Temple View Transitional Care Center

Based on observations, record review and staff interviews it was determined the facility failed to ensure medications were properly stored and not expired. This was true for the facility. This failure created the potential for residents to receive expired medications with decreased efficacy. Findings include:The following was observed during the medication cart audits. On 1/6/26 at 10:52 AM, the 200 Hall medication cart was audited with RN #1 present. Observed the following: - one bottle of Gas Relief with an expiration date of 7/25 printed on the bottle On 1/6/26 at 10:56 AM, RN #1 stated, the bottle of Gas Relief should have been discarded and had not been. On 1/6/26 at 2:25 PM, the DON stated the expired medications should have been removed from the medication cart and had not been.

Based on review of the State Operations Manual, interview, and record review, it was determined the facility failed to employ a qualified Director of Food and Nutrition Services. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. Findings include:On 1/5/26 at 7:40 AM, during the initial tour of the kitchen, the Dietary Supervisor stated he is not a Certified Dietary Manager or qualified Director of Food and Nutrition Services but was enrolled in a Certified Dietary Managers course.On 1/5/26 at 7:41 AM, the Assistant Dietary Supervisor stated she is not Certified Dietary Manager, or Qualified Director of Food and Nutrition services but she took the Certified Dietary Manager course in 2023. She stated she did not attend the required 3-day in person training that was required to complete the course and had to take the course over.On 1/7/26 at 2:10 PM, the Administrator stated the Dietary Supervisor and Assistant Dietary Supervisor are not qualified Directors of Food and Nutrition services but are enrolled in an…

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 accurate medical records were maintained for each resident. This was true for 2 of 17 residents (#2 and #4) whose records were reviewed for pain management. This deficient practice resulted in inaccurate documentation and created the potential for harm if inappropriate care and/or treatments were provided to the resident. Findings include: Resident #2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including right above knee amputation and diabetes. On 1/7/26 at 10:10 AM, during record review Resident #2's November 2025 medication administration record documented Percocet Oral Tablet 10-325 Mg (Oxycodone w/Acetaminophen) had been administered by CNA #4 on 11/1/25 at 8:34 PM, 11/7/25 at 4:33 PM, and 11/29/25 at 1:10 PM. On 1/7/26 at 10:30 AM, review of the Active Employee List had CNA #4 listed as a registered nurse and an initial hire date of 7/9/13 with a termination…

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, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. 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 Infection Control Prevention and Control Program - Hand Hygiene Policy Updated 1/1/22, documented wash hands with soap and water for the following reasons: a. Before eating or after using the restroom b. When hands are visibly soiled; and c. After contact with a resident with infectious diarrhea including but not limited to infections caused by norovirus and C. difficile. The following was observed for hand hygiene: a) On 1/5/26 at 7:48 AM, observed LPN #1 serve Resident #23 his meal tray in his room. Resident #23 was not offered or encouraged to perform hand hygiene before eating. On 1/5/26 at 7:50 AM, observed LPN #1 serve Resident #8 her meal tray in her room. Resident #8 was not offered or encouraged to perform…

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 interview, it was determined that the facility failed to treat each resident with respect and dignity. This was true for 1 of 1 resident (Resident #101) observed for dignity. This deficient practice had the potential for residents to experience embarrassment, and low feelings of self-worth. Findings include: Resident #101 was admitted on [DATE], with multiple diagnoses including multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves) and overactive bladder. On 4/22/25 at 9:30 AM, Resident #101 was observed in her wheelchair in the hallway with her urinary drainage bag without a privacy cover. On 4/22/25 at 2:06 PM, the DON was interviewed and stated the urinary drainage bag should have been covered and was not.

