Totally Kids Specialty Healthcare - Sun Valley

Based on observation, interview and record review, the facility failed to provide care in a manner that maintained a resident's dignity and promoted respect by failing to ensure Licensed Vocational Nurse (LVN 1) knocked or request permission before entering the room of one of two sampled residents (Resident 37) reviewed under the dignity care area. This deficient practice violated the resident`s rights to be treated with respect and dignity and had the potential to negatively affect the resident's sense of self-worth and self-esteem. Findings: During a review of Resident 37's admission Record, the admission Record indicated the facility initially admitted Resident 37 on 10/18/2018 and readmitted the resident on 11/7/2023, with diagnoses including tracheostomy (a surgical procedure that creates an opening in the neck leading directly into the trachea [windpipe]) and dependence on a ventilator (a medical machine that helps a patient breathe or completely takes over their breathing when they cannot do so on their own). During a review of Resident 37's Minimum Data Set (MDS-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 notify a resident's responsible party (RP-the person designated for all care decisions of a resident) regarding a change of condition for one of five residents (Resident 1) reviewed for unnecessary medications when the facility failed to notify Resident 1's responsible party (RP 1) of a critically high (a test result that is so far outside the normal range that it indicates a potentially life-threatening situation) Depakote (brand name to valproic acid - medication used to treat epileptic seizures [sudden surge of abnormal electrical activity in the brain, causing jerking and stiffness]) laboratory value (reference range was 50-100 micrograms per millimeter [mcg/ml-unit of measurement]) greater than 150 mcg/ml on 10/10/2025. This deficient practice resulted in RP 1 not being informed of the critical lab values and prevented RP 1 from participating in Resident 1's care planning. Findings: During a review of Resident 1's Admission Record, the admission Record indicated the facility admitted Resident 1 on 7/17/2024 with…

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 confidential personal information of residents were protected by failing to ensure meal tickets containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were shredded prior to disposing in the trash receptable for two of six residents (Resident 5 and Resident 35) who receive food from the kitchen. This failure had the potential to violate the residents' rights to privacy and confidentiality of personal and medical records. Findings: a. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident to the facility on 3/17/2022 with diagnoses that included osteochondrodysplasia (a group of rare, typically genetic, disorders that cause abnormal development of bone and cartilage, resulting in stunted growth, two short stature, and skeletal deformities), other…

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 the necessary services to maintain good grooming and personal hygiene for three of three sampled residents (Resident 10 and Resident 5) by failing to: 1.Ensure Resident 10 was provided oral care in accordance with the facility policy and procedure (P&P) titled Oral Hygiene, reviewed 12/3/2025, which indicated Each resident will be provided proper oral hygiene daily, beginning in the morning, after every meal, before bedtime, and as needed to maintain a healthy oral cavity and prevent complications of poor oral hygiene. This deficient practice placed the resident at risk for oral infections and tooth decay.2. Ensure Resident 5 and Resident 35's nails were trimmed.This deficient practice placed the resident at risk for skin injury or scratches, infection, and may cause discomfort and affect the resident's overall being. Findings: 1.During a review of Resident 10's admission Record (AR), the AR indicated that the facility admitted the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Registered Nurse (RN 1) maintained current CPR (cardio-pulmonary resuscitation - an emergency, life-saving technique performed when someone's breathing or heartbeat has stopped) certification for healthcare providers through a CPR provider whose training includes a hands-on session in accordance with accepted national standards for one of five staff members investigated during review of the staffing facility task. This deficient practice had the potential for delayed provisions of emergency care, including CPR to residents who wish to have full treatment in life threatening illnesses or injuries. Findings: During an employee file review on [DATE] at 2:15 p.m. with Human Resources staff 1 (HR 1), HR 1 reviewed RN 1's employee file. HR 1 stated RN 1's CPR certification was all web based without the required in person hands on component. During an interview on [DATE] at 5:15 p.m. with RN 1, RN 1 stated she was sorry and she did not know a hands-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 interview and record review, the facility failed to implement a bowel (tube-shaped organ in the abdomen that completes the process of digestion) and bladder (a hollow organ that stores urine) training program (B&B retraining program - aim to establish or regain control over bowel and bladder function) for one of two sampled residents (Resident 5) by failing to ensure Resident 5 was placed on the toilet every two hours per physician's order. This deficient practice had the potential for Resident 5 to not their highest functional level and not establish or regain control over bowel and bladder function.Findings: During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 3/17/2022 with diagnoses that included osteochondrodysplasia (a group of rare, typically genetic, disorders that cause abnormal development of bone and cartilage, resulting in stunted growth, short stature, and skeletal deformities), other congenital (a trait, disorder, or condition that is present at or before birth) deformities of skull, face, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1.Obtain and document the weight of two of five residents (Resident 4 and Resident 32) reviewed under the nutrition care area in accordance with the physician's order. This deficient practice had the potential to prevent staff from identifying significant weight changes and addressing potential nutritional concerns. 2. Ensure the total volume of water to be infused via gastrostomy tube (G-tube, a feeding tube inserted through the abdomen to provide nutrition, fluids, and medications) was documented on the water bag label for one of three residents (Resident 22) reviewed under the hydration care area, in accordance with the physician's order. This deficient practice had the potential for staff to be unaware of the amount of water to be infused per the physician's order, placing the resident at risk for fluid imbalance (a condition that occurs when the body has too much or too little fluid, disrupting the normal balance needed for the body…

