Patterson Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and facility document review, it was determined the facility failed to ensure a resident that was cognitively impaired and had a high risk of falls had appropriate interventions to prevent future falls for 1 (Resident #12) of 2 residents reviewed for accidents. Findings included: The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/30/2024 revealed, in part, Resident #12 was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #12 had moderate cognitive impairment, and was dependent on staff for toileting transfers. Further review revealed, prior to admission, Resident #12 had a previous history of falls and one fall which resulted in a fracture. Review of Resident #12's NSG: Morse Fall Scale Evaluation - V1 dated 09/25/2024 revealed Resident #12 had a previous history of falls, used a wheelchair, and overestimated and often forgot his limitations. Further review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, it was determined that the facility failed to monitor for the effectiveness and potential side effects of hypnotics, antidepressants, anti-anxiety medications, antipsychotics, and opioids for 1 (Resident #4) of 5 residents reviewed for unnecessary medications. Findings identified: Resident #4's Electronic Medical Record (EMR) revealed, in part, Resident #4 was admitted to the facility on [DATE] with diagnoses, in part, of unspecified dementia, anxiety disorder, depression, restlessness and agitation Review of Resident #4's November 2024 and December 2024 Physician's Orders revealed the following orders: - Haloperidol lactate (a medication used to treat psychosis) oral concentrate 2 milligrams (mg)/milliliter (ml), give 0.5 mls by mouth two times a day related to restlessness and agitation beginning on 11/13/2024 - Trazodone hydrochloride (a medication used to treat depression and/or anxiety) 50 mg oral tablet, give 2 tablets by mouth at bedtime for insomnia beginning…

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 interviews and observations, it was determined that the facility failed to: 1. Ensure the facility's hood fan was kept clean and sanitary; 2. Ensure the facility's double fryer was kept clean and sanitary; 3. Ensure stored foods in the facility's cooler were properly contained and had an open date for 1 (cooler d) of 2 coolers observed; 4. Ensure a dietary cook wore a proper hair restraint during food handling and preparation; and, 5. Ensure Auto-Chlor test strips were not expired. Findings included: 1. Observation on 12/09/2024 at 8:28 AM revealed the facility's hood fan had an unknown white and orange/red substance on the outside surface of the hood fan. In an interview on 12/09/2024 at 10:14 AM, S1Administrator indicated the facility's hood fan should not have an unknown white and orange/red substance on the outside surface and should have been kept in a sanitary manner. 2. Observation on 12/09/2024 at 10:15 AM revealed the facility's double fryer had a white substance on the outside of the fryer; and an unknown brown substance on the back ledge of the fryer. In an…

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, record review, and facility policy review, it was determined the facility failed to assess a resident for self-administration of a medication for 1 (Resident #25) of 2 residents observed for accidents/hazards. Findings included: Review of the facility's policy titled, Medication Administration, dated 07/08/2024, revealed resident may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of Resident #25's Quarterly Minimum Data Set with an Assessment Reference Date of 10/03/2024 revealed, in part, Resident #25 had a Brief Interview of Mental Status score of 15, which indicated Resident #25 was cognitively intact. Review of Resident #25's December 2024 Physician's Orders revealed an order dated 01/21/2023 for Flonase Sensimist Nasal Suspension (a nasal spray used to treat stuffy/itchy nose, and sneezing) 1 spray in each nostril one time a day for allergic rhinitis (inflammation in the nose).…

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

Based on observations and interviews, it was determined the facility failed to ensure shower rooms were maintained in a safe and sanitary manner for 2 (shower room y and shower room z) of 3 shower rooms reviewed for physical environment. Findings included: Review of Resident #82's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/2024 revealed, in part, Resident #82 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated Resident #82 was moderately impaired. Observation of shower room y on 12/10/2024 at 8:50 AM revealed shower stalls were in use and had an unknown black/brown substance on the surface and around the edges of the shower tiles. Observation of shower room z on 12/10/2024 at 8:55 AM revealed 3 shower stalls were in use and had an unknown black/brown substance on the surface and around the edges of the shower tiles. In an interview on 12/10/2024 at 9:06 AM, S14Housekeeping Manager indicated the housekeeper assigned to the hall was responsible for cleaning the shower room on that hall. In an interview on 12/10/2024 at 9:20…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that the facility failed to implement recommendations from the Office of Behavioral Health (OBH) for a resident with a mental health diagnosis for 1 (Resident #39) of 2 sampled residents reviewed for Pre-admission Screening and Resident Review (PASARR). Findings included: Review of Resident #39's Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses, in part, of anxiety disorder, depression, and schizophrenia. Review of Resident #39's Level II PASARR with an authority period of 04/09/2024 through 04/08/2025 revealed Resident #39 was referred to OBH for recommendations of psychiatric treatment. Review of Resident #39's OBH's recommendations dated 04/09/2024 revealed, in part, a recommendation for a comprehensive psychiatric evaluation. Review of Resident #39's EMR revealed no documented evidence, and the facility did not present any documented evidence that Resident #39 had a comprehensive psychiatric evaluation…

