Bear Canyon Rehabilitation Center

Based on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of at least 12 hours per year for 4 (CNAs #4, #5, #6, and #7) of 5 (CNAs #3, #4, #5, #6, and #7) CNAs randomly reviewed for required in-service training. This deficient practice is likely to result in the nurses aides not receiving the necessary training to meet the care needs of the residents. The findings are: A. Record review of the facility's employee training transcripts, dated 01/01/24 through 12/31/24, revealed the following: - CNA #4 completed 6.33 hours of training. - CNA #5 completed 6.30 hours of training. - CNA #6 completed 1.22 hours of training. - CNA #7 completed 1.38 hours of training. B. On 02/06/25 at 10:56 am, during an interview with the Director of Nursing (DON), the DON stated CNA #4, CNA #5, CNA #6, and CNA #7 did not have any other trainings during the last 12 months. She stated she was aware the CNAs did not meet the annual 12 hour training requirement.

Based on record review and interview, the facility failed to ensure residents or their guardians were aware of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #70) of 3 (R #31, R #58 and R #70) residents reviewed for unnecessary medications. If the residents or their guardians are not informed of the risks and benefits of the medication, they are not able to make informed decisions. The findings are: A. Record review of R #70's physician's orders revealed the following: - An order for buspirone HCI oral tablet (antianxiety medication), 5 milligrams (mg.) Give one tablet by mouth two times a day for anxiety/depression. Start date: 07/13/24. - An order for citalopram hydrobromide oral tablet (antidepressant medication) 10 mg. Give two tablets by mouth one time a day for depression, crying, wandering into other resident rooms, inability to redirect, hitting staff, and screaming. Start date: 01/11/24. B. Record review of R #70's medical record revealed the record did not contain a consent form from the resident/responsible party…

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 resident's current advance directive (a document which provides an individual's wishes for emergency and lifesaving care) was properly documented for 1 (R #16) of 1 (R #16) resident reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures. The findings are: A. Record review of R #16's face sheet revealed R #16 was admitted into the facility on [DATE]. B. Record review of R #16's facesheet, dated [DATE], revealed R #16's advanced directive was Full Code (desired life saving procedures, such ascardiopulmonary resuscitation (CPR)). C. Record review of R #16's physician orders, dated [DATE], revealed R #16 chose Do Not Resuscitate [DNR; does not want to have CPR attempted on them if their heart or breathing stops] for her advanced directive code status. D. On [DATE] at 1:05 PM during an interview with the Director of Nursing (DON), she stated R #16's code status should be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) for 1(R #42) of 3 (R #31, R #42 and R #58) residents reviewed for accuracy of assessments. If the MDS assessment is inaccurate, then residents are likely to not receive the services they need. The findings are: A. Record review of R #42's face sheet, dated 10/23/24, revealed an initial admission with the following diagnoses: - Cerebral palsy (group of conditions that affect movement, and posture caused by brain damage before birth), - Muscle weakness, - Lack of coordination, - Difficulty in walking, - Sequelae of cerebral infarction (long term effects and complications that can occur after a stroke), - Iron insufficiency anemia (when there is not enough iron in the blood), - Reduced mobility, - Peripheral vascular disease (PVD; disorder that causes abnormal narrowing of arteries). B. Record review of R #42's hospital discharge orders,…

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 create an accurate Baseline Care Plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) for 1 (R #42) of 3 (R #31, R #42 and R #58) residents reviewed for Baseline Care Plans. This deficient practice could likely result in a decline in the residents' health due to staff not being aware of the residents' needs and residents not able to attain or maintain their highest practical level of well-being. The findings are: A. Record review of R #42's face sheet, dated 10/23/24, revealed an initial admission with the following diagnoses: - Cerebral palsy (group of conditions that affect movement, and posture caused by brain damage before birth), - Muscle weakness, - Lack of coordination, - Difficulty in walking, - Sequelae of cerebral infarction (long term effects and complications that can occur after a stroke), - Abnormalities of gait and mobility, - Reduced mobility - Iron deficiency anemia (low iron levels in the blood), - Peripheral vascular disease…

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 complete staff competencies for 2 (Certified Nursing Assistants (CNA) #6, and CNA #7) of 5 (CNA #4, CNA #5, CNA #6, CNA #7, and CNA #8) CNAs sampled for annual training. This deficient practice could likely result in staff being undertrained and providing inadequate care. The findings are: A. Record review of the facility's employee competencies revealed CNA #6 and CNA #7 did not have a competency assessment (an evaluation of skills, knowledge, and core abilities required for fulfilling job duties) completed during the last twelve months. B. On 02/06/25 at 10:56 am, during an interview with the Director of Nursing (DON), she stated she did not have any documentation to show competency assessments were completed for CNA #6 and CNA #7 during the last twelve months. C. On 02/06/25 at 11:32 am, during an interview with the Educator, she stated staff competency assessments should be completed yearly in order to identify what trainings staff need. She could not state if all of the staff had a competency assessment completed 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 and interview, the facility failed to ensure the resident's medication regimen was free from unnecessary medications for 1 (R #104) of 1 (R #104) residents, when the attending physician: - Did not provide clinical basis when he disagreed with the facility's pharmacist consultant's recommendation on R #104's Medication Regimen Review (MMR), - Did not document in R #104's medical record the action he took to address the recommended medication dose reduction. This deficient practice is likely to cause R #104's medication regimen to not be properly evaluated resulting in a possible over medication. The findings are: A. Record review of R #104's face sheet, dated 09/17/24, revealed R #104 was under psychiatric care (branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders.) B. Record review of R #104's physician orders revealed the following: - On 09/13/24, R #104's psychiatrist entered an order for quetiapine (an antipsychotic medication) 12.5 milligrams (mg) twice daily for depression (a mood 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.