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 facility's policy and procedure (P&P) titled, Medication Administration, reviewed 12/3/2025, was followed for one of eight residents (Resident 1) observed during medication administration, when Licensed Vocational Nurse 4 (LVN 4) failed to check placement of Resident 1's gastrostomy tube (G-tube, a tube inserted through the abdomen, to deliver nutrition and medications directly to the stomach) prior to administration of medications. This deficient practice had the potential to place Resident 1 at increased risk for aspiration pneumonia (a type of lung infection that occurs when food, saliva, or other substances are inhaled into the lungs, which occurs when medication is accidentally delivered into the lungs instead of the stomach because an improperly placed tube could be in the esophagus or trachea, allowing medication to enter the airway). Findings: During a review of Resident 1 's admission Record, the admission Record indicated that the facility admitted the resident on 7/17/2024 with diagnoses including…

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

Based on observation, interview, and record review, the facility failed to ensure seven medium-sized and six large-sized boxes of drinks and food items were not stacked higher than 18 inches from the ceiling in the dry storage area of the facility's kitchen. This failure had the potential to prevent water sprinkler clearance to reach the top of these boxes in the event of a fire and the potential for the boxes to fall and dent resulting in harmful bacteria growth for six of 37 medically compromised and vulnerable residents who received food from the kitchen. Findings: During an initial kitchen observation on 2/20/2026 at 6:15 p.m., observed in the dry storage area, seven medium-sized and six large-sized boxes on two different wire racks that were stacked greater than 18 inches from the ceiling. During a concurrent observation and interview on 2/21/2026 at 11:25 a.m., in the dry food storage area of the kitchen with the Dietary Supervisor (DS), the DS stated it is against the facility's policy to stack items greater than 18 inches from the ceiling and stated there were about 13 boxes…

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 dispose garbage and refuse properly by failing to: 1. Ensure two of two black dumpsters (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) and one of one blue dumpster were completely closed while not actively being used. 2. Ensure there were no soiled gloves on the floor area and surroundings of the facility's dumpster. This deficient failure had potential to attract birds, flies, insects, pests, and possibly spread infection to 37 of 37 facility residents. Findings: During an observation on 2/21/2026 at 11:32 a.m., of the facility dumpster area with the Dietary Supervisor (DS), observed two black dumpsters and one blue dumpster fully open and a pair of soiled gloves on the ground near the dumpsters. During an interview on 2/21/2026 at 11:34 a.m., with the DS, the DS stated all the trash must be inside the dumpster and dumpster lids should always be closed. The DS stated the lids on the dumpsters must be…

