Mountain View Health Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure one of one resident (R) (R44) reviewed for respiratory services received oxygen as ordered by the physician out of a total sample of 37 residents. This failure placed the resident at risk of receiving insufficient oxygen to meet the assessed respiratory need. Findings include: Review of the facility's policy titled, dated October 2010, stated Review the physician's orders or facility protocol for oxygen administration .Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: .(3) The rate of oxygen flow, route, and rationale. Review of R44's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R44 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled Bed Safety and Bed Rails, the facility failed to ensure three of 37 sampled residents (R) (R78, R38, and R41) were appropriate for the use of quarter side rails on their beds. This failure had the potential to place R38 and R41 at risk for injury related to potentially unnecessary side rail use. Findings include: Review of the facility policy titled Bed Safety and Bed Rails, dated 2001, indicated . Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met.prior to the instillation or use of a side or bed rail, alternatives to use of side or bed rails are attempted. Alternatives may include. roll guard. foam bumpers. lowering the bed. use of a concave mattress to reduce rolling off the bed.If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of the facility's policies titled Administering Medications and Hypertension- Clinical Protocol, the facility failed to ensure two of five residents (R) (R23 and R35) reviewed for unnecessary medications were free from significant medication errors. Specifically, when R23 did not receive glargine (insulin medication) on four occasions, Novolog (insulin medication) on five occasions, and hydralazine (blood pressure medication) on three occasions, and when blood pressure medication was not held according to the physician's order for a low blood pressure for R35. These failures had the potential to place R23 and R35 at risk for medical complications and a diminished quality of life. Findings include: Review of the facility's policy titled Administering Medications, revised 4/1/2019, provided by the facility, revealed Medications are administered in accordance with prescriber orders . Review of the facility's policy titled, Hypertension- Clinical Protocol, revised…

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, review of manufacturer package insert, and review of the facility policies titled Medication Storage in the Facility and Administering Medications, the facility failed to discard an expired insulin vial for one of three medication carts and failed to monitor the temperatures of one of one medication storage refrigerators. The deficient practice could result in decreased or altered effectiveness of the medication and worsening of the resident's symptoms. Findings include: Review of the facility's policy titled Medication Storage in the Facility, dated [DATE], revealed Medications requiring refrigeration or temperatures between 36 degrees and 46 degrees Fahrenheit (F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Review of the facility's policy titled Administering Medications, revised on [DATE], revealed The expiration/beyond use date on the medication label is checked prior to administering. Review of the Novolog package insert titled…

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, resident and staff interviews, record review, recipe review, and review of the facility's policies titled Standardized Recipes and Preparing Pureed Foods, the facility failed to ensure recipes were followed to ensure the food was palatable for four of 37 sampled residents (R) (R60, R56, R45, and R25). This failure had the potential to place R60, R56, R45, and R25 at risk of decreased oral intake and weight loss. Findings include: Review of the facility's policy titled Standardized Recipes, dated 3/2025, revealed 1. Recipes contain the following: a. Ingredients and amounts required for the recipe. b. Preparation method. c. Other preparation information .2. Dietary Manager will provide recipes for the foods to be prepared. Review of the facility's policy titled, Preparing Pureed Foods, dated 3/2025, revealed 1. Prepare food following the recipe for the regular texture foods. Pureed food should have the same flavor as their regular texture counterpart. 2. Specific pureed recipes included in the menu system may be used. 3. If the specific pureed recipe is not…

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, staff interviews, and review of the facility's policy titled Administering Medications, the facility failed to ensure infection control was maintained for one of three residents (R) (R68) observed during medication administration. Specifically, the facility failed to ensure medications were not touched with bare hands or dropped during medication administration, which increased the risk for cross-contamination and infection. Findings include: Review of the facility's policy titled Administering Medications, dated 4/1/2019, included, Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. During observation and interview on 6/25/2025 at 9:23 am of medication administration with Licensed Practical Nurse (LPN) 3, the LPN opened multiple pill packs of medications for R68 and poured them into the pill cup. Two of the pills dropped on top of the medication cart. LPN3 picked up the unknown pills with her bare hand and placed…

