Casa Del Sol Center

Based on observation and interview, the facility failed to provide sufficient space for dining. This failure has the potential to affect all 57 (as listed on the Resident Census provided by the Administrator on 03/10/25) and could likely hinder safe movements and disrupt residents dining experience. The findings are: A. On 03/10/25 at 12:11 pm, during lunch, the following observation was made: 1. The dining area was very crowded with residents' wheelchairs and walkers, making moving around difficult to include serving and assisting the residents with dining, and exiting the area after the meal was complete. 2. A resident was trying to get to a table and his wheelchair wheels got caught up on another resident's wheelchair wheels. 3. Staff were assisting residents with eating while standing up beside them. B. On 03/13/25 at 12:26 pm, during lunch, the following observation was made: 1. The dining area was crowded with residents. 2. One resident had a difficult time leaving the area after he finished eating. 3. Staff were assisting a resident in a Geri chair (a large, padded chair 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 ensure care plan requirements were met for 6 (R #8, R #15, R #18, R #49, R #56, and R #162) of 10 (R #7, R #8, R #13, R #15, R #18, R #20, R #32, R #49, R #56, and R #162) residents reviewed for care plans when staff failed to: 1. Have the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) members participate in the care plan meeting for R #15 and R #49. 2. Ensure the care plan meeting was held after the completion of the admission Minimum Data Set Assessment (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) when creating the care plan for R #8, R #15, R #18, R #49, R #56, and R #162. 3. Revise the care plan with the most current resident information for R #56. These deficient practices could likely result in the care plan not being updated…

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

Based on interview and record review, the facility failed to ensure the CNA's are able to demonstrate competency in skills and techniques necessary to care for residents' needs for 3 (CNA #8, CNA #9, and CNA #16) of 3 (CNA #8, CNA #9, and CNA #16) CNAs reviewed for competent nursing staff, when they failed to: 1. Have a competency evaluation (the facility's way to measure an individual's knowledge and skills as related to safe, competent performance through demonstration of those skills) for CNA #8, CNA #9, and CNA #16 at the time of hire before they start to work with residents. 2. Have a competency evaluation for CNA #8, CNA #9, and CNA #16 routinely after hire. These deficient practices could likely result in CNA's working with residents without adequate knowledge to do so; likely resulting in injury or inappropriate care being provided to the residents. The findings are: A. Record review of CNA #8's personnel files revealed the following: 1. CNA #8 was hired on 12/03/24. 2. Staff did not document that a competency evaluation was completed for CNA #8 demonstrating their…

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 performance reviews at least every 12 months for 2 (CNA #10 and CNA #16) of 3 (CNA #8, CNA #10, and CNA #16) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being undertrained and providing inadequate care. The findings are: A. Record review of the employee files revealed the following: 1. CNA #10's hire date was 11/14/2018 2. There are no performance evaluations for CNA #10. 3. CNA #16's hire date was 02/25/2019. 4. There are no performance evaluations for CNA #16. B. On 03/17/25 at 3:51 PM, during an interview, the Nurse Practice Educator (NPE) confirmed that there were not any performance evaluations for CNA #10, and CNA #11.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to keep resident free from psychotropic medications (antidepressants, anti-anxiety medications, stimulants, antipsychotics, and mood stabilizers) for 3 (R #13, R #15, and R #19) of 4 (R #13, R #15, R #19 and R #20) residents reviewed for unnecessary psychotropic medications when they failed to: 1) Have the consents of resident/representative for psychotropic medications for R #13 and R #15. 2) R #19 did not receive psychotropic medications unless the medication was necessary to treat a specific psychiatric diagnosis and was documented in the medical record. These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: R #13 A. Record review of R #13's medical record, no date, revealed following diagnosis: 1. Major Depressive Disorder, single episode, unspecified (diagnosis used when an individual…

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

Based on record review and interview the facility failed to ensure residents obtained dental services for 2 (R #18 and R #23) of 3 (R #18, R #23 and R #46) residents sampled for dental services, when they failed to ensure residents receive routine dental care to include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. The findings are: R #18 A. On 03/12/25 at 9:32 AM, during an interview, R #18 stated one of her teeth fell out approximately a week ago and she has not been to the dentist since her admission to the facility. B. Record review of R #18's admission Record, no date, revealed an admission date of 11/03/23. C. Record review of R #18's physician's order dated 11/03/23 revealed dental, obtain consult as needed/indicated and treatment for patient health and comfort. D. On 03/17/25 at 11:58 AM, during an interview with Medical…

