Rolling Hills Health Center

The facility had a census of 47 residents. The sample included 14 residents and five Certified Nurse Aides (CNA) reviewed for performance evaluations and required in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's performance evaluation records revealed the following: CNA N, hired 01/11/22, no yearly performance evaluations were provided upon request. CNA Q, hired 06/23/20, no yearly performance evaluations were provided upon request. CNA LL, hired 07/12/16, no yearly performance evaluations were provided upon request. CNA MM, hired 11/16/21, no yearly performance evaluations were provided upon request. CNA NN, hired 03/02/22, no yearly performance evaluations were provided upon request. On 01/10/24 at 02:36 PM Administrative Staff A stated the facility did not do yearly performance evaluations for the employees. Administrative Staff A stated if there…

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.

The facility identified a census of 47 residents. The facility failed to provide the services of a full-time certified dietary manager for the 47 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 01/09/24 at 07:26 AM during the initial tour of the kitchen, Dietary Staff BB stated she completed the test to become a Certified Dietary Manager (CDM) but had not passed the test. On 01/10/24 at 11:19 AM Dietary Staff BB stated the Registered Dietician (RD) came to the facility at least every other week or weekly. On 01/11/24 at 12:09 PM Administrative Staff A stated the facility was without a CDM since August of 2022. Administrative Staff A verified the RD did come at least every other week or weekly to the facility. The facility's The Director of Dining Services Roles and Responsibilities policy dated 04/03/20 documented the Director of Dining Services supervised the day-to-day functions of the dining services department and maintained compliance with state and federal…

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.

The facility identified a census of 47 residents. The facility had one kitchen and one kitchenette. Based on observation, record review, and interviews, the facility failed to ensure proper transportation of food items from the kitchen to the kitchenette. The facility also failed to ensure that food items were properly stored in a safe and sanitary manner after the original sealed package had been opened, and the food items were not placed in a sealed container/storage bag with the proper labeling and date. This placed all residents who ate food from the facility at risk for food-borne illness. Findings included: - During the initial tour on 01/09/24 at 07:26 AM a package of unlabeled ham and cheese was found in the refrigerator. Observation on 01/10/24 at 11:16 AM Dietary Staff CC wore gloves as she prepared a grilled cheese sandwich. She reached into her pocket with her gloved hands to remove her phone. Dietary Staff CC then placed her phone back into her pocket and continued to prepare the grilled cheese sandwich with her soiled gloves. On 01/10/24 at 11:35 AM, Dietary Staff CC…

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.

The facility identified a census of 47 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to ensure a dignified dining experience for the residents who chose to eat in their rooms when the facility provided plastic silverware with the room trays. This deficient practice placed residents at risk for an undignified and unenjoyable dining experience. Findings included: - Observation during the initial tour on 01/09/24 at 08:34 AM room trays were served with plastic silverware. On 01/10/24 at 08:19 AM Resident (R)29 stated she always received plastic silverware and had never been offered regular silverware with a napkin at meals. Observation revealed she had plastic silverware on her breakfast tray. On 01/10/24 at 11:38 AM Dietary Staff BB stated the decision to send plastic silverware on the room trays was related to the loss of regular silverware, then not having enough silverware available, and the dietary budget. Dietary Staff BB stated the nursing staff offered the residents regular silverware when room trays were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 47 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure the residents were provided a safe, clean, comfortable, and homelike environment. This placed the residents at risk for decreased psychosocial well-being and impaired safety and comfort for the affected residents. Findings included: - On 01/09/24 at 07:40 AM there was a dirty towel and washcloth draped over the handrail outside of room [ROOM NUMBER]. On 01/09/24 at 07:45 AM, room [ROOM NUMBER] had a large area of the wall (the size of a dinner plate) that was missing paint and was scratched/torn up. On 01/09/24 at 07:47 AM, a strong urine odor was noted from the hall outside of R1's room. Upon walking into R1's room, it was noted her clothing had a strong urine smell as well as the bed linens. On 01/09/24 at 08:00 AM an inspection of the facility's main hall revealed the wall next to the elevator had a large hole (large enough for a fist to fit…

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.