Based on observation and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate and posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include: The State Operation Manual, Appendix PP revised on 8/8/24, documented §483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. On 10/24/24 at 1:30 PM, observed the Daily Staffing sheets for April 2024 through October 2024, noting 46 days were not completed accurately 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 observation, policy review, and staff interview, it was determined the facility failed to ensure the food was stored in a safe and sanitary manner. These deficiencies had the potential to affect all residents 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: The FDA (Food Drug Administration) Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, states marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded. The facility's Kitchen Resource: Food Safety for Your Loved One policy/procedure, non-dated, documented Food or beverages that have past the manufacturer's expiration dated should be thrown away. Food and beverages items without a manufacturer's expiration date should be dated upon arrival in the facility and thrown away…

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 residents were provided with a clean, safe, homelike environment. This was true for all 65 residents who resided in the facility whose equipment and environment were observed. This deficient practice created the potential for harm if: a) cross contamination due to equipment not being cleaned between use b) residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, undignified, or c) residents were injured due to unsafe areas in the facility. Findings include: The facility's Housekeeping policy, revision date May 2007, documented the facility would provide a clean, comfortable, homelike, and sanitary living area. The following areas were observed: a) On 10/22/24 at 8:35 AM, observed the sit-to-stand (a device used to rise from a seated position to a standing position without using hands for assistance) base sides had a white dried substance, while the center 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 observation 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 offer or encourage residents hand hygiene prior to meals and follow proper handling of medications. 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 following was observed: 1. On 10/21/24 at 8:00 AM, observed food tray delivery and set up on Resident #19's overbed table. CNA #1 did not encourage him to perform hand hygiene before eating. On 10/21/24 at 8:03 AM, observed food tray delivery and set up on Resident #42's overbed table. NA #1 did not encourage him to perform hand hygiene before eating. On 10/21/24 at 8:09 AM, CNA #1 stated she should have provided hand hygiene to the residents. On 10/21/24 at 8:12 AM, NA #1 stated she should have asked if the residents wanted their hands cleaned before eating their meals. On 10/24/24 at 10:21 AM, the IP stated the staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure dignity of residents when staff enter their rooms without knocking and waiting for acknowledgement to enter. This was true for 2 out of 2 resident rooms observed during the morning meal tray delivery. This deficient practice placed residents at risk of embarrassment and diminished sense of self-worth. Findings include: On 10/21/24 at 8:04 AM, observed CNA #2 had not knocked or waited for resident acknowledgement prior to entering room [ROOM NUMBER] when delivering the breakfast meal. On 10/21/24 at 8:05 AM, CNA #2 stated she normally does knock but the door was open, so I did not knock on the resident's door. On 10/21/24 at 8:06 AM, observed NA #2 had not knocked or waited for resident acknowledgement prior to entering room [ROOM NUMBER] when delivering the breakfast meal. On 10/21/24 at 8:07 AM, NA #2 stated she should have knocked before entering the resident's room. On 10/25/24 at 11:20 AM, the ADON stated staff need to knock prior to entering…

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 residents were assessed to determine if they were safe to self-administer medications for 2 of 6 residents (#3 and #36) reviewed for self-administration of medications. This failure created the potential for adverse effects if residents self-administered medications inappropriately. Findings include: The facility's Self Administration of Medications policy dated June 2023, documented: - If a resident desires to participate in self-administration of medications, the interdisciplinary team will assess and periodically re-assess the resident based on change in the resident's status. - If the resident is a candidate for self-administration of medications, a physician's order for self-administration of medications or for specific medications to be administered (example inhalers) will be obtained. Self-administration of medications will be care planned. - Resident will be instructed regarding proper…

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, the facility failed to ensure residents' Minimum Data Set (MDS) had correct assessment information. This was true for 4 of 4 residents (#3, #4, #15, and #38) reviewed for accuracy of MDS assessments. This deficient practice created the potential for residents to have their mental health needs not met due to inaccurate assessments. Findings include: The Resident Assessment Instrument (RAI), revised 10/1/2024, documents if a PASRR (Preadmission Screening and Resident Review) Level II determines a resident has a serious mental illness then section A1500 of the MDS should be marked yes. 1. Resident #3 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including schizophrenia and bipolar disorder. Resident #3's PASRR Level II dated 4/18/24, documented she had schizophrenia. Resident #3's admission MDS dated [DATE], documented she was not currently considered by the state level II PASRR to have serious mental illness and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, it was determined the facility failed to ensure a baseline care plan was developed within 48 hours of resident's admission. This was true for 1 of 5 residents (Resident #52) reviewed for baseline care plan. This failure created the potential for harm when the care plan failed to provide direction for care. Findings include: The facility's Comprehensive Person-Centered Care Planning policy, revised December 2023, documented under Procedure #1, Within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-center care. The State Operation Manual, Appendix PP revised on 8/8/24, documents §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-…

