West Valley Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) for three of four sampled residents (Resident 105, 55, and 56) with positioning, mobility, and restorative nursing ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) concerns by failing to: 1. Objectively measure Resident 105's ROM in both legs during the Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluations, dated 3/2/2025 and 7/22/2025. 2. Establish a treatment goal to improve Resident 105's left knee ROM after experiencing a decline from moderate ROM limitations (reflecting approximately 50 percent [%] of full ROM) to severe ROM limitations (reflecting 25% or less of full ROM) during the PT Evaluation, dated 7/22/2025. 3. Apply Resident 105's left resting hand splint (brace secured 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 the urinary catheter tubing (a hollow tube inserted into the bladder to drain or collect urine) was positioned free flowing, without dependent loops (a sagging or U shaped section of the drainage tubing that dips below the level of the drainage bag) or kinks (twist) and did not backflow to the urine drainage port (a component of a urinary catheter that allows urine to flow from the bladder into the collection bag) for two of two sampled residents reviewed under the urinary catheter care area (Resident 44 and Resident 15).This deficient practice had the potential to negatively affect Resident 44 and Resident 15 from receiving the proper care necessary to prevent UTI's (urinary tract infection - an infection in the bladder/urinary tract).Findings: a. During a review of Resident 44’s admission Record, the admission Record (front page of the chart that contains a summary of basic information about the resident) indicated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide nutritional care and services consistent with the resident's nutritional assessment and care plan for one of three sampled residents (Resident 8) reviewed under the nutritional care area by: 1. Failing to obtain the resident's weight on readmission from the General Acute Care Hospital (GACH, or simply hospital).2. Failing to obtain weekly weights This deficient practice had the potential to result in further weight loss for Resident 8 after their return from the GACH on 7/23/2025.Findings: During a review of Resident 8's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included stroke, protein-calorie malnutrition (a form of malnutrition that occurs when the body does not get enough protein and calories from food) and end stage renal disease (when kidneys no longer function well enough to meet a body's needs). During a review of Resident 8's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to: 1. 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 Resident 2 in one (1) of two (2) inspected medication carts (Medication Cart 3.) 2. Account for one (1) dose of CS for Resident 102 in one (1) of two (2) inspected medication carts (Medication Cart 2.) 3. Reconcile (the process of comparing transactions and activity to supporting documentation) and account for four (4) medication emergency kits (eKITs) containing CSs for August 2025, in one (1) of one (1) inspected Medication Rooms (Medication room [ROOM NUMBER].) As a result, control and accountability of CSs did not follow state and federal regulations and facility policy and procedures. 4. Replace one (1) open and used eKIT containing antibiotics within 72 hours of opening the kit in one (1) of one (1) inspected…

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 (%). Four (4) medication errors out of 28 total opportunities contributed to an overall medication error rate of 14.29% affecting three (3) of four (4) residents observed for medication administration (Resident 4, 49 and 99.) The medication errors were as follows:1. Resident 4 did not receive polyethylene glycol (a medication used for bowel management) as ordered by Resident 4's physician. 2. Resident 49 received Spiriva (a medication used to treat chronic obstructive pulmonary disease [COPD - a disease causing shortness of breath) at a different dose than ordered by Resident 49's physician. 3. Resident 49 was to be administered expired umeclidinium (a medication used to treat COPD) oral inhalation powder. 4. Resident 99 did not receive liraglutide (a medication used to manage blood sugar levels,]) injection as ordered by Resident 99's physician. These failures had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by: 1. administering three (3) doses of expired Umeclidinium-Vilanterol (a medication used for chronic obstructive pulmonary disease [COPD - a disease causing shortness of breath)]) Ellipa (medication delivery device) inhalation powder by Licensed Vocational Nurse (LVN) 7 and Registered Nurse (RN) 2 between 8/9/2025 and 8/11/2025 to Resident 63 in one (1) of two (2) inspected medication carts (Medication Cart 3,) not in accordance with standards of practice. This deficient practice had the potential to cause Resident 63 to experience serious complications such as shortness of breath, difficulty breathing, and exacerbation (worsening) of COPD, resulting in…

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

Based on observation, interview, and record review the facility failed to remove and discard from use: 1. one (1) open, expired insulin (a medication used to control high blood sugar levels) Lantus (brand name insulin for glargine, a long-acting insulin) Solostar (a type of insulin injection device) pen stored at room temperature for Resident 11, in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of two (2) inspected medications carts (Medication cart 3.) 2. one (1) open, expired Umeclidinium-Vilanterol (a medication used for chronic obstructive pulmonary disease [COPD - a disease-causing shortness of breath)]) Ellipa (medication delivery device) inhalation powder for Resident 63, in accordance with facility policy and procedures and manufacturer's requirements, in one (1) of two (2) inspected medications carts (Medication Cart 3.) These deficient practices increased the risk for Resident 11 to receive insulin that was compromised (decreased) in efficacy and potency (strength of a medication,) for treating Resident 11's blood sugar levels,…

