Adventist Health Sonora - D/P SNF

Based on observation and interview, the facility failed to ensure safe medication monitoring practices for a census of 60 when: 1. Vital Signs (or VS, markers such as heartbeat or Heart Rate [HR] and Blood Pressure [or BP, the pressure of blood flow into the arteries]) hold parameters (conditions in which nursing staff to hold the medication and/or call the doctor) were not ordered for cardiac (heart) and blood pressure medications for safe monitoring for Resident 28, Resident 11, and Resident 2; and, 2. Resident 28's high risk (drug with risk of adverse effects even with appropriate dose and indication) blood thinner medication, called Apixaban (or Eliquis, used to treat or prevent blood clot and can cause bleeding) did not have monitoring parameters in the Medication Administration Record (or MAR, a document that listed drugs administered and the daily nursing monitoring at the point of drug administration) to assess or prevent the risk of bleeding. These failures could contribute to unsafe monitoring and medication use. Findings: 1a. During a review of Resident 28's MAR, 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 interview, and record review, the facility failed to ensure safe use and monitoring of psychotropic (mind altering drugs) medication in 3 out of 5 sampled residents (Resident 209, Resident 20, and Resident 1) reviewed for unnecessary medication when: 1. Resident 209's specific behavior monitoring, and expression of distress was listed as resistant to care which did not pose a harm to resident or others when the root cause of resistance to care may have been an attempt to communicate unmet needs and a discomfort unable to articulate to nursing staff, 2. Resident 209 and Resident 20's psychotropic drug dosage range did not fit the usual dose range for elderly residents with dementia diagnosis and were not discussed with Resident's Representatives; and 3. Resident 209 and Resident 1's anxiety medication called lorazepam (or Ativan, medication used to treat anxiety) for PRN or as needed basis (PRN or Latin word pro re nata means as the thing is needed) was renewed for 6 months or longer without any clinical…

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

Based on observation, interview, and record review, the facility failed to ensure residents' right to a dignified existence was honored for 1 of 18 sampled residents (Resident 309), when Resident 309's urinary catheter bag (a drainage bag attached to a catheter (tube) that is inside the bladder to collect urine) was exposed and was not placed in a dignity bag (a bag used to the cover and hold the catheter drainage/collection bag so it is not visible) in the dining room. This failure had the potential of emotional harm for Resident 309. Findings: During an observation on 5/7/24, at 1:14 PM, Resident 309 ate lunch in the dining room. Resident 309's urinary catheter bag was exposed, was not in a dignity bag, and was hanging on a walker. During an interview on 5/7/24, at 1:18 PM, Licensed Nurse (LN) 7 stated residents who ate lunch in the dining room were alert. LN 7 confirmed Resident 309's urinary bag was not in a dignity bag in the dining room. LN 7 stated a resident's urinary bag had to be placed in a dignity bag for privacy. LN 7 further stated, People don't like other people see…

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 home-like environment for two of eighteen sampled residents (Resident 47 and Resident 57), when Resident 47's personal items were displayed on Resident 57's side of the room and Resident 57's items were displayed on Resident 47's side of the room. This failure had the potential to negatively impact Resident 47 and Resident 57's psychosocial well-being. Findings: 1. A review of Resident 47's Resident Face Sheet, indicated, she was admitted to the facility in 2023, with diagnoses which included dementia. A review of Resident 47's care plan dated 5/7/24, indicated, .Problem .memory/recall problem R/T [related to] dementia .avoid change in routine .Provide familiar items in room . A review of Resident 47's care plan dated 5/2/24, indicated, .Psychosocial Well- Being .Actual or Potential Adjustment Impairment .Provide privacy, personal objects. Encourage family to bring items of personal meaning to increase comfort . A review of Resident 47's clinical document titled, RESIDENT INCIDENT REVIEW, 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 interview, and record review, the facility failed to provide a copy of written Notice of Transfer or Discharge of a facility-initiated transfer to the appropriate parties for one of one sampled resident (Resident 13), when Resident 13 or Resident 13's representative (RR) and the Long Term Care (LTC) Ombudsman (a patient rights advocate) were not notified in writing of Resident 13's transfer to the emergency room (ER) on 3/11/24. This failure resulted in the State LTC Ombudsman not being informed of the resident's transfer, removed the opportunity for the State LTC Ombudsman to advocate on the resident's behalf, deprived the resident to be informed of resident rights regarding transfer/discharge, and had the potential for Resident 13 being inappropriately discharged . Findings: Review of Resident 13's SNF [Skilled Nursing Facility]/LTC Status Notification record dated 3/11/24, indicated Resident 13 was transferred to the ER on [DATE] for intractable pain (a permanent severe pain condition) of left lower…

