North Valley Nursing Center

Based on observation, interview, and record review, the facility failed to maintain infection control measures by failing to ensure Certified Nursing Assistant 1 (CNA 1) did not place her personal bag on a chair inside the resident's room for one of three sampled residents (Resident 48). This deficient practice placed Resident 48 at risk for exposure and possibly contracting infectious microorganisms. Findings: During a review of Resident 48's admission Record, the admission Record indicated the facility originally admitted Resident 48 on 4/2/2022 and re-admitted the resident on 1/16/2023 with diagnoses that included chronic (long-standing) congestive heart failure (CHF - progressive condition where the heart muscle becomes too weak or stiff to pump blood efficiently), rhabdomyolysis (a medical condition where damaged muscle tissue rapidly breaks down and dies), and immunodeficiency (body's defense system to fight infection is weakened) due to conditions. During a review of Resident 48's Minimum Data Set (MDS - a resident assessment tool) dated 3/17/2026, the MDS indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure to provide the name of the medication and its indication (reason for the use of the medication) prior to administration of the medication, affecting one (1) of five (5) residents observed for medication administration (Resident 3). This deficient practice violated Resident 3's rights to make decisions regarding their medication regimen, withhold treatment or seek alternatives, potentially resulting in psychosocial harm. Findings: During a review of Resident 3's admission Record (a document containing demographic and diagnostic information,) dated 3/24/2025, the record indicated Resident 3 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including diabetes (a disease characterized by high blood sugar levels,) pain, osteoporosis (a condition where the bones become fragile) and anemia (a condition characterized by a lower-than-normal number of red blood cells.) During a review of Resident 3'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to: 1. Include the witness signatures on the Medication Disposition Record/Pass Log for seven (7) non-CMs disposed on 2/14/2025, 13 on 2/28/2025, and eight (8) on 3/23/2025. 2. Account for one (1) dose of Controlled Substances (also known as Controlled Drug and Controlled Medications [CS, CD, CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Residents 21, in one (1) of two (2) inspected medication carts (Medication Cart Station 1 Cart 1.) 3. Reconcile (the process of comparing transactions and activity to supporting documentation) one (1) medication emergency kit (ekit) containing CMs for March 2025, in one (1) of tw2 (2) inspected medication carts (Medication Cart Station 1 Cart 1.) As a result, control and accountability of medications and CS's did not follow state and federal regulations and facility policy and procedures. These deficient practices increased the opportunity for CS diversion…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Three (3) medication errors out of 28 total opportunities contributed to an overall medication error rate of 10.72% affecting two (2) of five (5) residents observed for medication administration (Resident 45 and 48.) The medication errors were as follows: 1. Resident 45 did not receive a form of vitamin B complex (a supplement containing several B vitamins used in production of red blood cells) as ordered by Resident 45's physician. 2. Resident 48 received docusate (docusate (a medication used for bowel [intestine] management,) and cyanocobalamin (a medication used to treat low levels of vitamin B12), at a different time than ordered by Resident 48's physician. These failures had the potential to result in Resident 45 and 48 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result…

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. Label one open insulin (medication used to regulate blood sugar levels) Humulin N (intermediate-acting insulin) Kwikpen (a type of device containing insulin) stored at room temperature for Resident 70, in accordance with manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Cart Station 1 Cart 1.) This deficient practice increased the risk that Resident 70 could receive medication that had become ineffective or toxic due to inadequate storage, and labeling, experience medication adverse consequences (unwanted, uncomfortable, or dangerous effects that a medication may have) resulting in the negative impact to residents' health and well-being possibly leading to health complications, hospitalization, or death. Findings: During an observation on [DATE] at 10:22 a.m., in Medication Cart Station 1 Cart 1, and in the presence of Licensed Vocational Nurse (LVN) 3, the following medication was found either…

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 keep a copy of a resident's Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) in the medical record for one (Resident 21) out of 6 sampled residents reviewed under Advance Directive. This deficient practice had the potential to create confusion, which could lead to conflict with the resident's wishes regarding his/her health care. Findings: During a review of Resident 21's admission Record, the admission Record indicated the facility admitted the resident on 7/23/2024 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and hypertension (high blood). During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool), dated 1/22/2025, the MDS indicated the resident had the ability to usually makes self- understood and the ability to usually understand others and totally dependent on staff for most activities of daily living (ADLs- activities such as…

