Life Care Center of Farmington

Based on observations, record reviews and interviews, the facility failed to ensure the facility was free of the potential for accidents and hazards for residents in B unit, when staff failed to ensure the following: 1. The Emergency Cart (E-cart, a mobile unit that contains essential supplies, and equipment needed to respond to life-threatening emergencies in hospitals and other medical facilities) was locked to prevent access to scissors and other medical supplies. 2. Shower room was locked to prevent access to shaving razors and hazardous cleaning materials. These deficient practices are likely to affect all the 37 residents in B Unit listed on the resident census list provided by the Administrator on 05/12/25 and are likely to lead to residents experiencing avoidable accidents. The findings are: A. Record review of the facility's E-cart Policy, dated 07/22/24, revealed Emergency Carts should be in a central and convenient location and used only during emergencies. The policy did not address locking the E-cart to prevent unauthorized access. B. On 05/12/25 at 2:30 pm, observation…

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 Aides (CMAs) dated opened insulin (a medication prescribed to help the body turn food into energy and manages blood sugar levels) pens and discarded them within 28 days of opening date for 3 (R #44, R #45, and an unidentified R) of 3 (R #44, R #45, and an unidentified R) residents reviewed. This deficient practice is likely to result in all 3 residents receiving medications that are less effective or expired in the facility. The findings are: A. Record review of the facility's Medication Storage Policy, dated 2025, revealed if a multidose vial of an injectable medication has been opened or accessed, then the vial should be dated and discarded within 28 days, unless the manufacturer specifies a different date. B. On 05/14/25 at 1:09 pm, observation of the 100 Hall medication cart revealed the following: - Insulin Lispro (a short-acting insulin),100 units/milliliter (ml) multiple-dose pen was opened, not dated, and was labeled with R #45's last name only. The insulin pen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 1 (R #14) of 1 (R #14) 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 #14's face sheet revealed an admission date of 07/25/24 with the following diagnoses: - Chronic respiratory failure with hypoxia (low levels of oxygen in the blood), - Chronic obstructive pulmonary disease (COPD; lung disease), - Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), - Paroxysmal atrial fibrillation (a type of irregular heartbeat.) B. Record review of R #14's MDS, dated [DATE], indicated R #14's primary language was English. C. Record review of R #14's MDS, dated [DATE] indicated R #14's primary language was English. D. 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 record review and interview, the facility failed to revise the care plan for 1 (R #105) of 1 (R #105) resident reviewed for care plans. If the facility is not updating the care plan to reflect the resident's current care areas and treatment, then the facility may not be providing the appropriate care and treatment to meet the residents' needs. The findings are: A. Record review of R #105's face sheet indicated an admission date of 04/02/25 with the following diagnoses: - Type II diabetes (DM2, a condition which results from insufficient production of insulin, causing high blood sugar), - Dementia (affects memory, thinking and social abilities), - Hypertension (high blood pressure). B. Record review of R #105's physician orders, dated 05/08/25, indicated an order for oxygen at 2 liters/minute continuously per nasal cannula. Keep oxygen saturation above 90 percent (%). C. Record review of R #105's care plan revealed the care plan did not address the resident's use of oxygen. D. On 05/16/25 at 10:15 am during an interview, the Director of Nursing (DON) stated that if 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 provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for 1 (R #57) of 3 (R #16, #41 and #57) residents when staff failed to ensure R #57 received showers timely. This deficient practice could likely result in residents being at a higher risk for infection and to feel unimportant, embarrassed, and undignified. The findings are: A. Record review of R #57's Face Sheet, dated 05/15/25, revealed an initial admission date of 08/13/21. B. Record review of R #57's Care Plan, last reviewed on 05/15/25, revealed the resident required the assistance of one staff for activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating). C. Record review of R #57's shower tracking revealed the resident's scheduled shower days were Wednesday and Saturday evening. Further review revealed R #57 did not receive a shower from 05/07/25 through 05/14/25. D. Record review…

