Kiowa Hills Rehabilitation And Nursing, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents had a right to participate in the development and implementation of their person-centered plan of care for three (#5, #14 and #38) of five residents out of 33 sample residents. Specifically, the facility failed to invite and conduct regular care conferences to review the resident's plan of care with Resident #5, Resident #14 and Resident #38. Findings include: I. Facility policy and procedure The Resident Participation, Assessment/Care Plans policy, dated December 2016, was provided by the nursing home administrator (NHA) on 1/15/25 at 12:22 p.m. It read in pertinent part, The resident and his or her representative is encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. The social services director (SSD )or designee is responsible for coordinating care plan meetings or care conferences, with the resident or resident representative, including inviting 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 observations and interviews, the facility failed to provide a functional, sanitary and comfortable environment for residents on four of five neighborhoods. Specifically, the facility failed to maintain a comfortable air temperature range on four out of five neighborhoods. Findings include: I. Facility policy and procedure The Quality of Life-Homelike Environment policy, dated 12/19/16, was provided by the nursing home administrator (NHA) on 1/16/25 at 2:38 p.m. It read in pertinent part, The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include comfortable and safe temperatures of 71 to 81 degrees fahrenheit (F). II. Group interview Residents who frequently attended monthly resident council meetings and the resident council president were interviewed on 1/14/25 at 10:38 a.m. The four residents (#1, #50, #205 and #23) who attended the meeting said the facility was not warm enough. Resident #205 said he talked to the maintenance supervisor (MS)…

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 ensure residents were provided services that meet professional standards for five (#1, #205, #255, #46 and #4) of nine residents out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #1 and Resident #205 received medications in a timely manner according to the physician's orders; and, -Ensure lancets were used instead of a syringe with a needle to check blood sugar levels for Resident #205, Resident #255, Resident #46 and Resident #4. Findings include: I. Failed to ensure Resident #1 and Resident #205 received medications in a timely manner according to the physician's orders A. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope…

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 the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support. Findings include: I. Professional reference According to the National Certification Council of Activity Professionals (NCCAP) (2025), retrieved on 1/22/25 from https://www.nccap.org/assets/docs/F-TAG%20680%20QUALIFICATION%20OF%20ACTIVITY%20DIRECTOR.pdf, The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist, or an activities professional who is licensed or registered if applicable by the state in which practicing; and, Is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body; or, Has two years of experience in a social or recreational program within the last five years, one of which was full-time in a therapeutic activities program;…

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 medications and biologicals were properly stored and labeled in accordance with professional standards in two of four medication carts and one of one medication storage room. Specifically, the facility failed to: -Ensure expired medications were removed from the medication carts and medication storage room; and, -Ensure over the counter medications intended for use by a single resident were labeled with the resident's name. Findings include: I. Professional reference The United States Food and Drug Administration (USFDA) (2/8/21) Don't Be Tempted to Use Expired Medicines, was retrieved on 1/22/25 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once 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 residents were treated with respect and dignity by providing care in a dignified, respectful and individualized manner for one (#5) of three residents reviewed out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #5 was provided beverages of his choice when requested; and, -Ensure Resident #5 was provided clothing when he requested to get dressed and was not dressed in a hospital gown. Findings include: I. Facility policy and procedure The Resident Rights policy, dated 5/1/17, was provided by the nursing home administrator (NHA) on 1/16/25 at 2:38 p.m. It read in pertinent part, Employees should treat all residents with kindness, respect and dignity, and honor each resident's rights. These rights include the resident's rights for a dignified existence, to be treated with respect, kindness and dignity, self-determination and to be supported by the facility in exercising his or her rights. II. 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 honor resident choices for one (#46) of two residents out of 33 sample residents. Specifically, the facility failed to honor Resident #46's preference for assistance with bathing from female shower aides. Findings include: I. Facility policy and procedure The Accommodation of Needs and Preferences policy and procedure, dated 12/19/16, was provided by the nursing home administrator (NHA) on 1/16/25 at 2:38 p.m. It read in pertinent part, The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. II. Resident #46 A. Resident status Resident #46, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included cerebral infarction (a type of stroke that occurs when brain tissue dies due to a lack of blood flow), hemiplegia and hemiparesis (a neurological condition that…

