High Valley Lodge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to label and properly store food brought by family/ visitors for one out of nine residents (Resident 44), in accordance with the facility's Policy and Procedure (P&P) titled, Foods brought in by family/ visitors. This deficient practice had the potential to result in food borne illnesses (any illness resulting from eating contaminated/spoiled foods) and also lead to other serious medical complications and hospitalization for Resident 44. Findings:During a review of Resident 44's admission Record, the admission record indicated Resident 44 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 44's diagnoses included anemia (a condition where the body did not have enough healthy red blood cells) and ulcerative pancolitis (a chronic inflammatory bowel disease). During a review of Resident 44's Minimum Data Set (MDS - a resident assessment tool), dated 6/7/2025, the MDS indicated Resident 44's cognition (ability to…

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

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) completed ten hours of continuing Infection Prevention and Control education on an annual basis. This failure had the potential for the IP to be unaware and be unable to educate the facility's staff of updated information regarding Infection Prevention and Control practices.Findings:During an interview on 8/6/2025 at 10:30 a.m., with the facility's Infection Preventionist (IP), the IP stated he was not able to provide documentation indicating the completion of ten hours of continuing education in infection prevention and control for 2024. The IP stated he completed continuing education hours when he renewed his nursing license, however, those hours were not obtained in 2024. The IP stated it was his responsibility to complete ten hours of infection prevention and control education annually to ensure he was aware of any new guidelines or studies that were released and to be up to date with current infection prevention and control practices. During an interview on 8/7/2025 at 8:58…

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. Ensure that a resident's physician's orders to flush (gently pushing water through the tube to clean it) the gastrostomy tube (G-Tube, a tube inserted through the abdomen that brings nutrition and medications directly to the stomach) with five to 10 milliliters (ml-unit of measure) of water in between the administration of each medication for one of 13 sampled residents (Resident 6) was followed. 2. Ensure that facility staff verified tube placement (when a healthcare professional pushes air into the g-tube and listens to hear a gurgling sound in the stomach with a stethoscope [a medical instrument that allows a person to listen to sounds inside the body]; when a healthcare professional aspirates (pulling back of the plunger of a syringe to check if there are contents in the stomach) the syringe to check the stomach contents) when administering medications through a gastrostomy tube (G-tube -a plastic tube inserted into a resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Act upon the pharmacist's recommendation, dated 6/13/2024, to add vitamin B12 (supplement) to a resident's medication regimen for one of 13 sampled residents (Resident 15). 2. Act upon the pharmacist's recommendation, dated 4/29/2024, to discontinue a resident's docusate sodium (stool softener) for one of 13 sampled residents (Resident 15). 3. Document a rationale for why the physician disagreed with the pharmacist's recommendation for one of 13 sampled residents (Resident 8). These deficient practices had the potential to place the residents at increased risk of receiving unnecessary medications or experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: a. During a review of Resident 15's Face Sheet (admission record), the document indicated the facility originally admitted the resident on 1/18/2012 and readmitted the resident on 5/29/2020 with diagnoses including type 2 diabetes…

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: 1. Ensure licensed nurse did not leave two medicine cups with medications unattended. This deficient practice has the potential to result in unwanted serious side effects if placed in undesired hands which can lead to harm. 2. Ensure an open multi dose vial of Lidocaine 1% (local anesthetic agent [causes a loss of feeling in one small area of the body]) was labeled with an open date. This deficient practice had the potential to compromise the therapeutic effectiveness of the medication. 3. Ensure Licensed Vocational Nurse 1 (LVN 1) did not leave prepared medications unattended at a resident's bedside for one of 13 sampled residents (Resident 6). This deficient practice had the potential to result in unauthorized personnel or residents having access to the unattended medications. Findings: 1. During an observation on 8/9/2024 6:12 p.m., observed two medicine cups with medications on top of a medication cart, left unattended. During a concurrent observation and interview on 8/9/2024 at 6:20 p.m., with Licensed…

