Valley View Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to incorporate the recommendations from the PASRR (preadmission screening and resident review) Level II determination and evaluation report into the assessment, care planning and transition of care for one (#2) of five residents out of 32 sample residents. Specifically, the facility failed to: -Take steps to ensure services were provided as recommend in Resident #2 's PASRR Level II report; and, -Ensure the PASRR recommendations were included in Resident #2 's care plan. Findings include: I. Facility policy and procedure The PASRR Completion policy, revised 9/26/23, was provided by the nursing home administrator (NHA) on 5/16/24 at 4:30 p.m. It read in pertinent part, If the resident has a PASRR Level II, the community is responsible for ensuring that any recommendations from the PASRR Level II are implemented and care planned for the resident. II. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the May 2024…

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 (#23) of five residents reviewed for ancillary services out of 33 sample residents received routine dental care and 24-hour emergency dental care. Specifically, the facility failed to refer Resident #23 to the dentist to obtain dentures timely. Findings include: I. Facility policy The Ancillary Service policy and procedure, dated 11/4/13, was provided by the nursing home administrator (NHA) on 5/15/24 at 3:25 pm. It read in pertinent part 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. Any resident needing or requesting ancillary services such as dental, vision, audiology and podiatry will have their needs met timely. Social services/designee will be responsible for ensuring residents needing ancillary services receive needed/requested services…

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 observations, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in the main kitchen. Specifically the facility failed to: -Ensure the kitchen's oven was maintained to function properly; -Ensure two of six burners were functioning properly; and, -Ensure the kitchen oven door was repaired to ensure the oven maintained consistent and appropriate cooking temperatures for cooked food. Findings include: I. Facility policies and procedures The Kitchen Sanitation policy and procedure, undated, was provided by the nursing home administrator (NHA) on 5/15/23 at 4:30 p.m. It read in pertinent, All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. II. Observation On 5/13/24 at 9:06 a.m. the oven door was not latched and there was approximately a one inch gap between the oven door seal and the oven. 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 provide the necessary treatment and services to prevent pressure injuries from occurring for two (#1 and #2) of four residents reviewed out of four sample residents. Specifically, the facility failed to: -Notify the physician timely when a pressure ulcer was discovered and implement timely treatment orders for Resident #1; and, -Accurately complete a weekly skin assessment to reflect the Resident #1 and Resident #2's skin impairments. Findings include: I. Professional reference The National Pressure Injury Advisory Panel (NPIAP), Prevention and Treatment of Pressure Ulcers accessed on 10/17/23 from https://npiap.com/ read in pertinent part, steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. II. Facility policy The Pressure Ulcer policy, dated 3/10/23,…

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 one (#1) out of three sample residents were kept free from abuse. Specifically, the facility: -Failed to prevent a resident-to-resident altercations between Resident #1 and #2. Findings include: I. Facility policy and procedure The Abuse Policy, revised 10/28/2020, was provided by the nursing home administrator (NHA) on 9/7/23 at 11:36 a.m., included in part, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. II. Altercation on 7/8/23 A. Record review for Resident #2 A progress note from Resident #2's record dated 7/8/23 at 7:01 p.m. included, Certified nurse aide (CNA) was notified by…

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

Based on record review and interviews, the facility failed to have a registered nurse (RN) scheduled eight hours consecutively a day for seven days a week. Specifically, the facility did not have a RN between 1/13/23 to 1/19/23. Findings include: I. Record review Review of the January 2023 schedule, the facility did not have a RN in the facility from 1/13/23 through 1/19/23. II. Staff interviews The nursing home administrator (NHA) was interviewed on 1/19/23 at 1:40 p.m. He said there was no RN in the building at that time. He said the director of nursing left the building pending an investigation on 1/13/23. Since that day, there has not been a RN in the building. He said he was actively looking to hire a full time RN. At 3:30 p.m. the NHA said the facility would have a RN start 1/23/23. He said until the RN started, he had reached out to the medical director, and the medical director said he would be available over the weekend for any needs the facility might need to include coming into the facility by phone. At 4:30 p.m. the NHA said the facility would have a RN start 1/20/23.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure the dishwasher maintained sufficient levels of water temperature and sanitizing solution. Findings include: I. Chemical Sanitization A. Professional Reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg. 132-137, read in part, Cleaning and sanitizing may be done by spray-type, immersion ware washing, or by any other type of machine or device if it is demonstrated that it thoroughly cleans and sanitizes equipment and utensils. Chemical sanitizing ware washing machines (single-tank, stationary-tank, door-type machines and spray-type glass washers) may be used provided that: 1) The temperature of the wash water shall not be less than 120°F (49°C); 2) The wash water shall be kept clean; and 3) Chemicals added for sanitization purposes shall be automatically dispensed; and 4) Utensils and equipment…

