Westwood Vlge Nrsg And Rhb Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy to assess for self-administration of albuterol medication. This failure effected 2 residents (R58 and R79) out of 4 residents with chronic obstructive pulmonary disease (COPD) reviewed for self-administering medications in a total sample of 21 residents. Finding Include: 1.) R58's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: chronic obstructive pulmonary disease, muscle wasting and atrophy, not elsewhere classified, multiple sites, emphysema, unspecified, hypertensive heart disease without heart failure, cerebral infarction, unspecified. Care plan (dated 12/13/2023) documents that R58 has a diagnosis of COPD and exhibits the following symptoms, easily fatigued, periods of confusion due to oxygenation, anxiety and requires medication, oxygenation, shortness of breath placing resident at risk for death. R58's Physician Order (dated 12/12/2023) states: albuterol sulfate…

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 call light was within reach of one resident (R32) reviewed for the call light system. Findings include: 12/9/24 at 12:00 PM, observed R32's bed and call light placement. R32's bed was placed along one wall lengthwise. R32's call light was placed on the adjacent wall of the bed on the other side of the closet that was at the foot of the bed in the corner of the two walls. Surveyor asked R32 if R32 could reach the call light. R32 said I have to get up to get it. V2 (Director of Nursing/DON) joined surveyor in R32's room. V2 stated there is no way for R32 to reach the call light. 12/9/24 at 3:00 PM, V2 (DON) stated the purpose of call lights is to alert the staff that the resident needs help. The resident pulls the cord to activate the call light. The cord needs to be in the resident's reach. If R32 were in bed R32 could not reach the call light to alert staff that R32 needs help. R32 can call out if she needs help. 12/11/24 at 2:25 PM, V1 (Administrator) stated I expect the call lights to be within…

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 store insulin medications and gastrostomy tube (g-tube) feeding extension tubing supplies. This failure impacted 2 residents (R14 and R53) who had expired insulin inside the medication cart during inspection. This failure also resulted in expired gastrostomy tube feeding extension tubing supplies being found in the medication storage room. Finding Include: On 12/09/24, at 12:49 PM, the 1st floor Medication Cart # 3 was inspected with V20 (Licensed Practical Nurse/LPN). R14's Novolog FlexPen U-100 Insulin (insulin aspart u-100) was found in drawer, marked with the open date of 07/24/2024, and marked with the expiration date of 08/21/2024. Surveyor found 3 10mL (milliliter) syringes marked with the expiration date of 09/30/2024. On 12/09/24 at 1:14 PM, surveyor inspected 1st floor medication cart #2 with V9 (LPN). Surveyor found R53's Basaglar Kwik Pen (insulin glargine injection) in the drawer, marked with the open date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a reusable blood pressure cuff device was properly cleaned and disinfected in between resident use for 3 residents (R17, R22, R62) out of 8 residents reviewed for infection control and prevention in a total sample of 21. Finding Include: 1.) R17's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: primary generalized (osteo)arthritis, schizoaffective disorder, unspecified, diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. Care plan (dated 02/07/2024) requires a therapeutic diet related to type 2 diabetes mellitus and hypertension. Minimum Data Set (MDS) section C (dated 08/05/2024) documents that R17 has a Brief Interview for Mental Status (BIMS) score of 15, indicating that R17's cognition is intact. 2.) R22's Face Sheet…

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 a resident's plan of care interventions for fall prevention and failed to provide the resident with a working call light for a resident high risk for falls in one (R1) of three residents reviewed for falls. Findings include: R1 is a [AGE] year-old female with a diagnosis including Schizophrenia, Chronic respiratory failure, Epilepsy, Nondisplaced fracture of seventh cervical vertebra, Subdural hematoma, Drug induced secondary parkinsonism and Type 2 diabetes. R1 was first admitted to the facility on [DATE]. R1 has a BIMS (Brief Interview for Mental Status) of 10/15. R1 uses a wheelchair for mobility. R1 is assessed as a high risk for falls (latest 3/25 fall assessment scored 21). R1 is care planned for including history of multiple falls. R1 is physician ordered to wear cervical collar until follow up appointment for further orders. R1 was placed on 1:1 supervision on 3/20/24. On 4/12/24 at 11AM R1 was observed in R1's room by…

