University Heights Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#82) of three residents out of 43 sample residents.Specifically, the facility failed to:-Ensure an assessment was completed to identify potential trauma behaviors for Resident #82, who had a diagnosis of post-traumatic stress disorder (PTSD); and,-Develop a care plan for Resident #82's PTSD that included possible escalating triggers (stimuli that cause a person to experience intense emotional distress or for the person to react in ways that were reminiscent of past traumatic experiences) and appropriate interventions.Findings include:I. Facility policy and procedureThe Trauma-Informed and Culturally Competent Care policy, revised August 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 observations, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#42) of two residents reviewed for medications errors out of 42 sample residents.Specifically, the facility failed to ensure that Resident #42 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration.Findings include: I. Facility policy and procedureThe Medication Administration policy and procedure, revised 8/4/25, was received from the nursing home administrator (NHA) on 8/7/25 at 3:25 p.m. It documented in pertinent part, Medication is to be given in compliance with the physician orders and/or the manufacturer's recommendations.II. Manufacturer's recommendationsThe Lantus Solostar (prefilled insulin pen) medication package insert (2022) was retrieved on 8/11/25 from…

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 observations, record review and interviews, the facility failed to ensure proper storage of medications in two of four medication storage carts and one of two medication storage rooms. Specifically, the facility failed to: -Ensure medications were labeled with the date they were opened; and,-Ensure expired medications were removed and discarded from medication carts. Findings include: I. Professional ReferencePharMerica (1/12/25) Abridged List of Medications with Shortened Expirations Dates, was retrieved on 8/12/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://pharmerica.com/wp-content/uploads/2025/01/PMC-[NAME]-Meds-with-Shortened-Expiration-Dates_012025_FINAL.pdf. it revealed in pertinent part, Once certain products are opened and in use, they must be used within a specific timeframe to avoid reduced stability, sterility and potentially reduced efficacy. Product-specific storage and expiration details can be found in the drug product's Package Insert (PI) under the 'How…

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 record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#14) of two residents reviewed for hospice services out of 43 sample residents.Specifically, the facility failed to ensure the hospice agency notes regarding Resident #14's care were easily accessible to the facility staff in an attempt to effectively coordinate care with the hospice agency.Findings include:I. Facility policy and procedureThe Hospice Care policy and procedure, revised 2/29/24, was received from the nursing home administrator (NHA) on 8/7/25 at 3:25 p.m. It read in pertinent part, When a facility resident elects to have hospice care, the facility staff communicates with the hospice agency to establish and agree upon a coordinated plan of care that is based upon an assessment of the resident's needs and living situation in the facility. Hospice communication will be reviewed and added 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 record review and interviews, the facility failed to ensure three (#13, #1 and #6) of five residents out of 13 sample residents were kept free from abuse. Specifically, the facility failed to: -Ensure Resident #13 and Resident #1 were kept free from physical abuse by Resident #2; and, -Ensure Resident #6 was kept free from physical abuse by Resident #7. Findings include: I. Facility policy and procedure The Abuse policy and procedure, dated 2/29/24, was provided by the nursing home administrator (NHA) on 3/27/25 at 2:30 p.m. It revealed in pertinent part, Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment and willful neglect of the resident's basic needs. The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#4) of three residents reviewed for accidents out of 12 sample residents. Specifically, the facility failed to: -Ensure Resident #4 was provided with the supervision necessary to prevent elopement; and, -Ensure Resident #4's elopement on 3/2/25 was investigated thoroughly. Findings include: I. Facility policy and procedure The Elopement and Wandering policy and procedure, dated 2/29/24, was provided by the nursing home administrator (NHA) on 3/26/25 at 3:36 p.m. It read in pertinent part, It is a goal of the facility to provide a safe environment using the least restrictive measures available in care for residents who are exhibiting elopement behavior. 'Elopers' are defined as residents who make an overt or purposeful attempt to leave the facility and do not have the ability to identify safety risks. II. Resident #4 A. Resident status Resident #4, age less than 65, 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 observations, record review and interviews, the facility failed to ensure one (#2) of five residents out of 13 sample residents who were diagnosed with dementia, received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Specifically, the facility staff failed to implement person-centered interventions to prevent Resident #2 from displaying physically aggressive behaviors toward other residents related to her diagnosis of dementia. Findings include: I. Facility policy and procedure The Dementia-Clinical Protocol policy and procedure, dated 2/29/24, was provided by the nursing home administrator (NHA) on 3/27/25 at 2:30 p.m. It revealed in pertinent part, The staff will review the current physical, functional, and psychosocial status of individuals with dementia, and will summarize the individual's condition, related complications, and functional abilities and impairments. The IDT (interdisciplinary team) will identify 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 observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in two of two nourishment rooms. Specifically, the facility failed to: -Ensure frozen nutritional supplements and thickened liquids were dated appropriately; -Ensure timely cleaning of the ice machine; -Ensure food was labeled and dated in the nourishment rooms; -Ensure food was properly cooled; and, -Ensure food was reheated appropriately. Findings include: I. Ensure frozen nutritional supplements and thickened liquids were dated appropriately A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf, retrieved 1/29/24, read in pertinent part, Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or…

