Victoria Haven Nursing Facility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to ensure the main kitchen and 2nd floor kitchenette maintained sanitary conditions. Specifically, the facility failed to:1. Substitute pasteurized eggs (in-shell or liquid eggs gently heated between 130 degrees Fahrenheit (F) to 140 F to kill salmonella and bacteria without cooking them, making them safe for raw or undercooked recipes) for raw shell eggs when serving undercooked poached eggs to residents, placing them at risk for Salmonella Enteritidis (a virulent organism that may be present in raw shell eggs);2. Ensure open-refrigerated, ready-to-eat time/temperature controlled for safety, foods were labeled with the date of opening; and3. Ensure the second-floor kitchenette was regularly cleaned and did not contain expired foods. Findings include:1. Review of ServSafe Manager, 6th edition, indicated if you mainly serve high-risk populations, such as those in hospitals and nursing homes, use pasteurized eggs or egg products when serving dishes that are…

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 staff notified the Physician in a timely manner recommendations for a medication change from the consulting Psychiatric (Psych) Nurse Practitioner (NP) for one Resident (#27), out of a sample of 13 residents. Specifically, the facility failed to notify the Physician of recommendations to increase Cymbalta (an antidepressant medication) from 60 milligrams (mg) to 90 mg. This delay resulted in Resident #27 not receiving an increased dose for 41 days.Findings include:Resident #27 was admitted to the facility in July 2023 with diagnoses of anxiety and depression. Review of the Psych NP's progress note, dated 10/20/25, indicated but was not limited to:-Chief complaint- Please document using patient's own words why they are Here: Sad-Mood: Depressed-Recommendations: Mood. Cymbalta 60 mg daily. Sad mood. Consider increasing to 90 mg daily.-Psych NP is in a consultative role; recommendations are given to facility prescriber. Review of an email from the Psych NP to the Director of Nursing (DON) and Director of Social…

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 review, the facility failed to ensure laboratory services were provided for one Resident (#2), out of a sample of 13 residents. Specifically, the facility failed to ensure a urinalysis with culture and sensitivity were obtained according to the physician's orders. Findings include:Resident #2 was admitted to the facility in July 2025 with a diagnosis of failure to thrive. Review of the Nursing Progress Note, dated 11/12/25, indicated Resident #2 was seen by the physician the previous evening with an order to collect urine and send for culture and sensitivity. Review of the Physician Progress Note, dated 11/11/25, indicated Resident #2 was complaining of urinary tract infection symptoms again. Review of the Interim Physician's Order Sheet included an order, dated 11/11/25, for a urinalysis and a urine culture and sensitivity. Review of the paper and electronic medical record on 1/15/26 failed to include results from a urinalysis in November 2025. Review of the Physician Progress Note, dated 11/29/25, indicated Resident #2 complained of dysuria (painful…

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 interviews and records reviewed, the facility failed to timely notify the physician of an abnormal X-ray for one Resident (#1), out of 13 sampled residents. Specifically, the facility waited eight days to inform the physician of an X-ray result of osteomyelitis (an infection in the bone) to the right heel. Findings include:Resident #1 was admitted to the facility in October 2025 with deep tissue pressure injuries (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft) to the bilateral heels. Review of the medical record indicated Resident #1 was seen by the consultant Wound Nurse Practitioner on 12/26/25 following a recent hospitalization. The Wound Note indicated the heels had worsened and there was a concern for osteomyelitis with a recommendation to X-ray both heels. Review of the Interim Physician's Order Sheet included an order to X-ray both heels on 12/29/25. Review of the results, dated 12/29/25 at 8:35 A.M., 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 interview and observation the facility failed to ensure one Resident (#2), out of 13 sampled residents, was referred to hospice services for an evaluation.Findings include:Resident #2 was admitted to the facility in July 2025 with diagnoses of failure to thrive and a lung mass. Review of the medical record indicated on 12/10/25 a nurse received a call from a hospice agency indicating they were looking for a physician's order for Resident #2 to be evaluated by hospice, and the nurse contacted the physician. Review of the paper medical record included an order written on 12/10/25 by the physician for Resident #2 to be evaluated by hospice and to treat if indicated based on the Resident's diagnoses of failure to thrive and having a lung mass. Review of the paper and electronic medical record on 1/15/26 failed to include any information regarding Resident #2 being referred to hospice services as indicated. During an interview on 1/20/26 at 10:36 A.M., the Director of Nurses said he did not know if there was a hospice referral completed in December 2025. During an interview 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 record review and interview, the facility failed to provide education and/or offer the COVID-19 vaccination as required or appropriate per the Centers for Disease Control and Prevention (CDC) recommendations for one of one employee records reviewed for immunizations. Findings include:Review of the Centers for Disease Control (CDC) COVID-19 Vaccination for Long-term Care Residents, dated 6/11/25, indicated but was not limited to:-Vaccine recommendations: -CDC recommends an updated COVID-19 vaccine for most adults ages 18 years and older, including people who live and work in long-term care (LTC) settings, get 1 dose of an updated COVID-19 vaccine. -CDC recommends everyone ages 65 years and older, including people who live and work in LTC settings, get 2 doses of an updated COVID-19 vaccine 6 months apart. Review of the Facility Assessment, last updated 12/15/25, indicated but was not limited to:-We offer flu, Covid, and RSV vaccinations for all residents and staff including contracted staff if needed.-Staff are in-serviced and educated annually at a minimum on the prevention…