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 follow the menu and did not meet nutritional needs of residents when:a. [NAME] 1 used perforated spoon (a large spoon with slots or holes for draining liquids) when portioning carrots and broccoli.b. [NAME] 2 mashed the sweet potato fries in the number 8 scoops (1/2 cup, [c, household measurement) to fill it in causing more than 1/2 c of sweet potato fries per serving. This failure had the potential to decrease nutrient and fiber intake and increase nutrient intake of calories and carbohydrates resulting in unplanned weight loss, unplanned weight gain and ineffective diet therapy to 74 of 101 residents on regular texture (texture of food with no restrictions and modifications) diet and consistent carbohydrate (CCHO, diet consisting of the same amount of carbohydrate each meal), getting food from the kitchen. Findings:a. During a review of the facilities' daily spreadsheet (a list of food, amount of food that each diet would receive) titled Summer Menus, dated 8/11/2025, the spreadsheet indicated residents 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 observation, interview, and record review, the facility failed to prepare food by methods that conserve temperature when the puree corn salad was at 58 F ( F, a degree of temperature), sweet potato fries and sweet tater tots were at 79 F at the beginning of trayline. This deficient practice placed 95 of 101 facility residents on regular (texture of food with no modifications and restrictions) and modified texture diet at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Based on observation, interview, and record review, the facility failed to prepare food by methods that conserve temperature when the puree corn salad was at 58 F ( F, a degree of temperature), sweet potato fries and sweet tater tots were at 79 F at the beginning of trayline. This deficient practice placed 95 of 101 facility residents on regular (texture of food with no modifications and restrictions) and modified texture diet at risk of unplanned weight loss, a consequence of poor 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.

Based on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree diet/level four (4) received puree bread and puree beef were flat, and it did not hold its shape on the plate. This deficient practice had the potential to cause difficulty in eating, coughing, choking (to keep from breathing the normal way) and decrease of food intake resulting in weight loss for 18 of 101 residents on puree/level 4 diet. Findings:During a review of the facility's daily spreadsheet titled Summer Menus, dated 8/11/2025, the spreadsheet indicated residents on puree/level 4 diet would include the following foods on the tray: Puree roast beef moistened with broth 1/2 cup (c, a household measurement Puree roll 1/3 c Au jus 2 ounces (oz, a unit of measurement) Puree sweet potato fries 1/2 c. Puree corn coleslaw 1/3 c Cappuccino mousse 1/3 c Milk 4 ozDuring a concurrent observation and interview on 8/11/2025 at 12:32 p.m. of the puree/level 4 diet test tray (a process of tasting, temping, and evaluating the quality of…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen equipment and kitchen areas were not free from dust, dirt, food debris.a. Reach in freezer bottom shelves had boxes particles dirt debris and the gasket was torn and had dirt buildup.b. The walk-in refrigerator floor had sticky food spills and had dirt.c. The walk-in freezer floor had ice and dirt debris.d. Ice machine vent had dust build up and its internal parts had white dirt debris coming out when wiped with a paper towel.2. Ten dented cans were stored with non-dented cans. 3. Kitchen utensils and equipment were not smooth and free from chips, cracks and scratches.a. Fifty cracked, and chipped trays were used for lunch service.b. [NAME] chopping board with scratches and black stains.4. Staff failed to perform handwashing and hand hygienea. [NAME] 1 did not perform handwashing after turning off the water faucet with her thumb and proceeded to work in the kitchen. b. Dietary Aide 1 (DA 1) touched her…

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

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when one (1) of three (3) dumpsters (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) were not covered while not actively being used and there were trashes, empty cups, paper towel and salsa spills on the floor. This failure had potential to attract birds, flies, insects, pests and possibly spread infection to 100 of 101 facility residents.Findings: During a concurrent observation and interview on 8/12/2025 at 10:10 a.m. of the dumpster with the Dietary Supervisor (DS), observed one dumpster was overfilled with trash, not completely covered, and there were salsa drippings and plastic cans, paper towel on the dumpster floor. The DS stated the trash bin should always be kept close to prevent flies, insects and rodents going close to the facility and so that trash would not be spilling from the dumpster floor. The DS stated there were salsa spills, paper towels and empty…

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 timely and accurate resident medical records in accordance with accepted professional standards by failing to: 1. Complete timely documentation of a resident's urinary catheter care (flexible tube passed into the bladder to drain urine) for one of two sampled residents (Resident 15) reviewed under the urinary catheter care area.2. Document the application of a resident's splint for one of three sampled residents (Resident 55) reviewed under the care area of position/mobility, when Resident 55's left resting hand splint (brace secured with straps that extends from the fingers to the forearm to properly position the fingers and wrist and prevent contractures) and left elbow extension splint (brace designed to help maintain or improve the range of motion at the elbow joint, specifically focusing on the ability to straighten or extend the arm) application were not documented in the Restorative Nursing Aide ([RNA nursing aide program that helps…

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 dated for one of one sampled resident (Resident 125) reviewed under the respiratory care area. 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. Ensure a resident's urinary catheter (a flexible tube inserted into the bladder to drain urine) system was labeled for one of two sampled residents (Resident 15) reviewed under the catheter care area. This deficient practice placed Resident 15 at risk for infections and prolonged use of an old urinary catheter. 3. Ensure a staff member donned (put on) an isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness,…

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 a call light (a device used by a patient to signal his or her need for assistance from a professional staff) was within reach for one of three sampled residents (Resident 83) investigated under the environment facility task. This deficient practice had the potential to result in Resident 83 not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the residents' comfort and well-being.Findings: During a review of Resident 83's admission Record, the admission Record indicated the facility admitted the resident on 3/8/2024 with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and a history of falling. During a review of Resident 83's Minimum Data Set (MDS - an assessment and care screening tool) dated 6/11/2025, the MDS indicated Resident 83 usually makes herself understood and usually understands others. The MDS further 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.

