Indian Canyon Post Acute

Based on interview, and record review, the facility failed to protect against physical abuse for one of three sampled female residents (Resident 1) when a male resident (Resident 2) kissed Resident 1 on the mouth and fondled her (to touch in a sexual way) when Resident 1 did not have the capacity to consent. This failure had the potential to cause Resident 1 to suffer psychological distress, anxiety, and shock. Findings: An unannounced visit was made to the facility on January 29, 2025, at 10:45 AM, to investigate a facility reported incident regarding an allegation of physical abuse. A review of Resident 1 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an admission date of January 4, 2021. Resident 1 had diagnoses that included dementia (a brain disorder that causes a decline in mental abilities, such as memory, thinking, reasoning, and problem-solving) and quadriplegia (a condition characterized by the loss or severe impairment of motor function, sensation, and nervous system functions in all four limbs--arms and legs). A review of…

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

Based on interview, record review, and facility policy review, the facility failed to ensure the preadmission screening and resident review (PASRR) was accurately completed for 1 (Resident #44) of 3 sampled residents reviewed for PASRR requirements. Specifically, Resident #44 had a serious mental illness (SMI) that was not captured in their Level I PASRR screening. Findings included: A facility policy titled, PASRR Completion Policy, reviewed 12/2023, specified, The Center will a [sic] make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. The policy specified, 1. Center Administrator will designate the medical records to make sure that the [PASRR]and/or Level of Care (LOC) is done on all potential residents. If the referral indicates anything which might constitute an SMI or ID [intellectual disability], the PASRR must be completed prior to admission. An admission Record revealed the facility admitted Resident #44 on 08/02/2024. According to the admission Record, the resident had a medical history that that included diagnoses of…

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

Based on interview, record review, and facility policy review, the facility failed to ensure staff administered medication as ordered for 1 (Resident #16) of 5 sampled residents reviewed for unnecessary medications. Findings included: An undated facility policy titled, Medication Administration - General Guidelines specified, Medications are administered in accordance with written orders of the attending physician. An admission Record revealed the facility admitted Resident #16 on 01/28/2024. According to the admission Record, the resident had a medical history that included a diagnosis of hypertensive heart disease with heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/16/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #16's Order Summary Report, for active orders as of 11/13/2024, revealed an order dated 01/28/2024, for bumetanide oral tablet 2 milligrams, give one tablet by mouth one time a day for congestive heart…

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, record review, and facility policy review, the facility failed to provide facial grooming for 1 (Resident #76) of 2 sampled residents reviewed for activity of daily living (ADL) care. Findings included: A facility policy titled, ADL, Services to carry out, reviewed 12/2023, revealed, It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities. The policy revealed, 2. Residents who are unable to carry out activities of daily living (ADL) will receive necessary services to maintain, including Grooming. An admission Record indicated the facility admitted Resident #76 on 09/26/2024. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis (muscle weakness and paralysis on one side of the body) following a cerebral infarction (a stroke) and complete traumatic trans metacarpal amputation of left hand. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/13/2024, revealed Resident #76…

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, record review, and facility policy review, the facility failed to transcribe a physician order from an outside ear, nose, and throat (ENT) physician for 1 (Resident #70) of 1 resident reviewed for communication sensory concerns. Findings included: A facility policy titled, Physicians, Consulting, revised 12/2023, revealed, Purpose To promote continuity of care. The policy revealed, 5. If treatment or medications are ordered by the consulting physician, it will be communicated to a licensed staff to carry out the new treatment order. 6. Medication/treatment will be transferred to MAR [medication administration record]/TAR [treatment administration record], ordered from pharmacy/other, and treatment or medication regime initiated, and family and/or resident informed of change in plan of care. An admission Record indicated the facility admitted Resident #70 on 02/07/2024. According to the admission Record, the resident had a medical history that included diagnoses of intraspinal abscess and granuloma and muscle weakness. A quarterly Minimum Data Set (MDS), with an…