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 prevent the spread of foodborne illnesses by improperly thawing meat and not securing bulk item scoops. This failure has the potential to affect all residents receiving oral nutrition. Findings include: On 1/28/2024 at 9:22am surveyor observed a large package of chicken in a steel pan thawing on the top shelf of the refrigerator. Surveyor also observed a roll of ground beef in a steel pan thawing on the bottom shelf in the refrigerator. On 1/28/2024 at 9:25am V15 (Dietary Manager) stated, both meats (referring to chicken and beef) are raw so how they thaw in the refrigerator should not matter. On 1/28/2024 at 9:30am surveyor observed the serving scoop for the oatmeal, rice and flour was inside of the large container for each item. On 1/28/2024 at 9:35am V15 stated, he was told last year that it was ok to put the serving scoop inside of the large bulk containers. On 1/31/20224 at 10:45am V26 (Dietician) stated, chicken should not thaw out over ground beef in the refrigerator because the two items have different…

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 logged off the computer clinical record system prior to leaving the medication cart and failed to ensure empty medication dispensing cards which contained resident's health information were not left unattended. These failures affected 2 (R63 and R70) residents reviewed for confidentiality of records and has the potential to affect all the residents on Side 2 of the facility. Findings include: The (1/28/2024) census documented that there were 28 residents residing in rooms XXX - YYY. On 01/28/24 at 10:37am, R63's and R70's medications dispensing cards were facing upward and were left unattended on top of a medication cart. R63's medication dispensing card contained the name of medication, description, dose, frequency of the medication, route of administration, R63's room number, and Medical Doctor. R70's medication dispensing card contained the name of the medication, description, dose, frequency of the medication, route of administration, R70's room number and medical doctor. Also observed 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 observation, interview, and record review the facility failed to ensure two licensed nursing personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect three residents on side two medication cart who were prescribed controlled substances and eight residents on side one medication cart who are prescribed controlled substances. Findings include: On 01/30/2024 at 11:38 am review on side 2 medication cart with V22 (RN/Registered Nurse) surveyor observed the shift-to shift controlled substances check form for January 2024. The Nurse's Initials off box was blank for January 12, 2024 (3pm-11pm shift). The Nurse's Initials on box was blank January 15, 2024 (7am-3pm shift). The Nurse's Initials on box was blank January 15, 2024 (11pm-7am shift). On 01/30/2024 at 1:04pm review of the side 1 medication cart with V24 (RN) surveyor observed the shift-to-shift controlled substances check form for January 2024. The Nurse's Initials on box was blank for January 1, 2024 (11pm-7am shift). The Nurse's Initials on box 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 ensure two medication carts out of the three medication carts reviewed were free of loose tablets. This deficient practice has the potential to affect 27 residents who receive medications from side two medication cart and 22 residents who receive medications from side one medication cart. Findings include: On 1/30/2024 at 11:38AM surveyor accompanied by V22 (RN/Registered Nurse) inspected the side 2 medication cart. The following was observed: V22 pulled all the medication bingo cards from the drawers containing medication bingo cards and placed the medication bingo cards on the top of the medication cart. V22 pulled a total of (2) ½ white tablets, 6 white tablets, 1 brown tablet, 3 pink tablets and 1 yellow tablet from the bottom of the drawers of the side 2 medication cart. On 1/30/2024 at 11:45am V22 (RN) stated the nurses are supposed to clean the medication cart drawers. V22 stated the cleaning of the medication cart is to be done every day, the nurse should clean the medication cart before going off duty…