Based on interview and record review the facility failed to notify the resident's physician of a change of condition (COC, decline or improvement in a resident's status that will not resolve itself without intervention) in accordance with physician's orders for one of two residents (Resident 12) reviewed who were prescribed insulin (hormone that regulates blood sugar levels) by failing to: 1. Notify the physician when Resident 12's blood sugar was over 300. 2. Notify the physician when Resident 12' blood sugar was over 400 and change in condition form was not filled out. This had the potential for Resident 12 to suffer complications from elevated blood glucose such as infection and diabetic coma (a complication of diabetes where a person loses consciousness due to extremely high blood sugar levels).Findings:During a review of Resident 12's admission Record, the admission Record indicated the facility admitted the resident on 6/02/2025 with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and contact…

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 a qualified staff member adjusted the left extension knee splint (brace designed to help maintain or improve the range of motion at the knee joint) for one of three residents (Resident 105) with positioning and range of motion ([ROM] full movement potential of a joint) concerns in accordance with professional standards and the facility's job descriptions. This failure placed Resident 105 at an increased risk for developing injury, skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [strain produced by pressure], moisture, or pressure), and further ROM limitations on the left knee. Findings: During a review of Resident 105's admission Record, the admission Record indicated the facility admitted Resident 105 on 3/5/2025 and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following the cerebral infarction (brain…

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 - review of a resident's drug therapy to assure appropriateness of medication usage completed each month by the consultant pharmacist) was acted upon for one (Resident 12) of six residents investigated for unnecessary medications, by failing to act upon the facility consultant pharmacist's recommendation to provide a location of application for Diclofenac Gel (a nonsteroidal anti-inflammatory drug [NSAID] used topically for pain relief and inflammation).This had the potential for licensed nurses not to know the location of Resident 12's pain.Findings:During a review of Resident 12's admission Record, the admission Record indicated the facility admitted the resident the facility on 6/02/2025 with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and contact dermatitis (a skin condition caused by direct contact with an irritant or allergen, resulting in rash and inflammation). During a review of Resident…

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

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) on abuse for an allegation of financial abuse for one of three sampled residents (Resident 1) by failing to: 1. Conduct a thorough investigation of the alleged financial abuse. 2. Ensure the facility's Social Services Director (SSD) reported a suspicion of financial abuse to the Abuse Coordinator on 6/26/2025. 3. Complete and submit a written five (5) day follow-up investigation report indicating the results of the investigation for the allegation of financial abuse that occurred on 6/26/2025. This deficient practice had the potential to place Resident 1 at risk for further financial exploitation and resulted in a delay in investigation of a suspicion of financial abuse.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/19/2025 with diagnoses including generalized arthritis (swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age), syncope (a sudden…

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

Based on interview and record review, the facility failed to implement policies and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report an allegation of financial abuse for one of three sampled residents (Resident 1) to the State Survey Agency (SSA) within the required timeframe. This deficient practice had the potential to place Resident 1 at risk for further financial exploitation and resulted in a delay in investigation of a suspicion of financial abuse.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/19/2025 with diagnoses including generalized arthritis (swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age), syncope (a sudden temporary loss of consciousness, commonly known as fainting or passing out) and collapse (fall down), type two (2) diabetes mellitus (high levels of sugar in the blood) and depression (a mood disorder characterized by persistent…

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 two of five sampled residents (Resident 1 and Resident 2) received care and services in accordance with professional standards of practice by: 1. Failing to administer Resident 1's acetaminophen (a medication used to relieve mild to moderate pain) as prescribed by the physician. This deficient practice had the potential for Resident 1 to experience untreated pain. 2. Failing to ensure licensed nurses attempted and documented 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) to Resident 2. This deficient practice had the potential to place the resident at an increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted…

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

Based on observation, interview and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one of five sampled residents (Resident 3). This deficient practice had the potential to result in a delay of care and services and possible injury to residents when unable to obtain the needed care and services. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 7/7/2022 and re-admitted Resident 3 on 6/15/2024 with diagnoses including intervertebral disc degeneration (breakdown of one or more discs that separate the bones of the spine), muscle wasting and atrophy (refers to the loss of muscle mass and strength), limitation of activities due to disability, and adult failure to thrive (a syndrome of decline in older adults, characterized by weight loss, decreased appetite, inactivity, and a decline in the ability…

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

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) on care planning- interdisciplinary (a group of professionals from different fields who work together to achieve a shared goal for the resident) team by failing to ensure the required interdisciplinary team members, including a physician, a registered nurse (RN), and a certified nurse assistant (CNA), were in attendance during a scheduled care plan meeting for one of five sampled residents (Resident 1). This deficient practice had the potential to affect residents' care coordination, potentially leading to unmet needs and avoidable declines in condition. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/19/2025 with diagnoses including generalized arthritis (swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age), syncope (a sudden temporary loss of consciousness, commonly known as fainting or passing out) and collapse (fall down), type two (2)…

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 the needed care and services that were resident-centered for one of five sampled residents (Resident 4) by the facility failing to accurately transcribe Resident 4's Lenalidomide (a medication used to treat multiple myeloma [a type of blood cancer that originates in plasma cells - a type of white blood cells that produce antibodies {a protein produced by the immune system to identify and neutralize foreign substances like bacteria and viruses}]) order. This deficient practice resulted in Resident 4 not receiving Resident 4's prescribed medication as ordered and placed Resident 4 at risk for worsening medical condition and compromised immune system that may lead to infection. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility originally admitted Resident 4 on 5/15/2025 and re-admitted Resident 4 on 6/23/2025 with diagnoses including malignant neoplasm of bone (bone cancer) and multiple myeloma not having achieved remission (period where the signs and symptoms 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's attending physician documented and completed a resident's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) within 72 hours following a resident's admission for two of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential for inconsistent care coordination due to incomplete medical records for Resident 1 and Resident 2. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/19/2025 with diagnoses that included primary generalized arthritis (swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age), syncope (fainting) and collapse (fall down), and other chest pain. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 5/22/2025,…

