Alpine Care of Zion

Based on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) when entering a COVID-19 isolation room for 1 of 1 residents (R21) reviewed for infection control in the sample of 33. The findings include:On 08/11/2025 at 10:30 AM, there was a sign on R21's door. The sign indicated R21 was on isolation. The sign indicated everyone that entered the room was to wear the following PPE: a N-95 mask, gloves, isolation gown, and eye protection. On 08/11/2025 at 10:35 AM, R21 was in her room and V5 (Certified Nursing Assistant) entered R21's room with linens. V5 had on PPE however she did not have on any eye protection.On 08/11/2025 at 10:45 AM, V5 exited R21's room with a clear bag of what appeared to be dirty linens. On 08/12/2025 at 10:58 AM, V6 (Infection Control Nurse) said R21 was on isolation for COVID-19. V6 said staff should wear a N-95 mask, gloves, isolation gown, and eye protection when entering R21's room. R21's Order Summary Report dated 8/12/25 showed an order to maintain at all times strict contact…

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 notify a resident's representative of a significant change of condition. This applies to 1 of 3 (R1) residents reviewed for notification in the sample of 3. The findings include: R1's face sheet shows she is a [AGE] year old female with diagnoses including chronic respiratory failure with hypercapnia, candidiasis, congestive heart failure, type 2 diabetes, pulmonary hypertension, chronic kidney disease stage 3, lymphedema and tracheostomy status. R1's face sheet shows V11 is listed as responsible party/emergency contact #1 V12 (R1's daughter) is listed as emergency contact #2. On 12/17/24 at 9:29 AM, R1 was observed lying in bed with a tracheostomy in place. R1 said she came back from the hospital recently and does not recall being on a ventilator while at the facility before going to the hospital. R1 said her family was upset the staff did not notify them of her condition change. On 12/17/24 at 12:30 PM, V4 (Registered Nurse-RN) said 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 interview and record review the facility failed to address and follow-up with resident concerns brought forward in resident council. This applies to 1 of 1 residents (R71) reviewed for resident council grievances in the sample of 30 and 5 residents (R48, R75, R105, R74, and R24) outside the sample. The findings include: The facility's 6/20/24 Resident Council Minutes showed 25 residents attended. The minutes showed, Old Business-Treasures Report: The balance last month was $911.09. The balance this month is $356.33. The difference was the special Happy Hour sponsored by the Resident Council. (No follow up was documented regarding any complaints from previous resident councils.) The minutes continued, New Business- Alternative menu changes. Residents were asked to vote on which 3 items they wanted on the alternative menu. The Residents voted for Hamburger/Cheeseburger, chicken tacos, and peanut butter and jelly sandwich. The alternative menu will switch in September to the second alternative menu of chef salad, grilled ham and cheese, and hot dog. The meal of the month 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 wear appropriate personal protective equipment (PPE) for residents in isolation precautions, failed to remove PPE prior to exiting an isolation room, and failed to use gloves in a manner to prevent cross-contamination. This applies to 5 of 5 residents (R457, R98, R45, R204, R136) reviewed for isolation precautions in the total sample of 30. The findings include: 1) R457's electronic face sheet printed on 7/19/24 showed R457 has diagnoses including but not limited to anoxic brain damage, dependence on ventilator, chronic respiratory failure, and gastrostomy status. R457's facility assessment dated [DATE] showed R457 has severe cognitive impairment and is always incontinent of bowel and bladder. R457's physician's orders showed, 7/15/24 collect stool sample to rule out C-diff (Clostridium Difficile). R457's care plan dated 4/25/24 showed, Resident is on Enhanced Barrier Precautions due to tracheostomy and g-tube . Ensure that gown and gloves…

