Pleasant View Center

Based on interview and record review, it was determined that the facility failed to provide resident choice regarding meal times for 2 out of 3 residents reviewed for choices in a final sample of 30 residents (Resident identifiers are #48 and #64). Findings include:Resident #64Interview on 1/7/2026 at approximately 10:15 a.m. with Resident #64 revealed that the he/she has dialysis three times a week and usually returns to the facility during lunchtime. His/her meal tray is usually delivered and waiting for them when they return from dialysis and the food is cold. Resident #64 has requested the meal be reheated and staff stated they could not. Resident #64 has to eat the meal cold.Resident #48Interview on 1/6/2026 at approximately 9:20 a.m. with Resident #48 revealed that he/she was not always ready to eat when the meal tray was served. When Resident #48 requested the meal be reheated, staff stated they could not due to germs. Resident #48 said they had to eat the meal cold.Interview on 1/6/2026 at approximately 12:30 p.m. with Staff P (Licensed Nursing Assistant) revealed the staff…

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, it was determined that the facility failed to ensure admission medications and supplements were administered for 1 of 2 newly admitted residents reviewed. (Resident Identifier is #163).Findings include:Interview on 1/9/26 at 1:42 p.m. with Resident #163 revealed that he/she was admitted to the facility on [DATE] and was not given all of their medications that evening. Review on 1/9/26 of Resident #163's Progress Notes, dated 1/5/26 at 1:20 p.m., revealed a Social History and Initial Assessment was completed by Social Services. Review on 1/9/26 of Resident #163's January 2026 Medication Administration Record revealed the following medications and supplements ordered by the physician was not documented as administered:On 1/5/26:Melatonin Tablet 3 milligrams (mg) fat, scheduled for 8:00 p.m.,MiraLAX Powder 17 grams, scheduled for 7:00 p.m. to 11:00 p.m.,Olanzapine Tablet 2.5 mg, scheduled for 8:00 p.m.,Phenytoin Sodium Extended Oral Capsule 30 mg eight tablets (240…

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

Based on record review and interview, it was determined that the facility failed to develop and implement a comprehensive care plan for 2 of 3 residents reviewed for smoking, and 1 of 1 residents reviewed for dementia care in a final sample of 30 residents (Resident Identifiers are #38, #66 and #113). Findings include:Resident #66 Review on 1/9/26 of Resident #66's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/5/25 under section F0400 - Interview for Activity Preferences revealed that while Resident #66 was in the facility, very important was coded for the following: to have books, newspapers, and magazines to read; listen to music; be around animals; keep up with the news; do things with groups of people; do you favorite activities; do your favorite activities, and participate in religious services or practices. Review on 1/9/26 of Resident #66's care plan revealed there was no care plan interventions for activities. Interview on 1/9/26 at 9:35 a.m. with Staff D (Director of Social Services) confirmed the above findings. Resident #38 Interview on 1/6/26…

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, it was determined that the facility failed to follow professional standards for 1 of 2 residents reviewed for insulin, for 1 of 4 residents observed for medication administration, and for 1 of 3 residents reviewed for smoking in a final sample of 30 residents (Resident Identifiers are #4, #38, and #47). Findings include: Resident #4 Standard: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration…

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, observation, and record review it was determined that the facility failed to provide treatment and care in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for 1 of 1 residents reviewed for skin conditions in a final sample of 30 residents. (Resident identifier is #125). Findings include:Observation on 1/6/26 at approximately 9:30 a.m. of Resident #125 sitting in the hallway with his/her button shirt open at the top; and resident itching his/her chest area that was bright red and raised with bumps.Interview on 1/6/26 at approximately 9:45 a.m. with Resident #125 revealed I'm always itchy.Review of Resident #125's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/21/25 revealed in Section C Cognitive Patterns C0200 BIMS (Brief Interview for Mental Status) a score of 03 which indicates severe impairment.Review on 1/8/26 of Resident #125's medical record revealed a diagnosis of seborrheic dermatitis. Further review of Resident #125's MAR (Medication Administration Record)…

