Mountain View Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure one (#93) of three residents out of 53 sample residents received the proper treatment and assistive devices to maintain vision.Specifically, the facility failed to:-Follow up after an eye appointment for Resident #93; and,-Assist Resident #93 to make an appointment for cataract surgery. Findings include:I. Facility policy and procedureThe Hearing and Vision Services policy, undated, was provided by the nursing home administrator (NHA) on 12/11/25 at 4:00 p.m. It read in pertinent part, It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. Staff should refer any identified need for hearing or vision services/appliances to the social worker/social service designee. Once vision or hearing services have been identified, the social worker/social service designee will assist the resident by making appointments and arranging for transportation.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 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 diseases and infection.Specifically, the facility failed to:-Ensure housekeeping staff followed proper cleaning procedures for cleaning and disinfecting resident rooms and high-frequency touched areas; and ,-Ensure housekeeping staff performed hand hygiene and glove changes appropriately. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures (5/4/23) was retrieved on 12/18/25 fromhttps://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.htmlHigh-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning…

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 the call light system was functioning properly in its entirety. Specifically, the facility failed to ensure staff could hear the call light alerts when working in areas away from the centralized staff work area, where the call light alarm sound was heard when there were no staff in the centralized work area to hear the alarm. Findings include: I. Facility policy and procedure The Call Lights: Accessibility and Timely Response policy, revised 1/25/25, was provided by the nursing home administrator (NHA) on 4/16/25 at 3:45 p.m. It read in pertinent part: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. II. Observations On 4/15/25 at 10:56 a.m., during the walkthrough of the facility, 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 one (#6) of three residents out of seven sample residents received the highest practicable treatment and care per professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to ensure Resident #6 received her medications in a timely manner, as prescribed. Findings include: I. Professional reference According to [NAME], P.A. and [NAME], A.G. et.al., (2021), Fundamentals of Nursing, 10 edition, pp 607-609. Medication errors can cause or lead to inappropriate medication use or patient harm. Medication errors include inaccurate prescribing, administration of the wrong medication, giving the medication using the wrong route or time interval. Administering extra doses, and/or failing to administer medications. Preventing medication errors is essential. Professional standards such as the scope of nursing and standards of practice apply to the activity of medication administration.…

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 (#2) of three residents reviewed out of five sample residents. Specifically, the facility failed to ensure services and individualized care approaches were provided, and monitored with ongoing assessment, for Resident #2 in order to meet the emotional and psychosocial needs of the resident. Findings include: I. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE] and discharged to another long-term care facility on 2/13/25. According to the February 2025 computerized physician orders (CPO), diagnoses included anxiety, head injury, dementia, depression and epilepsy. The 12/27/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status…

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, observations and interviews, the facility failed to establish a system of records and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and failed to determine that drug records are in order and that an account of all controlled substances is maintained and periodically reconciled. Specifically, the facility failed to: -Maintain a system of controlled substance records for discontinued controlled substances. Findings include: I. Facility policy and procedure The Controlled Substance policy, revised November 2022, was provided by the nursing home administrator (NHA) on 9/5/24 at 10:56 a.m. The policy read in pertinent part, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Dispensing and reconciling controlled substances: -Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. -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, record review and interviews the facility failed to provide the necessary services to maintain personal hygiene for one (#11) of three residents reviewed for services to maintain highest practicable quality of life out of 25 sample residents. Specifically, the facility failed to provide timely incontinence care for Resident #11. Findings include: I. Facility policy and procedure The Supporting Activities of Daily Living (ADL) policy, revised March 2018, was received from the nursing home administrator (NHA) on 9/5/24 at 5:08 p.m. It revealed in pertinent part, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with elimination…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three (#2, #12 and #7) out of 25 sample residents. Specifically, the facility failed to: -Ensure the physician's orders for skin and wound care were followed for Residents #2 and #12; and, -Ensure Resident #7 received medication as ordered by the physician. Findings include: I. Facility policy and procedure The Wound Care policy, revised October 2010, was provided by the nursing home administrator (NHA) on 9/5/25 at 5:08 p.m. The policy read in pertinent part, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The following information should be recorded in the resident's medical record: The type of wound care given, the date and time the wound care was given, the position in which the resident was placed, the name and title of the individual performing the wound care, all assessment data (wound 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.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to ensure nursing staff followed proper infection control procedures for a resident on enhanced barrier precautions (EBP). Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 9/9/24 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds…

