Power County Skilled Nursing Facility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including dementia and hypertension. Resident #1's Quarterly MDS assessment, dated 1/20/25 was transmitted to the CMS database. but her Quarterly MDS assessment with ARD of 4/22/25 was not transmitted, it was 23 days overdue. 6. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including Huntington's disease (a neurological disorder that affects a person's movements, thinking ability, and mental health, with symptoms often including chorea, which are rapid, involuntary movements of the limbs and face). Resident #6's Quarterly MDS assessment, dated 1/23/25 was transmitted to CMS database, but her Quarterly MDS assessment with ARD of 4/25/25 was not completed, it was 20 days overdue. 7. Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including dementia. Resident #13's Annual MDS assessment dated [DATE] was transmitted to CMS data base, but her Quarterly MDS assessment with ARD 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 record review, policy review, and staff interview, it was determined the facility failed to ensure person-centered comprehensive care plans were developed and implemented to address residents' needs. This was true for 6 of 12 residents (#1, #2, #9, #11, #15, and #120) whose care plans were reviewed. This failure created the potential for harm should residents receive inappropriate or inadequate care. Findings include: The facility's Care Plans policy, dated 1/1/24 documented the care plan for each resident at the facility would be individualized according to each resident's needs or wants as much as possible. 1. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including dementia and hypertension. Resident #1 physician's order documented the following: - Risperidone (antipsychotic) 0.5 mg by mouth two times a day, ordered 1/24/25 - lorazepam (antianxiety) 0.5 mg by mouth at bedtime related to anxiety disorder, ordered 1/17/25. - Monitor and document her behavior: . yelling 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.

Based on staff interview, it was determined the facility failed to ensure there was a qualified dietary manager with required competencies and skills. This deficient practice had the potential to affect all the 20 residents residing in the facility who received food from the kitchen. Findings include: On 5/29/25 at 12:38 PM, the DM stated she started in the facility working as a dietary manager about five weeks ago. She stated she did not have the certification yet, but she registered herself to take the classes to become a certified dietary manager. The DM stated she was being supervised by their Registered Dietitian and is in constant communication with him/her. On 5/29/25 at 2:13 PM, the DON stated the Dietary Manager was not certified, but she is being supervised by their Registered Dietitian. When asked if the facility had a full-time dietitian, the DON stated No. The Registered Dietitian visits the facility at least once a week

Based on observation and staff interview, it was determined the facility failed to ensure kitchen staff wear their hair restraints appropriately and discard outdated food items in the kitchen. These deficiencies had the potential to affect the 20 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food borne illnesses. Finding include: 1. The FDA Food Code 2022, Section 1-402.11 Effectiveness. (Hair Restraints) states except as provided in paragraph (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-serve and single-use articles. On 5/29/25 at 12:10 PM, the Dietary Aide #1 was observed in the kitchen with her hair not completely restrained to cover her bangs and the hair around her face. On 5/29/25 at 2:24…

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 facility document review, and staff interview, it was determined the facility failed to ensure the Quality Assessment and Assurance (QAA) committee took actions to identify and resolve systemic problems. This failure affected 20 of 20 residents residing in the facility. The deficient practice resulted in failure to report resident assessments and comprehensive care planning which had the potential for adverse outcomes when residents' needs were not identified. Findings include: The facility's QAPI plan revised on 1/2/24, directed the QAPI committee to do the following: - Include all departments and employees in the plan. - Maintain a comprehensive, effective system for monitoring and evaluating. - Assure patient care is provided at an optimal level. - Focus on improving systems and processes using a systemic approach. - Increase communication and transparency of corrective action to improve processes and systems facility wide. - Develop criteria for identifying causes with potential risks and correcting the problem. - Protecting financial resources The facility's Long-Term…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure residents' assessments accurately reflect their status. This was true 4 of 12 residents (#2, #11, #16, and #17) whose bedrails were assesed as a restraint. This created the risk for harm when residents' were not accurately assessed. Findings include: 1. Resident #17 was admitted to the facility on [DATE], with a diagnosis of adult failure to thrive (a decline in overall health and functional abilities). Resident #17's Quarterly MDS assessment dated [DATE], documented he used his bed rails daily under section P- Restraints Resident #17's care plan dated 8/19/24, documented his bed rails were used for mobility. It also documented that he has been informed of the risk of using side rails. A bed rail assessment dated [DATE], documented the bed rails would be used for improved independence. 2. Resident #11 was admitted to the facility on [DATE], with multiple diagnoses including bipolar disorder, anxiety, and major depressive…