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 maintain records of certified nurse aide (CNA) training for continuing competency that included no less than 12 hours of mandatory training per year for each CNA employed by the facility for one CNA (#1), out of five employee training records reviewed. Findings include:Review of the Facility Assessment, last revised 12/15/25, indicated but was not limited to:-Staff training/education and competencies: -All employees complete training and competencies upon hire and annually thereafter. -Nurse Aides are provided 12 hours of annual training/education in house.-Nurse Aides: Annual in-service training for nurse aides is a minimum of 12-hours per year. During an interview on 1/21/26 at 12:19 P.M., the Director of Nursing said he and the Administrative Assistant were responsible for educating staff. He said there was not a system to track the number of hours of education provided or quantify the number of hours of education provided in a year for CNAs. He said CNAs had a yearly competency fair, dementia training, and if he…

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, observation, and interviews, the facility failed to ensure that infection control measures were implemented in order to prevent the potential development and spread of disease for two Residents (#1, #9), out of a total sample of 12 residents and three Residents during medication administration. Specifically, the facility failed: 1. For Resident #1, to ensure that transmission-based precautions (TBP) were implemented when the Resident was suspected to have a contagious respiratory illness; 2. For Resident #9, to ensure that TBP were implemented when the Resident refused COVID-19 testing during facility outbreak testing; and 3. To ensure staff donned gloves when touching the inside of the medication cup and/or its contents during medication administration. Findings include: Review of the facility's policy titled Staff and Resident Testing Procedures, undated, indicated but was not limited to the following: -Outbreak testing: Test all staff and residents in response to an outbreak (any single new infection). Continue to test all staff and residents that tested…

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, document review, and interview, the facility failed to implement policies and procedures to ensure residents/residents' representatives were educated on benefits and potential side effects of immunizations, ensure the medical record contained documented consent or refusal of the immunization, and offer and administer the influenza and pneumococcal immunizations in a timely manner for two Residents (#3, #10), out of five sampled residents. Specifically, the facility failed: 1. For Resident #3, to educate the Resident and/or the Resident's representative on the benefits and potential side effects of the influenza vaccine, offer the immunization, and document on the Informed Consent the Resident's consent to receive or refusal of the vaccine and place in the Resident's medical record; 2. For Resident #10, to educate the Resident and/or the Resident's representative on the benefits and potential side effects of the influenza and pneumococcal vaccines, offer the immunizations, and document on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide education, assess for eligibility, and offer COVID-19 vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for five Residents (#1, #3, #10, #23, #327), out of a total sample of five residents reviewed for immunizations. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled Stay Up to Date with COVID-19 Vaccines, revised 1/7/25, indicated but was not limited to the following: -Everyone ages 6 months and older should get the 2024-2025 COVID-19 vaccine. This includes people who have received a COVID-19 vaccine, people who have had COVID-19, and people with long COVID. -People ages 65 years and older: You are up to date when you have received: 2 doses of any 2024-2025 COVID-19 vaccine 6 months apart. 1. Resident #1 was admitted to the facility in April 2023 and was over [AGE] years old. Review of the Consent for Immunizations, signed by the Resident on 4/16/23, failed 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 document review, the facility failed to ensure two Residents (#327, #2) were informed of and actively participated in his/her baseline plan of care within the first 48 hours following admission, out of a total sample of 12 residents. Findings include: Review of the facility's policy titled Baseline Care Plans, undated, indicated but was not limited to the following: (1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must: -be developed 48-72 hours of a resident's admission [sic] to the facility -include the minimum healthcare information necessary to properly care for a resident (2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan is developed within 48 hours of the resident's admission. (3) The facility must offer the resident and their representative a copy with a summary of the baseline…