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 interviews, and review of the facility's policies titled, ''Date Marking for Food Safety'' and ''Food Safety Requirements,'' the facility failed to date, label, and/or cover food, and discard food with expired expiration dates or signs of spoilage stored in the facility's kitchen and the facility's ''Diet Room.'' Additionally, the facility failed to serve [NAME] stew from the kitchen's tray line at an internal temperature of 135 degrees Fahrenheit (F) or higher. This failure had the potential to affect all 67 residents who consumed food prepared from the facility's kitchen. Findings include: Review of the facility's undated policy titled, ''Date Marking for Food Safety,'' indicated, ''Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for food safety . 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall 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 observation, resident and staff interview, record review, and review of the facility's policies titled, ''Resident Dining, and Promoting/Maintaining Resident Dignity the facility failed to provide care and services in a manner to ensure a dignified existence for six of six residents (R) (R64, R118, R11, R50, R31, and R47) reviewed for dignity. Specifically, the facility failed to promote a dignified dining experience by serving desserts and beverages in disposable bowls and cups and serving disposable plastic eating utensils at meals for four of four residents (R64, R118, R11, and R50) reviewed for dignity while dining. Additionally, the facility failed to assist and encourage R31 and R47 to dress in clothes other than a hospital gown. Findings include: 1. Review of the facility's undated policy titled, ''Resident Dining,'' indicated, ''Resident dining should take place in an environment and in a manner that maintains or enhances each resident's dignity and respects his or her individuality . Provide…

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 staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect and Exploitation, the facility failed to protect the resident's right to be free from verbal and sexual abuse for one of five Residents (R) R52 by R219. Specifically, the facility failed to intervene after multiple incidents of verbal sexual abuse towards female residents by R219, that resulted in physical sexual touching towards R52, who was a target of prior verbal abuse by R219. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation dated 2017, stated Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Residents must not be subject to abuse by anyone, including, but not limited to; .other residents .5. Prevention of Abuse, Neglect, and Exploitation-The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents: .b. Observe resident behavior and their reaction to other residents, roommates, and tablemates .m. Assess,…

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

Based on observations, record review, staff interviews, and review of facility's policy titled, ''Restraint Free Environment Policy,'' the facility failed to ensure one of one Resident (R) (R4) reviewed for physical restraints was free from an unnecessary physical restraint. Specifically, R4 did not have the necessary consent or an assessment in place for seatbelt to be applied and used with use of wheelchair. Findings include: The facility's ''Restraint Free Environment Policy'' dated 2/2023 read, ''It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints;'' and ''3.Behavioral interventions should be used and exhausted prior to the application of a physical restraint;'' and ''5.Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints,…

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 reviews, staff interviews, and review of the facility's policy titled, Abuse, Neglect, and Exploitation,, the facility failed to ensure that an allegation of verbal abuse was reported immediately, but no later than two hours of the alleged verbal abuse for two of six Residents (R) (R31, and R218) reviewed for resident-to-resident abuse. Findings include: Review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated 2017, stated .13. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment .are reported immediately, but not later than 2 hours after the allegation is made .to other officials (including State Survey Agency and adult protected services where the state law provides for jurisdiction in long-term care facilities) in accordance with State law. Review of R218's Departmental Notes, dated 9/22/2023 at 11:03 pm, provided by the facility, stated At or around 1800 [6:00 pm] it was reported to this nurse by hall…

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 reviews, staff interview, and review of the facility's policy titled, Abuse, Neglect, and Exploitation the facility failed to ensure a thorough and complete investigation was conducted following a resident-to-resident altercation, involving two of six Residents (R) (R7 and R9) reviewed for alleged abuse. This failure not to conduct a thorough abuse investigation had the potential to result in other residents not being identified as potential victims of abuse. Findings Include: Review of the facility's policy titled Abuse, Neglect, and Exploitation dated 2017, stated .7. Investigation of Alleged Abuse, Neglect, and Exploitation- When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include .c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area . Review 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.