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 serve food under sanitary conditions by professional standards of food service safety for 4 (R #15, R #23, R #42, and R #54) of 4 (R #15, R #23, R #42, and R #54) residents when staff failed to perform hand hygiene prior to assisting residents with eating and drinking. If the facility fails to adhere to safe food handling practices and hygiene practices, residents could likely be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 03/10/25 at 12:17 PM, during an observation of the dining room the following was revealed: 1. CNA #16 assisted R #42 with eating and drinking. 2. CNA #16 assisted R #15 with cutting her sandwich, she did not perform hand hygiene prior to assisting R #15. 3. CNA #16 returned to assist R #42 with eating and drinking, she did not perform hand hygiene prior to returning to assist R #42. 4. CNA #16 returned to assist R #15 with placing her drink closer to R #15, she did not perform hand hygiene prior to assisting 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 observation and interview, the facility failed to ensure a resident was treated with respect and dignity for 1 (R #23) of 1 (R #23) resident when the staff failed to sit next to the resident while assisting them to eat. This deficient practice could likely result in residents feeling embarrassed, angry, and that their feelings are unimportant to the facility staff. The findings are: A. On 03/10/25 at 12:11 PM, during an observation of lunch, CNA #9 assisted R #23 with eating his lunch. CNA #9 stood over R #23. CNA #9 was not sitting down beside R #23 while she fed him. CNA #9 left the dining area and asked CNA #16 to assist R #23 with his lunch. CNA #16 stood over the resident to feed him also. B. On 03/13/25 at 8:56 AM, during an interview, CNA #16 confirmed that she did assist R #23 during lunch on 03/10/25. CNA #16 confirmed she stood over R #23. CNA #16 said they are supposed to be sitting down next to the resident, but the dining area was so crowded that she ended up standing instead of sitting down next to the resident. C. On 03/13/25 at 9:32 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 and interview, the facility failed to provide a homelike environment that was in good condition for 1 (R #18) of 1 (R #18) resident reviewed for a homelike environment by not repairing the trimming on the windowsill in R #18's room. Failure to maintain and provide a comfortable environment is likely to result in residents feeling unimportant and undervalued. The findings are: A. On 03/12/25 at 9:34 AM, during an interview with R #18 she pointed to her windowsill which had areas of trimming that were broken off. R #18 stated trimming on her windowsill had been broken off for months but could not remember exactly how long. B. On 03/12/25 at 9:34 AM, an observation of R #18's revealed a section of the trimming on the windowsill was broken off near R #18's bed. C. On 03/14/25 at 3:03 PM, during an interview with the Maintenance Director, he confirmed R #18's windowsill trim was broken and needed to be replaced again. The Maintenance director stated it had been replaced in the past because it has been broken due to R #18's bed being moved up and down and scraping 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 notify the resident and the resident's representative(s) of the transfer in writing for 1 (R #35) of 1 (R #35) resident sampled for hospitalization when staff failed to: 1. Notify the resident and resident's representative(s) of the resident's transfer to the hospital in writing and in a language and manner they understand. 2. Send a written copy of the Transfer to the Ombudsman. These deficient practices could likely result in the resident and/or their representative not knowing the reason for a transfer, the location of the transfer, and their rights to advocate and make informed decisions regarding the resident's healthcare. The findings are: A. Record review of R #35's medical record revealed the following: 1. On 01/07/25, R #35 was sent to the hospital for altered mental status (change in mental function that stems from illnesses, disorders and injuries affecting your brain which can lead to changes in awareness, movement and behaviors). 2. 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 record review and interview, the facility failed to ensure a comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was completed within 14 calendar days after admission for 1 (R #162) of 4 (R #13, R #17, R #60 and R #162) residents reviewed. This deficient practice could likely result in residents' preferences and care needs not being met. The findings are: A. Record review of R #162's admission record revealed an admission date of 12/29/24. B. Record review of R #162's admission MDS assessment revealed the admission MDS assessment was completed on 01/21/25. C. On 03/21/25 at 9:43 AM, during an interview with the MDS Coordinator, she confirmed R #162's admission MDS assessment was not completed within 14 days of admission. The MDS Coordinator confirmed that the admission MDS assessments should be completed within 14 days of admission.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete and transmit (electronically sending encoded information) a Significant Change (major decline or improvement in the patient's health status) Minimum Data Set assessment within 14 days after the facility determined a significant change in the resident's physical or mental condition for 1 (R #32) of 1 (R #32) resident reviewed for MDS assessment timing. This deficient practice could likely result in the residents not receiving the appropriate care and services they need. The findings are: A. Record review of R #32's nursing progress note dated 11/13/24 revealed R #32 was admitted to hospice. B. Record review of R #32's change of condition MDS assessment dated [DATE], revealed the MDS assessment was not completed and signed off by the Registered Nurse (RN) until 12/19/24. C. On 03/17/25 at 2:08 PM, during an interview with the MDS Coordinator, she confirmed R #32's was admitted to hospice on 11/13/24 and that the Significant change MDS assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Minimum Data Set Assessment (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) was accurate for 3 (R #13, R #17, and R #60) of 7 (R #7, R #8, R #13, R #17, R #18, R #20 and R #60) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: R#13 A. Record review of R #13's admission record revealed R #13 was admitted to the facility on [DATE]. B. Record review of R #13's physician's orders revealed the following: 1. An order, dated 03/21/23, pregabalin (nerve pain medication) capsule 150 mg give 1 capsule by mouth two times a day for neuropathy (damage, disease, or dysfunction of one or more nerves which can cause burning or shooting pain, numbness and/or tingling) 2. An order, dated 12/16/22, for clopidogrel (antiplatelet medication that reduces 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 an accurate, person-centered comprehensive care plan for 1 (R #56) of 3 (R #15, R #49, and R #56) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: A. Record review of R #56's admission record (no date) revealed the following: 1. R #56 was admitted to the facility on [DATE]. 2. Diagnoses: a. Traumatic subdural hemorrhage without loss of consciousness (bleeding between the brain and the dura mater (the outermost layer of tissue covering the brain) caused by a head injury, where the person remains alert and conscious). b. Acute Embolism and Thrombosis of Right Axillary Vein (a type of deep vein thrombosis (DVT, blood clot) that specifically affects the axillary vein, located in the armpit) c. Thrombocytopenia (abnormally low number of platelets in the blood. Platelets are small blood cells that play a crucial role in 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.

