Avista Nursing and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that one resident (Resident #25) of 2 residents observed had their dry nebulizer mask stored in a storage bag when not in use, resulting in the potential for cross contamination with respiratory infection, and increased antibiotic usage. Findings Include: Resident #25: Review of the Face Sheet, care plans dated 2/25 through 4/25, orders and electronic medication admission record/EMAR dated 4/25 and 5/25, revealed Resident #25 was [AGE] years old, admitted to the facility on [DATE], alert with a Guardian in place, and required staff assistance with all Activities of Daily Living. The residents' diagnosis included, chronic heart and lung disease, Alzheimer's Disease, weakness, acute on chronic respiratory failure with hypoxia, Myocardial Infarction, Anxiety Disorder, Adjustment Disorder, Depression, and cerebral aneurysm. Review of the residents' Physician orders dated 2/25, stated Albuterol Sulfate Inhalation Nebulization Solution…

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

Based on observation, interview, and record review the facility failed to maintain cold holding refrigeration temperatures of potentially hazardous food in the kitchen resulting in an increased potential for foodborne illness, potentially affecting the facility's total census of 79 residents who receive meal services. Findings include: On 6/4/24 at 11:47 AM, while observing lunch being plated from the kitchen's steam table, the surveyor observed the two door reach-in cooler located between the juice and coffee stations with both doors in the fully opened position. At this time the surveyor inquired with Dietary Manager, staff E, on if this was a normal practice during meal service to which they replied, yes. On 6/4/24 at 1:10 PM, upon review of the contents in the two door reach-in cooler the surveyor asked staff E, if they could take a temperature of the remaining portion of milk from the days lunch service to which they stated, of course. On 6/4/24 at 1:12 PM, temperature verification from staff E's thermometer probe revealed a temperature of 55 degrees F. At this time the…

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

Based on observation, interview and record review, the facility failed to act upon grievances reported in Resident Council meetings and provide responses to grievances as reported during Resident Council with the potential to affect all residents that attend the council meetings, resulting in, unresolved resident concerns and a decreased quality of life. Findings Include: During Resident Council on June 4,2024 at 3:30 PM, the four residents in attendance were asked if their concerns voiced in the meetings were followed up on and resolution/update provided at the next scheduled meeting. The attendees reported staff will ask generalized questions regarding if their issues have been resolved but there is no other discussion past issues or how the facility will resolve them. On 6/5/2024 at approximately 9:00 AM, a review was completed of Resident Council Notes from June 2023 to May 2024. While residents voice their concerns in resident council the notes did not specify the issues with that specific discipline. Furthermore, there was not a response documented to the residents' concerns…

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.

