents (Resident 2, Resident 3, Resident 63 & Resident 51) experienced a comfortable noise level at the facility. This finding had the potential to result in inability for the residents to rest and sleep, necessary for the body's renewal and well-being. Findings: During a concurrent interview and observation on 5/13/24 at 9:46 a.m., Resident 3 stated the noise level was too high at all times of the day and night. Resident 3 stated she had heard staff talking loudly and laughing spontaneously as late as 10:30 p.m., disturbing residents. Record review of Resident 3's MDS (Minimum Data Sheet-An assessment tool), dated 5/01/24, indicated her BIMS (Brief Interview of Mental Status-A cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 15, which indicated her cognition was intact (A score of 1-7 indicates the cognition 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 interview and record review, the facility failed to ensure the Resident Council knew how to file a grievance. This failure could potentially result in residents' issues going unresolved. Findings: During a record review on 5/13/24 at 3:12 p.m., the past four months of Resident Council Meeting Minutes were reviewed. All minutes indicated at the top, that the notes were taken by the Activities Director. Resident Council Meeting Minutes, dated 3/26/24, revealed, New Business: . The council has asked for SS (Social Services) department to attend meeting with them and go over theft and loss, grievance an [sic] other SS related question they may have and to meet the news [sic] staff in SS. Section of minutes titled, Department concerns, revealed, Social Service: R.C. (Resident Council) has invited SS to attend next meeting to go over grievances and theft and loss. Resident Council Meeting Minutes, dated 4/30/24, revealed, New Business: *SS still to meet with the resident council. During a confidential interview on 5/14/24 at 2:43 p.m., 10 out of 12 residents in attendance did 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 record review, the facility failed to ensure professional standards of practice were followed, when: 1. A Licensed Vocational Nurse (Licensed Staff A) left several medications in a resident's bedside table without a physician order, and; 2. Licensed Vocational Nurses were signing for the administration of intravenous medications they had not administered. These findings had the potential to result in inaccurate medical records, medication errors, and harm to the residents of the facility. Findings: 1. Record review indicated Resident 3 was admitted to the facility on [DATE], with medical diagnosis including Alcoholic Cirrhosis (A late stage of alcohol-related liver disease that causes the liver to become scarred, swollen, and stiff) according to the facility Face Sheet (Facility demographic). During an interview and observation on 5/13/24 at 9:46 a.m., Resident 3 was in her wheelchair, inside her room, with six cups of medications, with medications inside, sitting on top of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that three of six sampled residents (Resident 78, Resident 33 and Resident 4), who did not participate in social activities, were provided with activities of interest, and supplies to engage in these activities (For resident 78). This failure had the potential to result in boredom, depression and frustration to the residents involved. Findings: Resident 78 Record review indicated Resident 78 was admitted to the facility on [DATE], with medical diagnoses including Amyotrophic Lateral Sclerosis (A nervous system disease that weakens muscles and impacts physical function) and Dysphagia (Difficulty swallowing), according to the facility Face Sheet (Facility demographic). During multiple observations since the beginning of the survey, on 5/13/24 at 8:30 a.m., to the end of the survey on 5/17/24 at 3:30 p.m., Resident 78 was not involved in any activities at all. Resident 78 was spending every hour of every day staring at the wall, with a…

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

Based on observation, interview and record review, the facility failed to ensure the safety and functional environment in the kitchen, when cracks and missing tile on the kitchen floor were not repaired. This failure could cause dirt to build up on the floor, attracting cockroaches and rodents, and could cause trips and falls among the kitchen staff. Findings: During an initial observation in the kitchen on 5/13/24, at 8:35 AM, a sunken circular cut on the tile, with dark matter or accumulated dirt along the edges, beside the drain on the contaminated side of the dishwashing section of the kitchen, was noted. During continued observation in the kitchen on 5/13/24, at 8:37 and 8:42 AM, cracks on the floor tile, below the low temperature dishwasher and cracks on floor tiles, by the clean side of the dishwashing section of the kitchen, were noted. During a follow-up visit at the kitchen on 5/14/24, at 11:27 AM, a broken tile on the floor, by the corner of the kitchen center island near the entrance door, was noted. During an interview on 5/14/24, at 11:29 AM, the Maintenance Supervisor…