The facility identified a census of 47 residents. The sample included 14 residents. The facility identified two influenza (highly contagious viral infection) positive residents. Based on record review, observations, and interviews, the facility failed to ensure infection prevention standards were followed related to disinfecting shared equipment, urinary catheter care, laundry services, and wound treatment practices. This deficient practice placed the residents at risk for infectious diseases. Findings included: - On 01/09/24 at 07:23 AM a bag of soiled linen was on the floor in Resident (R)30's room. On 01/09/24 at 09:09 AM Certified Nurse Aid (CNA) M and CNA O transferred R23 from her Broda chair (specialized wheelchair with the ability to tilt and recline) to her bed via Hoyer lift (total body mechanical lift). While transferring R23 to the bed, staff placed the Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) collection bag directly on her bed with the urine in the tube backflowing into her body as they adjusted R23's positioning in her bed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 47. The sample included 14 residents with 14 reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to revise Resident (R)30's Care Plan to reflect his needs related to the type of wheelchair needed. The facility failed to revise R32's Care Plan to ensure the interventions listed matched the resident's current needs and goals. The facility failed to ensure R25's Care Plan was revised to address antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication use. This deficient practice placed R30, R32, and R25 at risk for impaired care due to uncommunicated care needs. Findings included: - The Medical Diagnosis section within R30's Electronic Medical Records (EMR) included diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (weakness and paralysis on one side of the body), Parkinson's disease (slowly progressive neurologic disorder characterized 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 47 residents. The sample included 14 residents with five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide the necessary assistive care and services to Resident (R) 29. This deficient practice placed the resident at risk for poor hygiene, decreased self-esteem, and impaired dignity. Findings included: - R29's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis and hemiplegia (weakness and paralysis on one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 47 residents. The sample included 14 residents with five residents reviewed for activities of daily living (ADL). Based on observation, record review, and interviews, the facility failed to ensure a compression glove was provided for Resident (R) 29's left hand. This deficient practice placed R29 at risk for increased left-hand edema, pain, and skin related difficulties. Findings included: - R29's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis and hemiplegia (weakness and paralysis on one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 47 residents. The sample included 14 residents with three residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing measures were placed on Resident (R) 10's bilateral lower extremities and failed to ensure staff implemented appropriate infection control practices during wound care. This deficient practice placed these residents at risk of development of pressure ulcers, wound worsening, and complications related to infections. Findings included: - R10's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion 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 The facility identified a census of 47 residents. The sample included 14 residents with three residents sampled for position and mobility. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 26's carrot (conical-shaped item used to treat contractures [abnormal permanent fixation of a joint or muscle]) was applied as directed, to prevent an avoidable reduction of range of motion (ROM) and/or mobility of his left hand. This deficient practice left R26 at risk for further decline and decreased ROM or mobility. Findings included: - The Electronic Medical Record (EMR) for R26 documented a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Minimum Data Set (MDS) dated [DATE] for R26 documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 47 residents. The sample included 14 residents with three reviewed for accidents/falls. Based on record review, interviews, and observations, the facility failed to ensure Resident (R) 41's non-slip floor strips remained in place next to her bed per her care plan. The facility further failed to ensure R10 had her call light within reach. This deficient practice placed the residents at risk for preventable falls and injuries. Findings included: - The Medical Diagnosis section within R41's Electronic Medical Records (EMR) included diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (weakness and paralysis on one side of the body), cerebrovascular accident (stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), insomnia (inability to sleep), dysfunction 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.