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 five sampled residents (Resident 4) was free from significant medication error by failing to ensure Resident 4's Lenalidomide (a medication used to treat multiple myeloma [a type of blood cancer that originates in plasma cells - a type of white blood cells that produce antibodies {a protein produced by the immune system to identify and neutralize foreign substances like bacteria and viruses}]) was administered as ordered. This deficient practice resulted in Resident 4 receiving one dose of a 21-day cycle medication. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility originally admitted Resident 4 on 5/15/2025 and re-admitted Resident 4 on 6/23/2025 with diagnoses including malignant neoplasm of bone (bone cancer) and multiple myeloma not having achieved remission (period where the signs and symptoms of a disease, such as cancer, decrease or disappear). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 5/19/2025, 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 interview and record review, the facility failed to implement the facility's policy by failing to investigate a report regarding a resident's missing bilateral (affecting both sides) hearing aids one of four sampled residents (Resident 1). This deficient practice had the potential for a delay in resident's right to retain and use personal property (bilateral hearing aids). Findings: During a review of Resident 1's admission Record, the document indicated the facility admitted Resident 1 on 8/27/2024 with diagnoses that included hemiplegia (one-sided paralysis [complete or partial loss of muscle function]) and hemiparesis (one-sided muscle weakness) following cerebral infarction (when the blood supply to part of the brain is blocked or reduced) affecting right dominant side, aphasia (a language disorder that affects your ability to speak and understand what others say) following cerebral infarction, and dysphagia (difficulty swallowing) following cerebral infarction. During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated…

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

Based on interview and record review, the facility failed to: 1. Ensure the designated Administrator (DADM) held a current and active license from the State to serve in the capacity of a nursing home administrator (NHA) 2. Implement its policy and procedures (P&P) for ensuring the background check of the DADM was initiated and completed prior to employment. This deficient practice resulted in DADM operating the facility with an inactive NHA licensed that could potentially negatively affect the facility's functions. Findings: 1. During a review of the DADM's employee file, the DADM's employee files indicated the following: a) The DADM's Notice to Employee indicated that the DADM's start date at the facility as 9/9/2024. b) The DADM signed for the administrator job description on 9/9/2024, that included, Must maintain licensing credentials for an Administrator. During a review of the undated facility's Department Heads 2024 listing submitted to the surveyor on 10/22/2024, the Department Heads listing indicated the DADM's title as Administrator of the facility. During a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a copy of a resident's Advance Directive (a written statement of a person's wishes regarding medical treatment) was kept in the resident's chart and easily retrievable for three of four sampled residents (Resident 83, 49, 18). This deficient practice has the potential to create confusion which could lead to conflict with the resident's wishes regarding his/her health care. Findings: a. During a review of Resident 83's admission Record, the document indicated the facility admitted the resident on 9/1/2023 with diagnoses of cerebral vascular disease (condition that affect the blood vessels that supply blood to your brain), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well), and type two (2) diabetes mellites (a chronic condition that affects the way the body processes blood glucose [sugar]). During a review of Resident 83's Minimum Data Set (MDS- a standardized assessment and screening tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was initially admitted on [DATE] with diagnoses including type 2 diabetes mellitus (DM II - a long-term condition in which the body has trouble controlling blood sugar and using it for energy). During a review of Resident 13's MDS dated [DATE], the MDS indicated Resident 13 had intact cognition. The MDS indicated that Resident 13 required substantial assistance from staff with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 13's Order Summary Report, the Order Summary Report indicated Resident 13's physician ordered for insulin Tresiba (a long-acting insulin injection that helps control blood sugar levels over a period of time) subcutaneous (fat tissue) solution pen-injector 200 unit/milliliter (ml - unit of measurement), inject 30 units subcutaneously one time per day dated 7/8/2024. During a review of Resident 13's Care…

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

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards by not labeling food stored with a use by date. These deficient practices had the potential for 98 of 100 residents who receive food from the facility kitchen to be at risk for food borne illness (illness caused by food contamination with bacteria, viruses, parasites, or toxins). Findings: During a concurrent observation and interview on 9/3/2024 at 8:00 a.m., with the Dietary Director (DD), observed in the storage room one container of instant pudding mixes, five pounds (lbs. - unit of measurement) of corn bread mixes, six lbs. of brownies mixes, four lbs. of cheesecake mixes, one clear container of premium topping, seven boxes of seedless raisins, one clear container of instant pudding mixes, four boxes of premium beef flavor soup, and three boxes of premium chicken flavor soup not labeled with a use by date. The DD stated there should have been a label with a use by date and if there was not, that could affect the residents and the residents could get…

