Vivo Healthcare St Petersburg

Based on observations and interviews, the facility did not follow requirements for food service safety in two of two dumpsters as evidenced by garbage was not properly contained and the area was not maintained in a sanitary condition.Findings included: On 6/29/25 at 9:38 a.m., an observation of the dumpster area, conducted with Staff A, Cook, revealed the lids were not closed on two of two dumpsters. An observation of the dumpster, specifically for cardboard boxes, revealed boxes protruding out of the top and not broken down as indicated on the signage. An observation of the second dumpster revealed the two doors were not covering the exposed bags containing refuse. The two dumpsters observed were located on top of dirt, leaves, and gravel rather than a non-porous surface. On 7/2/25 at 10:53 a.m., an interview was conducted with the Certified Dietary Manager (CDM). She said the lids of the dumpsters should be closed. A review of photographic evidence obtained on 6/29/25 of the dumpsters and the surrounding area was conducted with the CDM. The CDM stated, It's an issue. She said all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to follow infection control practices related to staff with artificial nails, an ice scoop in the ice not in the holder, hand hygiene during medication distribution and transmission-based precautions were followed for Resident #82.Based on observation, record review and interviews, the facility failed to follow infection control practices related to staff with artificial nails, an ice scoop in the ice not in the holder, hand hygiene during medication distribution and transmission-based precautions were followed for Resident #82. Findings Included: During an observation on 06/29/2025 at 12:11 p.m., Staff Q, Certified Nurse Assistant (CNA) was observed with artificial nails protruding past the tips of her fingers. 06/30/2025 at 10:50 a.m., the Assistant Director of Nursing (ADON) and Infection Preventionist (IP) was observed with artificial nails protruding past the tips of her fingers During an interview on 7/2/25 at 6:49 p.m., the 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 observations, record reviews and interviews the facility failed to ensure dignity was provided related to residents having private access to a phone for two residents (#47 and #40) out of 21 sampled residents, and failed to ensure dignity was provided during meals in one of two dining rooms and failed to ensure dignity was provided related to standing while assisting one resident (#35) of 21 sampled residents.Findings Included: 1. During an interview on 07/01/2025 at 10:15 a.m., Resident #47 stated he had an issue last night with staff not allowing him to have a private phone call in the dining room. He stated he was on the phone when a staff member came in and told him he was not allowed to be in the dining room at that time. I had to hang up with the person I was speaking with and go back to my room. I would like a private area to have a conversation where my phone gets service at. Review of Resident #47's admission record revealed an admission date of 05/01/2025. Resident #47 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Findings included: 1. During an interview on 06/29/25 at 10:52 AM Resident #32 stated having concerns regarding not receiving medications as ordered by the physician. Review of the admission Record for Resident #32 revealed an admission on [DATE] and re-admitted on [DATE] with the following diagnosis: urinary tract infections (UTI), paraplegia, multi-drug-resistant infection, bell's palsy, low back pain, pain, other intervertebral disc displacement, lumbar region, female pelvic inflammatory disease, muscle spasm, need for assistance with personal care, hereditary idiopathic neuropathy, and other co-morbidities. Review of Resident #32's Minimum Data Set (MDS) assessment, dated 04/08/25, revealed Section C Cognitive Patterns, revealed a score of 14 out 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating the resident was cognitively intact. Review of Resident #32's physician order dated to 06/23/2025 at 09:49 AM for INVanz Injection Solution Reconstituted 1 gram (GM) to be given intravenously…

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 privacy of resident information on one floor (1st) out of two floors in the facility.Findings Included: An observation was conducted on 6/30/25 at 12:27 p.m. in the 100 [NAME] Hall of a medication cart with the computer screen unlocked. A resident's private information was visible to anyone in the hall and there was no staff member present. An interview was conducted on 6/30/25 at 12:29 p.m. with Staff M, Licensed Practical Nurse (LPN). Staff M, LPN returned to her medication cart and confirmed she left the screen unlocked with a resident's medical record displayed. Staff M, LPN said she only walked away to get a blood pressure cuff. She confirmed the screen should have been locked. An observation was conducted on 7/1/25 at 10:15 a.m. of a resident's lab order sitting face up on the upper counter of the first-floor nurses' station. No staff were working at the counter. An observation was conducted on 7/1/25 at 11:51 a.m. of a medication cart on the 100 East Hall with no staff present. There was a piece of paper face…

