Canyon View Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide treatment and services to maintain hearing in a timely manner for one (#3) of one resident reviewed out of 41 sample residents. Specifically, the facility failed to ensure recommendations for Resident #3 were followed after an audiologist appointment. Findings include: I. Facility policy and procedure The Ancillary Services policy, dated 11/4/13, was provided by the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. The policy read in pertinent part, Any resident needing or requesting ancillary services, such as dental, vision, audiology and podiatry will have their needs met timely. The facility will keep available a provider for ancillary services and/or assist the resident with utilizing the provider of their choice. II. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included unspecified intracranial injury with loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals for one (#49) of two residents reviewed for pain out of 41 sample residents. Specifically, the facility failed to: -Consistently and accurately assess Resident #49's pain to ensure the resident's pain was at or below the resident's stated tolerable pain level; -Ensure Resident #49's care plan included person-centered non-pharmacological interventions for pain; and, -Ensure the physician's order for routine pain medication for Resident #49 was administered as ordered. Findings include: I. Facility policy and procedure The Pain Management policy, dated 5/3/23, was provided by the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. It revealed in pertinent part, Acceptable (tolerable) pain control is defined by the resident. All residents will be evaluated 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.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four out of five staff reviewed. Specifically, the facility did not complete annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #2. Findings include: I. Record review CNA #2 (hired on 6/23/22) did not have an annual performance review completed. CNA #2 did not have an in-service education plan based on the outcome of the review. II. Staff interviews The director of staff development (DSD) was interviewed on 7/22/24 at 2:18 p.m. The DSD said she completed an audit of the system when she accepted her position in the beginning of 2024. She said she discovered there was an issue with staff completing their training as required. She said she worked on a spreadsheet to help track the training staff needed to complete. She said the staff completed a performance every year and if 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.

Based on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement was thoroughly and accurately explained to the residents and or resident representatives before signing the agreement for two (#176 and #40) of three residents out of 41 sample residents. Specifically, the facility failed to: -Thoroughly explain the binding arbitration agreement in a form and in a manner to ensure Resident #176 and Resident #40 and/or their representatives understood the agreement before signing the arbitration agreement; and, -Ensure staff reviewing the arbitration agreement with Resident #176 and Resident #40 and/or their representatives understood the components of the agreement. Findings include: I. The Arbitration Agreement The Arbitration Introduction form, undated, was provided by the nursing home administrator (NHA) on 7/22/24 at 2:51 p.m. The Arbitration Introduction read in pertinent part, Arbitration is a cost effective, private and time saving alternative means of resolving disputes outside of the courts. In arbitration, disputes are heard…

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 environment for residents, staff and the public that is safe, functional, sanitary and comfortable. Specifically, the facility failed to ensure appropriate communication occurred regarding the facility's [AGE] year old hot water heater. The facility's failure to address the concerns timely resulted in the hot water heater failing and the facility was without hot water to provide a comfortable bathing experience for residents during a three week time period. Finding include: I. Facility policy and procedure The Promoting/Maintaining Resident Dignity policy, dated 1/1/23, was obtained from the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. It documented in pertinent part, All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. The resident's former lifestyle and personal choices will be considered when providing care and services to meet 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 three (#12, #13 and #18) of eight residents reviewed out of 19 sample residents were provided personal privacy during care. Specifically, nursing staff failed to: -Ensure privacy during medication administration and treatment for Resident #13; -Ensure staff pulled the privacy curtain and/or closed the door while Resident #18 was getting dressed; and, -Ensure privacy during nail care for Resident #12. Findings include: I. Facility policy The Statement of Resident Rights and Responsibilities, undated, was provided by the regional operations manager (ROM) on 11/7/23 via email. According to the policy statement, the residents had the right to personal privacy. The Medication Administration policy, revised 11/1/22, was provided by the nursing home administrator (NHA) on 11/7/23 at 1:40 p.m. the policy directed staff to provide privacy during medication administration. II. Resident #13 A. Resident status Resident #13, age [AGE], 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 one (#3) of three residents reviewed for dementia care received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being out of 19 sample residents. Specifically, the facility failed to: -Prevent Resident #3 from eloping the facility; -Have a procedure in place for the nurses to know which residents needed supervision when leaving the facility and which residents were able to independently leave the facility; and, -Ensure Resident #3 was assessed appropriately for his elopement risk. Findings include: I. Facility policy The Elopement and Wandering policy, revised March 2023, was provided by the nursing home administrator (NHA) on 11/7/23 at 3:24 p.m. read in pertinent: The purpose is to ensure the safety and well-being of all residents with potential elopement risk. A wander/elopement assessment will be completed on all residents upon admission to the facility. The outcome is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure resident rights to be treated with respect and dignity in keeping with their individuality for five (#3, #12, #13, #14 and #16) out of 16 sample residents. Specifically, the facility failed to: -Provide dignified assistance when Resident #3 requested a bedpan instead of instructing her to use her brief and be changed at a later time; -Provide timely and dignified call light response when Resident #3 needed assistance with pain medications and care; and -Provide timely and dignified call light response when Residents #12, #13, #14 and #16 needed assistance with care when they were choking, incontinent or needed colostomy care or assistance to the bathroom. Findings include: I. Facility policy The Dignity policy, revised February 2021, provided by the regional director of operations (RDO) on [DATE], included in pertinent part: Each resident shall be cared for in a manner that promotes and enhances their sense of well-being, level of satisfaction…

