Clovis Healthcare and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 6 (R #3, R #4, R #7, R #24, R #27 and R #48) of 9 (R #1, R #3, R #4, R #5, R #7, R #9, R #24, R #27 and R #48) residents reviewed when staff failed to:1. Revise R #3's care plan to include use of psychotropic drugs (drugs that affect a person's mental state),2. Update R#4's care plan to remove the use of Voltaren (medication used for pain),3. Revise R#7's care plan to include appropriate interventions for falls.4. Revise R #24's discharge goals in the care plan to include current discharge goals. 5. Revise R #27's care plan to include the current size of bed rails.6. Revise R#48's care plan to remove the use of a wander guard (wearable device that tracks movement.)These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are:R#3A. Record review of R #3's admission Record revealed R #3 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 observation, record review, and interview, the facility failed to obtain physician orders and informed consent prior to installation of bed rails for 2 (R # 3 and R #5) of 5 (R #3, R #5, R #9, R #27 and R #60) resident reviewed for accidents. This deficient practice could result in the physician and the resident not knowing the needs, risks and benefit of bed rails. The findings are:R #3A. Record review of R #3 admission Record revealed R #3 was admitted to the facility on [DATE], with the following diagnoses:1. Spondylolysis (a stress fracture in a small bone), cervical region (neck area of the spine),2. Osteoarthritis (degenerative joint disease where the protective cartilage cushioning your bones wears down over time),3. Reduced Mobility (movement is limited), 4. Muscle weakness,5. Paraplegia (paralysis affecting the lower half of the body).B. Record review of R #3's bed rail assessment dated [DATE] revealed a recommendation for quarter size bed rails on the left and right upper sides of the bed.C.…

