Casa Arena Healthcare LLC

Based on record review and interview, the facility failed to submit direct care staffing information to the federal agency overseeing certification for long term care facilities for July 2024 through December 2024. This has the potential to affect all 98 residents in the facility, (residents were identified by the Resident Matrix provided by the Administrator on 06/01/25). This deficient practice could likely result in inaccurate direct care staffing information for residents/facility. The findings are: A. Record review of Payroll Base Journal (PBJ) Staffing Data Report (report from the data base of the federal agency overseeing certification for long term care facilities) dated Quarter #3 and #4 2024 (July 1 through December 31) revealed low weekend staffing. B. On 06/05/25 at 9:33 AM, during an interview, the Administrator revealed that contracted staff are not being captured on the PBJ report. The Administrator stated that contract staff don't clock in and out at the facility like staff do, and their agency keeps their time. The Administrator said that they are working with 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 Recite from [DATE] Based on observation and interview, the facility failed to provide a comfortable and homelike environment for all 69 residents who do not reside in the secure unit (residents were identified by the census provided by the Administrator on [DATE]) when staff failed to: 1. Store a deceased resident's belongings out of common areas share by residents. 2. Repair the floor in front of R #31's restroom, and replace ceiling covers above R #31's bed. These deficient practices could likely cause residents to feel like they are not living in a comfortable home like environment and like they are not valued. The findings are: A. On [DATE] at 2:28 PM an observation of R #31's room revealed the floor in front of R #31's restroom door had a deep indention in the floor, and the ceiling above R #31's bed had 2 large brown stains. B. On [DATE] at 2:28 PM during an interview with the Maintenance director, he confirmed the floor in front of R #31's restroom door had a deep indention in the floor, and the ceiling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 4 (R #14, R #15, R #33 and R #63) of 7 (R #14, R #15, R #18, R #28, R #33, R #35 and R #63) residents reviewed for unnecessary medications, when staff failed to ensure: 1. A gradual dose reduction (GDR; stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) was carried out for R #14 and R #63. 2. Psychotropic medications ordered to be given as needed (PRN) for R #15 and R #33 were not prescribed for longer than 14 days without documentation of the rationale to extend beyond 14 days in the resident's medical record including an indication for the duration of the PRN order. These deficient practices could likely result in residents receiving medications without a medical reason 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 Recite from 08/21/24 Based on record review and interview, the facility failed to ensure care plan revisions occurred for 2 (R #68 and R #86) of 6 (R #21, R #28, R #33, R #35, R #68, and R #86) residents when the staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #68 A. Record review of R #68's admission documents, no date, revealed he was admitted to the facility on [DATE]. B. Record review of R #68's physician's orders, multiple dates, revealed the following: 1. An order dated 05/27/25, to monitor right heel daily for redness. 2. An order dated 05/20/25 and discontinued on 05/27/25 for wound care to the right heel. 3. An order dated 03/19/25 and discontinued on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure residents received necessary behavioral health care to meet their needs for 1 (R #63) of 2 (R #14 and R #63) residents reviewed for behavioral health concerns when staff failed to ensure consistent psychiatric services. This deficient practice could likely result in residents not receiving the behavioral or mental health care and assistance needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The findings are: A. Record review of R #63's admission record (no date) revealed the following: 1. R #63 was admitted to the facility on [DATE]. 2. R #63 diagnoses as follows: a. Unspecified dementia, moderate, with psychotic disturbance (diagnosis that encompasses a range of symptoms that lead to a decline in skills your brain uses to complete daily tasks, can cause abnormal thinking and perceptions but specific details regarding the condition are not clearly defined). b. Other recurrent depressive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a resident diagnosed with dementia (group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells) received appropriate treatment and services to attain his highest mental and psychosocial well-being for 1 (R #33) of 1 (R #33) resident reviewed for dementia treatment and services when the facility failed to: 1. Ensure R #33's care and services are person centered and help maximize his dignity and autonomy. 2. Utilize individualized, non-pharmalogical (treatments or interventions that do not involve the use of medications or drugs) approaches to his care. This deficient practice could likely result in a lack of meaningful relationships, engagement in day-to-day activities and diminished quality of life. A. Record review of R #33's admission record, no date, revealed the following: 1. R #33 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (set of reasons or a logical basis for a course of action) for not following the consultant pharmacist's recommendation for 3 (R #14, R #33 and R #63) of 7 (R #14, R #15, R #18, R #28, R #33, R #35, and R #63) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). The findings are: R #14 A. Record review of R #14's admission record (no date) revealed the following: 1. R #14 was admitted to the facility on [DATE]. 2. R #14 had a diagnosis of other recurrent depressive disorders (mental health…

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.

Recite from 04/24/24 Based on observation and interview, the facility failed to store food under sanitary conditions for all 94 residents who eat food from the kitchen (residents were identified by the resident matrix provided by the administrator on (06/01/25) when staff failed label and date all items in the kitchen refrigerator. Failure to store food under safe and sanitary conditions could likely lead to foodborne illnesses in residents. The findings are: A. On 06/01/25 at 9:25 AM, an observation of the kitchen revealed the following: 1. The refrigerator had two trays with 10 lid-covered beverages, the lids were not dated. 2. The walk-in refrigerator had three trays with covered desserts on them. The desserts did not have a date to indicate when they were prepared. B. On 06/01/25 at 9:32 AM, during an interview, the Dietary Manager confirmed that the drinks and desserts should all be labeled with the date they were prepared.

Based on observation and interview, the facility failed to ensure residents were treated with respect and dignity for 2 (R #86 and R #253) of 3 (R #33, R #86 and R #253) residents when the facility failed to do the following: 1. Use a privacy bag for R #86's foley catheter bag (a urine drainage bag that collects urine from the bladder). 2. Treat R #253 with dignity when serving him lunch. The findings are: R #86 A. On 06/02/25 at 3:15 PM, during an observation of the 600 unit, R #86's catheter bag did not have a privacy bag (a discreet cover that conceals the urine drainage bag from view). B. On 06/02/25 at 3:18, during an interview, CNA #8 confirmed that there was not a privacy bag on R #86's catheter bag. C. On 06/02/25 at 3:42, during an interview, the DON said that catheters bags should have a privacy cover. R #253 D. Record review of R #253's administration record, no date revealed the following: 1. R #253 was admitted to the facility of 05/12/17. 2. R #253 diagnoses included the following: a. Muscle weakness (generalized). b. Hemiplegia, unspecified affecting the left non…

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 Recite from 04/24/24 Based on observation, record review, and interview, the facility failed to notify the provider of missed medication doses and treatment for 2 (R #46 and R #86) of 2 (R #46 and R #86) residents reviewed for medication administration and edema, (swelling caused by an accumulation of fluid in the body's tissues, often in the feet, ankles, and legs). when staff failed to: 1. Notify the provider that R #46 refused her lactulose (medication used to treat constipation. It can also treat liver disease) on 06/04/25. 2. Notify the provider that R #46 received a partial (incomplete) dose of Albuterol (medication that is inhaled to treat or prevent spasms of the respiratory tract) on 06/04/25. 3. Notify the provider that R #86 does not wear her compression stockings (specialized hosiery designed to help prevent the occurrence of, and guard against further progression of, venous disorders such as edema, phlebitis and thrombosis) as ordered. These deficient practices could likely result in residents not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Recite from 04/24/24 Based on interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; federally mandated assessment instrument completed by facility staff) were accurate for 2 (R #35 and R #66) of 9 (R #14, R #21, R #28, R #35, R #46, R #60, R #63, R #66 and R #77) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: R #35 A. Record review of R #35's admission documents, no date, revealed R #35 was admitted to the facility on [DATE]. B. Record review of R #35's history and physical (H&P, physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their findings), dated 04/25/25 revealed the following: 1. R #35 had a diagnosis of chronic systolic heart failure with an onset (start) date of 11/27/24. 2. R #35 had a diagnosis of chronic diastolic heart failure with an onset date 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Recite from 10/18/24 Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #254) of 3 (R #33, R #72 and R#254) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: A. Record review of R #254's admission Record, no date, revealed R #254 was admitted into the facility on [DATE]. B. On 06/01/25 at 12:08 PM during an interview, R #254 said he has had a catheter for a while, no date given. C. Record review of R #254's order dated 05/30/25 revealed foley catheter (a thin, flexible…

