Ryze West

Based on observation, interview, and record review, the facility failed to properly assess and implement interventions related to the psychosocial needs of one resident (R8) who was involved in and exposed to fire and smoke surrounding a fire related incident that occurred on 1/6/25 in R8's room. These failures resulted in R8 expressing emotional distress and fear after the incident. The findings include: R8's admission record showed admission date on 12/7/20 with diagnoses not limited to Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, Dysphagia oral phase, Anemia, Peripheral vascular disease, Absence epileptic syndrome, Other hereditary and idiopathic neuropathies, Encounter for attention to gastrostomy, Hyperlipidemia, Unspecified dementia, Chronic embolism and thrombosis, Gastro-esophageal reflux disease, Crohn's disease, Obstructive and reflux uropathy, Other sequelae of cerebral infarction, Type 2 diabetes mellitus with diabetic neuropathy, Aphasia, Essential (primary) hypertension, Heart failure, 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, interview and record review, the facility failed to provide monthly surveillance and maintain patient care equipment, to ensure that it is in safe operating condition. This failure affected one (R8) out of five residents (R4, R8, R12, R13, R14) reviewed for preventative maintenance. Findings include: On 01/21/25 at 1:30 PM, V5 (Director of Maintenance) stated the fire was caused by the R8's motorized wheelchair. V5 stated he does not know if the facility has a policy on wheelchair maintenance. V5 stated, I don't do any routine checks or monitoring on the electric wheelchairs because they are owned by the residents, not by the facility and if we do something to the electric wheelchair then we are liable, so it is not part of our responsibility. V5 stated he took R8's motorized wheelchair out of the room the night of the fire and V41 (R8's Son) came that same night and replaced a part. V5 stated V5 does not know what part V41 replaced or what R8's son did to the wheelchair. On 1/21/25 at 2:22…

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 The facility failed to ensure the resident's call light device was within reach for two residents (R1, R3) out of three residents reviewed for quality of care. This failed practice placed the resident at risk for not being able to call for help, if needed. Findings include: On 10/22/2024, 10:41 AM R1's call light was on top of 3 pillows without pillowcases that are on top of R1's nightstand. R1 was sleeping, easily arousable, and in no apparent distress. R1 states that she is not sure when she first came to the facility. R1 states I have memory loss, maybe about 6 months ago, I don't like it here. R1 cannot remember the names of the staff that take away her call light. R1 states that when they do come to check on her, R1 states that she forgets what she even yelled out for. R1 cannot remember when she yelled out for help. R1 states that currently, she cannot reach her call button. R1 states look and see they took it away from me, I can't reach it. On 10/22/2024, 10:55 AM V3 (Certified Nursing Assistant) states…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and review of records the facility failed to follow policy in giving/providing a shower/bath to 1 (R1) out of 4 residents reviewed for resident shower or bathing schedule. This failure has the potential to affect 1 resident (R1) in maintaining hygiene through bathing at least once a week. Findings include: R1 is [AGE] years old, initially admitted on [DATE] with medical diagnosis that includes paraplegia and bilateral (right and left) foot drop. On 9/17/2024 at 12:50 PM, R1 was seen in her room laying on her bed. R1 was alert and able to maintain conversation within topic very well. In front of R1 was a moving table with her cell phone and TV remote control. During conversation the cell phone rings that was answered by R1. After R1's phone conversation, R1 stated that it was her daughter on the phone (V7). R1 confirmed that the phone and TV remote control was her own. R1 stated that she had a scheduled surgery but was not able to go. R1 stated that she did not have any formal…

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

Based on observation, interview, and record review the facility failed to provide proper positioning for 1 (R1) resident during dining. This failure has the potential for R1 to be at risk for choking and aspiration during dining experience. Findings Include: R1 has diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Aphasia Following Cerebral Infarction, Essential (Primary) Hypertension, Atrial Fibrillation, Type 2 Diabetes Mellitus, Anxiety Disorder due to Known Physiological Condition and Post-Traumatic Stress Disorder. R1's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 04 indicating severe cognitive impairment. R1's Care Plan document in part: Focus: Bed Mobility: R1 has a self-care deficit in bed mobility r/t (related/to) (Decreased ability to position or reposition self in bed/ Turn from side to side/ Move from lying to sitting or sitting to lying position). Intervention: Position and reposition resident in bed for comfort, joint support, and skin integrity. During the initial tour of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to a.) follow their policy and monitor vital signs during a medical emergency and b.) perform needed interventions for a resident who experienced a change in condition for one (R2) resident out of three residents reviewed improper nursing care. Findings include: On 6/9/24 at 11:22 AM V8 (Licensed Practical Nurse/LPN) states that she was doing rounds with the unit manager, and they noticed R2 was shaking, in his bed. V8 states that she performed vital signs on him, and they were high, V8 states that R2 normally has low blood pressure. V8 states that the doctor was called and V8 states that the doctor gave orders to send R2 to the hospital. V8 states that the paramedics informed her that they were transferring R2 to a closer hospital because R2 ' s blood pressure kept spiking and R2 was seizing. V8 states that R2 was not having any seizure when the private ambulance picked him up. V8 states that R2 was antsy and trying to remove his belt and picking at his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility failed to provide an adequate supply of linens to meet staff and resident needs in the provision of resident care. This failure has the potential to affect all 180 residents of the facility. Findings: On 5/21/2024 at 2:30 PM observed three CNAs (certified nursing assistant) carts on the 2nd floor. No bath towels were observed on any of the three carts. On 5/21/2024 at 2:35 PM, V9 (CNA) was interviewed. V9 stated that the CNAs start the shift with a linen cart that each CNA puts together. Linens are brought up by the laundry room and put in an alcove in the hallway. Each resident uses three towels to shower or bathe so V9 stated that the staff go through towels quickly. Once the towels are gone, V9 stated that staff call the laundry room to get more. Our shift is over at 3, so there are no towels on the floor. The laundry room will bring new linens for the 3-11 shift. Laundry bring the cart each shift. V9 stated that they sometimes have to wait 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.