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: 1. Ensure there was no moldy food inside the designated resident refrigerator. 2. Ensure a bag of prepared French toast found inside the refrigerator in the kitchen was labeled with the date it was prepared. 3. Ensure that food found inside the designated resident refrigerator was labeled with a resident identifier and the date it was placed inside the refrigerator. These deficient practices had the potential to place 44 out of 48 residents living in the facility at risk for foodborne illness (illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent observation and interview on 8/9/2024 at 6:17 p.m., observed the kitchen refrigerator with Dietary Aide 1 (DA 1). Certified Nursing Assistant 1 (CNA 1) provided translation assistance. Inside the refrigerator, observed an unlabeled clear plastic bag with something wrapped in foil inside it. When DA 1 opened the bag and the foil, DA 1 stated it contained prepared slices of French toast. DA 1 stated it should have been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1.Ensure a resident's urinal was not placed hanging on a trash receptacle for one of two sampled residents (Resident 7). 2. Ensure a resident's urinal had the residents' name on the urinal for two of two sampled residents (Resident 7 and Resident 33). This deficient practice had the potential to result in contamination of the residents' care equipment and place residents at risk for and place the residence at risk for infection. 3. Ensure staff did not store their personal food inside the kitchen refrigerator along with the residents' food. This deficient practice had the potential to place 44 out of 48 residents living in the facility at increased risk of infection. Findings: a. A review of Resident 7's admission Record indicated the facility admitted the resident on 3/3/2024 with diagnoses that included fracture (broken bone) of unspecified part of neck of right femur (thighbone), age related osteoporosis (a condition in which bones…

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 call lights (a device used by a resident to signal his/her need for assistance from staff) were within residents' reach while in bed for two out of three sampled residents (Resident 6 and Resident 25). This deficient practice had the potential to delay the provision of services and residents' needs not being met. Findings: a. A review of Resident 6's admission Record indicated the facility readmitted the resident on 9/16/2023 with diagnoses that included encounter for attention to gastrostomy (the creation of an artificial external opening into the stomach for nutritional support), hypotension (low blood pressure), and dysphagia (difficulty swallowing). A review of Resident 6's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 6/26//2024, indicated Resident 6's cognition (a mental process of acquitting knowledge and understanding) is severely impaired. The MDS indicated Resident 6 is dependent with eating,…

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 protect the resident's right to be free from verbal abuse (at type of abuse that uses language) for one of two sampled residents (Resident 36), when on 8/7/24, Resident 32 called Resident 36 an asshole while pointing at Resident 36 in the main dining room. This deficient practice resulted in Resident 36 being subjected to verbal abuse while under the care of the facility. Residents whoa re subjected to verbal abuse are at increased risk for low self-esteem (when someone lacks confidence in themselves and their abilities), anxiety (a feeling of fear, dread, and uneasiness), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities for long periods of time) and social isolation (.when someone has few or no social connections or support, and lacks relationships with others). Findings: During a review of Resident 36's Face Sheet (admission Record), the face sheet indicated the facility admitted the resident 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 develop and or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report to the State Survey Agency (SSA) an allegation of verbal abuse ( at type of abuse that uses language) for one of two sampled residents (Resident 36). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse. Findings: During a review of Resident 36's Face Sheet (admission Record), the face sheet indicated the facility admitted the resident on 11/29/2023, with diagnoses including heart failure (occurs when the heart can't pump enough blood and oxygen to support the body's organs). During review of Resident 36's Minimum Data Set (MDS- an assessment and care screening tool) dated 3/26/2024, the MDS indicated Resident 36's cognitive (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise and renew a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for two of three sampled residents (Resident 18 and 4). This deficient practice had the potential to result in failure to deliver the necessary care and services. Findings: a. During review of Resident 18's Face Sheet (admission Record) indicated the facility originally admitted the resident on 3/02/2022 and readmitted on [DATE] with diagnoses that included hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 18's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/28/2024, the MDS…

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 that to ensure that two of three sampled residents (Resident 47 and Resident 45), who were assessed and identified to be a candidate for the facility's bowl (a tube-shaped organ in the abdomen that helps the body digest food and absorb nutrients) and bladder (a sac-shaped muscular organ that stores the urine secreted by the kidneys) retraining program (when facility staff assist a resident to the restroom at specific timed intervals) , were placed on the bowel and bladder retraining program per facility policy. This deficient practice has the potential for Resident 47 and Resident 45 to not to achieve or restore normal bowel and bladder function. Findings: 1. During a review of Resident 47 admission Record, the admission Record indicated the facility admitted Resident 47 on 9/13/2023 with diagnoses that included arthritis of the right knee (swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age),…