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

Based on observation, interview, and record review, the facility failed to ensure a resident wore her oxygen, and the oxygen ran continuously for 1 (R #105) of 1 (R #105) resident reviewed for oxygen. If the facility is not following orders for oxygen use then the resident may be low on oxygen, which had the potential to cause health concerns such as headache, difficulty breathing or rapid heart rate. The findings are: A. Record review of R #105's face sheet indicated an admission date of 04/02/25 with the following diagnoses: - Type II diabetes (DM2, a condition which results from insufficient production of insulin, causing high blood sugar), - Dementia (affects memory, thinking and social abilities), - Hypertension (high blood pressure). B. Record review of R #105's physician orders, dated 05/08/25, indicated an order for oxygen at 2 liters (L)/minute continuously per nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs). Keep oxygen saturation (the amount of oxygen in blood) above 90 percent (%). C. Record review of R #105's oxygen…

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 identify quality deficiencies through their Quality Assurance and Performance Improvement Plan (QAPI; a structured framework used in healthcare to enhance the quality of care provided to patients) when staff were unaware the exit doors in the Memory Unit did not function as they were supposed to when the fire alarm was activated. This deficient practice is likely to affect all 118 residents, per census list provided by the Administrator (ADM) on 05/12/25. This deficient practice could likely result in staff and residents not able to safely evacuate the facility in case of emergency. The findings are: A. On 05/15/25 at 1:56 pm during an observation, staff activated the fire alarm, and all three exit doors on the Memory Unit failed to unlock when the fire alarm was activated. B. On 05/16/25 at 10:29 am during an interview, the Administrator stated he was not aware the exit doors in the Memory Unit did not function correctly. He stated he became aware of this issue on 05/15/25 when staff tested the fire alarm. He stated his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the family member/Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) for 1 (R #1) of 3 (R #1, #2, and #3) residents when changes in R #1's medication were made. If the facility is not notifying the resident's POA when the resident has a change in medication, 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 R #1's face sheet indicated R #1 was admitted to the facility on [DATE] and was discharged on 11/22/24. R #1 had the following diagnoses: - Alzheimer's disease (causes memory loss, language loss and impaired judgement), - Anxiety (feelings of fear or apprehension), - Depression (causes persistent feeling of sadness and loss of interest), - Dementia with psychotic disturbance (a decline in thinking and problem solving skills as well as delusions or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to maintain proper infection prevention measures when staff failed to remove a leg catheter bag for 1 (R #1) out of 1 (R #1) resident while he lay in bed. This deficient practice of not adhering to an infection control program could likely cause a urinary tract infection. The findings are: A. Record review of the medical record face sheet for R #1 revealed he was admitted on [DATE]. He was admitted with the following diagnoses: - Dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life) - Difficulty walking, - Communication deficit, - Intracerebral hemmorrhage (a brain bleed and a type of stroke. It causes blood to pool between the brain and skull and prevents oxygen from reaching the brain. It is life-threatening), - Type II diabetes (the body does not use insulin properly), - Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body…

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 a resident was treated with respect and dignity for 3 (R #1, #20 and #21) of 3 (R #1, #20 and #21) residents observed during dining. This deficient practice could likely create a feeling of frustration, embarrassment, and disappointment. The findings are: A. On 07/08/24 at 12:20 pm, during lunch observation, Certified Nursing Assistant (CNA) #1 stood and fed two unknown residents. CNA #1 went back and forth between the two residents who sat at the same table. B. On 07/08/24 at 12:25 pm, during lunch observation, CNA #2 stood and fed an unknown resident. C. On 07/08/24 at 12:30 pm, during lunch observation, Nurse #3 brought a bedside tray table to an unknown resident. The resident sat in a reclining type chair. Nurse #3 stood while she fed the resident. D. On 07/08/24 at 12:38 pm, during an interview with Nurse #3, she stated she stood to feed the resident so she could see the other residents and make sure everyone was alright. E. On 07/08/24 at 1:15 pm, during an interview with the Administrator and and Director of…