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

Based on observations and staff interviews, the facility failed to ensure garbage and refuse was properly disposed of and the dumpster lid was closed to prevent harborage to pests and insects for two of three dumpster areas. Specifically, the facility failed to ensure garbage and potentially hazardous medical waste was disposed of in the proper receptacles or dumpster. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (2019) the Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf., retrieved on 1/30/24, read in pertinent part, Receptacles and waste handling units for refuse, recyclables, and returnable used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers. Cardboard or other packaging material that does not contain food residues and that is awaiting regularly scheduled delivery to a recycling or disposal site may be stored…

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

Based on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included all resources, education, staff competencies and facility based risk assessments. Findings include: I. Facility policy and procedure The Facility Assessment policy, dated October 2018, was provided by clinical nurse consultant (CNC) #1 on 1/27/24 at 4:58 p.m. It read in pertinent part, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. The facility assessment includes a detailed review of the resident population. The facility assessment also includes a detailed review of the resources available to meet the needs of the…

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

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to infection control. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to infection control. Findings include: I. Facility policy The Quality Management Plan policy, reviewed on 11/26/19, was received on 1/17/24 from the nursing home administrator (NHA). The policy read in pertinent part, on going quality management program designed to objectively and systematically monitor and evaluate the resident's care and health care services. The comprehensive program is designed to provide care that is optional within resources and is consistent twitch the achievable goals to ensure that monitoring of residents' care is performed systematically and continuously. To identify the organizational components responsible for quality…

