Hillcrest Health Care, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure a mechanical transfer lift was cleaned after resident use for 3 of 3 residents (R9, R45, R26) and that appropriate sanitizer was used to clean the lift observed for infection control practices. Findings Include: R9's Face Sheet printed 6/13/24, included diagnoses of obesity, bipolar disorder, difficulty in walking and unsteadiness on feet. R9's significant change Minimum Data Set (MDS) dated [DATE], indicated R9 was dependent on staff for all transfers and required assist of 2 and a lift. During observation on 6/11/24 at 3:36 p.m., nursing assistant (NA)-E and NA-F with the assist of a mechanical lift (device utilized for transfer) transferred R9 from her bed to her wheelchair. NA-F removed the lift from the room and moved it to another hallway and parked it in room [ROOM NUMBER]. NA-F left the room. NA-F confirmed he did not clean the lift and should have. During observation on 6/13/24 at 8:39 a.m., NA-A was observed in R45's room cleaning a hoyer…

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, the facility failed to ensure 4 of 5 vents in the 400 hallway, and 5 of 5 vents in 500 hallway were clean when they had a black substance present on the 3 tiered vents. This deficient practice had the potential to affect all residents, staff, and visitors on the 400 and 500 wings. In addition, the facility failed to ensure resident rooms were maintained in a clean, sanitary manner for 13 of 60 residents (R7, R163, R16, R29, R39, R57, R2, R4, R162, R260, R37, R45, R22) whose rooms and/or bathrooms lacked upkeep, and who were reviewed for environment. Findings include: Hallway Vents During an observation on 6/10/24 at 3:29 p.m., the 500 unit hallway was observed to have five vents that had a black substance present on the rungs of the 3 tired vents. The maintenance director (MD)-A indicated it appears like dust buildup and the vents need to be taken down and cleaned. MD-A added it likely due to moisture after starting the air conditioning units causing the dirt to stick. MD-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 document review, the facility failed to ensure 1 of 1 resident (R16) who was observed to have medications in his room, had been appropriately assessed and deemed safe to self-administer medications. Findings include: R16's facesheet printed on 6/13/24, indicated history of a stroke. R16's annual Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, clear speech, could usually understand and be understood. R16 was dependent upon staff for activities of daily living. R16's physician orders included: 1. Calcipotriene external ointment 0.005 %, apply to affected area on right leg topically two times a day every Saturday and Sunday for psoriasis, dated 10/25/23. 2. Aspercreme arthritis pain external gel 1 % (diclofenac sodium topical), apply to left hand and finger joints topically every morning and at bedtime for contracture pain, dated 4/18/24. 3. Systane solution 0.4-0.3 %; instill 1 drop in both eyes every morning and at bedtime for dry eyes,…

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 update the care plan and the [NAME] with behavioral interventions for 1 of 1 resident (R39) reviewed for care plans. Findings include: R39's facesheet printed on 6/13/24, included diagnoses of metabolic encephalopathy (a chemical imbalance in the brain which can lead to personality changes), bilateral below the knee amputations, and depression. R39's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R39 was cognitively intact, had clear speech, could understand and be understood, was independent with eating and toileting, refused oral care and bathing. Due to bilateral below the knee amputation, R39 used a wheelchair. R39's physician orders dated 8/22/23, and 3/20/24, included psychotropic, antipsychotic, and anti-depressant medication monitoring for side effects. Orders did not include mood and behavior monitoring. R39's care plan dated 6/2/22, indicated the potential for alteration in mood and behavior related 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 document review the facility failed to provide timely incontinence care for 1 of 2 residents (R42) who was dependent upon staff for assistance with activities of daily living (ADL). Findings include: R42's Face Sheet printed 6/13/24, included diagnoses of disorientation, malnutrition, Parkinson's disease (progressive disorder that affects the nervous system and parts of the body controlled by the nerves), and epilepsy (seizures). R42's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R42 had a moderate cognitive impairment, inattention behavior continuously present, and behaviors including rejection of care that occurred 4-6 days out of 7. Activities of daily living (ADL's) included R42 uses a wheelchair and dependent on staff to wheel 50 feet, has impairment on both side of lower extremities for range of motion and requires substantial to maximal assist for transfers, bed mobility, toileting and personal hygiene. Eating requires setup or clean up assist.…

