Vivo Healthcare Winter Haven

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain physician orders, assess the residents or develop care plans for two (#38 and #89) of two residents related to self-medicating for nebulizer treatments. Findings included: 1. An observation on 04/07/2025 at 10:25 a.m revealed Resident #38 sitting in his room in his bed. The head of the bed was elevated. His un-bagged nebulizer mask was laying on the overbed table. The nebulizer machine was off. He stated the nurse brought in medicine for his machine and left. Resident #38 stated he took it off after it was finished. He stated the nurse did not stay with him. An observation on 04/07/2025 at 11:26 a.m revealed Resident #38's un-bagged nebulizer was still laying on the overbed table. An observation on 04/08/25 at 8:58 a.m., revealed Resident #38 was sitting in bed with the head of the bed elevated. The nebulizer mask was in a plastic bag on the overbed table. An observation on 04/09/2025 at 10:30 a.m., revealed Resident #38 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 interview the facility failed to provide notification to the resident representative for one of six residents (Resident #106) sampled for accidents out of a total sample of 52 residents. Findings Included: Review of Resident #106's admission Record showed an admission date of 07/11/2024, discharge date of 07/16/2024 to an acute care hospital, and diagnoses to include urinary tract infection, osteoporosis, leukemia, hypertension, rheumatoid arthritis, muscle wasting and atrophy, difficulty walking, and repeated falls. Resident #106 had three family members listed as emergency contacts on the admission Record. Review of the Change in Condition Evaluation dated 07/15/2024 at 2:43 a.m. showed Resident #106 fell on [DATE] at 2:20 a.m. Section 3. Resident/Representative Notification was blank. Review of the progress notes showed no documentation the family was called post fall on 07/15/2024. Review of the Situation, Background, Assessment, Recommendations (SBAR) dated 07/16/2024 showed…

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 reviews, and interviews, the facility failed to revise the care plans and related interventions accurately for one residents (#93) of fifty-two sampled residents related to indwelling urinary catheter. Findings included: Review of Resident #93's care plan revealed the following focuses and relevant interventions: - Enhanced Barrier Precautions related to (r/t) indwelling urinary catheter (and) wound. The focus was initiated on 1/27/25 and revised on 4/7/25. - Has a[n] [indwelling] Catheter. Diagnosis (DX) wounds. The focus was initiated on 1/15/25 and revised on 4/9/25. The goal was for the resident to remain free from catheter-related trauma through review date. On 4/7/25 at 11:28 a.m., Resident #93 was observed lying in bed. No urinary catheter was observed. During an interview on 4/8/25 at 5:43 p.m., Resident #93 reported not having a urinary catheter and stated it came out on its own about 3 weeks ago. The nurse at the time was going to put it back but needed a 16 French (fr) sized catheter, but only had a 14 fr available and did not have an order…

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 interview, the facility failed to assess, document and/or treat a surgical wound for one (#96) of one resident sampled for skin conditions. Findings included: On 4/7/25 at 5:10 p.m., Resident #96 was observed with a blue cast on his right arm and a mesh pad covering a black area approximately 2 centimeters (cm) x 3 cm on his interior left ankle. The mesh was lifted off the skin in one corner. The resident stated the doctor did not want it to come off and it had been there for about a month. Review of Resident #96's admission Record revealed the resident had been admitted on [DATE] and included diagnoses not limited to unspecified fracture of right femur subsequent encounter for closed fracture with routine healing, stress fracture right ankle subsequent encounter for fracture with routine healing, and multiple sites muscle wasting and atrophy not elsewhere classified. Review of Resident #96's Admission/readmission Nursing Evaluation, effective 2/7/25, showed the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation staff interview and record review, the facility failed to ensure a contracture management program to include wearing of splints/orthotics was implemented for one (#7) of fifty - two sampled residents during three of three days observed (4/7/2025, 4/8/2025, and 4/9/2025). Findings included: On 4/7/2025 from10:30 a.m. to 12:30 p.m. Resident #7 was observed in her room lying in bed with both of her upper extremities noted to be contracted. Both of her hands and fingers were in a closed position. Resident #7 was not observed wearing either splints or orthotics. There were no splints or orthotics visible in the room during the multiple visits. Resident #7 was not able to answer any questions related to her medical care and services as she was observed with cognitive deficits. On 4/7/25 at 1:00 p.m. an interview was conducted with Staff C, Certified Nursing Assistant (CNA). Staff C confirmed she had Resident #7 on her assignment for the day and that she did not know the resident well. Staff C was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure physician orders were in place for one (Resident #19) of two residents sampled for a Foley catheter. Findings included: A review of admission record revealed Resident #19 was readmitted on [DATE] with diagnoses including multiple sclerosis, neuromuscular dysfunction of bladder, quadriplegia, resistance to multiple antibiotics, carrier of other enterobacterales and other co-morbidities. A review of Resident #19's care plan revealed the following: Focus: Resident #19 Urinary catheter r/t (related to) Neuromuscular Dysfunction of Bladder Date Initiated: 04/04/2024 Revision on: 02/22/2025. Interventions included: Change catheter as needed Date Initiated: 04/13/2024; Foley Catheter as ordered Date Initiated: 04/13/2024 Revision on: 04/07/2025; Observe/document for pain/discomfort due to catheter Date Initiated: 04/04/2024; Observe/record/report to MD for s/sx (signs/symptoms) (Urinary Track Infection) UTI - pain, burning, blood-tinged…