Based on record review and interview, the facility failed to ensure the resident medication regimen was free from unnecessary medications for 1 (R #104) of 1 (R #104) resident, when R #104's hospice physician ordered an as needed (PRN) antipsychotic (a class of drugs that treat psychotic symptoms and disorders) medication without a 14 day stop date. This deficient practice is likely to cause R #104's medication regimen to not be properly evaluated and result in a possible over medication. The findings are: A. Record review of R #104's face sheet, dated 09/26/24, revealed R #104 was under hospice care. B. Record review of R #104's Hospice Physician order, dated 01/14/25, revealed an order to give haloperidol (antipsychotic medication) 2 milligrams (mg) every six hours PRN for agitation (a feeling of irritability, mental distress or severe restlessness). The hospice physician entered the stop date as indefinite. C. Record Review of R #104's Medication Regimen Review (MMR), dated 01/16/25, revealed the following: - The facility's Pharmacist Consultant recommended an evaluation of 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.

Based on observations, interviews, and record review, the facility failed to ensure nurses and Certified Medication Aids (CMAs) dated opened insulin glargine (a medication prescribed to help the body turn food into energy and manage blood sugar levels) pens and discarded glargine pens within 28 days of opening for 1 (R #19) of 1 (R #19) resident and to ensure medication carts were locked when unattended. These deficient practices are likely to result in R #19 receiving medications that are less effective or expired and is likely to negatively impact the health of residents on the 200 unit if they were to ingest (swallow) medications not intended for them. The findings for medication storage are: A. Record review of R #19's physician orders, dated 02/04/25, revealed R #19 received insulin glargine. B. Record review of the manufacturer's instructions for insulin glargine pens, dated 08/2022, revealed staff must throw away all opened pens after 28 days of first use, even if there was insulin left in the pen. C. On 02/04/25 at 1:47 pm, during an observation of the 600-hall 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 provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers for 1 (R #1) of 1 (R #1) residents reviewed for ADL care. This deficient practice is likely to negatively affect the dignity and health of the residents. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] and discharged on 10/17/24. B. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) indicated R #1 was dependent on staff assistance for showers. C. Record review of the facility's shower logs revealed the record did not contain shower sheets for R #1 for the months of September and October, 2024. D. On 11/14/24 at 9:35 am, during an interview, R #1's daughter stated R #1 had a series of falls at home and ended up in the trauma intensive care for 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.

Based on record review and interview, the facility failed to notify the family member/Power of Attorney (POA; a power of attorney grants, in writing, a particular agent the power to make healthcare decisions on another's behalf) for 1 (R #5) of 3 (R #5, #6 and #7) residents when a resident began to decline, consistently refuse medications, and was not eating or drinking. If the facility is not notifying the resident's POA when the resident has a change of condition, then the POA is unable to make decisions related to treatment and advocate for the resident's care. The findings are: A. Record review of a nursing progress note for R #5, dated 06/11/24, indicated the resident refused all the medications, and she kept saying, I don't want it. The resident put her hands against her face/mouth and pushed away the medications when when staff attempted to administered them. B. Record review of a nursing progress note for R #5, dated 06/11/24, revealed the facility nurse (unidentified) spoke with the hospice nurse and informed the hopsice nurse that R #5 spat out medications and experienced…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to provide adequate supervision for 1 (R #1) of 3 (R #1-3) residents reviewed for elopement (when a resident leaves the facility without the knowledge of the staff) risk when R #1 was not adequately assessed for risk for elopement. If the facility fails to properly assess and supervise residents then serious injury is likely to occur. The findings are: A. Record review of R #1's hospital Discharge summary, dated [DATE], revealed R #1 was admitted to hospital and treated for a broken leg. He was also treated for a urinary tract infection, and he had symptoms of alcohol withdrawal which was treated with benzodiazepines (anti-anxiety medication) and vitamins. At the time of hospital discharge (01/09/24), R #1 walked with assistance. B. Record review of R #1's face sheet identified R #1 was admitted to the facility on [DATE]. B. Record review of R #1's Elopement Risk Assessment, dated 01/10/24, revealed R #1 ambulated (walked) or self-propelled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to develop a comprehensive care plan for 2 (R #3 and R #6) of 4 (R #3, #5, #6, and #7) residents sampled for Foley catheters (a flexible tube inserted into the bladder and anchored by a balloon to allow the free flow of urine into an attached bag). This deficient practice could likely result in residents not receiving the care they need for maintaining good catheter care. The findings are: A. Record review of the face sheet for R #3 indicated the following: R #3 was admitted on [DATE] with a diagnosis of urinary tract infection (UTI), acute and chronic respiratory failure with hypoxia (serious condition that affects the oxygen levels in the blood and can damage vital organs), sepsis (a serious condition in which the body responds improperly to an infection), pneumonia (inflammatory/infection of the lungs), feeding tube (medical device to provide nutrition to people who cannot obtain nutrition by mouth) and cellulitis (serious bacterial…