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 document review the facility failed to provide timely repositioning for 1 of 1 resident (R42) who was dependent upon staff for repositioning and high risk for pressure ulcers. Findings include: R42's Face Sheet printed 6/13/24, included diagnoses of disorientation, malnutrition, Parkinson's disease (progressive disorder that affects the nervous system and parts of the body controlled by the nerves), and epilepsy (seizures). R42's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R42 had a moderate cognitive impairment, inattention behavior continuously present, and behaviors including rejection of care that occurred 4-6 days out of 7. Activities of daily living (ADL's) included R42 uses a wheelchair and dependent on staff to wheel 50 feet, has impairment on both side of lower extremities for range of motion and requires substantial to maximal assist for transfers, bed mobility, toileting and personal hygiene. R42 is at high risk for pressure ulcers, has…

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 document review, the facility failed to ensure staff were educated and following the fall risk interventions for 1 of 2 residents (R42) identified at risk for falls to prevent further falls. Findings include: R42's Face Sheet printed 6/13/24, indicated R42 had diagnoses of age related cognitive decline, disorientation, obstructive and reflux uropathy (blockage of urine flow), Epilepsy (seizures) and Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). R42's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R42 had a moderate cognitive impairment, had inattention behavior continuously present, and behaviors of rejection of care that occurred 4-6 days out of 7. Activities of daily living (ADL's) included R42 uses a wheelchair and dependent on staff to wheel 50 feet, has impairment on both side of lower extremities for range of motion and requires substantial to maximal assist for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review the facility failed to ensure activities of daily living (ADLs) including timely assistance with toileting and changing soiled clothing were provided for 1 of 1 resident (R57) who needed assistance with toileting and hygiene. Findings include: R57's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R57 had moderately impaired cognition, no rejection of care, required supervision or touching assistance with transfers, was independent with personal hygiene and toilet hygiene, did not use a wheelchair, and was occasionally incontinent of bladder. Diagnoses included non-Alzheimer's dementia (vascular dementia) and unsteadiness on feet. R57's Care Area Assessment (CAA) dated 4/24/24, indicated the need for assistance with toilet use. R57's care plan printed 6/13/24, indicated R57 had an ADL self-care deficit related to vascular dementia without behavioral and psychotic disturbance, muscle weakness, history of falling, and osteoarthritis of knee…

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 document review, the facility failed to ensure personal privacy was maintained for 1 of 5 residents (R6) reviewed who required staff assistance with personal care. R6's face sheet identified R6 admitted on [DATE] with diagnoses of type 2 diabetes, obesity, dementia, unspecified psychosis. R6's current care plan identified an alteration in behavior and interventions included to go into room with two staff when completing care. On 3/27/24 at 10:22 a.m., nursing assistant (NA)-D came into room to change roommate d/t a strong urine odor in room. Curtain was drawn between roommates. NA-D yelled from the R6's side of the room [LPN-A] he keeps throwing his fists up at me, his sheet is wet. NA-D came over to R3's side of the room angrily with a garbage bag and stated, He just keeps laughing now, it isn't funny. NA-D then left the room. LPN-A stated when a resident was not cooperative staff should let the nurse know and reapproach in 10 minutes. LPN-A stated she would talk to NA-D…

