Vista Knoll Specialized Care Facility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents receiving antipsychotic (medication for mood, behavior, or thinking) medications had an appropriate diagnosis and monitored for side effects (SE) as recommended by the pharmacist for two of five residents (Resident 127 and Resident 16) sampled .These deficient practices placed both residents (Resident 127 and Resident 16) at risk for inappropriate treatment with psychotropic medication and undetected adverse (serious life-threatening SE) drug reactions, which could lead to dizziness, fainting, falls, or other serious complications. 1.According to the current admission Record, Resident 127 was admitted to the facility on [DATE], with a primary diagnosis of Paranoid Schizophrenia (a serious mental health condition that affects how people think, feel and behave. It may include hallucinations - seeing or hearing things that aren't there or delusions - a strong fixed belief about things that are untrue). On 9/24/25 at…

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

Based on observations and interviews the facility failed to clean up trash around the kitchen dumpsters.This failure had the potential to cause rodent and other pest infestations, which in turn could affect infection control.Findings:On 9/24/2025 at 9:08 A.M., a concurrent observation of the trash dumpsters and interview with the Dietary Manager (DM) was conducted. Three facility dumpsters were observed to be locked behind steel fencing. A pinkish-orange substance appearing to be food waste and food wrappers were observed in a two foot by two-foot area between two dumpsters. The DM stated that the expectation is that the area around the dumpsters should be clean with no food waste or debris between dumpsters. The DM stated that this could attract rodents and other pests. On 9/24/25 at 12:45 P.M., a concurrent interview with the Director of Maintenance-(DOM) and observation of pictures of dumpster area was conducted. The DOM stated after a dumpster is emptied, the maintenance workers move the dumpsters, sweep the area, and power wash the area. The DOM stated the expectation is there…

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 obtain an ordered medication from its contracted pharmacy for one resident (1), who had comfort care (care given to people who are near the end of life) orders. As a result, Resident 1 did not receive the ordered medication to provide comfort prior to his passing (dying). Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure (a condition in which the kidneys lose their ability to filter waste from the blood), pneumonia (an infection that affects the lungs), COPD (Chronic Obstructive Pulmonary Disease, a progressive lung disease that causes breathing problems), heart failure (a condition in which the heart does not pump enough blood for the needs of the body), Parkinson ' s disease (a brain disorder that causes uncontrolled movements such as shaking, stiffness and difficulty with balance), and Alzheimer ' s Disease (a progressive irreversible brain disorder that affects memory, thinking and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure showers were provided as scheduled for one of three sampled residents (Resident 1) reviewed for Activities of Daily Living (ADL). This failure had the potential to result in poor personal hygiene and decreased psycho-social well-being for Resident 1. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included chronic osteomyelitis (bone infection) of the right ankle and foot ulcer (open sore), per the facility's Face Sheet. Resident 1's history and physical, dated 11/7/23, indicated that Resident 1 was alert and oriented to person, place, and time and had the capacity to understand and make decisions. Resident 1's minimum data set (MDS- an assessment tool), dated 11/9/23, indicated Resident 1's brief interview for mental status (BIMS - resident's cognition status) was 12 (8- 12 identified as moderate impaired cognition). The MDS section G indicated Resident 1 needed minimal assistance to complete activities. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident room temperatures were kept at a comfortable and homelike level for one out of 24 sampled residents (87), five unsampled residents (1, 38, 96, 309, 312), and two confidential group residents. This deficient practice had the potential for residents to feel uncomfortable. Findings: A review of Resident 87's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 38's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 96's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 309's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 312's admission Record indicated the resident was admitted to the facility on [DATE]. On 8/23/22 at 10…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 3) was free from unnecessary psychotropic (is any medication that affects brain activities associated with mental processes and behavior.) medications as per the facility's policy & procedure. * The facility failed to attempt gradual dose reduction (GDR, the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.) and no clinical contra-indication was documented. * In addition, the facility failed to implement any non-pharmacological interventions (interventions not involving a medication for mental illness). Resident 3 was receiving several psychotropic including Anti-psychotic (used to manage/treat symptoms of some mental health disorders); Anti-depressant (used to relieve symptoms of depression); Anti-anxiety (used to treat anxiety and panic issues); and Hypnotic (used for the treatment of insomnia which…