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 treat a resident in a dignified manner for 1 of 2 residents (R457) reviewed for dignity in sample of 30 and one resident (R147) outside of the sample. The findings include: 1. R147's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include malignant neoplasm of esophagus, dysphagia, malignant neoplasm of pharnyx, malignant neoplasm of head, face, and neck, anxiety disorder, and severe protein calorie malnutrition. R147's undated care plan showed, . ADL (Activities of Daily Living) Self Care Performance Deficit and Impaired mobility related to history malignant neoplasm of esophagus . Eating: I require supervision with set up with staff participation to eat . I would like staff to ensure my privacy and promote my dignity during ADL cares . On 7/18/24 at 12:12 PM, this surveyor was walking down one of the halls on the second floor. R147's door to his room was open and V19 CNA (Certified Nursing Assistant) 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 interview and record review the facility failed to ensure a resident's heels were off-loaded for 1 of 1 residents (R204) reviewed for wounds in the sample of 30. The findings include: On 7/16/24 at 10:58 AM, R204 was laying in bed with gauze dressings intact to his bilateral feet and heels. R204 did not have any off-loading devices in place. On 7/16/24 at 11:15 AM, V5 CNA (Certified Nursing Assistant), V7 CNA, and V8 RN (Registered Nurse/MDS care plan coordinator) went into R204's room to provide care. R204's heels were resting on the bed; no off-loading boots or pillow in place to off-load heels. V5 CNA stated R204 had heel wounds and his heels should be off the bed. V5 told V7 they needed a pillow to get his heels up. V5 and V7 provided incontinence care for R204. When they were finished providing care they covered him with a sheet and put his bed in a low position. V5 and V7 did not off-load R204's heels. On 7/16/24 at 11:54 AM, V8 LPN (Licensed Practical Nurse) stated, R204's heels should be offloaded. V8 stated R204 has diabetic sores to his toes and heels but 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 the facility failed to ensure nectar thick liquids were provided to a resident for 1 of 9 residents (R4) reviewed for safety in the sample of 30. The findings include: R4's face sheet printed on 7/18/24 showed diagnoses including but not limited to dementia with behaviors, schizoaffective disorder, kidney disease, and heart disease. R4's facility assessment dated [DATE] showed severe cognitive impairment and staff supervision for eating. R4's July 2024 order review report showed an active order for a regular diet, mechanical soft texture foods and nectar thick liquids. The same report showed active orders for aspiration precautions (potential to swallow or breath food, liquids, or stomach contents into the lungs). On 7/17/24 at 9:53 AM, R4 was lying in bed and alone in her room. R4's bedside table was over her and she was drinking a bottle of liquid nutritional supplement from a straw. A half empty cup of water was on the bedside table. A yellow dietary ticket…

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 a resident's catheter drainage bag was kept below the level of the bladder, catheter tubing was free of obstruction, and catheter securement device was in place for 1 of 1 residents (R204) reviewed for catheters in the sample of 30. The findings include: On 7/16/24 at 10:58 AM, R204 was laying in bed on his back on top of the indwelling urinary catheter tubing. R204 did not have a sheet covering him and his hospital type gown was over to his left side. R204's incontinence brief was open on one side; his bilateral thighs were exposed and no catheter tubing securement device was in place. V7 LPN (Licensed Practical Nurse/MDS Care Plan Coordinator)was in the hallway outside R204's room and was asked to come into his room. V7 confirmed R204 did not have a device in place to secure R204's catheter. V7 stated they use the sticky devices and that the ones they use here are square. V7 stated the catheter secure devices they use at the facility don't stick as sell as the ones in the hospital. V7 checked R204's bed to see if…