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 and their representatives were provided prompt efforts by the facility to resolve grievances for one (#14) of four residents out of 33 sample residents. Specifically, the facility failed to document and follow-up on grievances reported by Resident #14 regarding a missing blanket and socks. Findings include: I. Facility policy and procedure The Filing Grievance/Complaints policy, dated December 2021, was provided by the nursing home administrator (NHA) on 1/15/25 at 5:37 p.m. It read in pertinent part, Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members and theft of/missing property without fear of threat or reprisal in any form. Grievances and/or complaints may be submitted orally or in writing. Residents or the resident representative also has the right to file a grievance anonymously.…

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 (#16) of three residents reviewed for activities out of 33 sample residents received an ongoing program of activities designed to meet needs and interests and promote physical, medical and psychosocial well-being. Specifically, Resident #16 was not provided with meaningful activities or one-to-one staff visits per his individualized plan of care. Findings include: I. Facility policy and procedure The Activity Programs policy, revised June 2018, was provided by the regional clinical resource (RCR) on 1/16/25 at 1:30 p.m. The policy read in pertinent part, The activities program is ongoing and includes facility-organized group activities, facility-sponsored individual activities (including one-on-one activities) and independent individual activities. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Activities are offered seven days a week 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 the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#17) of two residents reviewed for hospice services out of 33 sample residents. Specifically, for Resident #17, the facility failed to: -Obtain a physician's order for hospice care; -Ensure the hospice agency's notes were easily accessible to the facility staff and had consistent communication and documentation of hospice care visits and updates; and, -Initiate a hospice care plan timely. Findings include: I. Facility policy and procedure The Hospice Program policy, dated October 2016, was provided by the regional clinical resource (RCR) on 1/16/25 at 3:40 p.m. It read in pertinent part, When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and…

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

Based on interviews, observations and record review, ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to: -Ensure resident food was palatable in taste, temperature, texture and appearance; and, -Address resident food complaints. Findings include: I. Resident and resident representative interviews All residents were identified by facility and assessment as interviewable. Resident #25 was interviewed on 12/4/23 at 12:06 p.m. He said the food was terrible, had no taste and it looked like prison food. He said, I am the last room at the end of the hall and my food always comes cold which doesn't help the taste. The kitchen never provides fresh fruit. Resident #4 was interviewed on 12/4/23 at 12:38 p.m. He said the food was terrible and it was cold most of the time when they served it. He said they offer an alternative meal but that was no better than the regular meal. Resident #23 was interviewed on 12/4/23 at 1:08 p.m. He said the food was terrible. He…

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 staff interviews, the facility failed to ensure food was stored, prepared and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process; -Cutting boards were free from deep scratches and stains; -Hand hygiene practices were followed during meal preparation; -Kitchen and food service areas were kept clean; and, -Staff were familiar with the sanitation process of the dishwashing machine to ensure proper sanitation level was being reached during use. Findings include: I. Food temperatures A. Professional reference According to the United States Public Health Service Food and Drug Administration (FDA) 2022 Food Code, current as of 11/7/23 retrieved 11/12/23 from https://www.fda.gov/food/fda-food-code/food-code-2022 Time/Temperature Control for Safety Food (TCS) that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least…

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 develop and implement appropriate quality assurance and performance improvement (QAPI) plans of action to correct identified quality deficiencies, potentially affecting all the residents in the facility. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify concerns and or implement effective action plans to mitigate the repetition facility failures in resident rights, quality of care, pharmacy services, food and nutrition services, infection control and physical environment. Findings include: I. Facility policy The Quality Management and Quality Assurance (QAPI) policy was provided by the nursing home administrator (NHA) on 12/4/23 at 1:08 p.m. The policy included: The QAPI program is designed to objectively and systemically monitor and evaluate the resident's care and health care services. The comprehensive program is designed to provide care that is optimal within available resources and is consistent with the achievable goals. Objectives: -To ensure that monitoring…