Based on interview and record review, the facility failed to ensure to have sufficient certified nursing assistant (CNA) on weekends to care for residents' needs based on the staffing scheduling, PBJ (Payroll Based Journal) staffing data report and facility assessment. This failure could potentially affect 180 residents residing in the facility as of census 5/21/24. The findings include: On 5/21/24 at 10:45 AM R92 observed lying in bed, alert, and oriented x 3, verbally responsive, with long beard more than 5inches. Stated he can have staff assist him with shaving. He said staff did not offer or assist him with shaving. At 11:19 AM Requested V3 (Restorative Nurse) to R92's room and R92 stated he wanted his beard shaved off. R92 said beard is about 5-6 inches long and he wanted to take off everything. On 5/22/24 at 10:15 AM V19 (Scheduler / Staffing Coordinator) said she has been working in the facility for about 6 months. V19 said, V19 schedules both nurses and CNAs. V19 said, facility does not use agency for both nurses and CNAs. V19 said, the breakdown for staff schedule to work…

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

Based on observations, interviews, and record reviews, the facility failed to a.) ensure food items were labeled and dated with an opened and use by date, b.) discard expired or spoiled food, c.) keep food storage areas clean, d.) sanitize cooking equipment based on manufacturers' directions. These failures have the potential to affect all 176 residents receiving food prepared in the facility's kitchen. Findings include: On 05/21/24 at 8:57 AM, during initial kitchen tour V11 (Dietary Director) stated everything that comes into the kitchen must be labeled and date and when something is opened it needs to be labeled with the open date and use by date. V11 stated all refrigerated food needs to be used within seven days. V11 stated that even if the item is marked with a manufacturer use by date, the kitchen goes by seven days from when the item is opened, not the manufacturers use by or best by date for when the item should be thrown out. On 05/21/24 at 9:05 AM, observed the following in Refrigerator #2: 1.) Opened case of fresh strawberries dated 05/03/24 observed to shriveled, 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 observation, interview and record review, the facility failed to ensure dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 180 residents who reside in the facility. Findings include: On 05/21/24 at 9:37 AM, turning observation of outside dumpster with V11 (Dietary Manager) observed one large dumpster with two of the three lids wide opened. Also, observed debris and trash on the ground around the dumpster. V11 stated the lids should probably not be left open like that because birds and insects can get inside and feed off the garbage inside. V11 stated there should be no garbage on the ground near the dumpster. On 05/22/24 at 3:28 AM, V32 (Divisional Manager for Laundry and Housekeeping Services) stated the lids to the dumpster must be closed after putting garbage inside and there should be no debris or garbage on the ground around the dumpster. V32 stated the lids should be fully closed to keep rodents from getting in the dumpster because eventually this will lead 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 and interviews, and record review the facility failed to repair a hole in the ceiling and replace the missing/stained ceiling tiles in the first-floor dining room and failed to maintain the walls in the residents' rooms in good repair for 3 (R114,R86, R58) residents in a sample of 35. Findings Included: During the facility tour of the first-floor dining room on 05/21/24 at 09:16 AM a missing ceiling tile was observed at the west end of the dining room and 4 ceiling tiles with brown stains. The ceiling that was observed above the missing tile was peeling. There was a large yellow garbage can positioned near the area of the missing tile with what appeared to have water in it. On 05/21/24 at 11:25 AM R112 was observed sitting in the first-floor dining room. When asked by the surveyor does the ceiling leak in the dining room R112 responded water leaks from the ceiling and it bothers me to see the water. They know about it and have not done anything. On 05/21/24 at 11:34 AM R137 was observed in the first-floor dining room. R137 stated I got on maintenance about the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to (a) ensure that smoking materials including cigarette and lighter were given to designated staff; (b) complete smoking assessment / evaluation in a timely manner; (c) develop comprehensive care plan and follow plan of care for smoking. These failures could potentially affect 4 (R28, R84, R92, and R132) residents reviewed for smoking in a total sample of 35. The findings include: R92's health record documented admission date on 2/16/2019 with diagnoses not limited to Alcohol dependence with withdrawal, Esophagitis, Thrombocytopenia, Gastro-esophageal reflux disease with esophagitis, Constipation, Personal history of covid-19, Age-related nuclear cataract bilateral, Tension-type headache, Vitamin d deficiency, Insomnia due to medical condition, Decreased white blood cell count, Spinal stenosis cervical region, Nontraumatic intracerebral hemorrhage, Cervicalgia, Dysphagia following other cerebrovascular disease, Traumatic hemorrhage 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, interview, and record review the facility failed to a.) ensure narcotic medications were administered in accordance with physician orders, b.) ensure the narcotic count was correct at the change of shift and c.) document ordered narcotic medications when given for 2 (R76, R118) of 2 residents reviewed in 2 of 3 medication carts. Findings Include: On 05/21/24 at 09:59 AM the third-floor medication cart 2 was reviewed with V5 (Licensed Practical Nurse). R76 Physicians order document in part: Morphine Sulfate Oral Solution 20 MG (Milligram)/5ML (Milliliter) 0.25 ml sublingually every 8 hours for pain -Start Date- 04/17/24. During the narcotic reconciliation review R76 Individual Controlled Substance Record document: Date received 04/19/24. Quantity received 30 ML (Milliliter) with 43 doses given. First dose dispensed 04/19/24 at 06:00 AM. On the April and May Medication Administration Record dated between 04/19/24 06:00AM and 06:00 AM 05/21/24 there were only seventy-four doses administered out of ninety-seven scheduled doses with twenty-three doses refused.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow professional standards of practice and facility policy to prevent and control infection in the provision of patient care. This failure has the potential to affect all 180 residents in the facility. Findings On 05/21/24 at 9:13 AM V33 (CNA) was observed leaving room R121's room which had a sign for enhanced barrier precautions (EBP) on the door. V33 took the breakfast tray out of room , placed the tray in the return cart, did not perform hand hygiene and then entered room [ROOM NUMBER] which also had a sign for EBP on the door. V33 took the breakfast tray out of R162's room, placed it in the return cart, did not perform hand hygiene and began to push the cart down the hall. V33 was asked about the EBP signage. V33 stated It means that we gown up before doing care. We wear gown and gloves and use hand sanitizer before we put gloves on. If we are going to pass or pick up trays, we put gloves on. I didn't put gloves on. I should have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to follow their policy and procedure (a) to determine and assess a resident if self-administration of medications is appropriate; (b) to obtain a physician's order for medication self-administration; and (c) to implement a person-centered care plan addressing self-administration of medications for 1 (R124) out of 1 resident reviewed for self-administration of medications in the final sample of 35 residents. Findings Include: On 5/21/24 at 12:17 PM R124 was in R124's room. Surveyor noted wound dressings on top of R124's drawer. R124 stated that R124 has colon cancer and uses the dressings for R124's wound on R124's buttock. R124 opened R124's drawer and showed Surveyor the solution R124 uses for R124's wound. R124 stated that the wound care nurse gave the solution for R124 to use. R124 was unable to identify the wound care nurse. Surveyor also noted a bottle of Multivitamins in R124's drawer. R124 stated that R124 takes the multivitamin every…

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

Based on observation, interview, record review facility failed to follow facility policy in reporting an abuse and neglect allegation by one resident (R23) out of a total of 35 residents in the sample. Findings On 05/21/24 at 9:18 AM, R23 approached surveyor and asked Are you with the state? R23 stated They are stealing my money and stuff. R23 stated that she told the administrator. V13 (LPN) approached surveyor and R23 and stated It hasn't reached us yet. Surveyor repeated to V13 R23's statement that They are stealing my money and stuff. R23 stated They also neglect me a lot. They bully people. (V13 did not report the allegation to V1 Administrator) On 05/22/24 at 10:40 AM, V1 (Administrator) was interviewed about the facilities abuse allegation and reporting process. V1 stated that when a resident alleges abuse, V1 is the first person notified. If the allegation is staff-to-resident, the staff member is sent home, resident is sent to the hospital if necessary, and police are called. V1 stated that she then does her investigation. V1 talks to the resident and other residents who…