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

Based on interview and record review, the facility failed to electronically submit direct care staffing information daily, based on payroll data in the first quarter of 2024. This deficient practice had the potential to not provide the required staffing to ensure residents' care and safety. Findings: During a review of the Certification and Survey Provider Enhanced Report (CASPER) payroll-based Journal (PBJ) Staffing Report, dated 1/1/2024 through 3/31/2024, the CASPER Report indicated that the facility failed to submit data for the first Quarter of 2024. During an interview on 12/29/202024 at 12:51 PM with the Financial Coordinator (FC), the FC stated that she submitted the Staffing Data report [NAME] Report every quarter for the year of 2024. The FC stated that she did not keep the copies of the PBJ Reports. The FC further stated she was receiving electronic confirmation of data submission after the submission of Quarterly Reports. The FC was not able to provide any documentation that indicated the staffing report was submitted for the dates of January 1, 2024, through March 31,…

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 3.a. During a review of Resident 22's admission Record, the admission Record indicated the facility originally admitted the resident on 1/6/2020 with diagnoses including cerebral palsy (central nervous system [CNS] motor disorders which are characterized by impairment of voluntary muscle movement), anoxic brain damage (condition when the brain is completely deprived of oxygen, causing damage to brain cells due to a lack of necessary oxygen supply), and convulsion (sudden , uncontrolled shaking of the body muscles, often associated with seizures). During a review of History and Physical, dated 1/7/2024, the History and Physical indicated that Resident 22 had seizures. During a review of Resident 22's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/8/2024, the MDS indicated that the resident had severely impaired cognition (severely damaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 4 was…

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

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principals by failing to: 1. Ensure staff did not leave two of two medication carts (Medication Cart A and B) unlocked and unattended and leave medications unattended. This deficient practice had the potential for unsafe facility practices, unauthorized entry to the medication cart, and contamination of the prepared medications. 2. Ensure two opened (in-use) olopatadine hydrochloride (HCL) solution (type of eye drops used to treat eye itching) 0.1% (measurement of concentration) vials were discarded after 30 days after opening for one of one sampled resident (Resident 24). 3. Ensure an expired antibiotic (a drug used to treat infections), nitrofurantoin (antibiotic used to treat urinary tract infections [UTI- an infection in the bladder/urinary tract]) was removed from the medication card and disposed of for one of one sampled resident (Resident 11). These deficient practices had the potential for the residents to receive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 16) with limited range of motion (ROM- full movement potential of a joint) received appropriate treatment and services to prevent further decrease in range of motion by failing to: 1. Provide Passive Range of Motion (PROM-when an outside force such as a therapist exclusively causes movement of a joint) exercises as ordered by the physician. 2. Develop and implement a person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) for Resident 16`s contracture. These deficient practices had the potential to put the resident in further decline of his range of motion and developing increased contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).…

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 a resident with a physician's order to wear a soft helmet when out of the crib was wearing the soft helmet when the resident was out of the crib for one of three sampled residents (Resident 13) This deficient practice placed Resident 13 at risk for injury if a fall incident occurred. Findings: During a review of Resident 13`s admission Record, the admission Record indicated the facility admitted the resident on 2/1/2018, with diagnoses including other specified congenital (present from birth) malformations, congenital malformation of brain, and encounter for attention to tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck). During a review of Resident 13's Minimum Data Set (MDS - an assessment and care screening tool), dated 2/1/2024, the MDS indicated the resident's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily…