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 meet professional standards of quality by not maintaining accurate weights for 3 (R #3, #6 and #9) of 3 (R #3, #6 and #9) residents sampled for feeding tubes (medical device used to provide nutrition) and nutrition. This deficient practice could likely result in resident nutrition or urinary retention not to be accurately assessed, causing a potential in unidentified medical issues or weight gain or weight loss. The findings are: Resident #3 A. Record review of the face sheet in the medical record for R#3 indicated resident was admitted on [DATE] with a feeding tube. B. Record review of the physician orders dated 10/24/23 indicated the following: weigh every day shift every Wednesday for four (4) weeks and every day shift for one (1) month starting on the 1st for five (5) days. C. Record review of the weights log in the medical record, dated 10/24/23 revealed that R #3 was admitted to the facility weighing 207.0 pounds. Resident was weighed again 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 observation, record review, and interview the facility failed provide quality care for Foley Catheters (a flexible tube inserted into the bladder and anchored by a balloon to allow the free flow of urine into an attached bag) for 3 (R #3, #6, and #7) of 4 (R #3, #5, #6, and #7) residents by not: 1. Monitoring for urinary outputs for R #3 to be able to identify urinary retention. 2. Emptying the catheter bag timely for R #6. 3. Not ensuring that a Foley catheter was hung in the right position so that urine could drain freely when R #7 was placed in his wheelchair. These deficient practices could likely result in a resident's catheter backing up and causing a (UTI) urinary tract infections (an infection in any part of the urinary system), and other disease; and by not monitoring urine output this could likely result in more serious medical issue such as urinary retention (difficulty urinating and emptying the bladder) to go unidentified. The findings are: Resident #3 A. Record review of the face sheet for…

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

Based on observation, record review, and interview, the facility failed to provide sufficient nursing staff to: 1. Assist residents in getting dressed to go eat in the dining room; 2. Assist residents to shower and; 3. Provide formal/structured restorative nursing services. These deficient practices may affect all 140 residents listed on the census that was provided by the facility on 10/04/23 as it could likely result in 1. Residents feeling frustrated as they cannot honor their preference of eating in the dining room; 2. Residents feeling uncomfortable as they cannot bath on a regular basis; and 3. Residents experiencing poor quality of life due to not receiving restorative needs/services and having to wait for care while restorative services were being provided to others. The findings are: Dining findings: A. On 10/04/23 at 12:28 pm, during a lunch observation, a total of eight (8) residents attended lunch in the dining room. B. On 10/05/23 at 8:28 am, during an interview, R #85 explained We [residents] were not going to the dining room because they [staff] couldn't serve us.…

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 observations and interviews the facility failed to: 1. Ensure that opened and accessed (has been opened and used) insulin flex pens were dated as to when they were initially opened by nursing staff. 2. Ensure that expired medications were not stored with unexpired medications. 3. Ensure that expired supplies were not stored with unexpired supplies in the storage room. 4. Document the daily medication refrigerator internal temperatures and daily medication storage room temperatures. These deficient practices are likely to result in 144 residents that were identified on the census list provided by the Centers Executive Director (CNE) on 10/04/23, to receive expired or improperly temperature-controlled medications that have either lost their potency, or effectiveness. The Findings are: Findings related to Insulin flex pen: A. On 10/04/23 at 8:09 am, an observation of the 300-hall medication cart revealed: 1. One Insulin Glargine (a long-acting type of insulin) flex pen (prefilled with insulin you do not have to load it) for R #10. This flex pen showed there were 180 units left…

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: 1. Discard fresh produce that was older than seven (7) days; 2. Document a date on prepared food; 3. Place a splash guard on the bottom shelf of a wire rack; 4. Measure the temperature of prepped food before serving. These deficient practices have the potential to affect all 144 residents listed on the census that was provided by the facility on 10/04/23. This deficient practice could likely lead to a forborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in residents if food and equipment are not being stored properly. The findings are: A. On 10/04/23 at 8:06 am, during an initial tour of the kitchen, revealed the following: -Walk-in fridge: 1. Mushrooms- receive date 09/18/23, observed to be dark and slimy 2. Jalapenos- receive date 09/13/23, observed to have black spots 3. Meat sauce- not dated 4. Pork roast- not dated -Food prep area: 1. Pots and pans stored on bottom rack of shelving unit without a splash guard on bottom rack B. On 10/04/23 at 8:26 am, 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 observation, record review and interview, the facility failed to maintain proper infection prevention measures by: 1. Performing hand hygiene between residents. This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between the residents all 144 as produced on 10/04/23 by the Center Executive Director, and/or staff. The findings are: Findings for performing hand hygiene A. Record review of the facility's policy on infection control hand hygiene titled, Hand Hygiene, revised date 05/01/23, revealed, Adherence to hand hygiene practices is maintained by all Center personnel. Purpose: To improve hand hygiene and reduce transmission of pathogenic microorganisms (bacterium, virus, or other microorganisms). Process:1. Perform hand hygiene. 1.1 Before patient/resident (hereinafter patient) care; 1.4 After patient care; 1.5 After contact with the patient's environment. B. On 10/11/23 at 7:44 am, during an observation of Licensed Practical Nurse (LPN) #4, she failed to perform hand hygiene prior to putting on gloves to give an injection…

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

Based on interview, the facility failed to ensure staff implemented a comprehensive antibiotic stewardship program (The effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Improving antibiotic prescribing and use is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance). This deficient practice has the potential to affect all of the 144 residents identified on the census provided by the Executive Director (ED) on 10/04/23, and who might be placed on antibiotics, which could result in the inappropriate use of antibiotics and can lead to resistance of a multi-drug resistant organism. These findings are: A. On 10/05/23 at 12:13 pm, during an interview, the Director of Nursing (DON) stated the previous Infection Preventionist (IP) left the position on 09/29/23, and she was taking over the responsibilities until their replacement started. The DON stated she could not provide the antibiotic stewardship program documentation and folders, because she did 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.

Based on interview the facility failed to have a qualified, trained, or Certified Infection Preventionist. This deficient practice could likely to affect all 144 residents identified on the census provided by the Director of Nursing (DON) on 10/04/23. This deficient practice could likely result in residents being at greater risk of infectious disease. The findings are: A. On 10/05/23 at 12:13 pm, during an interview, Director of Nursing (DON) stated the last IP left the job on 09/29/23, and she was currently the IP. The DON said she did not have a current IP certification/license and neither did anyone else currently employed at the facility.