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 a care plan (a document outlining how to best care for a resident and meet their needs) for one of three sampled residents (Resident 3) after Resident 3 suffered a fall with injury. This failure had the potential for Resident 3 to suffer a subsequent fall that could result in another injury or worsening of Resident 3's current injury to his left ribs. Findings: During a review of Resident 3's admission Record (a document with basic client information), the admission Record indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD - a disease of the lungs that causes air-flow blockage and breathing-related problems), Epilepsy (abnormal electrical brain activity, also known as a seizure) and History of Falling (resident has fallen in the past). During an observation on February 8, 2024 at 9:48 AM, in the facilities 400 hallway, Resident's 3 room was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the psychosocial wellbeing of 1 out of 3 residents (Resident 1) when the facility put a screw on the window in Resident 1's room to prevent widow from opening all the way. This failure placed resident 1 at risk of depression, and a decline in psychosocial harm when Resident 1 stated he does not feel safe with screw is in the window. Findings: An unannounced visit was made to the facility on December 27, 2024, at 10:25 AM to investigate a complaint regarding Quality of Care/Treatment and Physical Environment. During a review of resident 1 ' s admission Record (general demographics), the document indicated resident 1 was admitted to the facility on [DATE], with a diagnosis to include Muscle weakness, other lack of coordination, low back pain, Encephalopathy (a group of conditions that cause brain dysfunction). During an interview with Resident 1, on December 27, 2023, at 10:45 AM, he stated he is doing well and is just concerned…

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, observation and record review, the facility failed to remove a building hazard, a threshold (a strip of wood, metal, or stone forming the bottom of a doorway and crossed in entering a house or room) that leads to the patio and is used by residents and families creating a hazard which poses a risk for falls. This failure placed two out of three residents (Resident's 1 and 2) at risk for severe injuries due to falls. Findings: An unannounced visit was made to the facility on November 27, 2023, at 1:19 PM, to investigate a complaint regarding quality of care and Accidents. During review of resident 1's admission Record (general demographics), the document indicated resident 1 was admitted to the facility August 1, 2023, with diagnosis to include Muscle weakness, Hemiplegia(paralysis on one part of the body) and Hemiparesis (weakness or the inability to move on one side of the body) affecting right dominant side following Cerebral Infarction(a lack of adequate blood supply to brain cells deprives…

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 request for documents was fulfilled in a timely manner for two of three sampled residents (Resident 1 and Resident 2) when the facility did not provide the requested documents within the timeframes specified in their policies. This failure had the potential to result in the Resident ' s denial of a timely due process. Findings: An unannounced visit was made to the facility on November 15, 2023, at 11:00 AM, to investigate a complaint regarding quality of care. During a review of the Medical Records Requests: 1. Resident 1 had a letter sent to the facility by [name of legal firm] which indicated the facility received a request for release of Resident 2 ' s medical records on October 24, 2023. Review of the confirmation fax document (states when the document was sent to the legal firm) indicated the medical records for Resident 1 was sent on November 14, 2023 (sixteen days after they received the typewritten documents request) to the [name 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.

F642 Based on interview and record review, the facility failed to ensure proper security measures were in place to protect the use of an electronic signature. When (Licensed Vocational Nurse LVN1) used (Registered Nurse RN 1), electronic signature to sign a (Minimum Data Set MDS) verifying the MDS is complete for 66 residents. This failure had the potential to cause inaccuracies in the completed comprehensive assessment in the MDS's for 66 clinically compromise residents. During an interview on October 4, 2023, at 11:22 AM, with the Activities Director, (Activities Director focuses on creating activities that enrich participants' lives with physical and cognitive exercise and socialization through recreational activities such as sports, dancing, arts, and crafts). The Activities Director stated she assesses residents by filling out the Minimum Data Set Assessment (MDS- a computerized resident assessment instrument) States she goes to the residents' room and uses a paper form, then goes on PCC (PointClickCare, a cloud-based healthcare Software provider) to document and keeps paper…