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 an accurate weight was obtained on a resident (R92) showing a significant weight loss, failed to identify a significant weight gain for a resident (R46). These failures apply to 2 of 7 residents reviewed for nutrition in the sample of 30. The findings include: 1) R92's electronic face sheet printed on 7/19/24 showed R92 has diagnoses including but not limited to Parkinson's disease, displaced fracture of left femur, hypertension, insomnia, major depressive disorder, personality disorder, alcohol abuse, and bipolar disorder. R92's weight log showed, 2/14/24 190.4lbs (pounds) 3/14/24 196lbs 4/5/24 194.8lbs 4/24/24 183.6lbs 6/11/24 169lbs 7/18/24 178.5lbs. R92's progress note dated 6/30/24 showed, RD (Registered Dietician) note secondary to weight. Resident receives a NAS (no added salt), regular diet with thin liquids. In addition resident receives Ensure TID (three times a day) for additional calories and protein. No reported issues tolerating the diet. PO (oral) intake is documented to be good/adequate with 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 obtain orders and assess a resident's dialysis site for 1 of 2 residents (R56) reviewed for dialysis. The findings include: R56's electronic face sheet printed on 7/19/24 showed R56 has diagnoses including but not limited to hypertensive heart and chronic kidney disease, brief psychotic disorder, morbid obesity, congestive heart failure, end stage renal disease, dependence on renal dialysis, small b-cell lymphoma, non-Hodgkin's lymphoma, and malignant neoplasm of right eye. R56's facility assessment dated [DATE] showed R56 has no cognitive impairment. R56's physician's orders dated 6/21/24 showed, Permacath on right chest for hemodialysis. R56's physician's orders for July 2024 showed no orders for assessment of R56's permacath site. On 7/18/24 at 1:05PM, V15 (Registered Nurse) stated, We assess (R56's) dialysis site before and after dialysis. We should be checking it on non-dialysis days as well but there is no order for that so it'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 administer medications in a timely manner leading to a missed dose of medication, and failed to follow manufacturer instructions for an inhaler medication. This applies to two residents (R143, and R146) outside the sample. The findings include: 1. R143's admission Record shows her diagnoses to include nontraumatic intracerebral hemorrhage, acute respiratory failure with hypoxia, dependence on respirator (ventilator) status, hypertension, and nonverbal. R143's MAR (Medication Administration Record) shows she has an order for Hydralazine 100 mg (milligrams) at 9:00 AM, 1:00 PM, and 5:00 PM, for hypertension. On 7/17/24 at 11:06 AM, V3 Nurse manager/ADON (Assistant Director of Nursing) approached V24 LPN (Licensed Practical Nurse) and asked what she could do to help her. V24 named R143's medications needed to be passed. V3 then called R143's doctor to inform her that Moore's first dose of hydralazine for the day had not yet been given and her second dose was soon due to be given and either the first or second…

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 offer a resident a dietary substitution for 1 of 1 resident (R147) reviewed for dietary preferences outside of the sample of 30. The findings include: 1. R147's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include malignant neoplasm of esophagus, dysphagia, malignant neoplasm of pharnyx, malignant neoplasm of head, face, and neck, anxiety disorder, and severe protein calorie malnutrition. R147's undated care plan showed, . ADL (Activities of Daily Living) Self Care Performance Deficit and Impaired mobility related to history malignant neoplasm of esophagus . Eating: I require supervision with set up with staff participation to eat . R147's undated care plan showed, Compromised nutritional status due to increased risk for dehydration and/or malnutrition . On 7/18/24 at 12:12 PM, V19 CNA (Certified Nursing Assistant) was sitting in a chair against the wall across from R147's end of bed. V19 was heard by this…

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 maintain the third floor shower room in a safe, comfortable, and sanitary condition and failed to maintain a resident's air conditioning unit in a safe manner (R1). This applies 53 residents that use the third floor shower room. The findings include: 1. The facility listed 53 residents that use the third floor shower room on the facility's 7/8/24 Census for the third floor. On 7/9/24 at 11:24 AM, V4 (Maintenance Director) arrived at the third floor shower room. V4 said this shower room is used for all the residents on the third floor that take showers. V4 said the shower room was still in use and had not been shut down. The shower room had a keypad to lock the door. V4 was not aware of the code and had to seek out staff assistance to get the shower room open. The shower room was still still damp and humid. The first shower stall to the left of the door, had a grates in the ceiling above the shower area. There were steady drops of water falling from the grates. The surveyor asked V4 where the water was coming…