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 obtain consents and inform the resident in advance of the risks and benefits of the psychotropic (medications capable of affecting the mind, emotions, and behavior) medications for one of three sampled residents (Resident 13). This deficient practice violated Resident 13's right to know about and make decisions about their medical care. Findings: During a review of Resident 13's admission Record, the document indicated the facility admitted the resident on 11/15/2018 with diagnoses including encounter for orthopedic (relating to muscles and or bones) aftercare following surgical amputation (a surgery to remove all or part of a limb [arms or legs]), acquired absence of right leg below the knee (right leg amputation), and acquired absence of left leg below the knee(left leg amputation). During a review of Resident 13's History and Physical (H&P) dated 7/9/2024, indicated the resident had the capacity to understand and make decisions. During a review of Resident 13's Minimum Data Set (MDS, a standardized assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of two sampled residents (Resident 18) by failing to develop a comprehensive person-centered Care Plan for the activity needs (any activities that are intended to improve a resident's quality of life and promote their physical, cognitive, and emotional health) of Resident 18. This deficient practice had the potential for Resident 18 to not receive the necessary care and services to address and allow Resident 18 to participate in activities. Findings: During a review of Resident 18's admission Record, the admission Record indicated that Resident 18 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), type 2 diabetes mellitus (a disease in which the resident's blood glucose, or blood sugar, levels are too high 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 immediately (no later than 21 days after admission) develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of two sampled residents (Resident 91). Resident 91 received a physician order for the use of Apixaban (a type of anticoagulant [blood thinning] medication) on 6/23/24, a care plan for anticoagulants was not developed until 7/22/24. This deficient practice had the potential for Resident 91 to not receive the necessary care and services to address and prevent complications of anticoagulant therapy for Resident 91 such as excessive bleeding. Findings: During a review of Resident 91's admission Record, the admission Record indicated Resident 91 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), and long-term use of anticoagulants. During a review of Resident 91`s Minimum Data Set (MDS a standardized assessment 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 reassess one of 19 sampled resident's (Resident 156) pain level (the amount of pain a resident is experiencing), 30 minutes to one (1) hour after the administration of oxycodone (medication used to treat pain). This deficient practice increased the risk of Resident 156 having untreated and prolonged unrelieved pain. Findings: During a review of Resident 156's Face Sheet, the Face Sheet indicated Resident 156 was admitted to the facility on [DATE] with diagnoses that included lower back pain, and a wedge compression fracture (a type of spinal fracture [break in bone] that occurs when the front of a vertebra [small circular bones that form the spine] collapses, causing it to take on a wedge shape) of third lumbar (lower back) fracture. During a review of Resident 156's Minimum Data Set (MDS, an assessment and care screening tool) dated 9/04/2024, the MDS indicated that Resident 156 had modified independence (some difficulty in new situations only) in…

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

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 32) received needed dental services. This deficient practice placed Resident 32 at increased risk for deterioration of oral hygiene and gum disease (bacteria attacks the gums, causing swelling and bleeding) Findings: During a review of Resident 32's admission Record, the admission Record indicated that the facility admitted Resident 32 on 1/27/2017 with diagnoses including chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems) and essential hypertension (high blood pressure). During a review of Resident 32's Minimum Data Set (MDS-a care screening tool) dated 8/2/2024, the MDS indicated that Resident 32 had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 32 needed supervision for showering, dressing, oral and toileting hygiene. During a review of Resident 32's Physician Orders dated…

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

Based on observation, interview, and record review, the facility failed to prepare pureed (consists of food that have been blended into smooth, soft consistency) egg noodles according to the facility recipe on 9/4/2024 for 14 of 100 residents who are on a pureed diet. This deficient practice had a potential for residents who are on pureed diet not to eat the served food and could potentially lead to weight loss. Findings: During concurrent observation and interview on 9/4/2024 at 11 a.m., observed [NAME] 1 (C1) preparing pureed egg noodles for lunch. C1 stated that C1 was preparing 14 portions of pureed egg noodles for lunch. C1 stated that each portion of noodles was four (4) ounces (oz.-unit of measurement). C1 stated that C1 is using cooked noodles with chicken broth. Observed C1 add four oz of chicken broth. Observed C1 add milk to the blender (an electrical kitchen appliance used for mixing liquids and soft foods together) without first measuring the amount of milk. When C1 was asked how much milk was added to the blender, C1 stated around three to four oz of milk. Observe C1…

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 one of three sampled residents (Resident 1) was provided a clean and homelike environment when on 8/28/2024, observed the floor of Resident 1's room soiled with multiple plastic wrappers, two plastic containers, one plastic spoon, several pieces of paper and a soiled washcloth on the floor around Resident 1's bed. This deficient practice had the potential to negatively impact Resident 1's quality of life, had the potential to result in the spread of infection; and increased the risk of accidents or injuries to residents, staff, and visitors. Findings: A review of Resident 1's admission record indicated the facility originally admitted the resident on 11/9/2015 and re-admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a lung disease that damages the airways and makes it hard to breathe), paraplegia (partial or complete paralysis [loss of muscle function] of the lower half of the body), schizophrenia (a serious…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices by: 1. Failing to ensure one of five sampled staff (Housekeeping 1 [HK 1]) performed hand hygiene (HH - cleaning hands by either washing with soap and water, or by using a hand sanitizing [removing germs] gel) after exiting Resident 4's room which was placed on novel respiratory precautions (NRP - precautions should be used for residents known or suspected to be infected with { Coronavirus Disease 2019 [COVID-19 - a highly contagious respiratory illness in humans capable of producing severe symptoms]}). 2. Failing to ensure that facility staff did not store used face shields with new unused face shields together in two of two sampled personal protective equipment (PPE - protective items worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission [the transfer of germs from one area to another]) organizers. These deficient practices had the…

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

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 plan for a resident ' s specific health needs and desired health outcomes) for three of three sampled residents (Resident 2, 7 and 8) by: 1. Failing to ensure a care plan was developed for Resident 2 ' s use of Warfarin (a medication used to treat and prevent blood clots [gel-like clumps of blood]). 2. Failing to ensure a care plan was developed for Resident 7 ' s use of Digoxin (medication use to treat congestive heart failure [CHF- A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs]). 3. Failing to ensure a care plan was developed for Resident 8 ' s use of Phenytoin (Dilantin- a medication used to treat seizures [a sudden, uncontrolled burst of electrical activity in the brain which can cause changes in behavior, movements, feelings, and levels of consciousness]). These deficient practices had the potential to result in failure to deliver necessary care…