This Citation pertains to Intake Number MI000144366. Based on observation, interview and record review, the facility failed to that ensure residents' food choices were honored, food was palatable (with temperature maintained), and an adequate amount of food was offered to one resident (Resident #47), and 4 of 4 residents in the Resident Council Meeting on 06/04/24 at 3:20 PM, resulting in anger, frustration and verbalizations of being hungry. Findings Include: Observation done on 6/3/24 at the noon meal revealed chili, a salad and beverages were served in the main dining room. The facility menu dated 6/3/24, revealed lunch was to include Texas toast. The resident's were not offered any toast, bread nor crackers to go with the chili. During an interview done on 6/3/24 at 1:50 p.m., Dietary Manager E stated (food company name given) makes our menu's; we follow the menu. They (resident's) didn't have bread or crackers today, it wasn't on the menu. The cook must of overlooked the toast today (Texas toast). We are getting tablets to take resident's orders. The Dietary Aide or the Aide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure assessment and documentation of incompetency prior to enacting a Durable Power of Attorney (DPOA) and accurate documentation of advance directive forms for one resident (Resident #28) of two residents reviewed for Advance Directives, resulting in DPOA enactment prior to incompetency determination, medical decisions being made for the resident without legal documentation of determination of incompetency, including consent for psychoactive medications and the likelihood for the resident's care wishes to not be followed. Findings include: Resident #28: Record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbance, dysphagia (difficulty swallowing), osteoporosis, failure to thrive, and difficulty walking. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to maximum assistance 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 Based on observation, interview and record review, the facility failed to ensure that hygiene care was provided to two residents (Resident #23 and Resident #28) of four residents reviewed, resulting in a lack of comprehensive documentation and provision of daily care, long, visible facial hair on a female resident, and the likelihood for feelings of psychosocial distress utilizing the reasonable person concept. Findings include: Resident #28: On 6/3/24 at 1:40 PM, Resident #28 was observed sitting in a wheelchair in their room with a food tray in front of them on an overbed table. The Resident was female and had multiple, visible, thick colored hairs on their chin. An interview was attempted to be completed at this time. When spoke to, Resident #28 was pleasantly confused and did not consistently provide appropriate responses to questions when asked. Record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbance, dysphagia (difficulty…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and operationalize a comprehensive Restorative Nursing program to ensure appropriate assessment, services, and treatment to maintain or improve Range of Motion (ROM) for two residents (Resident #36 and Resident #44) of two residents reviewed, resulting in a lack of ongoing and accurate assessment and documentation of Range of Motion (ROM) and contractures, a lack of implementation of Restorative Nursing services and residents with known contractures and limitations in ROM, and the likelihood for further decline in ROM, functional decline, and avoidable pain. Findings include: Resident #36: On 6/3/24 at 11:05 AM, Resident #36 was observed sitting in a wheelchair in their room. The Resident's right arm was bent at the elbow with their hand in a fist. Their arm was bent upwards and positioned against their chest. The wheelchair had one leg rest on the right side and the Resident's right foot was positioned on the leg rest. Their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure adequate staff training, equipment monitoring, prevention, reporting, investigation, and a thorough analysis of accidents for one resident (Resident #44) of four residents reviewed for falls, resulting in a lack of reporting, thorough investigation, comprehensive procedures to prevent accidents, Resident #44 experiencing a fractured tibia and fibula bones (both bones in lower leg) necessitating emergency medical treatment, unnecessary pain, and the likelihood for decline in overall functioning and health status. Findings include: Resident #44: On 6/3/24 at 10:19 AM, Resident #44 was not in their room. A raised edge mattress was present on the Resident's bed and multiple splints/braces were observed on top of the Resident's closet. Record review revealed Resident #44 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure assessment, maintenance and care of an indwelling urinary catheter, per professional standards of practice, for one resident (Resident #39), and failed to complete treatment of a Urinary Tract Infection (UTI) for one resident (Resident#18) of four residents reviewed, resulting in an indwelling urinary catheter being maintained in an unsanitary manner, a lack of a urinary catheter securement device, delayed, and incomplete antibiotic therapy with the likelihood of ongoing UTI's with continued and increased Multi-Drug Resistant Organisms (MDRO- infections caused by microorganisms that are resistant to treatment), difficulty in treatment, and a decline in overall health. Resident #18: On 6/04/24, at 9:19 AM, During infection control task, the line listings were reviewed which revealed Resident #18 had been treated for a urinary tract infection (UTI) on 4/24/2024. On 6/4/2024, at 1:30 PM, a record review of Resident #18's electronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Peripherally Inserted Central Catheter (PICC line - catheter inserted in the body through the arm that extends to the heart and is utilized for long term administration of intravenous [IV] medications) care was provided, per professional standards of practice and health care provider's order, for one resident (Resident #37) of one resident reviewed, resulting in a lack of dressing change completion, a lack of sterile technique during dressing change, resident verbalizations of concerns related to a lack of care, and the likelihood for infection and alteration in overall health status. Findings include: Resident #37: On 6/3/24 at 11:04 AM, Resident #37 was observed in their room, laying in bed. An IV pole with an empty bag of Meropenem (IV antibiotic medication) was present in the room. The medication bag was labeled for administration to Resident #37 but did not include the date/time the medication was hung and the IV tubing was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Numbers MI00129714, MI00129826, and MI00131653. Based on observation, interview and record review, the facility failed to ensure residents' dignity by 1) Not ensuring that a shower was given for 1 resident (Resident #39), 2) Being left wet, 3) Environment odor (100 Hall), 4) Answering call lights timely, 5) Ensuring that clothing protectors were used during meals and staff assisted with meals, 6) Ensuring that a call for assistance was responded to by staff for (Resident #34), of a total of 20 residents reviewed for dignity, resulting in incontinence, resident and environmental odor, shame, and embarrassment, with the likelihood for isolation and decreased socialization and unmet care needs. Findings Include: Resident #39: Review of the Face Sheet, current Care Plans and orders dated 3/22 through 3/23, revealed Resident #39 was 75 years-old, had decreased cognitive ability with behaviors and was dependent on staff for assistance with Activities of daily Living. The resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the Facility failed to maintain a call light device, used to request needed assistance, within reach of 5 residents (Residents #8, Resident #18, Resident #34, Resident #38, and Resident #63) of 20 Residents reviewed for call light use/accessibility, resulting in the potential of care needs not met, feelings of frustration, anger, and safety concerns. Findings include: On 3/22/23, an initial tour of the facility was conducted. The following observations were made: -At 9:17 AM, Resident #38 was observed with the Resident in bed. The call light was observed on the floor and not in reach of the Resident. -At 9:23 AM, Resident #63 was observed sleeping in bed. An observation was made of the call light cord over the top corner of the bed with the call light function on the floor and not in reach of the Resident. -At 9:42 AM, Resident #8 was observed sleeping in bed with the head of the bed elevated. The Resident was observed further down in the bed. The call light…