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 clinical records of 14 residents (Residents 311, 151, 310, 309, 308, 48, 307, 306, 305, 304, 303, 302, 81, 96) in rooms A through H were stored in a safe and secure manner when the residents' clinical records were stored on a rolling bookcase in the residential hallway. This deficient practice had the potential for Residents 311, 151, 310, 309, 308, 48, 307, 306, 305, 304, 303, 302, 81, and 96's private health information to become lost, destroyed, or accessed by unauthorized persons. Findings: A review of Resident 311's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 151's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 310's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 309's admission Record indicated the resident was admitted to the facility on [DATE]. 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 ensure one of 24 sampled residents (Resident 301) was provided privacy during wound care when the resident's privacy curtain was not closed all the way. During Resident 301's wound treatment, the resident's roommate (Resident 88) was brought back to the room by staff. This deficient practice had the potential for Resident 301's care and treatment to be observed by other persons, and for the resident to feel embarrassed and undignified. Findings: A review of Resident 301's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include a stage 3 pressure ulcer (injury to the skin that extends into the fatty tissue layer) of the sacral region (area where the lower back and tailbone meet). A review of Resident 301's Minimum Data Set Assessment (MDS, an assessment tool) dated 8/18/22, indicated the resident scored 03 on the brief interview of mental status (this meant the resident was severely…

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, medical record review, and facility P&P review, the facility failed to provide pharmaceutical services to two non-sampled residents (Residents 1 & 2) to assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of the residents. * The facility failed to ensure there was a valid physician medication order for Resident 1's morphine (controlled medication used to treat moderate to severe pain) infusion via morphine pump implanted (a surgical procedure performed to permanently implant a pump that delivers morphine to the spinal fluid to treat chronic pain) on 8/3/22. * The facility also failed to ensure Percocet (oxycodone/acetaminophen, controlled medication used to treat moderate to severe pain) tablets taken out of the Resident 1's controlled drug records (CDR) were administered to Resident 1 and documented on the medication administration record (MAR). * In addition, the facility failed to ensure Resident 2's Dulera (a combination of mometasone furoate and formoterol fumarate, used to…

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

Based on interview and record review, the Consultant Pharmacist (CP) failed to report irregularities in Resident 2's Dulera inhaler (a combination of mometasone furoate and formoterol fumarate, used to prevent and lessen asthma symptoms) to the attending physician, Director of nursing and/or medical director and the facility administrator. This failure had the potential to negatively impact the resident's well-being. Findings: On 8/24/22 at 9:40 A.M., during an observation on Unit 1 with LN 2, the medication cart was inspected. Resident 2's Dulera inhaler was observed in the medication cart, labeled to inhale 1 puff every 4 hours as needed for asthma. On 8/24/22 at 9:50 A.M., during Resident 2's record review, the medication order showed Dulera inhaler, 1 puff inhale orally every 4 hours as needed for asthma ordered on 3/28/22. During an interview on 8/25/22 at 12:55 P.M., the CP stated her record showed Resident 2's Dulera inhaler order was 1 puff twice a day. The CP also stated she downloaded residents' medication orders from the facility dispensing pharmacy. Review of 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, facility P&P review, and facility document review, the facility failed to ensure medications were stored as per the facility's P&P and outdated medications were not available for residents' use. * Multiple expired medications observed in Unit 1 and Unit 2. * The opened Tuberculin PPD 1 ml vial (purified protein derivative, a multi-dose injectable solution used in skin test to determine if a patient has tuberculosis) was not labeled with the open date and was stored in the refrigerator in Unit 2 locked medication room. These failures had the potential to result in unsafe administration of medications to the residents and posed the risk of the test not showing an accurate result when determining if a resident had tuberculosis. Findings: 1. On 8/23/22 at 11:00 A.M., an inspection of house supply Medication Room in Unit 2 was conducted with LN 3. The following outdated medications were observed: Adult tussin expectorant (guaifenesin 200 mg/10 ml, used to clear mucus from the chest) 118 ml expired on 3/22 x 1 bottle. Famotidine 20 mg tablet (used to treat…

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 food was served at an appetizing and palatable temperature for two of 15 confidential group residents and during a meal test tray observation. This failure had the potential for residents not to enjoy their food. Findings: On 8/24/22 at 10:03 A.M., a confidential resident group meeting was conducted. Two out of 15 confidential residents stated that their food was not palatable because the hot food was not served hot and the cold food was not served cold. On 8/25/22 at 11:30 A.M. an observation was conducted in the facility's kitchen of the lunch time food service. At 12:33 P.M., the food was observed being placed on resident trays for Unit 2. At 1:31 P.M., the last food cart was brought to Unit 2. On 8/25/22 at 1:36 P.M., the last tray on the food cart on Unit 2 was tested. The director of dietetic services (DDS) 2, using the facility's thermometer, tested the temperatures of the food and drink items on the test tray. The facility's registered dietitian (RD) was also present. The DDS 2 tested the food…