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 tracheostomy care was provided in a manner to prevent cross-contamination and was completed as ordered for 1 or 3 residents (R1) reviewed for tracheostomy care in the sample of 5. The findings include: On 7/9/24 at 1:36 AM, V6 (Respiratory Therapist - RT) donned a gown, mask and gloves to enter R1's room. R1's door had a Enhanced Barrier Precautions sign affixed to it. R1 was in lying in bed with the head of the bed elevated. R1 had a tracheostomy (trach) attached to humidified oxygen. V6 informed R1 that he was going to provide trach care and R1 removed her speaking valve from the tracheostomy opening. V6 removed R1's inner cannula and placed the old one the bed, next to her right hand. R1's old inner cannula had some secretions noted inside the tube. V6 used the same, soiled gloved hand to open a new inner cannula and place the clean one into R1's trach. V6 continued to use these same gloves to removed R1's trach dressing. 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 provide ADL (Activities of Daily Living) assistance for residents that require assistance for two of three residents (R2, R3) reviewed for ADL assistance in the sample of five. The findings include: 1. R2's Order Review Report dated January 8, 2024, shows R2 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, acute kidney failure, alcohol abuse, cocaine abuse, history of falling, heart failure, schizoaffective disorders, and major depressive disorder. An order for isolation-contact precautions, reason for isolation: ESBL [Extended Spectrum Beta Lactamase] in urine was entered January 7, 2024. On January 8, 2024 at 10:01 AM, V5 CNA (Certified Nursing Assistant) was in R2's room. There was an incontinence brief on the floor next to R2's bed that was full of urine. V5 said he was checking on R2. V5 picked up the soiled brief and put it in the garbage. V5 said that R2 had two incontinent briefs on. V5…

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 wear personal protective equipment (PPE) and failed to perform hand hygiene and change their gloves in a manner to prevent cross contamination during incontinence care for two of three residents (R2, R3) reviewed for infection control in the sample of five. The findings include: 1. On January 8, 2024 at 9:37 AM, there was a sign on R2's door that showed Contact Precautions-gown, gloves. R2's Order Review Report dated January 8, 2024, shows R2 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, acute kidney failure, alcohol abuse, cocaine abuse, history of falling, heart failure, schizoaffective disorders, and major depressive disorder. An order for isolation-contact precautions, reason for isolation: ESBL [Extended Spectrum Beta Lactamase] in urine was entered January 7, 2024. On January 8, 2024 at 10:01 AM, V5 CNA (Certified Nursing Assistant) was in R2's room. R2 did not have any gloves or gown on.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to have a physician ordered dressing in place on a pressure ulcer and failed to ensure pressure relieving interventions were in place for 1 of 3 residents (R2) reviewed for pressure ulcers in the sample of 4. The findings include: R2's face sheet printed on 12/28/23 showed admitting diagnoses including but not limited to compression of the brain, right radius fracture, malnutrition, heart failure, and altered mental status. R2's facility assessment dated [DATE] showed severe cognitive impairment and is dependent on staff for eating, hygiene, dressing, and transfers. The same assessment showed R2 is always incontinent of urine and bowel. R2's wound evaluation report dated 12/26/23 showed a right sacrum pressure wound measuring 6.9 x 4.1 x 3.4 centimeters. R2's December 2023 physician orders showed an order start dated 11/27/23 for: right sacrum-cleanse site, apply Dakin's moist gauze and ABD pad (thick abdominal dressing) and cover with dry…