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, observation, and record review, the facility failed to ensure residents had access to their bilateral hearing aids and failed to assist in locating and/or arranging for audiologist (ear doctor) referral consult services for two of two sampled residents (Resident 311 and Resident 309) when: 1. A Certified Nursing Assistant (CNA) asked Resident 311's wife to take Resident 311's hearing aids home; and, 2. The facility did not assist or refer for follow-up auditory services for Resident 309 to obtain hearing aids. These failures had the potential to impede Resident 311's and Resident 309's maintaining and/or achieving independent functioning, dignity, and well-being due to not being able to hear adequately during a conversation. Findings: 1. Review of Resident 311's Initial Care Plan, dated 2/24/24 [sic], indicated, .Initial information .Hearing .Hearing adequate .Hearing impaired . was marked. Review of Resident 311's undated Resident Belongings Sheet, indicated that Resident 311 had a right and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide restorative services (activities to assist residents with maintaining or improving physical function) for one of twenty residents (Resident 310) referred to the RNA program (Restorative Nursing Aide; administers restorative services) when, a recommendation for RNA services was written for Resident 310 on 4/23/24 by the Physical Therapy (PT) Department, but was not relayed to the skilled nursing facility to initiate. This failure resulted in the potential for Resident 310 for not attaining and maintaining their highest possible level of physical and functional well-being. Findings: Review of Resident 310's Resident Face Sheet, indicated Resident 310 was admitted to the facility on [DATE]. Review of Resident 310's Physician Order Report, indicated that Resident 310 had an admitting diagnosis which included but not limited to cerebral infarction due to embolism unspecified (blood supply to the brain is blocked or reduced and prevents brain tissue…

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, observation, and record review, the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for two of two sampled residents (Resident 311 and Resident 48) when: 1. There was no oxygen safety signage posted outside Resident 311's room; and, 2. Oxygen tubing was not labeled and was not changed out within seven days for Resident 48 and Resident 311's oxygen tubing was not labeled. These deficient practices had the potential for Resident 48 and Resident 311 to have complications related to improper treatment while receiving oxygen therapy. Findings: 1. During a review of Resident 311's Physician Order Report, indicated that Resident 311 had an admitting diagnosis which included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body). During an interview and observation on 5/6/24, at 10:05 a.m., Resident 311 was observed in his room sitting in a wheelchair next to his bed and was receiving oxygen at one point five liters per minute (LPM) via nasal canula…

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 Physical Therapy (PT- the treatment of disease, injury, or deformity by physical methods such as message, heat treatment, and exercise) as ordered by the physician for one of three sampled residents (Resident 309) with physical therapy orders when, Medical Director (MD) 1 had ordered PT on 4/26/24 for Resident 309, but the services had not yet been provided by the PT department. This failure resulted in the potential for Resident 309 for not attaining and maintaining their highest possible level of physical and functional well-being. This failure also had the potential to delay necessary treatment and delay necessary assistive services needed for Resident 309. Findings: Review of Resident 309's Resident Face Sheet, indicated Resident 309 was admitted to the facility on [DATE] with diagnosis which included but not limited to history of falling, other sequelae of cerebral infarction (stroke; blood supply to the brain is blocked or reduced 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 ensure safe infection prevention practices for a census of 60 when: 1. When Licensed Nurse (LN) 8 carried the stock bottle of test strips (test strip used to measure blood sugar) into an isolation room (restricted room to prevent the spread of infection) without cleaning or sanitization before and after use, 2. Resident 309's urinal (a bottle used for urination) was not labeled with Resident 309's name or another identifier; and, 3. Resident 309 's urinary bag (a drainage bag attached to a catheter (tube) that is inside the bladder to collect urine) was hanging on Resident 30's walker. These failed practices could contribute to spread of infection in the facility. Finding: During a medication administration observation with LN 8, in the facility's Unit 7, on 5/7/24, at 11:25 AM, LN 8 gathered the blood sugar measurement supplies including a glucometer (a device that measured blood sugar), test strip bottle (stock bottle of test strip; when single test strip was soaked with blood, inserted into glucometer 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 interview and record review, the facility failed to ensure one of eight sampled residents (Resident 2) who used the Sara Steady (a manual sit-to-stand transfer aid that enables one caregiver to transfer patients safely and with ease) device environment was free of accident hazards when staff left Resident 2 unattended while the Sara Steady device was in front of Resident 2. This failure had the potential to place Resident 2 at risk of falls and possible injury. Findings: During an interview on 3/21/24 at 10:15 am with Certified Nursing Assistant (CNA) 1, CNA 1 stated that she placed the Sara Steady device in front of Resident 2 while she used the commode (a portable toilet or a chair with a container underneath) in the room. CNA 1 further stated she would leave the call light within reach for Resident 2 to call her when she was done using the commode or the restroom. During an interview on 3/21/24 at 10:30 am with the Director of Staff Development (DSD), the DSD stated the residents who used the Sara…