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 container of the multi blood glucose test strips were labeled with the open date. This failure has the potential to affect 15 residents who receive blood glucose monitoring. Findings include: On 1/29/24 at 11:40am, with V13 (Licensed Practical Nurse/LPN), during medication pass, an opened container of the multi blood glucose test strips with no open date labeled was observed in the medication cart. The label on the container of multi blood glucose test strips states open date with a blank place to write the open date on the container. On 1/30/24 at 10:56am, with V16, (LPN), during observation of medication cart storage, an opened container of the multi blood glucose test strips with no open date labeled was observed. The label on the container of multi blood glucose test strips states open date with a blank place to write the open date on the container. When asked if there should be an open date on the container of the multi blood glucose test strips, V16 stated, No. V16 referenced the manufacturing…

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 disinfect shared equipment used on three residents (R62, R83, and R98) and failed to safely handle a needle for one resident (R50). These failures affected four (R50, R62, R83, and R98) residents in the sample of 55 residents in preventing the spread of microorganisms when reviewed for infection control. Findings include: 1.) On 1/29/24 at 9:25am, V13 (Licensed Practical Nurse/LPN) walked in hallway to retrieve the electronic vital signs machine which is housed on a pole with roller wheels. V13 then wheeled the blood pressure machine into R98's room and applied the blood pressure cuff on R98's upper arm without sanitizing the blood pressure cuff. R98's Brief Interview for Mental Status (BIMS) dated 11/29/23 documents R98 with a score of 15 which indicates that R98 is cognitively intact. R98's face sheet documents, in part, R98's diagnoses including but not limited to schizophrenia, dementia, major depressive disorder, and obesity. 2.) On 1/29/24 at 9:37am, V13 (LPN) walked in hallway to retrieve 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 ensure that a call light device was within a dependent resident's reach to call for staff assistance which affected one resident (R52) in the total sample of 55 residents when reviewed for accommodation of needs. Findings include: On 1/28/24 at 10:38 am, R52 observed in R52's room in a reclining personalized wheelchair with a mechanical lift pad under R52's body. R52's wheelchair was positioned on the left side at the end of R52's bed (towards the center of the room). No call light observed near R52. Surveyor asked R52 how R52 requests for staff assistance. R52 stated, I (R52) do need help. But I don't have my call button. I can't reach it. This surveyor walks around R52's wheelchair and observes R52's call light string hanging from the wall call light unit onto the floor. This surveyor stepped outside R52's room and requested that V10 (Agency Registered Nurse/RN) come into R52's room to see where R52's call light was. V10 entered R52'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 ensure a resident's Practitioner Order for Life-Sustaining Treatment (POLST) form was completed properly which affected one resident (R79) in the total sample of 55 residents reviewed for advance directives. Findings include: On [DATE] at 10:17 am, R79 stated, R79 filled out advance directive's (POLST) form with a lady (V21, Social Worker) and R79 is a full code. R79's Face Sheet documents, in part, diagnoses of bipolar disorder, major depressive disorder, asthma, cerebrovascular disease, hyperlipidemia, osteoarthritis, and chronic obstructive pulmonary disease. R79's Minimum Data Set, dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 15 which indicates that R79 is cognitively intact. R79's Practitioner Order for Life-Sustaining Treatment (POLST) form, dated [DATE] and signed by R79, documents, in part, in Section A (Required to Select One) for Orders for Patient in Cardiac Arrest (follow if patient has NO pulse),…

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 residents have a home like environment. This failure affected 2 residents (R75 and R86), reviewed for resident's rights to have a comfortable home like environment, in a total sample of 55 residents. Findings Include: On 1/28/24 at 10:30am, R86 pointed at the window next to (R86's) bed which had towels secured to the bottom of the window with clear tape and stated that (R86) had to do that about a week ago because the wind blows through the closed window. R86 stated that the wind coming through the closed window even moves the blinds. R86 stated (R86) reported it to the nurses a few times and all the nurses did was turn up the heat. R86 stated, The wind coming through gives me a chill. I am going to get pneumonia. R86's admission Record documents, in part, R86's diagnoses including but not limited to chronic obstructive pulmonary disease, major depressive disorder, lupus erythematosus, hypertensive heart disease without heart…