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

Based on observation, interview, and record review, it was determined that the facility failed to implement established infection prevention policies for transmission-based precautions (TBP) for 1 of 6 residents reviewed for droplet precautions. (Resident identifier is #136.)Findings include:Observation on 1/6/2026 at approximately 10:15 a.m. of Resident #136's room revealed signage for Droplet Precautions. Further observation revealed two housekeepers don personal protective equipment (PPE) to include mask, gown and gloves. After performing some cleaning tasks, Staff A (Housekeeper) wore all PPE out of the room to access the housekeeping cart and speak with other staff. Staff A walked down the hall and accessed another room with all the same PPE from Resident #136's room and Staff A had not performed hand hygiene.Interview on 1/6/2026 at approximately 10:15 a.m. with Staff A confirmed that he/she left PPE on after exiting Resident #136's room and entering the hallway and another resident's room.Review on 1/7/2026 of facility outbreak line list revealed Resident #136 was on Droplet…

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, record review, and observation it was determined that the facility failed to care plan according to their smoking assessment for 1 of 3 residents reviewed for smoking in a final sample of 30 residents. (Resident identifier is #68.)Resident #68Review on 1/6/26 of Resident #68's smoking assessment, dated 11/6/25, revealed that Resident #68 is a supervised smoker. Review on 1/6/26 of Resident #68's smoking care plan, revised 1/6/26, revealed that Resident #68 may smoke without supervision per smoking assessment. Interview on 1/7/26 at approximately 9:30 a.m. with Resident #68 revealed that he/she smokes independently. Interview on 1/8/26 at approximately 11:00 a.m. with Staff J (Nurse Supervisor) confirmed Resident #68 smokes independently.Review on 1/9/26 of the facility policy titled Resident Smoking implemented on 7/1/21 revealed .Policy Explanation and Compliance Guidelines: #7. Residents who smoke will be further assessed, using the Smoking Evaluation, to determine whether or not supervision is required for smoking , orif resident is safe to smoke at all .#10.…

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, record review, and policy review, it was determined that the facility failed to implement the facility's antibiotic stewardship program and antibiotic use protocols for 1 of 1 month of antibiotic line list reviewed. (Resident identifier is #41.)Findings include:Review on 7/1/25 of the facility policy title, Antibiotic Stewardship Program, review date of 6/2025, revealed the following: .Antibiotic Stewardship Program leaders utilize existing resources to support antibiotic stewards' effort by working with the following partners: a. Infection Preventionist - utilizes expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections, and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms .3. Licensed nurses participate in the program through assessment of residents and following protocols as established by the program. 4. The program…

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, record review, and policy review, it was determined that the facility failed to ensure residents could formulate for 2 of 2 residents reviewed for advance directive in a final sample of 29 residents. (Resident identifiers are #118 and #125.)Findings include:Review on 7/1/25 of the facility policy titled, Communication of Code Status, review date of 6/2025, revealed the following: .Policy: It is the policy of the facility to adhere to resident's rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individual who need to know this information. Policy Explanation and Compliance Guidelines: . 2. When an order is written pertaining to a resident's presence or absence of an Advance Directive, the direction will be clearly documented in designated sections of the medical record .3. The nurse who notates the physician order is responsible for documenting the directions in all relevant sections of the medical record. 4. The designated sections of the medical record…