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 one of two sampled residents (Resident 6), was observed to have bed side rails in place despite being evaluated that bed side rails were not recommended for use. This deficient practice had the potential for inappropriate use of bed rails that could lead to entrapment (when a person is trapped by the bed rail in a position they cannot move from) and result to injury. Findings: A review of Resident 6's admission Record indicated the facility readmitted Resident 6 on 9/16/2023 with diagnoses that included encounter for attention to gastrostomy (the creation of an artificial external opening into the stomach for nutritional support), degenerative disease of the nervous system (conditions that gradually damage and destroy parts of your nervous system [organized network of nerve tissue in the body] especially areas of the brain), hypotension (low blood pressure), and dysphagia (difficulty swallowing). A review of Resident 6's Minimum Data Set (MDS- a standardized assessment and screening tool) dated…

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

Based on interview and record review, the facility failed to implement the facility's policy on medication administration by failing to ensure one of three sampled resident's (Resident 19) administration of Ambien (medication used to treat insomnia [persistent problems falling and staying asleep]) was accurately reflected on the Controlled Drug Record (accountability record of medications that are considered to have a strong potential for abuse). This deficient practice had the potential to result in medication errors and had the potential to result in confusion on when the medication was administered. Findings: During a review of Resident 19's admission Record indicated the facility originally admitted the resident on 5/5/2017 and readmitted the resident on 4/19/2019 with diagnoses that included anxiety disorder, and unspecified mood disorder (also known as affective disorder, described by marked disruptions in emotions (severe lows or highs), and hypertension (high blood pressure). During a review of Resident 19's Minimum Data Set (MDS - a standardized assessment and screening…

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 laboratory services timely for one of three sampled residents (Resident 45). This deficient practice placed Resident 45's well-being at risk and had the potential for the resident not to receive appropriate care and treatment in a timely manner. Findings: A review of Resident 45's admission Record indicated the facility admitted Resident 45 on 9/23/2022 with diagnoses that included encephalopathy (brain disease that alters brain function or structure), essential hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]) without complications. A review of Resident 45's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 7/9/2024, indicated Resident 45's cognition (a mental process of acquitting knowledge and understanding) was intact. The MDS indicated that Resident 45 required set up or clean up assistance with eating, oral hygiene,…

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 Licensed Vocational Nurse 3 (LVN 3) did not willfully falsify (knowingly make a false entry into a resident's medical record) the medication administration of Ativan (brand name for lorazepam, a medication used for anxiety [a feeling of fear, dread, and uneasiness]) on 8/9/2024 for one of two sampled residents (Resident 19). This willful material falsification (WMF - when staff purposefully documents false information in a medical record) resulted in Resident 19's clinical record falsely reflecting the care provided. Findings: During a review of Resident 19's admission Record indicated the facility originally admitted the resident on 5/5/2017 and readmitted the resident on 4/19/2019 with diagnoses that included anxiety disorder, and unspecified mood disorder (also known as affective disorder, described by marked disruptions in emotions (severe lows or highs), and hypertension (high blood pressure). During a review of Resident 19's Minimum Data Set (MDS - a standardized assessment and screening tool)…

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 hospice care (specialized care that provides physical comfort and emotional, social, and spiritual support for people nearing the end of life) staff was present for two Interdisciplinary Team (IDT-a group of healthcare professionals from different disciplines who work together to treat a resident) meeting for one of one sampled resident (Resident 18). This deficient practice had the potential to result in a delay or lack of coordination in delivery of hospice care and services to one of one sampled resident (Resident 18). Findings: During review of Resident 18's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted Resident 18 on 3/02/2022 and readmitted Resident 18 on 8/23/2023 with diagnoses that included hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), Type 2 Diabetes Mellitus (A long-term condition in which the body has trouble controlling blood sugar and using it for energy), and dementia (impaired ability 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 develop and or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report to the State Survey Agency (SSA) two incidents of injuries of unknown origin (injuries resulting without knowing how it happened) that occurred on 4/15/2023 and 12/12/2023 for one of four sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse. Findings: 1. A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included functional quadriplegia (paralysis [unable to move some or all of body] below the neck that affects all of a person's limbs [arms and legs]) and osteoporosis (a disease in which bones become fragile and more…