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 provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to grievances concerning environment, choices and personal items. Findings include: I. Facility policy and procedure The Grievance policy, dated 5/8/23, was provided by the nursing home administrator (NHA) on 12/6/23. It read in pertinent part, Upon the receipt of a grievance and complaint report or complaint concern form, the social services director or designee will begin an exploration into the allegations/concerns. The grievance and complaint investigation report must be filed with the administrator within five working days of the receipt of the grievance or complaint form. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within ten working days of the filing of the grievance or complaint. II. Resident interview 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 observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 23 of 50 resident rooms in five hallways. Specifically, the facility failed to ensure: -Walls, baseboards and doors were properly maintained, and rooms were cleaned and free of mice droopings; and, -Comfortable room temperature levels for all rooms in the facility. Findings include: I. Initial observations Observations of the resident living environment were conducted on 12/5/23 at 12:10 p.m. revealed: room [ROOM NUMBER]: The wall along the resident's bed had a large amount of mice droppings and food debris and trash under the resident's bed. The shower room door on the 600 hall had water damage approximately 36 inches wide by three feet high with the composite wood swelling due to the absorption of the water. The door next to the nurse station had a large chip approximately two feet wide by 10 inches high. The door had a peeling and damaged corner approximately eight…

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 environment were free of accidents and hazards. Specifically, the facility failed to: -Ensure space heaters temperatures were mointored for resident safety; -Ensure hot liquids were mointored for resident safety; -Ensure loose medications were not in the room for Resident #27; and, -Ensure Resident #6 was provided the interventions available to prevent falls. Findings include: I. Failed to monitor electric space heaters in the facility and resident rooms A. Observations of the resident living environment were conducted on 12/4/23 at 8:35 a.m. revealed: -Three electric space heaters were observed at the end of the 300 hall by the exit. A housekeeping staff was observed to be mopping the floor next to all of the three space heaters. Several residents' were observed walking by and self-propelling by the space heaters. -Two space heaters were located at the end of 100 hall next to the emergency door. Resident #54 had a space heater…

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 licensed nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, facility assessments, and described in the plan of care for four of four licensed practical nurses (LPNs) and two of two registered nurses (RNs). Specifically, the facility failed to: -Complete competencies as identified on the licensed nurse competency checklist for LPN #1, #2, #3 and #5; and, -Complete competencies as identified on the licensed nurse competency checklist for RNs #1 and #4. Findings include: I. Facility policy The Medication Administration policy, dated 5/31/23, was provided by the nursing home administrator (NHA) on 12/6/23 at 11:14 a.m. The policy included, Resident medications are administered in an accurate, safe, timely, and sanitary manner. Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medication. II.…

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 residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for four (#6, #23, #27 and #9) of five residents reviewed for unnecessary medications out of 27 sample residents. Specifically, the facility failed to: -Accurately track behaviors for the continued use of psychotropic medication for Resident #6. -Follow pharmacist recommendations for gradual dose reductions of psychoactive medications for Resident #23 and #27; -Identify non-pharmacological interventions on psychotropic medication behavior trackers for Residents #23 and #27; -Ensure consents were obtained and contained black box warnings for the usage of psychotropic medications for Resident #27; and, -Ensure identified resident specific behaviors were being tracked for Resident #9. Findings include: I. Facility policy The Behavior Monitoring…

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, observations, and interviews, the facility failed to ensure four (#23, #31, #9 and #6) of six residents were free of significant medication errors out of 27 sample residents. Specifically, the facility failed to: -Complete the medication administration records for Residents #23, #31, and #9 to reflect if a medication was administered; -Notify the physician of missed doses of medication for Resident #6; and, -Notify the physician when a medication was administered outside of the order instructions for Resident #6. Findings include: I. Resident #23 A. Resident status Resident #23, age [AGE], was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), the diagnoses included hyperlipidemia, chronic obstructive pulmonary disease (COPD), insomnia, bipolar disorder and anxiety. The 8/29/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. No behaviors 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 and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards in three of five medication carts. Specifically, the facility failed to: -Date a Trilegy inhaler when opened; -Date and identify the owner of an Ozempic pen; -Date an Anoro ellipta inhaler; -Date an Fluticasone propion-salmeterol diskus inhaler; and, -Date an open Budesoride inhaler when opened. Findings include: I. Manufacturer's guidelines According to the Trelegy inhaler website, retrieved on 12/7/23 from: https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Trelegy_Ellipta/pdf/TRELEGY-ELLIPTA-PI-PIL-IFU.PDF, TRELEGY ELLIPTA should be stored inside the unopened moisture-protective foil tray and only removed from the tray immediately before initial use. Discard TRELEGY ELLIPTA 6 weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first. The inhaler is not reusable. Do not attempt to take the inhaler apart. According to the Ozempic…