Based on record reviews, and interviews, the facility failed to meet professional standards of quality for 1 (R #49) of 1 (R #49) residents when staff failed to administer medications according to physician's orders. If the facility is not providing care that meets professional standards of quality, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician. The findings are: A. Record review of R #49's admission record, no date, revealed R #49 was admitted to the facility 06/11/24. B. Record review of R #49's physician order, dated 12/06/25, for Renvela (is used to control phosphorus levels in adults with chronic kidney disease) 800 mg three times a day with meals for end stage renal disease (ESRD, a condition in which the kidneys lose the ability to remove waste and balance fluids). C. Record review of R #49's medication administration record (MAR; a form used to document medication administration), dated March 2025, revealed staff documented the following: 1. On 03/10/25…

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

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) assistance for 1 (R #23) of 1 (R #23) residents reviewed for ADL care when staff failed to assist R #23 with brushing his teeth at night. This deficient practice is likely to affect the dignity and health of the residents. The findings are: A. On 03/11/25 at 11:02 AM, during an interview, R #23's sister said R #23 doesn't get his teeth brushed on a regular basis. B. Record review of R #23's Quarterly Minimum Data Set (MDS) dated [DATE] revealed R #23 required assistance is dependent for ADL care. C. On 03/12/25 at 3:23 PM, during an interview, CNA #8 said she sometimes brushes R #23's teeth at night if it is needed. CNA #8 said she usually rinses R #8 mouth out but she doesn't brush his teeth regularly. CNA #8 said that the morning shift usually brushes the resident's teeth. D. Record review of R #23's ADL sheet, dated February 2025, revealed that oral care is not being documented. E. On 03/12/25 at 3:39 PM,…

