The Lodge At Red Rocks

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents maintained adequate hydration for one (#17) of three residents reviewed for hydration out of 47 sample residents. Specifically, the facility failed to encourage fluid intake for Resident #17.Findings include:I. Facility policy and procedureThe Food Preparation Guidelines policy and procedure, dated 6/1/25, was provided by the nursing home administrator (NHA) on 1/16/26 at 12:13 p.m. It read in pertinent part, drinks, including water and other liquids, shall be provided in sufficient amounts to maintain resident's hydration. Residents will be offered additional fluids throughout the day, consistent with the resident's plan of care.II. Resident #17A. Resident statusResident #17, age [AGE], was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with mood disturbance and shortness of breath.The 12/12/25 minimum data set (MDS) assessment…

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

Based on record review and interviews, the facility failed to develop, implement and maintain an effective training program for staff based on the facility assessment and resident population for four of five certified nurse aides (CNA) reviewed. Specifically the facility failed to:-Ensure CNA #6 and CNA #7 had dementia training;-Ensure CNA #6, CNA #7 and CNA #8 had behavioral health management training;-Ensure CNA #5 and CNA #7 had resident rights training;-Ensure CNA #5 and CNA #7 had infection control training;-Ensure CNA #5, CNA #6 and CNA #7 had quality assurance performance improvement (QAPI) training; and,-Ensure CNA #7 had effective communication. Findings include:I. Record reviewA request for abuse, dementia management, behavioral health management, infection control, communication, QAPI, compliance and ethics, and resident rights training was made on 11/3/25 at 10:30 a.m. for CNA #5, CNA #6, CNA #7 and CNA #8.The facility was unable to provide documentation that CNA #5 (hired on 6/1/25) had received QAPI training upon hire.The facility was unable to provide documentation…

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 were free from significant medication errors for one (#1) of three residents reviewed for medications errors out of 27 sample residents. Specifically, the facility failed to ensure Resident #1 received intravenous (IV) vancomycin (an antibiotic used to treat bacterial infections) for a diagnosis of staphylococcus hominis bacteremia (a bloodstream infection) per physician's orders. Findings include:I. Professional referenceAccording 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 and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you…

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 one (#3) of three residents reviewed out of 15 sampled resident representatives were immediately informed of an accident involving the resident. Specifically, the facility failed to notify Resident #3's representative following the resident's low blood pressures that created a change of condition ultimately resulting in the resident being transferred out to an acute care hospital. Findings include: I. Facility policy and procedure The Notification of Changes policy, revised January 2023, was received from the nursing home administrator (NHA) on 2/26/25 at 9:08 a.m. It read in pertinent part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and /or notify the resident's…

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 who required dialysis services received such services consistent with professional standards of practice for one (#2) of two residents reviewed for dialysis out of 15 sample residents. Specifically, the facility failed to consistently and thoroughly complete the dialysis communication forms between the facility and the dialysis center for Resident #2. Findings include: I. Facility policy and procedure The Hemodialysis Policy, dated March 2019and revised April 2024, was provided by the nursing home administrator (NHA) on 2/26/25 at 11:42 a.m. via email. It revealed in pertinent part, This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. The facility will assure that each…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure temperatures in five of 14 resident rooms and the resident's activity room were within the safe range of 71 degrees F (Fahrenheit) to 81 degrees F. Findings include: I. Facility policy and procedure The Safe and Homelike Environment policy, revised April 2022 was provided by the interim nursing home administrator (INHA) on 12/3/24 at 8:13 a.m. It read in pertinent part, Definitions Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/ hyperthermia and is comfortable for the residents. Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby,…