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 identify, implement, monitor, and modify interventions for one (Resident #33) out of 52 related to coughing during meals. Findings Included: During an observation on 04/07/2025 at 12:18 p.m., Resident #33 was observed sitting in the dining room with a plate of spaghetti, meatballs and garlic toast. Resident #33's eyes became watery and was observed coughing after taking a bite of food. Resident #33 continued to cough for a few seconds when staff approached Resident #33 raised her hands and removed the plate of spaghetti and toast. During an interview on 04/07/2025 at 1:19 p.m., Resident #33's Family Member (FM) stated that she had had an issue with the facility not assisting the resident with eating. She stated the resident had had issues with chewing her food and was supposed to be on a pureed diet. She stated the last time the resident went to the hospital and came back to the facility, she brought up that the resident needed…

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 oxygen therapy was provided in accordance with professional standards of practice for two residents (#38 and #26) of four residents sampled and failed to ensure respiratory equipment was stored appropriately for two residents (#14 and #89) of four sampled residents. Findings included: 1. An observation was conducted on 4/7/2025 at 10:25 a.m. of Resident #38 sitting in bed with an oxygen nasal cannula in place in his nose. The oxygen concentrator set to 3.5 liters/minute. An observation was conducted on 4/8/2025 at 8:58 a.m. of Resident #38 sitting in bed with an oxygen nasal cannula in place in his nose. The oxygen concentrator set to 3.5 liters/minute. An observation was conducted on 4/9/2025 at 10:30 a.m. of Resident #38 sitting in bed with an oxygen nasal cannula in place in his nose. The oxygen concentrator set to 1.5 liters/minute. A review of Resident #38's medical record revealed he was admitted on [DATE]. Review of the…

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

Based on observation, interview, and record review the facility failed to provide behavioral health care services to one (#36) of three residents reviewed for mood and behaviors. Findings Included: During an observation on 04/07/2025 at 10:45 a.m., Resident #36 was heard from the nurse's station yelling out. During an observation on 04/08/2025 at 9:23 a.m., Resident #36 was observed hitting her leg and yelling out. Resident #36 was unable to answer any questions regarding her care. Review of Resident #36's admission record revealed she was originally admitted in 2018, most recently admitted in June of 2024, and had diagnoses to include Vascular Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, Adjustment Disorder with Mixed Disturbance of Emotions And Conduct, Other Specified Persistent Mood Disorders, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Dysarthria following Cerebral Infarction, Aphasia, and Dysphagia, Oropharyngeal Phase. Review of Resident #36's Quarterly…

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 did not ensure physician orders for medications with parameters were followed for two (#29 and #11) out of two residents reviewed. Findings included: 1. On 6/03/2025 at 10:05 a.m. an observation and interview was conducted with Staff A, Licensed Practical Nurse (LPN) during medication administration for Resident #29. Staff A, LPN stated she will make a call to the physician to inform the physician of the late administration of medication for the resident. Staff A, LPN took Resident #29's blood pressure and obtained a result of 111/68 millimeters of mercury (mmHg). Staff A pulled Lisinopril 2.5 milligrams (mg) from the medication cart and administered the medication. A record review of Resident #29's admission Record showed an admission date of 6/14/2019 with diagnoses to include but not limited to essential hypertension. A record review of Resident #29's physician orders showed an order dated 5/25/2025 for Lisinopril 2.5 mg to give one tablet by mouth one time a day for hypertension, hold if systolic blood pressure…