Based on observation, record review and interview, the facility failed to have the Interdisciplinary Team (IDT consists of a team professionals of various roles within the facility who review and determine resident needs and abilities) determine if residents could self-administer medication for 3 (R #15, R #43 and R #87) of 3 (R #15, R #43 and R #87) residents reviewed. If the facility is not assessing the residents to determine if a resident is capable of self-administering medications, then this deficient practice is likely to result in residents self-administering medications inappropriately and or incorrectly, likely causing harm. The findings are: Findings for R #43: A. On 10/04/23 at 11:20 am, during an observation in R #43's room revealed an inhaler Wixela (used to treat asthma) with 26 puffs left. R #43 refused to answer any questions regarding the inhaler on his bedside table. B. Record review of R #43's Physicians orders revealed R #43 did not have an order to self-administer Wixela medication. Findings for R #87 C. On 10/05/23 at 9: 08 am, during an observation in R #87's…

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

Based on observation, interview and record review, the facility failed to promote resident self determination through support of resident choice for 9 (R #s 2, 3, 20, 58, 85, 86, 94, 98, and 139) of 9 (R #s 2, 3, 20, 58, 85, 86, 94, 98, and 139) residents reviewed for preferences as indicated by: 1. Not having the dining room open for all three meals and 2. Not allowing a family member/Power of Attorney (POA) to make decisions about her husbands care. These deficient practices have the potential to affect residents who want to eat in the dining room and didn't allow the family member/POA to make decisions about her loved ones care. The findings are: Dining Services: A. On 10/04/23 at 8:06 am, during a breakfast observation, residents did not attend meal service in the dinning room. B. 10/04/23 at 8:26 am, during an interview, the Dietary Manager explained that lunch was the only meal where residents ate in the dining room. C. On 10/04/23 at 12:28 pm, during a lunch observation, a total of eight (8) unidentified residents attended meal service in the dining room. D. On 10/05/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to: 1. Update the EHR (Electronic Health Record) to match MOST forms (Medical Orders for Scope of Treatment- a type of advanced directive that indicates what type of care an individual would like to receive in the event that their heart stops beating) and; 2. Obtain an advanced directive (a written document indicating end-of-life preferences that are to be referred to if the individual becomes incapacitated (unable to make decisions on their own) for 6 (R #'s 13, 15, 27, 32, 39, and 242) of 6 (R #'s 13, 15, 27, 32, 39, and 242) residents reviewed for advanced directives. These deficient practices could likely result in a resident's wishes not being honored. Findings for R #13 A. Record review of R #13's MOST form, dated [DATE], indicated that R #13 to receive CPR (Cardiopulmonary Resuscitation - an emergency lifesaving procedure performed when the heart stops beating). B. Record review of R #13's dash board (header of EHR that constantly displays…

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 and implement a comprehensive person-centered care plan for 4 (R #15, R #74, R #114, R #242) of 4 (R #15, R #74, R #114, R #242) residents reviewed for Comprehensive Care Plans. Failure to develop a person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being. The findings are: R #15 A. Record review of R #15's Physician's Orders, dated 07/10/23, revealed oxygen at 2 liters per minute via nasal cannula (device to deliver air into the nose) continuously. B. Record review of R #15's care plan, dated 07/14/23, revealed staff did not careplan his oxygen. Findings for R #114 C. Record review of R #114's Electronic Health Record (EHR) revealed R #114 was admitted to the facility on [DATE]. D. Record review of R #114's physician orders revealed the following: 1. Physician order, dated 09/22/23, escitalopram Oxalate (a type 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 Based on record review and interview, the facility failed to provide care plan meetings on a quarterly basis for 2 (R #39 and R #85) of 2 (R #39 and R #85) residents reviewed for care plan meetings. This deficient practice could likely result in the lack of input from a resident regarding their care interventions and preferences. The findings are: Findings for R #39 A. On 10/04/23 at 3:16 pm, during an interview, R #39 confirmed he has not recently had a care plan meeting but would like to attend when invited. B. Record review of R #39's Electronic Health Record (EHR) revealed R #39 was admitted to the facility on [DATE]. C. Record review of R #39's MDS (Minimum Data Set- a collection of data that represents a resident's level of function and type of care provided), revealed quarterly assessments occurred on the following dates: 12/30/22, 03/30/23, 06/27/23, and 09/25/23. D. Record review of R #39's EHR revealed care plan meetings occurred on the following dates: 10/19/22 and 04/05/23. Findings for R #85 E. 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, record review, and interview, the facility failed to meet professional standards of care for 2 (R #15 and R #118) of 3 (R #15 and R #118) residents reviewed for respiratory care by: 1. Not properly dating the oxygen tubing and not dating the humidifier bottle (bottle of water that provides water to the oxygen to prevent the air from being too dry) for residents; These deficient practices could likely lead to respiratory infections by the oxygen tubing becoming clogged due to condensation (process where water vapor becomes liquid) or becoming dirty leading to the reduced flow of oxygen. The findings are: A. Record review of Genesis Healthcare Oxygen NC (nasal cannula - a small, flexible tubing that contains two open prongs that sit just inside the nostrils of the nose that delivers oxygen from the oxygen source) policy revised on 08/07/2023 states the following: Replace nasal cannula set up (NC and oxygen tubing) every seven days and note the date and time the oxygen was started. R #15: B. Record review of R #15's physician orders, dated 07/10/23, revealed R #15…