The facility identified a census of 47 residents. The sample included 14 residents with three residents reviewed for urinary catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Based on record review, observations, and interviews, the facility failed to provide catheter care that met the standards of practice when staff failed to securely anchor Resident (R) 2's suprapubic (inserted through the abdomen into the bladder) catheter tubing to his abdomen. This placed R2 at risk for catheter dislodgement and potential injury. Findings included: - The Diagnoses tab of R2's Electronic Medical Record (EMR) documented the diagnosis of benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), retention of urine, restlessness and agitation, and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Significant Change Minimum Data Set (MDS) dated 11/27/23,…

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

The facility identified a census of 47 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure R4 was provided physician-ordered supplemental shakes and/or failed to monitor intake for the supplement. This placed R4 at risk of additional weight loss and related complications. Findings included: - The electronic medical record (EMR) for R4 documented diagnosis of hypertension (HTN-elevated blood pressure), gastroesophageal reflux disease (GERD-backflow of stomach contents to the esophagus), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and obesity (excessive body fat). The Annual Minimum Data Set (MDS) dated 05/31/23 for R4 documented a Brief Interview for Mental Status (BIMS) score of eight which indicated a moderately impaired cognition. R4 required set-up assistance from staff for eating. R4 was substantial/maximal to dependent on staff for functional abilities. R4 was not on a physician prescribed weight-gain regimen. R4's Quarterly…

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.

The facility identified a census of 47 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R)23's PRN (given as needed) Ativan (antianxiety medication that calms and relaxes people with excessive anxiety, nervousness, or tension) medication lacked a 14 day stop date or specified duration with rationale. This deficient practice placed the resident at risk for ineffective treatment and unnecessary side effects. Findings included: - The Medical Diagnosis section within R23's Electronic Medical Records (EMR) included diagnoses of major depressive disorder (major mood disorder), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), acute kidney failure, dementia (progressive mental disorder characterized by failing memory, confusion), and multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord).…

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.

The facility identified a census of 47 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to provide a 14-day stop date or intended duration of therapy, and rationale for extended use related to Resident (R)23's PRN (given as needed) Ativan (antianxiety medication that calms and relaxes people with excessive anxiety, nervousness, or tension) medication. This deficient practice placed the resident at risk for ineffective treatment and unnecessary side effects. Findings included: - The Medical Diagnosis section within R23's Electronic Medical Records (EMR) included diagnoses of major depressive disorder (major mood disorder), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), acute kidney failure, dementia (progressive mental disorder characterized by failing memory, confusion), and multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). R23's Significant Change…

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.

The facility identified a census of 47 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed five percent (%) when staff failed to ensure Resident (R)23's Keppra (a medication used to treat violent involuntary series of contractions of a group of muscles- seizures) was administered as ordered. The facility failed to ensure the insulin (a hormone that lowers the level of glucose in the blood) pen was appropriately primed before insulin administration to R32 and R6. This resulted in a medication error rate of 8.82%. Findings included: - On 01/10/24 at 09:27 AM during medication administration for R23, Certified Medication Aide (CMA) R did not administer R23's physician-ordered Keppra 500 milligram tablet as it was unavailable. On 01/11/24 at 07:20 AM Licensed Nurse (LN) H prepared to administer R32's Novolog insulin. LN H screwed a new needle onto the insulin pen. LN H dialed the ordered 13 units on the pen dial but failed to prime the pen before the administration 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.

The facility identified a census of 41 residents. Based on observations, record reviews, and interviews, the facility failed to maintain an effective quality assessment and assurance (QAA) program to identify and develop corrective actions plans and monitor them to correct identified quality deficiencies prior to survey. This deficient practice placed the resident's at risk for ineffective care. Findings Included: - The facility failed to maintain dignified care practices for Residents (R)3, R19, R20 and R25. (Refer to F550) The facility failed to ensure bathing and personal hygiene was provided for R21 and R8 who required assistance from staff to complete the care. (Refer to F677) The facility failed to provide an activity program for Saturday and Sundays, placing the residents in the facility at risk for increased boredom, loneliness, and decreased socialization by not providing activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence. (Refer to F679) The facility failed to implement a physician order for daily weights to monitor 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.