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 provide services according to professional standards of practice for one (#1) out of three sample residents. Specifically, the facility failed to monitor Resident #1, who had a change of condition after suspected illicit drug use. Findings include: I. Facility policy and procedure The Acute Condition Changes policy, revised March 2018, was received from the nursing home administrator (NHA) on 2/5/24 at 2:59 p.m. The policy documented in pertinent part, The physician will help the staff monitor a resident with a recent acute changes of condition until the problem or condition resolved or stabilized. II. Resident #1 Resident #1, less than age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 computerized physician order (CPO), diagnoses included diabetes mellitus, epilepsy (seizures), acute respiratory failure, bipolar disorder, anxiety and stimulant use. The 1/1/24 minimum data set (MDS)…

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

Based on interviews, 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. I. Facility policy and procedure The Food and Nutritional Services policy, revised September 2017, was provided by the nursing home administrator on 11/16/23 at 4:34 p.m. It revealed in pertinent part, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. II. Resident and resident representative interviews All residents were identified by facility and assessment as interviewable. Resident #29 was interviewed on 11/13/23 at 9:49 a.m. He said we still had a long wait for food and it was cold when I get it. Resident #2 was interviewed on 11/13/23 at 10:07 a.m., Resident #2 said,…

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; -Follow accepted hand hygiene practices during meal preparation; and, -Kitchen and food service areas were kept clean Findings include: Facility policy The Food Preparation and Service policy, revised November 2022, was provided by the corporate numse consultant (CNC)on 11/16/23 at 3:45 p.m. It read in pertinent part: Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. 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 11/22/23 from https://www.fda.gov/food/fda-food-code/food-code-2022…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY III. Water testing failure A. Professional reference According to CDC, Legionella (Legionnaires 'Disease and Pontiac fever), last reviewed 3/25/21, retrieved from on 11/28/23: https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html and https://www.cdc.gov/legionella/wmp/overview.html. It read in pertinent part, Many buildings need a water management program to reduce the risk for Legionella growing and spreading within their water system and devices. Legionella bacteria are typically found naturally in [NAME] environments, but can become a health concern when they grow and spread in human-made water systems. Legionella can cause a serious type of pneumonia (lung infection) known as Legionnaires ' disease. Some water systems in buildings have a higher risk for Legionella growth and spread than others. Legionella water management programs are now an industry standard for many buildings in the United States. Legionella bacteria can…

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 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 the hand held shower hose in room [ROOM NUMBER], #1308 and the shower room on 1400 hall, increasing the risk of contamination to the facility's main water supply. Findings include: I. Backflow prevention devices A. Professional references According to the Environmental Protection Agency's Distribution System Water Quality Protecting Water Quality through Cross-Connection Control and Backflow Prevention, October 2021 rerieved on line 11/22/23 from: https://www.epa.gov/system/files/documents/2021-12/ds-toolbox-fact-sheets_ccc.pdf, it read in pertinent part, Cross-connections are actual or potential connections between a potable water supply and non-potable water plumbing. Backflow is the unintended reversal of water flow through a cross-connection, which can result in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents were treated with dignity for five (#29, #35, #45, 85 and #329) of six reviewed out of 54 sample residents. Specifically, the facility failed to: -Ensure residents were treated with dignity when staff failed to respond timely to call lights for Residents (#29, #35, #45, #85, #329); -Ensure staff provided a structured daily routine when possible for dementia care; and, -Ensure an adequate system was in place to provide meal services in a timely fashion to residents waiting to be served their meals. Findings include: I. Facility policies and procedures The Resident Rights policy, dated December 2016, was requested and received from the nursing home administrator (NHA) on 11/15/23 and read in pertinent part: Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: -A…