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 resident who depends on staff assistance for ADL (Activities of Daily Living) care and grooming receive nail care. This affects 1 resident (R80) reviewed for accommodation of needs in the total sample of 55 residents. Findings include: On 01/28/24 at 11:00 AM, R80 was observed in bed with long fingernails on both hands and brown substances underneath the nail beds. R80 stated, she would like her fingernails trimmed and has asked staff multiple times to have her nails trimmed, but they still have not trimmed them. R80's admission Record documents, in part, diagnoses of moderate protein-calorie malnutrition, dermatitis, hypertension, schizophrenia, and major depressive disorder. R80's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 10 which indicates that R80's cognition is moderately impaired. On 1/28/24 at 11:14am, while in R80's room observing her (R80) nails, V2…

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 that an adaptive device (splint/palm grip) was in place for a contracted hand which affected one resident (R57) in the total sample of 55 residents when reviewed for limited mobility. Findings include: On 1/28/24 at 10:42 am, R57 observed sitting in R57's reclining, personalized wheelchair in the small television room. R57's left hand is contracted with left arm bent towards R57's upper body. No hand assistive device (splint/palm grip) was on R57's left contracted hand. On 1/29/24 at 10:01 am, R57 observed sitting in R57's reclining, personalized wheelchair in the large dining room for activities with no splint/palm grip noted on R57's left contracted hand. On 1/30/24 at 11:16 am, R57 observed sitting in R57's reclining, personalized wheelchair in R57's room with no splint/palm grip noted on R57's left contracted hand. Surveyor stepped out of R57's room and requested V11 (Restorative Nurse) come to R57's room. On 1/30/24 at 11:18…

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 oxygen tubing and humidifier bottle was changed weekly and labeled with the date for two residents (R19 and R72). These failures have the potential to affect 2 residents (R19, R72) out a total of 12 residents who receive oxygen therapy. Findings include: R19 has a diagnosis of but not limited to Chronic Obstructive Pulmonary Disease, COPD Exacerbation, Schizophrenia, Type 2 Diabetes Mellitus and Hypertensive Heart Disease. R19's has a Brief Interview of Mental Status score of 14. R72 has a diagnosis of but not limited to Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure, Chronic Bronchitis, Emphysema and Dependence on Oxygen. R72 has a Brief Interview of Mental Status score of 12. On 1/28/2024 at 11:06am surveyor observed R72's oxygen tubing without a date and R72's humidifier container with a date of 1/19/2024. On 1/28/2024 at 11:07am R72 shook his head and said no, they are not changing my oxygen tubing weekly. On 1/28/2024 at 11:11am surveyor observed R19 oxygen tubing with…

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

Based on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were four medication errors out of 28 medication opportunities, resulting in a 14.29% medication error rate and affected three residents (R50, R62 and R102) observed for medication pass. Findings include: 1.) On 1/29/24 at 8:59am, V9 (Licensed Practical Nurse/LPN) was observed passing medications with the medication cart. Surveyor observed V9 prepare and count 9 pills total (Tizanidine 2mg-1 tablet, Amlodipine 5mg-1 tablet, Colace 100mg- 1 tablet, Escitalopram 10mg- 2tablets, Losartan 100mg- 1 tablet, Metformin 500mg- 1 tablet, Gabapentin 100mg- 1 tablet, and Rosuvastatin 5mg- 1 tablet) that were prepared to be administered to R102. When asked how many pills are in the medicine cup that are being administered to R102, V9 replied 9 pills. Upon surveyor reconciling R102's above medications that were ordered and scheduled for administration (total of 10 tablets) and the medications that were observed as administered and documented by V9 (total of 9…

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 resident was treated with dignity and respect for 1(R8) of 3 (R1, R2, R8) residents in a sample of three. Findings include: On 10/6/23 at 9:45AM observed V21 (Certified Nurse Assistant/CNA) go into R8's room. R8 was sitting on edge of bed. R8's walker was laying on its side between the bed and wall. R8 asked V21 to help him pick up walker. V21 stepped over the walker and placed an item on R8's bedside table. V21 did not respond to R8 and did not attempt to help R8 get his walker. V21 left the room. Surveyor observed R8 lean forward to grab walker and started to fall forward. Surveyor intervened by verbalizing to sit back down. Surveyor picked up walker and placed it within R8's reach. On 10/7/23 at 1:50PM V1 (Administrator/Abuse Prevention Coordinator) stated the R8 incident observed by surveyor involving V21 (CNA) will be investigated. The facility Abuse Prevention Policy will be followed. Facility policy titled Abuse Policy, Revised 10/2022 Included statement The facility affirms the right of our…