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, homelike environment for residents. Specifically, the facility failed to ensure: -Residents were not subjected to uncomfortable noise levels in their rooms; -Resident room doors opened properly and safely; -Resident rooms were clean, comfortable, free of urine and cigarette smoke odors and in good repair; -Common areas were homelike and well-maintained; and -Bed linens were in good condition. Findings include: I. Facility policy The Homelike Environment policy, revised February 2021, provided by the regional director of operations (RDO) on 8/24/23, included in pertinent part: Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management maximizes to the extent possible the characteristics of the facility that reflect a personalized, homelike setting to include: -clean, sanitary and orderly environment; -clean bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews and observation, the facility failed to assess and ensure nutritional and hydration parameters were met and food and drink preferences provided for four (#3, #12, #13 and #4) out of 16 sample residents, and failed to provide dietary preferences for multiple additional facility residents as voiced by resident council members. Specifically, Resident #3 was admitted to the facility on [DATE] and discharged to the hospital on 8/7/23 with severe intractable pain from metastatic cancer with the goal for strengthening so she could move home with her family. Her nutritional and hydration needs were not assessed, care planned or provided. Current facility residents including Residents #12, #13 and #4 likewise said during individual interviews and in resident council their food preferences were not honored and/or available and the facility was not responsive to their stated concerns. Findings include: I. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE] 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 interviews and observations, the facility failed to consistently ensure a phone was available for resident use for two (#13 and #3) out of 16 sample residents. Specifically, the facility failed to consistently provide operational phones for residents to use from their rooms or other private areas. Resident #3 was told by staff that there was no facility phone available for resident use. Resident #13 said it was hard to access a private phone at the facility if her cell phone did not work. Findings include: I. Resident/family interviews Resident #13 was interviewed on [DATE] at 11:25 a.m. She said it was hard to access a private phone conversation. My cell phone doesn't always have service because Wi-Fi's often down. The Wi-Fi here is terrible; it's down most of the time. She said she could always make a call at the nurses' desk but it was not private. Resident #3's son was interviewed on [DATE] at 11:04 a.m. He said Resident #3 was in the facility from [DATE] through [DATE] (Friday through Monday) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure the medical durable power of attorney (MDPOA) and the physician were notified of changes in condition for one (#2) out of 15 sample residents. Specifically the facility failed to: -Add the resident's MDPOA to the charting system with contact information; -Notify the MDPOA and physician of the resident's high blood glucose (BG); -Notify the MDPOA when the nurse observed black coffee ground-like stool; and -Notify the MDPOA of Resident #2's death in a timely manner. Cross-reference F684, quality of care regarding diabetic and anticoagulant management and monitoring. Findings include: I. Resident status Resident #2, age [AGE], was admitted on [DATE] and passed away on 3/14/23 at 10:13 p.m. in the facility. According to the March 2023 computerized physician orders (CPO), diagnoses included acute embolism and thrombosis of the right internal jugular vein (what happens when a blood clot blocks a vein in your neck), acute kidney failure, chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to assess, report, and treat high blood sugar and potential side effects of anticoagulants (blood thinner) for one (#2) of 15 sample residents. Specifically the facility failed to: -Get clarifying orders for an sliding scale insulin and transcribe admission order for insulin upon admission for Resident #2; -Notify the physician and medical durable power of attorney (MDPOA) in a timely manner about Resident #2's extremely high blood glucose levels -Call rather than fax the physician and call the MDPOA to report that the resident bowel movements were tarry black stools and resembling coffee grounds; -Update Resident #2's care plan for diabetes and anticoagulant management; and -Have a physician examine and assess the resident upon admission due to his complicated diagnoses and condition changes. Cross-reference F580, for failure to notify the resident physician and MDPOA of the resident change of condition. Findings include: I. Facility policies The…