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

Based on interview, the facility failed to investigate an injury of unknown origin for 1 (R #11) out of 3 (R #1, #11 and #12) residents reviewed for reporting to the State Agency. The deficient practice could cause residents to go without treatment and may expose them to injuries. The findings are: A. On 07/09/24 at 8:52 am, during an interview with the daughter of R #11, she stated she received a call from facility staff about 1:30 pm on 06/26/24 that something happened with her mother in the shower. She stated staff told her that her mother was fine, and there was not anything wrong with her. She stated staff told her since R #11 did not want the staff to touch her, they were going to send her mother out to the emergency room. She stated the physician from the hospital called her around 3:30 pm. The daughter stated when she got to the hospital, the hospital staff told her they needed to do surgery on her mother, because both of her mother's legs were fractured. The daughter stated she spoke to her mother in Navajo, and her mother told her the guy (unknown staff) who took care 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 record review and interview, the facility failed to report unwitnessed falls resulting in injury (an indicator of possible neglect or abuse) to the State Survey Agency, for 2 (R #7 and R #10) of 3 (R #7, R #8, and R #10) residents reviewed for falls. This deficient practice is likely to result in the State Survey Agency not being aware of facility incidents and unable to assure residents have a safe and hazard free environment. The findings are: A. Record review of facility provided fall reports included: - R #10 experienced an unwitnessed fall on 12/05/2024 resulting in an abrasion (skin damage due to scraping) on his right knee and hematoma (pooling of mostly clotted blood under the surface of the skin) on his face. - R #10 experienced an unwitnessed fall on 01/18/2024 resulting in lacerations (cuts or tears) on his forehead and the bridge of his nose, as well as, bruising and swelling on his left hand, wrist, and forearm. - R #7 experienced an unwitnessed fall on 01/28/2024 resulting in an abrasion on his left knee. - R #7 experienced an unwitnessed fall on 02/04/2024…

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 develop comprehensive, person-centered care plans which included information about current fall prevention strategies being used for 2 (R #7 & R #10) of 3 (R #7, R #8, and R #10) residents reviewed for care plans. This deficient practice could likely result in residents not receiving the care needed to reach their highest practicable level of well-being. The findings are: Resident #7 A. Record review of R #7's health status note by LPN #5 in the Electronic Medical Record (EMR), dated 02/20/2024, stated the resident stayed at the nurse's station for observation while he struggled to fall back to sleep. B. Record review of R #7's care plan, dated 12/21/2023, indicated that placing the resident at the nurse's station for increased observation was not listed as an intervention. Resident #10 C. On 02/29/2024 at 5:45 pm, R #10 sat at the nurse's station in his wheelchair and propelled himself slowly in circles. D. Record review of R #10's care plan, dated 01/24/2024, indicated placing the resident at the nurse'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 observations and interviews the facility failed to: 1. Ensure all medication carts were locked when not in use. This deficient practice is likely to affect all 35 residents in A hall, identified on the census list provided by the Executive Director (ED) on 2/28/24, by allowing unauthorized persons access to their medications and personal health information. The findings are: Findings for unlocked medication cart. A. On 02/29/24 at 3:52 pm, during observation, the A hall medication cart was unlocked and accessible. Observation also revealed the staff did not use or control the cart, for five minutes. Further observation revealed the nearby nurses station was also vacant during this time. B. On 02/29/24 at 4:00 pm during an interview with Licensed Practical Nurse (LPN #2), she stated the medication cart was hers, and it should be locked.