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 Recite from 08/21/24 Based on observation, record review, and interview, the facility failed to develop and implement accurate, person-centered comprehensive care plan for 2 (R #21 and R #33) of 4 (R #21, R #28, R #33, and R #35) residents reviewed for care plans when staff failed to: 1. Ensure R #21 had a fall mat in place next to her bed as indicated in her care plan. 2. Include R #33's diagnosis of dementia and interventions in place to treat R #33's dementia. These deficient practices could likely result in resident injury and staff being unaware of the current and actual needs of the residents. The findings are: R #21 A. Record review of R #21's admission documents, no date, revealed the following: 1. R #21 was admitted to the facility on [DATE]. 2. R #21 had the following diagnoses: a. History of falling. b. Muscle weakness. c. Cognitive communication deficit (a person has difficulty communicating because of injury to the brain that controls the ability to think). d. Personal history of traumatic brain…

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.

Recite from 10/18/24 Based on observation, interview, and record review, the facility failed to ensure residents received care that meets professional standards for 1 (R #86) of 1 (R #86) resident sampled for limited range of motion, when staff failed to follow the order for compression stockings (specially designed hosiery that provide controlled compression to the legs, promoting blood flow and reducing swelling). This deficient practice could likely result in worsening of resident's edema (excess of watery fluid collecting in the cavities or tissues of the body) or unnecessary pain and discomfort. The findings are: A. On 06/02/25 at 2:55 PM during an interview and observation, R #86 said that she did not have compression stockings on. R #86 said that staff had only put the stockings on a couple of times since she has been in the facility. R #86's legs were swollen and puffy. B. Record review of R #86's orders revealed an order dated 01/26/25 for compression stockings to be put on in the morning before getting dressed for pitting edema for 30 administrations and every 24 hours as…

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, observation, and interview, the facility failed to provide activities of daily living (ADL) assistance for 2 (R #2 and R #33) of 2 (R #2 and R #23) residents reviewed for ADL care when staff failed to do the following: 1. Assist R #2 with toenail care. 2. Assist R #33 with nail care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: R #2 A. Record review of R #2's admission record, no date revealed the following: 1. R #2 was admitted to the facility on [DATE]. 2. R #2 is diagnosed with Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. B. On 06/03/25 at 9:24 AM, during an interview with R #2 and observation of R #2's foot, she stated that her toenails are long and her great toe on right foot is curving and it hurts. R #2 stated she didn't remember when her toenails were last cut. C. On 06/03/25 02:08 PM, during an interview, CNA # 25 stated nurses' trim residents' nails of residents who are diagnosed with diabetes D. On 06/04/25…

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 secure a treatment cart for all 69 residents who do not reside in the secure unit (residents were identified by the census list provided by the Administrator on 06/01/25). This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects. The findings are: A. On 06/01/25 at 9:45 AM, an observation of the facility revealed the treatment cart was in a central location near hall 600 and was unlocked. B. On 06/01/25 at 9:45 AM, during an interview LPN #28 confirmed that the treatment cart was unlocked. C. On 06/01/25 at 9:45 AM, during an interview, with DON confirmed that treatment carts and medications carts should be secured when staff are not present.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Recite from 04/24/24 Based on record review, observation, and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #14 and R #35) of 4 (R #14, R #21, R #28, and R #35) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact on the care staff provided to meet residents' needs due to missing or inaccurate records and resident information. The findings are: R #14 A. Record review of R #14's admission record (no date) revealed the following: 1. R #14 was admitted to the facility on [DATE]. 2. R #14 has a diagnosis of unspecified psychosis not due to a substance or known physiological condition (mental health disorder characterized by a loss of touch with reality, hallucinations, delusions, disordered thinking and behavioral changes that encompasses a range of disorders that do not fit into specific categories). B. Record review of R #14's physician's orders revealed an order dated 04/08/25 for Abilify (aripiprazole generic…

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 Recite from 04/24/24 Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections when staff failed to implement and follow enhanced barrier precautions (EBP, an infection control intervention) for 2 (R #15 and R #21) of 2 (R #15 and R #21) residents reviewed for infection prevention. If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness. The findings are: A. Record Review of the [Name of Federal Agency] Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 03/20/24, revealed the following: 1. MDRO transmission is common in long term care (LTC) facilities. 2. EBP refers to an infection control intervention designed to reduce transmission of MDRO that…

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

Based on record review and interview, the facility failed to report allegations of abuse within two hours to the State Agency (SA) for 5 (R #1, R #2, R #16, R #17, and R #18) of 5 (R #1, R #2, R #16, R #17, and R #18) residents sampled for abuse. If the facility fails to report allegations of abuse to the SA within two hours, then residents could likely continue to be abused, suffer serious bodily injury, and/or experience psychosocial distress (unpleasant emotions associated with a highly stressful situation) or worsening of current mental health conditions. The findings are: R #1 and R #2 A. Record review an incident report, dated 08/05/24, revealed the following: 1. The facility submitted a resident-to-resident abuse report to the SA regarding an incident between R #1 and R #2. 2. R #1 used a wheelchair to push R #2 onto his bed. 3. The incident occurred on 08/03/24 at 4:30 PM. 4. The report was submitted to the SA on 08/05/24 at 12:41 PM, not within two hours of the incident. R #16 and R #17 B. Record review an incident report, dated 07/25/24, revealed the following: 1. 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 record review and interview, the facility failed to provide services that meet professional standards of practice for 2 (R #1 and R #19) of 3 (R #1, R #3, and R #19) residents reviewed for medication orders when staff failed to: 1. Obtain orders for R #1 when the resident returned from the emergency room. 2. Enter medication orders for R #19 upon admission. This deficient practice could likely result in worsening of medical conditions. The findings are: R #1 A. Record review of R #1's medical record revealed the following: 1. R #1 was sent to the hospital on [DATE] due to physical aggression. 2. R #1 was discharged from the hospital back to the facility on [DATE] at 11:09 AM. B. Record review of R #'1's emergency department physician note, dated 10/16/24 at 11:13 AM, revealed: 1. Diagnosis urinary tract infection (UTI; an infection in any part of the urinary system.) 2. Medically cleared to discharge to nursing home. 3. Cephalexin (antibiotic) 250mg every 12 hours for five days for UTI. C. Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #3) of 2 (R #3 and #R #19) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: A. Record review of R #3's admission Record, no date, revealed the following: 1. R #3 was admitted into the facility on [DATE]. 2. R #3's had the following diagnoses: cramp (sustained and painful involuntary muscle contractions) and spasm (involuntary muscle contractions, which can be mild twitching sensations), chronic pain (persistent or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met for 1 (R #3) of 4 (R #1, R #3, R #19, and R #20) residents reviewed for medications when they failed to provide routine medication for a resident. This deficient practice could likely lead to unnecessary pain for the resident. The findings are: A. Record review of R #3's electronic medical record revealed the following: 1. R #3 was admitted into the facility on [DATE]. 2. R #3 was transferred to the local emergency room on [DATE]. B. Record review of R #3's Physician orders revealed: 1. An order, dated 10/04/24, for pregabalin (medication is used to treat pain caused by nerve damage), 75mg. Give one capsule by mouth at bedtime for nerve pain. 2. An order, dated 10/05/24, for pregabalin, 50mg. Give one capsule by mouth one time a day for nerve pain. B. Record review of R #3's Medication Administration Record (MAR; form used to documentation 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 record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 2 (R #2 and R #21) of 5 (R #1, R #2, R #3, R #21, and R #22) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: R #2 A. Record review of R #2's admission Record (no date) revealed the following 1. R #2 was admitted to the facility on [DATE]. 2. R #2 diagnoses is as follows: a. bipolar disorder (serious mental illness characterized by extreme mood swings, that can include extreme excitement episodes or extreme depressive feelings) b. depression (mood disorder that causes a persistent feeling of sadness and loss of interest). B. Record review of R #2's Care Plan dated 05/23/24 revealed the following: 1. R #2 has a behavior problem r/t (related to) anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure care plan revision occurred for 1 (R #21) of 3 (R #1, R #21, and R #22) residents reviewed for care plans, when they failed to update R #21's care plan after he fell. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: A. Record review of R #21's medical record revealed R #21 was admitted on [DATE]. B. Record review of R #21's progress notes, dated 05/05/24, revealed R #21 fell in the bathroom. C. Record review of R #21's care plan, dated 04/23/24, revealed the following: 1. R #21 was a high risk for falls. 2. Staff did not revise R #21's care plan to include R #21's fall on 05/05/24. 3. Staff did revise R #21's care plan to include interventions to prevent R #21 from falling…