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

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases, including COVID-19, for 10 (#72, #26, #79, #24, #38, #4, #81, #52, #11, #17 and #56) of 10 residents reviewed for COVID-19 immunizations out of 52 sample residents. Specifically, the facility failed to ensure tracking, offering and administration of the COVID-19 vaccination. Findings include: A. Facility policy and procedure The Immunizations policy, reviewed 7/28/23, was provided by the clinical nurse consultant (CNC) #1 on 1/17/24 at approximately 11:00 a.m. It read in pertinent part, Purpose: To minimize the risk of residents acquiring, transmitting, or experiencing compilations for influenza, pneumococcal pneumonia, and COVID-19 by assuring that each resident is informed about the benefits and risks of immunizations and has the opportunity to be immunized unless medically contraindicated or if refused by the resident or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal and influenza vaccinations for 11 (#72, #26, #79, #24, #38, #4, #81, #52, #11, #17 and #56) of 11 residents out of 52 sample residents. Specifically, the facility failed to: -Administer the pneumococcal vaccination after Resident #72, #79, #4 consented to the vaccination; -Obtain a physician's order to administer the annual influenza vaccination for Resident #72, #26, #79, #24, #38, #4 and #11; -Determine if additional doses of the pneumococcal vaccination were needed and offer the additional doses of the pneumococcal vaccination as needed to Resident #26, #24, #35, #52, #17, and #56; -Document declination forms, document risk versus benefit education and re-offer the pneumococcal vaccination annually for Resident #81 and #11; and, -Document risk versus benefit education for the influenza vaccination for Resident #81, #52 and #56. Findings include: I. Professional reference According to 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 observations and interviews, the facility failed to provide a comfortable and homelike environment for the residents on two of two units in the facility. Specifically, the facility failed to ensure residents were provided with clean washcloths and hand towels in their rooms on the South and North units. Findings include: I. Observations On 1/17/24 beginning at approximately 9:20 a.m., the following observations were made: -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; and, -room [ROOM NUMBER] had no hand towels or washcloths. On 1/18/24 at approximately 9:00 a.m., the following observations were made: -room [ROOM NUMBER] had no hand towels or washcloths; and, -room [ROOM NUMBER] had no hand towels or washcloths. On 1/18/24 at 3:18 p.m., room [ROOM NUMBER] had no hand towels or washcloths. On 1/22/24 beginning at approximately 11:00 a.m., the following observations were made: -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM…

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

Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents nutritional needs. Specifically, the facility failed to: -Follow correct portion sizes to ensure adequate nutrition was provided to the residents; and, -Follow recipe modifications for minced and moist diets. Findings include: I. Facility policy and procedure The Therapeutic Diets policy, revised October 2017, was provided by the clinical nurse consultant (CNC) #1 on 1/23/24 at 12:03 p.m. It read in pertinent part, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Diet order should match the terminology used by the food and nutrition services department. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet. If a mechanically altered diet is ordered, the provider will specify…

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

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable, attractive at the appropriate temperatures and met the nutritional needs of the residents. Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and appearance. Findings include: I. Facility policy and procedure The Meal Preparation for Nutritive Value and Palatability policy, dated April 2023, was provided by the corporate nurse consultant (CNC) #1 on 1/23/24 at 12:59 p.m. It read in pertinent part, Food is prepared by methods that conserve nutritive value, flavor, and appearance. Food and drink that is palatable, attractive, and at a safe and appetizing temperature. II. Observations A test tray for a regular diet was evaluated immediately after the last resident had been served their room tray for lunch on 1/22/24 at 12:49 p.m.by four surveyors. The test tray consisted of beef stroganoff with egg noodles, broccoli and a fruit cocktail cup. -The beef stroganoff was bland and tasted like raw flour; -The egg noodles were…

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

Based on observations, record review and interviews, the facility failed to provide food and beverages that accommodated resident preferences for five (#66, #79, #59, #14 and #83) of five residents reviewed food and beverage preferences out of 52 sample residents. Specifically, the facility failed to offer food choices to residents who preferred to eat in their room for Residents #66, #79, #59, #14 and #83. I. Facility policy The Resident Food Preferences policy, revised July 2017, was received from the corporate nurse consultant (CC) #1 on 1/23/24. It read in pertinent part: Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. The food services department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. II. Resident interviews Resident #79 was interviewed on 1/17/24 at 10:41 a.m. Resident #79 said he preferred to eat in his room. Resident #79 said there was 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 observations, interviews and record review, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#79) of one out of 52 sample residents. Specifically, the facility failed to ensure Resident #79 was assessed for safe self-administration of medications. Findings include: I. Facility policy and procedure The Self-Administration of Medications policy, revised February 2021, was provided by clinical nurse consultant (CNC) #1 on 1/27/24 at 4:58 p.m. It revealed in pertinent part, Residents have the right to self-administer medication if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. Self-administered medications are stored in a safe and secure place,…