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

Based on observation, interview, and record review, the facility failed to follow professional standards of practice. Specifically, the facility failed to ensure a treatment order was in place for a dressing to Resident #327's left lower extremity. Findings include: Review of Lippincott Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.…

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

Based on observations, interviews, and record review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#10), in a total sample of 12 residents. Specifically, the facility failed to ensure nail care was performed for Resident #10. Findings include: Review of the facility's policy titled Care of Nails, undated, indicated but was not limited to: -Objective: 1. to provide cleanliness 2. to prevent infection -Procedure: 1. Trim Nails Resident #10 was admitted to the facility in February 2024 with diagnoses that included peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 11/24/24, indicated Resident #10 required substantial/ maximal assistance (helper does more than half the effort) for personal hygiene and that he/she scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. Review of the care plans indicated Resident #10 was totally dependent with ADLs and would not initiate or follow through due to cognitive…

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 that the monthly Medication Regimen Review (MRR) reports for two Residents (#9, #23), out of a total sample of 12 residents, were included in the medical record and acted upon in a timely manner. Specifically, the facility failed: 1. For Resident #9, to ensure the monthly MRR reports were included in the medical record or readily available for review to indicate the Physician's response to the recommendations made by the Consultant Pharmacist; and 2. For Resident #23, to act promptly upon recommendations made by the Consultant Pharmacist during the monthly MRR for consideration of a gradual dose reduction (GDR) of Clozapine (an antipsychotic medication). Findings include: 1. Resident #9 was admitted to the facility in October 2019 with diagnoses including cerebral infarction (stroke) and depression. Review of Resident #9's Physician's Orders indicated but was not limited to the following: -Amitriptyline (antidepressant) 25 milligrams (mg) Give 2 tabs (50 mg) by mouth at bedtime (8/13/24) Review of the medical 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.

Based on record review and interview, the facility failed to ensure one Resident's (#23) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 12 residents. Specifically, the facility failed to ensure a gradual dose reduction (GDR) of the antipsychotic medication Clozapine was attempted, unless clinically contraindicated and documented in the medical record, in an effort to discontinue the drug. Findings include: Review of the facility's policy titled Antipsychotic Medication Use, revised 2/24/24, included but was not limited to the following: -Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review; -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; -The attending Physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. Resident #23 was…

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

Based on observation and interviews, the facility failed to ensure that all drugs were labeled in accordance with currently accepted professional principles. Specifically, medications were stored, unlabeled, in a small box in the top right-hand side of the top drawer of the facility's only medication cart. Findings include: On 2/12/25 at 2:57 P.M., the surveyor inspected the medication cart, located on the first floor, with Nurse #3. The surveyor observed multiple unit dose medications in the top drawer, on the right side, of the medication cart. The medications were observed to be loose and sitting in a small cardboard box. There was no label or identifying information to indicate that it had come from the facility's pharmacy, they lacked resident names, and there was no administering/cautionary information or directions for administering the medication. The unit dose medications observed unlabeled in the medication cart were as follows: -Cefpodoxime (antibiotic) 100 milligrams (mg) #6 -Carbamazepine (anticonvulsant) 100 mg chewable tabs #2 -Doxycycline (antibiotic) 100 mg #2…

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 interview, the facility failed to provide care in accordance with professional standards of practice for three Residents (#1, #3, and #14), out of a total sample of 12 residents. Specifically, the facility failed: 1. For Resident #1, to schedule a cardiology appointment as ordered after hospitalization for heart failure; 2. For Resident #3, to obtain a speech therapy evaluation as ordered; and 3. For Resident #14, to follow physician's orders for the daily use of a splint to the right arm with geri sleeve (stocking sleeves that protect from friction and shearing). Findings include: 1. Review of the facility's policy titled Medical Appointment Guideline, undated, indicated but was not limited to the following: -It is the policy of the facility to assist with appointment making with outside consultants. Resident #1 was admitted to the facility in August 2020 with diagnoses which included heart failure, chronic kidney disease, and asthma. Review of the Minimum Data Set (MDS) assessment, dated 11/26/23, indicated Resident #1 had a Brief…

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 facility policy, the facility failed to ensure that drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. Specifically, 1. The facility failed to ensure that medications stored in the medication storage room, including but not limited to, single-use parenteral medications, were labeled with the appropriate information including the resident's name, dose, route, time and frequency of administrations, when dispensed by the pharmacy; and 2. The facility failed to ensure staff properly labeled all medications stored in one of one medication cart reviewed. Findings include: 1. Review of the facility's policy titled IIA3 Vials and Ampules of Injectable Medications, effective date February 2019, indicated but was not limited to the following: -Vials and ampules dispensed by the pharmacy are maintained…