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

Based on observation, record review, and interview, it was determined that the facility failed to keep residents free from physical restraints for 1 of 1 residents reviewed for physical restraints in a final sample of 29 residents (Resident identifier is #146).Findings include:Observation on 7/2/25 between 9:12 a.m. to 9:25 a.m. on the third floor common room revealed Resident #146 was sitting in his/her pedal broda chair with his/her leg rest elevated parallel to the floor and 2 of the 4 wheels were in a lock position. Resident #146 had one leg off on each side of the leg rest and feet on the ground and struggling to propel forward and backwards. Further observation revealed Resident #146 was able to turn himself/herself in a quarter circle and appeared agitated. Interview on 7/2/25 at 9:25 a.m. with Staff L (Licensed Nursing Assistant (LNA)) confirmed that Resident #146 appeared agitated and was struggling to move their broda chair due to the 2 of the 4 wheels being locked. Interview on 7/2/25 at 10:11 a.m. with Staff M (LNA) revealed that he/she had brought Resident #146 into 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 interview and record review, it was determined that the facility failed to ensure medications were available for 2 of 2 newly admitted residents reviewed in a final sample of 29 residents. (Resident identifiers are #254 and #258).Findings include:Resident #254Interview on 6/30/25 at approximately 9:45 a.m. with Resident #254 revealed they had not received all of their medications since admitting to the facility. Review on 6/30/25 of Resident #254's medical record revealed they had been admitted to the facility on [DATE]. Review on 7/1/25 of Resident #254's June 2025 Medication Administration Record (MAR) revealed the following medications were not given on 6/29/25:Arformoterol Inhaler give by nebulizer twice a day for COPD (Chronic Obstructive Pulmonary Disease);Atrovastatin Calcium 10 mg once a day;Budesonide Inhaler twice a day;Duloxetine 20 mg once a day for depression;Furosemide (Diuretic) 40 mg (milligrams) twice a day for heart failure;Ipratopium- Albuterol inhaler twice a day for COPD;Losartan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that the facility failed to develop and implement a comprehensive care plan for 7 residents in a final sample of 29 residents (Resident identifiers are #33, #47, #70, #97, #118, #146, and #11).Findings include:Resident #33Review on 7/2/25 of Resident #33's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/14/25 under section F0500 - Interview for Activity Preferences revealed that while Resident #33 was in the facility, that very important was coded for the following: to have books, newspapers, and magazines to read; listen to music; be around animals; keep up with the news; do your favorite activities, and participate in religious services or practices. Review on 7/2/25 of Resident #33's care plan revealed there was no care plan for Resident #33's group or individual activity preferences or what Resident #33's likes to do.Interview on 7/2/25 with Staff V (Licensed Nursing Assistant (LNA)) revealed that he/she would look in 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 interview and record review, the facility failed to determine what may have caused or contributed to falls, and when necessary revise the resident's plan of care and/or facility practices, to reduce the likelihood of another fall for 1 of 2 residents reviewed for falls in a final sample of 29 residents (Resident identifier is #42).Findings include:Interview on 6/30/25 at approximately 12:00 p.m. with Resident #42's DPOA-HC (Durable Power of Attorney for Health Care) revealed that he/she have had repeated falls from their bed and from their wheelchair. Resident #42's DPOA-HC stated that Resident #42 sustained a fractured clavicle as a result of one of the falls.Review on 6/30/25 of Resident #42's progress notes from March 2025 to April 2025 revealed the following falls:3/23/25 slide out of bed on to sacrum;4/1/25 found on floor next to their bed;4/10/25 found on floor in the dinning room and was sent to the emergency room for shoulder pain;4/29/25- und sitting on floor in the hallway.Review on 7/1/25 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.

Based on interview and record review, it was determined that the facility failed to ensure that trauma survivors have identified triggers and interventions to eliminate or mitigate triggers that may cause re-traumatization for 1 of 2 residents reviewed for behavioral and emotional status in a final sample of 29 residents. (Resident identifier is #97).Findings include:Review on 6/30/25 of Resident #97's medical record revealed that Resident #97 had a diagnosis of Post Traumatic Stress Disorder (PTSD). Further review revealed that Resident #97 had an incomplete Social History and Trauma Assessment that was initiated on 5/16/25. Resident #97's care plan did not have a care plan for PTSD with identified triggers and interventions to eliminate or mitigate triggers that may cause re-traumatization. Interview on 7/2/25 at approximately 9:00 a.m. with Staff J (Licensed Nursing Assistant) revealed that he/she was unaware of any residents with diagnosis of PTSD and observed him/her defer to nursing for sources of this information. Interview on 7/2/25 at approximately 9:10 a.m. with Staff 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 interview and record review, the facility failed to obtain radiology services for 1 of 1 residents reviewed for radiological services in a final sample of 29 residents. (Resident identifier is #46.)Findings include:Interview on 7/3/25 at 10:00 a.m. with Resident #46 revealed they went to have a CT (Computed Tomography) scan done in March 2025 but left the appointment before it could be completed. Resident #46 did not recall the reason the CT scan was not done.Review on 7/3/25 of Resident #46's medical record revealed an Infectious Disease note, dated 1/3/25, .We decided to re-image the pubic area for any new collections, Pt [patient] is at a high risk for recurrence of infection and thus we opted to continue antibiotic therapy with [NAME] [Outpatient Parenteral Antimicrobial Therapy] until imaging is addressed .Orders Placed CT Abdomen & Pelvis w [with] Contrast . Further review of medical record revealed no results of follow up for the CT scan or radiology imaging.Interview on 7/3/25 at approximately…