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 have an individual designated as an infection preventionist who had completed specialized training in infection prevention and control. Specifically, the facility had not had an infection preventionist (IP) employed since August 2022. Findings include: I. Facility policy The Infection Prevention and Control policy, revised October 2018, was provided by the nursing home administrator (NHA) on 1/25/23. It read in pertinent part, The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. II. Observations Between 1/17/23 and 1/24/23 during the survey while conducting an infection control investigation, there was no infection preventionist in the building. III. Staff interviews The NHA was interviewed on 1/19/23 at 1:40 p.m. He stated that there was no IP present in the building. He was actively seeking to hire a full time nurse to fill the IP role. The NHA was interviewed…

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 provide a meal service for residents in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for residents served in two dining rooms. Specifically, the facility failed to: -Ensure residents had complete access to the dining room and ensure dining room doors were not locked during meal times; and, -Ensure an adequate system was in place to provide meal services in a timely fashion to residents waiting to be seated in the dining room. Findings include: A. Posted mealtimes The posted meal times for the main dining room were scheduled to begin breakfast at 7:00- 8:30 a.m., lunch at 11:00 a.m.-12:30 p.m. and dinner at 5:00 p.m.-6:30 p.m. B. Resident interviews Resident #32 was interviewed at 10:40 a.m. Resident #32 said he eats at 11:30 a.m., because he had a scheduled meal time and if he missed it he would have to eat in his room. On 1/19/23 at 11:19 a.m. Resident #52 was asked if he was waiting to go into the dining room. He said, Hell yes I…

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 staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 12 of 26 resident rooms, three of three hallways and kitchen. Specifically, the facility failed to ensure walls, baseboard coves, halls, floors, handrails, and ceiling tiles were repaired, painted and properly maintained. Findings include: I. Initial observations Observations of the resident living environment conducted on 1/23/23 at 10:57 a.m. revealed: room [ROOM NUMBER]: The corner next to the residents' bed had chipped and peeling sheetrock approximately three feet high by five inches wide, the metal corner piece was exposed. The room was painted a light yellow but had a section approximately five feet by four feet, which were repainted in a medium brown shade of paint. The flooring was damaged throughout the room with a section approximately six feet by five wide, which was black and worn. The corner next to the restroom had chipped and peeling sheetrock approximately…

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 prevent resident to resident altercations for six (#42, #40, #7, #17, #20 and #59) of six residents out of 21 sample residents. Specifically, the facility failed to prevent resident to resident physical abuse altercations between: -Resident #42 and Resident #40; -Resident #7 and Resident #17; and, -Resident #20 and Resident #59. Findings include: I. Facility policy and procedure The Abuse policy, modified on 11/15/19, was received from the nursing home administrator (NHA) on 1/19/23 at 10:47 a.m. It read in pertinent part: The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff member, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsor, friends, or any other individuals. Every resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment…