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 residents were provided prompt efforts by the facility to resolve any grievances for one (#16) of one resident reviewed for grievances out of 52 sample residents. Specifically, the facility failed to ensure grievances regarding missing clothing items was followed up timely with a satisfactory resolution for Resident #16. Findings include: I. Facility policy The Grievance policy, dated 5/8/23, was provided by corporate nurse consultant (CNC) #1 on 1/24/24 at 3:15 p.m. It read in pertinent part, To provide residents and responsible parties with information on the facility grievance procedure. To ensure that residents are afforded their right to file a grievance without discrimination or reprisal and that such grievance shall be responded promptly and in written form. Upon the receipt of a grievance and complaint report or complaint concern form, the social service director or designee will begin an exploration into the allegations/concerns. The appropriate department director will be notified of the nature 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 interviews and record review, the facility failed to take steps to protect one (#6) of three residents out of 52 sample residents. Specifically, the facility failed to ensure Resident #6 was free from physical abuse from Resident #11. Findings include: I. Facility policy and procedure The Abuse policy, dated 5/3/23, was provided by clinical nurse consultant (CNC) #1 on 1/17/24 at approximately 11:00 a.m. It revealed in pertinent part, Purpose: Communities does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. Intent: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents received pre-admission mental health screenings for one (#24) of one resident reviewed for mental health screenings out of 52 sample residents. Specifically, the facility failed to perform a level two pre-admission screening and resident review (PASRR) for Resident #24. Findings include: I. Facility policy and procedure The PASRR policy, created 9/26/23, was received from the corporate nurse consultant (CNC) on 1/29/24 at 12:29 p.m. It read in pertinent part: If a Level II is needed, this will be scheduled and completed and (name of partner with government agency) will provide recommendations that should then be filed in the facility's record along with all other PASRR documents. II. Resident #24 A. Resident status Resident #24, age younger than 65, was admitted to the facility on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included mild cognitive impairment, depressive episodes, insomnia,…

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 record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#79) of one resident reviewed for discharge planning out of 52 sample residents. Specifically, the facility failed to assist Resident #79 with his discharge planning goals. Findings include: I. Facility policy and procedure The Discharge Planning policy, dated [DATE], was provided by the clinical nurse consultant (CNC) #1 on [DATE] at 12:03 p.m. It revealed in pertinent part, The facility will develop and implement an effective discharge planning process that focuses on the resident's discharge goals. This will include identifying ways for residents to be active participants and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Discharge planning is a process that begins on admission and involves identifying the resident's discharge goals and potential barriers, developing and implementing interventions to address them, 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 observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#79) of two residents reviewed for vision out of 52 sample residents. Specifically, the facility failed to offer vision services to Resident #79. Findings include: I. Facility policy and procedure The Ancillary services policy, dated 11/4/13, was provided by the clinical nurse consultant (CNC) #1 on 1/23/24 at 1:02 p.m. It revealed in pertinent part, Purpose: Ancillary services, including, but not limited to, dental, vision, audiology and podiatry will be provided to the resident per state and federal regulatory guidelines; at the resident/responsible family members request; and as needed. Ancillary services are available to all residents requiring routine and emergency ancillary services care. Social Services/Designee will be responsible for ensuring residents needing ancillary services receive needed/requested services in a timely manner. Records 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 observations, record review and interviews, the facility failed to ensure two (#38 and #79) of three residents reviewed for pain out of 52 sample residents had an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences. Specifically, the facility failed to: -Ensure Resident #79 was referred to a pain clinic in a timely manner after the physician requested a pain clinic referral; -Thoroughly document Resident #38's pain level after administration of as needed (PRN) pain medication and the non-pharmacological interventions used prior to administration; -Ensure prescribed PRN pain medication was administered prior to wound care according to the physician orders; -Thoroughly and accurately complete pain assessments for Resident #38; and, -Ensure Resident #38's pain was managed effectively according to the resident's stated pain management goal. Findings include: I. Facility policy The Pain Management policy,…