Based on record reviews, staff interviews, and review of the facility's policy titled, ''Comprehensive Care Plans,'' the facility failed to ensure two of 26 Residents (R) (R11 and R219) reviewed for care plans had a complete and comprehensive care plan. Specifically, R11 care plans did not address the resident's prescribed psychotropic medication problem area and/or interventions. Additionally, R219 known inappropriate sexual behaviors was not identified on the resident's care plan. Findings include: Review of the facility's undated policy titled, ''Comprehensive Care Plans,'' indicated, ''Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.'' 1. Review of R11's undated ''Face sheet'' located in the ''Basic Information'' tab of the Electronic Medical Record (EMR) revealed R11 admitted with a…

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

Based on observations, record review, staff and resident interviews, and review of the facility's policy titled, ''Activities of Daily Living (ADLs) Policy,'' the facility failed to ensure one of three Residents(R) (R56) reviewed for Activities of Daily Living (ADLs) received ADL assistance according to his plan of care. Specifically, staff did not ensure the resident received consistent nail care. Findings include: The facility's ''Activities of Daily Living (ADLs) Policy'' dated 10/2022 read, in pertinent part, ''The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable;'' and ''Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care.'' R56's ''Face Sheet'' dated 10/26/2023 and found in the Electronic Medical Record (EMR) under the ''Basic Information'' tab, indicated R56 was admitted with diagnoses including cardiomyopathy and chronic pain. R56's…

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

Based on observations, record reviews, staff interviews, and review of the facility's policy titled, ''Activities Policy the facility failed to ensure three of four Residents (R) (R17, R31, and R47) reviewed for activities were provided with an activities program to meet their individual needs. Specifically, staff did not ensure residents who were room and/or bed bound were provided with consistent activities. Findings include: Review of the facility's policy titled, ''Activities Policy dated 10/2022 read, in pertinent part, ''It is the policy of the facility to provide an ongoing program to support residents in their choices of activities based on their comprehensive assessment, care plan, and preferences. Facility sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and spiritual well-being. 1. Review of R17's ''Face Sheet'' dated 10/26/2023 and found in the Electronic Medical Record (EMR) under the ''Basic Information'' tab, indicated the R17 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.

Based on observations, record review, staff interviews, and review of the facility's policy titled, ''Catheter Care Policy,'' the facility failed to ensure consistent infection control for one of three Residents (R) (R56) reviewed for urinary catheters. Specifically, staff failed to ensure sanitary maintenance of the resident's catheter bag and tubing. Findings include: The facility's ''Catheter Care Policy'' dated 10/2022 read, in pertinent part, ''It is the policy of the facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.'' R56's ''Face Sheet'' dated 10/26/2023 and found in the Electronic Medical Record (EMR) under the ''Basic Information'' tab, indicated the R56 admitted to the facility with diagnoses including cardiomyopathy and obstructive uropathy. R56's Significant Change Minimum Data Set (MDS) assessment, with an Assessment Reference (ARD) date of 8/22/2023 and found in the EMR under the ''MDS'' tab, indicated a Brief Interview for Mental Status (BIMS) score…

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, staff interviews, record review, and review of the facility's policy titled, ''Food Safety Requirements,'' the facility failed to maintain and ensure the kitchen's three door reach-in freezer operated at zero degrees Fahrenheit (F) or below for safe food storage for one of two freezers used to store food. Findings include: Review of the facility's undated policy entitled, ''Food Safety Requirements,'' indicated, ''Refrigerated storage - foods that require refrigeration shall be refrigerated immediately upon receipt or placed in the freezer, whichever is applicable. Practices to maintain safe refrigerated storage include i. Monitoring food temperatures and functioning of refrigeration equipment daily and at routine intervals during all hours of operation .'' Review of the facility's ''Maintenance Log'' revealed an entry dated 8/1/2023 which specified to measure gaskets for all coolers in kitchen and get replaced. The entry was not marked as completed. Review of the October 2023 ''Temperature Log'' for the kitchen's three door reach-in freezer revealed no…

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 policy review, the facility failed to maintain sanitary conditions of the kitchen to prevent cross contamination by ensuring the kitchen surfaces of shelving, ceiling, floors, and appliances were easily cleanable. This deficient practice had the potential to affect 60 of 61 residents who received meals prepared in the facility's only kitchen. Findings include: Review of the Kitchen Environment policy, revised 9/17, revealed All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. Review of the United States Federal Food & Drug Food Code 2017: http://www.fda.gov/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/, revealed: 4-101.11 Characteristics. Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: P (A) Safe; P (B) Durable, corrosion-resistant, and nonabsorbent. 4-101.19 Nonfood-Contact Surfaces.…