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

Based on interview and record review, the facility did not have a system to track staff compliance in mandatory trainings. This finding had the potential to result in inadequate staff competency to care for the residents, within professional standards or practice, poor quality of care, and harm to the residents of the facility. Findings: During an initial interview with the Director of Staff Development (DSD) on 5/15/24 at 3:12 p.m., she presented a binder, with the in-person training's provided to staff, within the last four months at the facility. These training's included bowel & bladder, urinary tract infections, abuse, pressure injuries, and infection control, among others. The DSD provided the staff sign-in sheets for these training's. The DSD was asked if these trainings were mandatory, to which she responded they were. Some of the sign-in sheets for specific trainings, presented to the Surveyor, included less than twenty staff signatures, while others had more than forty signatures, and Certified Nursing Assistants (CNAs) signed for the majority of these trainings. The DSD…

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

Based on interview and record review, the facility failed to notify the Long-term Care Ombudsman's office of one of three residents sampled for a closed record review, Resident 209, when he was hospitalized . This failure could potentially prevent the Ombudsman from advocating for a vulnerable resident who may require advocacy services. Findings: Review of Resident 209's medical record revealed an admit date of 2/14/24, with medical diagnoses including fracture (break) of shaft of humerus (bone of upper arm) left arm, fracture of shaft of humerus right arm, cognitive communication deficit, and muscle weakness, among others. Resident 209's Progress Notes indicated a note, dated 2/17/24 at 3:15 p.m., Swelling to [left] arm noted to be worse. Increased swelling down arm and increased warmth noted. [Patient] to be sent out. During a record review and concurrent interview on 5/16/24 at 3:37 p.m., the Medical Records Director provided Resident 209's document, Notice of Proposed Transfer / Discharge, dated 2/17/24. When queried, the Medical Records Director stated the form 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 observation, interview and record review, the facility did not ensure one (1) of twenty-four (24) sampled residents (Resident 78) and one (1) of four (4) discharged residents (Resident 209) had comprehensive care plans developed when: 1. Resident 78 did not have a comprehensive care plan for activities that reflected her admission activities assessment, and; 2. Resident 209 did not have a comprehensive care plan developed for a broken arm. These findings had the potential to result in boredom and frustration for Resident 78, for not participating in her activities of interest. For Resident 209, this finding had the potential to result in inability for staff to care for his broken arm properly, poor quality of care and harm. Findings: 1. Record review indicated Resident 78 was admitted to the facility on [DATE], with medical diagnoses including Amyotrophic Lateral Sclerosis (A nervous system disease that weakens muscles and impacts physical function) and Dysphagia (Difficulty swallowing), according to…

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

Based on interview and record review, the facility failed to accurately assess the fall risk of one of three residents sampled for closed record review (Resident 209). This failure could have potentially contributed to Resident 209 falling when his risk level was inaccurate. Finding: During a record review on 5/15/24 at 12:53 p.m., Resident 209's face sheet indicated an admission date of 2/14/24, with medical diagnoses including fracture (break) of shaft of humerus (bone of upper arm) left arm, fracture of shaft of humerus right arm, cognitive communication deficit, and muscle weakness, among others. Resident 209's physician history of present illness note, from his Emergency Department visit on 2/14/24 (prior to his admission), indicated Resident 209 had a right fractured arm in a sling from a fall in January 2024. Review of Resident 209's care plan revealed he did not have a care plan for the fractured arm. Resident 209's admission assessment, dated 2/14/24, did not include the sling or mention the arm fracture. Resident 209's falls risk assessment, dated 2/14/24, indicated he 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 and record review, the facility failed to follow its Nursing Staff Competency Policy, Facility Assessment Policy and Resident rights Policy, for one sampled Resident (Resident 306), as evidenced by: 1. Licensed Staff B did not have updated annual competencies for Change of Condition assessment and documentation. This failure had the potential to result in Resident 306 not receiving emergency care in a timely manner and for Residents in the facility being potentially at risk due to incompetent staff. Findings: 1. During a review of Resident 306's medical record, History and Physical, from the transferring hospital, dated, [DATE], authored by MD 1, indicated, Resident 306 was 79 years-old with medical comorbidities including; Subacute Frontal Lobe Stroke (hypertension (high blood pressure in the blood vessels), atrial (upper chamber of heart) fibrillation (irregular heart beat), pulmonary hypertension (high blood pressure in the lungs), pericardial effusion (buildup of extra fluid…