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

Based on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored and labeled in two medication carts and one storage room out of four medication carts and two storage rooms. Specifically facility failed to: -Ensure loose medications in carts were properly disposed of; -Ensure the temperature of the refrigerator was kept within a safe range; -Ensure medications were not poured from one bottle to another; -Ensure medication carts were locked when unattended; and, -Ensure proper disposal of medications. Findings include: I. Facility policy and procedure The Medication Storage policy, undated, was provided by the facility on 9/29/22 at 5:30 p.m. It revealed, in pertinent part,, the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature. Only persons authorized to prepare and administer medications have access to locked medications. Drugs and biologicals are stored in the packaging,…

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 resident interviews, staff interviews, record review, and the tasting of the test tray, the facility failed to consistently serve food that was palatable and at the proper temperature. Specifically, the facility failed to ensure resident food was palatable in taste, texture, appearance, and temperature. Findings include: I. Resident interviews Resident #33 was interviewed on 9/26/22 at 10:09 a.m. She said she did not like the food at the facility. She said she liked to eat in her room but her tray would arrive without the right condiments or an item would be missing. She said the food was cold and needed more flavor. Resident #23 was interviewed on 9/26/22 at 10:46 a.m. She said she did not like the food. She said she preferred to eat in her room. She said she had been served food that was still frozen and cold. She said the food tasted bad and needed more seasoning. Resident #50 was interviewed on 9/26/22 at 2:58 p.m. He said he did not like the food because it was greasy and unhealthy. He said he had complained to staff but things never improved. He said he preferred 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 observations, interviews and record review, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases and infections. Specifically, the facility failed to: -Ensure resident rooms were cleaned appropriately; -Ensure proper infection control procedures were followed during wound care; and, -Enusure proper infection control procedures during medication administration. I. Failed to appropriately clean resident rooms A. Professional reference Centers for Disease Control and Preventions: Healthcare-Associated Infections (HAIs) 4.1 General Environmental Cleaning Techniques was reviewed on 4/21/2020 and was retrieved on 10/5/22 at https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html. The document revealed, to clean from a clean area to a dirty area to avoid spreading dirt 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 observations, record review, and interviews, the facility failed to ensure two (#440 and #339) of two residents reviewed received services in the facility with reasonable accommodation of resident's needs of 39 sample residents. Specifically, the facility failed to ensure: -Resident #440's room was set up so the resident was able to access items such as her call light, nightstand and bedside table, have access to her television remote and orient the resident on how to work her television, which was her preferred activity (cross-reference F679); and, -Resident #339 had access to her walker which provided independence. Findings include: I. Resident #440 A. Resident status Resident #440, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO) diagnoses included orthopedic fracture T11-T12 vertebra (backbone), hypertension, osteoporosis, asthma and depression. The resident had a history of falls. The 9/29/22 minimum data set (MDS) assessment documented 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 observations, record review, and interviews, the facility failed to develop and implement a baseline care plan for one (#440) of one resident reviewed for baseline care plans out of 39 sample residents. Specifically, the facility failed to fully develop, review with the resident, and implement within 48 hours of admission, a person-centered baseline care plan for Resident #440 to include resident care focus areas, goals of care and interventions. Findings include: I. Resident status Resident #440, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO) diagnoses included orthopedic fracture T11-T12 vertebra (backbone), hypertension, osteoporosis, asthma and depression. The resident had a history of falls. The baseline care plan was documented as closed and completed on 9/20/22, however only one focus care plan area was completed under pain management. The 9/29/22 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure two (#8 and #64) of four residents out of 39 sample residents for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to provide Resident #8 and #64 with bathing according to their plan of care. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) policy and procedure, revised March 2018, was provided by the nursing home administrator (NHA) on 9/29/22 at 5:30 p.m. It revealed, in pertinent part, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support 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 observations, record review, and interviews, the facility failed to ensure a program to support residents in their choice activities, designed to meet the interests and support the physical, mental, and psychosocial well being of each resident, encouraging independence for one (#440) of one out of 39 sample residents. Specifically, the facility failed to ensure Resident #440 was offered and assisted with independent leisure activities in her room. Cross-referenced to F558 failure to accommodate resident needs. Findings include: I. Resident status Resident #440, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO) diagnoses included orthopedic fracture T11-T12 vertebra (backbone), hypertension, osteoporosis, asthma and depression. The resident had a history of falls. The 9/29/22 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The staff assessment…

