Warren Barr Gold Coast

Based on interview and record review the facility failed to complete a resident's assessment and transmit data to the CMS (Centers for Medicaid and Medicare) system within 14 days after resident discharged from the facility for one (R151) resident reviewed in a sample of 35 residents. Findings include: 12/05/24 at 3:39 PM, V34 (MDS/Clinical Coordinator) states that she is familiar with R151, when residents go to the hospital, MDS completes the discharge return anticipated assessment and plan needs to be completed per MDS guidelines. V34 states that she has to check R151's assessments. V34 states that when residents are admitted MDS completes an entry assessment. V34 states that if the resident gets sent out to the hospital an assessment must be completed within 14 days. With V34, R151's MDS assessment reviewed and V34 states that R151's discharge assessment was not completed. V34 states that R151's discharge assessment will be completed today. R151's MDS assessment documents in part Discharge complete by 08/5/2024- 122 days overdue. Facility document note dated title RAI OBRA-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to refer one resident (R143) of seven residents reviewed with serious mental disorders for a Preadmission Screening and Resident Review (PASARR) level 11 assessment in a sample of 35. Findings include: R143 current face sheet documents R143 is a [AGE] year-old individual with medical diagnosis dated 4/11/2024 include but not limited to: schizoaffective disorder, unspecified, anxiety disorder, unspecified, depression, unspecified. Brief Interview for Mental Status (BIMS) dated 10/15/2024, does not document R143's BIMS. R143's Preadmission Screening and Resident Review (PASRR) 1 Screening dated 04/09/2024 documents R143 does not have suspected of known mental diagnosis. On 12/05/2024, at 1:02 PM, V2 (Director of Nursing-DON) said R143 has mental health diagnosis of schizoaffective disorder, depression, and anxiety and should have been evaluated for PASARR 11 so R143's behavior can be monitored as well as the medications he is taking for behavioral health.…

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 pressure ulcer preventative measures were accurately applied for three residents (R3, R26 and R49) in a sample of 35 residents reviewed for pressure ulcer. Findings include: 12/4/24, at 12:24 PM, observed R49 low air loss mattress setting at approximately 310 LBS (pounds). 12/4/24, at 12:27 PM, observed R3 lying on a low air loss mattress. The mattress had a flat sheet on it and there was a fabric chuck/pad underneath R3 and R3 was wearing an adult brief. 12/3/24, at 1:15 PM, observed R26 low air loss mattress setting at 90 LBS. There was a fitted sheet on the mattress and a fabric chuck/pad underneath R26 and R26 was wearing an adult brief. 12/4/24, at 1:27 PM, V31 (Registered Nurse) verified there was a fitted sheet on R26's low air loss mattress and a pad that is referred to as a chuck and R26 was wearing an undergarment/adult brief. V31 stated R26 has a low air loss mattress for wounds. The general purpose of the low air loss…

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 records review, the facility failed to keep record of receipt and disposition of one controlled drug in sufficient detail to enable an accurate reconciliation in a medication cart that serves 23 residents on the 8th floor and failed to keep an account of all controlled drugs is maintained and accurate for three (R61, R117, R429) in a sample of 35 reviewed. Findings include: 12/03/2024 at 10:20 AM, V5 (Registered Nurse) states that she is an agency nurse. After reviewing narcotics in the medication cart, there was one Hydromorphone 2mg (milligram) tablet in a three-tablet bingo card, appeared as if it was cut into this section, with no resident name and no controlled substance record form. V5 states that when she counted the narcotics with the previous nurse, V5 states that she was informed that it was an extra medication. V5 states that this medication should not be in the cart and unaccounted for. V5 states that there is no controlled substance record form to account for this medication (Hydromorphone 2mg one tablet). V5 states that she does…