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

Based on interview and record review, the facility failed to refer one resident (R3) to the appropriate state designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation out of 5 residents reviewed for PASARR in a total sample of 35. Findings include: R3's OBRA - Initial Screen (Identification for Individuals for Whom There is a Reasonable Basis to Suspect a Developmental Disability or a Mental Illness) completed by state-designated authority dated 11/15/28 documents in part based upon all information and data available to me for this person there is a reasonable basis for suspecting DD (Developmental Delay) or MI (Mental Illness) with the no box checked. R3's diagnosis includes but not limited to Unspecified Dementia, Anxiety Disorder, Major Depressive Disorder, Bipolar Disorder, and Restlessness and Agitation. On 05/23/24 at 1:24 PM, V16 (Social Service Director) stated PASARR level I screen is completed prior to admission and depending on the residents added diagnosis and behaviors the facility then requests a PASARR level II assessment. V16…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to (a) provide the necessary care and services to ensure that one (R92) resident was assisted or supervised with personal hygiene / shaving and (b) follow facility policy and standards of professional practice in providing care and communication in one resident's (R179) primary language. These failures affected two (R92 and R179) residents reviewed for activities of daily living (ADL) in a sample of 35. The findings include: R92's health record documented admission date on 2/16/2019 with diagnoses not limited to Alcohol dependence with withdrawal, Esophagitis, Thrombocytopenia, Gastro-esophageal reflux disease with esophagitis, Constipation, Personal history of covid-19, Age-related nuclear cataract bilateral, Tension-type headache, Vitamin d deficiency, Insomnia due to medical condition, Decreased white blood cell count, Spinal stenosis cervical region, Nontraumatic intracerebral hemorrhage, Cervicalgia, Dysphagia following 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.

Based on observations, interview and record review, facility failed to identify and address an alteration in skin integrity for one resident (R147) out of 35 residents in the sample. This failure resulted in unaddressed skin lesions and resident discomfort. Findings: On 05/21/24 at 12:40 PM R147 was observed to have multiple round lesions on the left arm. Some lesions were open and red. Some lesions were scabbed over. R147 showed surveyor his upper back and legs which had multiple lesions that are scabbed over. R147 stated that the lesions were uncomfortable. On 05/22/24 at 12:05 PM V17 (Wound Nurse) was interviewed and stated that wound care was no longer following R147. V17 stated that R147 had MRSA (Methicillin-resistant Staphylococcus aureus) and an infection on his cheek, but that heeled. V27 stated that nursing was previously putting an ointment on R147's arms. We are not aware of any wounds that he currently has. On 5/22/2024 at 12:10 PM, Surveyor and V17 (Wound Nurse) visited R147. R147 showed arms, upper back and legs with lesions present. Several of the lesions on R147'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 observation, interview, and record review, the facility failed to follow care plan to ensure pressure redistribution mattress or low air loss mattress was provided as ordered and complete an assessment or tool used to identify resident at risk for pressure ulcer in a timely manner. These failures affected 1 (R90) resident reviewed for pressure ulcer in a sample of 35. The findings include: R90's health record documented admission date on 1/11/2024 with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Type 2 diabetes mellitus without complications, Unspecified severe protein-calorie malnutrition, Nontraumatic intracerebral hemorrhage, Neuromuscular dysfunction of bladder, Hyperlipidemia, Gastro-esophageal reflux disease without esophagitis, Chronic atrial fibrillation, Iron deficiency anemia, Acquired absence of other specified parts of digestive tract, Dysphagia oropharyngeal phase, Essential (primary) hypertension, Gastrostomy status,…

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

Based on observation, interview and record review the facility failed to provide physician ordered oral nutritional supplements and other nutrition interventions. These failures potentially affected 2 residents (R18, R21) of 7 residents reviewed for nutrition in a total sample of 35. Findings include: On 05/21/24, during initial kitchen tour conducted between 8:57-9:55 AM V11 (Dietary Director) stated Magic Cup (fortified high calorie ice cream) supplements are in stock and are put on resident meal trays when listed on the meal ticket. Observed 8-ounce cartons of whole milk in the refrigerator and case of Magic Cup supplement stored in the facility freezer. On 05/21/24 at 12:20 PM, observed R18 eating lunch in the unit dining room. R18 received ground barbeque chicken, macaroni & cheese, spinach, frosted chocolate cake, and fruit punch on R18's lunch tray. R18's meal ticket read double portions, and Magic Cup with lunch. R18 did not to receive double portions and R18 did not receive a Magic Cup supplement or an equivalent substitution on R18's lunch tray. V7 (4th Floor Unit…