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 maintain accurately documented medical records for vital signs, medication, and indwelling catheters for two (#98, #93) of 52 total sampled residents. Findings included: 1. On 4/8/25 at 4:06 p.m., Resident #98 was observed with Staff Q, Licensed Practical Nurse (LPN) during the administration of medication. Review of Resident #98's April 2025 Medication Administration Record (MAR) showed a physician order for staff to monitor vital signs every shift. Review of the MAR documentation showed: - Identical vital signs on 4/1/25 evening and night shift of 132/72 blood pressure (bp), 97.3 temperature (temp), 72 pulse, 17 respiratory rate (resp), and 98% oxygen saturation rate (O2 sats). - Identical vital signs on 4/2/25 night shift and 4/3/25 evening and night shift of 122/88 bp, 97.6 temp, 77 pulse, 18 resp, and 97% O2 sats. - Identical vital signs on 4/4/25 day, evening, and night shift and 4/5/25 evening shift of 118/68 bp, 97.1 temp, 65 pulse, 19 resp, and 96% O2 sats. - Identical vital signs on 4/5/25 night…

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, observation, and record review, the facility failed to maintain a safe, clean, and comfortable homelike environment in 16 out of 52 resident rooms and in three Wings/Common areas (100, 400 and 600) of six Wings toured. Findings included: On 4/8/2025 at 12:40 p.m., 4/9/2025 at 09:50 a.m., and on 4/10/2025 at 10:10 a.m. the following was observed: Resident room [ROOM NUMBER] was observed with bio growth on the ceiling at the fire sprinkler head. Resident room [ROOM NUMBER] was observed with a brown, rough surface over the toilet seat. Resident room [ROOM NUMBER] was observed with a brown, rough surface over the toilet seat. Resident room [ROOM NUMBER] was observed with bio growth on the ceiling at the fire sprinkler head. Resident room [ROOM NUMBER] was observed with unfinished walls near the TV and bio growth on the ceiling at the fire sprinkler head. Resident room [ROOM NUMBER] was observed without a call light pulling string in the bathroom. Resident room [ROOM NUMBER] was observed with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Forty-one medication administration opportunities were observed, and fourteen errors were identified for four residents (#40, #98, #93, and #53) of six residents observed. These errors constituted a 34.15% medication error rate. Findings included: 1. On [DATE] at 8:24 a.m. an observation of medication administration with Staff P, Licensed Practical Nurse (LPN) was conducted with Resident #40. The staff member searched medication cart for a bottle of Calcium 500 milligram(mg) tablets. Staff P went to the central supply office cupboard and retrieved an over-the counter bottle before revealing the bottle was Calcium with Vitamin D and not the medication the resident was ordered. The staff member proceeded to dispense the following: - Carvedilol 3.125 mg tablet - Furosemide 40 mg tablet - Jardiance 10 mg tablet - Lisinopril 40 mg tablet Staff P confirmed dispensing four (4) tablets prior…

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 interview, observation, and record review, the facility failed to maintain an effective pest control management system in nine rooms (100, 103, 108, 106, 207, 210, 303, 410, and 604) out of 52 rooms toured, and for one resident (#78) of one resident sampled. Findings included: On 4/9/2025 at 12:45 p.m. and on 04/10/2025 at 10:10 a.m., observations were made of live crawling bugs and what appeared to be insect feces in resident rooms and common areas. The rooms included rooms 100, 103, 108, 106, 207, 210, 303, 410, and 604, and common areas of the 400 Wing. On 4/7/2025 at 11:00 a.m., an interview was conducted with Staff B, Certified Nursing Assistant (CNA). She stated she had seen pests throughout the entire facility. On 4/10/2025 at 11:08 a.m., an interview was conducted with the Director of Maintenance (DOM). The DOM said, he walked the facility daily and if he saw an issue he resolved it immediately or entered it into the electronic maintenance work order system. The staff also entered issues into an electronic maintenance work order system, and he reviewed the system…