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 update a resident's care plan (a comprehensive document that outlines a patient's healthcare needs, goals, and interventions) to reflect his current nutrition status for one (Resident 2) out of two sampled residents investigated for tube feeding (a method of providing nutrition to individuals who are unable or unwilling to eat or drink adequately). This deficient practice had the potential to result in the resident receiving incorrect care from providers. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted the resident on 3/1/1998 and readmitted the resident on 7/9/2024 with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 2's Minimum Data Set (MDS - a resident…

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

Based on observation, interview, and record review, the facility failed to ensure the resident's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) was set according to the resident's weight for one of three sampled residents (Resident 21) reviewed under the pressure ulcer/injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) care area. This deficient practice had the potential to place Resident 21 at risk for discomfort and increase the resident's risk for the development of pressure injuries. Findings: During a review of Resident 21's admission Record, the admission Record indicated the facility admitted the resident on 7/23/2024 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and hypertension (high blood pressure). During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool), dated 1/22/2025, the MDS indicated…

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

Based on interview and record review, the facility failed to ensure licensed nurses attempted nonpharmacological interventions (treatments or strategies that do not involve the use of medications) prior to administering as needed (PRN) hydrocodone-acetaminophen (medication used to treat severe pain) for one (Resident 18) out of four sampled residents reviewed for pain management. This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects such as drowsiness, constipation, and decrease in respiration. Findings: During a review of Resident 18's admission Record, the admission Record indicated the facility admitted the resident on 2/24/2025 with diagnoses including stage 3 pressure ulcer (full-thickness loss of skin; dead and black tissue may be visible) on the left buttock, history of falling, right hip pain, intervertebral disc degeneration (a condition where the cushioning discs between vertebrae in the spine break down or deteriorate, often due to aging or injury, leading to pain and potentially other issues), and poisoning…

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 that one of two sampled residents (Resident 27) investigated under dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) received services consistent with professional standards of practice by failing to ensure the pre-dialysis assessment was communicated to Resident 27's dialysis center on 3/7/2025. This deficient practice placed the resident at risk for developing complications such as bleeding at the dialysis access site, high or low blood pressure, and delays in care. Findings: During a review of Resident 27's admission Record, the admission Record indicated the facility admitted Resident 27 on 1/9/2025 and readmitted on [DATE] with diagnoses including, but not limited to, End Stage Renal Disease (ESRD-irreversible kidney failure), dependence on renal dialysis, and a left lower leg fracture. During a review of Resident 27's History and Physical (H&P) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one of 22 sampled residents (Resident 64) had accurately documented medical records when the resident's code status (a patient's documented wishes regarding the level of medical intervention to be provided in a medical emergency, specifically if their heart or breathing stops) indicated in Resident 64's Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life), dated [DATE] and signed by the physician on [DATE] was not accurately reflected in the admission Record and Interdisciplinary Care Conference meeting notes, dated [DATE]. This deficient practice placed the resident at risk for not having her wish to allow for a natural death honored. Findings: During a review of Resident 64's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were provided with a safe, clean, comfortable, and homelike environment for five of six sampled residents (Resident 2, 3, 4, 5, and 6) by failing to provide a clean bathroom. The deficient practice violated the residents' right to a comfortable, homelike environment and had the potential to negatively impact the quality of life. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated that the facility originally admitted the resident on 5/2/2024 and readmitted the resident on 8/4/2024 with diagnoses that included dementia (a progressive state of decline in mental abilities) and bipolar disorder (mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 11/7/2024, the MDS indicated the resident's cognitive (the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices by failing to ensure a shared bathroom for five of six sampled residents (Resident 2, 3, 4, 5, and 6) was not soiled with dried up feces (stool) on the bathroom floor and toilet bowl. This deficient practice had the potential to result in the spread of infection placing residents, staff, and visitors at risk to be infected with germs. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated that the facility originally admitted the resident on 5/2/2024 and readmitted the resident on 8/4/2024 with diagnoses that included dementia (a progressive state of decline in mental abilities) and bipolar disorder (mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 11/7/2024, the MDS indicated 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 that the facility use no more than two layers of linen when use a low air loss mattress (LAL - a specialty bed that alternates pressure to help heal and prevent pressure injuries [an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]) for one of two sampled residents (Resident 1). This deficient practice had the potential to impede wound healing process and cause further skin breakdown. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 4/8/2024 and readmitted the resident on 5/20/2024 with diagnoses including type two (2) diabetes mellitus (DM - a chronic condition that affects the way the body processes blood glucose [sugar]) and pressure induced deep tissue damage (damage of underlying soft tissue from pressure and/or sheer) of left buttock. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 4/15/2024, indicated Resident 1's cognition (the mental action…