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 safeguard resident medical record information for all 101 residents (residents were identified by the census provided by the Administrator on 04/15/24). This deficient practice could likely result in the residents' information being viewed by unauthorized residents, visitors, and staff. The findings are: A. On 04/15/24 at 2:35 PM, during an observation of the medication cart it revealed that the computer on the medication cart was open and the screen was not locked. All resident information was visible. B. On 04/15/24 at 2:39 PM, during an interview, LPN #11 confirmed that the computer was left open with resident information visible. C. On 04/24/24 at 5:05 PM, during an interview, the DON confirmed that the computer screen should be locked when not in the direct control of staff so that resident information is not accessible.

Based on record review and interview the facility failed to maintain a grievance policy that maintained records of grievances results for up to three years. This has the potential to affect all 101 residents in the facility (residents were identified by the resident matrix provided by the Administrator on 04/15/24). If the facility does not maintain a grievance policy, then resident concerns could go without resolution leaving residents depressed and anxious. The findings are: A. On 04/19/24 at 9:58 AM, during an interview the Social Services Director (SSD) was asked if she had grievances from the previous year 2023, The SSD stated that she throws out the grievances at the end of the calendar year. The SSD confirmed she did not have any grievances for the year 2023 B. Record review of the facility's Grievances/Complaint, Filling Policy revised date April 2017, revealed the results of all grievances files investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision.

Based on observation and interview, the facility failed to provide a clean, sanitary area for food storage and preparation of food and a holding temperature for puree cold foods at 41 degrees Fahrenheit or lower. This deficient practice is likely to affect all 100 residents (residents were identified by the census provided by the Administrator on 04/15/24) could likely lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) if: food is stored or prepared in unsanitary conditions and is not held at a temperature outside the danger zone (the temperature range where bacteria grow at a rapid rate, between 41 degrees (°) Fahrenheit (F) and 140° F). The findings are: Kitchen Cleanliness A. On 04/15/24 at 10:21 am, during an observation of the kitchen revealed: 1. Ice machine was dirty with yellowish stains on door. 2. Staff did not have the ice machine cleaning logs (to show the facility is cleaning the ice machine). 3. Oil on fryer with food crumbs inside and around the edges. 4. Two brownish sticky substances on floor and underneath…

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

Based on record review and interview, the facility failed to ensure that nursing staff have completed the mandatory QAPI (Quality Assurance/Performance Improvement) training for 5 (ADON #1, ADON #2, CNA #21, LPN #24, and CNA #31) of 5 (ADON #1, ADON #2, CNA #21, LPN #24, and CNA #31) staff randomly sampled for staffing. This deficient practice could likely result in staff being unable to identify opportunities for improvement, address gaps in systems or processes, develop and implement an improvement or corrective plan, and continuously monitor the effectiveness of interventions. The findings are: A. Record review of the employee training file undated revealed that ADON #1 did not complete QAPI training. B. Record review of the employee training file undated revealed that ADON #2 did not complete QAPI training. C. Record review of the employee training file undated revealed that CNA #21 did not complete QAPI training. D. Record review of the employee training file undated revealed that LPN #24 did not complete QAPI training. E. Record review of the employee training file undated…

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 provide reasonable accommodations of resident needs for 2 (R #102 and R #359) of 2 (R #102 and R #359) residents reviewed for care when the facility failed to ensure that resident's bedside table with frequently used items and call light were within the resident's reach. This deficient practice could result in the residents' needs not being met, leaving them at risk for accidents and falls. The findings are: R #359 A. On 04/16/24 at 11:47 AM, during an observation and interview of R #359, revealed the call light was hanging on the back of the bed and was not within reach. R #359 confirmed she did not know where the call light was and had to get up to look for it. B. On 04/16/24 at 12:10 PM, during an interview the CNA #31 confirmed R #359 did not have the call light within resident's reach. R #102 C. On 04/17/24 at 2:04 PM, during an observation of R #102 room revealed the bedside table with a pitcher was across the room and not within the resident's reach. D. On 04/17/24 at 2:06 PM during an interview the ADON #2 confirmed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the provider of a change in condition for 1 (R #108) of 1 (R #108) residents reviewed for change of condition, when they failed to notify the facility provider about R #108's nausea. This deficient practice could likely result in residents not receiving necessary care or a delay in treatment. The findings are: A. Record review of R #108's face sheet, revealed R #108 was admitted on [DATE]. B. Record review of R #108's physician progress note dated 11/28/23, revealed resident had a diagnosis of chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should) stage 3 (mild to moderate loss of kidney function). C. Record review of R #108's physician's orders revealed Bactrim (an antibiotic used to treat ear infections, urinary tract infections, and other infections) 800-160 mg was started on 01/15/24 for a diagnosis of UTI. D. Record review of nursing progress note dated 01/15/24, 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.

Based on observation and interview the facility failed to provide a home-like environment for all 16 residents in the secure unit (residents were identified by the resident Matrix provided by the Administrator on 04/15/24) when they left resident meals and drinks on the serving trays during the lunch meal for all 16 residents. This deficient practice could likely cause residents to feel depressed and anxious that they are not living in a comfortable home-like environment. The findings are: A. On 04/15/24 at 11:59 AM, during an observation of the lunch meal on the secure unit revealed the following: 1. CNA #21 and the Activities Assistant were passing out meals in the dining room. 2. CNA #21 and the Activities Assistant placed the plastic serving trays with meals, in front of each resident in the dining room. 3. CNA #21 and the Activities Assistant distributed meals to the resident's rooms. 4. CNA #21 and the Activities Assistant placed the plastic serving trays with meals, on the bedside table of each resident in the resident rooms. B. On 04/15/24 at 12:13 PM, during an interview…