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 effective pest control program so the facility was free from pests and rodents on two of four units. Specifically, the facility failed to keep the resident's rooms free from mice. Findings include: I. Facility policy and procedure The Pest Control policy, revised February 2023, was provided by the interim nursing home administrator (INHA) on 12/3/24 at 8:13 a.m. via email. It read in pertinent part, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Effective pest control programs are defined as measures to eradicate and contain common household pests (bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats). II. Observations and interviews Resident #4 was interviewed on 12/2/24 at 10:46 a.m. Resident #4 said he saw mice almost daily in his room. Resident #4 said last night a mouse crawled across the floor in his room. Resident #4 said he had several traps in his room and the mice often eat 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, interviews and record review, the facility failed to ensure nine (#7, #9, #6, #1, #12, #13, #14, #15 and #16) of nine residents out of 17 sample residents were provided prompt efforts by the facility to resolve any grievances. Specifically, the facility failed to: -Ensure concerns from the group regarding Resident #10 wandering into residents' room were followed up timely with a satisfactory resolution; -Ensure Resident #7's personal concern regarding Resident #10 entering his room without permission was followed up timely with a resolution that was satisfactory to Resident #7; and, -Ensure the resident council president was appointed based on the majority vote of the residents. Findings include: I. Failures regarding grievances A. Facility Policy The Resident and Family Grievances policy, updated July 2022, was received from the nursing home administrator (NHA) on 4/2/24 at 1:47 p.m. The policy read in pertinent part, Social services designee has been designated as the grievance official. The grievance official is responsible for overseeing the grievance…

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 create an environment that protected residents from physical abuse for one (#5) of three residents out of 17 sample residents. Specifically, the facility failed to ensure Resident #5 was protected from abuse by Resident #4. Findings include: I. Facility policy and procedure The Abuse Prohibition policy and procedure, reviewed December 2022, was provided by the regional nurse consultant (RNC) on 4/2/24 at 1:47 p.m. It read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also…

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 a clean, comfortable and homelike environment for residents. Specifically, the facility failed to ensure: -Residents were not subjected to foul odors in their rooms and common hallways of the units; -Residents were not subject to trash piling up in their rooms and in common areas contributing to odors throughout the building; -Residents were not subject to mice running around their rooms, getting into their beds and belongings; and running around the building (cross-reference to F925 failure to maintain effective pest control); -Ensure that residents could eat their meals in the dining room without having to look at and smell the piled-up dirty dishes with uneaten food scraps on them left over from the prior meal; -Residents were provided with clean unstained face washcloths and hand towels; -Resident rooms were clean, comfortable and in good repair; -Ensure common areas and dining room was clean and maintained in good repair;…

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 implement its written policies and procedures to prohibit and prevent abuse and/or mistreatment of facility residents. Specifically, the facility failed to: -Implement policies and procedures to inform staff of their responsibility to report abuse and neglect and the right to not be retaliated against for not reporting allegations of abuse and neglect (cross-reference F609 for reporting and F610 for investigating allegations of abuse); and, -Assure that reporters were free from retaliation or reprisal by posting a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if they believed the facility had retaliated against an employee or individual who reported a suspected crime with details of how to file such a complaint. Findings include: I. Professional reference According to the Elder Justice Act notice undated, retrieved online 9/25/23 from https://lms.healthcareacademy.com/courses/HCA_Annual/ElderJusticeAct1d/EJA_poster.pdf, What you need to know: The Elder Justice…

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, they failed to employ sufficient dietary and food and nutrition staff to carry out the functions of the food and nutrition services. Specifically, the facility failed to: -Provide sufficient numbers of adequately trained food and nutrition staff which contributed to prolonged wait times for meals and overall decreased resident satisfaction with the dining experience; and, -Clean trays from the day before and had them stacked up in the dining area and hallway. Findings include: I. Facility policy and procedures The Professional staffing and the Department Staffing revised August 2017, was provided by the corporate dietary manager (CDM) on 9//21/23 at 9:54 a.m. It revealed in pertinent part, The dining services department will employ sufficient staff, with appropriate competencies and skills set to carry out the functions of food and nutrition services, taking into consideration the resident assessment, individual plans of care and the number, acuity and diagnosis of the resident population. This includes a qualified dietitian or…