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 each resident's drug regimen was free from unnecessary drugs by ensuring medications have an adequate indication of use and ensuring indication of use is based off of the residents' current diagnosis for 5 (R #1, R #3, R #5, R #9, and R #60) of 7 (R #1, R #3, R #5, R #9, R #11, R #40 and R #60) residents reviewed for unnecessary medications. This deficient practice could likely lead to adverse drug effects and poor patient outcomes. The findings are:R #1A. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE] with the following diagnoses:1. Chronic obstructive pulmonary disease (COPD; progressive lung disease that makes it difficult to breathe, irreversible damage to the lungs and airways).2. Hypertension (high blood pressure)3. Hyperlipidemia (high cholesterol)B. Record review of R #1's physician records revealed an order for Aspirin oral tablet 81 milligrams (MG). Give 1 tablet by mouth one time a 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 ensure the medical records contained documentation that each resident received, or was offered the COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccinations (treatment with a vaccine to produce immunity to a particular infections disease or pathogen) for 2 (R #4 and R #5) of 5 (R #3, R #4, R #5, R #8, and R #40) residents reviewed for immunizations. This deficient practice could likely result in residents not having the knowledge or opportunity to get needed vaccinations. The findings are:R #4A. Record review of R #4's admission record revealed R #4 was admitted to the facility on [DATE]. B. Record review of R #4's Electronic Health Record (EHR) revealed R #4 did not receive or was offer the COVID vaccination. R #5C. Record review of R #5's admission record revealed 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 record review and interview, the facility failed to provide a Facility Initiated Report (mandatory self-initiated facility report of an incident) and a five day follow up report to the State Survey Agency (SSA) for 1(R#7) of 1 (R #7) resident reviewed for incidents when staff failed to report the following incidents:1) Unwitnessed fall with injury for R #7.2) Injury of left hand for R #7 within two hours of becoming aware of the injuries.This deficient practice is likely to result in the State Survey Agency (SSA) not being aware of facility incidents and being unable to assure residents safety. The findings are:A. Record review of R #7's nursing documentation, dated 09/16/25 at 6:13 am, revealed R #7 reported falling into wheelchair. Noted swelling, mild deformity (a minor physical abnormality in the shape, size, or alignment of a body part), bruising, pain rated 6/10 (pain scale; a rating zero to ten where zero is no pain and ten is the worst pain possible) to left hand.B. Record review of the facility's complaint intake report dated 10/10/25 revealed R #7 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 1 (R #8) of 1 (R #8) resident reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met. The findings are:A. Record review of R #8's admission Record revealed R #8 was admitted to the facility on [DATE] with the following diagnoses:1. Adult failure to thrive (a syndrome that describes a decline characterized by weight loss, decreased appetite, poor nutrition, inactivity and often accompanied by dehydration, depressive symptoms, and impaired immune function, among others.),2. Chronic heart failure (a long-term condition where the heart muscle becomes too weak or stiff to pump enough blood to meet the body's needs),3. Need for assistance with personal care. B. Record review of R #8's MDS assessment dated [DATE], section H revealed R #8 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to create a 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 #67) of 1 (R #67) resident 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 #67's admission Record revealed R #67 was admitted to the facility on [DATE] with the following diagnoses:1. Partial intestinal obstruction (a person's intestines are impacted with stool), 2. Essential hypertension (HTN; high blood pressure),3. Colostomy [a surgical procedure in which the colon is connected to the abdominal wall 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 observation, record review, and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 1 (R #8) of 3 (R #8, R #12, and R #25) residents reviewed for care plans when staff failed to include R #8's use of an external catheter (external catheter (a non-invasive medical device used to collect urine from outside the body) and interventions needed to care for R #8 and the external catheter. This deficient practice could likely result in an increase in infections and other health concerns. The findings are: A. Record review of R #8's admission Record revealed R #8 was admitted to the facility on [DATE] with the following diagnoses:1. Adult failure to thrive (a syndrome that describes a decline characterized by weight loss, decreased appetite, poor nutrition, inactivity and often accompanied by dehydration, depressive symptoms, and impaired immune function, among others.),2. Chronic heart failure (a long-term condition where the heart muscle becomes too weak or stiff 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 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, transfers, toileting, and eating) assistance for transfers (assisting a resident from one place such as a bed to another place such as a wheelchair) for 1 (R #50) of 3 (R #27, R #50, and R #60) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are:A. Record review of R #50's admission record revealed R #50 was admitted to the facility on [DATE] with the following diagnoses:1. Acute respiratory failure with hypoxia (a medical condition where a sudden decrease in oxygen levels in the blood is due to the lungs' inability to exchange gases), 2. Morbid (severe) obesity, 3. Chronic obstructive pulmonary disease (COPD; lung disease). B. Record review of R #50's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure a resident with an external catheter (a non-invasive device worn over the genitals) had an order that demonstrated that a catheter was necessary, what type of catheter was needed, and how to care for the catheter for 1 (R #8) of 1 (R #8) resident reviewed for catheter use. This deficient practice could likely result in an increased and unnecessary risk of infections for residents. The findings are: A. Record review of R #8's admission Record revealed R #8 was admitted to the facility on [DATE] with the following diagnoses:1. Adult failure to thrive (a syndrome that describes a decline characterized by weight loss, decreased appetite, poor nutrition, inactivity and often accompanied by dehydration, depressive symptoms, and impaired immune function, among others.),2. Chronic heart failure (a long-term condition where the heart muscle becomes too weak or stiff to pump enough blood to meet the body's needs),3. Need for assistance with…

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

Based on observation, record review, and interview, the facility failed to maintain appropriate staffing levels to meet the needs of the 1 (R #8) of 2 (R #8 and R #27) residents reviewed for staffing. This deficient practice could likely result in residents not receiving the care and service needed while in the facility. The findings are: A. Record review of facility PPD (per patient day; staffing ratio posted daily) log revealed a staffing ratio of 2.32 (a calculation of staff hours based on the number of residents in the facility; standard average ratio is 2.5 to 3.48) on 11/24/25. Cross reference tag F-690

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medical records were updated and accurate for 1 (R 48) of 1(R 48) resident reviewed, when the facility failed to document an admit to Hospice (palliative and supportive services to meet the physical, psychological, social, and spiritual needs of terminally ill residents).order upon admission to facility.This deficient practice is likely to result in residents having an inaccurate medical record, which could result in the residents receiving less than optimal care and treatment. The findings are: A. Record review of R #48's face sheet revealed R #48 was admitted into the facility on [DATE] with the following diagnoses:1. Unspecified severe protein-calorie malnutrition (occurs when an individual does not consume enough protein and calories, leading to significant muscle and fat loss, and impaired bodily functions).2. Acute and chronic respiratory failure with hypoxia (respiratory failure when you don't have enough oxygen in your blood).3. Cachexia…