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 did not ensure quality care and services were provided to one resident (#33) out of thirty-six residents reviewed related to physician orders for intravenous (IV) site dressing changes. Findings included:On 6/29/25 at 10:06 a.m., an observation of Resident #33 revealed he was sitting up in bed with the television on and looking at his personal cell phone. Further observation of the resident revealed a central line IV site on his right chest with the dressing dated 6/18/25. Further observation of the dressing revealed an initial that appeared to be, AN. Photographic evidence obtained with the permission of Resident #33.On 6/30/25 at 10:21 a.m., an observation of Resident #33 revealed the central line IV site on his right chest dressing was still dated 6/18/25.On 6/30/25 at 10:23 a.m., an interview was conducted with Staff F, Licensed Practical Nurse (LPN). She said Resident #33 declined for staff to remove the central IV line. Staff F, LPN said he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide appropriate bathing equipment for three residents (#32, #11, & #2) out of three sampled residents.Findings included: On 06/29/25 at 10:17 a.m. Resident #2 was observed in a Geri-chair at the nurses' station with a staff member. Resident #2's hair was not brushed and looked unwashed. Review of the admission Record for Resident #2 revealed an admission on [DATE] with the following diagnosis: dementia with behavioral disturbance, schizophrenia, seizures, major depressive disorder, anxiety disorder, need for assistance with personal care, reduced mobility, drug induced subacute dyskinesia, and other co-morbidities. Review of Resident #2's physician visit dated: 05/31/25 revealed: Resident is alert and oriented to self only, able to answer short questions. Review of Resident #2's MDS assessment, dated 04/05/25, revealed: Section GG, Functional Status indicated Resident #2 required total assistance with shower/bathe self, rolling side…

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 did not ensure monitoring and interventions were put in place related to a significant weight loss for one resident (#44) out of three residents reviewed for nutrition.Findings included: Review of admission Records showed Resident #44 was admitted on [DATE] with diagnoses including end stage renal disease and unspecified protein-calorie malnutrition. Review of Resident #44's weights showed the resident had a post-dialysis weight of 163.9 pounds (lbs.) on 5/21/25 and a post-dialysis weight of 149.6 lbs. on 6/16/25, showing an 8.72% weight loss in less than 30 days. Review of Resident #44's Mini Nutritional Assessment, dated 5/20/25, showed the resident had not had any weight loss in the previous 3 months. The assessment also indicated the resident was at risk of malnutrition. Review of Resident #44's Progress Notes did not show any dietary notes since the nutrition assessment on 5/20/25. An interview was conducted on 7/1/25 at 2:45 p.m. with the Registered…

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 a Calcium Tomography Angiography (CTA) was competed for one (Resident #4) out of 21 residents sampled.Findings Included: During an interview on 06/30/2025 at 10:29 a.m., Resident #4 stated she was supposed to have a cat (CT) scan completed on Friday (06/27/2025) at 8:00 a.m. When I asked transportation about the appointment on Friday, I was told he cannot just take me to appointments. The CT is supposed to be done before I see my Vascular Surgeon on Wednesday (07/01/2025) so that he can review it and schedule my surgery. Now I am afraid the CT is not going to be scheduled in time for my appointment on Wednesday. I was told it would be rescheduled but no one has told me if it has been rescheduled. Review of Resident #4's admission record revealed an admission date of 06/04/2025. Resident #4 was admitted to the facility with diagnosis to include unspecified sequelae of cerebral infarction, muscle weakness (generalized), altered…