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

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1), who's toenails were long, thick, and curved, received foot care and treatment. This deficient practice had the potential to result in complications such as an infection or injury to the resident and had the potential to result in a negative impact on the resident's self- esteem. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 4/8/2024 and readmitted the resident on 5/20/2024 with diagnoses including type two (2) diabetes mellitus (DM - a chronic condition that affects the way the body processes blood glucose [sugar]) and pressure induced deep tissue damage (damage of underlying soft tissue from pressure and/or sheer) of left buttock. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 4/15/2024, indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately…

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 arrange timely a nephrology (branch of medicine concerned with the kidneys) consult for one of six sampled residents (Resident 1) when on 8/10/2023, the facility admitted Resident 1 with a follow up order for a nephrology appointment in one week, however, the facility did not arrange the follow up appointment until 9/21/2023. This deficient practice had the potential to result in a delay of necessary care and services. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 8/10/2023 with diagnoses that included thoracic (middle portion of the spine) compression fracture (break in a bone caused by pressure and in which the bone collapses), rheumatoid arthritis (a disease that causes severe inflammation of the joints) and acute kidney failure (occurs when the kidneys suddenly become unable to filter waste products from the blood). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-planning tool) dated 11/17/2023, indicated Resident 1 had moderately…

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 the Physician Progress Notes (record that documents the physician's role in the assessment, evaluation, and care of residents) were completed as required, for one of six sampled residents (Resident 1). This deficient practice had the potential for inconsistent care coordination due to incomplete records and placed Resident 1 at risk for poor continuity of care and care needs. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 8/10/2023 with diagnoses that included thoracic (middle portion of the spine) compression fracture (break in a bone caused by pressure and in which the bone collapses), rheumatoid arthritis (a disease that causes severe inflammation of the joints) and acute kidney failure (occurs when the kidneys suddenly become unable to filter waste products from the blood). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-planning tool) dated 11/17/2023, indicated Resident 1 had moderately impaired cognition (mental action…

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 timely radiology ( a branch of medicine that uses imaging technology to diagnose and treat disease) service for one of six sampled residents (Resident 1) when on 9/27/2023, Resident 1's physician ordered for a magnetic resonance imaging (MRI - a noninvasive medical imaging test that produces detailed images of the internal structure of the body) for lumbar (lower part of the back) and thoracic (middle portion of the spine) compression fracture (break in a bone caused by pressure and in which the bone collapses) however, the facility did not arrange the MRI until 10/10/2023. This deficient practice had the potential to result in an undiagnosed problem which could have placed Resident 1 at higher risk for a decline in health. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 8/10/2023 with diagnoses that included thoracic compression fracture, rheumatoid arthritis (a disease that causes severe inflammation of the joints) and acute kidney failure (occurs when the kidneys…