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 initiate, comprehensively assess, monitor, and treat skin conditions for 4 of 4 residents (R2, R3, R4, and R5) reviewed for impaired skin integrity. R2's face sheet undated identified an admission date of 7/2021. Diagnoses morbid obesity (obesity categorized by a body mass index greater than 40), type 2 diabetes, urinary incontinence, and erythema intertrigo (inflammatory skin condition caused by skin-to-skin friction (rubbing) that is intensified by heat and moisture). R2's Minimum Data Set (MDS) dated [DATE], identified R2 needed maximum assistance with movement and complete dependence with toileting. R2 used a motorized wheelchair. R2's current care plan identified an alteration in skin integrity with a goal to remain free of skin breakdown. Interventions included: followed by wound care, monitor skin integrity daily during cares, weekly skin inspection by nurse, treatment to open areas per order, turn and reposition or reminders 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 observation, interview and document review, the facility failed to follow manufacturers instructions for cleaning and sanitizing two ice machines used for resident consumption. This had the potential to affect all 59 residents who resided in the facility. Findings include: During an observation and interview on 7/24/23 at 8:18 a.m., culinary services director (CSD)-A stated the facility had two ice machines, one located in the kitchen and one in the adjacent dining room. CSD-A stated dietary staff cleaned the outside and maintenance staff deep cleaned the inside. CSD-A stated residents had the potential to consume ice from both ice machines. During document review, paper logs titled Ice Machine Cleaning indicated ice machines had been cleaned monthly in 2022 and 2023. The log did not indicate the type of cleaning that had been conducted. During an interview on 7/26/23 at 11:53 a.m., maintenance assistant (MA)-A stated he was not sure if there were manufacturer instructions for how to, or how often ice machines should be cleaned and sanitized; he had not thought to look at…

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 implement and maintain an infection control program that included thorough data collection, analysis of facility infections, and tracking and trending to reduce the spread of infections within the facility. The facility failed to include in their surveillance viral-like illnesses not treated with an antibiotic for staff or residents. The facility had no process in place to identify and monitor other types of infection in the facility and there was no analysis of the data collected. This had the potential to affect all 59 residents residing in the facility. Furthermore, the facility failed to ensure staff were implementing standard precautions for infection control and prevention, appropriately disinfecting reusable resident medical equipment including a scissors (R13) and glucometer (R29). This had the potential to affect all 7 residents using reusable glucometers residing on the southwest (200) wing of unit and two residents using reusable scissors for wound care on the 100 wing of unit. Findings include: On 7/25/23 at…

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 implement a process for antibiotic review to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance. This had the potential to affect any of the 59 residents at the facility. Findings include: On 7/25/23 at 2:31 p.m., the director nursing (DON) stated she was the infection prevention nurse and assisted with infection prevention since she started the position as the DON one month ago. The DON stated the antibiotic use was not tracked. The DON stated the nurses completed monitoring of resident symptoms, possible infections, and reported to the provider. The DON stated the providers were responsible to review or track culture results to ensure proper antibiotics were prescribed. The DON confirmed infections, antibiotic indications for use, dosage, duration, cultures, signs, symptoms of infection upon onset, follow-up to ensure symptoms had resolved or an antibiotic had been discontinued timely was not tracked. On 7/25/23 2:45 p.m., during an interview the administrator and regional…

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 document review the facility failed to inform resident/resident representative in advance of care, of the risks and benefits, possible alternatives to treatment, and receive consent of proposed care prior to initiating psychotropic (mood) medication for 1 of 4 residents (R44) reviewed for dementia care. Findings include: R44's quarterly minimum data set (MDS) assessment dated [DATE], indicated moderate cognitive impairment, had clear speech, was able to understand and be understood by others, exhibited mild symptoms of depression (mood disorder), had no behaviors, wandered occasionally, and received antipsychotic and antidepressant (mood disorder) medications. Furthermore, the MDS indicated R44's diagnoses included list Alzheimer's dementia (brain disease causing memory loss and abnormal thinking), anxiety, depression, and hallucinations (mental disorder causing abnormal perception). Facility Medication Review Report, printed on 7/27/23, indicated an order dated 7/2/23, initial order start…

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 document review, the facility failed to ensure adequate and required information was documented and communicated to a receiving healthcare facility to ensure continuity of care for 1 of 1 resident (R44) reviewed for hospitalization, had transferred to hospital emergently. This deficient practice had the potential to affect all 59 residents residing in the facility. Finding include: R44 was admitted to the facility on [DATE], R44's diagnoses listed on face sheet included: Type 2 diabetes (blood sugar abnormality), muscle weakness, Alzheimer's disease (brain disease causing memory loss and abnormal thinking), malnutrition, major depression (mood disorder), hallucinations (mental disorder causing abnormal perception), anxiety, chronic kidney disease, and pseudo hole of right eye (visual changes). R14's quarterly minimum data set (MDS) assessment dated [DATE], identified R44 as having moderate cognitive impairment. R44 was able to understand and was understood. R44 required extensive…