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

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 22 of 105 resident rooms in six hallways. Specifically, the facility failed to -Ensure heating units in resident rooms and in common resident shared areas were in good repair; and, -Ensure that the walls, baseboards, ceilings, counters, and doors in resident rooms and common resident areas were properly maintained. Findings include: I. Observations Observations of the resident living environment were conducted on 11/15/23 at 9:11 a.m. revealed: The heater in the main hallway had an area approximately five feet long by 14 inches high with an unfinished sheetrock patch area with several large copper pipes exposed and coming out of the side of the heater. A second heater in the main hallway had the same damage and unfinished sheetrock; the copper pipes were covered. room [ROOM NUMBER]: The wall next to the resident ' s bed had deep scratches approximately seven feet long 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure that all residents were free from abuse, neglect, and exploitation, for seven out of nine incidents of abuse involving 11 residents (#99, #27, #19 #230, #98, #61, #4, #78, #24, #79 and #60) out of 54 sample residents. Specifically, the facility failed to: -Ensure that Resident #27, Resident #19 and Resident #230 on the Columbine unit were not subject to physically abusive behavior by Resident #99; -Ensure Resident #99, who had a history of dementia and physical aggression towards other residents, received adequate supervision and implementation of effective personalized interventions to prevent the resident from abuse other vulnerable residents; -Ensure abuse prevention and protection interventions for Resident #27 and #19 were assessed, documented and implemented: and, -Ensure that Resident #99 ' s care plan focus for physically aggressive behaviors and interventions to protect other residents from being victimized and abused 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 record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for five (#90, #83, #42, #79, and #85) of 6 out of 51 sampled residents. Specifically, the facility failed to consistently provide person-centered approaches to Residents #90, #83, #42, and #79, who had diagnoses of dementia, involved in resident to resident altercations on the secured unit (cross-reference F600 for abuse). Findings include: I. Memory support unit activities programming The memory support unit activities calendar for 11/13/23 through 11/14/23 revealed the scheduled activities for those days included: 11/13/23 Activities programming schedule 8:45 a.m. daily chronicles 9:00 a.m. verse of the day 11/14/23 Activities programming schedule 1:00 p.m. bowling 1:00 group manicures -However, none of the scheduled activities occurred.…

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 assist one (#38) of two residents reviewed for preferences out of 54 sample residents. Specifically, the facility failed to: -Ensure staff provided assistance and encouragement for the resident (#38) to treat the edema in both of his lower legs; -Ensure the resident could comfortably elevate his legs while in his bed and in his room; -Ensure resident was treated with kindness, respect and dignity when he practiced self advocacy to alter his environment to meet his needs; and, -Ensure the resident ' s care plan was updated timely to reflect the Resident #38 ' s unique needs and preferences within his environment that facilitated the treatment of the edema in his legs. Findings include: I. Facility policy A. The Statement of Resident Rights, undated, included with each admission packet was received on 11/15/23 by the nursing home administrator (NHA). The document read in pertinent part: You have the right to be informed on, and participate…

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, resident and staff interviews, the facility failed to investigate one allegation of resident to resident altercation physical abuse for two (#29, and #99) of five residents reviewed for abuse of 54 sample residents. Findings include: I. Facility Policy The Abuse Prevention and Reporting Guideline, dated 12/31/15, was provided by the nursing home administrator (NHA) on 11/15/23 at 3:54 p.m. It read in pertinent part: Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. Residents will be free from verbal abuse, physical abuse, mental abuse, sexual abuse, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other resident consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friend, or other individuals. To ensure the resident ' s rights are protected by providing a method for prevention,…

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 complete and transmit encoded, accurate Minimum Data Set (MDS) data to the CMS (Center for Medicare and Medicaid Services) system for one (#58) of three out of 54 sample residents. Specifically, the facility failed to complete MDS Discharge assessment upon Resident #58 ' s discharge from the facility to the community. Findings included: I. Facility policy The Resident Assessment policy, revised in March 2022, was provided by the nursing home administrator (NHA) on 11/15/23 at 11:30 a.m. The policy read in pertinent part: A comprehensive assessment of every resident ' s needs is made at intervals designated by OBRA (Omnibus Budget Reconciliation Act) and PPS (prospective payment system) requirements. OBRA-Required Assessments - are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team…