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

Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in the kitchen. Specifically, the facility failed to: -Ensure foods were held at appropriate temperatures; -Ensure proper hand hygiene; -Ensure the refrigerators had thermometers; and, -Ensure the wall near the fruit drink machine had a cleanable surface after repair. Findings include: I. Holding temperatures A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; The food shall have an initial temperature of 41ºF or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control. B.Observations 1. Dinner meal 9/12/23 At 7:05 p.m., the holding temperatures were taken after the last resident was served. The temperatures were as follows: - The zucchini was 121 degrees F.…

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 garbage and refuse was properly disposed of and the dumpster lid was closed to prevent harborage to pests and insects. Specifically, the facility failed to: -Ensure all dumpster lids were closed and not overflowing with garbage; and, -Ensure garbage was cleaned up around and under dumpsters. Findings include: I. Observations Observations on 9/13/23 at 3:45 p.m. the recycling and trash compactor were located in one area. There was trash including empty milk jugs, boxes, bags and other debris between the trash compactor and the fence. There was a pallet board leaning against the trash compactor and trash surrounding the board. There was a large stain on the sidewalk indicating fluid had spilled on the sidewalk. Observations on 9/19/23 at 8:19 a.m. with the maintenance director (MTD) revealed the recycling bins were overflowing and the lids were not capable of shutting. There were food products, used briefs, pillows, used protective pads and other trash from the facility mixed in with the…

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

Based on interviews and record review, the facility was not administered in a manner that enabled it to use its resources efficiently and effectively to attain and maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the resources of the facility were not effectively and efficiently utilized as evidenced by findings that revealed in part conditions of immediate jeopardy for failure to investigate an allegation of abuse of two residents by one facility staff(cross-reference to F610); and other systemic failures. (Cross-reference to F600, F609, F607, F584, F802, F812, F867 and F925) Findings include: I. Abuse and neglect During the recertification survey from 9/11/23 to 9//21/23, it was identified that there were multiple concerns over preventing, reporting, investigating and protecting the resident from abuse incidents. Staff and administration failed to identify resident abuse and neglect and failed to respond properly to report the abuse to the proper entities (facility administration, the State oversight agency, and /or 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 record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment that included all resources, staff education, staff competencies, an updated staff list and facility-based risk assessments. Findings include: I. Record review The facility assessment was last reviewed on 7/14/22 with the quality assurance and performance improvement (QAPI) committee. The facility assessment failed to include the following: -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; -Staff training/education necessary to provide the level and types of support and care needed for the resident population; -Facility resources needed to provide competent resident support during day-to-day operations…

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

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life, freedom from abuse, quality of care, administration and infection control. Findings include: I. Facility policy The Quality Assurance and Performance Improvement (QAPI) Plan dated 4/5/22 was received by the nursing home administrator on 9/21/23. The policy read in pertinent part, The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of change. The facility uses a thorough and highly organized/structured approach to determine the root cause of identified problems. The facility will utilize a variety of tools…