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 wound care orders were obtained and implemented timely for 1 (R #7) of 5 (R #1, R #7, R #34, R #35 and R #49) residents reviewed for pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time), when staff failed to: 1. Have wound care orders obtained and implemented for R #7's pressure wound on the sacrum (area of spinal column just above the coccyx) for 2 days after R #7 was admitted . 2. Have wound care orders obtained and implemented for R #7's pressure wounds on the Left and Right heel for 3 days after being admitted . These deficient could likely result in the provider being unaware of the resident's current condition, leading to inconsistent interventions and worsening of pressure ulcers. The findings are: A. Record review of R #7's admission record (no date) revealed R #7 was admitted to the facility on [DATE]. B. Record review of R #7's Convalescent Care Orders (admission orders provided 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 effectively (use of different techniques and medication to reduce and control the amount of pain a person experiences) manage pain for 1 (R #13) of 2 (R #13 and R #46) residents reviewed for pain when the facility failed to implement orders for treatment of pain for 17 days after R #13's appointment with her provider. This deficient practice could likely result in residents experiencing unnecessary pain. The findings are: A. On 03/10/25 at 3:31 PM, during an interview, R #13 stated she is always in pain. R #13 stated she has had pain in her nose and tongue for several months. B. Record review of R #13's admission record revealed R #13 was admitted to the facility on [DATE]. C. Record review of R #13's Ear, Nose and Throat (ENT) Institute (specialist in the treatment of the ears, nose, throat, sinuses, head and neck) provider progress note, dated 01/29/25, revealed the following: 1. Chief complaint: Patient is here for pain in her nose and throat. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents have a written, signed, and dated progress notes at each visit from the provider (physician or nurse practitioner) for 1 (R #7) of 1 (R #7) resident reviewed for physician's visits, when they failed to have R #7's provider: 1. Sign their progress notes at the time of the visit. 2. Provide their progress note at the time of the visit. This deficient practice could likely result in the residents' needs not being met due to facility not having written, signed, and dated progress notes from the provider. A. Record review of R #7's admission record (no date) revealed R #4 was admitted to the facility on [DATE]. B. On 03/13/25 at 10:06 AM, during an interview with Medical Records staff, she confirmed there were no wound care consultation progress notes scanned into R #7's medical record. C. Record review of R #7's wound care consultant (outside provider coming to facility to provide wound care treatment) progress notes revealed: 1. Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #56) of 2 (R #15 and R #56) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: A. Record review of R #56's admission record (no date) revealed the following: 1. R #56 was admitted to the facility on [DATE]. 2. Diagnoses: a. Traumatic subdural hemorrhage without loss of consciousness (bleeding between the brain and the dura mater (the outermost layer of tissue covering the brain) caused by a head injury, where the person remains alert and conscious). b. Acute Embolism and Thrombosis of Right Axillary Vein (a type of deep vein thrombosis (DVT, blood clot) that specifically affects the axillary vein, located in the armpit) c. Thrombocytopenia (abnormally low number of platelets in the blood. Platelets are small…

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 behavioral health training (training that helps staff recognize and respond to various behavioral and mental health issues that residents may present with) for 1 (CNA #8) of 3 (CNA #8, CNA #10, and CNA #11) staff sampled for training. This deficient practice could likely result in residents not receiving the services necessary to attain or maintain their physical, mental, and psychosocial (involving both psychological and social aspects) well-being. The findings are: A. Record review of R #19's admission record, (no date) revealed that she was admitted to the facility on [DATE] with the diagnosis of Anxiety disorder, unspecified (condition where individuals experience anxiety-like symptoms that cause severe distress or impairment). B. Record review of R #23's admission record, (no date) revealed that he was admitted to the facility on [DATE] with the diagnosis of schizophrenia (chronic mental disorder characterized by disruptions in thought…

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 the facility failed to report the results of all the investigations of misappropriation of resident property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) and allegations of abuse within five days of the incident to the State Agency for 2 (R #20 and R #58) of 2 (R #20 and R #58) residents reviewed for reporting. If the facility fails to report the results of the investigations to the State Agency within five (5) days, then corrective action may not be taken, and residents may suffer serious bodily injury due to abuse or suffer increased anxiety and financial hardship. The findings are: Misappropriation of Resident Property R #20 A. Record review of the initial incident report, dated 02/20/25, revealed R #20 reported that 45.00 dollars was taken from her purse. R #20 was unsure when it was taken or by whom it was taken. B. Record review of R #20's facility 5-day follow-up report revealed the administrator completed the investigation on 03/18/25. C. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) accurately reflected the resident's status at the time of the assessment for 1 (R #46) of 3 (R #1, R #46, and R #55) residents sampled for MDS accuracy. This deficient practice could likely result in residents not receiving the care and treatment they need. The findings are: A. Record review of R #46's progress notes revealed a medical provider note, dated 09/01/23, which documented R #46 had a diagnosis of depression. B. Record review of R #46's physician orders revealed an active order, dated 11/11/23, for sertraline HCL (medication used to treat depression). Give one tablet by mouth once a day for depression. C. Record review of R #46's care plan, initiated 02/17/22, revealed the following: 1. Administer medication for major depression. 2. [Name of local behavioral health service provider] consult related to major depression (mental condition…