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 one of two residents (Resident 1) with self-release seatbelts, remained free from a physical restraint, when Resident 1 was not able to buckle and unbuckle the seatbelt consistently on her own. Staff applied and removed Resident 1's seatbelt rather than reminding Resident 1 to apply the safety belt on her own per Resident 1's care plan intervention implemented on 2/6/24 related to the seatbelt use, following a fall in the bathroom on 2/2/24. This failure resulted in loss of freedom of movement for Resident 1, with the possibility of injury and psychosocial distress. Findings: During an interview on 2/20/24, at 4:12 pm, Resident 1 stated that she could not unbuckle the seatbelt and could only ever do it one time during the demonstration of how to use the seatbelt. Resident 1 stated after the demonstration she tried to unbuckle the seatbelt, but she could not do it. Resident 1 confirmed that she could also not buckle the seatbelt on her own. Resident 1 stated she felt perturbed [feeling anxiety or concern; unsettled]…

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, clinical record and policy and procedure review, the facility failed to protect one of three sampled residents (Resident 1) from sexual abuse, when Resident 2 who had a known history of inappropriate sexual comments and gestures was sitting in close proximity to her with no staff supervision. This failure resulted in Resident 2 rubbing Resident 1's inner thigh and placed other vulnerable residents residing in the facility at risk for abuse. Findings: According to the admission record, Resident 1 was admitted to the facility early this year with diagnoses which included anxiety disorder (excessive and persistent worry and fear about everyday situation) and Parkinson's disease (a progressive disease of the nervous system characterized by shaking, stiffness, and difficulty with mobility). A review of the Minimum Data Set (MDS, an assessment tool) dated, 9/12/23 indicated Resident 1 scored 7 out of 15 on the cognitive assessment, which indicated she had severe memory impairment and 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 interview and record review, the facility failed to submit a summary of investigation of an alleged sexual abuse to the Department within five (5) working days of an incident for one of three sampled residents (Resident 1). This failure placed Resident 1 at potential risk for further abuse. Findings: Resident 1 was admitted to the facility early this year with diagnoses which included anxiety disorder (excessive and persistent worry and fear about everyday situation) and Parkinson's disease (a progressive disease of the nervous system characterized by shaking, stiffness, and difficulty with mobility). Resident 2 was admitted to the facility in 2023 with multiple diagnoses which included anxiety and heart disease. A review of Resident 1's nursing progress note, dated 12/3/23 and timed at 5:10 p.m., indicated Resident 2 was observed rubbing [Resident 1's] inner thigh up to her groin area when they were sitting beside each other near the nursing station. The nurse documented the incident was witnessed by two Certified Nursing Assistants (CNA 1 and CNA 4). The note indicated…