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 inquire about daily meal preferences for 6 (R #'s 2, 18, 26, 32, 68, and 85) of 6 (R #'s 2, 18, 26, 32, 68, and 85) residents reviewed for meal satisfaction. This deficient practice could likely result in residents feeling frustrated as they cannot make their own choice about their meal preference for the day. The findings are: A. On 10/04/23 at 11:29 am, during an interview, R #26 stated, The food is ok. I eat what they feed me. It doesn't matter. I don't get choices, they just feed me whatever they want. I don't have any choice. We used to get a menu with choices, but that stopped. B. On 10/04/23 at 11:38 am, during an interview, R #68 stated, Yes, the food is ok. They don't give me a choice. Sometimes if we don't like it, we get a peanut butter sandwich. We have to eat what they bring. C. On 10/04/23 12:11 pm, during an observation, R #32's tray arrived in her room with a turkey sandwich on wheat bread, ice cream, and a bag of chips. D. On 10/04/23 12:11 pm, during an interview, R #32 stated They never…

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 for 1 (R #104) of 1 (R #104) resident reviewed for dignity was not shaved as frequently as R #104 would like. This deficient practice could likely have caused the resident to not maintain her shaving preference. The findings are: A. On 10/04/23 at 7:45 am, observation was made of R #104 with very long chin hairs. B. On 10/05/23 at 7:58 am, observation of breakfast on the 100 unit revealed R #104 was in the same clothes as yesterday (10/04/23) and had very long chin hairs. C. On 10/05/23 at 8:42 am, during an interview, R #104 was asked if she would like to have her chin hair/whiskers shaved? R #104 indicated by touching her chin and stated that she would like for them to be gone. D. On 10/06/23 at 11:15 am, during an interview, Certified Nursing Assistant (CNA) #13 stated she gave R #104 a shower today but couldn't find a razor so R #104 didn't get shaved.

Based on record review and interview the facility failed to notify facility management (Center Executive Director (CED) and Director of Nursing (DON)), the facility physician, and the representative/Power of Attorney (POA) of a resident not returning to the facility after not returning from an offsite visit for 1 (R #141) of 1 (R #141) resident looked at for discharge. This deficient practice resulted in R #141 being discharged Aganist Medical Advice (AMA) with no information or follow up from the facility. The findings are: R #141 A. Record review of a nursing progress note dated 07/15/23 revealed that R #141 was oriented to person, place and time. B. Record review of the nursing progress notes, dated 07/31/23 at 17:21 (5:21 pm), revealed R #141 left out on pass and signed out at front desk. C. Record review of the resident's EHR indicated staff did not document the following when R #141 did not return to the facility: - Notification to the facility physician or on-call physician services. - Notification of the Center Executive Director (CED) or the Director of Nursing (DON). -…

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 safe, functional, and comfortable environment for 1 (R #118) of 1 (R #118) resident, as identified by the facility census provided by the Administrator on 10/04/23, by failing to maintain and repair a curtain railing system (a metal rail that is attached to the ceiling and allows a curtain give a patient privacy). This deficient practice is likely to affect their safety and psychosocial well being. The findings are: A. On 10/04/23 at 12:00 pm, while observing R #118's room, the curtain railing system was hanging from the ceiling tiles and three screws were not attached. The unattached screws caused 18 inches of the railing system to hang from the ceiling. B. On 10/04/23 at 12:00 pm, during an interview, R #118, stated the curtain railing has been hanging from the ceiling for a few weeks.

Based on observation, record review, and interview, the facility failed to provide an ongoing activity program to meet the resident's interests and support residents' psychosocial well-being for 1 (R #68) of 1 (R #68) resident reviewed for activities and during random observation. If the facility is not providing engaging activities to residents, then residents are at risk of boredom, depression, and decrease in actitivies that are important. The findings are Findings for R #68 A. On 10/04/23 at 2:18 pm, during an interview, R #68 stated, I want to go out and be outside, and I haven't been out in about a year. I just stay in my room. I do nothing. No one brings me anything, and I can't get out of bed myself. B. On 10/06/23 at 10:30 am, during an observation of R #68, she laid in bed. The resident stated she did not get to go outside. C. Record review of R #68's care plan, dated 8/09/22, identified: 1. Invite and encourage participation to activity of interest such as: Bingo/Uno games, Nail Care, Exercise, Time Outdoors, Pet Program, and a Tea Party (likes [NAME] Tea). 2. Invite to…

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

Based on record review and interview, the facility failed to provide quality care for 1 (R #6) of 1 (R #6) resident due to the facility not fixing or replacing the resident's wheelchair. This deficient practice could likely result in the resident not getting out of bed per her preference. The findings are: A. Record review of the nursing progress notes, dated 05/17/23, indicated the nurse and maintenance director went to look at resident's (R #6) wheel chair to see what could be done for fall/tipping prevention. Maintenance director stated that they could lower the back of the wheelchair wheels so the resident would be sitting slightly further back in wc (wheelchair). Resident was ok with trying this intervention. Resident stated, Anything you can do to help. Resident was pleased with plan of care. B. On 10/04/23 at 9:56 am, during an interview, R #6 stated her wheelchair does not fit her. Her feet do not touch the ground or the leg rests, and she flipped out of the first wheelchair they gave her. C. On 10/13/23 at 11:17 am, during an interview, R #6 stated her wheelchair is still…

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 manage pain for 1 (R #87) of 1 (R #87) residents reviewed for pain by not assessing for pain and providing pain treatment. This deficient practice could likely result in R #87 experiencing a significant (long) period of pain without sufficient relief for pain. The findings are: A. Record review of the R #87's admission record revealed she was admitted to the facility on [DATE] with the following diagnosis: Vertebrogenic Low back Pain (a type of chronic back pain caused by damage to the vertebral endplates), Heredity and Idiopathey Neuropathy (are two types of nerve disorders that affect the peripheral nervous system. Hereditary neuropathy is passed on genetically from parent to child, while idiopathic neuropathy has no apparent cause. Both types can affect the motor, sensory, and autonomic nerves, and cause similar symptoms), Unspecified, Osteoarthritis of knee (is a condition where the cartilage in the knee joint wears away causing pain,…

