Envive Of River City

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure proper tracheal suctioning and oxygen services were provided according to physician orders for 1 of 1 residents reviewed for respiratory care. (Resident 24)Finding includes:On 1/4/26 at 11:23 A.M., Licensed Practical Nurse (LPN) 15 was observed walking into Resident 24's room without donning Person Protective Equipment (PPE). Resident 24 was on Enhanced Barrier Precautions (EBP) because of a tracheostomy. Prior to preparing to suction the tracheostomy, the inner cannula was observed sitting on the resident's bedside table with the speaking valve present. LPN 15 donned clean gloves and proceeded to take the used (contaminated) suction catheter from an open package near the suction machine. LPN 15 then proceeded to use the catheter to suction the tracheostomy several times without the inner cannula present. LPN 15 replaced the used (contaminated) inner cannula with the speaking valve on.On 1/5/26 at 12:50 P.M., Resident 24's clinical…

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 thoroughly assess resident for pain, failed to follow the facility policy for pain management, and ensure attempts for pain management were made for residents who experienced pain for 1 of 1 residents reviewed for fall resulting in fracture. (Resident 7) A resident did not receive pain management after a fall that resulted in a fractured shoulder. Finding includes:On 1/5/26 at 2:37 P.M., Resident 7's clinical record was reviewed. Resident 7 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/18/25, indicated Resident 7 was cognitively intact, required substantial assistance (staff does most of the work) for toileting and transfers, and indicated the resident had a fall with major injury since the prior MDS assessment. The MDS Assessment indicated Resident 7 had frequently experienced pain in the last five days,…

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, record review, and interview, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 1 of 6 residents (Resident 24) observed during the medication pass. There were 31 opportunities observed with 6 errors, resulting in a 19.35 percent medication error rate. Finding includes: During an observation of medication administration on 1/6/26 at 7:50 A.M., Qualified Medication Aide (QMA) 7 prepared the following medications for Resident 24. The QMA did not check for residual or flush the PEG tube prior to administration of the medications. The following medications were all crushed together along with the liquid medications and given to the resident through the Percutaneous Endoscopic Gastrostomy (PEG) at one time:methadone 30 milligrams (mg) from 10 mg/mL (milliliters) liquidlorazepam 0.5 mg tabletNorvasc 5 mg tabletSenna 8.6 mg tabletLexapro 10 mg from 5mg/5mL liquidFerrous Sulfate 325 mg taabOn 1/5/26 at 12:50 P.M., Resident 24's clinical record was reviewed. Diagnoses included, but were not limited to, Chronic Obstructive…

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 obtain radiology services, or transportation to receive radiology services in a timely manner, to meet the needs of a resident following a fall for 1 of 1 residents reviewed for fall with fracture. (Resident 7) Finding includes: On 1/5/26 at 2:37 P.M., Resident 7's clinical record was reviewed. Resident 7 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/18/25, indicated Resident 7 was cognitively intact, required substantial assistance (staff does most of the work) for toileting and transfers, and indicated the resident had a fall with major injury since the prior MDS assessment. The previous MDS Assessment, dated 8/20/25, indicated Resident 7 was cognitively intact, required substantial assistance for toileting, and required partial assistance for transfers. Current physician orders included, but were not…

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 Administrator failed to dispose of illegal substances, report illegal substances to law enforcement and the State Survey Agency (SSA), and follow the Controlled Medication Disposal policy. Confiscated marijuana was kept in an open container in an unlocked closet in the Administrator's office. (Administrator)Finding includes:During an interview on 1/5/26 at 9:35 A.M., Resident 3 indicated that a staff member had confiscated smoking paraphernalia out of his bedside table drawer. On 1/5/26 at 10:35 A.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, chronic pain syndrome. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 10/27/25 indicated Resident 3 was cognitively intact, was independent in all Activities of Daily Living (ADLs), and had no behaviors.A care plan conference was completed on 10/9/25 with the resident in attendance. His care plan was reviewed.Current care plans included, but were not limited to:I am at risk for complications related to substance abuse: alcohol…