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 activities designed to support residents' physical, mental and psychosocial well-being were provided for one (#51) of four residents reviewed for meaningful activity programming activities out of 54 sample residents. Specifically, the facility failed to ensure: -Resident #51 received individualized meaningful activities to meet her social, emotional and recreational needs; -Resident #58 was consistently offered her eyeglasses so she could see fine details and possibly participate in preferred independent activities; and, -Review with Resident #58 her activity preferences and update the resident ' s changes in activity preferences on a quarterly basis. Findings include: I. Facility policy and procedure The Activities Program policy, revised August 2006, was provided by the nursing home administrator (NHA) on 11/14/23 at 3:30 p.m. The policy read in pertinent part: Our activity programs are designed to encourage maximum individual…

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 ensure supervision and assistive devices to prevent accidents for one (#186) of three residents reviewed for falls of 54 sample residents. Specifically, the facility failed to implement fall prevention care planned interventions for resident #186 who experienced several recent falls. Findings included: I. Facility policy Assessing falls and their causes, dated March 2018, was provided by the nursing home administrator (NHA) on 11/15/23 at 3:54 p.m. It read in pertinent part:The purpose of this procedure is to provide guidelines for assessing a resident after a fall to assist staff in identifying causes of the fall. II. Resident #186 A. Resident status Resident #186, age [AGE], was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included quadriplegia, dysphagia, anoxic brain injury, anxiety, and depression, According to the 11/6/23 minimum data set (MDS) assessment, the resident has…

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 two (#185, and #2) of four residents reviewed for supplemental oxygen use out of 54 sample residents. Specifically, the facility failed to administer oxygen therapy at the appropriate rate/ liter flow in accordance with the physician's order for Residents #185 and #2. Findings include: I. Facility policy The Oxygen Administration Policy revised 4/14/23, was provided on 10/25/23 at 1:55 p.m. by the nursing home administrator (NHA). It read in pertinent part, 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 goal and preferences. II. Resident #185 A. Resident status Resident #185, age [AGE], was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included end stage renal disease, diabetes…

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 who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one (#66) of two residents ' reviewed for dialysis out of 54 sample residents. Specifically, the facility: -Failed to ensure communication between the dialysis center and the facility; -Failed to have a physician's order for dialysis treatment or orders to assess the shunt site for thrill and bruit (for blood flow); -Failed to consistently assess the shunt site for thrill/bruit and the resident post dialysis; and, -Failed to have an individualized person-centered dialysis care plan. Findings included: I. Facility policy A request was made for the facility dialysis policy on 11/16/23 at 5:40 p.m., The dialysis policy was not provided at time of exit on 11/16/23. II. Resident #66 A. Resident status Resident #66, under the age [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, record review and interviews, the facility failed to provide food that accommodated resident allergies, intolerances and preferences for three (#87, #84 and #53) of three residents out of 54 sample residents. Specifically, the facility failed to: -Ensure Resident #87 received an accommodation for a food allergy and food intolerance by receiving her preferred beverage for her morning cereal and coffee; -Ensure Resident #84 received his preferred side of brown sugar with his morning oatmeal; and, -Ensured that Resident #53 received his preferred breakfast meal. Findings include: I. Facility policy and procedure The Food Allergies and Intolerances policy, revised August 2017, was provided by the corporate nurse consultant (CNC) on 11/16/23 at 3:45 p.m. The policy read in pertinent part: Residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure 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.

Based on observations, record review, and interviews the facility failed to ensure each resident received their meals, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. Specifically, the facility failed to ensure the residents did not have prolonged wait times of 30 minutes or longer for their meal to be served; and that meals were served to the residents at the regular posted meal times. Findings included: I Facility policy and procedure The Food and Preparation policy and procedure, no date, provided by the nursing home administrator (NHA) on 11/16/23 at 4:14 p.m., read in pertinent part: Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food and handling practices. II. Posted mealtimes The posted meal times for the main dining room were scheduled to begin breakfast at 7:15 a.m., lunch at 11:15 a.m. and dinner at 4:45 p.m. III. Resident interviews Resident #29 was interviewed on 11/13/23 at 9:49 a.m. He said we still have a long…