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

Based on record review and interview the facility failed to report an allegations of abuse or neglect within two hours to the State Agency (SA) for 1 (R #66) of 1 (R #66) residents sampled for abuse and accidents. If the facility fails to report allegations of abuse or neglect to the SA within two hours, then residents could likely continue to be abused or suffer serious bodily injury. The findings are: A. On 04/16/24 at 10:08 am, during an interview, R #66 said that she had been assaulted while sitting in her room. R #66 said she did not remember when. B. Record review of the Health Facility Incident Report dated 02/29/24, revealed the following: 1. R #20 and R #66 got in an argument over a a water mug. 2. R #20 scratched R #66 on the face during the incident. 3. R #66 had scratch marks on her face. 4. The time of the incident was 02/28/24 at 1:00 pm. 5. Date the report was sent to the SA on 02/29/24 at 8:50 am (outside the two hours reporting time). C. On 04/17/24 at 3:02 pm, during an interview, the Administrator said that an allegation of abuse must be reported within two hours.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure that residents and their representatives received a written notice of transfer as soon as practicable for 1 ( R #89) of 3 (R #82, R #86, and R #89) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative not knowing the reason or location the resident was discharged . The findings are: A. Record review of the nursing progress note dated 02/03/24, revealed R #89 was transferred to the hospital after a fall on 02/03/24. B. Record review of R #89's nursing progress note dated 04/06/24, revealed R #89 was transferred to the hospital on [DATE] due to bruising on chest and abdomen. C. Record review of the nursing progress note dated 04/09/24, revealed R #89 was transferred to the hospital on [DATE] for extreme agitation. D. Record review of R #89's medical record revealed staff did not provide a written transfer notice to R #89 or his representative for R #89's transfer to 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 record review and interview, the facility failed to ensure that residents and their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 3 (R #82, R #86, and R #89) of 3 (R #82, R #86, and R #89) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: R #82 A. Record review of R #82's nursing progress note dated 03/21/24, revealed R #82 was transferred to the hospital for behavioral changes on 03/21/24. B. Record review of R #82's medical record revealed R #82's medical record did not contain a written notice of bed hold policy for the transfer on 03/21/24. C. On 04/23/24 at 9:33 AM, during an interview with the Administrator, he stated that R #82 did not receive a written bed hold notice for his transfer to the hospital on [DATE] because R #82 returned to the facility the same day.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete and transmit (electronically sending encoded information) a Significant Change (major decline or improvement in the patient's health status) Minimum Data Set assessment within 14 days after the facility determined a significant change in the resident's physical or mental condition for 1 (R #30) of 2 (R #30 and R #31) residents reviewed for MDS assessment timing. This deficient practice could likely result in the resident not receiving the appropriate care and services they need. The findings are: A. Record review of R #6's Physician's Orders dated 02/24/24 revealed: admit to [name of company] hospice. B. Record review of R #6's change of condition MDS assessment dated [DATE], revealed that the MDS assessment was not completed and signed off by the Registered Nurse (RN) until 04/03/24. C. On 04/24/23 at 3:31 PM, during an interview with the MDS Coordinator and the Regional MDS(RMDS) coordinator, the RMDS confirmed that R #6's Significant change…

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

Based on record review and interview, the facility failed to ensure that an Minimum Data Set (MDS) was completed every three months for 3 (R #13, R #68, and R #73) of 5 (R #13, R #29, R #58, R #68, and R #73) resident reviewed for MDS assessments, when they failed to complete quarterly MDS assessments timely (completed 14 days after the assessment reference date (ARD)). This failed practice could result in residents assessments being outdated and residents not receiving care and treatment that meets their current needs. The findings are: A. Record review of R #13's quarterly MDS assessment revealed the following: 1. ARD date of 03/08/24. 2. Completion date 04/10/24. B. Record review of R #68's quarterly MDS assessment revealed the following: 1. ARD date of 03/08/24. 2. Completion date 04/10/24. C. Record review of R #73's quarterly MDS assessment revealed the following: 1. ARD date of 03/07/24. 2. Completion date 04/10/24. D. On 04/23/24 at 1:14 PM, during an interview, the Regional MDS Coordinator (RMSC) confirmed that R #13's, R 36's, and R #73's MDS assessments were not completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a baseline care plan within 48 hours, that accurately reflected the resident's current condition for 2 (R #100 and R #359) of 3 (R #100, R #359 and R #310) residents sampled for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and services and may place residents at risk of an adverse event (an event, preventable or nonpreventable, that caused harm to a patient as a result of medical care or lack of medical care) or worsening of current condition after admission. The findings are: R #100 A. Record review of R #100's face sheet revealed, R #100 was admitted on [DATE]. B. Record review of Baseline Care Plan dated 03/04/24, revealed the plan was initiated (effective) on 03/04/24 (not within 48 hours of admission). C. On 04/24/24 at 12:16 PM, during an interview with the MDS Nurse, she confirmed the following: 1. The baseline care plan should be created upon admission by the admitting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a comprehensive care plan for 2 (R #9, and R #108) of 2 (R #9, and R #108) residents sampled for care plans. This deficient practice could likely result in staff being unaware of the needs of residents. The findings are: R #9 A. On 04/15/24 at 11:35 AM, during an interview, R #9 revealed the following: 1. She said she wears dentures, and they feel uncomfortable and fit her loosely. She does not wear them and stores them in her drawer. 2. She said she has glaucoma (group of eye conditions that damage the optic nerve) and it has been getting worse since a year and a half ago. She has eye drops. R #9 said the nurse eye drops are given by the nurse more than twice a day. B. Record review of R #9's physician's order revealed the following: 1. 09/16/23 Xalatan Ophthalmic Solution 0.005 %, one drop in both eyes at bedtime for pre-glaucoma. C. Record review of R #9's care plan dated 03/11/24 revealed the following: 1. Staff did not document R #9'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 record review, observation, and interview, the facility failed to ensure that the care plan had been revised for 4 (R #66, R #86, R #88, and R #108) of 5 (R #62, R #66, R #86, R #88, and R #108) residents reviewed by: 1. Not revising R #66's care plan to reflect that she was not in the secured unit. 2. Not revising R #86's care plan to include his diagnosis of seizures. 3. Not revising R #88's care plan to include medications and orders for wounds. 4. Not revising R #108's care plan to include her diagnosis of urinary tract infection (UTI, an infection in any part of the urinary system). This deficient practice could likely result in staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #66 A. Record review of R #66's care plan 02/06/24 revealed, R #66 was care planned for being in the secured unit. B. Record review of R #66's medical record not dated revealed: 1. R #66 was admitted on…

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

Based on interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight for 1 (R #62) of 2 (R #25 and R #62) residents sampled for nutrition, when they failed to follow dietitian's order. This deficient practice could likely result in residents losing weight without the facility being aware causing physical and mental health issues. The findings are: A. Record review of R #62's Nutrition Assessment by the Registered Dietician (A resident's attending physician may delegate the task of writing dietary orders to a qualified dietitian or other clinically qualified nutrition professional.). dated 03/06/24, revealed the following: 1. R #62 had a decreased oral intake. 2. A health shake was order three times a day. B. Record review of R #62's medical record revealed, the record did not contain an order for a health shake, three times a day. C. On 04/22/24 at 3:48 PM, during an interview, the Dietary Manager (DM) confirmed that the health shake for R #62 was not ordered, and that R #62 was not getting the health shake…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to effectively (use of different techniques and medication to reduce and control the amount of pain a person experiences) manage pain for 1 (R #22) of 1 (R #22) residents reviewed for pain when staff did not assess for pain and provide pain treatment. This deficient practice could likely result in residents experiencing unnecessary pain. The findings are: A. On 04/16/24 at 10:58 AM, during an interview, R #22 stated she had not taken her pain medication (Tylenol #4; acetaminophen with codeine combination opioid medication used to treat moderate to severe pain) since the beginning of April and had been seen by the pain specialist on 04/15/24. R #22 stated I have pain all the time. R #22 stated her pain level was currently at a 7, and ranges from 5-10 daily, (1 to 10 scale: 1 least and 10 worst pain). B. On 04/18/24 at 5:53 PM, during an interview, R #22 stated pain scale is currently at a 6. The pain usually averages at five and can be at 10 when she does…