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 Certified Nurse Aides (CNAs) received the required in-service training of 12 hours per year for 1 (CNA #2) of 5 (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5) CNAs reviewed for training. This deficient practice is likely to result in the CNAs not receiving the necessary training to meet the care needs of the residents. The findings are:A. Record review of CNA #2's personnel file revealed CNA #2 was hired on 03/11/20.B. Record review of CNA #2's in-service training transcript report dated 12/05/25 revealed CNA #2 completed five and a half hours of in-service training from 12/06/24 to 12/05/25.C. On 12/05/25 at 10:30 am during an interview with the Payroll Specialist (PS), she stated that she expects all CNAs to complete the required amount of training each year and confirmed that CNA #2 has not.

Based on observations, staff interviews, and record review, the facility failed to ensure medication and biological refrigerator temperatures were maintained within the required range and recordings logged for three of three refrigerators in two medication rooms. This failure had the potential to result in residents being subject to unsafe or ineffective treatment or adverse effects leading to more serious illnesses. Findings include: Review of the facility's policy titled, IC401 Medication and Vaccine Refrigerator/Freezer Temperatures, with a revision date of 07/01/24, revealed, Policy: Refrigerators and freezers used to store medications and vaccines will operate within acceptable temperature range and will be checked twice a day for proper temperatures. The acceptable refrigerator temperature range for medication and vaccine storage is 36 degrees to 46 degrees Fahrenheit . Process: 1. Staff will be assigned on each unit to: 1.1 Check internal temperatures of refrigerators and freezers used to store medications and vaccines. 1.2 Document internal temperatures 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 interviews and records review, the facility failed to ensure resident representatives (RR) and two (R14 and R30) of two residents reviewed for transfer requirements were provided with a written transfer notice that contained all the required information. This failure had the potential to affect the residents and their RRs by not having knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the facility's policy titled, OPS404 Discharge and Transfer, with a revision date of 11/15/22, revealed, . Process: 5. For patients transferred to a hospital: 5.1 For unplanned, acute transfers for the patient must be permitted to return to the Center. Prior to the transfer, the patient and patient representative will be notified verbally followed by written notification using the Notice of Hospital Transfer or state specific transfer form. 5.1 .1 Copies of notices for emergency transfers must also be sent to the Ombudsman, but they may be sent…

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 interviews and records review, the facility failed to ensure resident representatives and two of two residents (Resident (R) 14 and R30) reviewed for transfer requirements out of a total sample of 18 were provided with written notification of the facility's bed hold policy prior to transfer to the hospital. This created a potential for the residents to experience distress or confusion related to readmission to the facility due to the facility-initiated discharge. Findings include: Review of the facility's policy titled, AR 102 Bed-Holds, with a revision date of 01/16/23, revealed, Bed hold notification is required per Federal Regulation Title 42, Chapter IV, Subchapter G, Part 483.15(d)(2)l The resident/resident representative may choose to pay to hold the bed privately if the bed hold is not covered by Medicaid, Medicare, insurance, etc. When a resident/patient (resident) is transferred out of the service location to a hospital or on therapeutic leave, the designee will provide the resident and his/her…