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 PPE (personal protective equipment) was worn in a manner to prevent cross contamination for 1 of 1 resident (R2) reviewed for pressure ulcers in the sample of 4. The findings include: R2's face sheet printed on 12/28/23 showed admitting diagnoses including but not limited to compression of the brain, right radius fracture, malnutrition, heart failure, and altered mental status. R2's facility assessment dated [DATE] showed severe cognitive impairment and is dependent on staff for eating, hygiene, dressing, and transfers. The same assessment showed R2 is always incontinent of urine and bowel. R2's wound evaluation report dated 12/26/23 showed a right sacrum pressure wound measuring 6.9 x 4.1 x 3.4 centimeters. R2's December 2023 physician orders showed an order start dated 11/27/23 for: right sacrum-cleanse site, apply Dakin's moist gauze and ABD pad (thick abdominal dressing) and cover with dry island dressing everyday shift 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 store bulk bin scoops in a manner to prevent cross-contamination and failed to ensure a plate was sanitized and dried before plating food and serving. This has the potential to affect all residents residing in the facility. The findings include: The CMS 672 dated 9/25/23 shows the facility has 146 residents residing in the facility. 1. On 9/25/23 at 10:23 AM, a soiled scoop was hanging inside the bulk flour bin. On 9/25/23 at 10:23 AM, a soiled scoop was lying in the sugar bulk bin with the handle in direct contact with the sugar. On 9/25/23 at 10:54 AM, V24 (Cook) said the scoop should be washed after each use and it should not be stored in contact with the food. On 9/25/23 at 10:55 AM, V23 (Acting Food Service Director) said that the bulk bin scoops should not be stored on top of the food and should be washed after every use. Facility Kitchen policy dated 7/23/23 states, . v. scoop handles in bulk items stored in such a way they do not touch bulk item. 2. On 9/25/23 at 11:28 AM, V24 grabbed a red plate 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 administer medications as prescribed by the physician. There were 29 opportunities with 3 errors resulting in a 10.34% medication error rate. This applies to 1 of 5 resident (R251) observed in the medication pass. The findings include: On September 26, 2023 at 8:50 AM, V7 Registered Nurse (RN) was passing R251 her morning medications. R251 was out of her ordered bisoprolol fumarate (hypertension/blood pressure medication). V7 stated, she will have to hold it. R251 had two potassium orders so V7 RN gave her two potassium tablets. V7 RN also gave R251 a regular multivitamin instead of a multivitamin with minerals. R251's medication administration record (MAR) shows, Bisoprolol Fumarate oral tablet 5 mg, give 1 tablet by mouth one time a day for hypertension. Multivitamin-minerals oral tablet, give 1 tablet by mouth one time a day for supplement. Potassium Chloride ER (extended release) tablet 20 MEQ (milliequivalent), give 1 tablet by mouth one time a day for supplement. Potassium Chloride ER tablet 20 MEQ, given…

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 PPE (personal protective equipment) was worn for residents on Enhanced Barrier Precautions. The facility also failed to ensure staff changed their gloves and washed their hands to prevent the spread of infection. This applies to 4 of 29 residents (R108, R131, R109 & R42) reviewed for infection control in the sample of 29. The findings include: 1. On September 25, 2023 at 1:47 PM, V6 Certified Nursing Assistant (CNA) turned and repositioned R108. R108 has a urinary drainage bag and on enhanced barrier precautions. V6 CNA was not wearing a gown. On September 26, 2023 at 9:07 AM, V4 Wound Care Nurse changed R108's sacral wound dressing. She removed the dirty dressing, cleaned the wound and applied a new dressing without removing her gloves and washing her hands. 2. On September 26, 2023 at 9:42 AM, V4 WCN was doing R131's wound care. R131 did not have a dressing on his sacral wound. V4 WCN cleaned the wound and applied a new dressing. She did not remove her gloves and wash her hands. 3. On September 25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide medical records when requested. This applies to 1 of 3 (R401) residents reviewed for medical records in the sample of 29. The findings include: R401's Face sheet dated [DATE] shows V27 (R401's Family Member) listed as R401's spouse and R401 was discharged on [DATE]. On [DATE] at 9:30 AM, V27 said R401 passed away on [DATE]. V27 returned to the facility a few weeks later to collect R401's belongings and had requested for R401's medical records in person. V27 said the facility provided V27 with a form to complete and V27 completed it while at the facility. Facility provided Medical Records Request list (no date) shows V27 first requested R401's medical records on [DATE]. On [DATE] at 11:34 AM, V31 (Guest Services) said V31 and V32 (Electronic Medical Record Licensed Practical Nurse) currently work on providing requested medical records. V31 has been in this role since [DATE] and V32 has been in this role since [DATE]. V31 and V32 said they 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 and record review the facility failed to ensure a resident who requires extensive assist received personal hygiene and bathing assistance. This applies to 1 of 29 residents (R113) reviewed for activities of daily living in the sample of 29. The findings include: R113's face sheet shows he is a [AGE] year old male with diagnosis including Parkinson's, osteoarthritis and hypertension. R113's Minimum Data Set assessment dated [DATE] shows he's cognitively intact, requires extensive assist with bathing and personal hygiene. On 9/25/23 at 10:44 AM, R113 was lying in his bed. Large white flakes was observed in his unkept hair. Dry flaky skin on his face and his beard was overgrown and thick. His lower legs bent in a 90 degree angle with braces on and a splint on his left hand. R113 said I haven't had a shower since August and the staff are supposed to shave me on my shower days. On 9/26/23 at 1:40 PM, V11 (Certified Nursing Assistant-CNA) said residents are scheduled for two showers 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure skin assessments were preformed on a resident with a leg brace, failed to ensure tube dressings were in place and failed to ensure weights were being monitored for a resident with CHF (Congestive Heart Failure). This applies to 2 of 29 residents (R131 & R52) reviewed for quality of care in the sample of 29. The findings include: 1. R131's face sheet list his diagnoses to include: paranoid schizophrenia, peripheral vascular disease, bilateral post-traumatic osteoarthritis of knee, spinal stenosis and post laminectomy syndrome. On September 25, 2023 at 9:49 AM, R131 was wearing a brace to his left leg from mid thigh to mid calf. He stated, he wears the brace to help keep his leg straight. On September 26, 2023 at 9:42 AM, V4 Wound Care Nurse (WCN) was changing R131's wound dressings. R131 had a brace on his left leg from mid thigh to mid calf. There was an opening on the knee where a wound dressing could be observed. V4 WCN was done…