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, interviews, and record review the facility failed to ensure menus were provided to one resident (#53) out of eight residents sampled. Findings included: During an interview on 06/29/2025 at 2:23 p.m., Resident #53 stated they used to bring me an alternative menu to order from, but they stopped doing that. They give me entirely too much chicken. During an observation on 06/29/2025 at 2:23 p.m., hanging on Resident #53's wall was an activity calendar. No food menu was observed in Resident #53's rooms. Review of Resident #53's admission record revealed an admission date of 01/03/2025. Resident #53 was admitted with diagnosis to include complete traumatic amputation at level between right hip and knee, generalized anxiety disorder, acquired absence of left leg above knee, unspecified complications of amputation stump, acquired absence of right leg above knee, and paraplegia. Review of Resident #53's Annual Minimum Data Set (MDS) dated [DATE], Section C. Cognitive Patterns, 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 observations, interviews, and record review the facility failed to offer a snack to residents who want to eat at non-traditional times or outside scheduled meal service times for one resident (#439) out of 8 residents sampled for dining and the Resident Council.Findings included: During the Resident Council (RC) meeting on 06/30/25 at 10:03 a.m. with eight regularly attending oriented residents, they stated not receiving or being offered snacks. The RC continued to state sometimes the first floor has some sandwiches, but it is not always available, or the facility runs out. The facility recently has not had them available. During an interview on 06/29/25 at 10:00 a.m., Resident #439 said he is supposed to get snacks like a sandwich and some fruit in between meals but they do not give it to him. He stated if he asks for a snack they bring a couple packs of cookies. Review of Resident #439's admission record revealed an admission date of 06/23/2025. Resident #439 was admitted to the facility 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 observation, record review and interviews, the facility did not ensure medical records were accurate, related to the location of a wound, for one resident (#33) of thirty-six residents reviewed.Findings included: On 6/29/25 at 10:06 a.m., an observation of Resident #33 revealed he was sitting up in bed, with the television on, and looking at his personal phone. He had a sheet over his legs, however, both feet were exposed. Observations of Resident #33's feet revealed he had a wound on his left great toe. Resident #33's toe wound seemed to be healed as evidenced by dry, scabbing skin. A review of Resident #33's admission record revealed an original admission date of 4/11/25 and re-admission date of 5/29/25. Further review of the admission record revealed diagnoses to include muscle wasting and atrophy, not elsewhere classified, multiple sites, unspecified protein-calorie malnutrition, muscle weakness (generalized), adjustment disorder with mixed anxiety and depressed mood, other malaise, and dependence…

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, record review and interview the facility failed to ensure equipment was functioning and timely follow-up and submission of work orders related to the automatic patio door, dish machine, walk-in freezer, and first floor nourishment room refrigerator.Findings included: 1. During multiple observations from 06/29/2025 thru 07/02/2025, the glass doors leading to and from the outside patio were observed to be stuck open or not functioning to open. During an observation on 06/30/2025 at 2:55 p.m., multiple residents were observed pushing the handicap button in the hallway to the door leading to the courtyard. The door did not open. During an observation on 06/30/2025 at 2:57 p.m., an unidentified staff member was observed pushing the handicap button under the covered outside walkway and the door did not open. During an interview on 06/30/2025 at 2:55 p.m., Staff N, Certified Nursing Assistant (CNA) stated the door has been like that for a while. During an interview on 07/02/2025 at 11:30 a.m., Staff O, CNA stated the buttons on the doors work but the doors get stuck.…

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 interview and record review, the facility failed to ensure care plans were accurate or developed for two residents (#2, #3) out of three sampled residents. Findings included: 1. Review of Resident #2's admission Record showed she was admitted to the facility on [DATE] with diagnoses to include senile degeneration of the brain, major depressive disorder, generalized anxiety disorder, heart failure, muscle wasting, weakness and reduced mobility. Review of Resident #2's medical record showed she was discovered to have bruising to her right shoulder and right side of her head on 01/15/25. Resident #2 was sent to the hospital for further evaluation. Further review of the medical record showed the resident was treated in the emergency room on [DATE] and was found to have a right clavicle fracture. During an interview with the Nursing Home Administrator (NHA) on 02/13/25 at 2:11 p.m., she stated through her investigation it was discovered the resident was observed by a staff member on the floor on the side 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, interviews and record review, the facility failed to ensure adequate supervision was provided for two residents (#2, #3) of three residents sampled for fall accidents. Findings include: 1. Review of Resident #2's admission Record showed Resident was admitted to the facility on [DATE] with diagnoses to include senile degeneration of the brain, major depressive disorder, generalized anxiety disorder, heart failure, muscle wasting, weakness and reduced mobility. Review of Resident #2's medical record showed she was discovered to have bruising to her right shoulder and right side of her head on 01/15/25. Resident #2 was sent to the hospital for further evaluation. Further review of the medical record showed the resident was treated in the emergency room on [DATE] and was found to have a right clavicle fracture. During an interview with the Nursing Home Administrator (NHA) on 02/13/25 at 2:11 p.m., she stated through her investigation it was discovered the resident was observed by a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the facility's policy Abuse Investigation and Reporting the facility failed to immediately report an allegation of abuse, upon resident disclosure, for one resident (Resident #2) of three residents reviewed for abuse. Findings included: A review of the admission Record showed Resident #2 was admitted to the facility on [DATE] with diagnoses that included but not limited to Acute kidney failure, insomnia, unspecified dementia, severity without behavioral disturbance, major depressive disorder, recurrent and anxiety disorder. Review of the Quarterly Minimum Date Set dated 01/24/24 showed Section C- Cognitive Patterns Resident #2 had a Brief Interview of Mental Status (BIMS) of 07 (cognitively impaired). Section I- Active Diagnoses showed Resident #2 had Non-Alzheimer's Dementia and Depression. Review of Resident #2's care plan showed: Focus - [Resident #2] has a potential for re-traumatization related to recent traumatic experience: being attacked by another…