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 plan for an individual's specific health needs and desired health outcomes) for one of four sampled residents (Resident 1). This deficient practice had the potential to result in a delay in or lack of delivery of care and services. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included functional quadriplegia (paralysis [unable to move some or all of body] below the neck that affects all of a person's limbs [arms and legs]) and osteoporosis (a disease in which bones become fragile and more likely to break) with pathological fracture (a broken bone caused by an underlying disease and not by force or impact). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 1/9/2024, indicated the resident's cognitive (the mental action or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents' effective pain management by failing to: 1. Document pre and post pain assessments for four of five sampled residents (Residents 4, 13, 8, and 144) investigated under the care of pain management. 2. Administer pain medication for the appropriate pain scale as indicated by the physician's orders for one of five sampled residents (Resident 144) investigated under the care area of pain management. These deficient practices may lead to inaccurate pain assessment and mismanagement of residents' pain. Findings: a. A review of the admission record indicated Resident 4 was admitted to the facility, on 09/28/2021, with diagnoses that included arthritis (inflammation of one or more joints, causing pain and stiffness that can worsen with age), acute pyelonephritis (inflammation of the kidney due to a bacterial infection), and hypertension (elevated blood pressure). A review of the Minimum Data Set (MDS - an assessment and care…

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 the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records for four of five sampled residents (Resident 4, 13, 8, and 144). This deficient practice resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: a. A review of Resident 4's Face Sheet (admission Record) indicated the resident was admitted to the facility on [DATE] with diagnoses that included arthritis (inflammation of one or more joints, causing pain and stiffness that can worsen with age), acute pyelonephritis (inflammation of the kidney due to a bacterial infection), and hypertension (elevated blood pressure). A review of…

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

Based on observation, interview, and record review, the facility failed to ensure proper food storage practices by: 1. Failing to label and date half-cut tomatoes and onions found in the facility refrigerator for 39 out of 44 residents who receive and consume food from the facility kitchen. 2. Failing to maintain a bag of potato dices off the floor in the dry storage area. These deficient practices had the potential to result in foodborne illness (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) Findings: a. During an initial kitchen tour observation, on 1/11/2022 at 8:03 a.m., observed the following unlabeled food items in the refrigerator: - two half-cut tomatoes with no date - a half-cut onion with no date During a concurrent observation and interview, on 1/11/2022 at 8:03 a.m., [NAME] 1 observed and verified the 2 half-cut tomatoes and 1 half-cut onion in the refrigerator were not labeled. [NAME] 1 stated the tomatoes and onion should…

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 infection control policy and procedure by failing to: 1. Ensure Certified Nursing Assistant 4 (CNA 4) doffed (removed) her contaminated gowns and gloves prior to leaving isolation room within the red zone (area of the facility designated only for residents with confirmed Coronavirus disease-2019 [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection]) to discard a tray in the trash bin located outside of the room. 2. Ensure Certified Nursing Assistant 5 (CNA 5) and Certified Nursing Assistant 6 (CNA 6) wore eye protection within six feet of providing care for Residents 17 and 143. 3. Ensure Licensed Vocational Nurse 1 (LVN 1) performed hand hygiene upon doffing contaminated gloves used to remove a dressing from a wound site and prior to donning (putting on) new gloves during Resident 39's wound care. 4. Check and monitor vital signs every four hours for one of one sampled resident (Resident…

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

Based on interview and record review, the facility failed to notify the resident's responsible party for 24 out of 44 residents (Residents 3, 5, 6, 11, 12, 13, 14, 16, 17, 18, 21, 24, 26, 27, 28, 29, 35, 36, 37, 38, 39, 40, 42, 142) by 5 p.m. the next calendar day following a confirmed COVID positive case within the facility. This deficient practice resulted in a delay in informing the residents' responsible parties regarding the status of the outbreak (a sudden rise in the incidence of disease) within the facility. Findings: During a phone interview, on 1/12/2022 at 1:45 p.m., Family Member 1 (FM 1) stated he was not aware of the facility's Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) outbreak (a sudden rise in the incidence of disease). FM 1 confirmed he did not receive any email, text, or phone call regarding a positive case among residents or staff within the facility. During an interview, on 1/12/2022 at 2:02 p.m., the Social Service Director (SSD) stated the responsible party of all residents are notified…