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 residents have the right to make treatment decisions based on their individuals needs and understanding for 2 (R #35 and R # 87) of 2 (R #35 and R #87) residents reviewed. This deficient practice could likely result in residents feeling anxious and unsupported and not receiving the treatment and services they need to attain or maintain their highest practicable physical, mental, and psychosocial (the minds ability to adjust and relate the body to its social environment) well-being. The findings are: Findings for R #35 N. Record review of R #35's EHR revealed the record did not contain a Psychotropic Administration Disclosure (a consent form that informs the residents of the risks and benefits of the antipsychotic medication) form. O. Record review of R #35's Physicians orders revealed: 1. Lorazepam (treatment for being anxious), oral tablet, 0.5 MG (milligram). Give 1 tablet by mouth every six (6) hours, as needed for anxiety for 14 days. Observe for restlessness, social withdrawal and isolation, irritability,…

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: 1. Administer medications as ordered by a physician and; 2. Notify the physician when a medication was not administered. This deficient practice was found to affect 1 (R #85) of 1 (R #85) resident reviewed for medication administration. This deficient practice could likely result in residents not feeling well due to the absence of a regularly administered medication. A. Record review of New Mexico complaint #69179, dated 09/07/23, revealed . they keep running out of her [R #85] meds [medications]. She goes two (2) or three (3) days without because they don't order. One is a blood thinner and the other is for cholesterol B. Record review of the Electronic Health Record (EHR) revealed that R #85 was admitted to the facility on [DATE] with the pertinent diagnoses of unspecified atrial fibrilation (an irregular and often very rapid heart rhythm) and hyperlipidemia (high amounts of fats in the blood). C. Record review of physician orders 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 store and serve food under sanitary conditions by not ensuring: 1. Food items stored in facilities refrigerators were labeled and dated, 2. Expired foods were disposed of, 3. Personal items and Personal Protective Equipment (PPE) were kept separate from food preparation, utensil and dining ware storage areas, and 4. Steeping tea was covered, labeled, and dated. These deficient practices are likely to affect all 118 residents, identified on Resident Census provided by the Center Executive Director on 07/27/22, residing at the home and could likely cause foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 07/27/22 at 8:58 AM during an initial brief tour of the facility's kitchen, several personal staff items were observed in the food preparation area. On the overhead ledge of the food preparation tables were a pair of Personal Protection Equipment eye goggles, a phone charger, and personal keys. Observed on the food preparation…

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 a resident was getting in and out of bed according to his preferences for 1 (R #113) of 1 (R #113) resident reviewed for choices. This deficient practice has the potential to prevent residents from attending social and religious activities, maintaining personal hygiene and skin health per their personal preference and could likely result in residents to suffer a decline in their social interactions, enjoying activities, decline in self-esteem and an increase of feelings of helplessness and depression. The findings are: R #113 A. Record review of R #113's face sheet revealed R #113 is diagnosed with the following conditions: paraneoplastic neuromyopathy (when cancer-fighting agents of the immune system also attack parts of the brain, spinal cord, peripheral nerves or muscle) and neuropathy (disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness); malignant melanoma (when the pigment-producing cells that give color to the skin become cancerous, the most…

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 revise the care plans for 2 (R #33 and 39) of 4 (R #33, 39, 66, and 105 ) residents reviewed for complete care plans. This deficient practice could likely result in the care plan not reflecting the resident's current goals and care needs and the facility not providing the appropriate care and treatment to ensure the resident gains or maintains their highest practicable level of well-being. The findings are: Finding for R #33 A. Record review of face sheet for R #33 revealed R #33 had been admitted on [DATE] with diagnosis that included, Schizophrenia [chronic and severe mental disorder that affects how a person thinks, feels, and behaves] and left above knee amputation. B. Record review of Recreation/Activity Department care plan from her admission date (02/22/20) until 07/27/22, for R #33 revealed, care plan section was initiated on 02/24/20 for the following interventions: a. I prefer to dine in my bedroom b. I like to get up in the morning between 7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to provide for all the needed hygiene and grooming for 3 (R #'s 33, 86, and 113) of 3 ( R #'s 33, 86, and 113) residents noted to have unclean hair, skin, teeth or overly long finger/toe nails. This deficient practice may likely lead to residents affected feeling uncomfortable as well as put them at increased risk for failing to maintain their optimal levels of well being. The findings are: Findings for R #33: A. Record review of face sheet revealed R #33 was admitted on [DATE] with diagnosis of above the knee amputation on the left side as well as obesity. B. On 07/27/22 at 10:00 am, during observation, R #33's toenails on her right foot are 1 to 1.5 centimeters long. C. On 07/29/22 at 8:32 am, during an interview R #33 revealed that a Podiatrist [doctor who works on feet] needs to come and trim her nails but, that hasn't happened in, a long time. D. On 0729/22 at 8:35 am, during an interview with Certified Nursing Aide (CNA) #3 confirmed 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, observation, and interview the facility failed to ensure treatment or services that met that resident's needs in accordance with accepted professional standards for 4 (R #'s 39, 97, 105 and 118) of 4 (R #'s 39, 97, 105 and 118) residents by: 1. The Hospice company lack of communication and documentation to the facility for R #97 2. Not administering timely and documenting accurately medications and nutritional feedings prescribed for R #118. 3. Providing oxygen therapy for residents with no order for the oxygen supplementation as well as failing to change the oxygen tubing and humidifier bottles timely for R #'s 39 and 105. These deficient practices may likely result in residents affected failing to achieve their highest practicable level of well-being. The findings are: Findings for R #118: A. Record review of face sheet revealed R #118 was originally admitted on [DATE] and most recently readmitted on [DATE] with primary diagnosis of quadriplegia [loss of muscle and sometimes sensation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain a process that would allow residents to receive outside appointments timely for 2 (R #'s 8 and 61) of 2 (R #'s 8 and 61) residents who revealed they needed vision services. This deficient practices may likely result in residents not receiving the specialized medical attention needed to address deficits in visual abilities and in failure to maintain or achieve their highest practicable level of well being. The findings are: Findings for R #61: A. Record review of face sheet revealed R #61 was originally admitted on [DATE] and readmitted on [DATE] with a primary diagnosis of, anemia [ lower-than-normal number of red blood cells or quantity of hemoglobin {a protein carried on red blood cells containing iron}] and a secondary diagnosis of, unspecified sequelae [a condition that is a result of a disease] of cerebral infarction [a stroke] . B. On 07/28/22 at 2:15 pm, during an interview with R #61 he revealed, A few weeks ago my right…