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 observations, record review, interviews, and review of the facility policy, the facility failed to ensure resident Care Plans were updated and revised with new goals and interventions for two residents (R30 and R41) of 18 sampled residents. The facility failed to update the Care Plan for R30 related to oxygen usage and for R41 related to falls. This failure created an increased risk for the residents' care and services to not be appropriate for the current clinical condition. Findings include: Review of the facility policy titled, Person-Centered Care Plan, revised 10/240/22, revealed, A comprehensive, individualized care plan will be . reviewed and revised after each assessment. After each assessment means after each assessment known as the Resident Assessment Instrument (RAI) or Minimum Data Set (MDS). Care plan includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition and mental and psychosocial needs that are identified in the comprehensive assessments. The policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure the designated resident smoking area was safe for one of 13 residents (Resident (R) 10) reviewed for smoking. The facility failed to provide a safe smoking environment by permitting non-self-extinguishing trash cans to be available for cigarette ashes and cigarette butts to be disposed of on top of trash. The failure created the potential for cigarette butts and ashes to ignite when thrown in the non-self-closing trash cans. Findings include: Review of the facility's policy titled, Smoking Policy and Procedure, revised on 05/01/24, revealed, Ashtrays made of non-combustible materials and safe design, and metal containers with self-closing covers into which ashtrays can be emptied, shall be provided in all designated smoking areas as well as at all entrances . The admitting nurse will perform a Smoking Evaluation on each patient who chooses to smoke . Patients will be re-evaluated quarterly and with a change 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 interview, observation, and record review, the facility's Administrator and the Director of Nursing (Administrative Staff) failed to administer the facility when they knew/ should have known and prevented the following deficient practices which occurred in the facility: 1. Unavailability of Administrative staff causing staff to reschedule resident meetings and to be without leadership or direction. 2. Administration unavailable to report absences timely by staff members delaying ability of scheduler to find appropriate coverage. 3. LPN #1 began working without completing an application, having a background clearance, training and demonstration of competency prior to providing care to residents 4. Nursing staff changed or wrote orders without Practitioner's knowledge or consent. 5. Not reporting or investigating allegations of abuse and neglect. 6. Not ensuring staff were trained and competent before providing care to residents. 7. Not ensuring medications were safely stored and accounted for. These…

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 Facility Initiated Reports (mandatory self-initiated facility report of an incident) to the State Survey Agency (SSA) for 6 (R #1, #4, #5, #8, #9 and #10) of 8 (R #1, #4, #5, #8, #9 and #10) residents reviewed for incidents when staff failed to report the following incidents: 1) Medication error for R #1 2) Injury of unknown origin for R #4 within two hours of becoming aware of the injuries. 3) Unwitnessed falls with injuries for R #5 and #10; 4) Allegations of abuse reported by R #8 and #9; This deficient practice is likely to result in the SSA not being aware of facility incidents and unable to assure residents safety. The findings are: R #1 A. Cross reference F760 B. On 05/14/24 at 1:04 pm during interview with the Administrator (ADM), she stated the Director of Nursing (DON) was responsible to report incidents to the State Agency (SA). The ADM confirmed the medication error for R #1 was not reported. R #2 C. Cross reference F602 D. On 05/08/24 at 10:00 am during an interview, the Nurse Practitioner (NP) stated…

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 prevent misappropriation (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) of resident property, when a resident's pain medication was given to another resident for 1 (R #2) of 1 (R #2) residents reviewed for misappropriation. This deficient practice could likely result in residents not receiving needed medications to maintain or improve their quality of life. The findings are: R #2 A. Record review of the Narcotic Tracking Sheet for R #2 revealed the following: - On 11/06/23 at 6:00 pm, staff documented 40 milligrams (mg) of morphine (narcotic pain medication) was spilled. - Signed by the Director of Nursing (DON) and Licensed Practical Nurse (LPN)/Unit Manager #2. B. On 05/07/24 at 5:31 pm during an interview, Registered Nurse (RN) #1 stated LPN #2 went into RN #1's medication cart and told her she was looking for morphine for an emergency situation. She stated LPN #2 told her that the Nurse Practitioner (NP) gave her a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to maintain an environment that was in good condition when staff failed to: 1. Paint walls that were patched with plaster, had patches of a different paint color, and food debris on the wall and ceiling; 2. Repair holes in walls; 3. Replace a heating/cooling vent cover in room [ROOM NUMBER]; 4. Properly repair various exposed wires and replace a missing ceiling tile in the dining room. These deficiencies could affect the 57 residents who lived in the facility and were listed on the resident census provided by the Administrator on 02/21/24. If the facility fails to maintain the building, then residents could feel uncomfortable in their environment. The findings are: A. On 02/21/24 at 12:30 pm during the initial tour of the building, several rooms on the 200 hall had plaster patches that needed to be painted. Some of the patches were large sections of the wall, and other patches were smaller, measuring a couple of inches in diameter. B. On 02/22/24 at 11:00 am…