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 document review, the facility failed to ensure activities of daily living (ADLs) were provided, including nail care for 1 of 6 residents (R112) reviewed, who needed staff assistance to maintain good personal hygiene. Findings include: R112's admission Minimum Data Set (MDS) assessment, dated 7/17/23, indicated R112 had moderate cognitive impairment and required staff assistance for personal hygiene. R112's order summary, printed on 7/27/23, indicated for licensed nurse to complete weekly skin inspection in the evening every Tuesday. R112's care plan, printed on 7/27/23; indicated R112 required assistance by 1 staff member for personal hygiene needs. R112's admission/data collection assessment, completed on 7/10/23, indicated bathing preference included showers during daytime, skin assessed with no concerns at time. Review of R112's weekly skin assessment, reviewed from 7/13/23-7/25/23, indicated a skin assessment had been completed on 7/25/23. Review of R112's bathing task, reviewed from 7/13/23-7/25/23, indicated shower received on 7/19/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to assess and provide proper wheelchair positioning to prevent foot drop/contractures for 1 of 2 residents (R16) reviewed for positioning needs. Findings include: R16's current diagnoses found on the undated diagnosis sheet included: cerebral vascular accident (CVA) (damage to the brain from interrupted blood supply), hemiparesis of the left side ( muscle weakness or partial paralysis on one side of the body) and muscle weakness (decreased strength of the muscles). Observation on 7/24/23 at 10:55 a.m., R16 was noted to be sitting in a wheelchair in a sloughed position. R16's right foot was dangling, with only the tip of the toes touching the floor. There was no foot pedal on the wheelchair to provide support. R16's left leg had a protective boot on and resting on a wheelchair pedal. R16's quarterly minimum data set (MDS) assessment dated [DATE], identified R16 as having a brief interview of mental status (BIM'S) score of 6 (meaning severely…

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 document review, the facility failed to ensure restorative services to maintain and/or improve mobility was received for 1 of 3 residents (R49), reviewed for mobility. Findings include: R49's significant change in status Minimum Data Set (MDS) assessment, dated 6/6/23, indicated R49 had intact cognition, had impairment to both lower extremities (LEs), no impairment to both upper extremities (UEs); required limited assistance for bed mobility and ambulating (walking) in room, required extensive assistance with transfers, used a wheelchair and walker for mobility needs. R49's face sheet, printed on 7/27/23, identified diagnoses list to include morbid obesity, chronic pain, history of falls, dementia (abnormal thinking and memory loss), major depression (mood disorder), acute osteomyelitis (bone infection) to left foot/ankle, partial amputation of left foot. R49's order summary report, printed on 7/27/23, indicated R49 was okay to walk with shoes or post op shoes, no walking with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure staff were implementing fall risk prevention measures for 1 of 3 residents (R44) reviewed for accidents. Findings include: R44's face sheet, printed 7/27/23, indicated diagnosis list included fracture of right femur (leg), type 2 diabetes (blood sugar abnormality), muscle weakness, Alzheimer's disease (brain disease causing memory loss and abnormal thinking), malnutrition, major depression (mood disorder), hallucinations (mental disorder causing abnormal perception), anxiety, chronic kidney disease, spinal stenosis (narrowing of spine) of lumbar (back) region with neurogenic claudication (nerve pain), and pseudo hole of right eye (visual changes). R44's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R44 had severely impaired cognition, exhibited no behaviors, occasionally wandered, required extensive assist by 1 staff for bed mobility, transfers, locomotion on/off unit, dressing, toileting, personal hygiene,…