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, review of maintenance records, interviews and policy review, the facility failed to ensure that it was maintained in a safe, clean, and comfortable home-like environment in six resident rooms (A2, A3, A5, A6, C11, C13). The census was 62. Findings include: Review of the undated policy titled Work Orders revealed the facility uses a clip board at the nursing station to document environmental problems. Policy Interpretation and Implementation number 1. In order to establish a priority of maintenance service, work orders must be fille out and forwarded to the Maintenance Director. Number 4. Work order requests should be placed in the appropriate basket at the nurse's station. Work orders are picked up daily. Number 5. Emergency requests will be given priority in making necessary repairs. Observation on 9/6/22 at 2:54 p.m. in room A2 revealed a hole under the window approximately one foot long by three inches high; the bedside table of bed-1 had large sections of paint/finish missing on the…

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

Based on record review and interviews, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) were completed with the estimated potential liability for continued services not covered by Medicare, for two of three residents (R) (R#18 and R#17) who were discharged off Medicare Part A services and remained in the facility. Findings include: A policy for beneficiary notices was requested but not provided during the survey. Review of a facility-completed worksheet Beneficiary Notice-Residents discharged Within the Last Six Months, revealed that R#18 and R#17 were discharged from a Medicare-covered Part A stay and remained in the facility after their last covered day. 1. Review of R#18 SNFABN dated 3/26/22, revealed that the effective date of coverage for Skilled Part A Nursing Services/Advanced Physical Therapies would end as of 3/29/22. The notice of a cut or change in services did not describe the estimated liability to the resident if services were continued. The form was verbally consented per phone conversation by resident's representative…

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, interview, and policy review, the facility failed to ensure bilateral side rails were not used as a restraint for one resident (R) R#8 reviewed for physical restraints. The sample size was 31. Findings include: Review of the policy titled, Use of Restraints, revised April 2017, revealed restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. Policy interpretation and implementation. Number 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Number 4. Practices that inappropriately utilize equipment to prevent 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.

Based on observations, record review, interviews, and policy review, the facility failed to ensure the medication error rate was not greater than five percent (5%). A total of 29 medication opportunities were observed, and there were two errors for one of five residents (R) (R#23), by one of two nurses observed giving medications, for a medication error rate of 6.9%. The sample size was 31. Findings include: Review of the undated policy titled Medication Administration revealed .Medications are administered as prescribed .using the six rights [right patient, right drug, right route, right times and right documentation] .Only the person who prepares the medication may administer it . Review of the undated policy titled ORAL INHALATION ADMININSTRATION revealed .To allow for safe, accurate, and effective administration of medication using .nebulizer .instruct the resident to take a deep breath .repeat the pattern throughout treatment .remain with resident throughout treatment .Approximately five minutes after treatment begins .obtain resident's pulse .Monitor for medication 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 record review, interviews, and policy review, the facility failed to maintain accurate medical records for two of five residents (R) (R#2 and R#45) reviewed regarding code status to ensure code status was consistent throughout the electronic medical record (EMR). The facility's deficient practice increased R#2 and R#45's risk for incorrect life sustaining treatment to be provided by the facility's clinical staff. Findings include: Review of the policy titled Advance Directive, revised 12/16, revealed .Information about whether or not a resident has executed an advance directive shall be displayed prominently in the medical record .Do Not Resuscitate-[DNR] indicates that, in the case of respiratory or cardiac failure .has directed that no cardiopulmonary resuscitation .or other life-sustaining treatments .are to be used . 1. Review of R#2's electronic medical record (EMR) revealed he was admitted to the facility on [DATE], with diagnose to include chronic obstructive pulmonary disease, diabetes, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to follow and implement the antibiotic stewardship program (ASP) by ensuring the appropriate use of antibiotics for two of three residents (R) (R#24 and R#63), who received antibiotics for a urinary tract infection (UTI) without having met the criteria for the use of an antibiotic. Findings include: Review of the policy titled, Infection Prevention/Antibiotic Stewardship Guide, dated 8/28/22, revealed the primary mission of antibiotic stewardship is to achieve the best possible improved antimicrobial resident outcomes by ensuring the optimal selection, dose, and duration of antimicrobials for treatment or prevention while minimizing the impact of possible side effects and antimicrobial resistance. Antibiotics are frequently over or inappropriately prescribed, a concerted effort to decrease or eliminate inappropriate use can make a big impact on resident safety and reduction of adverse events. Leadership will communicate annually 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.