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 Observation of room [ROOM NUMBER]: Observation of the resident was done on 3/23/23 at 8:55 a.m., revealed room [ROOM NUMBER] had an extremely offensive odor of urine; it could be smelled from outside the room. During an interview done on 2/23/23 at 9:00 a.m., Nursing Assistant/CNA A stated Third shift has been talked to before about not changing her (Resident who occupies room [ROOM NUMBER]), (Facility Management) Yes, it smells bad, I haven't gotten in there yet. During an interview done on 3/24/23 at approximately 11:20 a.m., the Director of Nursing stated, I know she (Resident #39) needs to be cleaned up, her room needs to be cleaned. Observation of room [ROOM NUMBER]: Observation was made on 3/22/23 at approximately 10:00 a.m., the resident was in his bed, blinds closed and the heater under the window was observed to have an area of about 4 to 5 inches across the whole front of black marks. During an interview done on 3/24/23 at approximately 2:30 p.m., the Director of Maintenance C said he was not informed…

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 Resident #19: Review of the Face Sheet, Diagnosis Sheet, Physician orders dated 12/22 through 3/23, care plans dated 1/23 and Social Worker notes dated 12/23 through 2/23, revealed Resident #19 was 64 years-old, cognitively impaired with an extensive mental health history and required staff assistance for all Activities of Daily Living. The resident's diagnosis included, Anemia, Schizophrenia, Anxiety, high blood pressure, Parkinson's Disease, altered mental status and organ dysfunction. Review of the facility BIMS (cognitive assessment) dated 5/6/2011, revealed the resident was not cognitively able to make any healthcare decisions. Review of the resident's medication orders dated 12/22, revealed he received Closapine 100 mg (an antipsychotic), Depakote Sprinkles 125 mg (for mania) and HydeOXYzine 50 mg (for antianxiety). Review of the resident's facility electronic record done by Social Worker D and this surveyor on 3/23/23, revealed no documentation at all of any PASARR's being done while at the facility…

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 This Citation pertains to Intake Number MI00131653. Based on observation, interview and record review, the facility failed to ensure that bathing/shower activities were provided and assist with dressing and shaving for six residents (Residents #1, Resident #4, Resident #12, Resident #18, Resident #57, and Resident #60) of 14 residents reviewed for Activities of Daily Living (ADL) care, resulting in poor hygiene and the potential for infection, skin irritation, body odor and feelings of embarrassment, diminished self-worth, and lack of dignity. Findings Include: Resident #4: A review of Resident #4's medical record, revealed an admission into the facility on [DATE] and re-admission on [DATE] with diagnoses that included diabetes, obesity, urinary tract infection, Alzheimer's disease, depression, and anxiety disorder. A review of the Minimum Data Set assessment, dated [DATE], revealed the Resident had intact cognition and needed extensive assistance with two persons physical assist for bed mobility, transfer,…

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

Based on observation, interview and record review, the facility failed to ensure 3 (Hall 2, 1 A and 1 B) of 4 medication carts were clean and sanitized, free of crushed pills, pieces of loose papers and dust in the drawers, resulting in the likelihood of cross contamination, low medications count with increased cost and missed resident medications (meds). Findings Include: Observation of facility medication carts done on 3/22/23 starting at 9:53 a.m., revealed the following: Cart 1 A: -In the first and 3rd drawers there was an excessive number of crushed medications and pieces of paper on the bottom of each drawer. During an interview done on 3/22/23 at 9:58 a.m., Nurse, LPN J stated Management did clean them out last week, night shift is supposed to clean them. -In the first drawer was observed a medication cup with 2 Tums inside, no resident name or date was on the cup. During an interview done on 3/22/23 at 10:00 a.m., Nurse, LPN They (Nurse's from third shift on 3/21/23) were from last shift. Cart: 1 B: During an interview done on 3/22/23 at 10:00 a.m., Nurse, K stated You…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide snacks and residents' choices of snacks for all residents, resulting in frustration of not getting snacks per their choice or no snack at all. Findings include: On 3/22/23, at 1:11 PM, an observation along with Nurse K of the medication room [ROOM NUMBER]B was conducted. Nurse K was asked where the snacks are stored for the residents and Nurse K pointed to a plastic bin approximate size 10 inches by about 14 inches that was sitting on top of the medication room counter. The plastic bin housed an empty box of oatmeal cream pies and only 1 single package of Fig Newtons. There was small jar of peanut butter. Nurse K opened the freezer which was full of personal purchased freezer items and had no ice cream treats for residents' snacks. The refrigerator housed 1 chocolate pudding and 1 apple sauce which the nurse stated they use for medication pass. There was a clear plastic container that housed 1 half deli lunch meat sandwich. 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.