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 document review, the facility failed to ensure consulting pharmacist recommendations were addressed or acted upon for 2 of 5 residents (R8, R12) reviewed for unnecessary medications. Findings include: R8's face sheet printed on 7/26/23, included diagnoses of schizophrenia (a disorder that affects ability to think, feel and behave), high blood pressure, atrial fibrillation (irregular heart beat) and kidney failure. R8's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment requiring extensive assistance of one or two staff for most activities of daily living (ADL's). R8's physician orders included multiple scheduled and as needed medications. R8's care plan dated 1/29/21, indicated R8's medications would be reviewed by a provider and pharmacist. During record review for the past 12 months, the consultant pharmacist entered a monthly progress note into R8's electronic medical record (EMR) indicating either no irregularities or see pharmacist…

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 document review, the facility failed to ensure residents were free of significant medication errors for 1 of 1 resident (R29) reviewed for insulin administration using an insulin pen. Findings include: R29's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R29 had intact cognition, diagnoses list included diabetes mellitus (abnormal blood sugars), Alzheimer's disease (brain disease causing abnormal thinking and memory loss), hemiplegia/hemiparesis (paralysis), depression (mood disorder), and received injectable insulin. R29's order summary, dated 6/27/23, indicated physician orders for insulin aspart flexpen subcutaneous solution pen-injector 100 unit/mL- Inject subcutaneously with meals related to type 2 diabetes mellitus (DM) with diabetic chronic kidney disease (CKD), blood sugar greater than 400 call medical doctor (MD) and insulin glargine subcutaneous solution 100 unit/mL- Inject 25 units subcutaneously at bedtime related to type 2 DM with diabetic…

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 doses of controlled substances were stored in a manner to reduce the risk of theft and/or diversion in 1 of 2 refrigerators observed in use for medication storage. This had potential to affect 2 of 2 residents (R15 and R48) residing in the facility who receive this medication. Findings include: On 7/26/23 at 11:44 a.m., the locked north medication room was observed with registered nurse (RN)-A, a locked refrigerator was present. RN-A opened the refrigerator and inside was a box of lorazepam oral concentrate 2 mg/ml labeled with R15's name and a bottle of lorazepam oral concentrate 2 mg/ml labeled with R48's name. RN-A stated the facility practice was to store the lorazepam in the refrigerator and the facility practice did not include the lorazepam stored in a separately affixed box within the refrigerator. On 7/26/23 at 11:58 a.m., during an interview the director of nursing (DON) confirmed lorazepam is a scheduled controlled substance and should be stored in a separately affixed box within the refrigerator. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure resident bathroom call light cords were within reach from the bathroom floor for 3 of 3 residents (R2, R43, R47), reviewed for call lights. Findings include: R2's facesheet printed on 7/27/23, included diagnosis of macular degeneration (eye disease that causes vision loss). R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R2 was cognitively intact, had clear speech, could understand, and be understood. R2 required supervision for most activities of daily living (ADL's) including walking in his room and transferring. R2 required extensive assistance of one for toileting. During an observation on 7/24/23 at 11:10 a.m., there was no call light cord observed in R2's bathroom, just a small, older style push button call light on the wall; not intended for a cord to hang from it. During an interview on 7/25/23 at 6:55 p.m., registered nurse (RN)-A confirmed R2 used the toilet in his bathroom and pressed the call light button for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to implement an effective pest control program to eliminate mice in the building. This failure affected R4, and had the potential to affect all 66 residents who resided in the facility. Findings include: R4's diagnoses included diabetes, end stage renal disease (renal failure) requiring dialysis (the process of removing toxins from the body), and transmission based precautions for recurrent clostridium difficile (a bacteria in the bowel which causes diarrhea and fever). R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R4 was cognitively intact, had adequate hearing and vision, clear speech, was understood and able to understand. R4 required assistance from staff for transferring in and out of bed and moving about in a wheelchair. R4 did not walk. During an interview on 2/14/22, at 1:51 p.m., R4 who resided in room [ROOM NUMBER], reported he had mice in his room, I hear them in the ceiling and I've seen them on 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 document review, the facility failed to ensure a system for routine reconciliation of controlled substances medication for 1 of 1 emergency kit (E-Kit) to prevent potential loss/diversion. Findings include: On 2/16/22, at 2:30 p.m., a tour of the North medication storage room with nurse manager (NM)-D. Located within the medication storage room was a portable refrigerator that contained the facility E-Kit. The E-Kit consisted of a small tackle box that was secured with a pull away colored tab. The tackle box contained 2 vials of injectable lorazepam (an anti-anxiety medication/controlled substance). Review of the documentation count in the Narcotic bound book,did not identify lorazepam had ever been reconciled by facility staff, to identify or account for any missing medication. Interview with NM-D on 5/12/21, at 11:00 a.m. confirmed staff were not periodically reconciling the E-Kit controlled substances. NM-D indicated she did not understand why reconciling of the E-Kit needed to be done, because only licensed staff had access to the medication…