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

Based on record review and interview, the facility failed to ensure staff adequately monitored medications for 1 (R #86) of 5 (R #1, R #86, R #88, R #89, and R #359) residents reviewed for unnecessary medications, when they failed to monitor R #86's antiseizure medication levels as ordered by the physician. If the facility is not adequately monitoring medication levels in the blood, then residents are likely to be at risk of agitation, drowsiness, difficulty breathing, and/or behavior changes. The findings are: A. Record review of R #86's physician's orders revealed the following: 1. An order dated 01/26/24, for levetiracetam (medication used alone or together with other medicines to help control certain types of seizures in the treatment of epilepsy) oral tablet 1000 milligram (mg, unit of mass equal to 1/1000 gram) twice a day for seizure disorder. 2. An order dated 01/26/24, for oxcarbazepine (medication used in the treatment of partial seizures) oral tablet 300 mg, twice a day, for epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). 3.…

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

Based on record review and interview, the facility failed to ensure residents did not receive unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for 3 (R #86, R #89 and R #359) of 5 (R #1, R #86, R #88, R #89, and R #359) residents reviewed for unnecessary medications when they failed to document appropriate diagnosis in the resident medical record for psychotropic medications. This deficient practice is likely to result in residents being administered medications they do not need and could likely suffer from adverse side effects (unwanted, harmful, or abnormal result). The findings are: R #86 A. Record review of R #86's physician's orders revealed the following: 1. R #86 had an order dated 04/05/24, for Seroquel (an antipsychotic medication used to manage psychosis (A mental disorder characterized by a disconnection from reality)) 25 milligram, twice a day for agitation/anxiety. 2. R #86 had an order dated 03/11/24, for mirtazapine (antidepressant medication used in the treatment of major depressive disorder),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #1 and R #108) of 2 (R #1 and R #108) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records. The findings are: R #1 A. Record review of R #1's physician's orders, dated 03/18/24, revealed an order for Eliquis (medication used to treat and prevent blood clots and to prevent stroke) Oral Tablet 5 MG related to acute embolism (blockage of an artery) and thrombosis (blood clot) of superficial veins of left upper extremity (region of the body that includes the arm, forearm, wrist and hand). B. On 04/24/24 at 3:09 PM, during an interview with the DON, she confirmed the following: R #1 has a history of CVA (cerebrovascular accident) (stroke) and coronary artery disease (CAD) and presence of coronary angioplasty implant (treats vessels, called coronary arteries,…

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

Based on record review, observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 (R #25, R #30, R #82, R #94, R #109, and R #359) of 6 (R #25, R #30, R #82, R #94, R #109, and R #359) when they failed to have: 1) PPE (personal protective equipment equipment designed to protect from infection) was available for R #25, R #30, R #82, R #94, and R #109, who were on enhanced barrier precautions (refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (bacteria that are resistant to three or more classes of antimicrobial drugs) that require gown and glove use during high contact resident care activities). 2) Staff wear eye protection when entering R #359 room who had Covid-19 (is an infectious disease caused by the SARS-CoV-2 virus). 3) Staff document findings made during process surveillance (the review of practices by 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.

Based on record review and interview, the facility failed to offer Covid-19 (is an infectious disease caused by the SARS-CoV-2 virus) vaccinations to 1 (R #1) of 5 (R #1, R #60, R #71, R #82, and R #88) residents sampled for Covid-19 vaccination. This deficient practice could result in residents getting Covid-19 resulting in other illnesses or death. The findings are: A. Record review of R #1's entire medical record, revealed that the staff failed to document that they offered Covid-19 vaccinations to R #1. B. On 04/24/24 at 3:28 PM, during an interview, the DON confirmed that the staff did not document if R #1 was offered the Covid-19 vaccination.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Minimum Data Set Assessment was accurate for 1 (R #31) of 5 (R #2, R #6, R #22, R #31, and R #32) residents review for MDS assessment accuracy. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: A. Record review of R #31's admission Record revealed the following diagnoses: 1. Huntington's disease ( a condition that leads to progressive degeneration of nerve cells in the brain that affects movement, cognitive functions, and emotions). 2. Need for assistance with personal care (assistance and provided to individuals in performing daily living tasks and maintaining personal hygiene). 3. Reduced mobility (decrease in the ability to move or alternate positions). A. Record review of R #31's physician orders revealed the following: 1. Order date 01/19/24, NPO (nothing by mouth) diet. 2. Order date 01/23/24, Jevity 1.2 (calorically dense, high-protein,…

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, the facility failed to ensure residents received proper treatment to maintain vision for 1 (R #9) of 2 (R #9 and R #30) residents reviewed for vision and hearing. This deficient practice could likely result in residents losing some independence if they cannot see, compromising their quality of life. The findings are: A. Record review of R #9's medical record revealed R #9's diagnosis of pre-glaucoma. B. On 04/15/24 at 11:35 AM, during an interview R #9 revealed the following: 1. She said she has glaucoma (group of eye conditions that damage the optic nerve) and it has been getting worse since a year in a half ago. She has not seen a eye doctor. C. On 04/18/24 at 11:10 AM, during an interview with Social Services (SS) confirmed she has not made any appointments for R #9 to see the eye doctor. SS confirmed that R #9 has not had any eye doctor appointments.

Based on record review, observation and interview, the facility failed to ensure the nutritional needs and preferences were met for 1 (R #66) of 4 (R #25, R #62, R #66 and R #87) residents by not following the menu. This deficient practice is likely to result in resident weight loss and frustration. The findings are: A. Record review of R #66's food ticket (what the resident was served for that meal) for 04/18/24 revealed: 1. Egg Salad 2. Crackers 3. Cucumber Dill Salad 4. Soft Chocolate Chip Cookie Bar B. On 04/18/24 at 5:54 PM, during an observation of dinner service R #66 was not served crackers and a soft chocolate chip cookie bar. (R #66 is blind and not able to see what she is served to notice what is missing). C. On 04/18/24 at 6:02 PM, during an interview, LPN #11 confirmed R #66 only had egg salad and cucumber dill salad on her tray. LPN #11 confirmed that R #66 was supposed to have crackers and a soft chocolate chip cookie bar.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure could provide cardiopulmonary resuscitation (CPR) (can help save a life during cardiac arrest, when the heart stops beating or beats too ineffectively to circulate blood to the brain and other vital organs) during an emergency for 3 (R #100, R #108, and R #309) of 3 (R #100, R #108, and R #309) residents reviewed for advanced directives, when they failed to ensure staff: 1) Knew and followed facility protocols for determining residents code status [the residents choice as to whether or not they would like to be provided CPR in the event that they stopped breathing and/or their heart stopped]. 2) Had resident code status available for staff use during an emergency. This deficient practice is likely to delay potentially lifesaving measures or cause residents to undergo CPR against their wishes, causing unnecessary suffering. The findings are: R #100 A. Record review of R #100's face sheet, revealed she was admitted to the facility on [DATE]. B.…

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 call lights in the residents' bathrooms were adequately equipped to allow residents to call for help using the call light system, for 17 (R #7, R #8, R #9, R #10, R #11, R #12, R #13, R #14, R #15, R #16, R #17, R #18, R #19, R #20, R #21, R #22, R #23) of 17 (R #7, R #8, R #9, R #10, R #11, R #12, R #13, R #14, R #15, R #16, R #17, R #18, R #19, R #20, R #21, R #22, R #23) residents randomly sampled for call light function, when the facility failed to have proper length pull cords for the call light system in the resident's bathrooms. This deficient practice could likely result in residents being unable to call for assistance in the bathrooms in the event of a fall to the floor. The findings are: A. On 10/17/23 at 11:08 AM, observation of the bathroom pull cords in residents' rooms on the 300 Hallway (R #7's, R #8's, R #9's, R #10's, R #11's, R #12's, R #13's, R #14's, R #15's, R #16's, R #17's, R #18's, R #19's, R #20's, R #21's, R #22's, and R #23's rooms) revealed the pull cords were too short to be accessible 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 interview and record review, the facility failed to send the initial report of an allegation of neglect to the State Agency in the proper timeframes for 1 (R #1) of 6 (R #1, R #2, R #3, R #4, R #5, & R #6) residents sampled for neglect. This deficient practice could likely result in residents suffering physically from receiving inappropriate care. The finding are: A. On 10/16/23 at 2:15 PM, during a phone interview, R #1's daughter stated the following: 1. She received a phone call from the nurse at the facility on 06/02/23 at 10:00 PM stating that R #1 received another resident's medications along with her own and was being sent to the hospital. 2. R #1 was hospitalized for a few days, and three of those days were in the ICU (Intensive Care Unit). B. Record review of R #1's Nursing Progress Notes revealed: 1. On 06/02/23, R #1 received another resident's medications which were sucralfate (medication used to treat duodenal ulcers) 1 GM (gram, unit of measure), melatonin (supplement given to regulate…