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 maintain an effective pest control program so the facility was free from pests and rodents. Specifically, the facility failed to keep all areas of the facility free from mice. Findings include: I. Facility policy and procedure The Pest Control policy, revised February 2023, was provided by the corporate nurse consultant (CNC) #1 on 9/21/23 at 11:44 a.m. It read in pertinent part: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Effective pest control program is defined as measures to eradicate and contain common household pests (bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats). II. Interviews and observations (cross-reference to F584 sanitary home-like environment) On 9/11/23 at 5:10 a.m. and throughout the entirety of the survey from 9/11/23 to 9/21/23 there were several silver box mousetraps placed on the floor next 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 record review and interviews, the facility failed to report alleged violations of potential abuse/neglect to the proper authority, including the police and state oversight agency in accordance with state law for three alleged violations out of five reported violations for abuse of a resident (#28, #10 and #111) by staff out of 66 sample residents. Specifically, the facility leadership failed to report three separate allegations of resident abuse by a staff member to the facility administrator, local law enforcement, or the State Agency; and staff failed to report suspicion of abuse and or neglect to leadership in a timely manner: -Allegation of verbal and physical abuse of Resident #28 by facility staff; and, -Allegation of verbal abuse of Resident #110 and #10 by facility staff. Cross-reference F610, failure to investigate/prevent/correct alleged violation. Findings include: I. Facility policy The Abuse, Neglect, and Exploitation policy, revised April 2022, was provided by the nursing home administration (NHA) on 9/11/23 at 9:33 a.m. The policy read, in pertinent part: It…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected residents' status based on the criteria outlined in the resident assessment instrument (RAI) for five (#20, #29, #105, #111 and #107) residents out of seven out of 66 sample residents. Specifically, the facility failed to appropriately assess and accurately document the resident status for: -Resident #107 and Resident #29 the MDS assessment did not accurately document the residents had level II preadmission screening and resident review (PASRR) conditions; and, -Resident #20, #105, #107, #111 immunizations history was not accurately documented. Findings include: I. Professional reference According to the American Association of Post-Acute Care Nursing (AAPACN), The Minimum Data Set (MDS) Resident Assessment Instrument (RAI) Process, October 2023, retrieved online from https://www.aapacn.org/resources/rai-manual/ on 9/30/23 The Resident Assessment Instrument (RAI) helps nursing home…

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 (ADL) support for three (#78, #90 and #29) of five dependent residents reviewed for ADLs out of 66 sample residents. Specifically, the facility failed to provide consistent ADL assistance to provide: -Assistance with grooming (fingernail care) for Residents #78 and #90; -Incontinent care and repositioning assistance to maintain Resident #78 skin integrity; and, -Assistance, cueing and supervision throughout the meal for Resident #29. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommendation for fingernail care, United States, 2022, retrieved on 9/28/23, from https://www.cdc.gov/hygiene/personal-hygiene/nails.html. It read in pertinent part: Appropriate hand hygiene includes diligently cleaning and trimming fingernails, which may harbor dirt and germs and can contribute to the spread of some infections, such as pinworms.…

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 an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for four (#23, #81, #112 and #105) residents out of eight reviewed for activity programming out of 66 sample residents. Specifically, the facility failed to: -Offer and provide personalized activity programs for Resident #23, #81 and #112 on secure unit and Resident #105 on the non-secure unit; and, -Conduct activity assessments for Resident #81, #112 and #23. Findings include: I. Facility policy and procedure The Activity Programs policy, revised October 2022, was provided by the clinical nurse consultant on 9/21/23 at 1:44 p.m. It revealed in pertinent part, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based 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 record review, the facility failed to ensure the residents' environment remained as free from accident hazards as possible for high water temperatures throughout the facility and for two (#324 and #8) of two dependent residents reviewed for smoking out of 66 sample residents. Specifically, the facility failed to ensure: -Appropriate interventions were in place to prevent potential smoking hazards for Resident #324 and Resident #8; and, -Facility water temperatures were safe for resident use. Findings include: I. Resident smoking A. Facility policies and procedure The Smoking and Safety policy, revised in April 2022, was provided by the corporate nurse consultant (CNC) #1 on 9/20/23 at 3:55 p.m. The policy revealed in pertinent part: The facility will take special measures to keep residents safe while protecting their environment. -Policy guidelines included residents may smoke only during scheduled breaks in the authorized smoking area to the south of the dining room. -Staff…