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 the use of wanderguards and staff competencies. Findings include: I. Record review The facility assessment was last reviewed on 3/10/23 by the nursing home administrator (NHA), director of nurses and the interdisciplinary team. The facility assessment failed to include the following: -Include staff competencies that were necessary to provide the level and types of care needed for the resident population or include the staff training program to ensure any training needs are met for all new and existing staff; and, -Include the use of wanderguards. II. Staff interviews The nursing home administrator (NHA) was interviewed on 12/7/23 at 10:20 a.m. She said the facility had four residents who utilized wanderguards. She said the use of wanderguards should be…

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 provide adequate outside ventilation by means of windows and/or mechanical ventilation. Specifically, the facility failed to ensure resident bathroom exhaust fans were functioning on the 300 hall out of five halls resident halls. Findings include: I. Observations An observation of the resident environment was completed on 12/5/23 at 12:10 p.m. Exhaust fans were installed in the ceiling of each bathroom. Bathroom fans in all rooms located on the 300 hall were not audible and did not create air movement with the switch turned on. As a measure of checking the function of each fan, a small square of single ply toilet paper was placed against the vent. The exhaust fans were unable to hold the toilet tissue in place which indicated the fans did not function properly. Urine odors were observed in 300 hall during the survey between 12/4/23 and 12/7/23. The bathroom exhaust fans were not functioning in all restrooms on the 300 hall. II. Staff Interview The environmental tour was conducted with the housekeeping supervisor…

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 an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to take the appropriate measures to control a mice infestation in the facility. Findings include: I. Professional reference According to the Center for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, last updated 2/15/19, pp. 94-95: 1. Cockroaches, spiders, and mice are among the typical pest populations found in health-care facilities. Insects and rodents can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects and rodents should be kept out of all areas of a health-care facility. 2. From a public health and hygiene perspective, pests should be eradicated from all indoor environments. Approaches to institutional pest management should focus…

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 (#6) of three residents reviewed for the use of supplemental oxygen out of 27 sample residents. Specifically, the facility failed to ensure oxygen was provided as ordered for Resident #6. Findings include: I. Facility policy The Oxygen policy, not dated, provided by the nursing home administrator (NHA) on 12/6/23 at 11:41 a.m. included, Oxygen is administered and stored to residents who need it, consistent with professional standards of practice, comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen is administered under orders of a physician. Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen. II. Resident #6 Resident #6, age…

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 diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain and maintain the highest practicable mental and psychosocial wellbeing for one (#23) of three residents reviewed out of 27 sample residents. Specifically, the facility failed to monitor and provide an ongoing assessment as to whether care approaches were meeting the emotional and psychosocial needs for Resident #23. Findings include: I Resident status Resident #23, age [AGE], was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), diagnoses included insomnia, bipolar disorder and anxiety. The 8/29/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. No behaviors were indicated. A lookback of depression screens for Resident #23 revealed no depression screens had been conducted…

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 that the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#42) of one resident reviewed for hospice services out of 27 sample residents. Specifically, the facility failed to orientate hospice aides to the facility including the policies and procedures for Resident #42. Findings include: I. Resident status Resident #42, age [AGE], was admitted on [DATE] and readmitted [DATE]. According to the December 2023 computerized physician orders (CPO), diagnoses included chronic heart failure and atherosclerotic heart disease. The 11/13/23 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 14 out of 15. She had no behaviors or rejections of care. The assessment identified hospice care. II. Record review The care plan, initiated 8/22/23 and revised on 11/22/23, identified 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 observations, record review and interviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections such as COVID-19 for one of five isolation rooms. Specifically, the facility failed to don (put on) personal protective equipment (PPE) prior to entering a resident's room who was COVID-19 positive. Findings include: I. Professional reference According to the Centers for Disease Control (CDC) guidance, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 6/3/2020, retrieved on 12/7/23 from https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf. It read in pertinent part, -PPE must be donned correctly before entering the patient area. -PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted.…

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 store, prepare, distribute and serve food under sanitary conditions in the kitchen. Specifically, the facility failed to ensure: -The kitchen and food service areas were kept clean; -Frozen and perishable food was stored properly and off the floor for a long period of time; and, -Staff was familiar with the sanitation process of the dishwashing machine to ensure proper sanitation level was being reached during use. Findings include: I. Kitchen and food service area A1. Professional reference Colorado Retail Food Establishment Rules and Regulations, effective 1/1/19, section 4-601.11 Nonfood-Contact Surfaces read, Nonfood-contact surfaces of equipment, including transport vehicles, shall be cleaned as often as necessary to keep the equipment free from the accumulation of dust, dirt, food particles, and other debris. Colorado Retail Food Establishment Rules and Regulations, effective 1/1/19, section 6-401 Cleaning Physical Facilities read, Floors, mats, duckboards, walls, ceilings, and attachments (light…