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 interviews, the facility failed to ensure certified nurse aides (CNA) were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to ensure nursing staff had completed competencies prior to providing skilled services as described in the plan of care for six out of six CNAs reviewed for competencies. Findings include: I. Competency records Review of the facility competencies records revealed four CNAs had one competency for Hoyer (mechanical) lift use: CNA #9 on 10/11/22, CNA #1 on 9/14/22, CNA #5 on 9/13/22, and certified nurse aide with medication authority #1 on 9/13/22. The facility had no other competencies for six of six CNAs reviewed. II. Interviews The interim director of nursing (IDON) was interviewed on 1/24/23 at 11:00 a.m. She said competencies were important to ensure staff were safe to provide cares to residents. She said she would work on ensuring staff could provide care safely. 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, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in one of two medication carts, and one of one medication storage rooms. Specifically, the facility: -Failed to discard an expired vial of tuberculin; -Failed to date a vial of tuberculin when opened; and, -Failed to date a Breo inhaler and Advair inhaler when opened. Findings include: I. Professional references According to the Breo Ellipta inhaler website, retrieved [DATE] from: https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Breo_Ellipta/pdf/BREO-ELLIPTA-PI-PIL-IFU.PDF, Safely throw away BREO ELLIPTA in the trash 6 weeks after you open the tray or when the counter reads '0', whichever comes first. Write the date you open the tray on the label on the inhaler. According to the Tubersol package insert, retrieved [DATE] from: https://www.fda.gov/media/74866/download, A vial of TUBERSOL which has 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure medical records were kept in a secure and confidential manner and the medical record was complete and accurate in keeping with accepted standards of practice for three (#54, #32 and #41) of five residents out of 21 sample residents. Specifically, the facility failed to keep all medical records for Resident #54, #32, and #41 information complete and accurate. Findings include: I. Resident #54 A. Resident status Resident #54, age under 65 years, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included bipolar disorder. The 11/30/22 minimum data set (MDS) assessment revealed the resident was not assessed for cognition and a brief interview for mental status (BIMS) was not done. B. Record review The elopement care plan, initiated on 11/23/22, documented the resident was an elopement risk/wanderer. The secure unit focus documented the resident required placement due to bipolar…

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 conduct testing in a manner that was consistent with current standards of practice for conducting COVID-19 tests all for 21 sample residents. Specifically, the facility failed to document in the resident records the results of COVID-19 tests for residents. Findings include: I. Record review Medical records were reviewed for 21 sample residents from November 2022 to 1/24/23. There were no COVID testing results in the resident's medical charts reviewed. II. Staff interview The interim director of nursing (IDON) was interviewed on 1/24/23 at 1:30 p.m. She said she did not know the results needed to be in the resident's charts, and would work with the facility to ensure the results were included in the resident's medical records going forward.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to incorporate the recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation report into the assessment, care planning and transitions of care for two (#54 and #41) out of five residents reviewed for PASRR out of 21 sample residents. Specifically, the facility failed to: -Take steps to ensure services were provided as recommended in the resident's PASRR level II for Resident #54; and, -Notify the state mental health agency recommendations could not be met for Resident #54 or #41. Findings include: I. Facility policy and procedure The Social Services PASRR (Pre-admission Screen and Resident Review) Policy, dated 11/3/17 was provided by the nursing home administrator (NHA) on 1/23/23. It revealed in pertinent part, The social services staff are responsible for assuring that the specialized services needed or recommended by the PASRR- level II are reviewed, implemented, and care planned within 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 notify the state mental health agency promptly after a significant change in the mental condition of three (#54 and #32) of five residents out of 21 sample residents. Specifically, the facility failed to notify the state mental health agency of Resident #54 and Resident #32 necessity for inpatient psychiatric hospitalizations. Findings include: I. Facility Policy and Procedure The Social Services PASRR (Pre-admission Screen and Resident Review) policy, dated 11/3/17, was provided by the nursing home administrator (NHA) on 01/23/23. It revealed in pertinent part, If a resident ' s status changes after admission, the social services staff are responsible for contacting OBRA (state mental health agency) coordinator via completion and submission of a post admission level I form (PAL) for a potential psychiatric status change review. If there is a change in category of psychiatric medications ordered or a psychiatric diagnosis change, significant…