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 medication error rate of less than 5% for two (R89, R427) of six residents reviewed for medication administration resulting in a 6.67% error rate in a sample of 35 reviewed. Findings include: 12/04/2024, 8:40 AM, observed V7 (Registered Nurse/RN) administer the following medication: V7 primed tubing, connected to machine, wiped lumen, no bubbles, connected to resident. V7 states it should run over 55 minutes. Surveyor observed pump set at 166ml/hr. Vancomycin 750mg/150ml. Label says infuse at 120ml/hr. nurse dated it with date and time. R427's current Physician Order Sheet document in part: Vancomycin HCI 750 MG/150ML Solution premixed vancomycin 750mg in 150ml water. Infuse intravenously at 120ml/hr (hour) over 75mins. Every other day for bone and joint infection until 12/31/24. 12/04/24, 9:57 AM, V7 (RN) states that nurses usually choose the intravenous (IV) medication dose in the pump, and the pump will set up the rate. V7 states that's the procedure. We put in the dose and the machine will give us…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and review of records the facility failed to provide planning of care related to oral/dental care for 1 (R1) of 3 residents reviewed for improper nursing care. Findings include: R1 is [AGE] years old, initially admitted on [DATE], with diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R1 is cognitively intact as assessed on 8/27/2024 with a BIMS (Brief Interview of Mental Status) of 15. On 10/15/2024 at 1:07 PM, R1 was seen laying on bed in her room. R1 was alert and verbally able to express her thoughts within topic during conversation. R1 stated that her tooth does not bother her as much as before. R1 stated that her tooth problem is located at the top left area in her mouth and now she does not chew on the left side where she used to chew and she knew that there was a problem on her tooth when she felt a sharp end on her tooth. R1 said, At first it was terrible, and it was swollen. It started around the second week of September. R1 had…

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 precaution interventions for two (R2, R4) residents identified as a fall risk out of three residents reviewed for fall precautions. Findings include: 1. On 08/31/2024 at 11:54AM, surveyor observes R2 lying in R2's bed resting inside of R2's room in a supine position with head of bed elevated at 45 degrees. Surveyor observes R2's bed alarm pad hanging on the rails at the top/head of R2's bed. R2 is verbal and noted with confusion. On 08/31/2024 at 12:00PM, V5 (Registered Nurse/RN) now located inside of R2's room and observes R2's bed alarm pad. V5 states R2's bed alarm pad should not be there and V5 is not sure why R2's bed alarm pad is hanging over the top/head of R2's bed. V5 states R2's bed alarm pad should be placed underneath R2's body while R2 is in bed. V5 states if R2's bed alarm pad is not in place then R2 could move while in bed and fall. V5 states R2 could potentially injure herself or fracture a bone if R2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure that a dependent resident's call device was answered promptly for 1 of 9 residents (R3) reviewed for care. Findings include: R3 is [AGE] year old with diagnosis including but not limited to: Secondary malignant neoplasm of brain, abnormalities of gait and mobility, unspecified lack of coordination, unsteadiness on feet, and other specified soft tissue disorders. R3 has a BIMS (Brief Interview of Mental Status) score of 14, which indicates cognitively intact. On 03/26/2024 during investigation, R3 was observed lying in bed in her room. On 03/26/2024 at 2:21 PM, R3 activated her call device by pressing the button on her device to call for help from her nurse assistant or nurse. The light outside of R3's bedroom was illuminated to indicate that R3's call device was activated. On 3/26/2024 at 2:48 PM, as R3 waited patiently for her someone to come to her room to assist her, R3 said, This happens frequently. There has been times that I…

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 administer medication per physician parameters prior to hemodialysis which affected one resident (R2) in the total sample of 10 residents reviewed for improper nursing care. Findings include: On 1/10/24 at 11:07 am, R2 stated that R2 goes to an external hemodialysis center for hemodialysis treatments on Tuesdays, Thursdays, and Saturday mornings at 4:45 am. R2 stated that R2 is transported to the external hemodialysis center approximately one hour before each session. R2 stated that R2 is to receive R2's Midodrine before leaving for the dialysis sessions for my blood pressure, and I have to tell the nurses about it. R2 stated that R2 has not received the Midodrine dose after reminding the nurse. R2's admission Record, documents, in part, diagnoses of , end stage renal disease, dependence on renal dialysis, encounter for surgical aftercare following surgery on the digestive system, personal history of COVID-19, gastroesophageal reflux disease,…