The facility identified a census of 41 residents. The sample included 12 residents with 12 reviewed for resident rights. Based on observation, record review, and interviews, the facility failed to maintain dignified care practices for Resident (R)3, R19, R20, and R25. This deficient practice placed the residents at risk unnecessary embarrassment and decreased psychosocial well-being. Findings Included: - On 07/11/22 at 09:45 AM staff transported R20 through the main television area uncovered and wearing only a loosely draped hospital gown in the facility's shower seat. On 07/11/22 at 09:10 AM staff transported R25 to his room after taking a shower. The door to the room failed to latch upon being closed and R25 was observed from the hallway sitting in the shower chair, wearing only an incontinence brief. Further observation revealed the privacy curtain was not utilized, and R25 was in full view of his roommate as well. On 07/12/22 at 12:53 PM R3 sat in the communal television area. A confused female peer sitting to his left grabbed the right side of his Broda (special wheelchair 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.

The facility identified a census of 43 residents. Based on observation and interview, the facility failed to maintain a clean, safe, homelike environment when it failed to ensure unused medical equipment was stored out of resident's way and in a manner which did not impede the residents' use of personal and common space. The facility further failed to ensure the facility carpet was clean and free of stains in the residents' communal area. This deficient practice placed the residents at risk for impaired comfort and decreased homelike environment. Findings Included: - On 07/11/22 at 07:15 AM an initial walkthrough was conducted in the facility. The main television area had a very large, oblong stain on the carpet, approximately 2 feet (ft) by 2 ft The three hallways that lead to the residents' rooms had Hoyer lifts (total body mechanical lift used to transfer residents ), medications carts, and Broda chairs (specialized wheelchair with the ability to tilt and recline) stored on both sides of the hallway. The hallway that lead to the dining area had several large stains on the carpet.…

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.

The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to provide weekend activities. This deficient practice placed the residents in the facility at risk for boredom and decreased socialization. Findings Included: - On 07/14/2022 at 10:41 AM during an interview with Resident (R)13 , she verbalized that the facility never offered activities on the weekends. She reported that while she did enjoy going to some of the activities throughout the week the facility never did anything on the weekends for the residents. She stated that she would like to attend Bingo or some other event if they provided it. A review of the April, May, June, and July activity calendar for 2022 revealed that activities had been scheduled for Monday thru Friday but not offered on the weekends (Saturday and Sunday). On 07/14/2022 at 02:13 PM Certified Medication Aid (CMA) R stated the facility's Activities Director left last month but staff tried to provide activities for the residents as much as they can, but not 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.

The facility identified a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to ensure a system to promote an accurate reconciliation of controlled drugs at the end of daily work shifts and maintain the staff count sheets for the controlled drugs. This placed residents at risk for misappropriation of medications by staff. Findings included: - On 07/14/22 at 10:02 AM, observation on the South Unit medication cart revealed staff had not counted or signed the Controlled Drug Record flow sheet reviewed for July 2022 on 07/02/22, 07/05/22, 07/06/22, 07/07/22, and 07/12/22. On 07/14/22 at 10:00 AM, Licensed Nurse (LN) H stated two staff should count the narcotic drugs every shift and sign the Controlled Drug Record flow sheet to verify the narcotic count was completed and accurate. On 07/14/22 at 10:44 AM, Administrative Nurse E stated the facility was unable to locate the past Controlled Drug Record flow sheets to review. Administrative Nurse E stated former staff, Administrative Nurse F, had disposed 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.