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 observations, interviews, record reviews, facility document review, and facility policy review, it was determined that the facility failed to ensure a resident was involved in the development and revision of the resident's Comprehensive Care Plan for 1 (Resident 58) of 2 residents reviewed for involvement in their Comprehensive Care Plan. Findings included: Review of a facility policy titled, Care Plans, Comprehensive Person-Centered, last reviewed November 2024, indicated the care planning process would facilitate resident and/or representative involvement. The interdisciplinary team must review and update the care plan when there was a significant change in the resident's condition, when the desired outcomes are not met, when the resident was re-admitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment. Review of Resident #58's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/03/2024 revealed, in part, Resident #58 had a Brief Interview for Mental Status (BIMS) score of 15,…

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, interviews, and record review, facility document review, and facility policy review, it was determined the facility failed to provide nail care to a dependent resident for 1 (Resident #76) of 5 residents reviewed for activities of daily living (ADL). Findings included: Review of the facility's admission Record revealed the facility admitted Resident #76 on 10/27/2023 with diagnosis that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) followed by a cerebral infarction affecting Resident #76's right dominant side. Review of Resident #76's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/03/2024 revealed Resident #76 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #76 was cognitively intact. Further review revealed Resident #76 required supervision and assistance with personal hygiene. Review of Resident #76's Care Plan initiated on 11/06/2024 revealed Resident #76 had an ADL self-care performance difficulty related to hemiplegia 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 observations, record reviews, interviews, and facility policy it was determined that the facility failed to develop a plan of care for 1 (Resident #287) of 1 residents investigated for oxygen use. Findings included: Observation on 12/09/2024 at 9:39 AM revealed Resident #287 received oxygen at 3 liters per minute (LPM) per nasal cannula (NC). Observation on 12/10/2024 at 8:40 AM revealed Resident #287 received oxygen at 3 LPM humidified per NC. Observation on 12/10/2024 at 8:40 AM revealed Resident #287 received oxygen at to 3LPM humidified per NC. Observation on 12/11/2024 at 11:56 AM revealed Resident #287 received oxygen at 2 LPM humidified per NC. Review of Resident #287's Physician's Orders revealed no documented evidence of an order for oxygen. Review of Resident #287's Altered Respiratory Status Care Plan initiated on 12/13/2022 and last revised on 04/08/2024 revealed, in part, no intervention for oxygen use was initiated. In an interview on 12/11/2024 at 11:58 AM, S18Licensed Practical Nurse confirmed Resident #287 was being administered oxygen. Review 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.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure only licensed personnel administered medications for 1 (Resident #25) of 27 residents observed during initial pool. Findings included: Review of the facility's policy titled, Medication Administration, dated 07/08/2024, revealed only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. Review of Resident #25's December 2024 Physician Orders, revealed, in part, an order dated 12/09/2021 for Resident #25's antifungal powder to be administered to Resident #25's lower abdominal skin fold, to skin folds on Resident #25's sides, and behind Resident #25's knees daily and as needed until resolved. Observation on 12/09/2024 at 10:21 AM revealed S21Certified Nursing Assistant (CNA) removed a bottle of antifungal powder from Resident #25's bedside table. S21CNA then applied the antifungal powder under Resident #25's right breast. Review of Resident #25's bottle of antifungal powder revealed the active…

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 and interview, it was facility determined the facility failed to ensure the following: 1. An insulin pen was not used past the expired open date [DATE]; 2. an open medication on a blister pack was not taped to secure it inside the pack for 1 medication cart (medication cart a) of 2 medication carts reviewed; and, 3. The facility's medication refrigerator stored medication at the proper temperature for 1 medication refrigerator c of 1 medication refrigerators observed. Findings included: 1. Observation of medication cart a on [DATE] at 8:50AM, revealed a medication insulin pen, Solastor (a medication used to lower blood sugar) pen with an open date of [DATE]. Observation further revealed a medication card with Hydrocodone-Acetaminophen 5/325 milligrams (mg). Further observation revealed pill #19 on the Hydrocodone-Acetaminophen 5/325 mg had been opened then secured in the medication card with a piece of tape. In an interview on [DATE] at 8:54 AM, S13Licensed Practical Nurse (LPN) indicated…