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 obtain a written contract with an outside resource detailing the services provided and the timeliness of the services. A pain clinic was providing services to a resident without a contract or communication about those services to the facility. (Resident 3)Finding includes:On 1/5/26 at 10:35 A.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, chronic pain syndrome and opioid dependence. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 10/27/25, indicated that Resident 3 was cognitively intact, was independent in all Activities of Daily Living (ADLs), and received an opioid medication during the 7-day lookback period. A care conference was completed on 10/9/25 with the resident in attendance. His care plan was reviewed. Current care plans included, but were not limited to:I am at risk for complications related to substance abuse: alcohol abuse, opioid dependence, initiated 6/26/25I have acute/chronic pain related to ulcerative colitis, sacral wound 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 implement infection prevention measures for 2 of 2 random observations, Hand washing was not completed according to professional standards and Personal Protective Equipment (PPE) was not worn as ordered. (Resident 24 and Resident 33)Findings include: 1. On 1/4/26 at 11:23 A.M., Licensed Practical Nurse (LPN) 15 was observed walking into Resident 24's room without donning Person Protective Equipment (PPE). Resident 24 was on Enhanced Barrier Precautions (EBP) because of a tracheostomy. Prior to preparing to suction the tracheostomy, the inner cannula was observed sitting on the resident's bedside table with the speaking valve present. LPN 15 donned clean gloves and proceeded to take a contaminated suction catheter from an open package near the suction machine. LPN 15 then proceeded to use the catheter to suction the tracheostomy several times without the inner cannula present. LPN 15 later replaced the contaminated inner cannula with the speaking valve on. On 1/5/26 at 12:50 P.M., Resident 24's clinical record…

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 staff members providing direct care, including contractual staff, were thoroughly trained for provision of tracheostomy care for 1 of 1 resident reviewed for tracheostomy care and care of a wound vac for 1 of 1 residents reviewed for surgical wounds. (Resident 24 and Resident 31)Findings include: On 1/4/26 at 11:23 A.M., Resident 24 was observed to receive tracheostomy care from a contractual staff member, Licensed Practical Nurse (LPN) 15. During the observation, LPN 15 failed to follow infection control techniques, including but not limited to the following:Did not don Preventive Protective Equipment (PPE) prior to providing care, Used clean gloves with a contaminated suction catheter to suction a tracheostomy, Did not use sterile gloves for a sterile procedure, andReplaced a contaminated inner cannula. On 1/5/26 at 12:50 P.M., Resident 24's clinical record was reviewed. Diagnoses included, but were not limited to, Chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure physicians orders were followed for 1 of 3 residents reviewed for medication administration, and care plan interventions were not implemented for 2 of 3 residents reviewed for falls. Blood pressure parameter orders were not followed, fall interventions were not implemented. ( Resident B, Resident D) Findings includes: 1. On 12/3/24 at 12:57 p.m., Resident D's clinical record was reviewed. Resident D admitted to the facility on [DATE]. Diagnoses included, but were not limited to, essential hypertension, orthostatic hypotension, fracture of unspecified part of neck left femur. An admission MDS (Minimum Data Set) assessment dated [DATE], indicated cognition was intact, no mobility devices used, toileting set up or clean up, shower/bathe set up or clean up, mobility sit to stand independent, chair/bed to chair transfer, independent, tub/shower transfer independent, walk 10 feet once standing, independent. Care plans were reviewed and…

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

Based on interview and record review, the facility failed to ensure insulin was given in accordance with professional standards for 5 of 5 residents reviewed for insulin. Residents were given insulin late and by unqualified staff. (Resident 18, Resident 1, Resident 17, Resident 11, Resident 8) Findings include: 1. On 10/9/24 at 10:06 A.M., Resident 18's clinical record was reviewed. Diagnoses included, but were not limited to, type 2 diabetes mellitus. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 7/22/24, indicated Resident 18 had no cognitive impairment and received insulin. Physician orders included, but were not limited to: Humalog (insulin lispro - a short-acting insulin) KwikPen Subcutaneous Solution Pen-injector 100 unit/mL (milliliters) - Inject as per sliding scale: if 0 - 140 = 0 units; 141 - 180 = 2 units; 181 - 240 = 4 units; 241 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 600 = 12 units subcutaneously before meals and at bedtime for type 2 diabetes mellitus, dated 7/11/24 The September 2024 Medication Administration Record…