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 an effective pest control program to ensure the facility was free of pests which impacted all residents residing in the facility. Specifically, the facility failed to take the appropriate measures to control a mice infestation in the facility. Findings include: I. Professional reference According to the Center for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, last updated 2/15/19, pp. 94-95: 1. Cockroaches, spiders, and mice are among the typical pest populations found in health-care facilities. Insects and rodents can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects and rodents should be kept out of all areas of a health-care facility. 2. From a public health and hygiene perspective, pests should be eradicated from all indoor environments.…

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 ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality. Specifically, the facility failed to ensure staff knocked before entering resident rooms. Findings include: I. Facility policy and procedure The admission agreement, no date given, provided by the nursing home administrator (NHA) on 9/18/23 at 4:36 p.m., it read in pertinent part: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. II. Failure to knock on doors before entering A. Observations On 9/14/23 at 10:00 a.m., certified nurse aide (CNA) #2 walked into Resident #2's room. He did not knock or introduce himself prior to entering the resident's room. -At 3:32 p.m., registered nurse (RN) #1 entered room [ROOM NUMBER]. She did not knock or introduce herself or knock…

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 ensure one (#2) of three residents reviewed for activities of daily living out of 10 sample residents were provided the necessary care and services to maintain or improve their level of functioning. Specifically, the facility failed to ensure Resident #2, who was a dependent resident, received incontinence care timely. Findings include: I. Facility policy and procedure The Activity of Daily Living policy and procedure, reviewed 9/18/23, was provided by the nursing home administrator (NHA) on 9/18/23 at 4:36 p.m. It documented in pertinent part, 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). 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. II. Resident #2 A. Resident status Resident #2, age…

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 maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection, including COVID-19 in five of five halls. Specifically, the facility failed to: -Ensure face coverings were worn by staff while providing care; -Ensure resident bedrooms were cleaned with proper infection control techniques; -Have a water plan to prevent Legionella disease; -Ensure residents were offered hand hygiene before meals in both the dining rooms and room trays; and, -Ensure resident equipment was cleaned between uses. Findings include: I. Personal protective equipment A. Professional reference According to the The Centers for Disease Control and Prevention (CDC) guidance, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 6/3/2020, retrieved on 8/29/22 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.

Based on interviews and record review, the facility failed to test residents, facility staff, and individuals providing services under arrangement and volunteers for COVID-19. Specifically, the facility failed to ensure: -Rapid point-of-care (POC) tests for COVID-19 were consistently conducted on staff prior to the start of their shift, based on the facility's county positivity rate; and, -Polymerase chain reaction (PCR) testing was not completed on all staff based on county positivity rate and outbreak status. Findings include I. Professional reference The Healthcare Community Transmission Levels for the facility's county of residence, obtained from https://covid19.colorado.gov/healthcare-providers/long-term-care-facilities/healthcare-community-transmission-levels, were reviewed for the time of survey (8/21/22-8/25/22) and found to be in High levels of transmission. The Centers for Disease Control and Prevention (updated 2/2/22), Interim Infection Prevention and Control Recommendations to prevent SARS-CoV-2 Spread in Nursing Homes COVID-19 Nursing Homes, retrieved on 8/29/22 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.

Based on observations, record review and interviews, the facility failed to develop and implement a COVID-19 staff vaccination process to address all facility staff, including unvaccinated staff who provided care, treatment and other services to facility and/or residents. Specifically, the facility failed to monitor each contracted staff member's vaccination status to ensure proper advanced PPE (personal protective equipment) strategies (as indicated in the facility's policy and procedure) were used to prevent the spread of COVID-19. The facility was unable to provide a listing of the vaccination status of all contracted providers/staff who enter the facility on a regular basis and provide direct care to residents. A review of the facility vaccination policy and procedure revealed the facility did not require proof of vaccination for all contracted providers, but instead, required a generalized provider company attestation agreement which indicated the provider agreed to comply with the facility's vaccination policy. Cross-reference F880 (Infection control), and F886 (COVID-19…