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 monitor and treat pressure ulcers (areas of damaged skin caused by pressure, shear or friction) for 1 (R #121) of 4 (R #s 61, 65, 66, and 121) residents reviewed for pressure ulcers. This deficient practice caused a delay in wound care treatment and could likely have contributed to resident being discharged to the hospital with a possible infection. The findings are: Resident #121 A. Record review of R #121's medical record indicated that R #121 was admitted on [DATE] and was discharged to the hospital on [DATE]. R #121 was admitted with a diagnosis of Anoxic brain damage (brain damage caused by a lack of oxygen to the brain),Tracheotomy (a cut or opening is made in the windpipe (trachea) to assist with breathing), Gastrostomy (procedure in which a gastrostomy tube is placed into your stomach for nutritional support), Pressure ulcers to the sacrum stage 4 (the sore is deep and big skin be black with signs of infection, you may be able to see tendons,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure that resident's received restorative [a nursing service that often follows rehabilitation services in nursing homes with the goal to maximize function and prevent functional decline in residents dependent on others for certain actions] treatment and services to optimize their well-being for 3 (R #'s 33, 61 and 86) of 5 (R #'s 33, 39, 61, 86 and 118) residents reviewed for restorative services by failing to provide: 1. Assistance to ambulate [walk] for R #61 2. Range of motion for dependent residents for R #'s 33 and 86. This deficient practice may likely result in decreased mobility or a decrease in the function in joints that can cause a loss of independence and sometimes pain for any resident affected. The findings are: Findings for R #61: A. Record review of face sheet for R #61 revealed, R #61 was originally admitted on [DATE] and readmitted on [DATE] with a primary diagnosis of, anemia [lower-than-normal number of red 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 observation, record review, and interview, the facility failed to maintain a hazard free environment for 3 (R #'s 26, 72, and 89) of 3 (R #'s 26, 72 and 89) residents reviewed for: 1. Placement of fall mat when R #'s 26 and 72 are out of bed, and 2. Resident positioning in bed and bed height for R #89. These deficient practices could likely result in an increased risk for an avoidable fall The findings are: Findings for R #26: A. On 07/28/22 at 2:08 pm, during an observation, R #26 was observed to be sitting in his wheel chair in his room next to his bed. The fall mat was observed to be on the floor next to his bed. B. Record review of the EHR (Electronic Health Record) revealed that R #26 was admitted to the facility on [DATE] with a pertinent diagnosis of dementia (a chronic or persistent disorder of the mental processes resulting in memory disorders, personality changes, and impaired reasoning) without behavioral disturbance. C. Record review of the Care Plan for R #26 revealed that R #26 requires…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to provide all care needed to prevent complications with use of Gastrostomy tubes [G-tube, tube through the abdomen wall and into the stomach used for people who cannot swallow safely] for 2 (R #'s 86 and 118) of 3 (R #'s 39, 86 and 118) residents by: 1. Not flushing the G-tube with water to clear contents when nutritional supplement discontinued for multiple hours for 2 (R #'s 86 and 118) 2. Flushing the G-tube with more water than ordered for 1 (R #86) which may likely result in an overfilled stomach and regurgitation [stomach contents being brought back up to the mouth]. These failed practices may likely result in clogged/obstructed gastrostomy tube or resident inhalation [breathing in] of stomach contents into the lungs which can cause Pneumonia [an infection in the lung] . The findings are: A. Record review, in pertinent part of, https://static.abbottnutrition.com/cms-prod/abbottnutrition-2016.com/img/M4619.005%20Tube%20 Feeding%20…