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, the facility failed to ensure 8 of 71 rooms (rooms 101, 103, 111, 112, 113, 115, 201, 216) were maintained in good repair and in sanitary conditions, impacting 11 residents (R21, R264, R1, R55, R46, R57, R13, R213, R59, R9, R4). In addition, the facility failed to ensure fans used in resident resident rooms (rooms [ROOM NUMBERS]), impacting residents (R3, R32) were kept in a clean and sanitary manner; free of dust and debris. Findings include: During resident screening on 2/14/22, from 12:30 p.m. to 4 p.m., the following observations were made: --room [ROOM NUMBER], occupied by R21: The white toilet bowl was heavily stained with a dark gold, rusty color. --room [ROOM NUMBER], occupied by R1 and R264: An excessive amount of gray dust and debris resembling thick dryer lint was observed in the return air vent on the floor under the window; three ceiling tiles near the window were stained with a gold-colored splatter pattern; the white toilet bowl was heavily stained with a dark…

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 document review, the facility failed to develop a comprehensive care plan for 1 of 1 resident (R26) reviewed for smoking,1 of 2 residents (R4) reviewed for transmission based precautions. Findings include: R26's admission record printed 2/17/22, indicated R26 was admitted 9/19, diagnoses included nicotine dependence, diabetes, malignant neoplasm of mandible (jaw cancer), and squamous cell carcinoma (cancer) of skin of other parts of face. R26's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R26 had intact cognition, no behavior symptoms, required two-person physical assist for activities of daily living, and mobility device of a wheelchair. On 2/14/22, the care plan dated 1/27/22, was reviewed and did not identify R26 smoked or any smoking interventions. The care plan was then updated on 2/14/22, interventions were added to the care plan and included R26 currently smoked, resident will smoke safely, educate on potential dangers of oxygen and cigarette…

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 document review, the facility failed to update the code status for 1 of 1 resident (R18) reviewed for advanced directives. In addition, the facility failed to accurately document resident's code status throughout the medical record. Findings include: R18's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R18 had intact cognition. R18's face sheet, dated [DATE] and updated on [DATE], identified diagnoses of cerebral infarction (lack of oxygen to brain causing brain damage), aphasia (loss of ability to understand or express speech), diabetes mellitus- type 2, hemiplegia (paralysis of one side of the body), and malignant neoplasm of prostate (prostate cancer). R18's face sheet, dated [DATE], identified advance directive as cardiopulmonary resuscitation (CPR). R18's hospice admission consent form identified on [DATE], R18 had transitioned to hospice care. R18's Provider Orders for Life-Sustaining Treatment (POLST), dated [DATE], identified Attempt Resuscitation/CPR (Full…

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 document review, the facility failed to comprehensively assess and monitor the progress of finger lesions for 1 of 1 resident (R28) with non-pressure related skin concerns. Findings include: R28 was admitted to the facility on [DATE], with diagnoses (identified on the diagnosis report sheet) dated 1/5/22, included; actinic keratosis ( rough scaly skin caused by the sun) congestive heart failure (CHF) ( a chronic condition in which the heart does not pump blood as well as it should), fibromyalgia (widespread muscle pain and tenderness) osteoarthritis (when bone protective tissue wears down ), spinal stenosis (narrowing of the spinal canal), history of pressure ulcer (PU) on coccyx and buttocks, dehydration and joint pain. Observation and interview on 2/14/22 1:40 p.m. R28 was in her room sitting in her wheelchair. R28 noted to have 3 bandaids on her thumb, 2nd and 3rd fingers of her left hand. The bandaids were partially on the lesions. The lesions looked crusty and cracked…