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 four (#17, #40, #19 and #61) of four out of 35 sample residents, had the right to participate in the development and implementation of his or her person-centered plan of care. Specifically, the facility failed to inform and invite residents and/or responsible parties to participate in care plan meetings for Resident #17, #40, #19 and #61. Findings include: I. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), the diagnoses included spinal stenosis, contracture to the right hand, acute transverse myelitis in demyelinating disease of the central nervous system and paraplegia. The 7/1/22 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 supervision with one person physical assistance with bed mobility, transfers, dressing, toileting and personal…

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 residents had the right to visitation for two (#40 and #35) residents out of 35 sample residents. Specifically, the facility failed to allow the residents to have visitors at the time of their choosing. Findings include: I. Observations The facility had a sign on the front door stating visitation hours are Monday through Friday 8:00 a.m. to 5:00p.m. II. Resident interviews Resident #40 was interviewed on 8/22/22 at 2:10 p.m. The resident stated visiting hours till at least 8:00pm would be nice. Resident #35 was interviewed on 8/25/22 at 12:00 p.m. She said she was denied visitation from her family. She said her family were not allowed to visit past 5:00 p.m. She said that she had asked for the reason why, however the facility did not give her an answer. She said her daughter worked and was not able to come to the facility prior to the end of visiting hours. III. Staff interviews The director of nursing (DON) and interim director of nursing (IDON) were interviewed on 8/25/22 at 4:21 p.m. The IDON said the facility 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 and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 16 of 49 resident rooms, five of five hallways. Specifically, the facility failed to ensure walls, baseboard cove, doors, floor tiles, and ceiling were repaired, painted and properly maintained: and failed to ensure resident's had clean bath linens. Findings include: A. Initial observations room [ROOM NUMBER]: Had a black picture wood frame approximately four foot long with metal staples exposed leaning in the corner of the restroom. room [ROOM NUMBER]: The wall in the bathroom had a painted area approximately six inches in diameter which had been repaired but not completed. The resident did not have any towels next to his sink. room [ROOM NUMBER]: The heater vent shield approximately four feet long was laying on the floor and not attached to the heater. The residents did not have any towels next to their sink. The swamp cooler vent between room [ROOM NUMBER] and room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure two (#17 and #26) of three out of 35 sample residents with limited range of motion (ROM) received appropriate treatment and services. Specifically the facility failed to: -Ensure preventative measures were put into place to prevent a decrease in ROM for Resident #26 and #17; and -Ensure a restorative nursing program was established for the continuity of care for Resident #17's right hand contracture. Findings include: I. Facility policy and procedure The Prevention of Decrease in ROM policy and procedure, undated, was provided by the nursing home administrator (NHA) on 8/25/22 at 10:46 a.m. It revealed, in pertinent part, Care plan interventions will be developed and delivered through the facility's restorative program, or through specialized rehabilitative services as ordered by the attending practitioner. Staff will be educated on the basic, restorative nursing care, like assisting residents with range of motion exercises,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review the facility failed to ensure residents were as free from accident hazards as possible for four (#55, #36, #16, and #26) out of 35 sample residents. Specifically, the facility failed to ensure: -A smoking apron was documented as a care plan intervention for Resident #55; -Resident #36's inhaler was kept in a secure place; -Resident #16's over the counter medications were secure; -Resident #26 received nectar thick liquids; and, -A tube feeding device was plugged into a medical electrical outlet power strip. Findings include: I. Failure to ensure Resident #55 had smoking apron A. Facility smoking policy The Resident Smoking policy, dated 2021, was received on 8/25/22 at 9:30 a.m. from the nursing home administrator. The policy read in pertinent part, This facility provides a safe and healthy environment for residents, visitors, and employees including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Residents who smoke will be…

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 one storage room. Specifically the facility failed to: -Ensure medications were labeled with open dates; -Ensure the oral medications were stored in a separate location from inhaled medications; -Ensure loose medications in carts were properly disposed; -Ensure narcotic medications were disposed of when the packaging was compromised; -Ensure expired medications were removed from the medication cart or medication rooms; -Ensure the temperature of the refrigerator was kept within a safe range; and, -Ensure the facility did not use a dormitory style refrigerator freezer combination in the medication room. I. Facility policy and procedure The Medication Storage policy and procedure, undated, was provided by the nursing home administrator (NHA) on 8/25/22 at 10:46 a.m It revealed, in pertinent part, ' All drugs and biologics are to be stored under the proper…