Based on observation, interview and record review, the facility failed to 1) Maintain food preparation and kitchen equipment in a sanitary and good working condition, and 2) Ensure that kitchen hand washing sinks and freezer door were properly maintained, resulting in an increased likelihood for improper food temperatures maintained, food borne illness with hospitalization, and cross contamination affecting 94 residents who consumed oral nutrition from the facility kitchen and of a total census of 95 residents. Findings Include: During the initial kitchen tour done on 3/22/23 at 9:30 a.m., accompanied by Dietary Manager G, the following observations were made: -At 9:30 a.m., the hand washing sink at the front of the kitchen did not drain properly, it was very slow to drain the water. During an interview done on 2/22/23 at 9:35 a.m., Dietary Manager G stated It (the hand washing sink) does not drain good, we have problems with the pluming here, the whole facility, it's been for a while. -At 9:36 a.m., the resident microwave inside top had the white coating picking off; directly above…

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 This Citation pertains to Intake Number MI00129842. Based on interview and record review, the facility failed to give information and direct Resident Representatives in obtaining an advance directive or guardianship for one resident (Resident #135), who was incapacitated, two residents reviewed for advance directives, resulting in not having arrangements for appropriate representation for health care decisions and a lack of care coordination. Findings Include: Resident #135: A review of Resident #135's medical records revealed an admission into the facility on 4/13/21, re-admission on [DATE] and discharged on 2/23/22, with diagnoses that included sepsis, acute respiratory failure with hypercapnia, altered mental status, dysphasia, dementia, Schizophrenia, bipolar disorder, cerebral infarction, cognitive communication deficit, aphasia, major depressive disorder, need for assistance with personal care, and metabolic encephalopathy. A review of Resident #135's Minimum Data Set assessment, dated 2/23/22, revealed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow up on a contaminated urine sample for one resident (Resident #37) of three residents reviewed for catheter care and Urinary Tract Infections (UTI), resulting in the potential for a urinary tract infection to be unidentified and untreated. Findings include: Resident #37: A review of Resident #37's medical record revealed an admission into the facility on 8/23/22 with a re-admission on [DATE] with diagnoses that included diabetes, stroke, heart failure, pneumonia, sepsis due to Methicillin Resistant Staphylococcus aureus, acute kidney failure, acute cystitis with hematuria, severe sepsis with septic shock, obstructive and reflux uropathy, and urinary tract infection. A review of the Minimum Data Set (MDS) assessment, dated 1/11/23, revealed a Brief Interview of Mental Status of 12/15 which indicated moderately impaired cognition and needed limited assistance with bed mobility, transfer, and dressing and needed extensive assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide medications per physician's orders and timely delivery from the pharmacy for two residents (Resident #22, Resident #238) and administer insulin pen per standards of practice for one resident (Resident #22) out of five residents reviewed during medication administration, resulting in missed medications, a high heart rate, feelings of nervousness with the likelihood of increased medical symptoms. Findings include: On 3/23/23, at 12:34 PM, During medication administration, Nurse Q prepared Resident #22's insulin supplies. Nurse Q dialed the insulin pen to 3 units. Nurse Q was asked what the dose of insulin was for Resident #22 and Nurse Q clarified the dose to be 3 units. Nurse Q did not prime the needle with the required 2 units of insulin. Nurse Q entered Resident #22's room, cleansed the area and placed the needle tip, pushed down on the pen leaving the pen in skin for only 5 seconds. Resident #22 dose of sevelamer carbonate 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, interview, and record review the facility failed to 1) Ensure that resident monthly infection data was analyzed for 1/23 and 2/23, and 2) ensure proper hand hygiene during medication pass for a census of 95 residents, resulting in the likelihood for cross contamination, resident, and staff illness, antibiotic usage with possible hospitalization. Findings Include: Infection Control Data Analyzing: Review of the Infection Control Guideline dated 11/28/17, reported The Infection Control Preventionist and the Infection Control Prevention and Control Committee will utilize the information collected from both Process and Outcome Surveillance activities in order to analyze the data to identify opportunities for improved care and process and identify an action plan for follow up and corrective action. The analyzing will compare current and past infection control surveillance data, compare the reported incidence of infections by type and location. Based on analysis of data, develop and implement an action plan that includes correction actions, staff education, 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.