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 and implement a comprehensive person-centered care plan for 2 (R #1 and R #38) of 5 (R #1, R #4, R #8, R #38 and R #46) residents reviewed for comprehensive care plans. Failure to develop a comprehensive 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 #1 A. On 12/11/23 at 3:39 PM, during an interview with R #1, she reported she had two falls in the bathroom. R #1 stated the staff told her she needed to press call bell when she wanted to go to the bathroom. B. Record review of R #1's admission Record, undated, revealed an admission date of 08/12/23. B. Record review of R #1's progress notes revealed, the resident fell on [DATE], 09/28/23, and 10/12/23. C. Record review of R #1's Quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 11/13/23,…

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 #8) of 5 (R #1, R #4, R #8, R #38, and R #46) residents reviewed for care plan revisions. This deficient practice could likely result in staff being unaware of changes in care being provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: A. Record review of R #8's Physician's orders revealed and order, dated 10/13/23. Apply hearing aid in the morning and remove at bedtime. B. Record review of R #8's Care Plan, initiated 06/24/22, revealed: 1. Focus: Resident/Patient has impaired communication as evidenced by impaired hearing. 2. Interventions: a. Speak in a normal tone voice clearly and slowly. b. Reduce external noise when communicating with patient (i.e. Turn off TV or radio). c. Speak facing the patient. C. On 12/18/23 at 2:54 PM, during an interview,the Unit Manager confirmed R #8 did have hearing aids, and staff did not revise the care plan to include assisting the resident with applying and removing her hearing…

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 2 (R #4 and 18) of 2 (R #4 and 18) residents reviewed received the care necessary to promote the prevention of pressure ulcer/injury development. If the facility is not implementing preventative measures, then residents are likely at risk of the development of pressure injuries. The findings are: R #4 A. Record review of R #4's face sheet, undated, revealed an admission date of 01/20/22. B. Record review of R #4's Braden Scale for Predicting Pressure Sore Risk (a tool developed to foster early identification of patients at risk for forming pressure sores), dated 10/26/23, revealed R #4 had a score of 14 which indicated R #4 had a moderate risk for the development of pressure ulcers. C. Record review of R #4's physician's orders revealed an order, dated 05/08/23, for a pressure-redistribution mattress (specialized mattress used for residents with decreased bed mobility that redistributes pressure evenly across the body instead to decrease the pressure to one area). D. On 12/11/23 at 3:02 PM, during 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 and interview, the facility failed to start restorative services (nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible and focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning) for 2 (R #8 and R #38) of 6 (R #4, R #5, R #8, R #21, R #38, and R #47) residents reviewed for activities of daily living (ADL's; daily self-care activities such as eating, dressing and using the toilet). This deficient practice could likely result in residents not receiving services as needed or ordered to improve or maintain their physical functional ability. The findings are: R #8 A. Record review of R #8's Quarterly Minimum Data Set (MDS; comprehensive assessment), dated 06/18/23, Section G: Functional Status revealed: 1. Question G0110.A - Bed Mobility; The resident was independent and required no staff assistance. 2. Question G0110.B - Transfer; The resident required supervision to move between…

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 obtain a physician's order for dialysis treatment or monitoring after dialysis treatment for the resident who received dialysis (clinical purification of blood as a substitute for the normal function of the kidney) for 1 (R #7) of 1 (R #7) residents reviewed for dialysis care. This deficient practice could likely result in residents not receiving dialysis treatment or the care and monitoring they need after dialysis treatment. The findings are: A. Record review of R #7's diagnoses revealed resident had a diagnosis of end stage renal disease (ESRD; chronic irreversible kidney failure). B. Record review of R #7's physician orders revealed the record did not contain an order for dialysis treatment or monitoring after dialysis treatment. C. Record review of R #7's progress notes revealed R #7 had a dialysis fistula (a special connection that is made by joining a vein onto an artery, usually in the arm which creates a large, robust blood vessel that can be needled regularly for use during dialysis) in the right arm. D. Record…