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 interviews, and record review, the facility failed to transmit Minimum Data Set (MDS) assessments (a federally mandated process for assessing resident's functional capabilities and health needs) following a significant change in status for 3 out of 22 sampled residents. This had a potential to cause harm due to missed tracking and trending of changes and/or declines in a resident's condition. Findings: During a record review on December 8, 2021, at 9:10 AM, it was noted that there were three MDS assessments for a significant change that had not been transmitted and were still in progress for Resident 60, Resident 66 and Resident 229. During an interview on December 8, 2021, at 10:00 AM, with the Administrator, he stated that the facility had been having trouble hiring and keeping an MDS coordinator and there hadn't been one for quite some time and he was aware that a lot of the MDS assessments had not been completed or transmitted. During an interview on December 8, 2021, at 2:00 PM, with the MDS Consultant, she stated that she knows that a lot of assessments are overdue to…

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

Based on interviews, and record review, the facility failed to transmit quarterly Minimum Data Set (MDS) assessments (a federally mandated process for assessing resident's functional capabilities and health needs) within the required quarterly timeframe parameters for 20 out of 22 sampled residents. This had a potential to cause harm due to missed tracking and trending of changes and/or declines in a resident's condition. Findings: During a record review on December 8, 2021, at 9:10 AM, it was noted that there were quarterly MDS assessments that had not been transmitted for Resident 29, Resident 60, Resident 9, Resident 28, Resident 7, Resident 14, Resident 61, Resident 13, Resident 25, Resident 8, Resident 3, Resident 53, Resident 15, Resident 26, Resident 12, Resident 54, Resident 6, Resident 30, Resident 27 and Resident 11. During an interview on December 8, 2021, at 10:00 AM, with the Administrator (ADM), The ADM stated that the facility had been having trouble keeping an MDS coordinator and there hadn't been one for quite some time and he was aware that a lot of the MDS…

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

Based on interviews, and record review, the facility failed to transmit Minimum Data Set (MDS) assessments (a federally mandated process for assessing resident's functional capabilities and health needs) within the required timeframes for 20 out of 22 sampled residents. This had a potential to cause harm due to missed tracking and trending of changes and/or declines in a resident's condition. Findings: During a record review on December 8, 2021, at 9:10 AM, it was noted that there were MDS assessments that had not been transmitted and were still in progress for Resident 29, Resident 60, Resident 9, Resident 28, Resident 7, Resident 14, Resident 61, Resident 13, Resident 25, Resident 8, Resident 3, Resident 53, Resident 15, Resident 26, Resident 12, Resident 54, Resident 6, Resident 30, Resident 27 and Resident 11. During an interview on December 8, 2021, at 10:00 AM, with the Administrator, he stated that the facility had been having trouble keeping an MDS coordinator and there hadn't been one for quite some time and he was aware that a lot of the MDS assessments had not been…

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

Based on interviews, and record review, the facility failed to ensure that a Registered Nurse (RN) was signing, and tracking completed Minimum Data Set (MDS) assessments (a federally mandated process for assessing resident's functional capabilities and health needs) for 20 out of 22 sampled residents. This had the potential to cause harm due to missed tracking and trending of changes and/or declines in a resident's condition. Findings: During a record review on December 8, 2021, at 9:10 AM, it was noted that there were MDS assessments that had not been transmitted and were still in progress for Resident 29, Resident 60, Resident 9, Resident 28, Resident 7, Resident 14, Resident 61, Resident 13, Resident 25, Resident 8, Resident 3, Resident 53, Resident 15, Resident 26, Resident 12, Resident 54, Resident 6, Resident 30, Resident 27 and Resident 11. During an interview on December 8, 2021, at 2:00 PM, with the MDS Consultant, she stated that the Director of Nurses (DON) is the RN responsible for signing and tracking the MDS Assessments. During an interview on December 8, 2021, at 2:20…

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 sufficient staffing to assure resident safety and the well-being of residents when: 1. A resident (Resident 279) did not receive a PRN (as needed) respiratory treatment in a timely manner. 2. A resident (Resident 17) had to eat in his room instead of the dining room due to not enough staff available to supervise the dining room during mealtimes. 3. A shortage of hours was noted on the Census and Direct Care Service Hours Per Patient Day (DHPPD) on five of six days (December 2, 3, 4, 5, and 6, 2021) reviewed. This failure had the potential to negatively affect the health and safety of medically compromised residents in the facility. Finding: 1. During a review of Resident 279's Face sheet (a facility document with basic information about the resident), the document indicated, Resident 279 was admitted on [DATE], with diagnoses which included chronic obstructive pulmonary disease (block in airflow through the lungs that causes breathing-related…