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, interview, policy review and photographic evidence the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items in both the walk in freezer and dry storage area. The facility failed to ensure the refrigerator and freezer temperature logs were completed. The facility failed to ensure the dishwasher temperature gauges were in good working order in one of one kitchen with the potential to affect 73 out of a census of 75 residents. Findings included: An observation on 02/13/23 at 10:40 a.m. showed both the refrigerator and freezer temperature logs were hanging up on the wall outside of the walk in refrigerator and walk in freezer. The freezer temperature log showed no temperature for the morning of 02/09/23 and no additional freezer temperatures documented for 02/10/23 to 02/13/23. The refrigerator temperature log showed no refrigerator temperatures documented for days of 02/10/23 and 02/12/23. There was no evening refrigerator temperatures documented for the day 02/11/23.…

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

Based on observation, interview and policy review the facility failed to ensure the call bell system was working and available on two of two floors for a census of 75 residents. Findings included: During an observation on 02/15/23 at 12:45 p.m., Resident #200 was in the door of his room. He stated he had been trying to get someone to come to his room, but his call bell wasn't working. He wasn't sure how long he had been trying to get assistance. Resident #200's call bell was tested as well as call bells in the rooms around his. It was discovered that no call bells were working on the second floor (both East and [NAME] wings). During an interview on 02/15/23 at 12:55 p.m., Staff D, Licensed Practical Nurse (LPN) stated that none of the call lights are working on the second floor. Staff D, LPN stated that she was just told the call bell system wasn't working by another staff member about five minutes ago. Staff D, LPN pointed out the maintenance staff down the hallway and stated, They are working on it now. During an interview on 02/15/23 at 1:02 p.m., Staff E, Maintenance Supervisor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure shared communication between the facility and the dialysis facility for three residents (#203, #208 and #209) of three residents sampled for dialysis care. Findings included: 1. The admission Record showed Resident #203 was admitted to the facility on [DATE]. The Dialysis Communication binder for Resident #203 was reviewed on 02/15/23 at 1:04 p.m. Review of dialysis communication forms for the dates of 2/11/23 and 2/14/23 showed the post dialysis portion of the form, Section 3 To be completed on return from dialysis, was not completed. 2. Review of Resident #208's Dialysis Communication binder revealed the resident had dialysis appointments on 2/15, 2/13, 2/10, 2/8, 2/6, 2/3, and 2/1. The Dialysis Communication forms Sections 2 To be filled out by Dialysis Center and post dialysis Section 3 were not completed on any of the dialysis days listed above. 3. Review of Resident #209's Dialysis Communication binder revealed the resident had…