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 (#185) of three residents reviewed for hospice services out of 54 sample residents. Specifically, the facility failed to: -Have a written plan of care for Resident #185, including 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 facility staff provided orientation regarding the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff who provide resident care in the facility environment. Findings include: I. Facility policy A request was made for the hospice policy on 11/16/23 at 5:40 p.m. The policy was not provided at the time of survey exit on 11/16/23. II. Resident #185 A. Resident status Resident #185, 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 staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for one (#43) of five residents reviewed for immunizations out of 54 sample residents. Specifically, the facility failed to offer and provide the pneumococcal conjugate vaccine (PCV13) and or pneumococcal polysaccharide vaccine (PPSV23) to Resident #43. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2024, retrieved on 11/15/23, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, The document read in pertinent part: Routine vaccination - pneumococcal: -For those over the age of 65 who meet age requirement and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20. For guidance for patients who have already received…

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 an adequate system was in place to provide meal services in a timely fashion to residents waiting to be served in the dining room. Findings include: I. Facility policy and procedure The Food and Preparation policy and procedure, no date, provided by the nursing home administrator (NHA) on 9/27/23 at 4:14 p.m., it read in pertinent part: Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food and handling practices. II. Meals served timely A. Posted mealtimes The posted meal times for the main dining room were scheduled to begin breakfast at 7:15 a.m., lunch at 11:15 a.m. and dinner at 4:45 p.m. B. Resident observations and interviews On 9/20/23 at 10:34 a.m., Resident #18 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to meet professional standards of quality for two (#30 and #11) of four residents reviewed of 30 sample residents. Specifically, the facility failed to ensure scheduled medications were given to Resident #9, #10, #11 and #12 in a timely manner. Findings include: I. Facility policy and procedure The Administration Medication policy, revised April 2019, provided by the nursing home administrator (NHA) on 9/27/23 at 4:14 p.m., it read in pertinent part: Medications are administered in a safe and timely manner, and as prescribed. II. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the September 2023 computerized physician orders (CPO), diagnoses included essential hypertension, delusional disorder, gastro-esophageal reflux disease, schizoaffective disorder, delusional disorder, congestive heart failure and chronic obstructive pulmonary disorder. According to the 6/25/23 minimum data set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) receives the necessary services and assistance during showers and baths for three (#2, #8 and #3) of three residents reviewed for hygiene assistance of 30 sample residents. Specifically, the facility failed to provide scheduled showers and baths or offer an alternative for Resident #2, #8 and #3. Findings include: I. Facility policy The Activities of daily living (ADLs) policy, reviewed March 2018, was provided by the nursing home administrator (NHA) on 9/27/23 at 4:14 p.m. The policy read in part, Residents would 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.…

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 sufficient nursing staff to ensure the residents receive the care and services they required in keeping with their comprehensive plans of care, to achieve and maintain their highest practicable physical, mental and psychosocial well-being. Specifically, -Eight interviewable residents (#5, #4, #20, #22, #24, #26, #12 and #3) out of 30 sample residents and two family members said the facility failed to provide sufficient staff which resulted in delayed and/or inadequate care; -Observations made during survey from 9/14/23 to 9/27/23 revealed care and services not being provided timely; and, -Call lights not accessible to residents. Cross-reference citations: -F550 the facility failed to honor residents rights to timely meal service. -F658 the facility failed to provide medications timely. -F677 the facility failed to provide activity of daily living (ADL) for dependent residents. -F686 the facility failed to provide services 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,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. I. Facility policy and procedure The Food and Nutritional Services policy, revised September 2017, was provided by the nursing home administrator on 9/27/23 at 4:14 p.m. It revealed in pertinent part, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. II. Resident and representative interviews All residents were identified by facility and assessment as interviewable. Resident #5's power of attorney was interviewed on 9/20/23 at 9:58 a.m. Resident #5's power of attorney (POA) was visiting with Resident #5.…

