Community Memorial Health Center

Licensure Reference Number 175 NAC 12-006.09 (H) iii Based on observation, record review, and interview, the facility failed to complete skin assessments per facility policy and standards of practice for 1 resident (Resident 3), of 4 sampled residents. The facility census was 62. Findings are: A record review of a document from the Wound Care Education Institute and titled Best Practices for Wound Assessment and Documentation dated 04/17/2025 revealed that a foundational element of wound assessment is accurate wound measurements using a standardized method like length, width, and depth. To be time sensitive and consistent documenting the wound assessment at consistent intervals based on facility protocol. A record review of a facility policy titled Skin Assessment and dated 06/12/2025 revealed it is the facility policy to perform skin assessment weekly if the resident has a notable wound or has a Braden assessment score deemed as high risk. Review of an admission Record revealed the facility admitted Resident 3 on 03/05/2024 with diagnoses of chronic kidney disease (a condition…

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 Licensure Reference Number 175 NAC 12-006.09(F) Based on observation, record review, and interview; the facility failed to implement and/or revise Residents 1, 29, 54, and 59's current care plans to reflect the resident's current status. The sample size was 22 and the facility census was 58. Findings are: A. Review of the facility policy Comprehensive Care Plans with a revision date of 12/14/2022 revealed the following: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs. The care planning process will include resident's strengths and needs, -The care plan will be developed within 7 days after the completion of the comprehensive Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) assessment, -The care plan will describe services that are to be furnished to attain or maintain 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.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observation, record review and interview; the facility failed to ensure meals served in the Special Care Unit (SCU) were palatable and served at the proper temperature. This had the potential to affect all 16 residents that resided on the SCU. The facility census was 58. Findings are: A. Review of the facility policy Record of Food Temperatures (undated) revealed it was the policy of this facility to record food temperatures daily to ensure food was served at the proper temperature. The following guidelines were to be followed: -food temperatures were to be recorded on all items prepared in the dietary department. -hot food items were to be maintained at 135 degrees Fahrenheit (F) or higher. -potentially hazardous food that was cooked and then cooled was to be reheated so that all parts of the food reached an internal temperature of 165 degrees (F) for at least 15 seconds before service. -ready to eat foods that required heating before consumption were to be taken directly from a sealed container of an intact package from an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.18(B), and 175 NAC 12.006.18(D) Based on observations, record review and interview: the facility staff failed to utilize gloves and to wash hands and/or perform hand hygiene at appropriate intervals during the provision of toileting and catheter cares for Residents 1, 26 and 54 and to implement enhanced barrier precautions when providing direct cares for Residents 29 and 59. The total sample size was 22 and the facility census was 58. Findings are: A. Review of the facility policy Hand Hygiene (undated) revealed hand hygiene was defined as the general term for cleaning hands by handwashing with soap and water or the use of an antiseptic hand rub also known as alcohol-based hand rub (ABHR). Hand hygiene was to be completed when: -hands were visibly soiled with blood or other body fluids. -between resident contacts. -after handling contaminated objects. -before applying and after removing personal protective equipment (PPE), including gloves. -before preparing or handling…

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.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04(F)(i)5 Based on record review and interview; the facility staff failed to notify the primary care practitioner (PCP) and the Registered Dietician (RD) of weight loss for 2 (Residents 27 and 12) of 3 residents reviewed. The facility identified a census of 58. Findings are: A. Review of the facility policy Notification of Changes with a revision date of 12/220/22 revealed the purpose of the policy was to ensure prompt notification to the resident's physician and the resident's representative when there was a change requiring notification. Circumstances which required notification included: -accidents resulting in injury or physician intervention. -significant change in the resident's physical, mental, or psychosocial condition. -circumstances that required a need to alter treatment. -a transfer or discharge from the facility. -a change in the resident's rights. -a change in the resident's roommate. B. Review of a Weights and Vitals Summary Sheet (form used to document a resident's weights, blood pressure, respirations, temperature, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(A) Based on record review and interview; the facility failed to ensure Level 1 Preadmission Assessment and Resident Review (PASARR-screening process required to be completed prior to admission to ensure residents with Serious Mental Illness (SMI), Intellectual Disability(ID), Development Disability(DD) or Related Disorders (RD) met the criteria for Nursing Home admission and had any additional services needed) screens were completed accurately prior to admission for Residents 48 and 44. The sample size was 3 and the facility census was 58. Findings are: A. Review of the facility policy Resident Assessment-Coordination with PASARR Program with a revision date of 7/18/24 revealed the following: -The facility coordinated assessments with the PASARR program under Medicaid to ensure that all individuals with a mental disorder, intellectual disability, or a related condition received care and services in the most integrated setting appropriate to their needs. -All…

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.