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 1 of 2 sampled residents, Resident 81, received a selected lunch meal and a chosen lunch entree. This deficient practice had the potential to result in weight loss and further compromise the resident's medical status. Findings: Per the facility's admission record, Resident 81 was admitted on [DATE] with diagnoses including surgery on the nervous system, and traumatic subdural hemorrhage (bleeding inside the skull after an injury). On 8/23/22 at 2:35 P.M., an interview was conducted with Resident 81. Resident 81 stated, I did not get my lunch yesterday. Resident 81 further stated, The CNA said she did not see a tray for me. Someone called the kitchen and came back with a sandwich and a bag of chips. Resident 81 stated, I didn't get what I wanted, instead I ate a sandwich for lunch. On 8/24/22 at 1:20 P.M., during a concurrent observation and interview with Resident 81, Resident 81 was observed lifting the lid off the plate…

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 food was stored in accordance with food safety standards, when: - Spoiled produce was stored among non-spoiled produce. - Dented cans were stored among non-dented cans and were in circulation to be used. These deficient practices had the potential for residents to be exposed to the risk of foodborne illness. Findings: On 8/23/22 at 8:30 A.M., an observation of the facility's kitchen was conducted with the director of dietetic services (DDS) 1. The walk-in produce refrigerator was inspected. There was a large box of romaine lettuce heads. In the box, approximately five heads had large brown spots on the leaves, fuzzy gray material on the leaves, and they were secreting a slimy substance onto the other heads of lettuce that were in the box. The DDS 1 stated the whole box should have been tossed out. In the dry storage area, there was an onion that was soft and squishy and a banana that was black and slippery and leaked a gray fluid. The DDS 1 stated that spoiled produce should not have been stored with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 2 of 3 residents (43, 98) with hearing loss received the necessary services. This failure had the potential to decrease the quality of life for these two residents and could have caused communication breakdown between the residents and the staff. Findings: 1. Resident 43 was admitted to the facility on [DATE], per the facility's admission Record. An observation of Resident 43 was conducted on 2/25/19 at 12:22 P.M. Resident 43 was sitting on her bed and the TV was on. Resident 43 stated she could not hear well and needed people to speak up, and did not have hearing aides. Resident 43 further stated that she did not attend many activities because she could not hear well. An interview was conducted with CNA 30 on 2/27/19 at 8:08 A.M. CNA 30 stated that Resident 43 had a hearing problem and needed staff to speak in a loud voice or use gestures. CNA 30 stated she did not know if Resident 43 had hearing aides. A concurrent interview 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 follow required standards related to the cool down process (a method to decrease the temperature within a required timeframe) for a potentially hazardous food (foods that require time and/or temperature control to prevent bacterial growth). As a result, there was a potential for food borne illness for 99 of 105 residents. Findings: On 2/27/19 at 10:45 A.M., a record review was conducted of the facility's Cool Down Log. A ham was cooked on 2/17/19 with the second phase of the cool down process which started at 11 A.M. and ended at 4 P.M., (five hours later). On 2/27/19 at 11:13 A.M., an interview was conducted with DS 1. DS 1 stated she was the one responsible for cooling down the ham. DS 1 further stated it should have been checked at 3 P.M. DS 1 stated she went on a break at 3 P.M. that day and forgot to check the temperature of the ham, and no one else checked the temperature. DS 1 stated it was important to check the temperature at the right time to ensure bacteria did not grow. DS 1 stated they still had the ham in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3b. Resident 68 was admitted to the facility on [DATE] with diagnoses which included Huntington's Disease (a progressive brain disorder that causes uncontrolled movements, emotional problems,and loss of thinking) and bipolar disorder (extreme mood swings which ranged from depression to mania). On 2/27/19 at 10:59 A.M., an observation was conducted of LN 2. LN 2 brought a pitcher of water from the medication cart to Resident 68's bedside table. LN 2 poured the water from the pitcher into a cup for the tube feeding and medication administration. LN 2 returned the pitcher of water to the medication cart and used the pitcher of water for other residents. On 2/28/19 at 9:48 A.M., an interview with the DSD/ICN was conducted. The DSD/ICN stated LN 2 should not have taken the pitcher inside Resident 68's room to avoid contamination and transmission of germs to other residents. On 3/4/19 at 11:30 A.M., an interview with the DON was conducted. The DON stated the pitcher should not have been taken into Resident 68's room.…

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 resident (Resident 30) was protected from exploitation and misappropriation of funds. This failure placed Resident 30 at further risk of abuse. Findings: Resident 30 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a chronic, disabling, and severe mental disorder that affects a person's ability to think, feel and behave clearly; a disconnection from reality); anti-social personality disorder (a mental health disorder characterized by a disregard for other people's rights; lack of regard for their own safety, inflated and arrogant self-appraisal; and irresponsible in sexual relationships); and traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head that disrupts the normal function of the brain), per the facility's admission Record. A review of Resident 30's medical record indicated Resident 30 was conserved (a court appointed adult who makes…