Based on observation and interview, the facility failed to discard food after it reached its shelf life or after it expired. This failure was likely to affect all 106 residents listed on the census provided by the Director of Nursing (DON) on 01/29/24. This deficient practice could likely lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in residents if food is not being discarded timely. The findings are: A. On 01/29/24 at 12:07 pm, an observation of the walk-in refrigerator revealed the following items: 1. A decomposed cucumber, 2. A container of left over soup dated 1/14 (2024), 3. Six, 1/2 gallon milk jugs expired on 01/20/24 or earlier. B. On 01/29/24 at 12:07 during an interview, the Dietary manager stated the staff should have discarded the cucumber, the container of soup, and the 1/2 gallons of milk.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to: 1. Ensure the medication carts did not contain loose medications. 2. Ensure expired supplies were not kept with unexpired supplies in the medication room. These deficient practices are likely to result in all 82 residents residing in halls 100, 300, and 600, as identified on the census list provided by the Executive Director (ED) on [DATE], receiving expired medication and having expired medical supplies used in their treatments. The findings are: Findings for loose medications found in medication carts. A. On [DATE] at 11:36 am, during observation of the Unit A medication cart, one oval white pill and one small white round pill lay under the medication cards (vertical cardboard and foil cards pre-filled with prescription medications for easy storage and dispensing) in the drawer of the cart. B. On [DATE] at 11:36 am, during an interview with Licensed Practical Nurse (LPN) #1, she stated loose medications should not be in the medication cart under 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 include information about a medication used to treat depression for 1 (R #102) of 3 (R #81, R #102, and R #259) residents reviewed for comprehensive care plans. This deficient practice could likely result in residents not receiving the follow-up care that is needed when being treated with an antidepressant medication. A. Record review of R #102's face sheet revealed R #102 was admitted to the facility on [DATE] with the diagnosis of depression, unspecified. B. Record review of R #102's current physician orders revealed an order, dated 12/21/23, for escitalopram oxalate (a type of antidepressant), 10 milligrams (mg). C. Record review of R #102's care plan, last revised 12/29/23, revealed R #102 received an antidepressant medication; however, the care plan did not include the side-effects of the antidepressant medication. D. On 02/01/24 at 1:34 pm, during an interview with the Director of Nursing, she stated the care plan should include the side-effects…

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 record was accurate and reflected resident care for 1 (R #39) of 1 (R #39) resident reviewed for wounds. This deficient practice could likely result in staff confusion as to the services and treatment provided. The findings are: A. Record review of R #39's care plan, last revised on 12/20/23, indicated R #39 was re-admitted to the facility on [DATE] and treated for a below the knee amputation (BKA) surgical wound, skin tear, and a coccyx (tailbone) pressure wound (wounds that occur over a bony prominence as a result of long-term pressure). Interventions included pressure reducing mattress anc cushion to chair, treatment as ordered, weekly skin checks. B. Record review of R #39's coccyx wound assessment, dated 11/24/23, indicated he was admitted with a stage 3 (full thickness tissue loss) coccyx wound on 06/02/23. The wound showed improvement, and the measurements of the wound were length 1.0 centimeters (cm), width 0.6 cm, and depth…

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 resident (R #51) out of 5 (R #'s 16, 43, 51, 64, and 92) residents reviewed were offered vaccinations in a timely manner. This deficient practice is likely to put residents at risk for developing illness or infections. The findings are: A. Record review of the Flu Vaccine Consent form for R #51, indicated the power of attorney (a person identified that acts on your behalf and best interest if unable to make decisions on your own) gave consent on 10/06/23 for R #51 to receive the influenza (flu) vaccine. B. Record review of the current electronic medical immunization record for R #51 revealed the shot was pending, and staff had not given it to the resident. C. On 02/01/24 at 11:32 am, during and interview with Director of Nursing (DON), she stated she was not aware until recently that R #51's consent form to receive the flu vaccine was signed. She stated she was going to give the resident the vaccine around 01/20/24, but she ended up going out to the hospital.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident and family members were fully aware of the next steps needed for their continuation of care upon discharge from the facility for 2 (R #3, and R #4) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for a safe discharge process. This deficient practice could likely result in residents not receiving the care they need to continue to heal and to prevent avoidable acute care admissions. A. Record review of the facility's policy Discharge Summary, last reviewed 08/10/23, revealed the post-discharge plan of care must indicate where the individual planned to reside, any arrangements made for the resident's follow-up care, and any post-discharge medical and non-medical services. Findings for R #3 B. Record review of R #3's face sheet revealed she was admitted on [DATE] for skilled nursing services as a result of a left hip fracture. Further review revealed R #3 discharged from the facility on 11/30/23. C. Record review of physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to meet professional standards for nursing care for 3 (R #'s 6, 60 and 76) of 12 (R #'s 6, 10, 13, 15, 22, 36, 60, 75, 76, 85, 89, and 93) residents reviewed for proper administration techniques when medications given to them, by: 1. Failing to administer eye drops to R #6 with techniques that are designed to ensure absorption in the eyes of correct dose, 2. Failing to educate residents on proper use of their prescribed respiratory inhalation medication devices, prior to administration, resulting in R #'s 60 and 76 likely not receiving the prescribed amounts of medication, and 3. Failing to check for patency [open, unblocked] of central venous [in a large vein close to the heart] intravenous [in a vein] (IV) line [in this case a, peripherally-inserted-central-catheter] (PICC) [a type of central venous IV] prior to administration of a medication to R #76 through the PICC line. If medication is not administered according to protocols from an…