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 reconcile, obtain, and provide medications as ordered, for two residents (#105 and #53) of five residents sampled for admissions/readmissions. Findings included: 1. Review of Resident #105's admission Record showed the resident was admitted on [DATE]. The primary admitting diagnosis was other seizures, with other diagnoses of unspecified benign neoplasm of brain, epileptic seizures related to external causes not intractable without status epilepticus, myasthenia gravis without (acute) exacerbation, and chronic pain syndrome. Review of Resident #105's Admission/readmission Nursing Evaluation, dated 11/19/24 at 4:08 a.m., revealed the resident's medications and physician orders had been reviewed and the resident had arrived via stretcher from a hospital for seizure activity and pain history (hx) left shoulder Arthropathy. The evaluation did not reveal an order had been received from the physician to administer medications when they became…

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 provide an environment that was clean, sanitary, and well-maintained related to lack of housekeeping three halls (100, 400 and 600) of six halls affecting 12 resident rooms (604, 609, 101, 103, 102, 104, 400, 404, 406, 408, 411, 412 ), two storage areas (600-hall oxygen room, clean utility room) and broken handrails located in the hallway across from the therapy room and the dining room, and failed to ensure the ceiling was free and a black like substance and in good repair in one of one kitchen. Findings included: 1. An observation on 7/10/23 at 9:53 a.m. of the 600-hall oxygen room revealed under an empty oxygen rack dirt and mulch-looking material and behind the door was piles of dead ants intermixed with dust. On 7/10/23 at 10:01 a.m., an observation was conducted in the bathroom for Resident room [ROOM NUMBER]. The observation revealed a black biofilm along the floor and in the corner of the shower, the light above the shower was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility 1) failed to ensure staff appropriately donned Personal Protective Equipment (PPE) prior to entering isolation rooms for two residents (#74 and #561) out of two residents on Contact Precautions, and 2) failed to ensure staff were educated on Enhanced Barrier Precautions (EBP) on two hallways (400 and 100) out of six hallways in the facility, 3) failed to implement proper PPE during wound care for one resident (#105) out of one wound care observation, and 4) failed to ensure staff followed proper infection control practices related to nail care during medication administration. Findings included: 1) On 7/12/2023 at 10:30 a.m. an Enhanced Barrier Precautions sign was observed on Resident #74's room door and no PPE caddy available to staff. (Photographic Evidence Obtained) On 07/12/23 at 11:06 a.m. an interview was conducted with Staff H, Licensed Practical Nurse (LPN). Staff H, LPN stated she was informed during her nurse-to-nurse communication…

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 facility policy review, the facility failed to ensure an effective pest control system was in place in four halls (100, 200, 400 and 600) of six halls and one resident (#60) who resided in one of the affected halls. Findings included: A review of a facility policy titled, Pest Control, revised date: 2/2023, revealed: 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 (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats). During multiple facility tours, observations were made of live and dead pests and flying insects in resident rooms and storage areas as follows: 1. On 7/10/23 at 10:04 a.m. in the bathroom of Resident room [ROOM NUMBER] an observation revealed dead and live cockroaches near the toilet and shower drain. On 7/10/23 at 10:10 a.m. in the bathroom 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, record review and interview the facility failed to ensure one resident (#28) was assessed and determined to be clinically appropriate and safe to self-administer medications of two residents sampled for self-administration of medications. Findings included: An observation on 07/10/23 at 10:44 a.m., showed four pills in a medication cup placed on Resident #28's bedside table. (Photographic Evidence Obtained) During an interview on 07/10/23 at 10:46 a.m., Staff A, Licensed Practical Nurse (LPN) stated Resident #28 did not have the ability to self-administer medications. Staff A, LPN identified the four pills as Norvasc, Lisinopril, Zoloft, and Namenda. Staff A, LPN stated the facility protocol for medication administration was for the nurse to watch a resident take their medications before walking away. Staff A, LPN stated she did not normally leave pills at bedside for residents to self-administer medication, but she had gotten sidetracked by another resident this morning and left Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and resident record review, the facility failed to ensure reasonable accommodations were made for one resident (#74) related to not providing an appropriate length mattress to ensure the resident's feet did not touch the footboard of six residents sampled. Findings included: During an observation and interview conducted on 7/10/23 at 9:55 a.m. Resident #74 said his feet frequently touch the footboard. Resident #74 stated staff need to reposition me although even with the knees raised, I slide right back down. I am 6'7; they don't have a bed for my height. When I requested a longer mattress, I was given this bed and was told this is the longest they have, it will have to do. On 7/10/23 at 12:20 p.m. Resident #74 was observed in his bed sitting up and eating his lunch. His feet were touching the footboard and his heels were not supported by the mattress as there was a gap of approximately 7 ½ inches. (Photographic Evidence Obtained) During an interview with Resident #74 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.