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 in one out of four medication carts. Specifically, the facility failed to ensure medication carts were locked when left unattended. Findings include: I. Facility policy The Medication Storage policy, revised July 2023, was provided by the corporate nurse consultant (CNC) #1 on 9/21/23 at 11:44 a.m. It read in pertinent part, During a medication pass, medications must be under the direct observation of the person administering medication or locked in the medication storage area/cart. II. Observations and interviews On 9/13/23 at 10:18 a.m. the overstock medication cart in the 300-unit hall outside of the nurses station in the facility's commons area was unlocked. The assigned medication nurse was not monitoring the unlocked medication cart. On 9/14/23 at 8:14 a.m. the overstock medication cart in the 300-unit hall outside of the nurses station in the facility's commons area was unlocked. Registered nurse (RN) #2 who was the assigned medication nurse…

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

Based on observations, record review, and interviews the facility failed to ensure menus were followed to meet the residents' nutritional needs. Specifically, the facility failed to: -Ensure the menu was followed; and, -Ensure food items were omitted without substitutions being made of the same nutritional value. Findings include: I. Facility policy and procedures The Menus policy and procedure, revised August 2017, was provided by the corporate dietary manager(CDM) on 9//21/23 at 9:54 a.m. It revealed in pertinent part, Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning. Menu cycles will include nutrient analysis to ensure that all client nutritional needs are met in accordance with the most recent edition of the food and nutrition board institute of medicine, national academies, and the dietary guidelines for Americans, 2015-2020 edition. A registered dietitian/nutritionist (RDN) or other clinically…

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 consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, texture, temperature and appearance. Findings include: I. Facility policy and procedures The Food Quality and palatability policy and procedure, revised September 2017, was provided by the corporate dietary manager (CDM) on 9//21/23 at 9:54 a.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 attractiveness refers to the appearance of the food when served to the residents. Food Palatability refers to the taste and flavor of the food. The cooks prepare food in a sanitary manner utilizing the principles of hazard analysis critical control point (HACCP) and time and temperature guidelines as outlined in the federal…

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 for two out of three units at the facility. Specifically, the facility failed to: -Ensure residents' personal toiletry items were labeled appropriately; -Ensure residents were provided with an opportunity to participate in hand hygiene before and after meals; and; -Ensure the hand hygiene was performed appropriately by staff. Findings include: I. Facility policy The Infection Prevention and Control policy, revised in December 2022, was provided by the nursing home administrator (NHA) on 9/11/23 at 8:10 a.m. It read in pertinent part, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections…

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 nine (#17, #20, #23, #25, #29, #67, #72, #82, #104 and #105) of 10 residents reviewed for immunizations out of 66 sample residents. Specifically, the facility failed to: -Offer Resident #25, #82 and #105 the pneumococcal vaccine upon admission; -determine which pneumococcal vaccine was given to Resident #17, Resident #23 and Resident #29 and offer additional doses as needed; and, -Offer additional doses of the pneumococcal vaccine to Resident #20, #67 and #104. 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, 2023, retrieved on 9/27/23, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part: Routine vaccination - pneumococcal -For those ages 19 or older with an additional risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to promote dignity and respect for one (#67) of one resident out of 66 sample residents. Specifically, the facility failed to promote dignity and respect for Resident #67 by allowing the resident to be present and participate while staff were cleaning, rearranging and disposing of contaminated belongings in the resident's room. Findings include: I. Facility policy and procedure The Promoting/Maintaining Resident Dignity policy and procedure, revised January 2023, was provided by the corporate nurse consultant (CNC) on 9//21/23 at 11:44 a.m. It revealed in pertinent part, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity, as well as care for each resident in a manner and an environment, that maintains or enhances residence a quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain…

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 proper treatment and assistive devices to maintain vision and hearing abilities for two (#82 and #67) of three residents reviewed for visual problems of 66 sample residents. Specifically the facility failed to: -Ensure the Resident #67's had access to glasses (corrective lenses) for visual deficits; -Follow through with getting post eligibility treatment income (PETI) to pay for the residents glasses for Resident #67; and, -Ensure that after Resident #82's family declined to pay for hearing aids, Resident #82 was provided with an alternative to help the resident hear effectively. Findings include: I. Facility policy and procedure The Hearing and Vision Services policy and procedure, revised June 2023, was provided by the corporate nurse consultant (CNC) on 9//21/23 at 11:44 a.m. It revealed 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…