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 interview, the facility failed to provide a clean and homelike environment for the residents. This failure applies to all 188 residents in the facility. Findings include: On 12/12/2023 at 1:39 pm, during the initial tour of the third floor observed missing tiles along the back of the tub in the spa/shower room. In the pantry on the third floor observed missing tiles on the lower right wall located adjacent to the refrigerator. On 12/12/2023 at 1:51 pm, during initial tour of the fourth floor observed four missing green and ivory tiles on the lower right wall in the pantry room. On 12/12 2023 at 1:54 pm, during the initial tour of the fifth floor observed pantry room, white cabinet underneath the sink with the floor of the cabinet cracking and covered with brown stains. Also observed in the fifth-floor pantry, white cabinet underneath the ice machine, the floor of the cabinet with brown stains. Observed a streak of food splattered on the right wall of the fifth-floor pantry room. On 12/12/2023 at 2:05 pm, during initial tour of the sixth floor, the spa/shower…

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 record review, the facility failed to ensure that fall care plan and interventions were updated and in place for one resident (R4) who has history of falls and is recognized as a high fall risk patient. This failure has the potential to affect 6 other individuals classified as 'High Fall Risk' patients. Findings include: R4 is [AGE] year old with diagnosis including but not limited to: Polyneuropathy, Bilateral Primary Osteoarthritis of knee, Lymphedema, Obesity, and Polyosteoarthritis. R4 was admitted to the facility on [DATE] and assessed to be a High risk for falls based on assessments dated 12/09/2023. R4 had a fall on 12/09/2023 and was sent to the hospital for evaluation. On 12/12/2023 during investigation (10:20 AM), R4 was observed in bed with V9 (R4's son) at the bed side. At that time, R4's bed was observed to be three feet elevated (from the floor) and no floor mat was noted on the floor next to R4's bed. On 12/12/2023 at 10:20 AM, V9 said, My mom (R4) just fell…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to immediately transfer a resident (R2) to a local hospital for emergent services after a fall with head injury. This failure affected one resident (R2) of three reviewed for falls and as a result, there was a delay of 39 minutes in R2 receiving treatment for an acute subdural hematoma. Findings include: According to Electronic Medical Record, R2 is [AGE] year old with diagnosis including but not limited to: Unsteadiness on feet, Lack of coordination, Venous Insufficiency, Chronic Venous Hypertension, Heart Failure and Unspecified Right Bundle- Branch Block. R2 was admitted to the facility on [DATE] and sustained a fall on 11/07/2023. On 12/11/23 during investigation, Surveyor inquired about R2's fall incident that occurred on 11/07/2023. On 12/11/23 at 10:55 AM, V12 (R2's daughter) said, My mom (R2) fell and hit her head in the facility and passed on 11/16/2023 at 2:54 PM in the hospital after the fall. My mom (R2) passed after the 11/07/23 fall. 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, a facility staff failed to wear the proper personal protective equipment while providing direct care for one resident (R4) on isolation. This failure has the potential to affect all 188 residents in the facility. Findings include: On 12/12/23 at 10:20 am, during rounds on the eighth floor, Surveyor observed V15 (CNA/Certified Nursing Assistant) entering R4's room without a gown on. V15 (CNA) proceeded to change R4's incontinence brief while R4 was in the bed. Surveyor observed V15 (CNA) leaning on R4's bed as she (V15) rendered care. On 12/12/23 at 10:21 am, surveyor observed the Contact Precautions Sign on R4's room door. The Contact Precautions Sign documents in part, providers and staff must also: Put on gown before room entry. On 12/12/23 at 10:27 am, Surveyor inquired about V15's PPE (Personal Protective Equipment). On 12/12/23 at 10:28 am, V15 (CNA) stated, I usually wear my gown, but R4 was such a mess that I wanted to hurry up and clean her. That's why I didn't wear my gown. I know I'm supposed to wear it (gown) for my…