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

Based on observations, interviews, record review, and facility document review, it was determined that the facility failed to follow the facility's lunch menu and ensure the substitution to the menu was approved by the facility's dietician for 6 (Resident #22, Resident #23, Resident #34, Resident #47, Resident #50, and Resident #61) of 6 residents lunch meal tickets observed for dining. Findings included: Observation on 12/09/2024 at 12:10 PM revealed the posted menu in the facility's dining room revealed a baked pork chop, broccoli and cauliflower, a dinner roll, and a frosted cake would be served for lunch. Review of the facility's approved menu for 12/09/2024 revealed beef roast, mashed potatoes, broccoli and cauliflower with cheese, dinner roll, and a frosted cake. Observation on 12/09/2024 at 12:10 PM revealed Resident #22's, Resident #23's, Resident #34's, Resident #47's, Resident #50's, and Resident #61's 12/09/2024 lunch meal served was baked pork chop, mashed potatoes, broccoli and cauliflower, and a frosted cake. Further review revealed the meal served to Resident #22,…

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

Based on observations and interviews, it was determined the facility failed to maintain an effective infection prevention and control program by: 1. not performing hand hygiene while administering medications for 1 (Resident #1) of 2 residents observed during medication administration; and, 2. failing to cover a resident's urinal for 1 (Resident #3) of 32 residents observed during the initial pool. Findings included: 1. Review of the facility's Handwashing-Hand Hygiene Policy and Procedures policy last revised in 2020 revealed hand hygiene during medication administration was achieved by use of an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water before preparing or handling medications. Observation on 12/09/2024 at 8:40 AM revealed Resident #1 asked S13Licensed Practical Nurse (LPN) to cut their Tylenol, cranberry, and Carafate (a medication used for gastric reflux) tablets in half. Further observation revealed S13LPN took the medication cup from Resident #1 and walked to her medication cart. Observation…

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 reviews, observations, and interviews, it was determined the facility failed to ensure a functional call bell system was available for 1 (Resident #18) of 32 sampled residents. Findings included: Review of Resident #18's Minimum Data Set (Minimum Data Sheet) with an Assessment Reference Date (ARD) of 11/15/2024 revealed, in part, Resident #18 required assistance with activities of daily living. Review of Resident #18's Care Plan initiated on 06/12/2019 and last revised on 12/09/2024 revealed Resident #18 had a self-care deficit with an intervention to encourage Resident #18 to use the call bell to call for assistance. Observation on 12/10/2024 at 8:50 AM revealed Resident #18's call light was wrapped around the bed's side rail and not plugged into the wall. Observation on 12/10/2024 at 4:30 PM revealed Resident #18's call light was wrapped around the bed's side rail and not plugged into the wall. Observation on 12/11/2024 at 8:50 AM, revealed Resident #18's call light was wrapped around the bed's side rail and not plugged into the wall. In an interview on 12/11/2024…

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 interviews and record reviews, the facility the facility failed to ensure residents identified as safe smokers maintained their rights to smoke at their leisure for 4 (Resident#1, Resident #2, Resident #3, Resident #4) of 4 (Resident#1, Resident #2, Resident #3, Resident #4) sampled residents. Findings: Review of facility's smoking policy, revised date 03/2024 revealed, in part, it is the responsibility of the facility to provide a safe and hazard-free environment for those residents having been assessed as being safe for facility smoking privileges. Residents wishing to smoke while at the facility will have a Smoking Safety Evaluation completed by the interdisciplinary team to determine the resident's ability to follow smoking policies safely. If a resident is determined to be a Safe Smoker and can smoke unsupervised then the resident can keep their smoking supplies, and smoke in designated areas at their leisure. Review of facility's safe smoker's list, revealed, in part, that Resident #1, Resident #2, Resident #3 and Resident #4 was listed as being safe smokers. Resident…

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 interviews and record reviews, the facility failed to ensure grievances was addressed and acted upon promptly per the facility's Grievance procedure for The Resident Council Meeting for 3(08/08/2024, 09/05/2024,10/03/2024) of 3(08/08/2024, 09/05/2024,10/03/2024) months reviewed for grievances. Findings: Review of the facility's policy entitled, Filing Grievances/ Complaints, revised date 06/2024, revealed, in part, that all grievances, complaints, or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to including rationale for the response. The Administrator has delegated the responsibility of grievance and/or complaint investigation to the Grievance Officer. Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within 72 hours of receiving the grievance and/or complaint. The Grievance Officer, Administrator, and Staff will take…