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

Based on observation, interview, and record review the facility failed to provide total volume of prescribed gastrostomy tube feeding as prescribed by physician. These failures could potentially affect 2 (R59, R67) of 2 residents reviewed for nutrition and tube feeding in a sample of 35. Findings include: On 05/22/24 at 09:02 AM, surveyor observed R59's tube feeding hung at bedside and infusing at 65 ml per hour via pump. The tube feeding formula hanging was a 1-Liter (L) bottle of Jevity 1.5 and on the bottle was a label. The label was dated 05/21/24 at 2:00 PM, rate 65 ml per hour. On 05/22/24 at 9:03 AM, surveyor observed R67's tube feeding hung at bedside and infusing at 75 ml per hour via pump. The tube feeding formula hanging was a 1L bottle of Jevity 1.5 and the bottle was labeled with the date 05/21/24 at 2:00 PM, rate 75 ml per hour. On 05/22/24 at 9:12 AM, V20 (Licensed Practical Nurse) stated R59 and R67's tube feedings are turned off from 10 AM to 2 PM daily. V20 stated these tube feeding bottles were hung yesterday at 2 PM and that when nurses hang the tube feeding they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to follow residents' care plans to ensure physician orders were followed and administer the correct oxygen flow rate for 2 (R39, R148) out of 2 residents reviewed for respiratory care in the final sample of 35. Findings Include: 1) On 5/21/24 at 10:56 AM, R39 was lying in bed alert and able to verbalize needs. R39 was noted using oxygen (O2) via nasal cannula with the flow rate set to 1.5 liters per minute (LPM). When asked R39 if R39 changes the dial on R39's oxygen, R39 answered, The nurse sets that up. I don't touch it. R39 stated that R39 uses oxygen for R39's diagnoses of Asthma and Chronic Obstructive Pulmonary Disease (COPD). On 5/22/24 at 9:53 AM, R39 was resting in bed alert and awake. R39's was using oxygen via nasal cannula with the flow rate set to 1 LPM. R39 denied changing the flow rate. 2) On 5/21/24 at 11:00 AM, R148 resting in bed alert and able to verbalize needs. R148 stated R148 has been in the facility for almost two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility [A] failed to ensure the physician documented in one [R125] resident's clinical record their assessment, current condition, and medical problems for each visit, [B] failed to ensure the physician sign and date psychotropic narcotic medication. These failures resulted in R125 not receiving a prescribed psychotropic medication for nine days. Findings Include: R125's clinical indicates in part, he is a twenty-eight-year-old admitted on [DATE], with the medical diagnosis of attention-deficit hyperactivity disorder, depression, paraplegia, neuromuscular dysfunction of bladder, essential (primary) hypertension. R125's physician order dated 5/15/24- Dextroamphetamine Sulfate Oral Tablet 5 MG (Adderall) [Controlled Drug], give 1 tablet by mouth in the morning and afternoon for ADHD. R125's Progress Notes: Documented in part. Dated 4/28/24- Nursing Note-R125 refused car and weights, he became verbally aggressive, nurse practitioner gave order for psych consult. R125'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 interview and record review the facility failed to follow their policy to (a) obtain an informed consent for psychotropic medication use; (b) ensure PRN (as needed) psychotropic medication will have a duration of no longer than 14days; (c) attempt Gradual Dose Reduction (GDR) for psychotropic medication use; (d) complete AIMS (Abnormal Involuntary Movement Scale) test in a timely manner. These failures could potentially affect 3 (R3, R130, R132) residents reviewed for Unnecessary Psychotic medication use in a sample of 35. The findings include: R132's health record documented admission date on 2/20/2024with diagnoses not limited to Malignant neoplasm of supraglottis, Moderate protein-calorie malnutrition, Cerebral infarction, Chronic respiratory failure, Unspecified protein-calorie malnutrition, Unspecified asthma, Tracheostomy status, Periorbital cellulitis, Hypothyroidism, Auditory hallucinations, Major depressive disorder, Somnolence, Hypoxemia, Covid-19, Lymphedema, Opioid dependence, Essential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident is free of significant medication errosr to 1 (R134) of 8 residents reviewed for medication administration resulting in administering 4 units of Humalog Insulin one hour before meal instead of with meal. This deficient practice has the potential to place R134 in Hypoglycemia distress. Findings Include: R134's electronic Medication Administration Record (eMAR) as at 5/2024 documents in part: Humalog Solution 100 Unit/ML. Inject as per sliding scale (251-300 = 4 units) subcutaneously with meals. R134's Minimum Data Set (MDS) dated [DATE] shows R134 is cognitively intact. On 5/21/24 at 11:43 AM, surveyor observed V39 (Licensed Practical Nurse/LPN) administering 4 Units of Humalog Insulin subcutaneously at Left Lower Quadrant (LLQ) to R134 before meal was served on the unit. When surveyor asked V39 what V39 should have done before administering the insulin. V39 stated V39 should have waited for the lunch tray to be served to…

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

Based on observation, interview, and record review the facility failed to a.) ensure medications were labeled when opened, b.) ensure expired medications were removed from the medication cart/medication room and c.) ensure medications for discharged residents were removed from the medication cart in 2 of 3 medication carts and 1 of 2 medication rooms reviewed for medication storage and labeling. Findings Include: On 05/12/24 at 10:28 AM the fourth-floor medication cart 1 was reviewed with V6 (Licensed Practical Nurse). Expired medications were observed in the top drawer of the medication cart including; Enteric Coated Aspirin 325 MG expiration date 09/23, Zinc 50 MG expiration date 01/24, Fish Oil 1000 MG expiration date 04/24, Vitamin E 450 MG expiration date 04/24, Acidophilus with pectin expiration date 03/24, Guaifenesin 400 MG expiration date 03/24, Vitamin B6 100 MG expiration date 02/24, Naproxen 220 MG expiration date 03/24 and Bisacodyl 5 MG expiration date 02/24. Surveyor asked V6 what is done when administering medication, V6 responded, check the MAR (Medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility failed to protect a resident from physical abuse. This failure affected one resident (R12) of seven residents reviewed for abuse. This failure resulted in R11 and R12 having an altercation. R11 put R12 into a headlock and scratched R12's face. Findings Include: Facility's Investigation Report (dated 02/29/2024) states: R11 noted with agitation while walking with staff member and he began flailing his arms, in the process of flailing his arms resident scratched R12, while he was sitting in the dining area. R12 was immediately removed from common area and placed with social services with de-escalation techniques initiated. MD made aware with orders received to send resident out to [community] hospital for psychiatric evaluation, orders noted and evaluated. Nursing staff and social services were successfully able to deescalate the situation and remove R11 from the common area and place him on 1:1 supervision until he was transferred to [community] hospital 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 interview and record review, the facility failed to report an injury of unknown origin to the regional office. This failure affects one of three residents (R9) reviewed for injury of unknown origin in a total sample of 19. Findings include: R9 is a [AGE] year-old male. R9 ' s diagnoses are but not limited to stroke affecting the right side of the body, stroke, aphasia, major depressive disorder, adult failure to thrive, and anxiety. R9 ' s MDS dated [DATE], notes R9 is not alert. Progress note dated 12/10/2023, notes R9 noted with some swelling, redness, pitting edema and warm to touch to right contracted arm. Patient vitals within normal levels. No signs or symptoms of shortness of breath, pain, anxiety, or distress noted. No adverse reactions to antibiotics. For ten days. Patient remains stable and resting currently. Progress note dated 12/10/2023, notes writer endorsed x-ray of right elbow to nurse practitioner with new orders to send patient out to local hospital due to x-ray stating (flexion…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to keep a resident (R6) free from physical abuse. Findings include: On [DATE] at 12:50 PM, R6 said it has been a long time since the altercation with R4 and R6 does not remember details. R6 said R4 bit R6 and R6 had a bloody finger. R6 said R6 thinks it was over the television and R4 wanted to watch a channel. R6 said I'm okay. I'm safe. On [DATE] at 1:00 PM, V1 (Administrator) stated I started as Administrator on [DATE]. When the Facility Reported Incident happened, I was the Director of Nursing. R4 and R6 were roommates. R6 had the television volume up and refused to turn it down. R4 pulled the privacy curtain closed and opened the window. R6 was always cold so R4 opened the window to irritate R6. R6 closed the window and R4 pushed R6. They got into a physical altercation. R4 bit R6 and had bleeding from the mouth. R6 had broken skin on the hand not bleeding. Staff heard the commotion and went to investigate. I was not in the building; it was a weekend.…