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, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperature. Specifically, the facility failed to ensure resident food was palatable in taste, texture and temperature. Findings include: I. Facility policy and procedure The Food Quality and Palatability policy and procedure, revised September 2017, was provided by the dietary manager (DM) on 8/25/22 at 4:00 p.m. It revealed, in pertinent part, Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs. Food attractiveness refers to the appearance of the food when served to the residents. Food palatability refers to the taste and/or flavor of the food. Proper (safe and appetizing) temperature: food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimizes 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 the self-administration of medications was clinically appropriate for one (#36) out of 35 sample residents. Specifically, the facility failed to conduct a self-administration assessment for Resident #36 to carry and administer an inhaler without staff assistance. Cross-reference F689: the facility failed to ensure an inhaler was not left out in a resident area unattended. Findings include: I. Facility policy and procedure The Resident Self-Administration of Medication policy and procedure, undated, was provided by the nursing home administrator (NHA) on 8/25/22 at 10:46 a.m. It revealed, in pertinent part, Each resident is offered the opportunity to self-administer medications during the routine assessment. The manner of storage prevents access by other residents. A care plan must reflect residents' self-administration and storage arrangements. II. Resident #36 status Resident #36, age [AGE], was admitted on [DATE]. According 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 provide services by qualified persons for three (#48, #18 and #44) out of 35 sample residents. Specifically, the facility failed to ensure Residents #48, #18 and #44 were assessed by a registered nurse (RN) following a fall. Findings include: I. Resident #48 A. Resident status Resident #48, age under 65, was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), the diagnoses included aphasia, cognitive communication deficit, muscle weakness and malignant neoplasm of the brain. The 7/22/22 minimum data set (MDS) assessment revealed the resident has severe cognitive impairment with a brief interview for mental status score of five out of 15. He required supervision with all activities of daily living (ADL). It indicated the resident did not sustain any falls since the previous assessment. B. Record review The fall risk care plan, revised on 6/6/22, documented 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 observation, record review and interviews, the facility failed to consistently provide activities of daily living (ADLs) support for two (#54 and #26) of six dependent residents reviewed for ADLs out of 35 sample residents. Specifically, the facility failed to: -Provide eating assistance for Resident #54; and, -Provide timely repositioning and oral care for Resident #26. Findings include: I. Resident #54 A. Resident status Resident #54, age [AGE], was admitted on [DATE]. The August 2022 computerized medical record (CPO) indicated a diagnosis of hypertension, Alzeimers disease, dementia, anxiety disorder and weight loss. According to the 8/1/22 minimum data set (MDS) the resident was cognitively impaired with a brief interview of mental status (BIMS) of three out of 15. The resident required extensive assistance with dressing, and supervision with eating. B. Observations 8/21/22 -At 6:45 p.m. Resident #54 received her dinner tray. -At 6:47 p.m. the resident left her room and roamed up and down the halls.…

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 have an ongoing activity program designed to meet the needs of one (#49) out of five reviewed for activities out of 35 sample residents. Specifically, the facility failed to provide person-centered activities that met the interest and needs of Resident #49. Findings include: I. Professional reference According to Second Wind Movement, The Importance of Social Interaction for Seniors, 5/1/18, http://secondwindmovement.com/social-interaction-for-seniors (6/27/19), retrieved on 9/8/22 read in pertinent part: -Lack of social interactions can lead to depression and loneliness. -Positive interpersonal social interaction can help to reduce cardiovascular problems (lower blood pressure) and prolong life. II. Resident#49 Resident #49, under age [AGE], was admitted on [DATE].The August 2022 computerized physicians orders indicated a diagnosis of traumatic brain dysfunction, hypertension, renal failure, diabetes, quadriplegia (paralysis of all limbs),…