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, policy review, and interview, the facility failed to implement policies and procedures to ensure residents/residents' representatives were educated on benefits and potential side effects of immunizations, ensure the medical record contained documented consent or refusal of the immunization, and offer and administer the influenza and pneumococcal immunizations in a timely manner for 5 out of 5 Residents sampled (#1, #3, #8, #11, and #14). Specifically, the facility failed: 1. For Resident #1, to educate the Resident and/or the Resident's representative on the benefits and potential side effects of the pneumococcal vaccine, offer the immunization, and document on the Informed Consent the Resident's consent to receive or refusal of the vaccine and place in the Resident's medical record; 2. For Resident #3, to educate the Resident and/or the Resident's representative on the benefits and potential side effects of the influenza and pneumococcal vaccines, offer the immunizations, and document on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the facility failed to provide education, assess for eligibility, and offer COVID-19 vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for five residents (#1, #3, #8, #11, and #14), out of a total sample of five residents reviewed for immunizations. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled Stay Up to Date with COVID-19 Vaccines, revised January 2024, indicated but was not limited to the following: People aged 12 years and older who are unvaccinated should get either: -1 updated Pfizer-BioNTech or updated Moderna COVID-19 vaccine, OR 2 doses of updated Novavax COVID-19 vaccine. People aged 12 years and older who got previous COVID-19 vaccine(s): -People aged 12 years and older who got COVID-19 vaccines before September 12, 2023, should get 1 updated Pfizer-BioNTech, Moderna, or Novavax COVID-19 vaccine. Review of the facility's policy titled Vaccine…

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, policy review, and record review, the facility failed for two Residents (#2 and #11) to develop and implement comprehensive care plans to reflect the individual needs of the Residents, out of a total sample of 12 residents. Specifically, the facility failed: 1. For Resident #2, to develop and implement a genitourinary system care plan related to urinary incontinence, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, chronic kidney disease stage three (CKD-Stage 3), and hyperkalemia (high potassium); and 2. For Resident #11, to develop and implement a genitourinary system care plan related to chronic urinary tract infections (UTIs), history of extended spectrum beta lactamase (ESBL) resistance, chronic obstructive pyelonephritis (kidney infection), and calculus of the kidney (kidney stone). Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated as last revised December 2016, indicated but was not limited to the following: -A comprehensive, person-centered care plan that includes…

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, records reviewed, policy review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent or greater when one of one nurse made two errors in 29 opportunities, totaling a medication error rate of 6.9%. These errors impacted two Residents (#11 and #6), out of seven residents observed. Findings include: Review of the facility's policy titled Medication Administration-General Guidelines, dated February 2019, indicated but was not limited to the following: Preparation: -Five (5) Rights - Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three (3) steps of the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. -Check #1: Select the medication - label, container and contents are checked for integrity, and compared against 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 policy review, the facility failed to develop a policy to ensure safe and sanitary storage, handling, and reheating of food brought to the facility for residents from family and visitors. Findings include: Review of the facility's policy titled Food Storage Second Floor Refrigerator, undated, indicated there were identified procedures for storage of food items. Further review of the policy indicated an absence of procedures or directions for reheating food to ensure safe consumption by the resident. During an observation of the 2nd floor nourishment kitchen/dining area on 2/28/24 at 1:45 P.M., the surveyor observed a piece of tattered and torn paper taped to the top of the microwave which indicated foods must be reheated to a minimum internal temperature of 165 degrees and maximum of 180 degrees. There were no further reheating instructions or procedures posted for staff. During an interview on 2/28/24 at 1:44 P.M., Certified Nurse Assistant (CNA) #1 said she was unaware of any procedure or guidelines for reheating of resident food. CNA #1 said…

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

Based on observation, record review, policy review, and interview, the facility failed for one Resident (#11), out of a total sample of 12 residents, to maintain an accurate medical record in accordance with accepted professional standards and practices. Specifically, the facility failed to ensure Resident #11's refusal to wear a splint and sling to their right arm was documented accurately. Findings include: Review of the facility's policy titled Assistive Devices and Equipment, undated, indicated but was not limited to the following: -Assistive devices are provided by the facility (including splints and braces) -Staff don (put on) and doff (take off) equipment and devices according to MD orders. -The care plan will reflect use of device/equipment. Review of the facility's policy titled Preferred Therapy Solutions: Splinting, dated as last revised January 2018, indicated but was not limited to the following: -Splints are used to provide proper support, prevent unwanted motion, contracture management, or reduction, pain management, and to facilitate motor activity. -Therapists…

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.