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 permit one of six sampled residents (Resident 1) to return to the facility after hospitalization. Resident 1 was permitted to the facility on 5/24/2024. This deficient practice subjected Resident 1 to an unnecessary prolonged hospitalization. Findings: A review of Resident 1 ' s admission Record indicated the resident was originally admitted to the facility on [DATE] and then readmitted on [DATE] with diagnosis including basal cell carcinoma (a type of skin cancer that most often develops on areas of skin exposed to the sun, such as the face), tachycardia (a heart rate over 100 beats per minute [normal heart rate is 60 to 100 beats per minute]), and orthostatic hypotension (a drop in blood pressure that occurs when moving from a laying down position to a standing position). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 2/27/2024, indicated Resident 1 is able to understand others and able to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident's personal belongings were returned to the resident's representative for one of three sampled residents (Resident 1). This deficient practice resulted in the violation of Resident 1's representative's right by not receiving Resident 1's belongings upon Resident 1's discharge. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on [DATE] and readmitted on [DATE] with diagnoses that included chronic myeloid leukemia (slowly progressing and uncommon type of blood-cell cancer that begins in the bone marrow [a spongy substance found in the center of the bones]), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dysphagia (difficulty swallowing), dementia (impaired ability to remember, think, or make decisions that interferes with a resident's daily life and activities), and benign prosthetic hyperplasia (a condition in men in which 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 develop a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of three sampled residents (Resident 1), who was identified to have an indwelling catheter (a flexible plastic or rubber tube that is inserted into the bladder to drain the urine). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 4/14/2022 and readmitted on [DATE] with diagnoses that included chronic myeloid leukemia (slowly progressing and uncommon type of blood-cell cancer that begins in the bone marrow [a spongy substance found in the center of the bones]), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dysphagia (difficulty swallowing), 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 to ensure one of three sampled residents (Resident 1) received care and services in accordance with professional standards of practice by failing to: 1. Administer Resident 1's Acetaminophen (a medication used to relieve mild to moderate pain) as prescribed by the Attending Physician when resident reported a ten out of ten pain on 12/28/2022. 2. Ensure a pain risk assessment was completed when a new onset of pain was identified on 12/28/2022 and quarterly as per facility policy. These deficient practices resulted in Resident 1 experiencing severe untreated pain (pain rated at ten out of ten, on a pain scale from zero to ten, where ten is the worst possible pain) on 12/28/2022 and placed Resident 1 at risk for further pain and suffering. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 4/14/2022 and readmitted on [DATE] with diagnoses that included chronic myeloid leukemia (slowly progressing and uncommon…

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 facility's medication administration policy by failing to ensure a licensed nurse signed the Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) after administering Albuterol Sulfate (a medication used to treat wheezing [a high pitched or coarse whistling sound heard when one breathes] and shortness of breath (SOB) caused by breathing problems) to one of three sampled residents (Resident 1) on 3/7/2023. This deficient practice had the potential to result in medication errors and had the potential to result in confusion on the delivery of care and services. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 4/14/2022 and readmitted on [DATE] with diagnoses that included chronic myeloid leukemia (slowly progressing and uncommon type of blood-cell cancer that begins in the bone marrow [a spongy substance…

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 that orientation was provide to hospice (a type of medical care for residents who are in the last stages of life) staff as per facility for two of two sampled residents (Resident 1 and Resident 2) as per facility policy. This deficient practice had the potential to delay coordination and delivery of hospice services. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 7/20/2022 and readmitted Resident 1 on 1/30/2023 with diagnoses that included chronic myeloid leukemia (slowly progressing and uncommon type of blood-cell cancer that begins in the bone marrow [a spongy substance found in the center of the bones]), Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), dysphagia (difficulty swallowing), dementia (impaired ability to remember, think, or make decisions that interferes with a resident's daily life and activities), and benign…

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. Ensure licensed nurses signed one of six sampled resident's (Resident 49) Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) for 3/2024 after administering Hydrocodone-Acetaminophen (Norco- medication that treats pain) and Alprazolam (medication to treat anxiety [feeling of uneasiness]) to the resident. 2. Ensure licensed nurses signed one of six sampled resident's (Resident 65) MAR for 3/2024 after administering Lorazepam (medication for anxiety) 0.5 mg to the resident. 3. Ensure licensed nurses signed one of six sampled resident's (Resident 139) MAR for 3/2024 after administering zolpidem tartrate (a medication given to treat insomnia) 10 mg to the resident. 4. Ensure the controlled medication (a type of medication with a high potential for abuse) Norco was disposed rather than placing it back into the bubble pack (plastic packaging in which a medication is stored…

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 Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) was acted upon for two of five sampled residents (Resident 51 and 12 by failing to: 1. Ensure the pharmacist recommendation on 9/26/2023 to verify duration of therapy of Lovenox (anticoagulant medication [blood thinner]) and consider oral replacement was discussed with the provider and provide a rationale why Lovenox was only discontinued on 12/19/2024 for Resident 51. This deficient practice has placed the resident at an increased risk of experiencing adverse side effects (unwanted undesirable effects that are possibly related to a drug) such as bleeding and pain on injection site during medication administration. 2. Ensure the pharmacy recommendation for a dose reduction of Ambien (can treat insomnia [inability to sleep]) was discussed with the provider 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 monitor a resident's behaviors for all nursing shifts, who was prescribed an antipsychotic medication (medications used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]) for one of five sampled residents (Resident 46) investigated for unnecessary medications. This deficient practice had the potential to result in adverse reaction (undesired harmful effect resulting from a medication or other intervention) or impairment in the resident's mental or physical condition. Findings: A review of Resident 46's admission Record indicated the facility admitted the resident on 2/3/2022 with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 46's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/2/2024, indicated Resident 46 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought,…