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 two (#19 and #48) out of 35 sample residents. Specifically, the facility failed to ensure: -A treatment order was in place for an open area for Resident #19; and, -Neurological checks were completed post fall with a head injury for Resident #48. Findings include: I. Failure to ensure a treatment order was in place A. Facility policy and procedure The Skin Assessment policy and procedure, undated, was provided by the nursing home administrator (NHA) on 8/25/22 at 10:26 a.m. It revealed, in pertinent part, A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. Staff will document findings including wounds including location, size, drainage, tissue condition, and pain and note any skin conditions such as redness,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations interviews and record review the facility failed to provide podiatry services for one resident (#16) out of two reviewed for podiatry services out of 35 sample residents. Specifically, the facility failed to ensure Resident #16's toenails were trimmed timely. Findings include: I. Facility policy and procedure The Skin Integrity-Foot Care policy, undated, was received from the nursing home administrator (NHA) on 8/25/22 at 10:46 a.m It read in pertinent part, residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. A licensed nurse with adequate training may perform nail care to non-diabetic residents, or diabetic residents who are low risk as determined by a podiatrist or physician. A referral to a podiatrist will be made when appropriate. II. Resident status Resident #16, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO)…

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, resident interview, record review, and staff interviews, the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for one (#49) of one resident reviewed for catheters of 35 sample residents. Specifically, the facility failed to: -Ensure the resident's urinary catheter down drain bag was kept from dragging on the floor; and, -Ensure the resident's urinary catheter was kept below the bladder. Findings include: I. Facility policy The Catheter Care policy was received from the nursing home administrator on 8/25/22 at 9:15 a.m. It read in pertinent part, the facility will ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Ensure the drainage bag is located below the level of the bladder to discourage backflow of urine. II. Resident #49 A. Resident status Resident #49, age less than 50, was admitted on [DATE].…

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 ostomy care to one resident (#40) out of 35 sample residents. Specifically, the facility failed to have order in place to provide ostomy care for Resident #40. Findings include: I. Resident #40 status Resident #40, age younger than 65, was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), the diagnosis include acute and chronic respiratory failure with hypoxia (decrease in oxygen saturation), colostomy, hyperlipidemia, and obesity. The 7/14/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required total assistance of two people with bed mobility, transfers and bathing. A. Observations and resident interview On 8/25/22 at 12:12 p.m. Resident #40's colostomy (an opening in the intestines for bowel movement) device was observed in place. It was reinforced with a clear dressing around the device 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, record review and staff interviews, the facility failed to ensure one (#48) of three residents reviewed for nutrition/hydration, out of 35 sample residents, maintained acceptable parameters of nutritional status to avoid unintended weight loss. Specifically, the facility failed to address Resident #48's weight loss. Findings include: I. Resident status Resident #48, age less than 65 years, was admitted on [DATE]. According to the August 2022 CPO, the diagnoses included aphasia, cognitive communication deficit, muscle weakness and malignant neoplasm (cancer) of the brain. The 7/22/22 MDS assessment revealed the resident has severe cognitive impairment with a brief interview for mental status score of five out of 15. He required supervision with all activities of daily living (ADL). It indicated the resident had not sustained a significant weight loss. II. Record review The nutrition care plan, revised on 7/27/22, documented the resident was at risk for a nutritional problem 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 resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#163) of two residents reviewed for supplemental oxygen use out of 35 sample residents. Specifically, the facility failed to administer oxygen in accordance with the physician's order for Resident #163. Findings include: I. Facility policy and procedures The Oxygen Administration policy and procedure, revised August 2022, was provided on 8/25/22 8:25 a.m., by the nursing home administrator (NHA). It read in pertinent part, ' Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person centered care plans, and the residents goals and preferences. II. Resident #163 A. Resident status Resident #163, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), acute chronic respiratory…

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 (#163) of two residents reviewed for hospice services out of 35 sample residents. Specifically, the facility failed to: -Have a written agreement for Resident #163 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 #163 A. Resident status Resident #163, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), acute chronic…

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 staff interview, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure a backflow prevention device was installed on a hose in the maintenance closet, increasing the risk of contamination to the facility's main water supply. Findings included: I. Observation Observations of the resident living environment conducted on 8/25/22 at 10:00 a.m. revealed: The hose in the maintenance closet across from the nursing station on 400 hall did not have a backflow prevention valve on it. The sink was approximately 30 inches long by 24 inches wide and 24 inch deep. The sink was set on four legs approximately three feet off the ground. The sink had visible water on the bottom of the sink. The hose was approximately five feet long and was coiled and sitting at the bottom of the sink in water. II. Staff Interview The housekeeping supervisor (HS) was interviewed on 8/25/22 at 10:00 a.m. He acknowledged he was not familiar with the backflow valve protocol. The HS was shown…

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.