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

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity for a census of 50 when: 1. Staff placed Resident 15 and Resident 47 in double incontinence briefs; and, 2. Staff stood while assisting Resident 17 with meals. These failures had the potential to negatively impact the residents' psychosocial well-being and physical health. Findings: 1. A review of Resident 15's admission Record indicated Resident 15 was admitted to the facility in 2020 with diagnoses which included urinary tract infection. A review of Resident 47's admission Record indicated Resident 47 was admitted to the facility in 2023. During a concurrent observation and interview on 3/15/23, at 6:10 a.m., with certified nursing assistant (CNA) 5 in Resident 15's room, CNA 5 confirmed she removed two incontinence briefs as she changed Resident 15. CNA 5 stated she did not know who placed double briefs on Resident 15 because she had started her shift late. CNA 5 further stated the expectation was for all residents to wear only one incontinence brief. CNA 5…

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 petty cash was available for a total of twenty residents who had a trust account with the facility, when personal funds were not available after business hours or on weekends. This failure resulted in personal funds not being available after business hours, with the potential to negatively effect a resident's psychosocial well-being. Findings: During an interview on 3/16/23, at 9:10 a.m., Resident 28 stated to obtain resident held money from the facility a request had to be made Monday through Friday. Resident 28 stated if you requested money late on Friday then you would not receive your money request until Monday. Resident 28 stated to have money on the weekend a request would have had to be made ahead of time. Resident 28 explained, if you did not request the money in advanced then you would be out of luck for the weekend. During an interview on 3/13/23, at 9:48 a.m., Resident 25 stated she was unaware if she could obtain money on the weekend. During an interview on 3/15/23, at 9:16 a.m., the…

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

Based on observation, interview, and record review, the facility failed to ensure three of nine residents (Resident 27, Resident 34, and Resident 40) who required assistance to maintain mobility received required services, when: 1. Resident 27's hand contracture (muscles, tendons, joints, or other tissues tighten or shorten causing a deformity which can result in pain and loss of movement) cushion was not present in both hands; and, 2. Resident 34 and Resident 40 were improperly discharged from their functional management interventions (nursing intervention to increase or maintain resident's mobility and to prevent further decline in mobility). These failures had the potential risk for Resident 27, Resident 34 and Resident 40 to not maintain their highest level of range of motion (ROM-the degree of movement that occurs at a given joint during an exercise) and mobility functioning. Findings: 1. During a concurrent observation and interview on 3/13/23, at 9:23 a.m., Certified Nurse Assistant (CNA) 1 confirmed Resident 27 had a blue contracture cushion in the right hand only. CNA 1…

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 provide adequate and sufficient nursing staff to ensure the Restorative Nursing Aide program (RNA, nursing aide program that helps residents to maintain their function and joint mobility) treatments and services were available for a census of 50. This deficient practice had the potential to decrease the residents' range of motion and mobility, which could affect the residents' overall function. Findings: During an interview on 3/15/23, at 11:44 a.m., licensed nurse (LN) 1 stated the facility did not have an RNA program. LN 1 further stated the CNAs were responsible for completing certain mobility interventions for residents on certain days and had to document on a resident's flowsheet. During an interview on 3/15/23, at 1:23 p.m., LN 3 stated the facility had no RNA program for at least 6 months. LN 3 further stated sometimes functional management interventions were not possible to complete depending on how many CNAs were on the floor. LN 3 explained certain functional management interventions were removed because they did…

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 develop and implement antibiotic (medication used to treat bacterial infections) use protocols within the antibiotic stewardship program for a census of 50 residents when; 1. No antibiotic use protocol was developed and implemented; 2. Minimum use criteria for the use of antibiotics was not applied for Resident 6 and Resident 45; and, 3. Resident 21's antibiotic order did not have an end date. These failures increased residents' risk to develop infections with bacterial organisms resistive to certain antibiotics (MDRO; multidrug-resistant organisms, germs that are resistant to many antibiotics) with the potential to result in adverse outcomes (allergic reactions, organ damage, subsequent infection with antibiotic-resistant organisms, and clostridium difficile infection(bacteria that causes an infection of the large intestine)) associated with the inappropriate/unnecessary use of antibiotics. Findings: 1. During a concurrent interview and record review on 3/15/23, at 11:12 a.m., facility documents titled FACILITY POLICY:…