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 notify the physician and resident representative when residents left the facility independently for 2 of 3 residents reviewed for elopement. (Resident 22, Resident 75) Findings include: 1. On 10/9/24 at 2:12 P.M., Resident 22's guardian indicated staff should contact her every time the resident left the facility. On 10/4/24 she let the facility know that it was ok for the resident to leave on Mondays, Wednesdays, and Fridays and did not need to be contacted on those days. On 10/9/24 at 9:12 A.M., Resident 22's clinical record was reviewed. Diagnoses included, but were not limited to, schizophrenia and stimulant dependence. Resident 22 was admitted to the facility on [DATE]. The most current admission Minimum Data Set (MDS) Assessment, dated 9/20/24, indicated Resident 22 had no cognitive impairment and was independent in all Activities of Daily Living (ADLs). A Letters of Temporary Guardianship document, dated 8/29/24, indicated Resident 22 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident had orders upon admission for their PICC (peripherally inserted central catheter), wound care, management of their wound vac, and an order for enhanced barrier precautions for 1 of 1 resident reviewed for infection control. (Resident 225) Finding includes: On 10/9/24 at 11:40 A.M., Registered Nurse (RN) 9 was observed preparing vancomycin 750 milligrams (mg) / 150 milliliters (mL) to administer to Resident 225. A sign on the door indicated the resident was on enhanced barrier precautions (EBP). RN 9 did not donn a gown prior to caring for the resident. RN 9 flushed the first lumen on Resident 225's PICC line with 10 mL of saline and then flushed the second lumen on the PICC line with 8 mL of saline. RN 9 hooked the vancomycin to the PICC line and set the medication to run at 150 drops per minute. At that time, a wound vac was observed on the resident's coccyx. On 10/9/24 at 1:53 P.M., Resident 225's clinical record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate Minimum Data Set (MDS) assessments were completed for a resident with Post Traumatic Stress Disorder and intravenous access and residents with falls for 1 of 1 residents reviewed for antibiotic use and 2 of 2 residents reviewed for falls. (Resident 21, Resident 10, Resident 2) Findings include: 1. On 10/8/24 at 2:32 P.M., Resident 21's clinical record was reviewed. Resident 21 was admitted on [DATE]. Diagnoses on admission included, but were not limited to, osteomyelitis, Post Traumatic Stress Disorder (PTSD), and borderline personality disorder. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 9/25/24, indicated Resident 21 was cognitively intact, did not have PTSD, and did not have IV (intravenous) access. A current care plan, dated 9/19/24, indicated (Resident) received IV Medications related to osteomyelitis of right foot, Date Initiated: 9/19/24. During an interview on 10/10/24 at 12:41 P.M., the Director 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 a resident had a baseline care plan related to their wounds and wound management for 1 of 1 residents reviewed for infection control. (Resident 225) Finding includes: On 10/9/24 at 11:40 A.M., a wound vac was observed on Resident 225's coccyx. On 10/9/24 at 1:53 P.M., Resident 225's clinical record was reviewed. Resident 225 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, osteomyelitis (infection in the bone). An admission skilled nursing note, dated 10/6/24, indicated that Resident 225 had a power injection catheter in right chest and wounds on the left gluteal fold, right gluteal fold, coccyx, and left toe. Initial wound measurements were: Left gluteal fold 6 cm (centimeters) x 2 cm x 0.2 cm Right gluteal fold 3 cm x 1.5 cm x 0.2 cm Coccyx wound vac in place Left toe 1.2 cm x 0.1 cm x 0.1 cm. The clinical record lacked baseline care plans for 4 of 4 of Resident 225's documented wounds, as well…