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 provide services that met professional standards of quality according to accepted standards of practice for one (#50) of five residents reviewed of 21 sample residents. Specifically, the facility: -Failed to communicate with other staff the care and treatment for a skin tear for Resident #50, and, -Failed to follow facility policy and write a treatment order received by the provider for Resident #50. Findings include I. Resident #50 Resident #50, age [AGE], was admitted on [DATE]. According to the January 2023 computerized physician order (CPO), diagnoses included dementia, psychotic disturbance, and unsteadiness on feet. The 11/17/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. He was noted to have verbal behaviors one to three days in the past seven. No rejection of cares noted. II. Observation Resident #50 was observed on 1/19/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide services by qualified persons for one (#42) out of 21 sample residents. Specifically, the facility failed to ensure Residents #42 was assessed by a registered nurse (RN) following a fall. Findings include: I. Resident status Resident #42, age [AGE], was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included dementia with agitation, epilepsy, chronic obstructive pulmonary disease (COPD), and acute kidney failure. According to the 11/10/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The resident had no behaviors. He required extensive assistance for bed mobility, transfers, grooming and toilet use. The MDS revealed no falls since admission. II. Record review The care plan, initiated 4/27/22 and revised 10/17/22, identified the resident was at risk for falls related 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 interviews, observations and record review, the facility failed to provide the necessary assistance with activities of daily living (ADL) for two (#54 and #32) out of five residents reviewed for ADLs out of 21 sample residents. Specifically, the facility failed to provide bathing according to the resident's preferences for Resident #54 and #32. Findings include: I. Facility policy The Activities of Daily Living (ADLs) Supporting policy, revised March 2018, was provided by the nursing home administrator (NHA) on 1/23/23. It read in pertinent parts, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. II. Resident #54 A. Resident status Resident #54, age under 65 years, was admitted on [DATE]. 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, record review and interview, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) receives the necessary services and assistance for bathing for one (#50) of four residents reviewed for bathing assistance of 21 sample residents. Specifically, the facility failed to provide bathing for Resident #50. Findings include: I. Resident status Resident #50, age [AGE], was admitted on [DATE]. According to the January 2023 computerized physician order (CPO), diagnoses included dementia, psychotic disturbance, and unsteadiness on feet. The 11/17/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. He was noted to have verbal behaviors one to three days in the past seven. No rejection of cares noted. He required extensive assistance with bathing. II. Record review The care plan, revised on 1/18/23, identified an ADL self-care performance deficit…

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 residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#2) of three residents reviewed for the use of supplemental oxygen of 21 sample residents. Specifically, the facility -Failed to ensure oxygen was administered according to physician orders for Resident #2, and -Failed to have a system in place to communicate oxygen concentrator settings for staff. Findings include: I. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 computerized physicians orders (CPO), diagnoses included muscle weakness, venous insufficiency, and epilepsy. The 12/6/22 minimum data set (MDS) assessment revealed the resident's cognitive status was moderately impaired with a brief interview for mental status (BIMS) score of eight out of 15. He had no identified behaviors or rejections of care during the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess/reassess, obtain consent, and review the risks and benefits for using side rails (transfer bars) with the resident/resident representative for one (#42) of one resident reviewed for use of bed rails for positioning use out of 21 sample residents. Specifically, the facility failed to assess and review the risk and benefits for using side rails (transfer bars) prior to the use by Resident #42. Findings include: I. Resident #42 A. Resident status Resident #42, age [AGE], was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included dementia with agitation, epilepsy, chronic obstructive pulmonary disease (COPD), and acute kidney failure. According to the 11/10/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The resident had no behaviors. He required extensive assistance for bed…

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 two (#54 and #41) residents of five were free from unnecessary psychotropic medications out of 21 sample residents. Specifically, the facility failed to ensure consents were obtained and contained black box warnings for the usage of psychotropic medications for Resident #54 and #41. Findings include: I. Resident #54 A. Resident status Resident #54, age under 65 years, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included bipolar disorder. The 11/30/22 minimum data set (MDS) assessment revealed the resident was not assessed for cognition and a brief interview for mental status (BIMS) was not done. B. Record review The comprehensive care plan, initiated on 6/14/22, revealed the resident exhibited obsessive and compulsive symptoms, severe manic and psychotic features and impaired decision making abilities. The resident was taking antipsychotic medications and antidepressant medications for…

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 the hospice services provided meet professional standards and principles that applied to individuals providing services in the facility for one (#42) of two residents reviewed for hospice services out of 21 sample residents. Specifically, the facility failed to: -Have a written agreement for Resident #42 that included both the most recent hospice plan of care and a description of the services furnished by the long term care (LTC) facility; and, -Ensure that the LTC facility staff provide orientation regarding the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents. Findings include: I. Resident #42 A. Resident status Resident #42, age [AGE], was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included dementia with agitation, epilepsy, chronic obstructive…