Licensure Reference Number 175 NAC 12-006.09(H)(iv) Based on interview and record review; the facility failed to ensure Resident 59's Bowel and Bladder management plan was coordinated and addressed in cooperative with the Hospice Care provider. The sample size was 1 with a census of 58. Findings are: A. Review of the undated facility policy Bowel Elimination revealed the following: The facility developed and implemented a process to assure that constipation was prevented/addressed in a timely fashion. Daily documentation of bowel elimination was reviewed. The night shift ran a report showing no Bowel Movement (BM) in the last 48 hours and no BM in the last 72 hours. The following steps were followed for all residents of Community Memorial Health Center: - If no BM in 48 hours the dietary staff was notified and the resident was offered bran flakes, prune juice or both. - If no BM in 72 hours the resident was offered Milk of Magnesia (laxative), 30 cubic centimeters (cc) by mouth. - If no BM for 4 days the resident was offered a Dulcolax Suppository (laxative) Rectally. - If no BM 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.

Licensure Reference Number 175 NAC 12-006.I(i) Based on observation, interview, and record review; the facility failed to ensure Residents 14 and 16's falls were reviewed for causal factors, fall prevention interventions were based on causal factors, and reviewed and revised to prevent ongoing falls. The sample size was 4 and the facility census was 58. Findings are: A. Review of the facility policy Fall Prevention Program dated 8/3/23 revealed the following: -Each resident was assessed for fall risk and received care and services in accordance with their individualized level of risk to minimize the likelihood of falls. -The facility used standardized risk assessment to determine a resident's fall risk, and initiated interventions that decreased the risk of falling including but not limited to a clear pathway to the restroom, locking of bed wheels, leaving call lights accessible, providing adequate lighting, and keeping equipment in good repair. In addition, the facility implemented routine rounding, monitoring residents for changes in condition, encouraged residents to wear shoes…

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.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview; the facility failed to ensure antibiotics were given in accordance with the facility Antibiotic Stewardship Program (ASP-program for optimizing treatment of infections and reducing adverse events from the use of antibiotics) for Resident 16. The sample size was 5 and the facility census was 58. Findings are: A. Review of the facility undated Antibiotic Stewardship Program policy revealed the following: -It was the policy of the facility to implement and Antibiotic Stewardship Program (ASP) as part of the facilities overall infection prevention and control program. -The purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. -The Infection Preventionist, with oversight from the Director of Nursing served as the leader of the Antibiotic Stewardship Program and received support from the Administrator and other governing officials of the community. -The Medical Director, Consultant Pharmacist, and Attending Physicians…

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 Licensure Reference Number 175 NAC 12-006.12(A) Based on record review and interview; the facility failed to attempt a Gradual Dose Reduction (GDR) of Residents 24, 26, and 29's psychotropic medications (medications which alter consciousness, mood, and thoughts) or to have a documented clinical rationale for continued use. The sample size was 5. The facility census was 58. Findings are: A. Review of the facility policy Use of Psychotropic Medications, implemented on 10/6/23 revealed the following: -a psychotropic drug was any drug that affected brain activities associated with mental processes and behavior. Psychotropic drugs included: antipsychotics, antidepressants, anti-anxiety, and hypnotics, -the indications for the use of the medications would be determined by assessing the underlying condition, current signs, symptoms, expressions, and preferences and goals for treatments, and identifying of underlying causes, when possible, -the attending physician would assume leadership in medication management by…

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

Licensure Reference Number 175 NAC 12-006.12B Based on record review and interview; the facility pharmacist failed to ensure emergency and immediate use medications were available. This had the potential to affect all residents in the building. The facility staff identified a census of 60. Findings are: A. Review of a Pharmacy Services policy and procedure (undated) revealed it was the policy of this facility to ensure pharmaceutical services; were provided to meet the needs of each resident, were consistent with state and federal requirements, and reflected current standards of practice. The pharmacist was responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that supported the residents' healthcare needs, were consistent with current standards of practice and met state and federal requirements. B. Observation on 10/18/23 at 11:47 AM with Licensed Practical Nurse (LPN)-H revealed there was not an emergency medication supply for the facility staff to use. During an interview on 10/18/23 at 11:50 AM, LPN-H confirmed the facility did…