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 sampled residents (Resident 26) received the appropriate treatment and services for bladder incontinence (the loss of bladder control) by failing to apply warm compress and bladder massage prior to the in and out catheterization and failing to perform in and out catheterization (when the catheter is inserted and left in only long enough to empty the bladder and then is removed) as ordered by the physician. This deficient practice had the potential to result in the inadequate care and monitoring of Resident 26 and placed him at an increased risk of infection. Findings: During a review of Resident 26's admission Record, the admission Record indicated that the facility admitted the resident on 9/15/2022, with diagnoses including anoxic brain damage (brain damage from a lack of oxygen to the brain), epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), personal history of urinary infections (UTI- an infection in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy on intake and output by failing to ensure licensed nurses documented the residents output every shift for two of two sampled residents (Resident 18 and 8). This deficient practice had the potential to place Resident 18 and Resident 8 at risk for dehydration (deficit of total body water, with an accompanying disruption of body processes). Findings: a. During a review of Resident 18`s admission Record, the admission Record indicated the facility admitted the resident on 10/8/2012, with diagnoses including spastic diplegic cerebral palsy (characterized by jerky movements, muscle tightness, and joint stiffness), encounter for attention to tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), dependence on respirator (ventilator) status, encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be…

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

Based on observation, interview, and record review, the facility failed to implement their enteral tube feeding (gastrostomy tube - GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) policy and procedure (P&P) for one of four sampled residents (Resident 4) investigated for gastrostomy tube care by failing to label Resident 4`s y-connector (a silicone tube used for patient with gastrostomy to deliver nutrition and medications directly to the stomach) with the date it was last changed. This deficient practice had the potential to place Resident 4 at an increased risk of infection and may cause adverse reactions (an undesired effect of a treatment) such as upset stomach and/or diarrhea (loose, watery stool more frequently than normal). Findings: During a review of Resident 4's admission Record, the admission Record indicated that the facility initially admitted Resident 4 on 1/15/2018, with diagnoses including encephalopathy (brain disease, damage, or malfunction of brain), acute 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 interview and record review the facility failed to ensure residents who needed respiratory care (the health care discipline that specializes in the promotion of optimum cardiopulmonary function and health and wellness) was provided such care, consistent with professional standards of practice by failing to change the aerosol/ventilator (a machine that helps a person breathe by moving air in and out of their lungs) humidifier water bottle (equipment to produce and dispense water vapor, adding moisture to oxygen and restoring healthy level of humidity [the amount of water vapor in the air]) every three (3) days for one of three sampled resident (Resident 22) investigated for respiratory care. This deficient practice had the potential for Resident 14 to develop a respiratory infection. Findings: During a review of Resident 22's admission Record, the admission Record indicated the facility originally admitted the resident on 1/6/2020 with diagnoses including cerebral palsy (central nervous system [CNS] motor disorders which are characterized by impairment of voluntary muscle…

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 maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 2) by failing to ensure a specific indication was written for an order of Augmentin (antibiotic- medication that fights bacterial infections). This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate resident medical care information and the potential to result in confusion in the care and services for Resident 2. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted the resident on 7/21/2005 and readmitted the resident on 12/21/2023 with diagnoses that included congenital (present at birth) malformation of ear, unspecified visual loss, lack of expected normal physiological development in childhood. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 9/23/2024, the MDS indicated Resident 2's cognition (the mental action or process…

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 an Arbitration Agreement (a legal contract that requires parties to resolve disputes through arbitration [a formal method of dispute resolution involving a third party who makes the binding decision] instead of going to court) that included the selection of venue (a location in which to carry out arbitration proceeding) which should be convenient to both parties (resident and facility) to ensure a fair arbitration process to the facility's residents. This deficient practice had a potential to not provide a neutral and fair arbitration process to the facility's residents. Findings: During a review of facility's Arbitration Agreement, the Arbitration Agreement did not include the selection of a venue that is suitable in meeting the needs of both the resident or his or her representative, and the facility. During a concurrent interview and Arbitration Agreement review on 12/29/2024 at 10:12 AM with the Social Service Director (SSD), the SSD reviewed the Arbitration Agreement and confirmed that the Arbitration…