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 and staff interview, it was determined the facility failed to ensure resident's right to privacy was maintained during cares. This was true for 1 of 1 resident (Resident #6) observed during cares. This deficient practice placed Resident #6 to experience embarrassment and psychosocial distress if her body was exposed to others unnecessarily. Findings include: The SOM Appendix PP, dated 4/25/25, documented each resident has the right to privacy and confidentiality for all aspects of care and services. A nursing home resident has the right to personal privacy or not only his or her own physical body, but of his or her personal space, including accommodations and personal care. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including Huntington's disease (a neurological disorder that affects a person's movements, thinking ability, and mental health, with symptoms often including chorea, which are rapid, involuntary movements of the limbs and face). On 5/28/25 at 2:08…

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, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated as needed. This was true for 1 of 12 residents (Resident #16) whose care plan was reviewed. This created the potential for Resident #16 to experience harm if cares and services were not provided appropriately due to inaccurate information in his care plan. Findings include: Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease and apraxia (a disorder of the brain and nervous system in which a person is unable to perform tasks or movements when asked) following stroke. The facility's Care Plans policy, dated 1/1/24 documented residents' care plans will be reviewed quarterly, annually, and with change of status to ensure that they are current for the residents' care. An I&A report documented the following: - On 3/15/25 at 4:10 PM, Resident #16 had an unwitnessed fall with no injury. The I&A documented 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 record review, and staff and resident interview, it was determined the facility failed to ensure professional standards of care were followed for 1 of 12 residents (Resident #69) reviewed for quality of care. Resident #69's physician's order was to restrict his fluid intake to 1,500 ml was not followed. This deficient practice had the potential to adversely affect or harm Resident #69 when his fluid intake was not restricted or monitored. Findings include: Resident #69 was admitted to the facility on [DATE], with multiple diagnoses including Syndrome of Inappropriate Secretion of Antidiuretic Hormone (a condition in which the body retain too much water and commonly leads to hyponatremia which is low levels of sodium in the blood). A physician's order, dated 12/9/23, documented Resident #69 was on 1,500 ml of fluid restriction. A care plan initiated on 11/26/24, documented Resident #69 was on fluid restriction of 1,500 ml, on which the kitchen would supply 1,200 ml and leaves him with 300 ml of other…

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 3. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including dementia and hypertension. On 5/28/25 at 10:40 AM, Resident #1 was observed in bed with one side rail in raised position. Resident #1's Side Rails Assessment form, dated 10/10/22, documented the following assessment/questions and next to it was Yes and No column: 1. Will side rails be used to improve mobility? 2. Will side rails be used to improve independence? 3. Will resident be able to use the bed controls? 4. Will the side rails in good working order? 5. Are the side rails installed correctly and safely? 6. Does the resident request the side rails are up when they are in bed? 7. Is there any potential or risk of the resident their extremities caught in the side rails? 8. They have been assessed and are safe to be used with this resident? 9. If side rails will be used, has resident and family been informed of risks of use such as upper injuries from falls and lim[bs] being caught in rails? Assessment/question #1, #2, #3,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure pharmacist recommendation was addressed by the physician. This was true for 1 of 5 residents (Resident #2) whose medications were reviewed. This failure created the potential for Resident #2 to receive medications that were unnecessary, ineffective, or used in excessive duration. Findings include: Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including dementia, urinary tract infection and chronic pain. A Physician Action Report/Pharmacist Report form, included a section for the pharmacist to write his/her detailed description of irregularity and recommendations and a section for the physician to make a comment regarding the pharmacist recommendation. Resident #2's Physician Action Report/ Pharmacist Report form, dated 4/30/25, documented the Pharmacist wrote Document citalopram dose. The physician's section had the physician signature, but the physician did not indicate the dosage 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 record review and staff interview it was determined the facility failed to ensure residents were properly assessed for anticoagulants. This was true for 1 of 5 residents (Resident #9) whose records were reviewed for unnecessary medications. This failed practice created the potential for harm when Resident #9 was not assessed for bleeding. Findings include: Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including non-surgical wound, history of falls, and right artificial hip joint. A physician's order dated 12/30/24, documented Apixaban (a blood thinner) oral tablet 5 mg give 1 tablet by mouth two times a day for deep [NAME] thrombosis (DVT) prevention. A physician's order dated 12/21/24, documented Aspirin oral tablet 81 mg give 1 tablet by mouth one time a day for DVT prevention. Resident #9's record did not include monitoring for bruising or bleeding. On 5/29/25 at 12:40 PM, the DON stated Resident #9's record did not include monitoring for adverse outcomes or monitors 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 review of Incidents and Accidents reports, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This affected 2 of 2 residents (#11 and #14) whose records were reviewed for medication error. This failure placed Resident #11 at risk for hypoglycemic episodes and even death and Resident #14 to experienced uncontrolled pain. Findings include: 1. Resident #11 was admitted to the facility on [DATE], with multiple diagnoses including Diabetes and restless leg syndrome. An I&A report dated 3/2/25, documented Resident #11 was given the incorrect insulin by Med-Tech #1. The incident report also documented the physician was notified and the following order was given: Check blood sugar every 30 minutes for 4 hours. Give soda, candy or juice to keep blood sugar above 150. If blood sugar drops below 80 send to emergency room. The I&A report documented the following blood sugar levels along with the following interventions: - At 9:10 PM her blood…