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, record review, and policy review, it was determined that the facility failed to implement their pneumococcal vaccine policy for 2 of 5 residents reviewed for immunizations. (Resident identifiers are #97 and #120.)Findings include:Review on 7/1/25 of the facility policy titled, Pneumococcal Vaccine, review date of 6/2025, revealed the following: .1. Each resident will be assessed for pneumococcal immunizations upon admission. Self-reported immunizations shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunizations or type of vaccine received. 2. Each resident will be offered a pneumococcal immunizations unless it is medically contraindicated or resident has already been immunized. Following assessment for any medical contraindications, the immunizations may be administered in accordance with physician-approved standing orders. 3. Prior to offering the pneumococcal immunizations, each resident or 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 interview, record review, and policy review, it was determined that the facility failed to implement their COVID-19 vaccine policy for 3 of 5 residents reviewed for immunizations. (Resident identifiers are #4, #97 and #120.)Findings include:Review on 7/1/25 of the facility policy titled, COVID-19 Vaccine, review date of 6/2025, revealed .Policy: It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine .Up-to-date is defines as receiving a 2024-2025 updated COVID-19 vaccine (as per CDC) .COVID-19 vaccinations currently in use include the updated 2024-2025 mRNA [messenger Ribonucleic Acid] COVID-19 vaccines .The number of updated 2024-2025 COVID-19 vaccines doses and individual needs is based on age and vaccination history. For people who are not moderately or severely immunocompromised (See Table 1) .Table 1. Routine COVID-19 vaccine schedule, October…

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, it was determined that the facility failed to ensure that an alleged violation of abuse was reported immediately to the State Survey Agency (SSA) for 1 of 1 resident reviewed for an alleged violation of Abuse or Neglect. (Resident Identifier is #5.) Findings include: Review on 2/26/25 of Resident #5's medical record revealed the following nursing note written by Staff E (Registered Nurse), dated 2/23/25 at 4:17 p.m.: During morning medication round I inadvertently administered the incorrect medication to the patient. While verifying the medication administration record (MAR) I recognized that the following medications were given. Ativan oral tab [tablet] 0.5 mg [milligrams] Zyprexa oral tab 7.5 mg Tramadol HCL [hydrochloric acid] 50 mg half tab Amantadine 100 mg tab Amlodipine 10 mg tab Cymbalta oral cap [capsule] delayed release particles 20 mg Gabapentin 300 mg capsule Protonix oral tab delayed release 40 mg tab Instead of the following prescribed medication Atenolol oral…

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 record review, it was determined that the facility failed to provide medications timely for 2 of 4 residents reviewed. (Resident identifiers are #1 and #4.) Findings include: Review on 2/26/25 of [NAME], [NAME] Griffin; [NAME], [NAME] A.; [NAME], Wendy; and [NAME], [NAME]. Clinical Nursing Skills & Techniques. 10th ed. [NAME], Pennsylvania: Elsevier, 2022, Page 597 , Safe Medication Preparation: Right Time revealed the following: With time-critical medications (e.g., antibiotics, anticoagulants, insulin, immunosuppressives), early or delayed administration of the maintenance doses of more than 30 minutes before or after the scheduled dose will most likely cause harm or result in subtherapeutic responses in a patient. Resident #4 Observation on 2/26/25 at approximately 8:35 a.m. of Staff H (Registered Nurse) during medication administration revealed on his/her computer screen that Resident #4's name was in red. Interview on 2/26/25 at approximately 8:35 a.m. with Staff H…

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, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents needs for 1 of 2 staff reviewed for competencies. (Staff identifier is E.) Findings include: Interview on 2/26/25 at approximately 10:00 a.m. with Staff E (Registered Nurse) revealed that on 2/23/25, he/she entered the facility for a shift that he/she had picked up through an agency. Staff E did not receive an orientation prior to the assignment or upon arrival. Staff E was assigned to do medication administration. Staff E had never used the electronic medical record that the facility used. Staff E stated that one resident required antibiotics and Staff E did not know where the medication room was located and did not know how to use the intravenous pump that was needed for administration. Interview on 2/26/25 at approximately 10:30 a.m. with Staff G (Night Supervisor) revealed that on the morning of 2/23/25, Staff E (Registered Nurse) arrived for their shift. Staff G revealed that Staff E voiced some concerns to Staff G that they 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.