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 appropriate use of personal protective equipment (PPE) was worn by staff caring for three residents(R6, R7, R8) with potential and known infectious disease. This failure has the potential to affect 77 residents residing on the fifth and seventh floor in facility. Findings include: On 11/29/2023 at 10:53AM, surveyor located on the fifth floor of the facility and observed a sign posted on R7's door. Sign posted documents in part, Enhanced Barrier Precaution Everyone Must: clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and gown for the following High-Contact Resident Care Activities. Device care or use: central line, urinary catheter, feeding tube, tracheostomy. V8 (Agency Licensed Practical Nurse/LPN) was observed inside of R7's room without gloves or gown and observed providing tube feeding care for R7. On 11/29/2023 at 10:54AM, V8 stated she just administered R7's bolus tube feeding. V8 stated she was supposed to be wearing a gown…

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 keep 4 residents (R30, R94, R97, R274) rooms clean. This failure has the potential all the residents residing on the 7th floor. Findings including: R30 has a diagnosis of but not limited to Radiculopathy, Major Depressive Disorder, Chronic Embolism and Thrombosis of Deep Veins of Left Lower Extremity and Heart Failure. R30 has a Brief Interview of Mental Status score of 15. R94 has a diagnosis of Multiple Sclerosis, Spinal Stenosis, Hyperlipidemia, Anxiety Disorder, Hypertension and Venous Insufficiency. R94 has a Brief Interview of Mental Status score of 15. R97 has a diagnosis of Folate Deficiency Anemia, Vitamin D Deficiency, Seizures, Acute Embolism and Thrombosis of Deep Vein of Right Lower Extremity, Unsteadiness on Feet, and Retention of Urine. R97 has a Brief Interview of Mental Status score of 11. R274 has a diagnosis of Urinary Tract Infection, Paraplegia, Chronic Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, and Cognitive Communication Deficit. R274 has a Brief Interview of Mental…

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 store food 6 inches off the floor in effort to prevent foodborne illness and failed to ensure the dish washer machine sanitized the dishes at the proper temperature. These failures have the potential to affect all 182 residents receiving oral nourishments in the facility. Findings include: On 10/30/23 at 9:30 am, in the dry storage room observation of a large bag of oats on the floor leaning up against a cart not 6 inches off the floor. Six stacks of bread crates stacked on top of each other and the bottom crate touching the floor, not 6 inches off the floor. On 10/30/23 at 9:40 am, surveyor observed a dish washing cycle where the wash and rinse temperature gages did not move. Both gages stayed at 118 thru out the entire wash cycle. On 10/30/23 at 9:45 am, Surveyor inquired to V4 (Dietary Aide) what color is the test strip that just came out of the washer machine. V4 stated the washer test script looks grey but it should be black, and it's probably not black because the machine was just turn on. 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 observation, interview and record review, the facility failed to properly log refrigerator temperatures for resident's personal refrigerators, ensure safe temperatures for resident's personal refrigerators, remove food items from the resident's personal refrigerators by the expiration date for six residents (R6, R29, R23, R58, R43 and R62) and check for a working thermometer in a resident's personal refrigerator(R6). These failures have the potential to affect all 56 residents in the sample. Findings include: 1. On 10/30/2023 at 11:05 am, observed R29 with a black colored refrigerator with a freezer at the top and refrigerator on the lower portion in her room. Surveyor observed no temperature log affixed in or near the refrigerator. Surveyor looked in the inside of the refrigerator portion and observed a 236ml (milliliter) carton of 2% milk dated 10/23/2023. On 10/30/2023 at 11:13 am, V7 (Housekeeper) stated the housekeeper is responsible for checking the temperature of the resident's personal…

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 record review the facility failed to ensure that a call light was accessible for one visually impaired resident (R43), from a sample of 60 residents reviewed for call devices. Findings include: R43 is a [AGE] year old with diagnosis including but not limited to: Acute transverse myelitis in demylelinating disease of central nervous system, Cerebral palsey, Low back pain, malignant neoplasm of prostate and unilateral primary osteoarthritis of left hip. R43's BIMS (Brief Interview for Mental Status) score is 15, which indicates that R43 is cognitively intact. On 10/30/23 during investigation, R43 was observed awake sitting in bed. R43's wheel chair was on the left side of R43's bed and R43's call device was observed hanging from the side of the wheel chair, touching the floor. On 10/30/23 at 11:30 AM, Surveyor asked how R43 was doing. R43 said, I need help but I don't know where my call light is. I'm legally blind and it can be hard getting help sometimes. Do you see my call…