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

Based on record review and interview, the facility failed to ensure care plans were revised for 2 of 3 residents reviewed for accidents. Care plans were not revised after falls, substance misuse, and determination of elopement risk. (Resident 2, Resident 22) Findings include: 1. On 10/9/24 at 12:22 P.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, repeated falls, hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, and symptoms and signs involving cognitive functions and awareness. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 9/13/24, indicated Resident 2 was mildly cognitively impaired, required partial assistance of staff (staff does less than half) with hygiene and dressing, and had no fall since the prior assessment. Physician's orders included, but were not limited to: Bilateral side rails to promote bed mobility every shift, dated 4/8/24. Activity Level: WBAT (Weight Bearing as Tolerated), dated 4/8/24. The current falls care plan indicated that Resident 2 was at 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure social services were provided to meet a resident's mental and psychosocial needs for 1 of 1 residents reviewed for mood disturbances. (Resident 21) Finding includes: During an interview on 10/8/24 at 11:38 A.M., Resident 21 appeared to be anxious and indicated he had a history of PTSD (Post Traumatic Stress Disorder) but had not met with mental health services since admission. On 10/8/24 at 2:32 P.M., Resident 21's clinical record was reviewed. Resident 21 was admitted on [DATE]. Diagnoses on admission included, but were not limited to, Post Traumatic Stress Disorder (PTSD) and Borderline Personality Disorder. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 9/25/24, indicated Resident 21 was cognitively intact and was independent for eating, toileting, and transfers. A review of current orders indicated Resident 21 was not receiving medications related to mental health diagnoses. Current care plans included, but were not…

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 residents were free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications. A resident's as needed antianxiety medication was ordered for greater than 14 days. (Resident 18) Finding includes: On 10/9/24 at 10:06 A.M., Resident 18's clinical record was reviewed. Diagnoses included, but were not limited to, generalized anxiety disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 7/22/24, indicated Resident 18 had no cognitive impairment and received an antianxiety medication. Physician orders included, but were not limited to: diazepam (an antianxiety medication) 2 milligrams (mg) - Give 0.5 tablet by mouth every 8 hours as needed for anxiety, dated 8/28/24 with no end date. The Medication Administration Record (MAR) from 8/28/24 to 10/9/24 indicated Resident 18 received as needed (PRN) antianxiety medication on the following dates: 8/28/24 8/29/24 8/30/24 9/2/24 9/3/24 9/4/24 9/6/24 9/10/24 9/11/24 9/16/24 9/17/24 9/18/24 9/23/24 9/24/24 9/25/24 9/26/24 10/1/24…

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 labeled, opened-multi-dose containers were dated, and medication carts were free of loose pills for 1 of 2 medication carts observed. (100 hall med cart) Finding includes: On 10/9/24 at 7:40 A.M., the following were observed in the 100 hall med cart: an oblong maroon colored pill a small round white pill two dropper bottles of medication with no patient label two open bottles of multi-dose medications with no date written on them to indicate when they had been opened On 10/10/24 at 1:50 P.M., the Director of Nursing (DON) indicated that multi-dose medications such as Miralax, did not need to have the date opened written on them. A Medication Labeling and Storage policy, provided by the Administrator on 10/11/24 at 8:30 A.M., indicated medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received . multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a…

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

Based on observation and record review, the facility failed to ensure food was correctly prepared for 2 of 2 residents who received puree altered diets. Finding includes: During an observation on 10/10/24 at 10:02 A.M., Dietary [NAME] 4 was preparing puree foods for resident's with altered dietary needs. The recipe #1028 titled Ham with Raisin Sauce Pureed Thick indicated the following measurements for 15 servings: Baked Ham with Raisin Sauce - 15 of three slices, 2 tablespoons sauce Apple Juice - 7.5 of four fluid ounces Food thickener - 3/4 cup 3 tablespoons Dietary [NAME] 4 gathered food and supplies for five (5) servings for each food. Dietary [NAME] 4 indicated she was unsure of the conversion from 15 servings to 5 servings. The Administrator wrote the conversions on the recipe and gave it to Dietary [NAME] 4. The handwritten conversions were written as follows: Five ham slices with raisin sauce 14 ounces of fluid for apple juice Thickener 1/4 cup and one tablespoon Dietary [NAME] 4 put the following food amounts in the puree machine: 15 slices of ham 1/2 cup (four fluid…