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 its policy titled, Sterile Tracheal Suction (a means of clearing the airway of secretions or mucus through the application of negative pressure via suction catheter) by failing to ensure that Respiratory Care Practitioner 2 (RCP 2) doffed (removing gloves in a way that avoids self-contamination [the act of contaminating oneself with potentially pathogenic organism]) nonsterile gloves before the donning (putting on personal protective equipment [PPE] to achieve the intended protection and minimize the risk of exposure) of sterile ( free of gems or living organisms, especially microorganisms) gloves when performing a sterile tracheal suction to one (Resident 4) out of five residents investigated during review of the infection control task. This deficient practice had the potential to increase the risk of healthcare acquired infection to Resident 4. Findings: During a review of Resident 4's admission Record, the admission Record indicated that the facility initially admitted Resident 4 on 1/15/2018…

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 electronically submit staffing information based on payroll data on a quarterly schedule to the Centers for Medicare & Medicaid Services (CMS) in 2022 for one of one fiscal (relating to a period of 12 months) quarter (Fiscal Quarter 4). The deficient practice prevented the provision of complete and accurate direct care staffing information to the public. Findings: During a concurrent interview and record review on 12/18/2023 at 6:30 p.m., with the Finance Coordinator (FC), reviewed the Payroll-Based Journal Staffing Data Report (PBJ-SDR) for fiscal quarter four (4) of 2022 (7/1/2022 to 9/30/2022). The FC stated that around this time the facility was using another software and has no record and recollection if the PBJ-SDR had been submitted based on the submission timeframe. The FC stated that the current software they are using has no capability to pull up the record beyond the previous 150 days. The FC stated that she cannot verify if the submission was done timely. A review of the facility's policy and procedure titled,…

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

Based on interview and record review, the facility failed to ensure the facility's Shift Change Narcotic (a drug that in moderate doses dulls the senses, relieves pain, and induces profound sleep) Check document was signed by the facility's licensed nurses for three of 30 shift opportunities. This deficient practice had the potential to place the facility at an increased risk for the potential loss or diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) controlled substances. Findings: During a concurrent interview and record review on 12/15/2023 at 6:15 p.m., with Registered Nurse 1 (RN 1) reviewed the facility's document titled Shift Change Narcotic Check for the month of 12/2023, located in the nurse's station's medication room. RN 1 stated that at the beginning and end of each shift licensed nurses, both oncoming licensed nurse and out-going licensed nurse, will count narcotic medications to ensure the narcotic medication count is accurate. RN 1 stated both licensed nurses who performed the count will then sign the Shift Change…

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 document temperatures for three of three refrigerators and one of one freezer located in the facility's medication room as per the facility's policy and procedure. This deficient practice had the potential to compromise the therapeutic effectiveness of stored medication. Findings: During a concurrent interview and record review on 12/15/2023 at 6:37 p.m., with Registered Nurse 1 (RN 1), reviewed the medication room refrigerator and freezer temperature logs. RN 1 stated there were no temperatures documented for the Coronavirus disease-2019 [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection] freezer, the COVID-19 refrigerator, the top medication refrigerator, and the bottom medication refrigerator for 12/13/2023 during the 7 p.m.-7 a.m. shift. RN 1 stated that temperature logs should be checked and documented every shift to ensure that the refrigerators and freezers are at the proper temperatures for medication storage. A review of the facility's policy and procedure…

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 implement the infection control practices by: 1. Failing to ensure one of three sampled staff (Housekeeping Staff [HS]) removed their gloves prior to exiting a resident's room and entering another resident's room. 2. Failing to ensure the facility's Infection Preventionist (IP) was able to articulate the facility's water management process to reduce the risk of Legionnaires' disease (a severe form of pneumonia [lung inflammation usually caused by infection]). The deficient practices had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents. 3. Failing to ensure gastrostomy feeding tube (GT- a tube inserted through the belly that brings nutrition directly to the stomach) was off the floor for one of one sampled resident (Resident 15). This deficient practice had the potential to result in…