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

Based on observation and interview, the facility failed to ensure there was a functioning call light system that allowed residents to call for assistance for 1 (R #12) of 1 (R #12) residents reviewed 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. The findings are: A. On 12/11/23 at 3:17 PM, during an interview with R #12, she stated the staff did not come when she pushed the call light. She stated the staff did not come when she pushed the call light for as long she can remember. B. On 12/11/23 at 3:19 PM, an observation of R #12's room revealed the call light did not turn on when R #12 pushed the button. C. On 12/11/23 at 3:29 PM, CNA #31 checked the call light and confirmed R #12's call light did not function. CNA #31 stated when R #12 needed something, the resident went to the nurses station or flagged down a staff member when they passed her room. D. On 12/14/23 at 11:29 AM, during an interview with the Maintenance Director, he confirmed R #12's call light was replaced…

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 inform residents when changes in coverage were made to items and services covered by Medicare and/or by Medicaid for 1 (R #2) of 3 (R #2, R #8, and R #56) residents reviewed for beneficiary notices when they failed to provide R #2 with Form CMS-10055- Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) of Non-Coverage [form used to inform the beneficiary (resident) about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services.] This deficient practice can likely result in confusion for the resident or their representative as to what services they receive or do not have financial coverage for under Medicare and/or Medicaid. The findings are: A. Record review of R #2's Electronic Medical Record revealed: 1. R #2 was admitted to the facility on [DATE] to continue skilled therapy services (Physical Therapy). 2. R #2 was discharged from Physical Therapy on 11/30/23 but…

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 comfortable and homelike environment for 1 (R #48) of 3 (R #3, R #37, and R #48) residents sampled for environment, when they failed to repaint the walls after repairs. This deficient practice could likely cause residents to feel like they are not living in a comfortable home-like environment and like they are not valued. The findings are: A. On 12/13/23 at 3:29 PM, an observation of R #48's room revealed 4 large white patches on two walls that did not match the paint on the rest of the wall. B. On 12/14/23 at 1:31 PM, during an interview, the Maintenance Director confirmed the wall near the side of bed and the wall next to the headboard of R #48's bed had been patched and not repainted.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents and their representatives received a written notice of transfer as soon as practicable for 1 (R #51) of 1 (R #51) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative not knowing the reason or location the resident was transferred or discharged . The findings are: A. Record review of R #51's medical record revealed the following: 1) The facility transferred R #51 to the hospital on [DATE]. 2) The record did not contain a written transfer notice. B. On 12/18/23 at 3:14 PM, during an interview, the Administrator confirmed the facility did not provide R #51 with a written notice of transfer.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents or their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 1 (R #51) of 1 (R #51) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: A. Record review of R #51's medical record revealed the following: 1) The facility transferred R #51 to the hospital on [DATE]. 2) The record did not contain a written notice of bed hold policy. B. On 12/18/23 at 3:14 PM, during an interview, the Administrator confirmed R #51 was not given a written notice of the bed hold policy at the time of transfer.

Based on interview and record review, the facility failed to have 12 hours of annual training that is associated with the facility assessment for 3 (CNA #6, CNA #7, CNA #8) of 3 (CNA #6, CNA #7, and CNA #8) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being under trained and providing inadequate care. The findings are: A. Record review of CNA #6's personnel file revealed 1) 12 hours of annual training. B. Record review of CNA #7's personnel file revealed 1) 12 hours of annual training. C. Record review of CNA #8's personnel file revealed 1) 12 hours of annual training. D. On 11/17/22 at 2:43 PM, during an interview Human Resources (HR) was asked how the facility develops their 12 hours of annual training for CNAs, she stated that the facility uses a computer based training platform that provides the curriculum. HR was asked how the facility incorporated the facility assessment into the 12 hours of training, she was not sure and stated that the DON may know. E. On 11/18/22 at 9:20 AM, during an interview the DON was asked how 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 an interview the facility failed to have an accurate resident assessment for 1 (R #46) of 1 (R #46) resident review for accuracy of assessment, when they failed to remove R #46's pneumonia infection (an infection that inflames the air sacs in one or both lungs) from the MDS assessment. This deficient practice could likely result in staff being unaware of residents needs if the assessment in not accurate. The Finding are: A. Record review of R #46's MDS dated [DATE] revealed active diagnosis of pneumonia. B. On 11/16/22 at 8:46 AM, during an interview R #46 was asked when she had pneumonia, she stated, about year and half ago. C. On 11/16/22 at 2:32 PM, during an interview the MDS Coordinator (MDSC) confirmed that R #46's active diagnosis for pneumonia was incorrect and should have been taken off her assessment. The MDSC confirmed that R #46 had pneumonia roughly a year/year and half ago but has since recovered. The MDSC explained that the MDS auto-populated it and he failed to remove it on…