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 records review, the facility failed to ensure the sanitary storage of a resident's portable plastic urinal after use. This failure had the potential to increase the risk of infection and disease transmission from bacteria and other microbes, breeding inside the portable urinal. Findings: During the initial tour and resident interview on 5/13/24, at 10:20 AM, the strong smell of urine in a resident room was noted. Resident 32 occupying Bed C stated he used a portable urinal to urinate in bed and his Certified Nursing Assistant (CNA) rinsed his urinal from time to time or occasionally. During a follow-up observation on 5/14/24, at 8:47 AM, Resident 71, occupying bed A in the same resident room, was seated bedside parallel to his bed with his bedside table in front of him. The smell of urine got stronger upon approaching the resident. Resident 71's portable urinal was noted on top of his overbed table beside his drinking mug. During an interview on 5/14/24, at 9:55 AM, the portable urinal of Resident 71 was pointed to Licensed Nurse A (LN A) and…

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

Based on observation, interview and record review, the facility failed to keep four of five residents' belongings safe in the facility. This failure caused the residents to lose items of sentimental and monetary value, causing the residents to feel upset. Findings: During a confidential group interview on 11/3/21 at 10:30 a.m., four of five confidential Residents stated they had lost personal items. Confidential Resident 1 stated she had lost a pink robe. When asked if the facility replaced the lost items, Confidential Resident 1 stated: Sometimes. Confidential Resident 1 further stated she got a missing item back and it's gone again. She stated she had to go to the laundry lady. Confidential Resident 2 stated he had found his quilt on another resident's bed. He stated he got it back by himself. Confidential Resident 3 stated she lost grey tan sweatpants weeks ago. She stated she was sure she had her label in it. She stated she went to the laundry and felt it was tremendously upsetting. Confidential Resident 4 stated she lost a red 49ers shirt and a burgundy hoodie. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not follow its Grievance policy when: 1) Multiple Confidential Resident's concerns with Resident 109's wandering behavior was not documented on the grievance log and was not investigated per policy; and 2) 4 of 5 Confidential Residents did not know how to file a grievance. These failures contributed to residents being upset, scared, and feeling their privacy had been violated, and potentially prevented facility staff from addressing and resolving resident's concerns. Findings: 1) Review of Resident 109's medical record revealed she was [AGE] years old, was diagnosed with dementia, and had a BIMS score (resident assessment tool) of 3/15 (severe cognitive impairment). Review of Resident 109's care plan (dated 11/7/16; revised 8/31/2021) indicated Resident 109, tends to wander and go into other patients (sic) room . The care plan revealed interventions included various activities and distraction, but did not include staff supervision. 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.

3. The Department received an anonymous complaint on 11/1/2021 that indicated the facility had sent Resident 49 (who had dementia, lacked decision-making capacity, and was conserved by the Public Guardian's office) unaccompanied to Physician W's office (offsite at a Community Health Center). The complaint indicated Resident 49 traveled to Physician W's office to complete a POLST (Physician Orders for Life Sustaining Treatment; written form that tells health care providers want treatments an individual wants during a medical emergency). The complaint indicated when Resident 49 was at Physician W's office, she did not understand the purpose of the appointment and was placed in danger, as she was not provided supervision by the facility staff to and from the appointment. Review of Resident 49's medical record revealed her physician diagnosed her with, unspecified dementia and, cognitive communication deficit. Her physician orders (dated 10/1/2021) indicated Resident 49, does not have the capacity to make health care decisions. Review of Resident 49's medical record revealed a cognitive…

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

Based on observation, interview, and record review, the facility failed to provide a restful environment for one of three residents sampled for resident-to-resident altercations when Resident 38's roommate, Resident 16, made anxious verbalizations day and night. This failure caused Resident 38 to feel mad, scream at Resident 16, and lose sleep. Findings: Review of Resident 38's facesheet revealed she had an admission date of 12/7/19. Resident 38's MDS (minimum data set, an assessment tool) dated 8/31/21 indicated a BIMS score of 8 (Brief Interview for Mental Status, a score of 8 indicates moderate cognitive impairment). Review of Resident 16's facesheet revealed she had an initial admission date of 6/16/15 and a re-admission date of 10/18/17. Resident 16's MDS indicated a BIMS score of 6 (indicates severe cognitive impairment). During an observation and concurrent interview on 11/1/21 at 10:18 a.m., Resident 38 was in her wheelchair in the doorway of her room, facing out into the hallway. Upon greeting her, Resident 38 stated, I'm ignoring someone right now and would not make eye…