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

Based on observation, interview and record review, facility failed to ensure wound care orders and wound care interventions are in place in order to be followed for 2 (R1 and R5) out of three residents reviewed for pressure ulcer prevention. Findings include: On 12/12/ 2023 at 10:00 AM, surveyor observed R5 laying flat on her back in her room. R5 is non-verbal. V11 (R5's POA), who is also her sister, was sitting in the room with her. On 12/12/2023 at 11:30 AM, R5's POA stated no one has come in to change her or turn her. She stated that R5 came to see her sister around 10 AM. On 12/12/2023 at 12:00 PM, surveyor went into R5's room and saw R5 was laying flat on her back. On 12/12/2023 at 2:19 PM V12 (Wound Care Nurse) stated that R5 does have a sacral wound. V12 stated that R5's sacral dressing needs to be changed every day, even through the weekends. V12 stated that R5 went out to the hospital and came back Friday 12/08/2023. V12 stated that before R5 went to the hospital, she had a set of wound dressing change orders. V12 stated that those orders got discontinued when R5 went to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for four of four residents (R3, R7, R5, R6) reviewed for ADL care. Findings include: On 10.14.2023 at 10:35 AM, R3 observed lying in bed, mat on floor next to bed, and bilateral bed bolster on bed. A strong odor of urine was noted upon entrance to room, flies too numerous to count were noted on resident's face, feet, privacy curtains, floor mat, furniture, resident's roommate, and flying around in room. R3 was able to answer simple yes or no questions. R3 was able to communicate that he was wet. 10.14.2023 at 10:41 AM R3's call light activated. V4 (RN-Registered Nurse) responded to call light. V4 said he smelled a urine odor and saw flies in R3's room. V4 said there should be no urine odor and no flies. V4 donned gloves, pulled down R3's sheet exposing R3's adult brief. V4 said he (R3) just went…

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

Based on observations and interviews, the facility failed to provide sufficient staffing to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for four of four residents (R3, R7, R5, R6) reviewed for ADL care. Findings include: On 10/14/2023 at 10:25 AM on the 4th Floor, the census was 49, there were two nurses (V3-Assistant Director of Nursing and V4-Registered Nurse), and three Certified Nursing Assistants (V5, V6, and V12). 10.14.2023 at 10:35 AM, R3 observed lying in bed, mat on floor next to bed, and bilateral bed bolster on bed. A strong odor of urine was noted upon entrance to room. flies too numerous to count were noted on resident's face, feet, privacy curtains, floor mat, furniture, resident's roommate, and flying around in room. R3 was able to answer simple yes or no questions. R3 was able to communicate that he was wet. 10.14.2023 at 10:41 AM R3's call light activated. V4 (RN-Registered Nurse) responded to call light. V4 said he smelled a urine odor and saw flies in R3's room. V4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement fall interventions for one of three residents (R1) reviewed for falls. Findings included: On 10.14.2023 at 10:25 AM, R1 observed slightly slumped over, sleeping in a chair in the middle of her room. On 10.14.2023 at 10:57 AM, R1 observed slightly slumped over, sleeping in a chair in the middle of her room. On 10.14.2023 at 12:08 PM, R1 was observed standing up in the middle of her room. Unable to tell Surveyor about fall of 8.23.2023. R1 stutters and speaks non-sensical words most of the time but did eventually say I got to pee and ambulated slowly to the bathroom. On 10.14.2023 at approximately 1:15 PM, R1 was observed sitting in her room eating lunch. On 10.16.2023 at 11:34 AM, V2 (DON-Director of Nursing) said, I was notified by V10 (LPN-Licensed Practical Nurse) of R1's fall (8.23.2023) the next day, that V10 sent her out to the hospital. I looked at the hospital paperwork, spoke with the nurse, the CNA, I looked at R1'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 observation, interview, and record review the facility failed to serve food as planned on the cycle menu, and failed to ensure standardized recipes were followed during food preparation. This has the potential to affect all 157 residents receiving food prepared in the facility's kitchen. Findings Include: On 08/15/23 at 10:42 AM, V6 (Cook) stated for lunch residents on regular diet consistencies would be receiving fried chicken, white rice, and salad. The residents on mechanical soft diets would be receiving ground chicken, white rice and green beans. The residents on pureed diets would be receiving pureed chicken, pureed rice and pureed green beans. V6 stated they are in the 4th week of the cycle menu and pointed to the menu posted on the bulletin board near the food preparation area. Surveyor observed four weeks of cycle menus posted on the bulletin board. Week At a Glance Week 4 Menu for lunch meal listed the following items to be served: Chicken Piccata, Garlic Buttered Fettuccini, Caesar Salad, Seasonal Fresh Fruit, Dinner Roll/Margarine, Beverage. On 08/15/23 at 10:44…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a.) kitchen staff wearing hair net and beard coverings b.) food items were properly labeled, dated, and stored, c.) to discard moldy food, d.) properly rotate food by first in, first out practice, e.) store scoops in separate area from bulk food container. This failure has the potential to affect all 157 residents receiving food prepared in the facility's kitchen. Findings include: On 08/15/23 at 8:59 AM, entered kitchen for initial tour and observed V6 (Cook) walking around the kitchen, not wearing a hairnet. When surveyor introduced self to V6, V6 quickly put on a hair net. Dietary Director was not in the building at the time. Initial tour conducted with V6 (Cook). V6 stated V6 has been working at the facility for over 19 years. On 08/15/23 at 09:02 AM, observed in 1st walk-in refrigerator the following items: Opened 48 ounces Concord Grape Jelly with delivery date 08/01/23. Opened 1-gallon Sweet Pickle Relish dated with delivery…