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 reasonable accommodation of needs were honored for two of 21 sampled residents (Resident 27 and Resident 30) when: 1. There was no documented attempt of an alternative call light used for Resident 27; and, 2. Resident 27 and Resident 30's call light were not within reach. These failure had the potential for Resident 27's and Resident 30's needs to go unmet with the potential to cause physical and/or psychosocial harm. Findings: 1. During a concurrent observation and interview on 03/13/23, at 9:23 a.m., Certified Nurse Assistant (CNA) 1 stated Resident 27 was unable to use the call light and was unable to speak. During an interview on 3/16/23, at 2:48 p.m., the Practice Administrator (PA) confirmed there was no record that other calls light types had been attempted in the past for Resident 27. During an interview on 3/15/23, at 4:29 p.m., the Director of Nursing (DON) stated she did not recall if other types of call lights had been tried in the past for Resident 27. The DON stated the facility had…

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 individual financial records were received on a quarterly basis for twenty residents who had a trust account with the facility, when there was no documented evidence that quarterly statements were provided to residents with facility managed funds. This failure had the potential for Resident 25 to be unaware of the amount of money available. Findings: During an interview on 3/13/23, at 9:48 a.m., when asked if a quarterly statement was received from the facility regarding money held in the trust account, Resident 25 stated she had never received anything, but would like to be aware of what money she had. During an interview on 3/15/23, at 9:16 a.m., the Practice Administrator (PA) stated the facility held resident trust accounts for a total of twenty residents. The PA confirmed Resident 25 had a trust account with the facility. The PA stated that residents who had a trust account received quarterly statements, with the last statement being provided in January of 2023. The PA stated it was important to provide…

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 have a process to provide a beneficiary notification form when two of two sampled residents (Resident 5 and Resident 9) did not receive the Notice of Medicare Non-Coverage (NOMNC, a form which indicates that Medicare might not pay for skilled services and how to appeal). This failure had the potential for Resident 5, Resident 9 and their representatives to be uninformed regarding their specific rights and protections related to financial liability for potential incurred medical expenses as well as the right to appeal. Findings: A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility in 2022. A review of Resident 9's admission Record indicated Resident 9 was admitted to the facility in 2022. During a concurrent interview and record review with the Director of Nursing (DON) on 3/15/23, at 3:12 p.m., the DON confirmed the facility did not provide a NOMNC to Resident 5 and Resident 9. The DON stated the facility was not aware a NOMNC needed to be provided because they handled very few…

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 implement a care plan intervention for two of 21 sampled residents (Resident 27 and Resident 30) when the care plan intervention of a stop sign barrier (a yellow banner with a stop sign on it that was placed across the doorway) was not in place over Resident 27's and Resident 30's doorway. This failure had the potential for Resident 27 and Resident 30's privacy to be invaded by unwanted persons, with a potential risk to safety. Findings: During an observation on 3/13/23, at 9:15 a.m., a stop sign barrier was hanging from the right side of the door frame of Resident 30's and Resident 27's shared room. During a concurrent observation and interview on 03/13/23, at 9:23 a.m., Certified Nurse Assistant (CNA) 1 confirmed Resident 30 and Resident 27 were in bed. CNA 1 confirmed the stop sign barrier was not across the doorway of Resident 30 and Resident 27's room. CNA 1 stated the stop sign barrier was used to prevent residents who wandered from going into other residents' rooms. During an interview on 3/15/23, at…

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 implement care planned fall precautions for Resident 10 and Resident 17, when the beds were not in low position and Resident 10's call light was not in reach. This failure had the potential to result in physical and psychosocial harm. Findings: During an interview on 3/14/23, at 9:50 AM, in Resident 10's room, Resident 10 stated she fell in November, which resulted in a shoulder injury that required surgery to repair. During a concurrent interview and record review on 3/14/23, at 9:57 AM, in Unit 6 nursing station, Licensed Nurse (LN) 3 stated Resident 10 had care planned interventions for fall risk and stated if Resident 10's bed was not in the lowest position, she could fall and hurt herself again. During a concurrent observation and interview on 3/15/23, at 8:28 AM, in Resident 10's room, Certified Nurse Assistant (CNA) 4 checked to see if Resident 10's bed was in the lowest position. CNA 4 pressed the bed controller, and Resident 10's bed moved lower. CNA 4 stated the risk to the resident was they could…