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 safe and sanitary food storage and food preparation practices by failing to: 1. Ensure three packs of frozen sliced ham and four packs of frozen ribs observed in the facility freezer were labeled with a received date (the date a food is first delivered to the facility). 2. Ensure newly delivered was not stored directly on the facility floor. These deficient practices had the potential to place 80 of 84 residents that receive food from the facility's kitchen, at increased risk of experiencing foodborne illness (an illness that comes from eating contaminated food or drinks). 3. Ensure leftover food brought from outside was stored in the refrigerator or discarded for one of one sampled resident (Resident 12). This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) for Resident 12. Findings: 1. During a concurrent observation and interview 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 protect one of three sampled residents' (Resident 70) personal belongings upon the resident's discharge to the General Acute Care Hospital (GACH) This deficient practice resulted in the loss of Resident 70's pants, shirts, socks, and phone charger without reimbursement from the facility. Findings: A review of Resident 70's admission Record, indicated Resident 70 was originally admitted to the facility on [DATE]. The resident was then readmitted on [DATE] with a diagnosis of basal cell carcinoma of skin (skin cancer). A review of Resident 70's History & Physical, dated 1/30/2024, indicated Resident 70 had the capacity to understand and make decisions. A review of Resident 70's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) dated 2/27/2024 indicated Resident 70 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 71) and/or responsible party (RP) the right to be informed of in advance of the risks and benefits of a psychoactive medication (medications capable of affecting the mind, emotions, and behavior), Depakote (mood stabilizer medication), when the medication order was documented incorrectly on informed consent forms. This failure resulted in a violation of Resident 71's and their responsible party's right to make an informed decision regarding the use of a psychoactive medication. Findings: A review of Resident 71's admission Record indicated the facility readmitted the resident on 2/6/2024 with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), and psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality). It also…

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

Based on interview and record review, the facility failed to develop a baseline care plan (a written document that summarizes a patient's needs, goals, and care) within 48 hours of admission for one of one sampled resident (Resident 82) investigated under anticoagulant (medication that stops your blood from clotting too easily) use. This deficient practice had the potential to result in a negative impact on residents' health and safety, as well as the quality of care and services received. Findings: A review of Resident 82's Face Sheet (admission record) indicated the facility originally admitted the resident on 2/6/2024 and readmitted the resident on 3/18/2024, with diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), gastro-esophageal reflux disease (stomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach) and chronic obstructive pulmonary disease (COPD - a chronic lung disease that makes it difficult to breathe). 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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a form where licensed nurses can summarize a person's health conditions, specific care needs, and current treatments) for one of four sampled residents (Resident 46) for a diagnosis of diabetes mellitus (DM, a chronic condition that affects the way the body processes blood glucose [sugar]). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 46. Findings: A review of Resident 46's admission Record indicated the facility admitted the resident on 2/7/2024 with diagnosis of DM. A review of Resident 46's History & Physical (H&P - a formal assessment of a patient and their problem) dated 2/9/2024, indicated that Resident 46 has DM. A review of Resident 46's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 2/22/2024, indicated Resident 46 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that Medical Doctor 1 (MD 1) signed the physician orders for one of three sampled residents (Resident 71) during MD 1's visit to the facility. This deficient practice had the potential for confusion, poor continuity of care and follow-up on the resident's status. Findings: A review of Resident 71's admission Record, dated 4/3/2024, indicated the resident was readmitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (brain dysfunction caused by diseases or toxins in the body), dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities) and psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality). The admission record indicated Resident 71's primary physician as MD 1. A review of Resident 71's History and Physical (H&P- a term used to describe a physician's examination of a…

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

Based on observation, interview and record review, the facility failed to ensure the control solution (a solution containing sugar that is used to checking that the glucometer [a blood glucose {blood sugar} monitoring machine] is working as intended) was labeled with an open date (when a nurse first opens the container and writes the date it is open to ensure it is removed from circulation in a timely manner) in one of three medication carts (Station 1 Medication Cart). This deficient practice had the potential to compromise the therapeutic effectiveness of the control solution and can lead to inaccurate glucometer readings. Findings: During a concurrent medication cart observation and record review with Licensed Vocational Nurse 1 (LVN 1) on 4/01/2024 at 3:55 p.m., observed the control solution for the glucometer for Station 1 Medication Cart with no open date documented. LVN 1 confirmed by stating that the control solution for the glucometer did not have an open date documented. During an interview and concurrent record review with the DON on 04/02/24 at 2:20 p.m., the [NAME]…