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

Based on interviews and record review, the facility failed to take action to resolve grievances of the resident council group, affecting 10 (#34, #24, #22, #23, #35, #60, #62, #54, #7 and #68) of 41 sample residents, and potentially affecting all the residents who lived in the facility. Specifically, the facility failed to follow-up with concerns that were brought up by the group of residents during the resident council meetings. Findings include: I. Resident group interview A resident group interview was conducted on 1/23/23 at 10:30 a.m. with 10 residents who were resident council officers, regularly attended resident council meetings, and were identified by the facility as interviewable. Residents said the facility did not have enough staff. They have good staff, just not enough of them. As a result, It takes longer to respond to a call light. One resident said his roommate was in bad shape and he had to keep an eye on him because he was unable to call staff for assistance. One thing we lack is a bath aide, because baths are a problem. I have a bath scheduled today but don't know…

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 consistently ensure a safe, clean, comfortable, homelike environment in resident rooms, shower/tub rooms and common areas in four of four neighborhoods. Specifically, the facility failed to ensure: -Resident rooms and bathrooms were properly cleaned and maintained; -Wash cloths and towels were available in residents' bathrooms; and -Shower/tub rooms were functional, safe and properly cleaned. Cross-reference F565, grievances of the resident group. Findings include: I. Observations during the initial facility tour on 1/19/23 at 9:30 a.m., and throughout the survey on 1/22, 1/23, 1/24, 1/25 and 1/26/23, revealed resident rooms and bathrooms were not thoroughly cleaned and needed repairs, and clean towels and wash cloths were not readily available for residents. Specifically, dust build-up and debris were not swept from under beds and furniture, toilets were soiled or stained and not properly cleaned, privacy curtains were soiled and/or stained, bedside…

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 level I and level II preadmission screening and resident review (PASRR) were completed for four (#4, #5, #37 and #57) out of five residents reviewed for PASRR to gain and maintain their highest practical medical, emotional, and psychosocial well-being out of 41 sample residents. Specifically, the facility failed to: -Ensure Resident #37, with a known psychological disorder, was properly assessed with a PASRR level I or level II assessment; -Ensure Resident #5 and #57 had a level I PASRR screening completed timely; and, -Have the training and knowledge to follow up with PASRR screening identified concerns for Resident #4. Findings include: I. Resident #57 A. Resident status Resident #57, age [AGE], was admitted on [DATE]. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Wernicke's encephalopathy (a brain disorder causing confusion), anxiety disorder, and delusional disorders. The 12/19/22 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 observations, interviews and record review, the facility failed to provide and deploy sufficient nursing staffing to meet the needs of residents in keeping with their comprehensive care plans, and ensure their highest practicable quality of care. Specifically, the facility failed to provide sufficient staffing to provide a dignified and respectful resident environment, keep residents free from abuse, prevent falls and accidents, provide adequate nutrition and hydration, and provide dementia care and services. Findings include: Cross-reference F565, grievances of the resident group involving care and services issues; F600, freedom from abuse; F689, falls and accidents; F692, nutrition and hydration; and F744, dementia care. I. Resident status According to the 1/25/23 Resident Census and Conditions report, 75 residents lived in the facility. For bathing, 37 residents needed assistance of one or two staff and 13 were dependent. For dressing, 69 residents needed assistance. For transfers, 60 residents needed assistance and five were dependent. For toilet use, 63 residents…