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 Resident 36's call light was within reach for one of 44 sampled residents. This deficient practice had the potential for residents not being able to summon health care workers for assistance when needed. Findings: A review of the admission record indicated Resident 36 was admitted to the facility, on 3/04/2021, with diagnoses that included diabetes mellitus (chronic condition characterized by high blood sugar), hypertension (elevated blood pressure), and repeated falls. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/04/2021, indicated Resident 36 had the ability to make self understood and the ability to understand others. The MDS indicated Resident 36 required supervision from staff with toileting and one-person limited assistance with dressing and personal hygiene. A review of Resident 36's Care Plan titled, Activities of Daily Living (ADL)/Self Care Deficit, reviewed on 12/2021, indicated an intervention to have the resident's call light within…

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 accurately reflect Resident 14's use of oxygen according to the Minimum Data Set (MDS - an assessment and care screening tool) for one out of 13 sampled residents investigated addressing accuracy of MDS assessments. The failure to accurately assess Resident 14's oxygen use had the potential to negatively affect the resident's plan of care and delivery of necessary care and services. Findings: A review of the admission record indicated Resident 14 was admitted to the facility, on 11/28/2012 with a readmission of 07/08/2021, with diagnoses that included angina pectoris (chest pain caused by reduced blood flow to the heart), chronic atrial fibrillation (irregular rapid heart rate), and moderate persistent asthma (condition in which a person's airway become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe). A review of the MDS, dated [DATE], indicated Resident 14 had the ability to make self-understood and 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 Resident 29's low air loss mattress (LALM, a pressure-relieving mattress used to prevent and treat pressure ulcers [a wound that occurs as a result of prolonged pressure on a specific area of the body]) was properly set per resident's weight, for one of two sampled residents investigated under the care area of pressure ulcer/injury. This deficient practice placed Resident 29 at risk for skin breakdown and development of pressure ulcers. Findings: A review of the admission record indicated Resident 29 was admitted to the facility, on 06/17/2013 with a readmission date of 09/17/2021, with diagnoses that included quadriplegia (paralysis of all four limbs), gastro-esophageal reflux disease (stomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach), and gastrostomy status (G-tube- a surgical procedure for inserting a tube through the stomach for feeding or drainage). A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident 3's environment remained free from accident hazards by failing to have padded side rails per physician's orders, for one of two sampled residents investigated under the care area of accidents. This deficient practice had the potential to cause injury to Resident 3. Findings: A review of the admission record indicated Resident 3 was admitted to the facility, on 07/04/2014 and readmitted on [DATE], with diagnoses that included Huntington's disease (progressive brain disorder that causes uncontrolled movements, emotional problems, and loss of thinking ability), dementia (loss of cognitive functioning- thinking, remembering, and reasoning), and gastrostomy status (G-tube- a surgical procedure for inserting a tube through the stomach for feeding or drainage). A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated 01/05/2022, indicated Resident 3 rarely/never made self-understood and usually…

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 test two out of eight sampled unvaccinated staff (Certified Nursing Assistant 1 [CNA 1] and Certified Nursing Assistant 2 [CNA 2]) twice per week for Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) during the sampled period of 01/03/2022 to 01/09/2022. This deficient practice had to potential for unvaccinated staff, who are at higher risk for contracting COVID-19, to spread infection within the facility. Findings: During a concurrent interview and record review, on 01/14/2022 at 12:14 p.m., with the Infection Preventionist (IP), the IP reviewed the COVID-19 test results for Certified Nursing Assistant 1 (CNA 1) and confirmed that she was tested on ly once during the week of 01/03/2022 to 01/09/2022 on 01/04/2022. The IP also reviewed the COVID-19 test results for Certified Nursing Assistant 2 (CNA 2) and confirmed that CNA 2 was tested on ly once during the week of 01/03/2022 to 01/09/2022 on 01/04/2022. The IP stated all unvaccinated staff are required…

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.