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

Based on interview and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one of three sampled residents (Resident 1). This deficient practice had the potential to result in a delay of care and services and possible injury to residents when unable to obtain the needed care and services. Findings: A review of Resident 1 ' s admission Record dated 5/15/2024, indicated the facility originally admitted Resident 1 on 4/30/2024 and re-admitted Resident 1 on 5/15/2024. Resident 1 ' s diagnoses included paroxysmal atrial fibrillation, cerebral infarction (stroke- damage to tissues in the brain due to a loss of oxygen to the area), hemiplegia (one-sided muscle paralysis [inability to move] or weakness) and hemiparesis (the weakness or inability to move one side of the body) following cerebral infarction. A review of Resident 1 ' s Minimum Data Set (MDS - a comprehensive assessment and…

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

Based on interview and record review, the facility failed to ensure laboratory orders were obtained for the use of Phenytoin Sodium (Dilantin- a medication used to treat seizures [a sudden, uncontrolled burst of electrical activity in the brain which can cause changes in behavior, movements, feelings and levels of consciousness]) for one of three sampled residents (Resident 8) in order to determine if the dose of the Phenytoin Sodium is within therapeutic drug levels (measures the amount of certain medicines in your blood, to determine if the dose of the medication is within expected range). This deficient practice placed Resident 8 at risk of not receiving appropriate care and services and had the potential to result in having nontherapeutic laboratory levels which may cause seizure activity. Findings: A review of Resident 8 ' s admission Record indicated the facility admitted Resident 8 on 7/5/2024 with diagnoses that included epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures). A review of Resident 8's Minimum Data Set (MDS- a standardized…

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 three sampled residents (Resident 1) was free of unnecessary medication, when on 2/2/2024, Registered Nurse 1 (RN 1) obtained a physician's order for Norco (a medication used to relieve moderate to severe pain) without performing a complete pain assessment. This deficient practice resulted in Resident 1 receiving an unnecessary dose of Norco on 2/2/2024 and placed Resident 1 at risk for side effects (unwanted, undesirable effects resulting from a medication) such as confusion, sleepiness, difficulty in breathing, dizziness, and drowsiness. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 1/31/2024 with diagnoses that included polyneuropathy (malfunction of nerves throughout the body), diastolic heart failure (a condition in which your heart's main pumping chamber [left ventricle] becomes stiff and unable to fill properly), cellulitis (a bacterial skin infection that causes redness,…

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 its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report the initial report of the physical abuse allegation within two (2) hours of the incident for one of four sampled residents (Resident 1). This deficient practice had the potential to result in delay of necessary actions to oversee the protection of the residents in the facility by the State Survey Agency (SSA). Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 12/12/2023 with diagnoses that included right knee transient synovitis (inflammation [a painful redness or swelling affecting the joint {the part of the body where two or more bones meet to allow movement}]), and dementia (impaired ability to remember, think, or make decisions that interferes with a resident ' s daily life and activities). A review of Resident 1 ' s Minimum Data…

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 the Dehydration (lack of sufficient water in a person's body) Risk Assessment was accurately completed for two of three sampled residents (Resident 1 and Resident 2). 2. ensure the Registered Dietitian (RD) conducted a nutritional assessment for two of three sampled residents (Resident 1 and Resident 2) upon admission, as per the facility's policy and procedure (P&P) titled Nutritional Assessment. These deficient practices had the potential to place Resident 1 and Resident 2 at risk for dehydration and placed both residents (Resident 1 and Resident 2) at risk for medical complications related to inadequate nutrition. Findings: 1. A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 9/27/2022 and readmitted Resident 1 on 10/19/2022 with diagnoses that included dysphagia (difficulty swallowing), dementia (impaired ability to remember, think, or make decisions that interferes with a resident's daily…

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

Based on interview and record review, the facility failed to notify the responsible party (RP) of a change in condition (COC - when there is a sudden change from a resident's health) timely for one of three sampled residents (Resident 1) when on 10/26/2022, Resident 1 was exposed to Coronavirus Disease 2019 (COVID-19 - a highly contagious respiratory illness in humans capable of producing severe symptoms). This deficient practice had the potential outcome to have had a negative effect on Resident 1's treatment if any decisions were needed at the time of the change of condition. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 9/27/2022 and readmitted Resident 1 on 10/19/2022 with diagnoses that included long standing persistent atrial fibrillation (abnormal heartbeat), dysphagia (difficulty swallowing), and unspecified mood disorder (a mental health condition that primarily affects a person's emotional state). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 9/30/2022,…