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 incontinence care to one resident (R30) out of a sample of 60 residents. Findings include: On 10/30/2023 at 12:46 pm, R30 stated that she has not been changed on this shift (6:00am-2:00pm) at all and that she is wet with urine and had a bowel movement. R30 stated she told the nurse that she needed to be changed at about 11:30 am but no one ever came back. On 10/30/2023 at 1:02 pm surveyor observed V11 (Agency CNA) provide incontinence care to R30 and there was a small of urine and R30 had had a bowel movement. V11 stated that she came in and checked R30 between 8 and 9:00am but she did not change her because she was dry. V11 stated rounds to check and provide incontinence care is done every two hours. On 11/01/2023 at 2:07 pm, V2 (DON) stated CNA's should be checking residents every 2 hours to provide incontinence care and should be documenting the care they provide or did not provide in Point of Care software (POC). On 11/02/2023 at about 10:20 am, surveyor observed R30's POC for Incontinence care 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 observation, interview, and record review, the facility failed to have low air loss mattress at the correct weight setting for a resident with pressure ulcer who is at high risk for further pressure ulcers. This failure affected one resident (R25) of two residents, reviewed for pressure ulcer prevention interventions, in a total sample of 60 residents. Findings include: On 10/30/23 11:41 am, R25 was observed in bed with V18 (RN/Registered Nurse). R25's Low air loss mattress (LALM) was set at a weight of 300 pounds but R25 weighs only 167.6 pounds. Again, on 10/31/23 at 1:32 pm, R25's LALM was still set at 300 pounds. V18 was notified and V18 changed the weight setting for R25. On 11/1/23 at 10:55 am, V25 (Wound Care Nurse) stated (R25) has MASD (Moisture associated skin damage), and the weight setting should always be at the patient's weight. R25's Pressure Ulcer Risk assessment dated [DATE] shows a score of 12 (high risk). R25's skin care plan dated 12/23/22 states in part: (R25) is at further risk 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 observation, interview and record review, the facility failed to label and date oxygen tubing per the facility policy. This failure affected one resident (R118) reviewed for oxygen equipment, in a total sample of 56 residents. Findings include: On 10/30/23 at 10:30 am, surveyor observed R118 in bed sleeping. R118 was observed with 2 liters oxygen via nasal cannula tubing in place in the nares unlabeled and not dated. On 11/01/23 at 11:23 AM, V19 (LPN/Licensed Practical Nurse) stated the oxygen tubing should be labeled with the date the tubing was changed. V19 stated the nurses are responsible for changing the oxygen tubing. V19 stated the oxygen tubing should be changed once a week or as needed. V19 stated no particular shift is responsible for changing the oxygen tubing. On 11/02/2023 at 2:07 pm, V2 (DON/Director of Nursing) stated the nurses are responsible for changing the oxygen tubing. V2 stated the tubing is to be changed weekly and as needed. V2 stated the night shift on a Sunday is when the oxygen tubing is to be changed by the nursing staff. V2 stated the nurses…

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 administer medications for two (R9, R10) residents reviewed for medications administration. This failure has the potential to affect R9 and R10's health. Findings include: On 10/17/2023 at 12:13 pm, V10 (Registered Nurse-RN Agency) was observed taking R10's blood pressure and blood glucose levels. Blood pressure was 140/80mmHg, Blood glucose was 307mg/dL. On 10/17/2023 at 12:38 pm, V10 was observed giving R10 medications. Medications given by mouth: Entresto 97-103 mg, 1 tablet, Bumetamide 2 mg, 1 tablet, Carvedilol 3.125mg 1 tablet, Metformin HCL 1000 mg, 1 tablet, Insulin lispro given 9 units subcutaneously. R10's physician order sheet documents above medications are to be given two times a day with the morning dose ordered for 9:00 am. V10 stated her schedule started at 9:00 am, and she is an agency nurse and does not know the residents, therefore it took her time to give medications today. V10 said medications should be given on time…