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

Based on interview and observation, the facility failed to ensure residents knew where the most recent survey was located. This could affect the 72 residents (identified by the facility census provided by the Administrator on 04/27/23). If residents are unable to locate the latest survey conducted by State Surveyors, then residents, representatives, and visitors are unable to know how the facility is doing and make decisions accordingly. The findings are: A. On 03/30/2302:13 PM, during the resident council meeting interview, R #3, R #10, R #33, R #41, R #45, R #54, R #57 revealed: 1. Residents were not aware that they have access to the most recent Survey results. 2. The residents did not know where the latest survey results were located. B. On 03/30/23 3:17 PM, during an observation of the front lobby revealed a displayed Survey binder. C. On 04/05/23 at 4:33 PM during an interview, the Administrator confirmed that the resident's have a right to know and have access to the previous Survey results.

Based on observation, record review, and interview, the facility failed to ensure residents were treated with respect and dignity for 3 (R #34, R #40, and R #220) of 7 (R #01, R #34, R #40, R #42, R #64, R #44, and R #220) residents randomly sampled, when the facility failed to: 1. Ensure Staff are speaking in a language that R #34 understands while receiving patient care, 2. Ensure R #40 has sheets on his bed, 3. Ensure R #220's room is free of odor, These deficient practices are likely to result in residents feeling embarrassed, ashamed, and that their feelings and preferences are unimportant to the facility staff. The findings are: R #34 A. On 03/28/23 at 2:10 PM, during an interview with R #34 and his wife revealed that 2 female CNAs will speak Spanish to each other while providing patient care to R #34. This makes the resident feel very uncomfortable because he doesn't understand what they are saying or if they are talking about him. They also disclosed reporting this to the Activity Director during a Resident Council meeting last month but the CNAs continue to Speak in Spanish…

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 the facility failed to protect residents against the loss of resident's personal property for 3 (R #16, R #41 and R #64) of 3 (R #16, R #41 and R #64) residents reviewed for loss of personal property. This deficient practice could likely cause the resident and/or the resident's family frustration with loss of personal belongings and a financial burden of having to purchase those items again. The findings are: A. On 03/27/23 at 2:59 PM, during an interview R #41 stated that her only pair of jeans are missing and have been missing for months. She also said that laundry goes missing all the time and she has reported it and is told, they are looking for the items. They have not found or replaced the items. B. On 03/28/23 at 1:22 PM, during an interview R #64's wife it was said that R #64's laundry has gone missing since he has been there (12/08/23) and that there are still items that have not been found. She further stated that the items that were not found have not been replaced. C. On 03/30/23 at 3:57 PM, during an interview R #16 stated that…

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

Based on interviews the facility failed to keep residents free from abuse for 4 (R #16 and R #21, R #64 and R #220) of 4 (R #16 and R #21, R #64 and R #220) residents reviewed for abuse and neglect, when the facility failed to protect: 1. R #16 from mental anguish (mental suffering which includes fright, feelings of distress, anxiety, depression, grief and/or psychosomatic physical symptoms) from PTA #11 (Physical Therapist Assistant) after she became angry that R #16 did not want to do therapy. 2. R #21 from physical abuse when PTA #11 physically attempted to force R #21 into the therapy room. 3. R #64 from physical abuse when PTA #11 pounded on R #64's contracted hand (condition that causes one or more fingers to bend toward the palm of the hand) to flatten it. 4. R #220 from abuse when PTA #11 attempted to manipulate a joint that had been immobile (A type of joint between bones in which there is no joint cavity, and with very little or no movement is possible under normal conditions) for ten years. These deficient practices could likely result in residents having anger, fear, 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 Based on record review and interview, the facility failed to notify the resident/resident's representative(s) of the transfer and the reasons for the move in writing for 3 (R #10, R #17, and R #47) of 3 (R #10, R #17, and R #47) residents sampled for hospitalizations. This deficient practice could likely result in the resident and/or their representative not knowing the reason for the transfer and their rights to advocate and make informed decision regarding their healthcare. The findings are: R #10 A. Record review of R #10's Progress Notes revealed the following: 1. R #10 was transferred to the hospital on [DATE] for a fall. B. Record review of R #10's medical record revealed no written Transfer Notice. R #17 C. Record review of R #17's Electronic Medical Record (EMR) revealed: 1. On 03/04/23 R #17 was sent to the Hospital for Shortness of Breath (SOB) and pain. 2. On 03/11/23 Respiratory infection Shortness of Breath (SOB). 3 On 3/27/23 GI bleed (Gastrointestinal bleeding is a symptom of a disorder in your…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide written information to the resident or resident representative that specifies the bed hold policy at the time of the transfer for 3 (R #10, R #17, and R #47) of 3 (R #10, R #17, and R #47) residents sampled for hospitalizations. This deficient practice could likely result in the resident and/or their representative being unaware of the resident being able to return to their previous room or the next available room upon return from the hospital. The findings are: R #10 A. Record review of R #10's Progress Notes revealed the following: 1. R #10 was transferred to the hospital on [DATE] for a fall. 2. No written Bed Hold Policy Notice was found. R #17 B. Record review of R #17's Electronic Medical Record (EMR) revealed: 1. On 03/04/23 R #17 was sent to the Hospital for Shortness of Breath (SOB) and pain. 2. On 03/11/23 Respiratory infection Shortness of Breath (SOB). 3 On 3/27/23 GI bleed (Gastrointestinal bleeding is a symptom of a disorder in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a significant change (major decline or improvement in the patient's health status) MDS (Minimum Data Set; assessment) in a timely manner (within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition) for 2 (R #31 and R #42) of 2 (R #31 and R #42) residents sampled for Hospice (care that focuses on alleviating symptoms of the terminally ill). This deficient practice could likely result in the resident not receiving the appropriate care and services they need. The findings are: R #31 A. Record review of R #31's Physician's Orders revealed, on 08/22/22; R #22 was placed on Hospice. B. Record review of R #31's MDS Assessment revealed no Change of Condition MDS was located. C. On 03/30/23 at 8:30 AM during an interview, the Cooperate Nurse confirmed that the facility did not do a Change in Condition MDS for R #19 for Hospice admission on [DATE]. R…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to have MDS documents completed, submitted, and finalized in a timely manner (within 14 days of completion) for 2 (R #64 and R #219) of 2 (R #64 and R #219) residents randomly reviewed for Minimum Data Set (MDS; tool for implementing standardized assessment and for facilitating care management in nursing homes) assessments. If MDS assessments are not completed, submitted, and finalized in a timely manner, it is likely that residents will receive less than optimal care: The findings are: A. Record review of R #64's admission record revealed that R #64 was admitted on [DATE]. B. Record review of R #64's Quarterly MDS assessment dated [DATE], revealed MDS Status: Export Ready (completed but not submitted) C. Record review of R #219's admission record revealed that R #219 was admitted on [DATE]. D. Record review of R #219's admission MDS assessment dated [DATE], revealed MDS Status: Export Ready E. On 04/05/23 at 5:02 PM, during an interview with DON, she…