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

Based on observation and staff interview, it was determined the facility failed to ensure medications available for residents were removed from the medication cart on expiration date. This was true for 1 of 1 medication carts inspected. This failure created the potential for residents to receive expired medications with decreased efficacy. Findings include: On 5/30/25 at 9:45 AM, a Novolog insulin pen was in the medication cart with the open date of 4/26/25 and expiration date of 5/24/25. On 5/30/25 at 9:47 AM, LPN #3 stated the insulin pen was expired. She also stated she had administered the expired insulin that morning to Resident #11.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, and staff interview, it was determined the facility failed to ensure rehabilitative services were provided. This was true for 1 of 1 resident (Resident #14) whose records were reviewed for rehabilitative services. This failure created the potential for poor quality of life and declined ability to perform activities of daily living. Findings Include: Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including age-related osteoporosis and pathological fractures. A physician's order dated March 2025, documented Resident #14 was to be evaluated and treated for a wheelchair. On 5/27/25 at 11:22 AM, Resident #14 stated she has been waiting for physical therapy to get her a wheelchair that fits appropriately but they keep telling her its being ordered. On 5/27/25 at 11:28AM, Resident #14 was observed sitting in her wheelchair. The hand rest of the wheelchair was observed at the same level of Resident #14's chest. Making it difficult to rest her arms on the hand…

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

Based on observation and staff interview it was determined the facility failed to ensure appropriate infection control measures were maintained. This was true for 1 of 1 resident (Resident #119) when LPN #3 failed to apply personal protective equipment while administering a nasal medication to Resident #119 who tested positive for methicillin-resistant staphylococcus aureus (MRSA - a bacterial infection). This failed practice created the potential for adverse outcomes including infection due to cross contamination. Findings include: On 5/30/25 at 9:40 AM, during a medication administration observation LPN #3 was observed performing hand hygiene and entering Resident #119's room to administer medication. Resident #119 was on enhanced barrier precautions due to testing positive for MRSA via a nasal swab. LPN #3 applied gloves and administered oral medication. On completion of oral medication LPN #3 then administered his nasal medication. LPN #3 was not observed putting on a mask or gown prior to administration of his nasal medication. On 5/30/25 at 10:07 AM, the DON stated LPN #3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure pneumococcal immunizations were offered and administered with the current CDC recommendation. This was true for 1 of 5 residents (Resident #9) reviewed for pneumococcal immunizations. This failure increased Resident #9's risk for contacting pneumonia with potential negative outcome. The CDC website's article titled Pneumococcal Vaccine Recommendation, dated 10/26/24 and accessed on 6/2/25, documented for routine vaccination, administer PCV15, PCV20, or PCV21 for all adults 50 years or older. - Who have never received any pneumococcal conjugate vaccine. - Whose previous vaccination history was unknown. If PCV 15 is used, administer a dose of PPSV23 one year later. Their vaccination is complete. If PCV20 or PCV 21 was used, a dose of PPSV 23 is not indicated. Regardless of which vaccine was used (PCV20 or PCV21), their pneumococcal vaccinations are complete. Resident #9, age [AGE] years old 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 resident and staff interview, review of grievances, and record review, it was determined the facility failed to ensure: - Residents were notified individually or through postings in the facility of how to file a grievance. - A functional process for filing a grievance anonymously was in place. - Residents received written responses to grievances which included the date the grievance was received, steps taken to investigate the grievance, and corrective action taken to resolve the grievance. This was true for 1 of 20 residents (Resident #3) interviewed regarding grievances and had the potential to impact all residents in the facility who may want to file a grievance. These failures impeded the ability of residents to file a grievance and to receive a resolution. The findings include: Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including dementia and anxiety. Resident #3's care plan documented she had a diagnosis of dementia, but was alert and oriented. On 7/8/24 at 11:25…