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 for 2 (R #2 and 8) of 3( R #2, 7 and 8) residents that the facility: 1. Provided a follow-up report within 5 working days from the date of the incident to the State Survey Agency for R #2 and R#8. 2. Implemented any preventative measures following an abuse accusation for R #2. Theses deficient practices could likely cause residents to feel frustrated and unsafe. The findings are: R #8: A. Record review of facility's incident report dated 02/14/24, which was received by the State Agency on 02/15/24 revealed this report was filed regarding sexually inappropriate behavior by the Director of Nursing (DON) towards R #8. The five day follow-up report was not submitted to the State Agency. B. On 02/22/24, at 10:57 am ,during an interview, R #8 stated that the DON and Certified Nursing Aide (CNA) #1 were sexually inappropriate with her. She stated that the DON had asked her if she ever been with a woman and whether she preferred to be with a man or with a woman. R #8 further stated that the DON told her that she (the 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 record review and interview, the facility failed to report an incident of alleged sexual inappropriateness to the State Survey Agency for 1 (R #2) of 3 (R #'s 2, 7 and 8) residents reviewed for sexual abuse allegations. If the facility fails to report incidents of abuse, then the State Agency will be unable to appropriately assess allegations for further investigation. This deficient practice could likely cause residents to feel frustrated and unsafe. The findings are: A. Record review of State Agency Consumer Complaint Intake, dated 01/25/24, revealed, that complainant was notified by a staff member that R #2 had reported that a male night Certified Nurse Assistant (CNA) would strip all her clothes off and make her lay in bed while he watched her. B. On 02/21/24 at 1:47 pm during an interview, R #2 stated there was a male worker who changed her and had her lay naked on her bed for a long time with the door to her room open. R #2 stated one of the other female workers stopped at the door and asked the male staff member what he was doing. The male worker said he was changing…

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 that they had sufficient staff to guarantee the needs of all 73 residents residing in the facility by not: 1. Using the appropriate number of staff to transfer resident with a Hoyer Lift (a mechanical device that helps staff to lift and transfer residents). 2. Having enough facility staff to meet the activities of daily living needs of the residents and providing baths/showers. These deficient practices are likely to negatively impact resident safety, comfort, and to impede (delay or prevent) processes such as timely showers and appropriate assistance. The finding are: Hoyer Lift: A. On 08/14/23 at 3:15 PM during an observation with R #274, CNA # 3 was observed entering R #274 room with Hoyer lift by herself. R #274 stated she did not want to be transferred to bed yet. CNA #3 agreed to return at later time. B. On 08/14/23 at 4:48 PM during an interview with CNA #3, she stated, she used Hoyer lift by herself to transfer R #274 to bed. She further stated when facility is short staffed, there is not enough staff to use…

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 #12) of 1 (R #12) resident reviewed for transfers/mobility. Failing to ensure that residents are allowed to transfer and have mobility around the facility is likely to cause psychosocial wellbeing and behavioral issues. The findings are: A. Record review facility face sheet for R #12 revealed admitting diagnoses which included: Hypertension (high blood pressure), Atherosclerotic Heart Disease of Native Coronary Artery (hardening of the arteries), Morbid (Severe) Obesity, Diastolic (Congestive) Heart Failure (heart attack), Chronic Pain, and Muscle Weakness. B. Record review of Activities of Daily Living (ADL) care plan for R #12 revealed the following: Focus: [name of resident] requires assistance for ADL care. Date Initiated: 06/06/2017; Revision on: 03/02/2022 Goal: [name of resident] ADL care needs will be anticipated and met throughout the next review period. Date Initiated: 06/06/2017; Revision on: 01/18/2023 Interventions: . Monitor for complications of immobility (e.g., pressure ulcers,…

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 the consultant pharmacist review for irregularities was acted upon by the medical director on a monthly basis for 1(R #21) of 1 (R #21) residents reviewed for unnecessary medications. If the facility fails to have the medical director act upon the monthly reviews, there is potential for residents to experience unnecessary drug interactions and potentially adverse side effects. The findings are: A. Record review of R #21 face sheet revealed resident was admitted into facility on 01/09/23 with following diagnoses, 1. ESSENTIAL (PRIMARY) HYPERTENSION (Pressure in blood vessels is too high). 2. PARKINSON'S DISEASE. (Brain disorder that causes involuntary movements) 3. TRANSIENT CEREBRAL ISCHEMIC ATTACK. (Temporary blockage of blood flow to the brain). 4. HEART FAILURE. (Condition when your heart doesn't pump enough blood for body's needs) B. Record review of R #21's physician orders dated 01/23/23 revealed, Propranolol HCl Oral Tablet (treats high blood pressure) 10 MG [Milligram]. Give 1 tablet by mouth two times…