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 (#111) of two residents who required respiratory care received care consistent with professional standards of practice out of 66 sample residents. Specifically, for Resident #111 the facility failed to: -Ensure a physician's order was in place to include the appropriate administration of a continuous positive airway pressure (CPAP) machine with oxygen therapy including machine settings, frequency and duration of use, method of delivery, machine and oxygen settings, device maintenance and cleaning of equipment; -Follow manufacturer recommendations to maintain, clean, sanitize and store the resident's CPAP equipment; -Ensure a care plan focus was in place to include oxygen therapy to include orders for use/administration, equipment maintenance and machine storage; and, -Accurately document the use of CPAP treatment in the resident's minimum data set (MDS) assessment under respiratory treatments. Findings include: I.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident and staff interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for two (#67 and #4) of two residents reviewed for psychosocial well-being out of 66 sample residents. Specifically, the facility failed to ensure appropriate behavioral health services to: -Identify, address, and/or obtain necessary services for the behavioral health care needs of Resident #67 and Resident #4; -Develop and implement a person-centered care plan that includes and supports the behavioral health care needs, identified in the comprehensive assessment; -Develop individualized interventions related to the resident's diagnosed conditions; and, -Review and revise behavioral health care plans that have not been effective. Findings include: I. Facility policy The Behavioral Health Services policy revised June 2023, was provided by the corporate nurse consultant (CNC) #1 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, record review, and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#58) of eleven residents reviewed for medication administration out of 66 sample residents. Specifically, the facility failed to ensure Resident #58 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration. Findings include: I. Professional reference According to [NAME] Lilly Kwikpen, BASAGLAR, Insulin glargine injection, solution manufacturer's recommendations, revised November 2022, retrieved online from https://uspl.lilly.com/basaglar/basaglar.html#ug0 on 9/26/23. Preparing your (insulin pen)Wash your hands with soap and water. Check the Pen to make sure you are taking the right type of insulin. Do not use your Pen past the expiration date printed on the Label or for more than 28 days after you first start using the Pen. Step 1. Pull the Pen Cap straight off. Wipe the rubber seal with an alcohol swab.…

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 provide or obtain dental services for one resident (#8) of one out of 66 sample residents. Specifically, the facility failed to assist Resident #8 with making an appointment for dental services when the resident complained that her dentures did not fit and was causing her pain when she wore them. Findings include: I. Facility policy and procedure The Dental Services policy and procedure, revised June 2023, was provided by the corporate nurse consultant (CNC) on 9//21/23 at 11:44 a.m. It revealed in pertinent part, It is the policy of this facility to assist residents and obtain routine and emergency dental care. Routine dental services mean an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental, radiographs as needed, dental, cleanings, feelings, minor, partial, or full denture adjustments, smoothing of broken teeth, and limited prosthetic procedures Taking impressions for dentures and fitting dentures.…

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 ensure essential equipment was in proper working order for the facility's kitchen. Specifically, the facility failed to ensure the kitchen equipment was repaired which included the walk-in freezer's fan system that was not working properly causing condensation and icicles. Findings include: I. Observation On the initial walk through on 9/11/23 at 6:00 a.m. the walk in freezers fan was loud. There was a foot in circumference and a three feet long icicle coming from the top of the freezer near the fan in the freezer. There was five large chunks of ice hanging down touching the top of the bread and icicles hanging off the electric cord. There was condensation on the ceiling. II. Staff interviews The corporate dietary manager (CDM) was interviewed on 9/20/23 at 10:26 a.m. The CDM said the kitchen staff were contracted workers. The CDM said the contracted workers did not put work orders in for kitchen equipment. The CDM said work orders and repairing equipment was the responsibility of the facility. The maintenance director…