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 documentation was complete and accurate for 2 of 3 residents reviewed for elopement and 1 of 2 residents reviewed for falls. Documentation required for a resident leave of absence (LOA) was not completed and neurological checks were not completed as ordered after a fall. (Resident 22, Resident 21, Resident 2) Findings include: 1. On 10/9/24 at 9:12 A.M., Resident 22's clinical record was reviewed. Diagnoses included, but were not limited to, schizophrenia and stimulant dependence. Resident 22 was admitted to the facility on [DATE]. The most current admission Minimum Data Set (MDS) Assessment, dated 9/20/24, indicated Resident 22 had no cognitive impairment and was independent in all Activities of Daily Living (ADLs). A Letters of Temporary Guardianship document, dated 8/29/24, indicated Resident 22 was assigned a court-appointed guardian. An admission Elopement Risk Assessment, dated 9/13/24, indicated Resident 22 was at low risk for elopement.…

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

Based on observation, interview, and record review, the facility failed to ensure a resident with a PICC (peripheral injection central catheter) and multiple wounds was provided enhanced barrier precautions (EBP) for 1 of 1 resident reviewed for infection control. (Resident 225) Finding includes: On 10/9/24 at 11:40 A.M., Registered Nurse (RN) 9 was observed preparing vancomycin 750 milligrams (mg) / 150 milliliters (mL) to administer to Resident 225. A sign on the door indicated the resident was on enhanced barrier precautions (EBP). RN 9 did not donn a gown prior to caring for the resident. RN 9 flushed the first lumen on Resident 225's PICC line with 10 mL of saline and then flushed the second lumen on the PICC line with 8 mL of saline. RN 9 hooked the vancomycin to the PICC line and set the medication to run at 150 drops per minute. At that time, a wound vac was observed on the resident's coccyx. On 10/9/24 at 1:53 P.M., Resident 225's clinical record was reviewed. Diagnoses included, but were not limited to, osteomyelitis (infection in the bone). An admission skilled nursing…

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 designation of a certified Infection Preventionist (IP). The IP did not currently dedicate at least part time to the role of IP for 1 of 1 staff members reviewed for IP. Findings include: On 10/8/24 at 12:10 P.M., the Director of Nursing (DON) indicated she was currently responsible for the infection prevention and control program in the facility. She indicated she worked full time as the DON, and was able to dedicate about 8 hours per week on the infection control program. On 10/9/24 at 1:49 P.M., the DON's employee file was reviewed. The DON had an IP certification dated 11/14/21. On 10/11/24 at 8:50 A.M. the Administrator provided a current undated Job Description: Infection Preventionist Nurse job description. The job description indicated . the IP provides assistance to the Director of Nursing when needed. On 10/9/24 at 11:30 A.M., the Administrator provided a current Infection Prevention and Control Program (IPCP), dated 8/2022, that indicated The community shall designate a member of the clinical team to…