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

Based on interview and record review the facility failed to implement the facility's antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics [a medicine that inhibits the growth of or destroys bacteria or germs]) by failing to provide documented evidence of the facility's monthly surveillance monitoring report for 11 of 11 months reviewed (1/2023- 11/2023). This deficient practice had the potential for residents to develop antibiotic resistance from unnecessary or inappropriate antibiotic use for future infections. Findings: During a concurrent interview and record review on 12/18/2023 at 6:43 p.m., with the Infection Preventionist (IP), the IP stated that antibiotic stewardship program is a program that monitors antibiotic use in the facility. The IP stated the process starts when the facility receives a physician's order for antibiotics for a resident, the licensed nurses will communicate to the IP, the residents are who are on antibiotics and the facility will monitor residents who are on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the State Long-Term Care (LTC) Ombudsman (advocates for residents of nursing homes, board and care homes, and assisted living facilities) of transfers to the General Acute Care Hospital (GACH) from the facility for two of four sampled residents (Resident 13 and 15) investigated under the care area of hospitalizations. These deficient practices had the potential to deny residents protection from being inappropriately transferred or discharged . Findings: a. A review of Resident 13's admission Record indicated the facility originally admitted the resident on 1/10/2018 and readmitted on [DATE] with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood) and gastroparesis (paralysis of the stomach). A review of Resident 13's Minimum Data Set (MDS-standardized assessment and screening tool) dated 10/11/2023, indicated the resident's cognitive (the mental action or process of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for two of seven sampled residents (Resident 13 and 5) by failing to: 1. Develop a comprehensive care plan for Resident 13's antibiotic (medicines that fight bacterial infections) therapy after they were readmitted to the facility with ongoing treatment for pneumonia (infection that affects one or both lungs). 2. Develop a comprehensive care plan for Resident 5 who had a physician order for hand mittens. These deficient practices had the potential for residents' needs not being provided and placed the residents at risk not to attain or maintain the residents' highest practicable level of physical, mental, and psychosocial well-being. Findings: a. A review of Resident 13's admission Record indicated the facility originally admitted…

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 facility provided care and services to maintain good grooming and personal hygiene for one of three sampled residents (Resident 5). This deficient practice resulted in Resident 5 having long fingernails that had the potential to result in a negative impact on the residents' self-esteem and self-worth. Findings: A review of Resident 5's admission Record indicated the facility admitted the resident on 1/27/2010 with diagnoses that included spastic quadriplegic cerebral palsy (a form of cerebral palsy [a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth] that affects both arms and legs and often the torso and face), chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), and encounter for attention to tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs). A review of Resident 5's Minimum Data Set…

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 their enteral tube feeding (method of feeding that uses the gastrointestinal tract [relating to the stomach and intestines] to deliver nutrition and calories) policy by failing to ensure the gastrostomy tube (GT-an opening to the stomach from the abdominal wall made surgically for the introduction of food and medication) feeding formula was labeled with the time, date, and initial of the licensed nurse that first administered the feeding formula for one of three sampled residents (Resident 18). This deficient practice had the potential to result in the feeding formula to remain for more than the allotted time which could potentially cause an upset stomach and/or diarrhea. Findings: A review of Resident 18's admission Record indicated the facility readmitted the resident on 4/27/2023 with diagnoses that included Lennox-Gastaut Syndrome (a severe condition characterized by repeated seizures [a burst of uncontrolled electrical activity between brain cells] that begin early in life), feeding…

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 residents' admission pain risk assessment was accurately completed for two of three sampled residents (Resident 189 and Resident 33) This deficient practice had the potential to result in Resident 189 and Resident 33 not maintaining the highest possible level of comfort. Findings: a. A review of Resident 189's admission Record indicated the facility admitted the resident on 11/21/2023 with diagnoses that included paraplegia (loss of muscle function in the lower half of the body, including both legs), chronic respiratory failure (condition in which your blood doesn't have enough oxygen), and encounter for attention to tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs). A review of Resident 189's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 11/28/2023, indicated Resident 189 had unclear speech, usually made self-understood, and usually had 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.