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 make immediate notification to the resident representative when the resident had a significant change in condition requiring a need to alter treatment; initiate a resident's transfer or discharge from the facility; or when the resident was involved in an accident with an injury for one (#72) of four residents out of 66 sample residents. Specifically, the facility failed to immediately inform the Resident #72's representative when the resident was transferred to the hospital for emergency medical care. Findings include: I. Facility policy The Notification of Changes policy, revised January 2023, was provided by the clinical nurse consultant (CNC) #1 on 9/21/23 at 11:44 a.m. It read in pertinent part: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies consistent with his or her authority, the resident's representative when there is a change requiring notification. Circumstances…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to develop a comprehensive person-centered care plan for three (#76, # 335, and #336) of 32 residents reviewed for person-centered care plans out of 53 sample residents. Specifically the facility failed to: -Care plan the use of antipsychotic medications and pain for Resident #76; -Care plan pain and falls for Resident #335; and -Care plan a stage III pressure injury for Resident #336. Findings include: I. Facility policy and procedure The Person Centered Care Plan policy, dated 7/1/19, was received from the corporate nurse consultant (CRC) on 9/25/19 at 5:55 p.m. The policy documented in pertinent part, the purpose of the care plan was to attain or maintain the resident's highest practicable physical, mental and psychosocial well being. The care plan must describe the services that are furnished. II. Resident #76 A. Resident status Resident #76, age [AGE], was admitted on [DATE]. According to the September 2019 computerized physician…

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 two of three medication carts had drugs and biologicals stored and labeled in accordance with accepted professional principles. Specifically, the facility failed to: -Remove expired medications from medication carts to prevent the use of expired medications; -Properly label prescription medications with the residents' names; -Date insulin when opened; and -Store medication in original packaging Findings include: I. Professional references According to Novo Nordisk (April 2019) About Levemir, retrieved from https://www.levemir.com/faqs.html, Levemir (insulin detemir injection), once opened, can be used up to 42 days. According to Novo Nordisk (January 2019) Storage information and travel tips for Novolog, retrieved from https://www.rapidactinginsulin.com/novolog/using-novolog/storage-and-handling.html, Novolog insulin, once opened, can be used up to 28 days. According to Humalog Kwikpen (2018) [NAME] Lilly and Company, retrieved from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one (#109) of two residents reviewed for dignity out of 53 sample residents were treated with respect and dignity and in a manner and in an environment that promoted the enhancement of quality of life. Specifically, the facility failed to redirect Resident #109 in a respectful manner, causing him to feel embarrassment with his peers. A. Resident status Resident #109, age [AGE], was admitted on [DATE]. According to the September 2019 computerized physician orders (CPO), diagnoses included depressive disorder, chronic pain end stage renal disease. The 9/19/19 minimum data set (MDS) assessment revealed the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident utilized a wheelchair. B. Observation On 9/24/19 at 11:53 a.m., Resident #109 was moving his wheelchair near the smoking area. He was wearing an oxygen cannula attached to a cannister on the back of his…

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 an ongoing program of activities to meet the interests of and support the wellbeing of one (#67) of three residents reviewed for activities out of 53 sample residents. Specifically, the facility failed to engage in a process to identify and provide individualized and independent activities to meet the recreational interests of Resident #67. Findings include: A. Resident status Resident #67, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the September 2019 computerized physician orders (CPO), pertinent diagnoses included seizures, history of falling, shortness of breath, chronic peripheral venous insufficiency, dementia, Alzheizer's disease and type II diabetes mellitus. The 7/26/19 minimum data set (MDS) assessment revealed the resident's cognitive status was moderately impaired with a brief interview for mental status (BIMS) score of 11 out of 15. The resident did not experience delirium or exhibit…