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 the facility failed to ensure drinks and other fluids were provided and consistent with the care plan, preferences and choices. Specifically, the facility failed to consistently offer, encourage and provide fluids for residents in between meals. Findings include: I. Facility policy and procedure The Hydration Clinic Protocol policy, revised September 2017, was provided by the nursing home administrator (NHA) on 9/27/23 at 4:14 p.m. The policy read in pertinent part: Assessment and Recognition 1. The physician and staff will help define the individual's current hydration status (fluid and electrolyte balance or imbalances). a. The physician will distinguish various types of fluid and electrolyte imbalance (for example, hyponatremia, hypernatremia, pre-renal azotemia) From true dehydration (clinically significant loss of total body water). 2. The staff, with the physician's input, will identify and report to the physician individuals with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#4) of three residents reviewed for pressure injuries received care consistent with professional standards of practice to prevent pressure injuries out of 30 sample residents. Specifically, the facility failed to implement interventions to prevent pressure injuries for Resident #4, who was at risk for pressure injuries. Findings include: I. Professional Reference According to the National Pressure Injury Advisory Panel, Pressure Injury Prevention Points, April 2016, retrieved from: http://www.npuap.org/wp-content/uploads/2023/06/Pressure-Injury-Prevention-Points-2023.pdf, the following recommendations were identified: -Cleanse the skin promptly after episodes of incontinence. -Reposition weak or immobile individuals in chairs hourly. -Ensure the heels are free from the bed. -Use heel offloading devices or polyurethane foam dressings on individuals at high-risk for heel ulcers. II. Facility policy and procedure The Preventions…

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 necessary ostomy care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#6) of one resident reviewed for ostomy care out of 30 sample residents. Specifically, the facility failed to provide routine monitoring of the coloostomy ensuring the coloostomy was not leaking and properly secured to Resident #6. Findings include: I. Facility policy The Colostomy/Ileostomy Care policy, revised October 2019, was provided by the nursing home administrator (NHA) on 9/27/23 at 4:14 p.m. The policy read in pertinent part: The purpose of this procedure was to provide guidelines that would aid in preventing exposure of the resident's skin to fecal matter. The policy described the procedures to take when changing an ostomy. According to the policy when changing an ostomy, staff should: Preparation 1. Review the resident's care plan to assess any special…

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 staff interview, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for two (#4 and #8) of five residents reviewed for vaccinations of 30 sample residents. Specifically, the facility failed to ensure Resident #4 was educated on refusal of pneumococcal and Resident #8 received pneumococcal immunization. Findings include: I. Professional reference According to the Center for Disease Control and Prevention (CDC), reviewed 11/21/22, retrieved on 9/27/23 from ttps://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm. It read, in pertinent part, If possible, all residents should receive inactivated influenza vaccine (IIV) annually before influenza season. For persons aged 65 years (or older), the following quadrivalent influenza vaccines are recommended: high-dose IIV, adjuvanted IIV, or recombinant influenza vaccine. If not available, standard-dose IIV may be given. In the majority of seasons, influenza vaccines…

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 policy review, the facility failed to store and prepare foods under sanitary conditions. Specifically, the facility failed to ensure that: 1. Dietary staff properly restrained hair in the kitchen; 2. Raw eggs were stored below ready-to-eat items; 3. Dietary staff washed their hands and used gloves properly; and 4. Items were dated and labelled in the resident nourishment refrigerators and expired items were discarded. Findings included: 1. A review of the 2017 Food and Drug Administration Food Code, section 2-402.11 regarding hair restraints indicated, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food. Observations in the kitchen on 07/25/2022 at 9:03 AM revealed Dietary Aide #1 with her hair in a ponytail and a baseball cap on. Hair in the ponytail was not covered. In an interview on 07/25/2022 at 9:10…