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 interview, it was determined that the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of food and nutrition services, including resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population. These deficiencies had the potential to affect the 20 residents requiring medical nutrition therapy, initial nutritional assessments, and appropriate supplementation and dietary interventions. Findings include: On 7/10/24 at 11:30 AM, the documentation of the DM certification was requested. No certification was provided. On 7/10/24 at 2:50 PM, both the RD and DM stated, for about 18-months, they have shared the responsibilities of resident nutritional assessments, interventions, progress notes, and care plan development and updates. They stated the Food Services Manager has an engineering degree and does not have a food and nutrition degree. On 7/11/24 at 12:20 PM, the DM stated she worked as a kitchen aide for one year before she was hired as a DM.…

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

Based on observation and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, appropriate hand hygiene was performed, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 20 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: 1. The FDA Food Code Section 2-301.14 When to Wash. Food employees shall clean their hands and exposed portions of their arms as specified under paragraph 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After coughing, sneezing, using a handkerchief or disposable tissue, using tobacco products, eating, or drinking; . E) After handling soiled…

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 policy review and staff interview, it was determined the facility failed to meet the minimum member requirement of a quality assurance and performance improvement (QAPI) committee. This failure placed all residents at risk of not receiving quality care. Findings include: On 7/11/24 at 3:42 PM, the QAPI monthly meeting minutes for the prior six months were reviewed and noted the Medical Director had not attended the QAPI meetings. On 7/11/24 at 3:45 PM, the DON stated the Medical Director had not attended the QAPI committee meetings and she was not aware he needed to be at the meetings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, it was determined that the facility failed to treat each resident with respect and dignity that promoted enhancement of his/her quality of life and dining experience. This was true for 2 of 13 residents (Resident #8 and Resident #9) who were observed eating in the dining room. The findings include: The following residents did not receive their meal trays or assistance during meal time in a timely manner: Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including hypertensive heart disease, hypothyroidism, and type 1 diabetes. On 7/8/24 at 12:04 PM, Resident #8 was observed sitting with her meal tray untouched. On 7/8/24 at 12:15 PM, it was observed that facility staff began assisting Resident #8 with eating her meal. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including hypertension and mild cognitive impairment. On 7/8/24 at 12:10 PM, Resident #9 was observed sitting at a dining room table…

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 policy review, observation, record review, and staff interview, it was determined the facility failed to ensure whether a resident had the ability to self-administer medications for 1 of 1 resident (Resident #14), reviewed for self-administration of medications. This failure created the potential for adverse effects if medications were self-administered inappropriately by the resident. Findings include: The facility's Self-Administration of Medication policy, dated 4/21/2014, stated, If the resident requests to self-administer their medications the following criteria and procedures will need to be met: - The charge nurse will do a basic evaluation of the resident's ability to self-administer medication, by filling out an evaluation. - The IDT will review the evaluation and determine the safety of the resident to self-administer medications. - If approved by the IDT a physician's order will be obtained. - The charge nurse will instruct the resident on what each medication is, why they are taking them,…

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, policy review, and staff interview, it was determined the facility failed to ensure a notices of transfer was provided to the State Long Term Care Ombudsman when transferred to the hospital. This was true for 1 of 1 resident (Resident #8) whose record was reviewed for hospital transfer. This deficient practice had the potential for harm if residents were not aware of or able to exercise their rights. Findings include: The facility's Transfer and Discharge policy, dated 10/01/19, documented: - When a resident is temporarily transferred to an acute care facility, a notice of transfer must be provided to the State Ombudsman. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including hypertensive heart disease, hypothyroidism, and diabetes. An MDS tracking record documented Resident #8 was discharged on 4/23/24, with an anticipated return, and readmitted to the facility on [DATE]. A hospital admission Summary documented she was hospitalized…