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 treatment and care in accordance with professional standards, the care plan and resident choice for one (#67) of two residents reviewed for non-pressure related skin conditions out of 53 sample residents. Specifically, the facility failed to implement physician ordered interventions and follow the resident's care plan to protect the skin to Resident #67's lower legs. Findings include: Resident #67 A. Resident status Resident #67, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the September 2019 computerized physician orders (CPO), pertinent diagnoses included seizures, history of falling, shortness of breath, chronic peripheral venous insufficiency, dementia, Alzheizer's disease, non-pressure chronic ulcer of right lower leg, type II diabetes mellitus, thrombophilia and atherosclerosis of native arteries of bilateral legs. The 7/26/19 minimum data set (MDS) assessment revealed the resident's cognitive…

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 the resident environment was as free from accident hazards as possible and to provide supervision and assistive devices to prevent avoidable accidents for three (#109, #13, #9) of 28 residents who smoked. Specifically, the facility failed to ensure: - Resident #13, #9 and #109 followed safe smoking practices; and, - Assess Resident #109 for safe smoking at the time of his admission to the facility. Findings include: I. Facility policy The smoking policy, revised 7/24/19, was provided by the director of nursing (DON) on 9/24/19 at 11:20 a.m. According to the policy, The facility will assess residents upon admission, quarterly, and with changes in condition for the ability to smoke safely and, if necessary, will be supervised. II Resident #13 A. Resident status Resident #13 age [AGE] was admitted on [DATE]. According to the September 2019 computerized physician orders (CPO), pertinent diagnoses included multiple sclerosis, bipolar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to ensure two (#108 and #121) of three residents who required respiratory care were provided such care in accordance with professional standards of practice out of 53 sample residents. Specifically, the facility failed to: -Obtain oxygen orders for Resident #108; and -Follow physician oxygen orders for Resident #121. Findings include: I. Facility policy and procedure The Oxygen: Nasal Cannula policy, dated 1/1/04, was received from the nursing home administrator (NHA) on 9/25/19 at 3:30 p.m. The first step in the procedure was to verify order. II. Resident #108 A. Resident status Resident #108, age [AGE], was admitted on [DATE]. According to the 2019 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease with acute exacerbation, pneumonia, and acute and chronic respiratory failure. The 8/28/19 minimum data set (MDS) assessment documented the resident had mild cognitive loss with a brief interview 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 and staff interviews, the facility failed to ensure pharmacy recommendations were acted upon in a timely manner for two (#31 and #124) of six residents reviewed for drug regimen review out of 53 sample residents. Specifically, the facility failed to ensure pharmacy recommendations were reviewed by the attending physician for Residents #31 and #124. Findings include: Cross-reference F758, failure to ensure drug regimen remained free of unnecessary psychotropic medications. I. Resident #31 A. Resident #31's status Resident #31, age above 70, was initially admitted on [DATE]. According to the September 2019 computerized physician orders (CPO), diagnoses included multiple myeloma, major depressive disorder, and febrile neutrophilic dermatosis (sweets syndrome). The 7/3/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He had cancer and deep vein thrombosis (DVT) and 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 observation, interview and record review, the facility failed to ensure two (#76 and #31) of six residents reviewed for medications of 53 sample residents were free from unnecessary drugs. Specifically the facility failed to: -Track target behaviors, assess the resident for other causes of behavior, use non pharmacological approaches, care plan and document that Resident #76 or their representative were advised of the risks and benefits of an antipsychotic medication; and -Discontinue a PRN (as needed) antipsychotic medication after 14 days for Resident #31. Findings include: I. Resident #76 A. Resident status Resident #76, age [AGE], was admitted on [DATE]. According to the September 2019 computerized physician orders (CPO), diagnoses included cerebral infarction, left hemiplegia, functional quadriplegia, aphasia, generalized anxiety disorder and depressive episodes. The 9/16/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental…

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.