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 allow one of five residents sampled for activities (Resident 68) go to social activities, which was how she wanted to spend her day. This caused Resident 68 to remain in bed isolated when she would rather be up in the common areas around other people. Findings: During an observation and concurrent interview on 11/1/21 at 4:21 p.m., Resident 68 was in her room in bed. When asked if she got to choose how she spent her day, Resident 68 stated she had not been able to get out of bed for a month. She stated that when she asked to get out of bed, the answer was no. Resident 68 stated she would like to go out in the halls where people are, and would like to go to activities. When queried, Resident 68 stated she liked music and she liked to go to the activities when they have people come play music. During an observation on 11/2/21 at 4:22 p.m., Resident 68 was in bed asleep. Six residents were in the dining room, one was at the piano with 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 provide adequate supervision to maintain resident safety when: 1. The facility did not provide a safe and supervised smoking area for one sampled resident (Resident 74) and one unsampled resident (Resident 99); 2. The facility did not provide supervision for one of two residents sampled for accidents, Resident 49, a cognitively impaired and non-verbal resident who was sent to a physician appointment unattended; and 3. The facility did not provide supervision to prevent repeated wandering into other residents' rooms for one of three residents sampled for resident-to-resident altercations (Resident 109); These failures had the potential to cause accidental injuries to residents, including burns or fractures, and could result in a fire in dry, windy weather. The failure to prevent wandering contributed to Resident 109 being kicked by another resident and caused other residents to feel scared and upset. Findings: 1. During an observation, 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.

Based on Observation, interview, and record review the facility failed to recognize medical changes for 2 of 22 sampled residents (Resident 33 and Resident 7) when: 1a) The staff did not identify Resident 33 had swelling on both legs. This failure had a potential delay of treatment for the underlying cause of swelling. 1b) The staff did not provide continuity of wound care for Resident 33. This failure had a potential delay of wound care which could lead to worsening of wound including wound infection. 1c) The staff did not have a process in identifying acute respiratory changes for Resident 33 who had a chronic cough related to COPD. This failure had a potential delay of respiratory treatment and affect Resident 33's daily routine (Reference F695). 2) Resident 7 had complaint of pain and was not medicated according to her level of pain (Reference F697). Findings: 1a) Resident 33 During an observation and interview with Resident 33 in her room on 11/04/21 at 8:39 a.m., Resident 33 was still in bed finishing up with breakfast, her feet were partially covered with her blanket.…

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

Based on interview, and facility document review, the facility's Quality Assurance and Performance Improvement (QAPI) Program failed to identify quality deficiencies as evidenced by: 1) Residents were not supervised while smoking, residents did not have smoking care plans developed timely, and the designated smoking area did not contain a fire extinguisher (Cross Reference F689); 2) Resident food preferences were not consistently honored (Cross reference F800); 3) The facility did not develop a policy and procedure for emergency water treatment, storage, monitoring and safe accessing/use of the water (cross reference F880); and 4) Resident grievances were not documented (logged) and investigated per policy (cross reference F585). The failure to identify quality deficiencies potentially prevented the QAPI committee from addressing issues and developing corrective plans of actions to mitigate those areas of concern. Findings: 1) During an interview on 11/1/21 at 12:29 p.m., Resident 41 stated Resident 74 had been caught smoking by staff, He smokes whenever and wherever he wants.…

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

Based on observation, interview, and record review, the facility failed to develop and implement an Infection Prevention and Control Program (IPCP) when: 1. Staff did not wear appropriate mouth, nose, eye protection or isolation gowns when providing care to one resident (Resident 262) who had a medical status that required Infection Control Precautions (a set of standard recommendations used to reduce the risk of transmission of infectious agents from body fluids or environmental surfaces); 2. Health care personnel (HCP) did not remove and discard Personal Protective Equipment (PPE) (medical grade supplies used every day by (HCP) to protect themselves, patients, and others when providing care) as appropriate per national guidelines; 3. Reusable treatment equipment, used for multiple residents in the facility, was not cleaned or disinfected per device and disinfectant manufacturer's instructions, prior to use with other residents; 4. Designated/ dedicated medical equipment was not located in the yellow room (designated room(s) in the facility to house newly admitted residents under…