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 B. Review of Resident 57's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 9/9/23 revealed the resident was admitted [DATE] with diagnoses of: unspecified dementia, non-Alzheimer's dementia, bipolar depression, and psychotic disorder. Resident 57 had severe cognitive impairment and displayed hallucinations and delusions. In addition, the resident had verbal behaviors directed at others, other behavioral symptoms not directed toward others (hitting or scratching self, pacing, rummaging, disrobing in public, verbal/vocal symptoms such as screaming or making disruptive sounds), the resident wandered daily and had episodes in which the resident rejected cares. Review of a Nursing Progress Note dated 7/21/23 at 4:35 PM revealed Resident 57 had attempted to have sexual interactions with another resident on the secured unit. Resident 57 insisted the other resident was their spouse but the other resident refused these gestures. Interview with the Administrator 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.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observations, record review and interviews; the facility failed to ensure foods were served at palatable temperatures to the residents on the secured unit. This had the potential to affect all 16 residents served in the secured unit dining room. The facility staff identified a census of 60. Findings are: A. Review of a Meal Temperature Log dated 10/2023 revealed the following food temperatures were obtained on the secured unit during the meal services. Further review revealed no foods were identified at each of the meals, only a temperature: -10/1 for breakfast 121 degrees, 138 degrees for the noon meal and no temperatures were obtained for the evening meal; -10/2 for the breakfast meal 130 degrees, the noon meal was 130 degrees, and the evening meal was 133 degrees; -10/3 for the breakfast meal a temperature of 125 degrees, the noon meal was 136 degrees and no documentation for the evening meal; -10/4 breakfast was 121 degrees, the noon meal was 118 degrees and no documented temperature check for the evening meal; -10/5 no food…

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 Licensure Reference 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure the MDS (The Long-Term Care Minimum Data Set (MDS) which is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and or Medicaid-certified long term care facility) was accurately coded for 1(Resident #34) of 1 sampled resident. The facility census was 60. Findings are: Record review of Resident #34 Quarterly MDS dated [DATE] Section N 0410 letter E anticoagulants (a blood thinner medication) had instruction to indicate the number of days the resident received the medication during the last seven days. Seven was entered as the response to this question. Record review of Resident #34 physician orders dated 10/18/23 showed order for Plavix 75 MG which is an antiplatelet drug taken to prevent blood clots. It keeps platelets in your blood from coming together and making clots. This is ordered to be…

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 Licensure Reference Number 175 NAC 12-006.09D5b Based on observations, record review and interview; the facility failed to provide individualized activities for 1 (Resident 55) of 2 sampled residents. The facility identified a census of 60. Findings are: Review of Resident 55's Minimum Data Set (MDS-a federally mandated comprehensive assessment used in the development of the resident's care plan) dated 8/26/23 revealed the resident was admitted [DATE] with diagnoses of seizure disorder, depression and psychotic disorder. The resident's cognition was assessed as moderately impaired and the resident had behaviors which included hallucinations, delusions, verbal behaviors directed at others and other behavioral symptoms not directed toward others (hitting or scratching self, pacing, rummaging, disrobing in public, verbal/vocal symptoms such as screaming or making disruptive sounds). Review of an admission Questionnaire dated 5/25/23 revealed Resident 55 enjoyed watching television, attending religious events 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.

Licensure Reference Number: 175 NAC 12-006.09D Based on record review and interviews, the facility failed to follow a provider order for 1 (Resident #34) of 1 sampled resident. Resident #34. Facility reported census of 60. Findings are: A record review of Resident #34's resident demographic record reflected facility admitted Resident #34 on 1/12/2021 with diagnoses that included Type 2 Diabetes mellitus which is a chronic condition that affects the way the body processes blood sugar (glucose). A record review of Resident #34's physician orders dated 10/18/23 revealed an order for HbA1c (a blood test that measured the average blood sugar levels over the past 3 months. It is one of the main laboratory tests that can help a health care team manage diabetes.) This was a routine order to be completed every 120 days with the most recent to be collected on 7/12/23. A record review of Resident #34's laboratory results labeled Final Cumulative dated 3/8/23 revealed a value of HbA1c 7.0 and was signed by provider on 3/09/2023. A record review of Resident #34's care plan reflected care plan…