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 document review, the facility failed to ensure consulting pharmacist recommendations were acted upon, addressed, and documented in the medical record for 1 of 5 residents (R17) reviewed for unnecessary medication use. Findings include: R17's admission Minimum Data Set (MDS) assessment dated [DATE], identified R17 had moderate cognitive impairment, mild depression, required extensive assist with bed mobility, transfers, dressing, toilet use, and personal hygiene. Diagnoses included Parkinson's disease (chronic and progressive movement disorder causes stiffness or slowing of movement), diabetes, anxiety disorder, depression, and age-related physical disability. The MDS indicated R17 received scheduled pain medication, non-medication interventions for pain, insulin, antidepressant, and opioids. R17's care plan dated 2/16/22, indicated potential for psychotropic drug ADR's [adverse drug reaction] r/t [related to] daily use of psychotropic medication related to diagnosis of depression with…

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

Based on observation, interview, and document review the facility failed to follow transmission-based precautions by ensuring closure of room doors for 2 of 3 residents (R14, R50) symptomatic and known to be positive with COVID-19. The facility's failure to ensure implementation of proper precautions to prevent or mitigate the risk of COVID-19 outbreak had the potential to affect all other 63 residents and staff within the facility. Findings include: During entrance conference on 2/14/22 at 12:47 p.m., the administrator identified three residents ( R14, R50, R38) confirmed to have COVID-19 and were on droplet/contact precautions, all three residents resided on 500 unit of facility. R14's medical diagnosis listed on admission face sheet, printed on 2/18/22, identified dementia with Lewy body (brain disease causing problems in thinking, movement, behavior, and mood). R14 was diagnosed with positive COVID-19 on 2/7/22, remained asymptomatic throughout isolation period, off precautions on 2/18/22. R50's medical diagnosis listed on admission face sheet, printed on 2/18/22, identified…

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 document review the facility failed to provide evidence pneumococcal vaccinations were up to date for 1 of 5 residents (R51) reviewed for vaccinations. Findings include: R51's admission Minimum Data Set (MDS) assessment dated 1/22, indicated an admission date of 1/13/22. The MDS further indicated R51 had intact cognition, was [AGE] years of age, had medically complex health conditions, and was not assessed for pneumococcal vaccination status. R51's admission MDS assessment, dated 1/20/22, identified diagnoses to include; cancer, anemia (a condition of lack of red blood cells), renal insufficiency (a condition that causes poor function of kidneys), cerebrovascular accident (CVA; a condition that causes damage to the brain/stroke), and respiratory failure (a condition that causes poor function of the lungs). When interviewed on 2/17/22, at approximately 1:45 p.m. the regional nurse consultant (RNC) confirmed R51's medical record did not include evidence of pneumococcal vaccinations had been…

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 document review, the facility failed to ensure COVID-19 vaccination doses were offered to 3 of 5 residents (R41, R49, R51) reviewed for COVID-19 vaccination status. Findings include: R41's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R41 was admitted to the facility on [DATE]. Reviewed R41's Resident Vaccine Administration Consent Form, signed by R41, her representative, and facility nursing staff on 7/2/21, did not address COVID-19 vaccination. Furthermore, R41's medical record lacked documentation R41 and/or her representative were offered the COVID-19 vaccine upon and/or after admission, nor were provided education related to the risk and/or benefits of the vaccine. R41's medical record lacked documentation that COVID-19 vaccine was administered or contraindicated. R49 R49's admission MDS assessment dated [DATE], indicated R49 was admitted to the facility on [DATE]. Reviewed R49's Resident Vaccine Administration Consent Form, unsigned and undated by R49, his…

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.