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

Based on observation, interview, and record review the facility failed to ensure that the Minimum Data Set (MDS) Assessments were accurate for 2 (R #47 and R #58) of 2 (R #47 and R #58) residents sampled for MDS accuracy 1. When Post Traumatic Stress Disorder (PTSD) was included as an active diagnosis for R #47 2. When they failed to capture the severity of R #58's vision problems. These deficient practices could likely result in residents not receiving the care and treatment they need. The findings are: R #47 A. Record review of R #47's Quarterly MDS completed 01/26/23 revealed PTSD marked off as an active diagnosis. B Record review of R #47's admission Record (no date) Diagnosis information did not include PTSD as a diagnosis. C. Record Review of R #47's Behavioral medicine outpatient Services (provides individualized treatment for adults who suffer from emotional, behavioral or mental health disorders). Progress note for 03/28/23 revealed no diagnosis of PTSD. D. On 04/05/23 at 4:47 PM, during an interview, the DON stated I believe it (PTSD diagnosis) was entered on the MDS in…

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

Based on record review, observation, and interview, the facility failed to develop a comprehensive person-centered care plan for 1 ( R #44) of 5 (R #9, R #17, R #40, R #44, and R #169) residents reviewed for Comprehensive Care Plans. Failure to develop a person-centered care plan is likely to result in staff's failure to understand the needs and treatments for residents to achieve their highest level of well-being. The findings are: R #44 A. Record review of R#44's Minimum Data Set assessment completed on 02/28/23 revealed: 1. Section K; Nutritional approaches: Check all of the following nutritional approaches that were performed during the last 7 days: a. Feeding tube (therapy where a feeding tube delivers nutrition directly to your stomach) was marked yes, while NOT a resident and yes, while a resident. 2. Section K; Percent Intake by Artificial Route (nutrition that is not provided through the mouth or by chewing): a. Proportion of total calories the resident received through parenteral (medical term for infusing a specialized form of food through a vein) or tube feeding was…

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

Based on observation and interview, the facility failed to ensure appropriate treatment and services for Foley Catheter tubing/Collecting bag (soft plastic or rubber tube that is inserted to the bladder to drain the urine and is connected to a collecting bag) care for 1 (R #221) of 1 (R #221) residents randomly observed when they failed to keep R #221's Foley catheter collecting bag and tubing off the floor. This deficient practice could likely result in residents getting infections. The findings are: A. On 03/29/23 at 10:58 AM, during an observation R #221's catheter tubing was dragging on the floor while sitting in his room. LPN #11 confirmed that R #221's foley tubing was dragging on the floor and shouldn't be. B. On 03/29/23 at 1:28 PM, during an observation of the physical therapy room, Physical Therapist #11 was transferring R #221 from one wheelchair to another and removed the catheter bag from the wheelchair and laid it on the floor. After transferring R #221, Physical Therapist #11 picked the catheter up off the floor and attached it to the wheelchair that R #221 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.

Based on record review and interview, the facility failed to conduct Nurse Aide performance review at least every 12 months and failed to provide evidence of CNA's completion of the required 12 hours per year In-Services for 3 (CNA #11, CNA #12, and CNA #13) of 3 (CNA #11, CNA #12, and CNA #13). This failed practice could lead to residents not receiving the appropriate care to meet their individual needs. The findings are: A. Record review of personnel files of CNA #11, CNA #12 and CNA #13, revealed no documentation of Nurse Aid Performance Reviews. The facility could not provide documentation that the Nurse Aide Performance review (yearly evaluation of the Nurse Aids performances) have been completed. B. On 04/15/21 at 3:30 pm, during an interview, the DON confirmed they were not able to locate any documented nursing staff trainings or evaluations. The DON stated that [Name of Previous Company] were throwing away documents and trainings for staff can not be confirmed.

Based on record review and interview, the facility failed to ensure that consultant pharmacists recommendations were reviewed and implemented by the physician or ensure that the physician provides rationale for not following the recommendation for 2 (R #9 and R #42) ) of 5 (R #9, R #30, R #41, R #42, and R #64) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions or adverse side effects. The findings are: R #9 A. Record review of pharmacy consultation report for R #9 dated 01/20/23 revealed: 1.[name of resident] receives 3 or more CNS (central nervous system; consists of the brain and spinal cord and is responsible for integrating and coordinating the activities of the entire body) active medications which can cause a risk for falls and fractures Please reevaluate the combination and attempt a trial D/C (discontinuation) of Divalproex (an anticonvulsant that works in the brain tissue to stop seizures, also used to treat the manic phase 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 observation, record review, and interview, the facility failed to ensure that the medication error rate was 5% or less when medications were not given and the wrong medication was given for 4 (R #7, R #41, R #49, and R #56) of 10 (R #2, R #7, R #10, R #13, R #25, R #38, R #41, R #49, R #53, and R #56) residents observed during medication pass. This deficient practice could likely result in residents not receiving the desired therapeutic effect and exposing residents to a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: A. RN #2 was observed conducting morning medication pass from 7:02 AM through 9:05 AM. R #7 B. On 04/04/23 at 8:42 AM, during observation of medication pass RN # 2 did not administer any inhaled medication to R #7. C. Record review of R #7's Physician's orders revealed: Order Date 03/02/23; (hour scheduled 8:00 AM)Breo Ellipta Inhalation Aerosol Powder (medication used to prevent and decrease symptoms (wheezing and trouble breathing) caused by asthma and ongoing lung disease such as chronic obstructive pulmonary…

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.

Recite from a complaint survey dated 03/31/23 Based on observation and interview the facility failed to properly store medications in the medication carts for all 72 residents (residents were identified by the resident matrix provided by the Administrator on 03/27/23) that were randomly sampled, when they failed to: 1. Secure the medication carts on the 500 unit. 2. Ensure medications were not expired (expired medications can be less effective or risky due to a decrease in strength) Memory Care Unit Medication Cart. These deficient practices could result in residents obtaining medication not prescribed to them and residents having adverse side effects. The findings are: Medication Cart 500 Unit A. On 03/28/23 at 2:29 PM during observation of the 500 Unit, RN #21 walked away from his medication cart, leaving it unsecured. B. On 03/28/23 at 3:42 PM during an interview, the DON confirmed that the medication cart must remain secure when nurse steps away. C. On 04/04/23 at 11:01 AM, during an observation of 500 Unit revealed the medication cart unlocked, no staff were present. D. On…

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

Based on observation, and interview, the facility failed to practice proper infection control practices, when they failed to perform proper hand hygiene in the dining room while assisting 2 (R #19 and R #28) of 2 (R #19 and R #28) residents randomly observed during dining. This deficient practice is likely to result in the spread of infections and illness. The findings are: A. On 03/27/23 at 12:29 PM during the lunch time dining observation revealed CNA #22 was observed feeding R #19 and R #28 and no hand hygiene was being done in between each task. B. On 03/27/23 at 12:36 PM during an interview, CNA #22 revealed she has had hand hygiene and infection control training and did not disclose why she did not perform hand hygiene. C. On 04/05/23 at 4:37 PM during an interview, the DON confirmed that staff should be doing hand hygiene between feeding more than 1 resident at a time to prevent the spread of germs.