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, interview, medical record review, and review of the policy for Drug Diversion, the facility failed to ensure the disposition of controlled medications reflected accurate accounting and record keeping for three residents (#52, #59, and #51) out of six residents sampled for pain. Findings included: 1.On 2/13/2023 at 11:30 a.m. Resident # 52 was in the hallway asking if she could have a pain medication. Staff L, Registered Nurse (RN) stated she already had one this morning. Staff L was asked why Resident #52's Controlled Drug Disposition Form for the Hydrocodone APAP 5-325 mg (milligram) reflected her last dosage was given on 02/12/2023 at 10:00 a.m. Staff L looked at the form, and then changed the number 2 to a number 3, indicating three doses had been given. On 2/14/2023 at 12:33 p.m. a review was conducted of the Control Drug Disposition book that revealed an empty bubble card for Resident #52. The card read for Hydrocodone APAP 5-325 mg and was then compared to the Controlled Drug Disposition form that reflected the amount remaining count as 1. On 2/14/2023 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review and policy review the facility failed to ensure a reported allegation of abuse was reported for one resident (#154) out of 31 one sampled residents. Findings included: A facility policy titled Abuse Protection and Response Policy, undated, was reviewed. The policy stated the following: Abuse, as hereafter defined, will not be tolerated by anyone, including staff, patients, volunteers, family members, or legal guardians, friends, or any other individuals. The health center Administrator is responsible for assuring that patient safety, including freedom from risk of abuse, holds the highest priority. Verbal Abuse: the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Identification: Policy: Any resident event that is reported to any staff by patient, family, other staff or any other person will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review and policy review the facility failed to ensure a reported allegation of abuse was investigated for one resident (#154) out of 31 one sampled residents. Findings included: On 2/14/23 at 9:30 a.m. an interview was conducted with Resident #154. The resident stated there was a nurse in the facility that called him a cripple and a cracker. He said the problems with this nurse began when they had a misunderstanding about him wanting his blood sugar checked and getting insulin. The resident stated the day that happened, he felt off and wanted his blood sugar checked. He said he was told his nurse was downstairs, so he went downstairs and had the nurse on the first floor check his blood sugar. He went back upstairs and told Staff L, RN, she then told him she didn't have the keys to the medication cart with his insulin in it. He felt like she wasn't helping him. He said Staff L, RN got angry and went downstairs and yelled at the nurse that took the resident's blood sugar. Resident #154…

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 medical record review, observation and staff interviews, the facility failed to ensure the Quarterly Minimum Data Set Assessment (MDS) accurately reflected the resident's status for the use of an opioid received for one resident (#51) of five sampled residents. Findings included: On 02/13/2023 at 11:38 a.m. Resident #51 said she had been at the facility for a short period of time after she had fallen and fractured her shoulder. She confirmed she had pain and rated it as a number 7 out of a total of 10, with 10 rated at the highest level of pain. She stated they had given her Tylenol for pain. She stated they told me they did not get the pain medication in right away. She went on to say they would give it to me in the hospital routine, but here she had to ask for it. She said that some of the nurses will ask her if she has pain and will give me a pain medication. She said the other night it took the nurse eight hours to get one for her. Review of the admission Record indicated Resident #51 had been at the facility for less than two weeks. The diagnoses included unspecified…

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 develop a comprehensive care plan related to smoking for two residents (#202 and #206) of three residents sampled for smoking. Findings included: 1. Review of the admission Record showed Resident #206 was admitted to the facility on [DATE] with diagnoses to include other psychoactive substance abuse, metabolic encephalopathy. Resident #206 was observed in the smoking area on 2/15/23 at 1:35 p.m. with other residents and two staff members present who were providing smoking materials. Resident #206 was interviewed in his room on 02/16/23 at 12:48 p.m. and said he can go out in his wheelchair to smoke whenever he wants. Staff keep his cigarettes for him, but he has no trouble getting a cigarette when he wants one. Review of Resident #206's medical record showed a Smoking Evaluation was completed on 1/28/23 by Staff K, RN. Results of the smoking evaluation were documented as resident requires supervise/assist while smoking due to poor…

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 medical record review the facility failed to follow professional standards of practice for pain management for two residents (#51 and #255) out of 6 residents sampled for pain as evidenced by not reordering a controlled substance in a timely manner. Findings included: 1.On 02/13/2023 at 11:38 a.m. Resident #51 said she had been at the facility for a short period of time after she had fallen and fractured her shoulder. She confirmed she had pain and rated it a number 7 out of a total of 10 ,with 10 rated at the highest level of pain. She stated they had given her Tylenol for pain. She stated they told me they did not get the pain medication in right away. She went on to say they would give it to me in the hospital routine, but here she had to ask for it. Resident #51 stated, The other night it took the nurse eight hours to get me one. I don't know why I am having to wait extended periods of time for pain medication. She stated just this past Friday (02/10/2023), around lunch…