Based on record review, interview, and policy review, it was determined that the facility failed to establish and maintain a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation for 1 of 1 residents reviewed for controlled drugs. (Resident Identifier is #2.) Findings include: Interview on 2/26/25 at approximately 10:00 a.m. with Staff E (Registered Nurse) revealed that on 2/23/25 they reconciled the narcotic count with the night shift nurse and discovered that the amount of narcotics for one resident did not match the documented count in the narcotic book. Staff E told Staff G (Night Supervisor) who changed the count in the narcotic book to match the physical count. Interview on 2/26/25 at approximately 10:30 a.m. with Staff G confirmed that there was a discrepancy with the narcotic count and revealed that Staff G counted the number of the actual pills and changed the narcotic book to match that number with no investigation. Interview on 2/26/25 at approximately 11:00 a.m. with Staff A revealed Staff A denied…

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

Based on interview and record review, it was determined that the facility failed to take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained for reporting alleged violations of abuse and neglect. Findings include: Review on 2/26/25 of Resident #5's medical record revealed the following nursing note written by Staff E (Registered Nurse), dated 2/23/25 at 4:17 p.m.: During morning medication round I inadvertently administered the incorrect medication to the patient. While verifying the medication administration record (MAR) I recognized that the following medications were given. Ativan oral tab [tablet] 0.5 mg [milligrams] Zyprexa oral tab 7.5 mg Tramadol HCL [hydrochloric acid] 50 mg half tab Amantadine 100 mg tab Amlodipine 10 mg tab Cymbalta oral cap [capsule] delayed release particles 20 mg Gabapentin 300 mg capsule Protonix oral tab delayed release 40 mg tab Instead of the following prescribed medication Atenolol oral tab 25 mg Lactobacillus capsule…

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, it was determined that the facility failed to ensure that medications were administered timely for 2 of 4 residents reviewed for timely medication administration (Resident Identifiers are #5 and #6). Findings include: Standard: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th ed. St. Louis, Missouri: Mosby Elsevier, 2021. Chapter 31 Medication Administration Page 595, .Medications that are time critical most likely cause harm or have subtherapeutic effects if they are not administered in time (usually 30 minutes before and after the scheduled dose). Non-time-critical medications most likely do not cause harm if they are given within 1 hour to 2 hours before or after the schedule time. Thus, you need to administer time-critical medications at a precise time, within 30 minutes before and after a scheduled time. You administer non-time-critical medications within 1 to 2 hours of their scheduled times . Resident #5 Review on 11/5/24 of Resident #5's active…

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

Based on record review and interview, it was determined that the facility failed to notify the resident's activated Durable Power of Attorney for Healthcare (DPOA-H) of a change in condition or needs to alter treatment for 1 of 3 residents reviewed for death (Resident Identifier #8). Findings include: Review on 9/24/24 of Resident #'8's medical record revealed the following: Provider note on 7/8 at 9:42 a.m.- Resident was seen due to reports of hypoxia and nasal congestion. Chest x-ray and Flonase was ordered. Nursing note on 7/9/24 at 1:30 a.m.- Resident complained of difficulty breathing and increased congestion. Resident refused chest x-ray. Provider note on 7/9/24 at 9:45 a.m.- Resident was seen for follow up and consider gradual dose reduction of morphine. Resident reports chest congestion, cough and shortness of breath. Resident refused chest x-ray. Resident was started on 250 mg [milligram] Azithromycin once daily for 5 days, discontinued 0.75ml [milliliter] of Morphine 10 mg/ 5 ml 4x [times] daily and started on 5 mg Oxycodone 3x daily. Nursing note on 7/9/24 at 1:07 p.m.-…