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

Based on record review and interview the facility failed to provide restorative services (measures provided by nursing staff and directed toward re-establishing and maintaining the residents' fullest potential) needed for 1 (R #44) of 1 (R #44) resident reviewed for restorative services. This deficient practice could result in any resident in need of restorative care to experience a decline in their ability to move in bed, transfer safely, walk, eat, and perform grooming or other activities of daily living (ADLs). The findings are: Findings for R #44: A. On 10/17/22 at 5:10 pm, during an interview, R #44 stated they (the facility) used to take her to work on her exercises and to walk with her but not anymore. B. Record review of R #44's care plan date 08/31/22 revealed a diagnoses of unspecified fracture (break) of the upper end of the right humerus (the long bone of the upper portion of the arm that connects to the shoulder). Interventions were therapy services as ordered. C. Record review of the medical records revealed no current or pending appointments for physical therapy or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to ensure residents maintain personal grooming for 5 (R #4, R #26, R #57, R #87 and R #91) of 8 (R #4, R #8, R #26, R #31, R #57, R #72, R #87 and R #91) residents reviewed for facial and nail grooming Activities of Daily Living (ADLs). These deficient practices could likely affect the residents' sense of dignity, resulting in feelings of shame or embarrassment, and could likely affect the health of the residents, causing infections. The findings are: Findings for R #26 A. On 10/17/22 at 4:15 pm during an observation and interview, R #26, a female resident, was observed to have a numerous facial hairs, approximately a 1/4 inch long, on her chin. She stated she would like the hairs cut but that she does not have tweezers or anything sharp to cut the hairs. B. On 10/20/22 at 2:27 pm during an interview with a family representative, the family representative stated that when she picked up R #26 for an appointment on 10/26/22, the hairs on 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 ensure that residents receive treatment and care in accordance with professional standards of practice for 2 (R #6 and 18) of 3 (R #4, 6 and 18) residents reviewed for wound care. Failure to provide wound care as ordered by the physician could likely cause residents to have worsening wounds that could become infected causing delayed healing. The findings are: Resident #6 A. On 10/17/22 at 4:44 pm, during an interview with R #6 she stated that the dressing on her foot is not getting changed as often as it should. B. Record review of the Treatment Administration Record (TAR) for R #6 indicated that an order for Wound care to the right toes: clean and change on Tuesday, Friday, and Sunday and PRN (as needed) if it becomes dislodged or soiled, every evening shift. Start date 09/01/22 for 14 days. The TAR indicated that there was no documentation on the 4th or the 6th and there was a code indicating a 10 which means other/see progress notes, was noted on the 11th, and the13th. C. Record review of the TAR for R #6 indicated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to assess for the benefit versus potential risk of increasing a dose of an antipsychotic medication (an reduce or relieve symptoms of psychosis, such as delusions (false beliefs) and hallucinations) after R #18 complained about not receiving wound care for 1 resident (R #18) of 5 (R #8, 18, 36, 54 and 91) reviewed for unnecessary medications. This deficient practice could likely cause residents to receive medications they do not need or may experience an adverse side effect. The findings are: A. Record review of the face sheet for R #18 indicated that she had a new diagnosis of dementia with agitation (agitation is a behavioral syndrome characterized by increased, often undirected, motor activity, restlessness, aggressiveness, and emotional distress) dated 10/01/22 and a diagnosis of major depressive disorder (a persistent feeling of sadness and loss of interest) on admission to the facility on [DATE]. B. Record review of the physician orders for R #18…