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 maintain accurate and complete clinical records in accordance with accepted professional standards and practices for two of two sampled resident's (Resident 48 and Resident 71) Physician Documentation of Informed Consents (PDIC - informed consent) by failing to: 1. Ensure Resident 48's PDIC for Wellbutrin (medication used to treat depression) 100 milligrams (mg, a unit of measurement) was signed and dated. 2. Ensure Resident 71's PDIC for Depakote (mood stabilizer medication) 125 mg was dated by the physician who obtained the informed consent. This failure had the potential to result in confusion in the care and services for Resident 48 and Resident 71 and placed the residents at risk of receiving unwanted treatment and/or not receiving appropriate care based on their wishes due to incomplete resident medical care information. Findings: a. A review of Resident 48's admission Record indicated the facility readmitted the resident on 3/4/2024 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.

Based on observation, interview, and record review, the facility failed to: 1. Ensure a resident's nasal cannula (device used to deliver supplemental oxygen placed directly on a resident's nostrils) oxygen tubing was not touching the floor for one of two sampled residents (Resident 82) investigated for infection control. This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. 2. Based on observation, interview, and record review, the facility failed to maintain infection control practices by failing to ensure one of one sampled resident's (Resident 138) nasal cannula was labeled and dated. This deficient practice had the potential to cause contamination of the oxygen tubing. Findings: 1. A review of Resident 82's Face Sheet (admission record) indicated the facility originally admitted the resident on 2/6/2024 and readmitted the resident on 3/18/2024, with diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's 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 observation, interview, and record review, the facility failed to fix one of one sampled resident's (Resident 28) call light (device used by residents that when pressed informs facility staff that assistance is being requested) after being told by Resident 28 that his light was not functioning. This deficient practice had the potential to cause a delay in resident care and for the residents' needs to remain unmet. Findings: A review of Resident 28's admission Record indicated the facility admitted the resident on 1/29/2024 with diagnosis of diabetes mellitus (DM, a chronic condition that affects the way the body processes blood glucose [sugar]). A review of Resident 28's History & Physical (H&P - a formal assessment of a patient and their problem), dated 1/31/2024, indicated Resident 28 had the capacity to understand and make decisions. A review of Resident 28's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) dated 1/15/2024, indicated Resident 28 had intact cognition (the mental action or process of acquiring knowledge and understanding…

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 staff failed to assess and document the dialysis access sites accurately and completely for two of two sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to result in confusion regarding Resident 1 and Resident 2 ' s access site condition and in identifying the patency of the dialysis access site that could lead to a delay in receiving hemodialysis (HD or dialysis – a process of purifying the blood of a person whose kidneys are not working normally through a machine that removes blood from your body, filters it through a dialyzer [artificial kidney] and returns cleansed blood back to the body) treatment. Findings: 1. A review of Resident 1 ' s admission Record indicated the facility originally admitted the resident on 4/27/2023 and readmitted Resident 1 on 1/5/2024 with diagnoses that included end stage renal (kidney) disease (ESRD - kidneys are no longer able to work as they should to meet the body's needs) dependent 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 ensure one of two sampled residents (Resident 1), who required hemodialysis (HD or dialysis – a process of purifying the blood of a person whose kidneys are not working normally through a machine that removes blood from your body, filters it through a dialyzer [artificial kidney] and returns cleansed blood back to the body) treatment, received care in accordance with standards of practice by failing to ensure Resident 1 ' s order for Vancomycin (a medication used to treat serious bacterial infections) intravenous (IV - a method of putting fluids, including drugs, into the bloodstream) therapy was transcribed (documented) in the resident ' s physician orders. These deficient practices had the potential to place the resident at risk for unidentified complications of the antibiotic (medication that treats infection) medication administered during the dialysis treatment. Findings: A review of Resident 1 ' s admission Record indicated the facility originally admitted the resident on 4/27/2023 and readmitted Resident 1 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 implement a person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for three of three sampled residents (Resident 1, Resident 2, and Resident 9). This deficient practice had the potential to result in a delay in or lack of delivery of care and services. Findings: a. A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 8/11/2023 and with diagnoses including end stage renal disease (ESRD- kidneys no longer function well enough to meet the needs of daily life), dependent on hemodialysis (HD - a procedure that helps removes waste from the blood when the kidneys can no longer do their job), pleural effusion (water in the lungs) and acute embolism (blood clots). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/20/2023, indicated that Resident 1 had intact cognition (ability to think and make…