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 safely store medication, failed to ensure that medication cart was locked, failed to label medication with expiration date as required for the following residents: R20, R36, R41, R49 and R74. This failure has the potential to affect all residents that reside in the facility. Findings include: R20's diagnosis includes but not limited to: Absolute Glaucoma, Type 2 Diabetes Mellitus, Dry eye syndrome and Disorder of urea cycle metabolism. R74's diagnosis includes but not limited to: Absolute Glaucoma, Autistic Disorder and Major Depressive Disorder. R36's diagnosis includes but not limited to: Absolute Glaucoma, Type 2 Diabetes, Malignant neoplasm of kidney, and cataract. R49's diagnosis includes but not limited to: Absolute Glaucoma, Anxiety Disorder, Diabetes Mellitus and Hypokalemia. R41's diagnosis includes but not limited to: Cataract, Glaucoma, Hypothyroidism, and Hyperlipidemia. On [DATE] at 1:55 pm, the surveyor observed 3 loose,…

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 outside dumpster was not overflowing with trash and failed to ensure the dumpster lid is closed to maintain a sanitary environment. This failure has the potential to affect all 86 residents in the facility. Findings include: On 3/27/23 at 9:30 am, the dumpster was found to be overflowing with garbage bags and cardboard boxes on the ground beside the dumpster. The dumpster lid was unable to completely close because of the overflow of garbage. On 3/28/23 at 10:40 am, V15 (Dietary Supervisor) stated that the garbage dumpster is supposed to be closed and all garbage is supposed to be in the dumpster not on the ground. On 3/28/23 at 2:30 pm, V4 (Assistant Director of Nursing) stated the garbage is expected to be inside of the dumpster with the lid closed. On 3/28/23 at 2:45 pm, V1 (Administrator) stated there should never be an overload of garbage where the garbage lid does not close. That staff do not have to notify V1 if the garbage is overflowing, and the lid will not close. V1 stated that V1 will…

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 call light was within reach for one resident (R52) out of a sample of 48. Findings include: R52's diagnosis includes but not limited to Bipolar Disorder, Dementia with Behavioral Disturbances, Parkinson's Disease, Hypertension, and Cardiomegaly. R52 has a Brief Interview Score of 14 that suggests cognitively intact. On 3/27/2023 at 10:41am surveyor observed R52's call light clipped to the bed sheet at the bottom of R52's bed. On 3/27/2023 at 10:41am R52 stated I don't know where the call light is. On 3/27/2023 at 10:43am V27 (Certified Nurse Assistant) stated it's at the end of the bed. (R52 was not able to reach the call light.) On 3/28/2023 at 10:59am V7 (Licensed Practical Nurse) stated that the call light should be within reach of the resident. On 3/29/2023 at 2:14pm V3 (Director of Nurses) stated we attach the call light to the bedsheet or the pillowcase so that it can be reachable. Care Plan dated 12/23/2022 that documents the resident is high risk for falls related to immobility problems 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 interview and record review, the facility failed to ensure that one resident (R62) was free from mental abuse. This failure affected one resident (R62) in the total sample of 48 residents. Findings include: On 03/27/23 at 10:10 AM, R62 stated, I asked her (V5) to empty the urinal. She (V5) asked, 'Can't you do it yourself?' She (V5) grabs it (urinal) with a [NAME]. After cleaning it out, she (V5) tosses it to me and gets water on my computer. So, I tossed it back to her (V5). Her (V5) mood was very sour so there was an annoyance factor involved. She (V5) said, 'Don't throw things at me or I'll beat the (bleep) out of you.' R62 added, It makes me very uneasy when she's (V5) working. I feel threatened by her (V5). On 03/27/23 at 10:28 AM, R60 (R62's roommate) stated, I was in my room. I was taking a nap. I heard a whole bunch of yelling. I wondered what was going on. I was tired, but I thought I better listen to what's going on. The one part that stuck out in my mind was when she (V5) said, 'You better…