Based on record review and interview the facility failed to transmit two comprehensive assessments for one resident (#96) out of two residents sampled for the task of Resident Assessments. Findings included: A review of Resident #96's Minimum Data Set (MDS) information identified a Modification of Entry assessment, dated 2/10/23, was Export Ready, the status of the original Entry assessment was modified and the Modification of admission assessment, dated 2/16/23, was Export Ready. The original admission assessment status was modified. The Discharge Return Not Anticipated assessment, dated 2/28/23 was accepted. On 7/13/23 at 11:26 a.m., during an interview Staff C, MDS Licensed Practical Nurse (LPN) stated they had some issues and couldn't transmit (at that time). The staff member stated both modifications should have been sent and Resident #96's assessments were missed. The policy titled, MDS 3.0 Completion and Transmission, dated 4/5/23, showed Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care…

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 the comprehensive Minimum Data Set (MDS) assessment was accurately coded for two residents (Resident #74 and #77) of fourteen sampled residents. Findings included: 1. Review of the admission Record showed Resident #74 was admitted on [DATE] with diagnoses of metabolic encephalopathy, obstructive sleep apnea, chronic pulmonary edema, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, chronic diastolic (congestive) heart failure and history of COVID-19 (coronavirus disease of 2019). An observation on 7/10/23 at 10:00 a.m. revealed Resident #74 with a non-invasive mechanical ventilator (BiPAP [bilevel positive airway pressure]/CPAP[continuous positive airway pressure]) at his bedside. During an interview on 7/11/22 at 3:00 p.m., Resident #74 stated he has had the BiPAP since his hospital stay. Resident #74 stated he had significant breathing problems that included having a tracheostomy (surgical opening…

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 confirm the accuracy of a Pre-admission Screening and Resident Review and failed to correct the document for three residents (#10, #105, and #36) out of forty-seven residents sampled when mental illness or suspected mental illness diagnoses were identified and added to the resident's medical diagnoses . Findings included: 1. A review of Resident #10's admission Record indicated an original admission date of 4/2/18 and a recent re-admission date of 3/23/23. The census list for the resident identified additional admission dates of 9/28/18 and 12/14/19. A Preadmission Screening and Resident Review, Level I Screen for Resident #10, dated 4/2/18, indicated N/A in sections A. Mental Illness (MI) or suspected MI and B. Intellectual Disability (ID) or suspected ID. Section II: Other indications for PASRR (PASARR) Screen Decision-Making identified the resident had no indications. Section IV indicated the resident may be admitted to a Nursing…

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 two residents (#93 and #461) of three residents sampled for skin impairments received wound care in accordance with professional standards related to changing dressings as ordered and documented and failed to assess and document skin conditions. Findings included: 1. An observation was conducted on 7/10/23 at 12:27 p.m. of Resident #93 lying in bed, the resident stated the bed sheets were piled. The observation identified an area of rolled gauze, dated 6/27/23, on the right upper arm and a white bordered dressing, dated 7/1/23, on the left knee. On 7/10/23 at 12:39 p.m., Staff P, Licensed Practical Nurse (LPN) observed Resident #93's dressings. Staff P reported not seeing the right upper arm rolled gauze earlier, another nurse was taking care of wounds, and maybe that nurse had dated (6/27/23) it wrong. Staff P removed the resident's sock from the left heel and stated the dressing was dated 7/1/23. The observation identified 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 observation, record review and interview the facility failed to ensure two oxygen administration orders were clarified for one resident (#77) of two residents reviewed for respiratory care. Findings included: An observation on 07/10/23 at 10:32 a.m., showed Resident #77 was being administered oxygen via a nasal cannula at 2 liters per minute (lpm). During an interview on 07/10/23 at 10:32 a.m., Resident #77 stated she was to be administered three liters of oxygen continuously. A review of Resident #77's admission Record showed a diagnosis of sleep apnea, unspecified. A review of the July 2023 Medication Administration Record showed two physician orders for oxygen. The first physician order, dated 05/26/23, documented, O2 [oxygen] at 2 lpm via nasal cannula continuous for sleep apnea. The second physician order, dated 06/13/23, documented, O2 [oxygen] at 3 lpm via nasal cannula every shift. The care plan, initiated on 4/10/23, showed Resident #77 was At risk for impaired respiratory status and showed interventions to include, Administer oxygen per order. During an interview…