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 ensure staff donned required PPE (personal protective equipment) prior to entering a Contact Precaution room during wound treatment and during meal tray pass; and failed to ensure isolation bins are provided for a resident on contact precaution. These failures affected 1 (R4) resident reviewed for communicable disease and have the potential to affect all the residents on the 5th floor. Findings include: On 08/21/2023 at 12:44 pm, there was a CONTACT Precaution sign posted by R4's door and a PPE bin outside of R4's room. Inside the PPE bin was R4's (7/22/2023) Isolation Information which indicated that R4 was on isolation due to ESBL (Extended Spectrum Beta-Lactamase) in the urine. Also noted, was a treatment cart outside of R4's room. On 08/21/2023 at 12:45 pm, V9 (Wound Care Nurse/RN) peeked by R4's door. This surveyor informed V9 that this surveyor needed to observe V9 doing wound treatment to R4. At this time, observed V10 (Wound Care Tech) exiting R4's room. On 08/21/2023 at 12:48 pm, this 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.

Based on interview and record reviews, the facility failed to complete quarterly restorative assessments that detail the progress or lack of progress in the restorative services for 5 of 5 residents(R8, R19, R21, R26, R37) reviewed for limited range of motion and/or restorative services in the sample of 35. Findings include: On 12/06/22 at 11:55 AM, R21 was lying comfortably in bed and noted with right arm and hand contractures with no assistive device in place. R21's splint was noted on top R21's dresser. R21 could not answer when surveyor asked if staff are doing range of motion exercises with her (R21). At 12:14 PM, R37 was sitting on a wheelchair in the dining room noted with some limitations on R37's upper extremities. R37 stated that the staff on the floor do not do range of motion exercises with her (R37). At 12:27 PM, R26 was lying in bed and noted with limitations on upper and lower extremities. R26 stated does not remember if staff provides range of motion exercises with him (R26). On 12/07/22 at 9:27 AM, R8 was lying in bed and noted with functional limitations on both…

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 properly discard a multi-dose insulin 28 days after opening for 1 resident (R65); to properly date opened multi-dose inhalers for 2 residents (R65, R101); and to properly date opened multi-dose insulin vials for 4 residents (R9, R79, R145, R150) from three of six medication carts inspected for medication storage and labeling. Findings include: On 12/06/2022 at 09:46 AM, 4th floor team 2 medication cart inspected with V7 (Agency Registered Nurse). The following were found inside the medication cart: - R65's Lantus insulin with opened date on the label 11/02/22 and to discard after 28 days of opening. - R65's Breo inhaler without the date opened on the label and shows to discard 6 weeks after opening. - R101's Advair inhaler without the date opened on the label and shows to discard 1 month after opening. V7 stated that insulin vials and pens should be dated when opened. On 12/06/2022 at 10:10 AM, 3rd floor team 1 medication cart inspected with V8 (Agency Licensed Practical Nurse). The following were found inside…

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 1 resident (R124) reviewed for call lights in a final sample of 35. Findings include: On 12/06/22 at 10:55 AM, surveyor observed R124's call light on the floor behind the resident. On 12/08/2022 at 01:13 PM, V2 (Director of Nursing) stated the call lights should be within resident's reach. Patients should be rounded on at least every two hours. If a call light is not next to a resident, they will not be able to call for any help. If the call light is not next to a resident and they try to get up, the resident could fall. If a staff members goes into a resident room and sees the call light on the floor they should pick it up and place it within reach, either if the resident is in bed or in the chair. R124's care plan documents in part: R124 is at high risk for falls related to actual fall. R124 is totally dependent on the staff. Ensure call light is within easy reach. Transfer R124 using a hoyer lift with 2 staff assist. R124 requires…