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

Based on observation, interview and record review, the facility failed to ensure the dumpsters was covered to prevent the harborage and feeding of pests. This failure has the potential to affect all 161 residents who reside in the facility. Findings include: On 08/15/23 at 9:28 AM, V8 (Dietary Aide) brought surveyor to compacter room which contained six dumpsters. The compactor room was a large room attached to the building. Four of the six dumpsters in the room had lids wide open with two of these dumpsters piled very high with garbage. Gnats were observed flying in swarms all over opened dumpsters and live gnats covering the ceiling tiles, walls, and doorway of the compacter room. When surveyor and V8 walked by the gnats on the walls and doorway the gnats started to fly all around. Surveyor observed standing water on the floor and large drain in the middle of the floor. V8 stated the dumpster lids should be closed to keep the flies away and they that they have a problem with flies. On 08/15/23 at 3:29 PM, V7 (Dietary Manager) and V21 (Regional Dietary Manager) went with surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that MDS (Minimum Data Set) assessments were transmitted within 14 days of the final completion date to thCenters for Medicare and Medicaid Services (CMS) system. This failure can potentially affect 11 (R4, R16, R17, R31, R51, R62, R72, R92, R93, R109, R112) of 11 residents reviewed for resident assessment in a sample of 32. The findings include: R4's health record documented admission date of 8/22/21 with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, Type 2 diabetes mellitus, Peripheral vascular disease, Gastro-esophageal reflux disease, Chronic kidney disease stage 3A, Heart failure, Major depressive disorder, Hyperlipidemia, Essential hypertension, Anemia, Atherosclerotic heart disease. R16's health record documented admission date of 6/20/16 with diagnoses not limited to Cerebral infarction, Heart failure, Cognitive communication deficit, Insomnia, Vitamin D deficiency,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure incontinence care was provided in a timely manner for a resident (R13) who is dependent in toileting, and to ensure nail care was provided to 3 (R69, R3, R42) of 4 residents who are dependent with personal hygiene reviewed for activities of daily living (ADL) in a total sample of 32. Findings Include: 1. On 8/15/23 at 11:26 AM, R69 was still lying in bed alert wearing a hospital gown, alert and able to verbalize needs. R69's fingernails were noted approximately 2.0 centimeters (cm) long with black substance under R69's fingernails. R69 does not remember the last time R69's fingernails were cut and cleaned. R69's clinical records show diagnoses not limited to End-Stage Renal Disease, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Weakness, Adult Failure to Thrive, and Cognitive Communication deficit. R69's Minimum Data Set (MDS) dated [DATE] shows R69's is moderately impaired in cognition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility: 1. Failed to ensure emergency tracheostomy care equipment was readily accessible for 2 (R70, R82) of 2 residents reviewed for tracheostomy care. 2. Failed to ensure that oxygen liter flow ordered by physician is followed for 3 (R33, R104, R413) residents. 3. Failed to place oxygen in use sign outside the room for 3 (R33, R104, R413) residents. 4. Failed to ensure oxygen cannula tubing is place in bag when not in use for 1 resident (R155). 5. Failed to ensure that oxygen cylinder / tank was in a cylinder stand for 2 (R104 and R413) residents. These failures have the potential to affect 6 (R33, R70, R82, R104, R155, R413) of 6 residents reviewed for respiratory care in the sample of 32. The findings include: R33's health record documented admission date of 4/16/23 with diagnoses not limited to Chronic obstructive pulmonary disease, Neoplasm of trachea, bronchus and lung, Major depressive disorder, Unspecified dementia, Schizoaffective disorder,…

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

Based on observations, interviews and record reviews, the facility failed to properly date opened multi-dose inhaler, nasal spray, and multi-dose insulin pens and vial for 4 residents (R42, R150, R413, R86), and to properly store medications according to the manufacturers' guidelines for 2 residents (R2, R11) from three of three medication carts inspected for medication storage and labeling. Findings Include: On 8/15/23 at 12:26 PM, inspected 4th floor's medication cart 2 with V18 (Licensed Practical Nurse). The following were noted: -R11's opened Lorazepam liquid oral concentrate stored inside the narcotic locked box. Label shows to STORE IN REFRIGERATOR. -R42's opened Novolog insulin vial without the date opened written on the label. At 12:32 PM, inspected 2nd floor's medication cart 2 with V17 (Registered Nurse). The following were noted: -R86's opened Fluticasone nasal spray without the date opened written on the label. -R2's unopened Lispro insulin pen that shows on the label to Refrigerate until opened. -R150's opened Lispro insulin pen without the date opened written 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 reviews and interviews, the facility failed to a.) administer the pneumococcal vaccination to 1 (R131) resident with a signed consent and b.) the facility failed to assess the residents for eligibility and ensure residents were offered the pneumococcal vaccination for 3 (R70, R82, R90) of 4 (R215) residents reviewed for immunization in a sample of 32. Findings Include: R70 has diagnosis not limited to Encounter for Attention to Tracheostomy, Chronic Respiratory Failure with Hypoxia, Dysphagia, Pressure Ulcer of Sacral Region, Stage 4, Chronic Obstructive Pulmonary Disease, Anoxic Brain Damage and Gastrostomy. R70: Pneumovax (There was no documentation) R82 has diagnosis not limited to Malignant Neoplasm of Hypopharynx, Epigastric Pain, Gastritis, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Solitary Pulmonary Nodule, Sialoadenitis, Aphonia, Malignant Neoplasm of Oropharynx, Dysphagia and Encounter for Attention to Tracheostomy. R82: Pneumovax (There was no documentation) R90 has diagnosis not limited to End Stage Renal Disease, Psychosis,…

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

Based on observation, interview, and record review, the facility failed to ensure a resident who was self-administering medications, had a self-administration of medications evaluation, a physician's order, and a care plan completed for 1 (R102) of 1 resident reviewed for self-administration of medications in a total sample of 32. Findings Include: On 8/15/23 at 10:01 AM, a medication administration observation conducted with V4 (Licensed Practical Nurse). At approximately 10:12 AM, V4 administered some of R102's morning medications except for R102's nasal spray and eye drops. V4 stated that R102 self-administers the nasal spray and R102 keeps it at bedside. At 10:37 AM, interviewed R102 and stated that R102 keeps the nasal spray in R102's room. R102 stated, I gave it to myself this morning. At 11:18 AM, Surveyor observed V4 enter R102's room with R102's eye drops. R102 stated, I'll do it myself. Surveyor observed R102 administered one drop in each eye without pulling R102's lower eyelids down. R102 then rubbed the solution off R102's eyes using his fingers. On 8/16/23 at 11:45 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow policy for comprehensive care plan to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's needs and problems. This failure can potentially affect 3 (R113, R138, R413) of 3 residents reviewed for comprehensive care plan in the sample of 32. The findings include: R113's health record documented admission date of 1/12/21 with diagnoses not limited to Paroxysmal atrial fibrillation, Essential hypertension, Type 2 diabetes mellitus, Major depressive disorder, Anxiety disorder, Vitamin D deficiency, Gastro-esophageal reflux disease, Hyperlipidemia, Anemia, Nicotine dependence, Heart failure, Atherosclerotic heart disease. R138's health record documented admission date of 9/22/22 with diagnoses not limited to Metabolic encephalopathy, Schizoaffective disorder, Insomnia, Alcohol abuse, Opioid abuse, Cocaine abuse, Hyperlipidemia, Nicotine dependence, 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, interview and record review the facility failed to ensure an air mattress used for pressure reduction was on the correct setting for 1 (R37) of 2 (R70) residents reviewed for pressure ulcers in a sample of 32. Findings Include: R37 was admitted to the facility on [DATE] with diagnosis not limited to Muscle Weakness, Elevated [NAME] Blood Cell Count, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Protein-Calorie Malnutrition, Acquired Deformity of hand, Left Hand, Sepsis, Paroxysmal Atrial Fibrillation, Chronic Embolism and Thrombosis, Pressure Ulcer of Unspecified Site, Disorder of Muscle, Disorder of Bone Density and Structure, Reduced Mobility, Abnormalities of Gait and Mobility and Lack of Coordination. R37 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 14 indicating intact cognitive response. R37 Weights and Vitals Summary dated 08/15/23 document in part: Weight Summary 07/01/23 100.3 pounds and 08/10/23 100.9 pounds. R37 Order Summary Report dated 08/15/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure pain was thoroughly assessed and adequately treated for in a timely manner for 1 (R102) of 1 reviewed for pain management in a total sample of 32. Findings Include: During the medication administration observation with V4 (Licensed Practical Nurse) on 8/15/23 at 10:02 AM, R102 requested pain medication from V4. V4 did not assess the type, location, and rate of R102's pain. At 10:12 AM, V4 administered some of R102's morning medications except the pain medication R102 requested. V4 stated that the pain medication ordered for R102 was not available in the medication cart. At 10:37 AM, interviewed R102 and stated that V4 has not given R102 the pain medication R102 requested. R102 stated that R102's pain is at 8 out of 10. R102 stated the R102 has generalized pain related to arthritis and also takes the pain medication for gout. At 11:13 AM, V4 administered R102's pain medication. V4 did not further assess R102's pain. 8/17/23 at 9:54…