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 allow one of two residents sampled for choices (Resident 68) go to social activities, which was how she wanted to spend her day. This caused one resident to remain in bed when she would rather be up in the common areas around other people. Findings: During an observation and concurrent interview on 11/1/21 at 4:21 p.m., Resident 68 was in her room in bed. When asked if she got to choose how she spent her day, Resident 68 stated she had not been able to get out of bed for a month. She stated that when she asked to get out of bed, the answer was no. Resident 68 stated she would like to go out in the halls where people are, and would like to go to activities. When queried, Resident 68 stated she liked music and she liked to go to the activities when they had people come play music. During an observation on 11/2/21 at 4:22 p.m., Resident 68 was in bed asleep. Six residents were in the dining room, one was at the piano with a staff member,…

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 assess acute respiratory changes for 1 of 22 sampled residents (Resident 33) when Resident 33 had a productive cough and not monitored for symptoms of possible respiratory infection. This failure had a potential delay of respiratory treatment and affect Resident 33's daily routine. Findings: During a clinical record review for Resident 33, the Face sheet (a document that gives a resident's information at a quick glance) indicated Resident 33 was initially admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - diseases that cause airflow blockage and breathing-related problems). During a clinical record review for Resident 33, the Care Plan for COPD initiated on 8/24/21 indicated interventions to include: monitor for signs and symptoms of acute respiratory insufficiency; monitor/ document/ report to the doctor as needed any symptoms of infection: fever, chills, increase in sputum (document…

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 effective pain management for one of 22 sampled residents (Resident 7) when: a) Resident 7 reported pain at a level of 8 to 10 using a numerical pain scale (A numerical scale from 0 to 10 based on self-reported data when 0 means no pain; 1-3 means mild pain; 4-7 is considered moderate pain and 8 and above is severe pain) and was given medication for moderate pain. b) Resident 7 reported pain medication given was ineffective on 10/10/21 and 10/22/21 and no additional intervention provided to manage Resident 7's pain. c) The facility did not develop a person-centered care plan incorporating Resident 7's desired level of pain. This failure had the potential to result in Resident 7 experiencing emotional distress by crying and refusing to get out of bed because of severe pain. Findings: During a clinical record review for Resident 7, the Face Sheet indicated Resident 7 was admitted on [DATE]. During a clinical record review for 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.

Based on observation, interview and record review, the facility failed to ensure that medications were labeled, stored and destroyed according to the facility policy and procedure. This failure had the potential to cause residents to receive expired medications. Findings: During an observation on 11/02/21 at 4:06 p.m., in Medication (Med) Cart 1B on station 1, one single Allergy Allegra (a medication is used to relieve allergy symptoms such as watery eyes and runny nose) 60 milligram tablet, with no expiration date, was in drawer 2. Licensed Nurse T validated this observation. During an observation on 11/04/21 at 10:43 a.m., in Med Cart 3, Station 3, One Fluticasone Propionate Nasal Spray 50 microgram, with expiration date 10/21, was in the top drawer, Licensed Nurse M validated this observation. During an interview with the Director of Nurses (DON) on 11/04/21 at 11:37 a.m., she stated expired medication should not be in the medication cart. The facility policy and procedure titled Medication Storage in the Facility, Storage of Medications, dated 2006, revised August 2014,…

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

Based on observation, interview, and record review, the food preferences of two residents were not honored during tray line observation. This failure had the potential to result in decreased intake at meals, and for one resident to not get the extra calories she needed for her healing wound. Findings: During a confidential group interview on 11/3/21 at 10:30 a.m., an anonymous resident stated that sometimes residents' food preferences were not being honored. The resident stated it was hit or miss. During a tray line observation on 11/3/21 at 12:15 p.m., Dietary Staff Y placed a lunch tray on the cart to go out to the residents for lunch. Review of the tray card indicated the resident's dislikes included spinach and squash (zucchini). Zucchini and carrots were on the plate. Informed Dietary Staff Y of the discrepency. Dietary Staff Y handed the plate to the cook, and told her the resident does not like zucchini, and handed the cook the tray card. The cook then made a new plate with just carrots. Continuing the observation of tray line, Dietary Staff Y placed Resident 52's tray on 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.