Based on record review and interview the facility failed to have required in-service training for nurse aides for 3 (CNA #11, CNA #12, and CNA #13) of 3 (CNA #11, CNA #12, and CNA #13) CNA's sampled for training when they failed to ensure: 1. Dementia management training and resident abuse prevention training were conducted, 2. Annual trainings are based, in part on facility assessment and performance evaluations. These deficient practices could likely lead to the CNA's not receiving the continuing education needed to provide competent care to the residents. The findings are: A. Record review of personnel files of CNA #11, CNA #12 and CNA #13, revealed that there was no documentation of Dementia management training and resident abuse prevention training. When asked, the facility could not provide documentation that dementia training and resident abuse prevention training had been completed. B. Record review of personnel files of CNA #11, CNA #12 and CNA #13 training transcript revealed that there was no documentation that annual trainings are based, in part on facility assessment…

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 the facility failed to provide quarterly statements for resident's personal funds for 1 (R #19) of 2 (R #19 and R #64) resident reviewed personal funds entrusted to the facility on the resident's behalf. This deficient practice is likely to cause a resident to be unaware of their personal funds balances. The findings are: A. On 03/27/23 at 3:56 PM, during an interview, R #19 stated that she does not get any of her quarterly statements for her personal funds account. B. On 03/30/23 at 10:26 AM, during an interview, the Business Office Manager confirmed that she never provided a quarterly statement to R #19, instead she was calling R #19's daughter and verbally reported R #19's account balance. C. Record review of Resident Funds: Handling & Recording Policy, revised August 2020 revealed: 1. Provide a means to protect resident funds managed by the Facility; 2. Provide for an individual and confidential accounting of funds received and disbursed on the resident's behalf; 3. Provide a means for the resident to access his or her funds or to have 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 record review and interview, the facility failed to ensure that Advance Directives (legal document that specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) form was completed for 1 (R #169) of 7 (R #3, R #9, R #44, R #46, R #47, R #58, and R #169) residents reviewed for Advance Directives. This deficient practice could likely result in staff being unaware of the medical intervention wishes of residents during an emergency. The findings are: A. Record review of R #169's Electronic Medical Record (EMR) revealed R #169 was admitted to the facility on [DATE]. B. Record review of R #169's EMR on 03/28/23 revealed no MOST (Medical Orders for Scope of Treatment; advance directive) form. C. Record review of Advance Directives Policy-Operational Manual-Social Services; date 08/2020 revealed: Policy: I. At the time of admission, admission staff or designee will inquire about the existence of an advance directive .…

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

Based on record review and interview, the facility failed to notify the resident's representative of an incident for 1 (R #21) of 4 (R #16, R #21, R #64, and R #220) residents reviewed for abuse. This deficient practice could likely result in resident's family members not being able to make decisions related to treatment and/or advocate for the resident's care. The findings are: A. On 03/29/23 at 3:11 PM, the Administrator reported that there was an allegation of abuse regarding R #21 being abused by PTA (Physical Therapist Aid) #11 and witnessed by ADON #1 on 03/27/23. B. On 03/31/23 at 9:22 AM during an interview ADON #1 stated that on 03/27/23, she witnessed PTA #11 grabbing R #21's arms and crossing them and telling her she was going to go to therapy. ADON #1 stated that R #21 is non-verbal and shows she is upset by flailing (to move energetically in an uncontrolled way) and movement. R #21 was flailing and moving. PTA #11 kept grabbing at R #21's arms forcefully. ADON #1 stated she did not like the way PTA #11 was grabbing R #21 and told her to leave the resident alone several…

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

Based on record review and interview the facility failed to report to the State Survey Agency an allegation of abuse for one 1 (R #21) of 4 (R #16, R #21, R #64, and R#220) residents sampled for abuse, when they failed to report the allegation of R #21's abuse within two hours to the State Agency. If the facility fails to report allegations of abuse to the State Agency within two (2) hours, then residents could likely continue to be abused. The findings are: A. On 03/29/23 at 3:11 PM, during interview with the Administrator, it was reported that there was an allegation of abuse regarding R #21 being abused by PTA (Physical Therapist Assitant) #11 and witnessed by ADON #1 and ADON #2 on 03/27/23. B. On 03/30/23 at 4:03 PM, during an interview ADON #2 stated that on 03/27/23 she witnessed the end of the incident with R #21 and PTA #11. ADON #2 acknowledged that ADON #1 was already present with R #21 and PTA #11. ADON #2 stated that R #21, ADON #1 and PTA #11 were all upset and agitated. ADON #2 agreed with ADON #1 to remove R #21 from the situation. ADON #2 stated that PTA #11 became…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a comprehensive assessment was completed within 14 calendar days after admission for 1 (R #169) of 1 (R #169) residents randomly sampled for completion of a comprehensive MDS (Minimum Data Set) assessment. This deficient practice could likely lead to the residents' preferences and needs not being met. The findings are: A. Record review of R #169's Electronic Medical Record revealed: 1. R #169 was admitted on [DATE] 2. Review of admission MDS revealed a completion date of 03/29/23. B. On 04/05/23 at 4:49 PM, during an interview, the DON confirmed that the admission MDS for R #169 was not completed within 14 days of admission.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to create a Baseline Care Plan (Plan that includes the instructions needed to provide effective and person-centered care upon admission) with interventions (actions required by staff to assist resident) within 48 hours of admission for 1 (R #169) of 2 (R #169 and R #217) residents sampled for Baseline Care Plans. This deficient practice could likely result in the resident not receiving the appropriate care and services and may place the resident at risk of an adverse event (An event, preventable or nonpreventable, that caused harm to a patient as a result of medical care or lack of medical care) that could occur after admission. The findings are: A. Record review of R #169's Electronic Medical Record revealed that R #169 was admitted on [DATE]. B. Record review of R #169's revealed Nurse Note 03/02/23 1:00 PM Resident seemed confused and kept asking if there was anything he could do to get out of the facility. Resident not sure why he is here…

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 residents receive treatment and care in accordance with professional standards of practice for 1 (R #44) of 1 (R #44) resident reviewed for insulin (hormone which regulates the amount of glucose in the blood used to treat diabetes) administration. This deficient practice could likely result in residents not receiving the appropriate care for current diagnosis, correct medication and exposes residents to a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: A. On 04/04/23 at 8:50 AM, during observation of medication pass, RN #2 administered insulin Lispro (fast-acting medication used to help lower the blood sugar) 10 units (dosage of medication in units) to R #44. B. On 04/04/23 at 8:53 AM, during observation of medication pass, RN #2 used the insulin Lispro pen (medication in a pen like device that can be easily measured and administered) that was labeled for R #23. C. On 04/05/23 at 5:26 pm, during an interview, the DON confirmed that medications are not to be shared…

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

Based on record review and interview the facility failed to ensure that psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) were not given as PRN (as needed) for more than 14 days for 1 (R #42) of 5 (R #9, R #30, R #41, R #42, and R #64) residents sampled for unnecessary medications, when they failed to discontinue or reevaluate the need for continued use of psychotropic medication. This deficient practice could likely result in residents receiving medications for longer than needed. The findings are: A. Record review of pharmacy Consultation Report dated 02/19/23 revealed (name of R #42) has a PRN order for an anxiolytic (medication used to treat anxiety), which has been in place longer than 14 days without a stop date. If the medication cannot be discontinued at this time, please document the indication for use, the intended duration of therapy and the rationale for the extended period of time. B. Review of R #42's Physician's orders revealed: 1. Order start date 01/31/23 Lorazepam (medication that affects a person's mental state…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident was receiving restorative rehabilitation (focuses on maximizing an optimal level of functioning, enabling clients to regain/retain their independence following the debilitating effects of illness or injury.) services as ordered by the physician for 1 (R #40) of 1 (R #40) resident reviewed for rehab services. This deficient practice is likely to result in a decrease in residents functional mobility. The findings are: A. On 03/27/23 at 3:24 PM during an interview, R #40 reported that his therapy was stopped and he does not have anyone working with his Range of Motion (ROM) and would like to continue therapy. B. Record review of R #40's Occupational Therapy Discharge summary dated [DATE] revealed: 1. Destination: Long term care setting 2. Discharge reason: Highest Practical Level achieved (the setting in which an individual needs medical or long-term care services.) C. Record review of R #40's Orders revealed: 1. On 09/15/2020 Restorative…

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.