The facility identified a census of 41 residents and one facility kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dining services related to equipment cleaning, and safe food temperatures and storage during service. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings Included: - On 07/11/22 at 07:15 AM an initial walk-through of the kitchen was completed. An inspection of the dish washing area revealed the floor drain had trash and debris visible and obstructing some of the drain holes. An inspection of the ice machine revealed food and trash items under the unit. A bug was observed crawling under the ice machine. An inspection of the dry good storage area revealed an undated, opened bag of noodles. On 07/12/22 at 12:24 PM a beverage cart was transported to the main dining for lunch service containing a pitcher of ice for the resident's drinks. The metal scoop used to serve the ice was left in the ice pitcher. On 07/12/22 at 12:47 PM a gallon jug of milk sat 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 The facility identified a census of 41 residents. The sample included 12 residents with 12 residents reviewed for care plan. Based on observation, record review, and interviews, the facility failed to revise the care plan to include resident-centered fall interventions for R21. This placed her at risk of future falls and uncommunicated care needs. Findings included: - R21's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of eight which indicated moderately impaired cognition. The MDS documented that R21 required extensive assistance of two staff members for activities of daily living (ADL's). The MDS documented R21 had no falls since admission. R21's Falls Care Area Assessment (CAA) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 41 residents. The sample included 12 residents with five residents reviewed for bathing. Based on observation, record review, and interviews, the facility failed to ensure bathing and personal hygiene was provided for Resident (R) 21 and R8 who required assistance from staff to complete the care. This deficient practice placed R21 and R8 at risk for potential skin breakdown and/or complications from not maintaining good personal hygiene and bathing practices. Findings included: - R21's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of eight which indicated moderately impaired cognition. The MDS documented that R21 required extensive assistance of two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 41 residents. The sample included 12 residents with four residents reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to implement a physician order for daily weights to monitor for congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid) for Resident (R) 9 and failed to follow up and/or implement a physician order for hospice services for R8. This deficient practice placed these residents at risk of delayed treatment and untreated illness. Findings included: - R9's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of CHF. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented that R9 required extensive assistance of two staff members for activities of daily living (ADL's). The MDS documented R9 received diuretic medication (medication to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 41 residents. The sample included 12 residents with two reviewed for the prevention of pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin). Based on observation, record review, and interviews, the facility failed to implement interventions to prevent pressure injuries for Residents (R)39 and R21. This deficient practice placed the residents at increased risk for skin breakdown. Findings Included: - The Medical Diagnosis section within R39's Electronic Medical Records (EMR) included diagnoses of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), epilepsy (brain disorder characterized by repeated seizures), retention of urine (lack of ability to urinate and empty the bladder), neuromuscular bladder dysfunction (dysfunction of the urinary bladder caused by a lesion of the nervous system), ileostomy (surgical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 41 residents. The sample included 12 residents with eight reviewed for falls. Based on observation, record review, and interviews, the facility failed to implement fall interventions per the plan of care for Residents (R) 39 and failed to develop and implement resident-centered fall interventions appropriate for R21 to prevent falls. This deficient practice placed the residents at risk for falls and injuries. Findings Included: - The Medical Diagnosis section within R39's Electronic Medical Records (EMR) included diagnoses of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), epilepsy (brain disorder characterized by repeated seizures), retention of urine (lack of ability to urinate and empty the bladder), neuromuscular bladder dysfunction (dysfunction of the urinary bladder caused by a lesion of the nervous system), ileostomy (surgical formation of an opening…

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.

The facility identified a census of 41 residents. The sample included 12 residents with one resident reviewed for dementia care (progressive mental disorder characterized by failing memory, confusion). Based on observations, record reviews, and interviews, the facility failed to provide dementia care and services to support Resident (R)3's highest practicable level of well-being. This deficient practice placed R3 at risk for decreased quality of life and impaired well-being due related to dementia. Findings Included: - The Medical Diagnosis section within R3's Electronic Medical Records (EMR) included diagnoses of encephalopathy (inflammatory condition of the brain), Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and intermittent explosive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 41 residents. The sample included 12 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to perform physician ordered weekly heart rate monitoring related to medication use. These deficient practices placed R8 at risk for side effects of unnecessary medications or complications. Findings included: - R8's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status…

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