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

Based on interview and record review, the facility failed to develop baseline care plans for one of three sampled residents (Resident 8) within 48 hours of admission. This deficient practice had the potential for the facility not to meet Resident 8 ' s immediate care needs. Findings: A review of Resident 8 ' s admission Record indicated the facility admitted the resident on 9/5/2023 with diagnoses including metabolic encephalopathy (ME - a problem in the brain caused by a chemical imbalance in the blood, and the imbalance is caused by an illness or organs that are not working as well as they should), dementia (a group of thinking and social symptoms that interferes with daily functioning), and chronic kidney disease (kidneys are damaged and can't filter blood the way they should). A review of Resident 8 ' s Minimum Data Set (MDS - a standardized assessment and screening tool) dated 9/9/2023, indicated the resident understood others and was understood by others. The MDS further indicated Resident 8 required extensive assistance from staff with walking, dressing, and personal 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that one of three sampled residents (Resident 2), with a peripherally inserted central catheter (PICC line-a long, flexible catheter [thin tube] that's put into a vein) was provided with a PICC line dressing change (a PICC line requires that the dressing be changed every seven (7) days or as needed due to the high risk of infection) on 9/1/2023 as ordered by the physician. This deficient practice placed Resident 2 at increased the risk for sepsis (the body's extreme response to an infection. Sepsis is a life-threatening medical emergency ) from a central line-associated bloodstream infection (CLABSI- a serious infection that occurs when germs [usually bacteria or viruses] enter the bloodstream through the central line). Findings: A review of Resident 2 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses including cellulitis (infection of the skin) of right lower limb (right leg) and osteoarthritis…

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 a residents' History and Physical (H&P) was documented and placed in one of three sampled resident ' s (Resident 8) medical record by the physician within the same day of his visit in which the assessment was completed as per facility policy. This deficient practice had the potential to result in a risk of poor continuity of care. Findings: A review of Resident 8 ' s admission Record indicated the facility admitted the resident on 9/5/2023 with diagnoses including metabolic encephalopathy (ME - a problem in the brain caused by a chemical imbalance in the blood, and the imbalance is caused by an illness or organs that are not working as well as they should), dementia (a group of thinking and social symptoms that interferes with daily functioning), and chronic kidney disease (kidneys are damaged and can't filter blood the way they should). A review of Resident 8 ' s Minimum Data Set (MDS - a standardized assessment and screening tool) dated 9/9/2023, indicated the resident understood others and was understood by…

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 maintain complete and accurate medical records for one of three sampled residents (Resident 2), when Registered Nurse 1 (RN 1) falsely documented that he provided a peripherally inserted central catheter (PICC line-a long, flexible catheter [thin tube] that's put into a vein) dressing change (a PICC line requires that the dressing be changed every seven [7] days or as needed due to the high risk of infection) as ordered by the physician for one of three sampled residents (Resident 2) on 9/1/2023. This deficient practice had the potential to result in confusion regarding Resident 2 ' s condition and what care and services provided to Resident 2. Findings: A review of Resident 2 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses including cellulitis (infection of the skin) of right lower limb (right leg) and osteoarthritis (flexible tissue at the ends of the bones wears down, causing pain and stiffness). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain infection prevention and control practices for one of three sampled residents (Resident 2) with a peripherally inserted central catheter (PICC line-long, flexible catheter (thin tube) that's put into a vein), when Registered Nurse 1 (RN 1) failed to provide Resident 2 with a PICC line dressing change (a PICC line requires that the dressing be changed every seven [7] days or as needed due to the high risk of infection) on 9/1/2023 as ordered by the physician. This deficient practice placed Resident 2 at increased the risk for sepsis (the body's extreme response to an infection. Sepsis is a life-threatening medical emergency ) from a central line-associated bloodstream infection (CLABSI- a serious infection that occurs when germs [usually bacteria or viruses] enter the bloodstream through the central line). Findings: A review of Resident 2 ' s admission Record indicated the resident was admitted on [DATE] 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.