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 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 at risk for dehydration (lack of sufficient water in a person's body). 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 9/27/2022 and readmitted Resident 1 on 10/19/2022 with diagnoses that included dysphagia (difficulty swallowing), dementia (impaired ability to remember, think, or make decisions that interferes with a resident's daily life and activities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in daily activities), and cerebral infarction (also known as stroke, occurs when the blood supply to 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 peripheral (the arms, hands, legs, and feet) intravenous (IV-into the vein) catheter (a thin plastic tube inserted into a vein using a needle) policy was implemented to provide safe care to prevent complications for one of three sampled residents (Resident 2). This deficient practice had the potential to place Resident 2 at risk for developing complications such as inflammation of the vein and infection. Findings: A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 11/29/2023 with diagnoses that included polyneuropathies (happens when multiple nerves [bundle of fibers that carry electrical impulses] that are located outside of your brain and spinal cord are damaged), nondisplaced comminuted fracture (where the bones are broken in several fragments and are not aligned) of shaft (long portion) of the right tibia (shin bone), and muscle weakness. A review of Resident 2's History and Physical Examination form dated 12/1/2023 indicated Resident 2 has the capacity 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 effective pain management was done by failing to: 1. Administer pain medication for the appropriate pain scale as indicated by the physician's orders for four of four sampled residents (Resident 66, 62, 81, and 68). 2. Document pain assessments on the Medication Administration Record (MAR) for two of two sampled residents (Resident 66 and 62). These deficient practices may lead to inaccurate pain assessment and inadequate management of residents' pain. Findings: a. A review of the admission record indicated Resident 66 was admitted to the facility, on 12/21/2021, with diagnoses that included polyneuropathy (disease of one or more peripheral nerves causing numbness or weakness), cellulitis (bacterial infection involving the inner layers of the skin) of left lower limb, and chronic pain (persistent pain that lasts weeks to years). A review of Resident 66's Minimum Data Set (MDS - an assessment and care screening tool), dated 12/25/2021, 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 provide dementia (brain disease causing memory problems) training and verify staff competency upon staff orientation for five out of five sampled newly hired staff (Certified Nursing Assistant 4 [CNA 4], Certified Nursing Assistant 5 [CNA 5], Licensed Vocational Nurse [LVN 9], Licensed Vocational Nurse [LVN 10], and Registered Nurse [RN 4]), investigated under the facility task of sufficient and competent nurse staffing. This deficient practice had the potential to place elderly residents with dementia at risk for harm due to lack of sufficient and competent staff training. Findings: During a concurrent interview and record review, on 01/27/2022 at 2:17 p.m., the Director of Staff Development (DSD) reviewed the employee files for CNA 4, CNA 5, LVN 9, LVN 10, and RN 4 and verified there was no documented evidence that dementia training was completed. The DSD stated that their competency in providing care for residents with dementia was verified upon hire. The DSD also reviewed the in-service binder and confirmed 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: 1. Ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR) for two of two sampled residents (Residents 66 and 62). This deficient practice resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. 2. Ensure Licensed Vocational Nurse 7 (LVN 7) labeled a transdermal lidocaine patch (a prescription topical analgesic used to treat the symptoms of nerve pain, and temporary pain relief) with the nurse's initials and date of administration for one of one sampled resident (Resident 28). This deficient practice had the potential to cause ineffective pain management for Resident 28. Findings: 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 safe storage and handling of medications for two of four medication carts (Med Cart 1 and Med Cart 3), one of two medication storage (Med Storage 1), and safe provision of pharmaceutical services for three of three sampled residents (Resident 76, 28, and 100) by: 1. Failing to ensure Med Cart 1's blood sugar strips was opened with an opened date. 2. Failing to ensure Med Cart 3 contained: - Resident 31 and Resident 4's ipratropium/albuterol (used to control and prevent symptoms [wheezing and shortness of breath] caused by ongoing lung disease) foil pouch was dated with an opened date. - Resident 41's Percocet (used to treat moderate to severe pain) bubble pack (container) slot #1 with a cracked seal was disposed accordingly. 3. Failing to ensure Resident 76's insulin (hormone that lowers the level of glucose [sugar] in the blood) Semglee glargine (long-acting type of insulin) was disposed after 28 days with open date 12/05/2021,…

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 proper storage, preparation and distribution of food was done under sanitary conditions for 112 of 116 residents of the facility by: 1. Failing to properly label one box of orange juice, one box of apple juice, one box of nectar water, five containers of an apple sauce-like substance, one container of cooked pasta, and one prepared salad. 2. Failing to ensure there was an air gap (the physical separation of the potable and non-potable water supply systems by an air space) between the ice machine drainage pipe and the drain. 3. Failing to ensure the quaternary ammonium sanitizing solution (ammonium solution used for sanitizing surfaces) log was completed. These deficient practices had the potential to result in foodborne illness (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) in residents with symptoms including upset stomach, stomach cramps, nausea,…

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

Based on observation, interview, and record review, the facility failed to implement infection control policy and procedure by failing to: 1. Ensure Resident 250's nasal cannula (thin, flexible tube containing two open prongs used to deliver oxygen) tubing was labeled with the date and kept off the floor. 2. Ensure staff doffed (took off) their personal protective equipment (PPE - specialized clothing, like glove, gown, mask, or eye protection, used to protect from exposure to potentially infectious materials to avoid injury or disease) properly as evidenced by Restorative Nursing Assistant 1 (RNA 1) removing her gown over her contaminated gloves when doffing in Resident 65's room. 3. Ensure Housekeeper 1 (HK 1) did not wear his contaminated gown and gloves in the hallway upon exiting an isolation room in the yellow zone (cohort of the facility consisting of following residents under quarantine: newly admitted or readmitted , resident who leave the facility for more than 24 hours, symptomatic, close contact to known Coronavirus disease-2019 [COVID-19, a highly contagious viral…