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 continuous communication with the dialysis center for one resident (#31) out of two residents reviewed for dialysis services. Findings included: During an interview on 07/10/23 at 10:09 a.m., Resident #31 stated he received dialysis services three days a week. A review of Resident #31's admission Record showed an admission date of 12/1/22 and diagnoses to include chronic kidney disease without heart failure, with Stage 5 chronic kidney disease, or end stage renal disease. A review of the July 2023 physician orders showed a physician order, dated 12/04/22, showed, Dialysis: May go to Dialysis on: Monday, Wednesday, Friday. A second physician order, dated 12/04/22, showed, Complete Dialysis communication form and send with Resident to dialysis center. A third physician order, dated 12/04/22, showed, Complete post communication dialysis form on return. A review of the care plan showed Resident #31 had a care plan focus, initiated on 12/5/22 and revised on 12/15/22, of Dialysis Care Plan: Renal failure 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.

Based on record review and interviews the facility failed to ensure staff administered medication with adequate indication for use and monitored the administration and effectiveness of this medication for one resident (#21) out of 28 sampled residents; and administered antihypertensive medication outside physician ordered parameters twelve out of thirteen administrations reviewed for one (#45) out of five residents observed during the task of medication administration. Findings included: 1. A review of Resident #21's admission Record showed diagnoses of insomnia unspecified, anxiety disorder, unspecified dementia with behavioral disturbance and disorganized schizophrenia. A review of medical record revealed a nursing progress note, dated 06/05/23, and showed, resident was very upset all evening, claiming devil was in my belly resident wouldn't take melatonin for sleep, (gave her pudding with melatonin in it to calm her). A review of Resident #21's June 2023 Medication Administration Record (MAR) showed no physician order for Melatonin. The June 2023 MAR showed no Melatonin 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.

Based on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed and three errors were identified for two residents (#45 and #70) of five residents observed. These errors constituted a 10% medication error rate. Findings included: 1. On 7/11/23 at 8:24 a.m., an observation of medication administration with Staff H, Licensed Practical Nurse (LPN), was conducted with Resident #45. Staff H placed an electronic blood pressure cuff on the upper portion of the resident's right arm, then removed it, placing it on the lower right forearm and obtained a blood pressure of 118/75 and a pulse of 80. Staff H returned to the medication cart and dispensed the following medications: - Atenolol 25 milligram (mg) tablet - Baclofen 10 mg tablet - Docusate Sodium 100 mg gelcap - Oxycodone/Acetaminophen 5-325 mg tablet Staff H confirmed a total of 4 tablets were dispensed, re-entered the resident's room and administered the medications. The Order Summary Report, dated…

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 record review the facility failed to maintain the kitchen in a safe and sanitary manner related to ensuring the range hood was free from dust. Findings included: Observations during the initial tour of the facility's kitchen on 6/28/21 at 10:30 AM revealed that the kitchen housed a range hood which was located over the stove and steam oven. Closer observation of the range hood revealed the light covers and piping were covered in dust particles. Closer observation of the range hood revealed the sealants had become dislodged from the seams of the range hood and was noted to be blowing back and forth over the stove and steamer. (Photographic Evidence Obtained) An interview at this time with the Certified Dietary Manager (CDM), who was present in the kitchen at the time of the initial tour revealed she was unsure as to when the range hood was last cleaned. An interview on 6/28/21 at 10:42 AM with the Maintenance Director revealed the vendor who cleans the hood is due to come tomorrow. They come every 3 months and in between visits the Maintenance…