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 with a history of falls was not left unattended in the bathroom (R54) and failed to ensure residents were safely transferred (R54 and R65) for 2 of 29 residents reviewed for safety and supervision in the sample of 29. The findings include: 1. R54's Fall Incident Reports shows that R54 had falls on 2/9/23 and 2/23/23 while unsupervised in her room. R54's Fall Incident Reported dated 6/17/23 shows, At 10:10 AM, CNA was taking resident to the bathroom, wheelchair was locked. CNA left to get wipes, and when returned resident was sitting on the floor. Resident unable to give description .Laceration on middle of the back noted. Resident remains alert and oriented x 1-2 per baseline with periods of forgetfulness Resident was transferred out to [local hospital]. On 9/27/23 at 10:32 AM, V6 (CNA) said that she had just got to the floor and someone asked her to bring R54 to the bathroom. V6 said that she was not familiar with R54…

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 medications were immediately administered after dispensing (R39 & R90) and failed to ensure a prescribed medication was received and administered (R251) for 3 of 5 residents (R39, R90 and R251) reviewed for medication administration in the sample of 29. The findings include: 1. R39's face sheet printed on 9/26/23 showed diagnoses to include but not limited to anxiety, epilepsy, hypertension, atrail fibrillation, and chronic obstructive pulmonary disease. R39's physicians order sheet printed on 9/26/23 showed R39 receives 9 medications at 9AM. R39's Medication Administration Record dated September 2023 showed R39 receives 9 medications at 9:00AM. R39's minimum date set showed R39 as cognitively moderately impaired. R39 requires limited assist with bed mobility, transfers and toileting. R39 receives an antipsychotic, antianxiety, antidepressant, and anticoagulant medications. R90's face sheet printed on 9/26/23 showed diagnoses to include but not limited to type 2 diabetes mellitus, seizures, major…