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 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 six (#32, #40, #56, #57, #71 and #226) of nine residents reviewed for mood and behavior out of 41 sample residents. Specifically, the facility failed to effectively identify and implement person-centered approaches for dementia care to prevent resident-to-resident altercations. Cross-reference: F600 failure to prevent resident abuse. Specifically, to create an environment to: -Provide consistent and engaging group activities when routine activity was not available; and, -Ensure the activity environment was appropriate for all residents in the memory care unit based on the resident ' s comprehensive care plan. Findings include: I. Professional reference The Alzheimer's Association Tips for Dementia Caregivers in Long-Term or Community-Based…

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

Based on observations, record review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 16%, or four errors out of 25 opportunities for error. Findings include: I. Facility policy and procedure The Medication Administration and General Guidelines policy and procedure, dated November 2022, was provided by the interim nursing home administrator/corporate director of operations (INHA/DO) on 1/26/23 at 6:53 p.m. It included medications were administered as prescribed, in accordance with State regulations using good nursing principles and practices. The proper steps in the administration of medications included adherence to the six rights of medication administration including: 1) Right dose 2) Right route 3) Right resident 4) Right Medication 5) Right time 6) Right documentation II. Medication error observations and interviews A. Licensed practical nurse (LPN) #3 was observed preparing and administering medications to Resident #42 on 1/25/23 at 5:13…

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 observations, the facility failed to 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, texture, appearance and temperature; and, -Meals were served at a palatable temperature. Findings include: I. Facility policy The Quality and Palatability policy, revised September 2007, was provided by the corporate dietary manager (CDM) on 1/25/23 at 2:44 p.m. The policy read in pertinent part: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet residents' needs. The policy defined food attractiveness as the appearance of the food when served to residents. The policy defined food palatable as the taste and/or…

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

Based on observations and interviews the facility failed to prepare and serve food in a safe and sanitary manner to prevent cross-contamination and potential food borne illnesses, in one of one kitchen during meal services, and one of two dining rooms. Specifically, the facility failed to: -Ensure staff followed accepted hand hygiene practices during the meal service to prevent potential cross-contamination; and, -Ensure resident food was served at the appropriate temperature. Findings include: I. Professional standards The Centers for Disease Control and Prevention (CDC), reviewed 8/5/22, retrieved on 2/4/23 from: https://www.cdc.gov/foodsafety/keep-food-safe.html, under Four Steps to Food Safety read to Wash your hands for at least 20 seconds with soap and warm or cold water before, during, and after preparing food and before eating. According to the CDC, food should be chilled promptly because bacteria could multiply rapidly if left at room temperature or in the ' Danger Zone ' between 40 degrees F (Fahrenheit) and 140 degrees F. II. Facility policy The Food Preparation policy,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record for one (#4) out of five residents reviewed for advanced directives out of 41 sample residents. Specifically, the facility failed to ensure a facility nurse assigned to Resident #4 knew where to locate Resident #4's advance directives to ensure the directives would be carried out in case of emergency. Findings inclue: I. Facility policy The Communication of Code Status policy, revised [DATE], was provided by the facility on [DATE] at 6:47 p.m. The policy read: It is the policy of this facility to adhere to the residents' rights to formulate advanced directives. In accordance to these rights, the facility will Implement procedures to communicate a resident's code status to those individuals who need to know this information. According to the policy, the designated sections in the medical record to find the resident's code status was the physician orders under code status, and 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 (#25) of 12 residents reviewed out of 41 sample residents was provided personal privacy during care. Specifically, nursing staff failed to ensure they pulled the privacy curtain and keep the door closed while providing incontinence care for Resident #25. Findings include: I. Resident #25 status Resident #25, age [AGE], was admitted on [DATE]. According to the January 2023 computerized physician orders, diagnoses included Alzheimer's disease, reduced mobility, and need for assistance with personal care. The 11/17/22 minimum data set assessment documented severe cognitive impairment, physical behavior directed toward others, and no care rejection. She needed extensive assistance with activities of daily living. II. Observation On 1/19/23 at 5:00 p.m., certified nurse aide (CNA) #3 was observed leaving Resident #25's room pushing a Hoyer (mechanical) lift ahead of her and parking it in the hallway. She had left the door open and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for two (#32 and #56) of eight residents reviewed for accident hazards out of 41 sample residents. Specifically, the facility failed to: -Ensure appropriate and effective measures were in place to prevent Resident #32 from repeated falls, often related to the need to use the restroom. The resident fell eight times between 12/1/22 and 1/23/23. The repeat falls resulting in increased pain for Resident #32; -Ensure fall prevention interventions were put in place after the Resident #56 had an increase in medications that increased the residents risk for falls.; and, -Ensure Resident #56 had walking/locomotion assistance as identified on the resident's minimum data set assessment. Findings include: I. Facility policy and procedure The Fall Management policy, revised December 2022, the policy read and pertinent part: The facility assists each resident in…