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 maintain a process that would allow each resident the opportunity to have a physician visit for 3 (R #'s 2, 15, and 57) of 3 (R #'s 2, 15, and 57) residents reviewed for frequency of physician visits. This deficient practice could likely result in an undiagnosed illness or an unaddress concerns. The findings are: Findings for R #2: A. On 07/27/22 at 3:35 pm, during an interview, R #2 stated I need to see the doctor B. Record review of the EHR (Electronic Health Record) revealed that R #2 was admitted to the facility on [DATE]. C. Record review of physician notes revealed that R #2 was seen by a physician on the following date for the following reasons: 01/03/22- progress note for wound to upper arm, 05/25/22- progress note for redness in groin area and wound on sacrum. Findings for R #15 D. Record review of the EHR, revealed that R #15 was admitted to the facility on [DATE]. E. Record review of physician notes revealed that R #15 was seen on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed 5% by failing to: 1. Give correct medication to R #118 2. Give a short acting muscle relaxant timely to R #118 for 1 (R #118) of 8 (R #'s 36, 39, 86, 103, 110, 118, 220, and 221] residents reviewed for medication administration. This resulted in two errors out of 27 opportunities for error and an error rate of 7.41%. If medications are not administered as ordered, residents are likely to experience an exacerbation [sudden worsening] of symptoms that the medication was ordered for to prevent, relieve, or decrease symptoms. The findings are: A. Record review of face sheet for R #118 revealed he was originally admitted on [DATE] and most recently readmitted on [DATE] with primary diagnosis of quadriplegia [loss of muscle and sometimes sensation in both arm and both legs] and Traumatic Brain Injury (TBI) [head injury causing damage to the brain from some external force]. B. Record review 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, interview, and record review, the facility failed to adhere to a process that would allow residents the ability to communicate for 1 [R #8] of 3 [R #'s 2, 8, and 80] residents reviewed for call light accessibility. This deficient practice could likely result in residents not receiving the help they need or developing feelings of frustration. The findings are: A. On 07/27/22 at 10:25 am, during an interview with R #8, when asked if he is able to reach his call light, he explained No, it is against the wall. I get on the floor to get to the call light button. B. On 07/27/22 at 10:25 am, during an observation, the bed is placed about 12 inches away from the wall. On the wall, above the bed, is an overhead lamp. The overhead lamp has a string attached to it to turn the light on or off. The call light button is attached to the string for the overhead lamp. Both strings hang directly behind the headboard of the bed. C. On 07/28/22 at 10:13 am, during an interview, R #8 stated, Maintenance was in here yesterday working on the light. D. On 07/28/22 at 10:13 am, during…

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 ensure a resident was treated with respect and dignity for 1 (R #118) of 1 (R #118) resident reviewed for dignity by not dressing a resident daily. This deficient practice could likely result in the resident becoming depressed, anxious, feeling of hopelessness and lacking self-worth. The findings are: Findings for R #118: A. Record review of R #118's face sheet revealed the following diagnoses for R #118: quadriplegia, C5-C7, incomplete (incomplete paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs and torso, due to spinal cord injury between the fifth and seventh cervical vertebra of the spine) personal history of traumatic brain injury, and major depressive disorder recurrent, mild (a mood disorder that causes a persistent feeling of sadness and loss of interest and is classified by the types of symptoms experienced, their severity, and how often they occur). These diagnoses are not comprehensive and does not include all of R #118's diagnoses. B. 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 interview and record review the facility failed to document in the resident record for 1 (R #120) of 1 (R #120) residents reviewed for available pertinent information about their discharge. This deficient practice could likely cause an unsafe discharge to the resident due to a lack of information or documentation on where the resident discharged to. The findings are: Resident #120 A. Record review of R #120's medical record indicated that R #120 was admitted on [DATE] and discharged on 05/20/22. There is no indication in the medical record if R #120 discharged to the hospital, was discharged AMA (against medical advice), was discharged home, or went to a different facility. B. On 08/01/22 at 1:25 pm, during an interview with the Social Services Director (SSD), she stated that she doesn't know much about R #120. The SSD looked up a note that had been made for R #120 and stated that she wasn't clear, but from a grievance that R #120's wife called about, he likely left AMA, or could have gone 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 develop a baseline care plan within 48 hours that would provide information about the residents care and needs upon admission for 1 (R #121) of 2 (R #'s 112 and 121) residents reviewed for baseline care plans. This deficient practice could likely result in needed care not being delivered and any resident affected failing to achieve or maintain their highest level of well-being. The findings are: Resident #121 A. Record review of R #121's medical record indicated that R #121 was admitted on [DATE] and was discharged to the hospital on [DATE]. R #121 was admitted with diagnosis of Anoxic brain damage (brain damage caused by a lack of oxygen to the brain). Tracheotomy (a cut or opening is made in the windpipe (trachea) to assist with breathing). Gastrostomy (procedure in which a gastrostomy tube is placed into your stomach for nutritional support). Pressure ulcers to the sacrum stage 4 (the sore is deep, you may be able to see tendons, muscles, and bone).…

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 change the urine collection bag as required for 1 (R #37) of 1 (R #37) resident reviewed for incontinence care was noted to be incontinent of urine [the involuntary loss of urine] and required the use of a urine catheter (a thin, sterile tube inserted into the bladder to drain urine-the urine drains through the catheter tube into a bag, which is emptied when full). This deficient practice may likely result in a resident being at increased risk for Urinary Tract Infection (UTI), avoiding social situations, having feelings of embarrassment, shame, and frustration. The findings are: A. A record review of R #37's face sheet revealed the following diagnoses: urinary tract infection site, not specified; paraplegia, unspecified; and neuromuscular dysfunction of bladder, unspecified (when a person lacks bladder control due to brain, spinal cord or nerve problems). B. On 07/28/22 on 1:36 PM, during an observation and an interview, R #37 stated she has been having problems with her urine collection bag being emptied. She reported it…

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 follow through with a needed dental appointment for 1 (R #13) of 1 ( R #13) resident reviewed for dental care. This deficient practice could cause residents to avoid eating causing weight loss and could also cause untreated dental issues to become infected causing further complications with the residents health. The findings are: A. On 07/27/22 at 2:35 pm, during an interview with R #13 she stated that her teeth were a mess and needed to see a dentist. She stated that everyone knows about her wanting to see a dentist it had been discussed. B. Record review of R #13's medical chart did not reveal any dental appointments. C. Record review of a summary of a care planning meeting that was held on 05/11/22 at 13:08 (1:08 pm) indicated that during that meeting it was established that R #13 wanted a dental referral to be made. D. On 08/01/22 at 1:30 pm, during an interview with Social Services Assistant (SSA), she stated that she would look to see if there was an appointment scheduled. She stated that the last time R #13 had an…

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