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's care plans were revised to reflect current needs and interventions. This was true for 2 of 17 resident's (#3 and #21) whose care plans were reviewed. This placed resident at risk of adverse outcomes if care and services were not provided due to care plans not being revised as resident's needs changed. Findings include: The facility's Comprehensive Person-Centered Care Planning Policy, revision date December 2023, documented the resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments. 1. Resident #3 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves resulting in nerve damage) and nicotine dependence. 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 policy review, record review, observation, and interviews, the facility failed to ensure residents were free from accidents. This was true for 1 of 1 resident (Resident #9) reviewed for accidents. This failure had the potential to cause residents significant injuries. Findings include: The facility's Smoking Policy, undated, documented: - An independent smoker is a smoker who has been evaluated by the IDT team using the smoking assessment form and determined to be safe to smoke independently. - An assisted smoker is a smoker who has been evaluated by the IDT team using the smoking assessment form and determined to require assistance with smoking privileges. Current residents who have been assessed as assisted smokers will be supervised during designated times and smoking material will be kept in the designated area. Resident #9 was admitted on [DATE], with multiple diagnoses including anxiety disorder, depression, and malnutrition. Resident #9's care plan dated 7/22/24, documented he required supervised…

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 interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 3 of 15 residents (#14, #28, and #52) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels. Findings include: 1. Resident #14 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic respiratory failure with hypercapnia (occurs when there is too much carbon dioxide (CO2) in the blood) and acute respiratory failure with hypoxia (occurs when the body doesn't have enough oxygen in the tissues). On 10/21/24 at 10:16 AM, observed Resident #14 outside her room without her oxygen cannula on, with staff present and talking to her. Resident #14's physician's order dated 7/2/24, documented oxygen at 3 liters per minute via nasal cannula continuously and check liter flow four…

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 monitored appropriately for medication, therapeutic range, and toxicity levels. This was true for 1 of 17 residents (Resident #49) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse reactions due to the lack of appropriate monitoring. Findings include: Resident #49 was admitted to the facility on [DATE], with multiple diagnoses including acute osteomyelitis (a bone infection that occurs when an infection spreads to the bones, usually within two weeks of the onset of disease) and cerebral palsy (a group of neurological disorders that affect a person's ability to move, balance, and maintain posture). Resident #49's physician's order dated 3/7/24, documented Levetiracetam Oral Tablet 1000 MG, give 1000 MG three times a day for Seizure Disorder. On 10/25/24 at 8:46 AM, the ADON and Clinical Resource nurse stated they were going to call the Physician 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 observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and stored appropriately. This was true for 1 of 1 medication storage rooms inspected, 2 of 46 residents (#3 and #36) resident rooms inspected, and 1 of 2 treatment carts observed. This failure created the potential for residents to receive expired medications with decreased efficacy, the potential for adverse effects if residents self-administered medications inappropriately, and the potential for residents to obtain prescribed wound care supplies used for other residents and presented the risk for cross-contamination of wound care products stored in the treatment cart. Findings include: The CDC guidelines for Preventing Unsafe Injection Practices, dated 3/26/24, documented once a multi-dose vial is opened (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer states another date for that opened vial.…

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 interviews, it was determined that the facility failed to employ sufficient staff with the appropriate competencies and skill 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 all residents requiring medical nutrition therapy, nutritional assessments, and appropriate supplementation and dietary interventions. Findings include: The State Operations Manual, Appendix PP, revised 8/8/24, documented, if a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services. The director of food and nutrition services must at a minimum meet one of the following qualifications: - A certified dietary manager. - A certified food service manager, or - Has similar national certification for food service management and safety from a national…