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 report an allegation of misappropriation of funds to the state agency for one residents (30). This failure had the potential to have placed Resident 30 at further risk of abuse. Findings: Resident 30 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a chronic, disabling, and severe mental disorder that affects a person's ability to think, feel and behave clearly; a disconnection from reality); anti-social personality disorder (a mental health disorder characterized by a disregard for other peoples rights; lack of regard for their own safety inflated and arrogant self-appraisal; and irresponsible in sexual relationships); and traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head that disrupts the normal function of the brain) per the facility's admission Record. A review of Resident 30's medical record indicated Resident 30 was conserved (a court appointed…

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 thoroughly investigate an allegation of abuse for one resident (30). This failure placed Resident 30 and other residents at risk of abuse due to the facility's incomplete investigation. Findings: Resident 30 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a chronic, disabling, and severe mental disorder that affects a person's ability to think, feel and behave clearly; a disconnection from reality); anti-social personality disorder (a mental health disorder characterized by a disregard for other peoples rights; lack of regard for their own safety inflated and arrogant self-appraisal; and irresponsible in sexual relationships); and traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head that disrupts the normal function of the brain) per the facility's admission Record. A review of Resident 30's medical record indicated Resident 30 was conserved (a court…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care and services to maintain or improve one of one sampled resident (13) with limited ability to sit upright. This failure had the potential to result in decline of Resident 13's ability to sit upright. Findings: Resident 13 was admitted to the facility on [DATE] with diagnoses that included Parkinson's (progressive disease of the nervous system), intracranial injury (an external force injures the brain), cervicalgia (injury to the neck), per the facility's admission Record. On 2/25/19 at 11:25 A.M., 2/26/19 at 12:20 P.M. and 2/27/19 at 8:24 A.M., observations of Resident 13 were conducted. Resident 13 was observed sitting in a geriatric chair (a large padded chair with wheeled bases, designed to assist residents with limited mobility) outside of the nursing station. Resident 13 was leaning over to the right with his head dangling to the right, drooling down the side of his mouth. On 2/27/19 at 9:14 A.M., an interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (13) remained free of injury from an accident hazard when they failed to identify the vinyl covering of a geriatric chair were torn, stiff and hard. This failure placed Resident 13 at risk to develop skin tears. Findings: Resident 13 was admitted to the facility on [DATE] with diagnoses that included Parkinson's (progressive disease of the nervous system), intracranial injury (an external force injures the brain), cervicalgia (injury to the neck), per the facility's admission Record. On 2/27/19 at 9:20 A.M., a joint observation and interview was conducted with LN 2 related to Resident 13's geriatric chair. Resident 13's geriatric chair had no vinyl covering over the right and left armrests, and the cushion below the right armrest was exposed. The vinyl pieces of the armrests were stiff and hard. On 2/27/19 at 9:45 A.M., an interview was conducted with LN 2. LN 2 stated the hard and sharp vinyl tears…

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 oxygen therapy was provided per the physician's orders for 1 of 3 residents (13) reviewed for oxygen therapy. In addition, a physician's order did not have an indication for use related to oxygen administration for 1 of 3 sampled residents (404). This failure had the potential for residents to experience low oxygen saturation (amount of oxygen in the blood) levels which could lead to shortness of breath and/or respiratory distress. Findings: 1. Resident 13 was admitted to the facility on [DATE] with diagnoses that included Parkinson's (progressive disease of the nervous system) and gastrostomy tube (feeding tube located in the stomach), per the facility's admission Record. On 2/27/19 at 9:20 A.M., an observation of Resident 13 was conducted. Resident 13 was constantly coughing and restlessness. LN 2 administered a bolus (a large volume of fluid given at one time) of tube feeding to Resident 13. During the tube feeding, Resident 13…

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 a hospice agency's prospective visit calendar was present in the clinical record for one of three hospice residents (54). As a result, there was a potential for delayed or uncoordinated care between the facility healthcare team and the hospice agency. Findings: Resident 54 was admitted to the facility on [DATE] with diagnoses that included encounter for palliative care (specialized care for people living with a serious illness), per the facility's admission Record. On 2/27/19 at 9:25 A.M., an interview and record review was conducted with LN 2. LN 2 reviewed Resident 54's medical record and was unable to find a hospice agency calendar for February 2019. On 3/4/19 at 8:31 A.M., an interview was conducted with the DON. The DON was unsure if a monthly calendar was required to be part of a patients record, but stated if it was required she would have expected the hospice agency to have made the visit calendar available in the patients chart. 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.