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

Based on interview and record review, the facility failed to follow their policy and procedure for Psychotropic Medication Program and ensure that a gradual dose reduction (GDR) was attempted for a resident receiving antipsychotic medication. This failure has the potential to affect 1 (R42) of 5 residents reviewed for psychotropic medications in a total sample of 32. Findings Include: On 8/17/23 at 9:28 AM, reviewed R42's Medication Administration Record (MAR) for August 2023 and revealed R42 was receiving antipsychotic medication SEROquel Oral Tablet (Quetiapine Fumarate) Give 12.5 mg by mouth in the morning related to ADJUSTMENT DISORDER WITH ANXIETY (F43.22) AND Give 12.5 mg by mouth in the evening related to ADJUSTMENT DISORDER WITH ANXIETY (F43.22). R42's progress notes dated 10/12/22 at 10:07 AM written by V41 (Psychiatry Nurse Practitioner) shows R42 was started on Seroquel 12.5mg twice a day. R42's electronic health records (EHR) do not show any documentation that facility attempted a GDR for R42's antipsychotic medication. R42's psychotropic notes dated 11/1/22, 12/20/22,…

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

Based on observations, interviews, and record reviews, the facility failed to follow their policy of dating opened boxes of food, and canned goods, in the refrigerator, freezer, and pantry. This had the potential to affect all 171 resident who reside at the facility. Findings include: On 6/21/22 during the initial kitchen tour the following were observed. On 06/21/22 at 11:42 am two open boxes of frozen Spinach without date opened. On 06/21/22 at 11:44 am, one 10lb open box of frozen Bratwurst without date opened. On 06/21/22 at 11:48 am, one open box of 6 Idaho Potatoes Flakes without date opened. On 06/21/22 at 11:50 am, large can fruit without date received. On 06/21/22 at 11:52 am, four large cans of tuna without date received. On 06/21/22 at 11:56 am, two boxes of Thicket(oral fluid thickener) open without date opened. On 06/21/22 at 12:16 PM V9 (Dietary Manager) stated staff is to put date on opened food so everyone can know if food can still be used, or it can get people sick. Facility policy titled, Labeling and Dating Foods, (2016) states in part: To decrease the risk 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, interview and record review, facility failed to follow their call light policy to ensure call lights are placed within reach for 5 (R331, R15, R88, R108, R160) residents reviewed for call lights in a final sample of 24. Findings include: 06/21/22 10:43 AM, surveyor saw R331's call light on the floor. R331 stated she does not know where her call light was. She (R331) also stated that it's been a couple hours since a nurse or CNA have come in the room. On 06/23/2022 at 1:55 PM, V2 (Director of Nursing) stated, hourly rounding is done every two hours. As soon as they see a call light, the nurse or CNA should tend to it. Call light should be placed within reach of the resident. If the call light is not within reach, they cannot call for their needs. On 06/22/22 at 10:53 AM R88 was observed sitting on the bed removing his (R88) Tee-Shirt and putting on a shirt. R88 call light was observed on the floor, between the bed and near the head of the bed, not within R88 reach. On 06/21/22 at 10:55 AM R108 was observed in bed in a semi-Fowler_position. R108 call light was…

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

Based on observation, interview and record review, the facility failed to follow their policy's on Physician's Orders and Weighing of residents, for 4 residents (R28, R43, R134 and R122) reviewed for quality of care. Findings Include: On 6/22/22 at 10:20 AM during record review of R28, R43, R134 and R122. Residents noted with physicians orders for bi-weekly weights to be done on Tuesday and Friday. Record review showed from the date order was placed on 2/16/22, for R28, R43, R134, R122, recordings to the electronic medical record inconsistent to said order, noted multiple weights not recorded. R28 was admitted to facility on 8/14/20; with a diagnosis, not limited to, Congestive Heart Failure (CHF). One weight recorded on 6/3/22, up to date of survey entrance of 6/21/22. One weight recorded on 5/5/22, no other weights recorded for May. R43 was admitted to facility on 3/15/21; with a diagnosis, not limited to, CHF. One weight recorded on 6/3/22, up to date of survey entrance, 6/21/22. One weight recorded on 5/5/22, no other weights for May noted. R122 was admitted to 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.

Based on observation, interview, and record review, the facility failed to a.) ensure medications were not pre-poured during one medication pass, b.) ensure expired medications were removed from the medication cart c.) ensure items other than medications were not stored in the medication refrigerator and d.) ensure the temperature was monitored in one of 2 medication refrigerators during the Medication Labeling and Storage and the Medication Administration observation. Findings Include: R55 has diagnosis not limited to Type 2 Diabetes Mellitus, Dementia and Mild Protein-Calorie Malnutrition. Order Summary Report dated 06/22/22 document in part: Lantus Solution 100 UNIT/ML (Milliliter) inject 6 units at bedtime. Medication Administration Record dated 06/01/22 - 06/30/22 document in part: R55 received Lantus Solution 100 UNIT/ML (Milliliter) inject 6 units 5 times from 06/16/22 - 06/21/22. R55 care plan document in part R55 has Diabetes Mellitus. R162 has diagnosis not limited to Type 2 Diabetes Mellitus, Major Depressive Disorder, Anxiety Disorder, Alzheimer's Disease and Chronic…

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

Based on observation, interview and record review the facility failed to ensure proper infection control practices were performed to prevent cross contamination when using blood glucose testing supplies. This deficient practice has the potential to affect 8 residents (R3, R50, R55, R61, R75, R79, R127, R162) receiving blood glucose monitoring on the 4th floor. The facility also failed to follow policy related to urinary catheter care by placing a urinary catheter bag directly on the floor for 1 (R177) of 4 residents with history of urinary tract infection (UTI) in a sample of 34. Findings include: On 6/21/22 at 11:05 AM, R177 was observed sleeping comfortably in bed. Surveyor noted urinary catheter drainage bag was placed directly on the floor with no privacy bag and approximately 80% full. At 11:18 AM, surveyor requested the assistance of V3 (Restorative Aide). Upon entering R177's room with V3, R177's urinary catheter drainage bag was seen on the floor with light yellow cloudy urine and no privacy bag. V3 checked urine output in the bag with approximately 1700 milliliters. V3…