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 reviews and interviews, the facility failed to ensure an allegation of physical abuse was reported to the required state survey agency for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents investigated for abuse. Findings: Review of facility's Abuse Prohibition Policy dated 05/17/2024 revealed, in part, the facility's policy intent was to prevent and prohibit neglect, mental or physical abuse of residents. Further review revealed the definition of abuse means the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes, hitting, slapping, kicking, shoving, pinching and controlling behavior through corporal punishment. Further review revealed residents have the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. Further review also revealed, in part, any employee who becomes aware of an allegation of abuse,…

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 reviews and interviews, the facility failed to ensure an alleged incident of staff to resident physical abuse was thoroughly investigated for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents investigated for abuse. Findings: Review of facility's Abuse Prohibition Policy dated 05/17/2024 revealed, in part, the facility's policy intent was to prevent and prohibit neglect, mental or physical abuse of residents. Further review revealed the definition of abuse means the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes, hitting, slapping, kicking, shoving, pinching and controlling behavior through corporal punishment. Further review revealed residents have the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. Further review also revealed the facility will conduct a thorough investigation of alleged or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews the facility failed to: 1). Act on a physician's progress note that contained an order to increase a medication dosage (Resident #13); 2). Implement a plan of care (POC) fall intervention to place two fall mats near a resident's bed (Resident #22); 3). Develop a POC after a resident's fall (Resident # 133); 4). Develop a POC for a resident's resuscitation status (Resident #183); and 5). Implement the POC for a fall intervention to place a fall mat near a resident's bed (Resident #433). This deficient practice was identified for 5 residents (Resident #13, Resident #22, Resident #133, Resident #183, and Resident #433) in a total sample of 19 residents (Resident #28, Resident #19, Resident #24, Resident #2, Resident #29, Resident #3, Resident #68, Resident #433, Resident #12, Resident #70, Resident #58, Resident #13, Resident #11, Resident #64, Resident #79, Resident #76, Resident #22, Resident #183, and Resident #133) sampled residents. Findings: Resident # 13…

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

Based on observations, record review, and interviews, the facility failed to: 1. Ensure a resident's enteral feeding was being administered per physician's orders (Resident #76); 2. Document the administration of a resident's enteral feeding (Resident #76); and, 3.Document the assessment of a resident's gastric tube (tube inserted into the stomach used to administer enteral feedings) placement and gastric residual volume (Resident #76). This deficient practice was identified for 1 (Resident #1) of 1 (Resident #76) residents investigated for enteral feeding. Findings: Review of the facility's Enteral Tube Feeding via Continuous Pump policy revealed, in part, the verification of a resident's gastric tube placement and the amount and type of enteral feeding administered to the resident should be documented in the resident's medical record. Review of Resident #76's medical record revealed Resident #76 had diagnoses including dysphagia (a swallowing disorder) and protein-calorie malnutrition. Review of Resident #76's Minimum Data Sheet with an Assessment Reference Date of 12/07/2023…

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

Based on observations and interviews, the facility failed to: 1. Ensure dented cans in the dry storage room were disposed of and not readily available for use; 2. Ensure cooking and serving items (oven, deep fryer, pots and pans) were clean and did not contain dark brown substance; and 3. Ensure the kitchen walls and two air vents were clean and did not contain black, furry substance. Findings: Observation of the facility's kitchen with S13Dietary Manager (DM) on 12/08/2024 at 9:46 a.m., revealed the dry storage room had 1 can of Rosarita Traditional refined beans, 2 cans of Mandarin orange in light syrup, and 1 can of Lucky Leaf filling/toping that were dented near the lip of the cans. In an interview on 01/11/2024 at 9:47 a.m. with S13DM confirmed the cans identified above were dented, available for use, and should have been discarded. Observation of the facility's kitchen with S13DM on 01/08/2024 at 10:24 a.m., 01/09/2024 at 1:13 p.m., 01/10/2024 at 10:53 a.m., and 01/11/2024 at 1:34 p.m., revealed, in part, the facility's deep fryer had dark brown buildup of unknown substance 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 complete a plan of care meeting for 1 (Resident #433) of 19 (Resident #28, Resident #19, Resident #24, Resident #2, Resident #29, Resident #3, Resident #68, Resident #433, Resident #12, Resident #70, Resident #58, Resident #13, Resident #11, Resident #64, Resident #79, Resident #76, Resident #22, Resident #183, and Resident #133) sampled residents. Findings: In an interview on 01/09/2024 at 11:30 a.m., the responsible party for Resident #433 stated she had never been informed of a plan of care meeting nor never attended a plan of care meeting for Resident #433. Review of Resident #433's record revealed, in part, no documented evidence of plan of care meetings for Resident #433. In an interview on 01/11/2024 at 9:50 a.m., S10Assisstant Administrator stated there was no documentation of plan of care meetings for Resident #433.