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 observations, record review and interviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (#72) of four out of 39 sampled residents. Specifically, the facility failed to ensure a treatment order was in place for an open area for Resident #72. Finding include: I. Facility policy and procedure The Pressure Injury Prevention policy and procedure, reviewed October 2019, was provided by the nursing home administrator on 9/29/22 at 5:30 p.m. It revealed, in pertinent part, Weekly, the facility will complete a thorough comprehensive skin evaluation in the electronic medical record on all residents. A skin evaluation may be completed more frequently if deemed necessary by nursing management or plan of care. The facility nursing assistants will complete a skin observation and document findings by completing the every shift skin observation question in the electronic medical record (point of care). The skin observation…

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 observations, record review and interviews, the facility failed to ensure two (#44 and #77) of six out of 39 sample residents with limited range of motion (ROM) received appropriate treatment and services. Specifically the facility failed to: -Ensure Resident #44 and #77 were provided braces, for contracture management, according to their plan of care; and, -Ensure parameters were clearly identified to indicate the length of time and how often the braces should be donned and doffed by the Resident #44 and #77. Findings include: I. Resident #44 A. Resident status Resident #44, age younger than 65, was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included paralytic syndrome (loss of motor function to the body), contracture of the right hand, and hypertension. The 8/8/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance 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 observations, interviews, and record review the facility failed to provide an environment free of accidents and hazards for two (#44 and #50) of five out of 39 sample residents. Specifically, the facility failed to ensure Resident #8 and Resident #44 did not have medications and supplements in their rooms. Findings include: I. Facility policy The Self-Administration of Medications policy and procedure, revised February 2021, was provided by the director of clinical services on 9/29/22 at 5:45 p.m. It read, in pertinent part, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. If it is deemed safe and appropriate for a resident 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 record review and interviews, the facility failed to ensure three residents (#29, #36 and #64) of five out of 39 sampled residents were free of unnecessary medication as possible. Specifically, the facility failed to: -Ensure informed consent was obtained prior to administration of psychotropic medication for Resident #29 and #64; and, -Ensure a gradual dose reduction (GDR) recommendation was followed for Resident #36. Findings include: I. Facility policy and procedure The Psychopharmacological policy and procedure, reviewed 9/28/22, was provided by the nursing home administrator (NHA) on 9/29/22 at 6:00 p.m. It revealed, in pertinent part, The community supports the appropriate use of psychopharmacological drugs that are therapeutic and enabling for residents suffering from mental illness. The psychopharmacological/behavior review Committee will make recommendations to the primary care physician for gradual dosage reduction of psychopharmacological drugs as recommended by Federal regulations. 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 observations, record review, and interviews, the facility failed to ensure drinks and fluids were provided consistent with the preferences and choices for one (#440) of one resident reviewed for hydration out of 39 sample residents. Specifically, the facility failed to ensure Resident #440 was provided water and drinks of choice daily and the drinks were within reach when provided in her room. Findings include: I. Resident status Resident #440, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO) diagnoses included orthopedic fracture T11-T12 vertebra (backbone), hypertension, osteoporosis, asthma and depression. The resident had a history of falls. The resident had a regular diet with thin liquids and did not have any fluid restrictions identified. The 9/29/22 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The staff assessment revealed the 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.