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 Licensure Reference Number 175 NAC 12-006.09D7 Based on observations, record review and interview; the facility failed to assure a safe environment as the staff failed to: 1) assess causal factors and to develop and/or revise fall interventions to prevent ongoing falls for 2 ( Resident 54 and 1) and implement interventions to prevent potential choking and/or aspiration for Resident 1. The sample size was 8 and the facility census was 60. Findings are: Review of a Fall Risk Assessment policy with a revision date of 8/22/23 revealed each resident was to be assessed for fall risk to identify and evaluate environmental hazards. The resident's Care Plan would then include interventions consistent with their needs and goals to reduce the risk for accidents. The facility would monitor the effectiveness of interventions and then modify or develop new interventions as necessary. A. Review of the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/2/23 revealed 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 Licensure Reference Number 12-006.09D8b Based on record review and interview; the facility failed to identify a significant weight loss and notify the Provider for 1 of 4 (Resident 21) sampled. The facility census was 60. Findings are: Review of the facility policy Weight Monitoring, dated 2022 revealed the following: -the facility would ensure all residents maintain acceptable parameters of nutritional status, such as body weight, or desirable body weight range, unless the resident's clinical condition demonstrated that was not possible or resident preferences indicated otherwise, -significant unintended weight changes (loss or gain) could indicate a nutritional problem, -a nutritional assessment was completed upon admission to identify those at risk for unplanned weight loss/gain, -information gathered from the nutritional assessment and current dietary standards of practice was used to develop an individualized care plan to assess the resident's specific nutritional concerns and preferences, -interventions…

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 Licensure Reference Number 175 NAC 12.006-19D Based on record review and interview; the facility failed to ensure 1 (Resident 21) of 5 sampled resident's as needed (PRN) psychotropic (a type of psychoactive medication which alters chemicals in the brain to effect changes in behavior, mood, and emotions) medication was limited to 14 days. The facility census was 60. Findings were: A. Review of the facility policy Psychotropic Medication, dated 10/6/2023 revealed the following: -psychotropic drugs included antipsychotics (used to treat psychotic disorders), antidepressants (used to treat depression), anti-anxiety (used to treat anxiety), and hypnotics (used to induce sleep), -non-pharmacological interventions were attempted, and the target symptoms for monitoring were included in the documentation, -residents who used psychotropic drugs also received non-pharmacological interventions, -PRN orders for all psychotropic drugs were used only when necessary and for a limited duration of 14 days, -if the attending…

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.

Licensure Reference Number 175 NAC 12-006.10E Based on observation, record reviews, and interviews: the facility failed to ensure a medication error rate of less then 5 percent (%) which affected 2 (Residents 19 and 34) of 3 sampled residents. The medication error rate was 13.79%. The facility census was 60. Findings are: A. During an observation on 10/16/23 at 11:04 AM, Licensed Practical Nurse (LPN)- C removed an insulin pen from the medication cart, removed the cap from the insulin pen, and screwed on a needle cap to the pen. LPN C then turned the dial on the pen to the ordered dose of 2 units insulin. LPN C did not prime the insulin pen prior to setting the ordered dose of insulin. LPN C applied gloves to both hands, cleansed Resident 19's site of injection and administered the injection and immediately withdrew the insulin pen from Resident #19's abdomen. LPN C then returned to the cart. LPN C obtained another insulin pen from the cart and screwed on needle cap. LPN C then turned the dial on the pen to the ordered dose of 43 units. LPN C did not prime the insulin pen prior 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.

Licensure Reference Number 175 NAC 12-006.12E1 Based on observation, record review and interview; the facility failed to provide safe storage of drugs as medications were left on top of the medication cart unattended. The total sample size was 16 and the facility census was 60. Findings are: Review of the facility policy titled Medication Storage dated 12/20/22 revealed the following: -all drugs and biologicals were to be stored in locked compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) and under proper temperature control; -only authorized personnel were to have access to the keys to locked compartments; and -during a medication pass, medications were to be under the direct observation of the person administering the medications. During observation of the Medication Pass on the secured unit by Medication Aide (MA)-B on 10/17/23 at 8:57 AM, the following was observed: -the medication cart was parked in the medication room adjacent to the dining area of the secured unit; -MA-B prepared medications which consisted of…

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.

Licensure Reference Number 175 NAC 12-006.17B Based on observation, record review, and interview: the facility staff failed to clean a multi-resident use glucometer with Environmental Protection Agency (EPA) approved cleanser for Resident 19 and failed to perform hand hygiene to prevent potential cross contamination when performing procedures for Residents 34, 37, and 19. Facility census was 60. Findings are: Record review of the facility policy labeled Glucometer Disinfection dated 09/16/2023 revealed the following: -the facility will ensure blood glucometers will be cleaned and disinfected after each use for multi-resident use. -the glucometers will be disinfected with a wipe pre-saturated with a EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus. A. Observation on 10/16/23 at 11:04 AM of Licensed Practical Nurse (LPN)-C revealed LPN-C completed a blood glucose check for Resident 19 with the blood glucometer. LPN-C then returned to the cart and removed a multi-purpose alcohol wipe from a package on top of the cart. LPN-C used…

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.