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, it was determined the facility failed to ensure that allegations involving neglect were reported to the State Survey Agency for 1 of 3 residents reviewed for elopement (Resident Identifier #3). Findings include: Review on 9/23/24 of Resident #3's progress note, dated 7/28/24, revealed that around 5:40 p.m. the nurse could not locate the resident inside or outside the facility. The resident had not signed out of the check out book on the unit floor or at the reception desk. Administration was notified and a statement was given to the police. The resident was found and reported back on the floor around 9:00 p.m. Interview on 9/23/24 at approximately 2:35 p.m. with Staff C (Assistant Director of Nursing) revealed Resident #3 had left the faciity on 7/28/24, without the facilities knowledge, and walked down the road. Resident #3 got a ride to the Holiday Inn where they went inside and proceeded to drink alcohol at the bar. The police located Resident #3 and notified the facility of their location. Review on 9/23/24 of Resident #3'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.

Based on record review, interview, and policy review, it was determined that the facility failed to establish a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation; and failed to determine that drug records were in order and that an account of all controlled drugs were maintained for 2 of 3 narcotic books reviewed and for 1 of 5 residents reviewed for unnecessary medications (Resident Identifier #101). Findings include: Review on 7/25/24 of the facility policy titled, Controlled Substance Administration & Accountability, revised 1/2024, revealed: .Policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure .Inventory Verification .b. For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift. 4th Floor…

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.

Observation on 7/23/24 from 12:30 p.m. to 12:45 p.m. of the North Medication Cart on 4th floor revealed it was unlocked in the hallway with no staff within sight. There were 2 residents wheeling themselves in the hallway. Interview on 7/23/24 at 12:45 p.m. with Staff I (Registered Nurse) confirmed the cart was unlocked and unattended for approximately 15 minutes. Review of facility policy titled, Storage of Medication, dated May 2018, revealed: .Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access .Based on observation, interview, and record review, it was determined that the facility failed to ensure that medications were labeled and stored in accordance with currently accepted professional principles for 2 of 3 medication carts observed and for 1 of 1 residents reviewed for self administration of mediations (Resident Identifiers are #18, #73, and #48). Findings include: Observation on 7/23/24 at approximately 8:40 a.m. of the [NAME] medication cart, on the third floor, revealed Resident #73's two Insulin Aspart Flex pens…

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, it was determined that the facility failed to follow physician orders for 1 out of 2 residents reviewed for skin conditions (Resident Identifier #80). Findings include: Resident #80 Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders, .The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Interview on 7/23/24 at 1:15 p.m. with Resident #80 revealed that he/she had wounds on his/her abdomen and groin. Resident #80 stated that they were supposed to be cleaned daily but no one had cleaned them since last week. Review on 7/25/24 of Resident #80's current physician's orders revealed that Resident #80 had an order for Abdomen/groin wounds:…

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

Based on record review, policy review, and interview, it was determined that the facility failed to report alleged misappropriation/diversion of medications. Findings include: Interview on 3/22/24 with Anonymous revealed that they noticed a pattern of narcotics that were signed out of the narcotic book (a book that tracks controlled substances) and were not signed out of the resident's electronic Medication Administration Record (eMAR) for several residents. Anonymous alleged that this practice could indicate drug diversion. Interview further revealed that Anonymous was told by a staff member that it was being dealt with by the unit manager and administration. Anonymous did not report the allegation to the Administrator. Interview on 3/28/24 with Staff E (Administrator) and Staff F (Director of Nursing) confirmed the above findings and they were not aware of any allegations of misappropriation/diversion of residents' medications.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review, and interview, it was determined that the facility failed to ensure accurate accounting for all controlled medications for 4 out of 8 residents reviewed for Pharmacy Services (Resident Identifiers are #1, #2, #3, and #7). Findings include: Review on 3/28/24 of the facility's policy titled Administration Procedures for All Medications effective date May 2018, revealed the following: J. After administration, return to cart, replace medication container (if multi-dose and doses remain), and document administration in the MAR [Medication Administration Record], TAR [Treatment Administration Record], and controlled substance sign out record, if indicated .M. When administering an as needed (PRN) medication, document the reason for giving, observe for medication actions/reactions and record pertinent details [on the PRN effectiveness sheet/nurse's notes]. [NAME] A. [NAME] and [NAME], Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 709:…

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.