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 an interdisciplinary team meeting (IDT- communication among healthcare team members) was conducted prior to Resident 23's self-administering medication for nasacort (used to treat inflammation caused by allergies such as runny nose and congestion), for one of one resident. This deficient practice had the potential to result in inappropriate use and unsafe resident self-administration. Findings: During an observation, on 01/25/2022 at 9:07 a.m., nasacort medication was at Resident 23's bedside. During a concurrent observation, interview, and record review, on 01/25/2022 at 9:12 a.m., the Licensed Vocational Nurse 1 (LVN 1) confirmed Resident 23 had 2 boxes of nasacort at bedside drawer with a total of 4 nasal sprays. LVN 1 stated she would remove it from the bedside for safety. LVN 1 stated the facility did not have an IDT for the use of Nasacort self-administration for Resident 23. A review of the admission record indicated Resident 23 was admitted to the facility, on 11/15/2021, 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 one of 26 sampled residents (Resident 52) was provided with a call light (device used to notify staff when assistance is needed). This deficient practice resulted in Resident 52 not being able to summon health care workers for assistance when needed. Findings: A review of Resident 52's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (damage to tissues in the brain due to interrupted blood flow to the area), dysphagia (difficulty swallowing), and gastrostomy (surgical procedure used to insert a tube through the abdomen into the stomach) status. A review of Resident 52's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/22/2021, indicated Resident 52 has severely impaired cognitive skills (ability to think, understand, and reason) for daily decision making. The MDS further indicated the resident was totally 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure documented evidence that Resident 94's advance directive (written instruction, such as a living will or durable power of attorney, of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them) was discussed, for one of eight sampled residents (Resident 94). This deficient practice violated the resident's right to be fully informed of the option to formulate their advance directive. Findings: A review of the admission record indicated Resident 94 was admitted to the facility, on 7/1/2019 and readmitted on [DATE], with diagnoses including acute respiratory failure with hypoxia (severe lung dysfunction affecting the ability to get oxygen to the body), end stage renal disease (chronic irreversible kidney failure), and diabetes mellitus (high blood sugar). A review of the Minimum Data Set (MDS, an assessment and care screening tool), dated 1/10/2022, indicated Resident 94…

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 meet professional standards of quality when the physician was not notified of Resident 28's missing lidocaine patch (a prescription topical analgesic used to treat the symptoms of nerve pain, and temporary pain relief) before Licensed Vocational Nurse (LVN 7) reapplied another one per facility's policy and procedure, for one of three sample residents (Resident 28). This deficient practice has the potential to result in an overdosage of Lidocaine to Resident 28 with symptoms that may include slow heartbeat, seizure (convulsions), loss of consciousness, or confusion. Findings: A review of the admission record indicated Resident 28 was admitted to the facility, on 3/1/2018, and was readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis (mild to severe loss of strength or paralysis on one side of the body) following cerebral infarction (a stoke) and polyneuropathy (a disorder of the peripheral nervous system that may 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.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 24 and 250) investigated under the Oxygen Care Area Task were provided safe oxygen administration by: 1. Failing to ensure Residents 24 and 250 had an oxygen treatment ordered by the physician. This deficient practice had the potential to receive an unnecessary medication. 2. Failing to ensure Resident 24 had a signage for oxygen in use while oxygen was in in the room. This deficient practice had potential for Resident 24 at increased risk of accident such as risk for fire hazard. Findings: A review of the admission record indicated Resident 24 was admitted to the facility, on 08/10/2021, with diagnoses including chronic obstructive pulmonary disease (COPD, progressive lung disorders characterized by increasing breathlessness) and dementia (a loss of mental ability severe enough to interfere with normal activities of daily living). A review of Resident 24's Updated Assessment, dated 01/18/2022, indicated the resident had mild dyspnea (difficulty breathing) 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 interview and record review, the facility failed to ensure the Medication Regimen Review (MRR - a review of a resident's drug therapy to assure appropriateness of medication usage) was acted upon for two of six sampled residents investigated under the care area of unnecessary medications (Resident 200 and 89) by: 1. For Resident 200, the facility's consultant pharmacist failed to identify Resident 200's Xanax (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) as needed (PRN) order did not have a duration and stop date. 2. For Resident 89, the facility failed to act on the pharmacist consultant's monthly MRR recommendation in a timely manner that included notifying the physician regarding an evaluation of the continuous use of Lexapro (medication used to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest] and anxiety). This deficient practice had the potential to cause adverse side effects (any…

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 five sampled residents (Residents 81) was free of unnecessary medication by failing to ensure the dabigatran etexilate mesylate (Pradaxa, an anticoagulant [a class of drugs used to treat or prevent the formation of blood clots]) was prescribed with an adequate indication. This deficient practice had the potential to result in the resident receiving unnecessary medication resulting in adverse effects (any unexpected or dangerous reaction to a drug) such as bleeding. Findings: A review of Resident 81's admission Record indicated the resident was admitted to the facility on [DATE] with a readmission date of 12/15/2021 with diagnoses that included metabolic encephalopathy (a syndrome of temporary or permanent disturbance of brain function) occlusion (blockage) and stenosis (narrowing) of the left vertebral artery (a major artery in the neck) and chronic pain syndrome (a syndrome where pain remains after illness or injury). 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 interview and record review, the facility failed to ensure one of six residents (Resident 200) reviewed for unnecessary medications, were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) by failing to ensure Resident 200's physician order for Xanax (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) as needed (PRN) had a duration (length of time of treatment). This deficient practice had the potential to result in adverse reaction (any unexpected or dangerous reaction to a drug) or impairment in the resident's mental or physical condition. Findings: A review of Resident 200's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder (GAD - exaggerated worry and tension that is much more severe than most people experience), major depressive disorder (mood disorder that causes a persistent feeling 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 call light system was in working condition for one of one sampled resident (Resident 400). This deficient practice had the potential to result in delay in response to the resident's requests and needs. Findings: A review of Resident 400's admission Record indicated the resident was admitted on [DATE] with diagnoses including Coronavirus disease 2019 (COVID-19 - an infectious disease caused by the SARS-CoV-2 virus) and history of falling. A review of Resident 400's At Risk for Falls Care Plan with initiated date 01/23/2022, indicated the goals to prevent and/or decrease falls, and with interventions that included ensuring the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. A review of Resident 400's admission assessment dated [DATE] indicated the resident is alert and oriented to person, place, time, and situation.…

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.