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, record review, review of the State Survey Agency's Long-Term Care Reporting Portal, resident interview, and staff interview, it was determined the facility failed to report allegations of potential abuse to the State Survey Agency within 24 hours. This affected 1 of 15 residents (Resident #1) whose records were reviewed for abuse. This deficient practice created the potential for harm if allegations were not acted upon in a timely manner and the alleged abuse continued. Findings include: The facility's policy, Abuse: Prevention of and Prohibition Against, dated 4/2019, stated: Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including left sided hemiplegia (paralysis of one side of the body) following a stroke,…

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, record review, review of the State Survey Agency's Long-Term Care Reporting Portal, resident interview, and staff interview, it was determined the facility failed to ensure allegations of potential abuse were thoroughly investigated. This was true for 1 of 15 residents (Resident #1) whose records were reviewed for abuse. This failure created the potential for residents to be subjected to ongoing abuse without detection and protective measures implemented by the facility. Findings include: The facility's policy, Abuse: Prevention of and Prohibition Against, dated 4/2019, stated: After receiving the allegation, and during and after the investigation, the administrator will ensure that all residents are protected from physical and psychosocial harm. The facility's policy stated the investigation will, at a minimum, include an interview with the person reporting the incident, an interview with the resident, interviews with witnesses to the incident, including the alleged perpetrator (as…

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, facility I&A review, and staff interview, it was determined the facility failed to ensure fall prevention interventions were implemented following a fall and that the care plan interventions were put into place, reviewed, and updated and carried out consistently. This was true for 1 of 15 residents (Resident #2) whose records were reviewed. This had the potential for harm if the resident sustained an injury from a fall. The facility's policy Fall Management, revised 1/2022, stated the following: - Each resident will have an appropriate assessment and interventions to prevent falls and minimize complications should a fall occur. - Care plan interventions would address the risk factors for the resident and be individualized. - After a fall, a fall risk evaluation will be completed. - Review of the fall will include investigation to include probable causes and will be reviewed by the IDT. - The resident's care plan will be updated. This policy was not followed.…

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 resident and staff interview, it was determined the facility failed to ensure residents' call lights were within reach for 1 of 12 (Resident #13) residents reviewed for call lights. This deficient practice had the potential to cause harm if the resident could not request assistance when needed or experienced an adverse medical event requiring prompt staff attention. Findings include: The facility's Call Light policy, dated 5/2007, directed staff to place the call device within the resident's reach before leaving the room. Resident #13 was readmitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis (a potentially disabling disease of the brain and spinal cord) and lack of coordination. Resident #13's 11/18/19 quarterly Minimum Data Set assessment documented he required two-person assistance for transfers. Resident #13's care plan, dated 7/25/19, directed staff to keep his call light within reach. On 2/4/20 at 8:49 AM, 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, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' were assessed for the safe use of enabling devices. This was true for 1 of 12 residents (Resident #14) whose assessments were reviewed. This deficient practice placed Resident #14 at risk of injury if the transfer pole in his bedroom was assessed and found to be unsafe for his use. Findings include: The facility's Enabling Device Assessment policy, dated 8/2007, documented assessments of enabling devices were to be completed prior to their use. This policy was not followed. Resident #14 was readmitted to the facility on [DATE], with multiple diagnoses including unsteadiness on feet and psychomotor deficit (a slowing-down of thought and a reduction of physical movements). Resident #14's care plan, dated 1/2/20, documented he used a transfer pole during transfers. Resident #14's physician's order, dated 1/2/20, documented an order for a transfer pole. Resident #14'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.

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 physician orders for as needed psychotropic medications were limited to 14 days unless the physician documented rationale for the continued use of the medication and specified a duration for its use. This was true for 1 of 5 residents (Resident #26) who were reviewed for unnecessary medications. This deficient practice created the potential for harm if residents experienced adverse effects from unnecessary psychotropic medications. Findings include: The facility's policy for Psychotropic Drug Use, dated 8/2017, stated as needed orders for psychotropic drugs were limited to 14 days. If the prescribing practitioner believed it was appropriate to extend beyond 14 days, the practitioner was to document the rationale and indicate a duration for the use of the as needed medication in the resident's medical record. This policy was not followed. Resident #26 was admitted on [DATE], with diagnoses which included…

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.