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

Based on interview and record review, the facility failed to follow their policy on immunization protocol and failed to provide documentation on the educational component on why the influenza and the pneumococcal vaccines are important for the elderly or immunocompromised residents for 6 residents (R37, R40, R57, R83, R332 and R433) reviewed for vaccines in the sample of 24 residents. Findings include, R433's Consent/Pneumonia Vaccine PCV 13 with education documents in part: Consent to Vaccination. R433's immunization records documents in part: R433 has no influenza or pneumonia vaccination administered. R332's immunization records documents in part: R332 has no pneumonia vaccine offered, or refusal documented. Reviewed R332's medical records, progress notes and physician orders. No documentation of benefits and risks of pneumonia vaccination education was noted. R57's immunization record documents in part: R57 not vaccinated for influenza and pneumonia. Reviewed R57's medical records, progress notes and physician orders. No documentation of benefits and risks of pneumonia…

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

Based on observation, interview and record review, facility failed to follow their policy to maintain a resident's dignity by placing a Foley catheter drainage bag in a drainage cover for 1 (R83) resident out of 3 residents reviewed for Foley catheter care in a sample of 24. The facility also failed to provide privacy during an insulin injection for 1 (R125) of 7 (R63, R78, R91, R121, R163, R171) residents reviewed during medication administration. Findings include: R125 has diagnosis not limited to Type 2 Diabetes Mellitus, Chronic Kidney Disease, Major Depressive Disorder, and Cerebral Infarction. Order Summary Report dated 06/22/22 document in part Novolog Flex Pen Solution Pen-injector 100 UNIT/ML (Milliliter) (Insulin Aspart) Inject 15 unit subcutaneously with meals and Novolog Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 201 - 250 = 3; 251 - 300 = 5; 301 - 350 = 8; 351 - 400 = 10 Greater than 400 mg/dL. Give highest dose and call MD (Medical Doctor)., subcutaneously with meals. On 06/22/22 at 11:08 AM during medication administration observation V16…

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

Based on observation, interview and record review the facility failed to ensure a resident who was self-administering medication had a physician's order, self-administration of medications assessment and a care plan completed. This failure has the potential to affect 1 resident (R91) for taking medication without supervision. Findings Include: R91 was readmitted to the facility 05/26/21 with diagnosis not limited to Unspecified Dementia, Mild Cognitive Impairment, Unspecified Glaucoma, Altered Mental Status and Post Traumatic Stress Disorder. Order Summary Report dated 06/23/22 document in part: Brimonidine Tartrate Solution 0.2% Instill 1 drop in both eyes at bedtime, Brimonidine Tartrate Solution 0.2% Instill 1 drop in both eyes in the afternoon, Brimonidine Tartrate Solution 0.2% Instill 1 drop in both eyes in the morning, Timolol Maleate Solution 0.5% Instill 1 drop in both eyes in the evening and Timolol Maleate Solution 0.5% Instill 1 drop in both eyes in the morning. Record review of sign posted at R91 bedside document in part Latanoprost 0.005% 1 drop both eyes once/bedtime…

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

Based on observation, interview and record review the facility failed to provide tube feedings as ordered for 1 (R108) of 2 (R41) residents reviewed for tube feeding. R108 has diagnosis not limited to Encounter for Attention to Gastrostomy, Cognitive Communication Deficit, Dysphagia, Cerebral Infarction and Gastritis. On 06/21/22 10:55 AM R108 was observed in bed in a semi-Fowler_position with the Enteral feeding infusing at 65 ml/hr (Milliliter/hour) per pump amount delivered 29 ml. On 06/21/22 at 11:42 AM V5 (Licensed Practical Nurse) entered R108 room with the surveyor. V5 stated R108 enteral feeding infuses at 65 ml/hr from 06:00 AM - 12:00 midnight. R108 enteral feeding pump was observed to be turned off. V5 stated I had to hang another bottle at 10:00 AM. I don't know who turned it off. It may have been a Certified Nurse Assistant. R108 Physician Orders document in part: in the afternoon related to Dysphagia following Cerebral Infarction Jevity 1.5 @ 65 ml/hr x 18 hours (start 2pm; end 8 am) and in the morning related to Dysphagia following Cerebral Infarction Jevity 1.5 @ 65…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to develop a person-centered dementia care plan for 1 (R103) out of 1 resident reviewed for dementia care in a sample of 34 residents. Findings include: R103 was initially admitted to the facility on [DATE]. R103 has a diagnosis, that is not limited to, Unspecified Dementia without Behavioral Disturbance. According to R103's most recent minimum data set (MDS), R103 is cognitively impaired. On 06/22/22 at 01:30 PM R103's entire care plan was reviewed. No individualized dementia care plan with interventions was identified in R103's electronic medical record. On 06/22/22 at 01:30 PM A printout of R103's social service care plans were provided by V1 (Administrator) and no individualized dementia care plan with interventions identified in R103's electronic medical record. On 06/23/22 at 11:03 AM V23 (Social Worker) stated, R103 does have a diagnosis of dementia. R103 should have a dementia care plan. On 06/23/22 at 12:07 AM V23 (Social Worker) stated, 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 observation, interview and record review the facility failed to ensure that all medications were administered without an error rate of 5% or more. for 3 of 7 residents (R121,R163, R125) During Medication administration on 06/22/22 the surveyor observed 3 nurses administer medication to 7 residents. There were 25 opportunities for error and 5 errors were observed. This deficient practice resulted in a medication administration error rate of 20%. Findings Include: 1. R121 has diagnosis not limited to Essential (Primary) Hypertension, Vitamin D Deficiency, Heart Failure, Dementia, Syncope and Collapse. Order Summary Report dated 06/22/22 document in part: Aspirin Tablet Chewable 81 MG by mouth in the morning and Cholecalciferol Tablet Give 2000 unit by mouth in the Morning. On 06/22/22 at 08:49 AM V15 (Registered Nurse) was observed preparing R121 medications. V15 put Aspirin Tablet Chewable 81 MG (Milligram), Cholecalciferol Tablet Give 2000-unit, (Vitamin D3 25 mcg 1000 IU (International Unit), was given), Cyanocobalamin Tablet 500 MCG Give 2 tablet, Ferrous Sulfate Tablet…

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

Based on observation, interview and record review the facility failed to ensure a resident was free from a significant medication error related to insulin administration for 1 (R125) of 7 residents reviewed for medication administration. Findings Include: R125 has Diagnosis not limited to Chronic Kidney Disease, Cerebral Infarction, Type 2 Diabetes Mellitus, Cognitive Communication Deficit and Major Depressive Disorder. Order Summary Report dated 06/22/22 document in part: Novolog Flex Pen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 15 unit subcutaneously with meals and Novolog Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 201 - 250 = 3; 251 - 300 = 5; 301 - 350 = 8; 351 - 400 = 10 Greater than 400 mg/dL. Give highest dose and call MD., subcutaneously with Meals. Medication Administration Record dated 06/01/22 - 06/30/22 document in part: Novolog Flex Pen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 15 unit was given at 11:02 AM (which was not given) and Novolog Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale was…

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