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 had the right to be free from physical abuse for five (#2, #15, #25, #40 and #47) of seven residents out of 26 sample residents. Specifically, the facility failed to ensure: -Residents #2, #15 and #47 were kept free from abuse by Resident #29; -Resident #40 was kept free from abuse by Resident #9; and, -Resident #25 was kept free from abuse by Resident 40. I. Facility policy and procedure The Abuse policy, last revised November 2019, was provided by the regional health information manager ([NAME]) on 11/29/21 at 12:00 p.m. It read in pertinent part, Providing a safe environment for the resident is one of the most basic and essential duties of our facility. Employees have a unique position of trust with vulnerable residents. This facility promotes an atmosphere of sharing with residents and staff without fear of retribution. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other…

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 residents received their meals in a timely manner and the facility failed to have substantial nourishing snacks available. Specifically, the facility failed to ensure: -There were not more than 14 hours between a substantial evening meal and breakfast the following day; and, -Nourishing snacks were offered to residents at bedtime. Findings include: I. Facility policy The Frequency of Meals policy, developed 1/12/16 and reviewed 2020, was provided by the corporate registered dietitian (CRD) on 12/2/21 at 10:57 a.m. It read, in pertinent part, There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except as provided when a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span, and a nourishing snack is served. The facility must offer snacks at bedtime. II. Meals served greater than 14 hours Posted meal times located on the back of…

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

Based on observation, and interviews the facility failed to follow infection control measures to prevent the potential cross contamination of SARS-CoV-2 COVID-19, with two (#2 and #13) of two residents out of 26 sample residents. Specifically, the infection preventionist (IP) failed to wear proper personal protective equipment (PPE), a protective gown, consistently when collecting SARS-C0V-2 COVID-19 specimens from two residents. Findings include: I. Professional reference According to the CDC guidance, Guidance for SARS-CoV-2 Point-of-Care and Rapid Testing, updated 7/8/21, available from:https://www.cdc.gov/coronavirus/2019-ncov/lab/point-of-care-testing.html#anchor_1615506986947, accessed on 12/6/21. It read in pertinent part: Rapid point-of-care tests provide results within minutes (depending on the test) and are used to diagnose current or detect past SARS-CoV-2 infections in various settings, such as: Long-term care facilities and nursing homes. Specimen Collection & Handling of Point-of-Care and Rapid Tests -Proper specimen collection and handling are critical for all…

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 residents who were unable to carry out activities of daily living received the necessary services to maintain meal assistance for two residents (#13 and #5) of three residents reviewed out of 26 sample residents. Specifically, the facility failed to ensure Resident #13 and #5 received assistance with meals and fluid intake. Finding include: I. Facility policy The Assistance with Meal policy, revised July 2017, provided by the corporated registered dietitian (CRD) on 12/1/21 at 2:30 p.m., it read in pertinent part; Policy Statement Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy interpretation and implementation Dining room residents: -All residents will be encouraged to eat in the dining room. -Facility staff will serve resident trays and will help residents who require assistance with eating. -Residents who cannot feed themselves will be fed with attention 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 observations, record review and interviews, the facility failed to ensure it was free of medication error rates of five percent or greater for two (#3 and #35) of four residents observed during medication administration. Specifically, there was an error rate of 6.67% percent with two errors out of 30 opportunities for error. Findings include: I. Facility policy and procedure The Medication Administration policy, revised 11/26/19, was provided by the corporate quality assurance nurse (CQAN) on 12/3/21 at 11:38 a.m. It read, in pertinent part, Medications are administered in accordance with written orders of the attending physician or physician or physician extender (an agent of the physician or licensed healthcare provider). II. Observation and interview of medication errors A. Resident #3 Licensed practical nurse (LPN) #1 was observed preparing and administering medication to Resident #3 on 12/1/21 at 6:29 a.m. The resident's orders included Docusate Sodium (stool softener) one tablet give 100 mg (milligram) by mouth two times a day for constipation, ordered 5/4/15. While…

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.