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. Ensure Insulin pens were labeled and dated. 2. Ensure that expired medications were not being stored with unexpired medications on the North Units medication cart and inside the North 100 and 200 unit's medication storage rooms. 3. Ensure that medications were stored properly and not found out of original labeled packaging. 4. Ensure expired medications were properly secured and stored inside of the 100 and 200 units medication storage room. 5. Ensure expired medication was not administered to R #27. These deficient practices are likely to negatively impact the health of all the residents on the 100 and 200 halls and on the North unit. Receiving expired medications could likely result in residents receiving medications that have lost their potency and effectiveness leaving them vulnerable to acquiring infections North units medication storage room: A. On 08/16/23 at 9:00 AM during observation of the North units medication storage room refrigerator two insulin pens were found on the top shelf inside a plastic bag with no…

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 proper infection control practices by: 1. Not having a closed door between the soiled laundry area and the clean laundry area. There is no negative pressure system observed in the soiled laundry area. 2. Not keeping doors to Covid 19 positive rooms closed off to hallways/common areas. 3. Not utilizing proper Personal Protective Equipment (PPE) such as gloves, during a Covid 19 outbreak, 4. Not utilizing bio hazard bags (a specially designed plastic or paper bag that is used to collect and transport bio hazard items) in laundry receptacles for means of transporting and identifying soiled contaminated laundry items to the washroom for proper laundering. 5. Not properly labeling Covid 19 contaminated laundry receptacles to identify them from common trash receptacles and storing them in hallway. 6. Not placing signs appropriately on doors during Covid outbreak to alert staff to don PPE prior to entering Covid 19 positive rooms. The findings are: A. 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 ensure that there was a functioning call light system that allowed resident to call for assistance for 1 (R #223) of 1 (R #223) residents review for call lights. If the facility does not have a functioning call light system then residents are unlikely to get their immediate needs met by facility staff. A. On 08/14/23 at 5:27 PM, during observation of call light and interview R #223 stated the call light was not working. Call light was observed to be a push light on her bedside table marked with a red cross, plugged into wall pushed several times to confirm it is not functioning. B. On 08/14/23 at 5:30 PM during interview, LPN #1 confirmed the call light was not functioning. C. On 08/17/23 9:43 AM during interview, CNA #5 confirmed the call light not working and out of residents reach. D. On 08/17/23 10:13 AM during interview, Director of Maintenance stated, he had not been informed of R # 223's call light not working.

Based on record review, observation, and interview the facility failed to develop a comprehensive care plan for 1 (R #24) of 1 (R #24) reviewed for comprehensive care plans. This failure is likely to delay residents in developing plans of care that are effective for their optimal well-being. The findings are: A. Record Review of the Facility Face Sheet for R #24 revealed admitting diagnoses which Included: Depression (feeling of sadness), Epilepsy (involuntary muscle switching), Urinary Tract Infection (bladder infection), Dementia (memory loss), Muscle Weakness, Cognitive Communication Deficit (difficulty communicating), Dysphagia (difficulty swallowing), and Hypertension (high blood pressure). B. On 08/14/23 at 4:36 pm, during observation and interview, it was observed that R #24 did not have arms/side ear pieces for her glasses. R #24 stated that she had some difficulty with reading and watching television sometimes due to having to hold her glasses on her face to see. She stated the glasses had been broken for awhile and she had told the facility that her glasses were broken 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.

Based on record review and interview, the facility failed to ensure 1 Certified Nurse Aides (CNA's #6) out of 5 sampled CNA's received the required in-service training of no less than 12 hours per year. 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 CNA # 6 personal file revealed that CNA #6 was hired on 06/07/2019. B. Record review of CNA # 6, 12-hour training's revealed that she has only completed 8 of the 12 hours of training since hire date. C. Record review of the facility staffing schedule dated August 2023 revealed the following: CNA #6 worked 08/03 - 08/06, 08/10 -08/13. D. On 08/18/23 at 9:30 AM during interview, CNE stated the 12 hours training for CNA # 6 were not completed.