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

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% by performing 5 medication errors out of 43 opportunities for 5 (R #'s 13, 15, 22, 60, 76,) of 12 (R #'s 6, 10, 13, 15, 22, 36, 60, 75, 76, 85, 89, and 93) residents reviewed during medication administration. This resulted in a medication error rate of 11.43%. If medications are administered without regard to manufacturer's instructions for administration or specific alternate instructions from a knowledgeable professional [such as a pharmacist], residents may likely not experience the maximum benefit intended and fail to achieve their highest level of well being. The findings are: Findings for R #13: A. On 10/20/22 at 8:34 am, during an observation of medication administration to R #13 by Licensed Practical Nurse (LPN) #4, the medication prescribed, Molnupiravir [an anti viral drug for people with COVID-19, a disease in humans caused by a coronavirus,that sometimes causes severe symptoms] 4 capsules, were opened and then crushed by LPN #4 and added 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 observation and record review the facility failed to ensure glucometer's [a medical device to measure glucose {sugar} levels in the blood] utilized by the facility for more than one resident were disinfected per manufacturers instructions after each time one was used, for 4 [R #'s, 13, 36, 89, and 93] of 4 [13, 36, 89, and 93] residents observed for capillary [small blood vessels] blood glucose (CBG) monitoring with glucometer's. This deficient practice may likely result in the spread of infections agents [viruses or bacteria] between residents and/or staff who utilize glucometer's. The findings are: A. On 10/19/22 at 11:42 am, during an observation of Licensed Nurse (LPN) #2 check R #36's CBG, after CBG test was completed LPN #2 was observed putting the glucometer in to her pocket then used alcohol based hand rub (ABHR) on her hands and returned to her medication (med) cart. After charting on her computer, she removed the glucometer from her pocket, wiped it down with one alcohol prep pad [small, individually packaged antiseptic wipes usually made of cotton saturated 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 interview and record review, the facility failed to notify and get consent from the Power of Attorney (POA) for R #18 for an antipsychotic medication increase for 1 (R #18) of 1 (R #18) residents reviewed for unnecessary medication. This deficient practice could likely cause residents to receive unwanted and unnecessary medications by not notifying the resident or the residents POA, and allowing them to decide if the medication was wanted or not. The findings are: A. Record review of the nursing progress notes dated 10/06/22, indicated the following, On Saturday after my (R #18) shower, you (speaking with LPN [License Practical Nurse] #1) did not change my dressing, I (R #18) sat with my family with socks on, the lady who is working now, she came & change it, she is not going to come & and tell me you were not here because you gave her money, I won't give up, I don't buy anybody, I told to (name) & will go to him and tell him, you didn't change my dressing, I thought you are good nurse but u r not you did not change my dressing Res constant going on with same conversation…

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 care plan was comprehensive and covered all care needs for 1 (R #18) of 1 (R #18) residents reviewed for wound care. If the facility fails to capture care needs this could likely put the resident at risk of not receiving the care and services they need. The findings are: A. Record review of the nursing progress notes indicated that R #18 had a partial amputation (partial or complete removal of a limb, as a preventative measure against malignancy (cancer) or gangrene (death of body tissues due to lack of blood flow)) of left hallux (hallux is the joint where your big toe connects to your foot) on 08/15/22. B. On 10/17/22 at 4:24 pm, during an interview with R #18, she stated that she got part of her toe (made a cutting motion with her hand) cut off. She stated that they are supposed to be doing dressing changes for it everyday but they aren't. C. Record review of the care plan that revised on 08/04/22 was completed and revealed no care plan intervention for the partial toe amputation. D. On 10/20/22 at 7:57…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to have physician orders for 1 (R #54) of 1 (R #54) resident by administering oxygen without a physician's order. If the facility fails to obtain orders for the administering of oxygen, it could likely cause the resident to not receive the therapeutic benefits, resulting in possible harm to the resident. The findings are: A. Record review of the face sheet indicated that R #54 had exacerbated COPD (Chronic Obstructive Pulmonary Disease is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Acute and chronic respiratory disease (Chronic respiratory failure is an ongoing condition that develops over time. Acute respiratory distress syndrome is a severe condition that occurs when fluid fills up the air sacs in the lungs). B. Record review of the care plan last revised on 09/14/22, indicated in interventions: oxygen settings, O2 (oxygen) via nasal cannula as ordered (see current MAR (Medication Administration Record)/physicians…

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