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 2 staff members are present during a resident transfer with a mechanical lift for 1 of 8 residents (R83) reviewed for safe transfers. Findings Include: R83's Face Sheet documents resident is a [AGE] year old with diagnoses including but not limited to: EXTENDED SPECTRUM BETA LACTAMASE (ESBL) RESISTANCE, UNSPECIFIED ABNORMALITIES OF GAIT AND MOBILITY, UNSPECIFIED LACK OF COORDINATION, MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED, OTHER LACK OF COORDINATION, PARAPLEGIA, UNSPECIFIED, PERSONAL HISTORY OF OTHER VENOUS THROMBOSIS AND EMBOLISM, MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION, SECONDARY MALIGNANT NEOPLASM OF BONE. Minimum Data Set Section G (MDS) (dated 12/05/2022) scored R2 as (4) total dependence and a (3) requiring 2-to-3-person physical assistance for transfers. Care plan (dated 10/14/2022) notes R83 has impaired mobility function related to weakness, paraplegia, Metastatic Prostate Ca. R83 is on a Bed Mobility…

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 follow their policy and procedure to ensure the use of indwelling catheter was assessed at least quarterly to determine if use is still justified for a resident with history of Urinary Tract Infection. This failure has the potential to affect 1 of 2 residents (R96) reviewed for Indwelling Catheter Care. Findings include: On 12/07/22 at 10:07 AM, R96 stated I have a catheter due to my wound on my sacrum. R96 stated I had UTIs (Urinary Tract Infection) before. On 12/08/22 at 9:49 AM, V2 (DON/Director of Nursing) stated, R96's indwelling catheter is for multiple wounds; the catheter is changed prn (as needed), catheter care is every shift, should be ordered in the physician order sheet and would be reflected in Treatment administration record and Care plan. The current POS (Physician Order Sheet) reviewed with V2. V2 stated that she was unable to find the order for indwelling catheter change as needed; catheter care every shift in the POS. V2 further stated…

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 one resident received physician ordered oral nutritional supplements. This failure affected 1 of 4 residents (R103) reviewed for nutritional supplements. Findings include: Physician order (07/16/2022) for R103 states: Ensure Plus (Dietary Supplement) with meals for supplement 1 carton by mouth. R103's admission record indicated that R103 was admitted to the facility on [DATE] at the weight of 99lbs. On 12/06/2022 at 12:23 pm, R103 was observed on the 7th floor hallway eating lunch. Surveyor noted that R103 did not receive oral nutritional supplement as per physician order. When surveyor interviewed R103, R103 stated, They did not give me the Ensure drink. They did not offer it to me at all. On 12/07/2022 at 12:19 pm, R103 was observed eating lunch in resident's own room. Surveyor noted that R103 did not receive oral nutritional supplement as per physician order. R103 stated, They did not give me the nutritional drink this morning 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, interview and record review the facility failed to follow physician order for administering the correct ordered amounts of enteral tube feeding and enteral water flushing for 1 of 2 residents (R93) reviewed for enteral tube feeding management. Findings include: On 12/06/22 at 11:54 AM, R93 observed lying on bed on his back, head elevated with enteral / GT(gastrostomy tube) feeding infusing via pump feeding 1.5 60ml / hr; water flush 200ml every 4 hours. On 12/06/22 at 12:01 pm, V7 (Registered Nurse) observed, removed / disconnected enteral (GT) tube feeding. At this time, V7 stated enteral tube feeding is to be off at 12 noon and total volume infused is 875ml. On 12/07/22 at 09:54 AM, R93 observed lying on his back, head elevated. Observed GT tube feeding infusing via pump @60ml/hr; water flush 200ml every 4 hours. On 12/07/22 at 11:35 AM, V2 (DON/Director of Nursing) stated that G-tube feeding and water flushes depends on physician order and could be continuous or bolus feeding. V2 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a person-centered dementia care plan for 1 of 1 resident (R26) reviewed for dementia care in a sample of 35. Findings include: On 12/08/22 at 12:10 PM, reviewed R26's electronic health record. R26 was initially admitted to the facility on [DATE]. R26 has diagnosis, that is not limited to, UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY. According to R26's Quarterly Minimum Data Set Assessment (MDS) with an assessment reference date of 9/26/22, R26 has dementia but there were no quarterly Social Service Assessment or progress note addressing dementia care found in the electronic health record (EHR). R26's comprehensive care plans were reviewed in the EHR and no care plan for dementia was identified. On 12/08/22 at 1:11 PM, V13 (Social Service Director) stated that the facility utilizes the care plan to ensure that residents' individualized dementia care needs are…

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.