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 with residents and staff, the facility failed to ensure water that was accessible to residents was maintained at safe temperatures at all times in seven of 14 hallways. Findings included: A review of the facility ' s policy, titled, 2.2 Hot Water Temperatures: Inspection revised 06/01/2007, revealed, Policy Hot water temperatures will be tested weekly. Purpose To ensure temperatures are at proper levels. Process . 3. If temperature does not meet state or local regulations, adjust accordingly. A review of an undated document, titled, TELS (The Equipment Lifecycle System) Masters revealed 1. Ensure patient room water temperatures are between 105º and 115º Fahrenheit (or as specified by state requirements). In an interview on 07/25/2022 at 1:11 PM, Resident #14 stated while they didn ' t mind the hot water being hot, they knew the hot water was not at the right temperature. On 07/25/2022 from 2:30 PM to 2:51 PM, the following observations were made when 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, record reviews, and facility policy review, the facility failed to serve palatable meals to five (Resident #84, Resident #119, Resident #134, Resident #55, and Resident #44) of five residents observed meal service. Findings included: A review of the facility's policy titled, Food: Quality and Palatability, revised on 09/2017, revealed, Food will be palatable, attractive and served at a safe and appetizing temperature. 1. A review of Resident #84's admission Record revealed the resident had diagnoses that included colostomy status, gastroesophageal reflux disease, alcohol-induced acute pancreatitis, alcoholic cirrhosis of the liver, and chronic kidney disease. A review of Resident #84's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident scored 15 of 15 on a Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. Resident #84 was assessed as being independent with eating. A review of Resident #84's care plan, initiated on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of facility documents, the facility failed to provide residents with meals at regular times consistent with posted mealtimes and resident preferences for 136 of 136 residents who receive meals from the kitchen, and failed to provide snacks for residents who wanted to eat outside of scheduled meal service times. Findings included: 1. A review of facility grievance reports revealed Resident #45 had filed a grievance on 04/20/2022 regarding breakfast trays being served late. The facility response was to educate the certified nurse aides on the importance of timely meal delivery. A review of the facility posted dining times indicated the following mealtimes: Breakfast: 7:30 AM to 9:00 AM Lunch: 11:30 AM to 1:00 PM Dinner: 5:00 PM to 6:30 PM Observation on 07/25/2022 at 9:03 AM revealed dietary staff serving breakfast trays. Staff stated they had just started breakfast service. Observation on 07/25/2022 at 10:24 AM revealed the Assistant Dietary Manager (Asst DM)…

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, record review, and facility policy review, it was determined that the facility failed to update person-centered care plans to reflect changes in interventions for one (Resident #84) of five residents reviewed for accidents. Specifically, the facility failed to update the accident/falls care plans with additional interventions after falls occurred for Resident #84. Findings included: A review of the facility's policy titled, Person-Centered Care Plan, revised on 07/01/2019, revealed the purpose of a person-centered care plan was To eliminate or mitigate triggers that may cause re-traumatization of the patient . Further review indicated, The care plan must be customized to each individual patient's preferences and needs . A review of Resident #84's admission Record revealed the facility admitted the resident on 03/10/2022 and had a medical history to include a diagnosis of repeated falls. A review of Resident #84's care plan, initiated on 03/10/2022, indicated the resident was at risk 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 record review, interviews, and facility policy review, the facility failed to provide medically related social services for one (Resident #55) of one sample resident reviewed for discharge planning. Specifically, the facility failed to ensure transition of care services were provided when Resident #55 requested a transfer to another facility. Findings included: The facility's policy, titled, Discharge Planning Process, revised date of 02/01/2019, indicated The Center must develop and implement an effective discharge planning process that focuses on the patient's discharge goals, preparation of patients to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable re-admissions. Continued review of the policy revealed Upon admission, all patients will be asked about their discharge goals and anticipated length of stay, and assessed for discharge potential. Discharge planning will begin upon admission and be completed as part of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, interviews, and facility policy review, the facility failed to ensure its medication error rate was not 5% or greater. There were five errors out of 38 opportunities observed for two (Resident #84 and Resident #86) of five residents, which resulted in a medication error rate of 13.16%. Findings included: A review of the facility's policy titled, Medication Administration: Oral, revised on 06/01/2021, revealed staff should verify the medication order on the medication administration record (MAR) with the medication label for the correct patient, drug, dose, route, and time. 1. During a medication administration observation on 07/28/2022 at 7:50 AM, Licensed Practical Nurse (LPN) #2 prepared medication for Resident #84 to administer orally. The following medications were prepared and/or crushed and given to the resident: - Omeprazole 20 milligrams (mg), one capsule - Buspar 10 mg, one tablet - Lactulose 10 grams (g)/15 milliliter (mL), 30 mL - Simethicone 125 mg chewable, one…

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.