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 interview the facility failed to provide a clean and homelike environment for 2 of 31 (#19, #27) sampled residents. Findings included: 1. Review of Resident #19's record revealed that this resident was admitted to the facility on [DATE] and has diagnosis that included hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side and receives nutrition via tube feed. Observations of Resident #19 on 6/28/21 at 12:05 PM revealed that the resident was lying in her bed with the head of her bed elevated and her tube feeding hanging. Inspection of the residents room surrounding her bed revealed that there was a puddle of a light brown substance pooled on the floor located in the area beneath the tube feed formula, on the tube feed pole and on the floor mat next to the bed. (Photgraphic Evidence Obtained) Observations of Resident #19 on 6/29/21 at 10:03 AM revealed that the resident was lying in her bed with the head of her bed elevated and her tube…

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, observation, and policy review the facility failed to ensure a grievance was acted upon for one resident (#46) of fifteen sampled residents. Findings included: Resident #46 was admitted to the facility with a diagnosis of perforated intestine, according to the face sheet in the admission record. A review of the Minimum Data Set (MDS) assessment in the medical record, dated 5/28/21, reflected a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #46's cognition was intact. On 6/28/21 at 10:39 AM an interview was conducted with Resident #46. She said the man that lives next door [Resident #16] is verbally abusive to the staff. He is obnoxious. He screams. He is vulgar. He wanders everywhere. She said he has not come in her room or spoke to her, but it's really a bother, and the staff aren't allowed to do anything about it. She has reported it to the ARNP [Advanced Registered Nurse Practitioner] and the DON [Director of Nursing]. Resident #46 also said that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and policy review the facility failed to ensure the necessary information was provided to the receiving facility during a transfer to the hospital for one resident (#16) of three residents sampled for a hospital transfer. Findings included: Resident #16 was admitted to the facility with diagnoses of schizophrenia and bipolar disorder, according to the face sheet in the admission record. A review of the Minimum Data Set (MDS) assessment dated [DATE], reflected a Brief Interview for Mental Status (BIMS) of 15, indicating an intact cognition. Further review of the assessment revealed the following information: Section G, functional status, locomotion on unit was marked supervision of one person. Section E, behaviors, verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) was marked 'behavior of this type occurred daily'. Other behavioral symptoms not directed toward others (e.g. physical symptoms such as hitting 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to obtain documentation from a hospice provider to ensure coordination of services for 1 of 2 (#17) residents receiving hospice services. Findings included: Review of the facility policy titled Hospice Care with an effective date of 11/30/14, and a revision date of 9/20/17 revealed the following: To ensure continuity of care between the center and the hospice provider, the Director of Nursing will designate a clinical member of the interdisciplinary team to work with the hospice including the following: Coordination of care plan process between the hospice and the center Communication with hospice representatives, hospice medical director and the patient/residence attending physician to ensure coordination of care. Ensure the following information is obtained from the Hospice: Most recent hospice plan of care A review of the Minimum Data Set (MDS) dated [DATE] indicates that Resident #17 is currently receiving hospice care. Review of the current 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 interviews, record review, and review of facility policy, the facility failed to provide care and services consistent with professional standards of practice related to communication with the dialysis facility, as evidenced by a failure of monitoring resident status pre and post dialysis for one resident (#25) of four residents receiving dialysis. Findings included: A review of the medical record for Resident #25 revealed diagnoses that included type II diabetes, end stage renal disease, and dependence on renal dialysis, and anemia. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review physician's orders revealed: -An order dated 2/23/2021 for Hemodialysis M/W/F (Monday, Wednesday, Friday) with pick up at 9:30 a.m., dialysis time 10:30 a.m. -An order dated 2/23/21 to assess dialysis port site on the left upper chest for bruising/bleeding/symptoms of infection. A review of Resident # 25's care plan…

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 interview it was determined that the facility failed to provide Quality Assessment and Assurance (QAA) practice that demonstrated implementation of an effective action plan to correct the previously cited deficient practice at F584 related to providing a clean and sanitary environment for one resident (#17) out of three residents who received nutrition through enteral feeding. Findings included: A review of the facility policy titled, Performance Improvement Committee, effective 11/30/2014 and revised 8/19/2020, identified that The committee will assure QAPI activities have indicators and standards/thresholds for evaluation, that appropriate actions are implemented, and that such correction has been evaluated by subsequent monitoring. Review of the admission Record for Resident #17 revealed the resident was admitted to the facility on [DATE] with readmission on [DATE] and the diagnoses included personal history of transient ischemic attack and cerebral infarction,…

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.