Based on record reviews, observations, and interviews, the facility failed to assess a resident for self-administration of medications for 1 (Resident #58) of 19 (Resident #28, Resident #19, Resident #24, Resident #2, Resident #29, Resident #3, Resident #68, Resident #433, Resident #12, Resident #70, Resident #58, Resident #13, Resident #11, Resident #64, Resident #79, Resident #76, Resident #22, Resident #183, and Resident #133) sampled residents. Findings: Review of the facility's Self-Administration of Medications policy revealed, in part, residents had the right to self-administer medications if the interdisciplinary team had determined that it was clinically appropriate and safe for the resident to do so. Further review revealed if it was deemed safe and appropriate for a resident to self-administer medications, this was documented in the medical record and the resident's care plan. Review also revealed self-administered medications were stored in a safe and secure place, which was not accessible by other residents. Review of Resident #58's Minimum Data Set with an Assessment…

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 clinical record contained a completed Advance Directive for 1 (Resident #183) of 2 (Resident #24 and Resident #183) sampled residents reviewed for advance directives. Findings: Review of Resident #183's record revealed, in part, an admissions date of 12/18/2023. Further review of Resident #183's record revealed no documentation of an advance directive for Resident #183. In an interview on 01/10/2024 at 10:28 a.m., S11License Practical Nurse (LPN) stated she was not able to find documentation of a code status or an advance directive in Resident #183's record. In an interview on 01/10/2023 at 10:40 a.m., S2Director of Nursing (DON) stated code status and Advance Directive should be documented in the Resident's record. S2DON further stated there was no documentation and the facility could not present documentation of a code status or Advance Directive for Resident #183.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Level II Preadmission Screening and Resident Review (PASARR) evaluation as required for 1 (Resident #29) of 1 (Resident #29) sampled residents reviewed for PASARR. Findings: Review of Resident #29 Level I PASARR dated 11/24/2021 revealed, in part, Resident #29 was assessed to have an active diagnosis of Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Further review revealed Level I PASARR was completed and Resident #29 did not require a Level II PASARR upon admission [DATE]. Review of Resident #29 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/05/2023 revealed, in part, Resident #29 was assessed to have an active diagnosis of Post-Traumatic Stress Disorder (mental health condition that is triggered by experiencing or…

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 act on two pharmacist's irregularities sent to the attending physician for 1 (Resident #19) of 5 sampled residents (Resident #13, Resident #19, Resident #22, Resident #28 , and Resident #70). Findings: Review of the consultant pharmacists' letters revealed, in part, any irregularities identified were communicated to the director of nursing and the attending physician(s) via consultant letters. Review of Resident #19's record revealed, in part, was reviewed by the consultant pharmacist on the following dates listed below. On 10/11/2023 the pharmacist sent a letter for psychiatric; and, On 11/17/2023 the pharmacist sent a letter for the medication Neudexta (a medication used to treat a certain mental/mood disorder) with no other noted explanation. In an interview on 01/10/2024 at 2:30 p.m., S2Director of Nursing (DON) stated that the facility did not have the medical doctor's response to the consultant pharmacist's request for the letter requests of 10/11/2023 and on 11/17/2023 and should have. S2DON further stated we should…

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 staff performed hand hygiene while passing ice. This deficient practice was observed for 1 (S4Certified Nursing Assistant) of 2 (S4Certified Nursing Assistant and S16Certified Nursing Assistant) Certified Nursing Assistants observed passing ice. Findings: Review of the facility's Handwashing-Hand Hygiene Policy and Procedures revealed personnel shall use alcohol-based hand rub or alternatively soap and water after contact with objects in the immediate vicinity of the resident. Observation on 01/08/2024 at 10:47 a.m. revealed S4Certified Nursing Assistant (CNA) went into room a, grabbed the pitcher with an ungloved hand for Resident #5 and Resident #52, filled the pitchers with ice using an ice scoop, returned ice pitchers back to Resident #5 and Resident #52, and exited the room without performing hand hygiene. Observation on 01/08/2024 at 10:51 a.m. revealed S4CNA go into room b, grabbed the pitcher with an ungloved hand for Resident #13 and the cup for Resident #67, filled the pitcher and cup with ice, returned 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.