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

Based on interview and record review, the facility failed to complete a Quality Assurance and Performance Improvement Program based on identification, investigation, analysis, and prevention of adverse events in the facility within the past year. The data collection form lacked sufficient detail to identify potential high-risk, high-volume, or problem-prone areas for improvement that were counted under the other category of the data collection form. Findings include: During an interview on 7/13/23 at 9:29 A.M. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), they indicated they were not aware of any Performance Improvement Projects occurring at the present time or during the past year. They indicated there was no formal mechanism for staff to report concerns; staff leave notes in the administrators' mailboxes. No QAA committee meeting minutes were available. During a phone call with the administrator on 7/13/23 at 10:51 A.M., the administrator indicated the meeting minutes were at home in her briefcase and she was out of town. During record review 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 11. On 7/12/23 at 6:48 A.M., Resident 2's clinical record was reviewed. Resident 2 was admitted on [DATE]. Diagnosis included, but was not limited to, Alzheimer's Disease. The most recent quarterly MDS (Minimum Data Set) assessment, dated 5/31/23, indicated Resident 2 had severe cognitive impairment, required limited assistance of 1 staff for transferring, eating, and toileting, and had delusions. The clinical record lacked documented care plan conferences between 1/5/21 and 5/16/23. 12. On 7/11/23 at 11:04 A.M., Resident 4's clinical record was reviewed. Resident 4 was admitted on [DATE]. Diagnosis included, but was not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the left nondominant side. The most recent quarterly MDS assessment, dated 4/12/23, indicated Resident 4 had moderate cognitive impairment and required extensive assistance of 2 staff for bed mobility, transferring, and toileting and extensive assistance of 1 staff for eating. The clinical record lacked documented…

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 ensure food was stored appropriately in 2 of 2 kitchen observations. Food containers were found not labeled in the the dry storage area and shelving in prep area in the kitchen.(Kitchen) Findings include: On 7/10/23 between 6:45 A.M. and 7:10 A.M., during the initial kitchen tour the following was observed: Spices under silver prep table 1 opened container of garlic bread seasoning with a use by day of 4/17/23 1 opened container of garlic herb seasoning with used by date of 6/23/23 1 opened container of ground nutmeg with a use by date of 5/12/23 1 opened container of onion powder with use by date of 1/15/23 1 opened container of minced onion undated 1 opened container of lemon pepper seasoning undated 1 opened container of garlic salt undated 1 opened container of whole gloves with a use by date 11/2/22 1 measuring cup covered with plastic wrap of white granular substance undated and unlabeled, which the cook indicated was food thickener On 7/10/23 between 7:11 A.M. and 7:35 A.M., during the initial kitchen tour 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 residents that were self administering medications were assessed for capability to self administer medications for 2 of 4 residents reviewed for medication administration. (Resident 20, Resident 21) Findings include: 1. On 7/12/23 at 7:37 A.M., LPN (Licensed Practical Nurse) 3 was observed to administer medications for Resident 20 in his room. Medications prepared for administration included, but was not limited to, a Juven packet (nutrition powder) mixed in 8 oz (ounces) of water. LPN 3 handed Resident 20 his medications and left the room before the resident took the Juven. On 7/12/23 at 9:36 A.M., Resident 20's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus with foot ulcer, dysphagia following cerebral infarction, and visual field defects. The most recent significant change MDS (Minimum Data Set) assessment, dated 6/1/23, indicated Resident 20 was cognitively intact and had a diabetic foot ulcer. Current physician orders included, but was not limited to:…

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

Based on interview and observation, the facility failed to provide each resident with food and drink that is served at a safe and appetizing temperature. Food that was supposed to be served hot was served at below the recommended temperature; food that was supposed to be cold was served above the recommended temperature for 1 of 1 meal trays reviewed for food temperature. Findings include: 1. During an interview with Resident 8 on 7/10/23 at 9:55 A.M., the resident stated Yuk when asked about the food. Then she indicated the hot food was served lukewarm. On 7/11/23 at 12:34 P.M., the temperatures were measured on the last food tray that was served on the resident's hall. The temperatures were: Broccoli 126.0 F Baked potato 128.0 F Milk 49.7 F Banana pudding 45.7 F Salad 50.1 F 2. During an interview on 7/11/23 at 11:22 A.M., the dietary supervisor indicated he takes temps for employee first who eat at 11:30 A.M., then re-checks the food temperatures before the residents eat at 12:00 to 12:15 P.M. During an interview on 7/12/23 at 11:22 A.M., the dietary supervisor indicated most 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.