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 implement a Gradual Dose Reduction (GDR) on a psychotropic medication per pharmacy recommendation and failed to ensure stop dates were in place for a PRN (as needed) psychotropic medication. This applies to 3 of 5 residents (R53, R301, R108) reviewed for unnecessary medications in the sample of 29. The findings include: 1. R53's Consultant Pharmacist Recommendation to Provider form dated 7/27/23 showed she is on the following psychotropic therapy since 1/13/23: Buspirone 20 mg (milligrams) for anxiety. Please review the for a GDR such as Buspirone 15 mg three times a day for anxiety and document if any change is contraindicated. If the GDR contraindicated, please review the following and check is appropriate. The form showed it was not completed or signed by the physician. R53's Physician Order Sheets (P.O.S) dated through September 2023 shows diagnosis including generalized anxiety, major depressive disorder and adjustment disorder with depressed mood. The P.O.S. shows orders for Buspirone 15 mg three times a day 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 ensure residents were free from significant medication errors. This applies to 3 of 29 residents (R7, R251 & R49) reviewed for significant medications in the sample of 29. The findings include: 1. R7's face sheet lists his diagnoses to include: acute embolism and thrombosis of unspecified deep veins of left lower extremity and atherosclerosis of native arteries of extremities, bilateral legs. R7's coumadin and protime/INR (international ratio) worksheet shows, On August 18, 2023 R7 had his PT/INR checked and the results were 51.4/5.3. The orders were to hold coumadin and re-check another PT/INR on August 20, 2023. R7's Medication Administration Record (MAR) for August 2023 shows, he received Vitamin K Oral Tablet 100 MCG (Vitamin K), Give 1 tablet by mouth STAT (right now) for PT/INR 5.3. There is no documentation showing why resident received vitamin K the next day and why it was given the next day and not on August 18, 2023. R7's coumadin and protime/INR (international ratio) worksheet shows, On August 20,…

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 a physician's order for 1 of 3 residents (R1) reviewed for Physician Orders in the sample of 7. The findings include: R1's Physician Order Sheet (POS) dated 8/2023 shows an order of: Ciprofloxacin HCL Solution 0.3% instill 1 drop in both eyes six times a day for conjunctivitis 6/9/23 and discontinue on 8/1/23 at 1533 (3:33 PM). On 8/2/23 at 10:00 AM, V4 (Registered Nurse-RN) was administering medications to R1. V4 (RN) applied an eye drop to R1's right eye. R1 asked, What was that eye drop you just gave me? V4 responded, It was your antibiotic eye drop-Cipro. R1 got upset and stated what? That has been discontinued! I have been on that antibiotic since June and I don't need another day of it, you should have checked the orders before you give that eye drop to me. At 11:00 AM, V4 (RN) showed R1's electronic medication administration (EMAR) and confirmed a physician order that R1's antibiotic was discontinued as of yesterday. V4 said she should have not given the antibiotic eye drop and 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.

Based on observation, interview, and record review, the failed to provide catheter care in a manner to prevent infection to 1 of 3 residents (R2) reviewed for catheter care in the sample of 7. The findings include: On 8/2/23 at 10:45 AM, R2 was in bed. R2's catheter bag was directly on the floor with no privacy bag. V7 (Certified Nursing Assistant/CNA) provided catheter care to R2. V7 (CNA) took R2's catheter tubing and wiped the tubing towards the resident. V3 (Registered Nurse/RN) who was in R2's room reminded V7 (CNA) that was wrong, and it should be from the resident up - away from the resident to prevent urinary tract infections (UTI). V3 also said catheter drainage bag should be placed in a catheter bag for infection control purposes. On 8/3/23 at 12:00 PM, V2 (Director of Nursing) said R2 has had UTI's in the past. R2's care plan did not address R2's catheter use. The facility policy titled Urinary Catheter Care dated 7/28/23 shows, The purpose of this procedure is to prevent catheter associated catheter 17. Use a clean washcloth with warm water and soap to clean and rinse…

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 handle contaminated linens to prevent cross contamination for 1 of 3 residents reviewed for infection control in the sample of 7. The findings include: R1's Physician Order Sheet dated 8/2023 shows an order of R1 Isolation- Contact precautions, Reason for isolation: MRSA (Methicillin-Resistant Staphylococcus Aureus) in wound. R1's facility assessment dated [DATE] shows R1 has no cognitive impairment. On 8/2/23 at 9:30 AM, R1 pointed to a contaminated linen at bedside with small amount of splattered blood. R1 said that linen was used this morning when the Wound Nurse changed her dressing. R1 said they do not put a barrier during dressing change that's why the bloody drainage goes directly to her linens during wound dressing change. R1 said she had MRSA in her wound. R1 had a sign in her door for contact isolation. R1 also has a sign for enhanced barrier precautions. Isolation carts were by her door. On 8/2/23 at 10 AM, V6 (Wound Nurse) said…

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.