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 that one resident (R2) was safe from falls. This failure affected one resident that is classified as a moderate to high fall risk. Findings Include: R52's diagnosis includes but not limited to Bipolar Disorder, Dementia with Behavioral Disturbances, Parkinson's Disease, Hypertension, and Cardiomegaly. R52 has a Brief Interview Score of 14 that suggests cognitively intact. On 3/27/2023 at 10:41am surveyor observed R52's bed in a high position and there were no CNAs (Certified Nurse Assistants) in the room. R52 stated that she does not like the bed this high. On 3/27/2023 at 10:43am V27 (CNA) said, When I am going to change someone it is, I was getting ready to change R52. On 3/28/2023 at 10:59am V7 (Licensed Practical Nurse) stated that bed should not be left in a high position if the CNA is not providing care for a resident and if the CNA leaves the room the bed should not be left in a high position because there is a risk 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.

R34's diagnosis includes Schizophrenia, Dependence on Renal Dialysis, and End Stage Renal Disease. Brief Interview of Mental Status score is 14 that suggests cognitively intact. On 3/27/2023 at 10:52am the surveyor observed R34's oxygen tubing on the floor under the bed not labeled. On 3/27/2023 at 10:57am V26 stated it (nasal cannula) was just in her nose but is now under the bed. On 3/28/2023 at 10:59am V7 (Licensed Practical Nurse) stated that the tubing is changed weekly and yes, it should be labeled with the date. V7 stated that the nasal canula should be on the resident and not on the floor. On 3/29/2023 at 2:14pm V3 (DON) stated that date should be included on the tubing when the oxygen tubing is changed. Based on observations, interviews, and record reviews, the facility failed to ensure the nasal cannula was labeled with the date it was changed and failed to ensure the nasal cannula was contained for 1 (R34) resident, failed to ensure the nasal cannulas were changed weekly for 2 (R35 and R46) residents, and failed to ensure the humidifier bottle was changed for 1 (R46)…

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 controlled substances were counted and accounted for per shift and failed to ensure that staff document the administration of a controlled substance at the time of administration for R339. Findings include: R339's diagnosis includes but not limited to: Schizophrenia, Psychosis, Mood Disorder, Anxiety Disorder, and Major Depressive Disorder. On 3/28/23 at 2:30 pm, the surveyor observed the facility's Narcotic Shift Sign In/Off Sheet located on the medication cart. The narcotic sheet had an empty spot for 3/28/23. The narcotic sheet was missing a signature or initials for the day shift Nurse V17 (Licensed Practical Nurse) that was assigned the medication cart for that day (3/28/23). On 3/28/23 at 2:30 pm, the surveyor observed the facility's Controlled Drug Receipt/ Record/ Disposition Form. The form documented a total number of 23 tablets of Alprazolam 0.5 mg for R339. The surveyor observed a total number of 22 tablets of Alprazolam 0.5 mg in R339's medication dispensing card. The surveyor inquired…

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 have a five percent (5%) or lower medication error rate. There were 5 medication errors out of 31 medication opportunities, resulting in a 16.13% medication error rate. Two residents (R29 and R81) were affected out of three residents (R29, R70, and R81) reviewed for medication administration in the total sample of 48 residents. Findings include: R81 On 03/28/23 at 8:42, the surveyor observed V10 (LPN/Licensed Practical Nurse) prepare scheduled 9 AM medications for R81. A total of 9 medications were counted by V10 in R81's medication cup. Upon medication reconciliation (checking ordered medications against medications administered), the following error was identified: #1: Omission error: R81's Pharmacy Order Summary documents an order for Topamax oral tablet 100 mg (topiramate) give 1 tablet by mouth every morning and at bedtime related to schizophrenia, unspecified. R81's Medication Administration Audit Report documents an Administration Time of 8:44 AM for the Topamax, which is approximately the same time 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.