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 one of twenty-one sampled residents (Resident 30) had access to fluid to maintain hydration when, Resident 30's drinking fluids were not within reach. This failure had the potential to result in a decline in Resident 30's health (dehydration) with the potential to result in physical harm (fall). Findings: During a concurrent observation and interview on 3/13/23, at 9:23 a.m., Certified Nurse Assistant (CNA) 1 confirmed Resident 30 was in bed and Resident 30's tray table with drinks on it was about two feet from the bed. CNA 1 confirmed Resident 30's call light was also not within reach. During an interview on 3/15/23, at 2:10 p.m., Licensed Nurse (LN) 1 stated resident drinks were located on the bedside table and the bedside table should be within the resident's reach. LN 1 stated the drinks should be with in reach so if the resident wants a drink they can get one. LN 1 explained a resident could try and reach for a drink and fall out of the bed. During an interview on 3/15/23, at 4:29 p.m., the…

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

Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for one of twenty-one sampled residents (Resident 21), when Resident 21's oxygen order had no indicated flow rate (the volume of oxygen delivered over time). This failure had the potential to result in negative impacts on Resident 21's health and safety including risks for ineffective oxygen therapy, and respiratory distress. Findings: A review of Resident 21's admission Record indicated Resident 21 was admitted to the facility in 2021 with diagnoses which included dependence on supplemental oxygen. During an observation on 3/13/23, at 1:19 p.m., Resident 21 was observed in his room with the oxygen concentrator on and running at a flow rate of 2 liters per minute (LPM, unit of measurement for oxygen delivery) via nasal cannula (a small flexible tube that contains two open prongs intended to sit just inside the nostrils). During a concurrent observation and interview on 3/13/23, at 1:24 p.m., with licensed nurse (LN) 1…

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.

2. During a concurrent observation and interview on 03/15/23, at 11:42 a.m., the Warehouse Distribution Technician (WDT) was observed on Unit 7 at the medication storage room door holding a red container. The WDT entered the code on the door keypad and walked into the medication storage room. The WDT exited the medication storage without the red container. The WDT stated, .I put the box on the counter in the back of the med room. If a nurse is available, I give it to them. If not I put it in the med room. I don't want to leave it on the counter where a resident could get it. The WDT further stated he was provided the code to the medication room one year ago by the individual who trained him. The WDT confirmed he was not licensed personnel nor was his trainer. The WDT looked at the sign on the medication room door that reads: Restricted Entry-Licensed Staff Only and stated, I should not go in there, I'm not licensed staff, I didn't know. During an interview on 3/15/23, at 11:59 a.m., LN 2 was unaware the WDT had the code to the medication storage room. LN 2 confirmed the risk of WDT…

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 maintain infection prevention and control practices for a census of 50 when: 1. One staff member did not follow infection control practices when Resident 20's wound dressing was changed; and, 2. One kitchen staff member was not wearing his mask correctly during the tray line prep. These failures had the potential risk for the development and transmission of diseases and infection to residents in the facility. Findings: 1. A review of Resident 20's admission Record indicated Resident 20 was admitted to the facility in mid-2022 with diagnoses which included a non-pressure chronic ulcer (an open wound with an exposed implanted device) of left lower leg, osteomyelitis (bone infection), and methicillin resistant staphylococcus aureus (MRSA, a bacteria that is responsible for several difficult to treat infections) infection. A review of Residents 20's Treatment Flowsheet indicated, .wound left knee once a day remove dressing, clean with chlorhexidine [topical antiseptic] and irrigate with NS [normal saline, 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 interview and record review, the facility failed to ensure that one of five sampled resident's (Resident 42) medical record indicated if immunizations were received and/or refused and education was provided on the risks and benefits of the immunization when, Resident 42's medical record did not indicate if the pneumococcal vaccine (protects against serious and potentially fatal pneumococcal infections caused by bacteria) was offered and/or refused and there was no documented evidence of the risk versus benefit education being provided. This failure had the potential for Resident 42 to go unvaccinated with the risk for serious health related illness and/or death and Resident 42 and/or Resident 42's responsible party to not make an informed decision in regards to the risk versus benefits of receiving the vaccine. Findings: During an interview on 3/15/23, at 2:28 p.m., the Director of Staff Development (DSD) confirmed there was no record of the pneumoccocal vaccine being offered to Resident 42, no documented refusal of the vaccine, and no documentation to show that the risks…

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.