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 (#42) out of one resident who required dialysis care, out of 41 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility: -Failed to blood pressure (BP) measurements were not checked on the right arm where the dialysis fistula/shunt was located; and, -Failed to ensure communication between the dialysis center and the facility. Findings include: I. Facility policy and procedure The Hemodialysis policy and procedure, dated 2022, was provided by the interim nursing home administrator/corporate director of operations (INHA/DO) on 1/26/23 at 12:35 p.m., and included the following: The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practices. This will include ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. 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 staff interviews, the facility failed to ensure one (#42) of 10 residents reviewed for medication administration of 41 sample residents were free from a significant medication error that involved insulin. Specifically, the insulin pen was not primed prior to injection for Resident #42. Findings include: A. Facility policy and procedure The Medication Administration and General Guidelines policy and procedure, dated November 2022, was provided by the interim nursing home administrator/corporate director of operations (INHA/DO) on 1/26/23 at 6:53 p.m. It included medications were administered as prescribed, in accordance with State regulations using good nursing principles and practices. The proper steps in the administration of medications included adherence to the six rights of medication administration including: 1) Right dose 2) Right route 3) Right resident 4) Right Medication 5) Right time 6) Right documentation B. Medication error 1. Observation Licensed practical nurse (LPN) #3 was observed preparing and administering medications to…

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

Based on interviews and record review, the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for nine residents (#37, #42, #305, #15, #34, #6, #18, #47 and #14) out of 24 residents reviewed for narcotic administration out of 33 sample residents. Specifically, the facility failed to ensure narcotic removal documentation in the narcotic log matched the dates of narcotic administration in the resident's electronic medical record (EMR) for Residents #37, #42, #305, #15, #34, #6, #18, #47 and #14. Findings include: I. Facility policy and procedure A Controlled Substance Administration and Accountability policy, undated, was provided by the nursing home administrator (NHA) on 12/20/21 at 12:39 p.m. that read: It is the policy of this facility to promote safe, high quality patient care, complaint with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental…

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 manage and alleviate pain for one (#37) of five residents reviewed for pain out of 33 sample residents. Resident #37 experienced daily, unrelieved, severe pain described at level 10 on a scale of zero to 10, with 10 being the worst possible pain. Facility assessment on 12/4/21 documented her pain was constant and severe at 8-10 in her back and joints. The pain interfered with her sleep, daily activities and quality of life. The pain evaluation further documented the resident was not satisfied with her pain regime with her pain described as stabbing, aching and shooting spasms. Furthermore, the facility failed to notify the physician of the resident's frequent breakthrough pain, or schedule a pain clinic consultation to find ways to alleviate the resident's pain. Findings include: I. Facility policy The undated Pain Management policy, provided by the corporate nurse consultant on the afternoon of 12/20/21, documented in pertinent part…

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.