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 for food service safety when: 1. Temperature logs were not updated for four shifts for the refrigerator and freezer. This failure had the potential to cause foodborne illnesses in a medically vulnerable resident population in the universe of 70 out of 72 who consumed food prepared in the kitchen. Findings: Review of the facility resident Diet List dated December 6, 2021, a total of 70 Residents out of 72 residents in the facility received food prepared in the kitchen. During an observation on December 6, 2021 at 11:30 AM, temperature logs for the walk-in refrigerator and walk-in freezer were not filled out for the PM shift of December 1, 2021, the AM shift of December 2, 2021, the AM shift of December 3, 2021. During an observation on December 9, 2021 at 9:30 AM, the temperature logs for the walk-in refrigerator and walk-in freezer were not filled out for the PM shift of December 7, 2021. During an interview on December 9, 2021 at 9:35 AM, the Dietary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident 42's right and left hand fingernails were clean and trimmed. This failure has the potential for Resident 42 to experience skin tears and infections. Finding: During a review of Resident 42 face sheet (a basic document which contains basic information about the resident) indicated Resident 42 was admitted to the facility on [DATE], with diagnoses which included dementia (a disease of the brain which causes memory loss), transient ischemic attack (a mini stroke), and convulsions (a disease of the brain which causes uncontrollable shaking). During an observation on December 6, 2021 at 3 PM, Resident 42 was in lying in bed. Resident 42's right and left hands fingernails were long and had dark colored matter underneath the fingernail. During an interview with Registered Nurse (RN 2) on December 6, 2021 at 3:20 PM, RN 2 confirmed the right and left hands fingernails were long and had dark color matter underneath the fingernails.…

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 18 sampled resident (Resident 46) individual needs and preferences were accommodated when a Resident 46 was not able to reach the pull cord for the overhead light to adjust the lighting according to her needs. This failure led to Resident 46 being dependent on staff and further decreasing her level of independent functioning. Finding: During a review of Resident 46 face sheet (a facility document which contains basic information about the resident), indicated Resident 46 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (high blood sugar), generalized muscle weakness, abnormalities of gait and mobility (not able to walk and move normally), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and insomnia (difficulty sleeping). During a concurrent observation and interview on December 9, 2021, at 9:10 AM, with Resident 46, in the…