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 staff interview, record review, and policy review, it was determined the facility failed to ensure an annual comprehensive MDS assessment was completed prior to the required completion date. This was true for 1 of 4 residents (Resident #4), whose records were reviewed for MDS accuracy. The deficient practice placed Resident #4 at risk of adverse outcomes if her preferences, goals, health status, and needs were not identified in the comprehensive MDS assessment. This failure created the potential for harm if Resident #4's care was not provided due to a delay in completion of the comprehensive MDS assessment. Findings include: The facility's Minimum Data Set policy, revised 12/15/18, documented a comprehensive assessment will be completed for Medicare recipients, at admission and annually. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including shortness of breath, gastroesophageal reflux disease, and diabetes. A review of the resident's MDS history and Final Validation…

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 staff interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans. This was true for 5 of 13 residents (#1, #3, #6, #14, and #17) whose care plans were reviewed. These failures placed residents at risk of negative outcomes if services were not provided, or provided incorrectly, due to lack of information in their care plan. Findings include: The facility's Care Plans policy, dated 1/1/24, documented care plans will be reviewed quarterly, annually, and with change of status to ensure that they are current for the resident's care. 1. Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including dementia and COPD (a group of lung conditions that make it difficult to breathe). Resident #14's care plan, dated 10/30/23, documented she was to wear oxygen at 2 Liters/minute at all times due to her COPD diagnosis. On 7/10/24 at 7:35 AM, Resident #14 was observed in the dining room without the nasal…

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, policy review, and staff interview, it was determined the facility failed to ensure resident care plans were revised to reflect current needs and interventions. This was true for 3 of 13 residents (Resident #6, #15, and #17) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include: The facility's Care Plans policy, dated 1/1/24, documented care plans will be reviewed quarterly, annually, and with change of status to ensure that they are current for residents' care. 1. Resident #6, was admitted to the facility on [DATE], with a diagnosis of Huntington's disease (a condition that causes nerve cells in the brain to decay over time). On 6/11/24 at 8:30 AM, Resident #6's care plan, initiated on 1/8/21, documented her care plan should have been reviewed on 1/15/24. On 7/11/24 at 11:28 AM, the DON stated that she should have updated…

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 staff interview, it was determined the facility failed to ensure CPAP use was discontinued with a physician's order. This was true for 1 of 1 resident (Resident #17) who used a CPAP machine. This failure created the potential for Resident #17 to experience increased respiratory problems if he did not receive treatment necessary to meet his respiratory needs. Findings include: A physician's order dated 2/2/24, documented to administer CPAP to Resident #17 nightly. The MAR indicated CPAP equipment care was initiated on 5/12/24 and discontinued on 6/1/24. On 7/8/24 at 2:45 PM, a CPAP machine was not observed in Resident #17's room. On 7/9/24 at 11:40 AM, the DON stated Resident #17 no longer used a CPAP and there was no order to discontinue CPAP use. She stated that stopping the CPAP was discussed in the IDT meeting, but there is no order on file for stopping CPAP use.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents had not expired; this was true for 1 of 1 medication storage room inspected and 1 of 1 medication cart inspected. This failure created the potential for residents to receive expired medications with decreased efficacy. Findings include: The facility's Disposition of Medication policy, dated 6/1/2019, documented all medications no longer in use, expired, or otherwise marked for disposition will be identified and disposed of in a timely manner and consistent with current standards of practice in a long-term care setting. 1. On 7/9/24 at 2:06 PM, during a medication storage room audit, the following was observed: - Tetanus Toxoid reduced Diphtheria Toxoid and Acellular Pertussis vaccine, 4 syringes, with expiration date 3/2024. - Influenza vaccine 3 doses, with expiration date 6/30/24. On 7/9/24 at 2:10 PM, LPN #1 stated the vaccines were expired and should have been removed from the refrigerator. She also stated she was not sure what to do 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, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not clean resident equipment properly, store oxygen supplies in a sanitary manner, perform proper hand hygiene, or use appropriate detergent for residents' personal laundry items. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: The facility's Hand Hygiene policy, dated 8/21/23, documented the facility will follow the Center for Disease Control guidelines. The facility's Glucose Point of Care Testing policy, dated 6/4/18, documented The Center for Disease Control and Prevention is concerned about the risks for transmitting Hepatitis B and other infectious diseases during assisted blood glucose monitoring. If it is not possible to assign the blood glucose meter to an individual, the device…

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.