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, interview, and medical record review the facility failed to ensure that outside services were collaborated for one resident (#56) out of one resident receiving hospice services. Findings included: On 02/13/2023 at 12:12 p.m. Resident #56 was sitting on the side of her bed and verbalized a concern about not being able to leave the facility on her own like her roommate. Resident noted with cognitive deficit at that time stating, To just leave for a while. She said she knew she was receiving hospice services but could not recall the last time someone visited her. Review of Resident #56's admission Record form indicated her last admission was two months ago with the primary payer as Hospice. The Hospice Face Sheet showed diagnoses of malignant neoplasm of unspecified (unsp.) part of unspecified bronchus or lung, secondary and unspecified malignant neoplasm of lymph node. On 02/16/2023 at 1:12 p.m. an interview was conducted with Staff N, Licensed Practical Nurse (LPN)/Unit Manager (UM). She stated, The hospice nurse and aide come one day a week. She was unsure what…

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 reviews, interviews, and a review of the facility policy, the facility failed to ensure allegations related to verbal, physical, and sexual abuse were reported immediately to the governing agency in accordance with the State law for five residents (#133, #72, #3, #56 and #7) out of the sampled 40 residents. Findings included: 1. A review of the admission Record revealed that Resident #133 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, and bipolar disorder with current episode manic severe with psychotic features. Section C Cognitive Patterns of the Quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #133 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired. Section E Behaviors indicated that the resident had verbal behavioral symptoms directed toward others for one to three days per week. A review of the progress notes revealed the following: 04/08/21 17:29 (5:29 p.m.) The police arrived to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that the plan of care for one resident (#61) out of 40 sampled residents was updated to reflect the use of a mechanical lift for transfers. Findings included: An observation was conducted on 06/09/21 at 2:05 p.m. in Resident #61's room of Staff E, Certified Nursing Assistant (CNA) transferring Resident #61 into bed using a mechanical lift. The resident was suspended in the air by a sling and being moved to his bed from his wheelchair, which was positioned a few feet away from the foot of his bed. Staff E was the only staff member in the room and was performing the transfer alone. Staff E said that she knew she was supposed to have two staff members present to perform transfers with a mechanical lift but, said she had been in the middle of weighing the resident using the lift when he requested to go to bed. Staff E confirmed that she had also performed the task of weighing the resident using the lift by herself without assist 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 observation, interview and record review, the facility did not ensure that the medication error rate was below 5.00%. A total of twenty-eight medications were observed administered and two errors were identified for two residents (#2 and #51) of three residents observed. These errors constituted a medication error rate of 7.14% percent. Findings included: An observation of second floor medication administration on 6/10/2021 at 8:15 a.m., resulted in Staff A, Licensed Practical Nurse (LPN), not providing Resident #2 with water to rinse her mouth after she was administered Trelegy Ellipta Aerosol Powder Breath Activated 100-62.5-25 MCG/INH, after she took one puff from the inhaler. An immediate interview was conducted at 8:29 a.m., with Staff A who stated, She (Resident #2) usually drinks water after I give her the medication. The medication label printed by the pharmacy read Rinse mouth after use. Record review of the active physician orders for June 2021 for the Resident #2 read, Trelegy Ellipta Aerosol…

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 upon observation, interview, and record review the facility failed to appropriately secure medications in two medication carts (2W and 2E) of four medication carts. Findings included: A review of the facility's policy and procedure titled, Storage of Medications, effective November 2020, included under Policy Heading: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Under Policy Interpretation and Implementation was included: 2. Drugs and biologicals shall be stored in the packaging containers or other dispensing systems in which they are received. On 06/10/21 at 3:47 p.m. an observation of the medication cart on 2W included one loose white pill, and a clear gel capsule located in the second drawer from the top of the medication cart. Staff B, Licensed Practical Nurse (LPN) confirmed the presence of the unsecured tablets. On 06/10/21 at 4:00 p.m. an observation of the medication cart on 2E included one white loose tablet in the second drawer, and one yellow round tablet in the third drawer from the top of the medication cart. Staff D,…

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.