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

Based on interviews, and record review, the facility failed to transmit Minimum Data Set (MDS) assessments (a federally mandated process for assessing resident's functional capabilities and health needs) within the required timeframe parameters for 20 out of 22 sampled residents. This had a potential to cause harm due to missed tracking and trending of changes and/or declines in a resident's condition. Findings: During a record review on December 8, 2021, at 9:10 AM, it was noted that there were MDS assessments that had not been transmitted and were still in progress for Resident 29, Resident 60, Resident 9, Resident 28, Resident 7, Resident 14, Resident 61, Resident 13, Resident 25, Resident 8, Resident 3, Resident 53, Resident 15, Resident 26, Resident 12, Resident 54, Resident 6, Resident 30, Resident 27 and Resident 11. During an interview on December 8, 2021, at 10:00 AM, with the Administrator (ADM), The ADM stated that the facility had been having trouble keeping an MDS Coordinator and there hadn't been one for quite some time and he was aware that a lot of the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 18 residents (Resident 10) received needed care and services when Physical Therapist ( PT ) did not follow physician orders for a physical therapy evaluation. This failure had the potential to lead Resident 10 to further decline in physical functioning. Finding: During a review of Resident 10's face sheet (a facility document containing basic information about the resident) indicated, Resident 10 was admitted to the facility on [DATE], with diagnoses which included hydrocephalus (fluid build-up in the brain that can affect walking, balance and normal brain functioning), hypertension (high blood pressure), and weakness (decrease in body strength). During an interview on December 6, 2021, at 3:52 PM, with Resident 10, in the resident's room, Resident 10 stated she requested for physical therapy but has not received it yet. During a review of Resident 10's physician orders dated December 2, 2021, the physician orders indicated, PT Evaluation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident 42 did not develop a reoccurrence of a pressure ulcer (a skin injury caused by pressure) to the right and left heels when facility was not following Resident 42's care plan of applying heel protectors. This failure resulted in Resident 42 developing a reoccurrence of a pressure ulcer to the right and left heels. Finding: During a review of Resident 42 face sheet (a document which contains basic information about the resident) indicated Resident 42 was admitted to the facility on [DATE], with diagnoses which included dementia (a disease of the brain which causes memory loss), transient ischemic attack (a mini stroke), and convulsions (a disease of the brain which causes uncontrollable shaking). During an observation on December 6, 2021 at 2:30 PM, Resident 42 was in lying in bed. Resident 42 had a small dark color wound to the right and left heels. Further observation, Resident 42 did not have right and left heel protectors…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident 42 physician's order were followed when 1. Right and left heel protectors (a device used to prevent skin breakdown) were not applied as ordered by the physician. 2. Left carrot hand splints (a device used to prevent contractures from getting worse) was not applied as ordered by the physician. These failures had the potential to jeopardize Resident 42 health and safety. Findings: 1. During an observation on December 6, 2021 at 2:30 PM, Resident 42 was in laying in bed. Resident 42 right and left heel did not have heel protectors. A review of Resident 42's physician orders, dated March 10, 2021, indicated, Heel Protectors while in bed for skin maintenance every shift. During an interview with Registered Nurse (RN 2) on December 6, 2021 at 2:40 PM, the RN 2 confirmed the right and left heel did not have heel protectors. RN 1 stated, The right and left heel should have heel protectors. The RNA usually applies the heel…

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 medication was available for administration to a resident (Resident 71) when her 6:00 AM dose of Levothyroxine (Thyroid medication) was not found in the medication cart. This had the potential to cause harmful symptoms such as weight gain, depression, muscle cramps, weakness and memory problems due to low thyroid levels Findings: During an observation and concurrent interview on October 8, 2021 at 5:48 AM, with a Licensed Vocational Nurse (LVN), she is observed administering medication for Resident 71. Levothyroxine 125mcg was missing from the medication cart and was not available to administer. The LVN stated that the medication is not available in the e-kit, (a kit containing medication that can be given in an emergency when it is not available in the medication cart) so she will leave a message for the Doctor to let them know it wasn't given. During a record review of Resident 330's medication administration record, there is an active order for Levothyroxine Sodium Tablet 125 MCG, Give 1 tablet…

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 medication was disposed of per facility policy when a bottle of medication and a blister pack of pills was found in the medication disposal container in the med room. This had the potential to cause harm due to medication being able to be removed from the waste container and misappropriated. Findings: During an observation and concurrent interview on December 8, 2021, at 1:20 PM, with a Licensed Vocational Nurse (LVN 2), in the medication room, a medication disposal container was seen to have a bottle of medication and a blister pack with full pills inside. LVN 2 stated that medication should be emptied out of bottles, and pills should be removed from blister packs before being disposed of in the medication waste container. During an interview on December 8, 2021, at 1:25 PM, with the Director of Nursing (DON), she stated that medication should never be left in the original containers when they are being disposed of in the medication disposal container. She stated that pills should be emptied out…

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 an antibiotic stewardship program (an effort to measure and improve how antibiotics are prescribed by physicians and used by patients) when Resident 330 was prescribed antibiotics and there were no criteria used to ensure that they had been prescribed appropriately. This failure had a potential to ineffectively treat infections, protect patients from harm caused by unnecessary antibiotic use and combat antibiotic resistance. Findings: During an interview with Licensed Vocational Nurse (LVN 1), she stated that the physician orders antibiotics, but she doesn't know about an antibiotic stewardship program. During an interview and concurrent record review with the Director of Nurses (DON), she stated that they have an antibiotic stewardship program which includes ensuring that residents are prescribed antibiotics appropriately using the McGeers criteria. A review of the antibiotic stewardship binder shows no entries of antibiotic use for 2021. During an interview and concurrent record review with the DON 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.