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

Based on interview and record review, the facility failed to ensure that residents receive proper treatment to maintain vision for 1 (R #36) for 1 (R #36) resident sampled for vision, when they failed to follow up with R #36's eye doctor after he requested from the nurse to know why he not received his eye glasses several days after his appointment. This deficient practice could likely result in resident losing some independence if they cannot see. The findings are: A. On 11/15/22 at 11:23 AM, during an interview R #36 stated he went to the eye doctor but hasn't received his glasses yet. B. Record review of R #36's Progress Notes revealed the following: 1) On 10/02/22 at 2:40 pm, General Note: Resident requested eye doctor visit. Stated not able to see with current eyeglasses. 2) On 10/13/22 at 8:59 am, General Note: Optomology (Eye doctor) appointment scheduled . on Thursday November 3, 2022 @ (at)10:00 am. 3) RN #5 documented on 11/13/22 at 2:14 pm, General Note: Resident states that after visiting eye doctor he is expecting new eyeglasses to improve his vision . C. On 11/16/22 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.

Based on interview and record review, the facility failed to ensure that the nurses aides had competencies (is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) in skills necessary to care for resident needs for 2 (CNA #7, and CNA #8) of 3 (CNA #6, CNA #7, and CNA #8) CNAs sampled for competency. This deficient practice could likely result in staff working who are not competent to give care to residents. The findings are: A. Record review of CNA #7's personnel file revealed 1) No CNA competencies were found. B. Record review of CNA #8's personnel file revealed 1) No CNA competency were found. C. On 11/17/22 at 2:43 PM, during an interview Human Resources confirmed that CNA #7 and CNA #8 did not have any of the CNA competencies.

Based on interview and record review the facility failed to have performance reviews every 12 months for 2 (CNA #7, and CNA #8) of 3 (CNA #6, CNA #7, and CNA #8) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being under trained and providing inadequate care. The findings are: A. Record review of CNA #7's personnel file revealed 1) No performance evaluation. B. Record review of CNA #8's personnel file revealed 1) No performance evaluations. C. On 11/17/22 at 2:43 PM, during an interview Human Resources confirmed that CNA #7 and CNA #8 did not have a performance evaluation.

Based on observation and interview, the facility failed to properly store medication in a medication cart for all 17 residents on 100 hall (residents were identified by the resident matrix provided by the Administrator on 11/15/22) that were randomly sampled, when they failed to lock the medication cart when not in use. This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects. The findings are: A. On 11/17/22 at 8:28 AM, during an observation of the 100 hallway revealed the medication cart unlocked. No staff were present. B. On 11/17/22 at 8:30 AM, during an interview RN #5 confirmed the cart was unlocked. C. On 11/17/22 at 10:20 AM, during an interview the DON confirmed that the medication cart should be locked when not in use.

Based on observation, interview, and record review, the facility failed to follow proper infection control practices for 2 (R #21 and R #28) of 2 (R #21 and R #28) residents identified during random observation when the facility failed to: 1) Ensure R #21's nasal cannulas (flexible tubing that sits inside the nostrils and delivers oxygen) were not on the floor. 2) Ensure R #28's Nebulizer masks (nebulizer is a device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) were covered when not in use. These deficient practices could likely result in the spread of contagious and resistant illnesses to other residents. The findings are: R #21 A. On 11/16/22 at 12:30 PM, during observation by the main entrance of the building, R #21 was sitting in her wheelchair waiting for the Transporter to change the tubing to her portable oxygen when the tubing connected to the portable oxygen tank was seen laying on the floor. B. On 11/16/22 at 12:35 PM, during an interview, the Transporter revealed that he did not notice the tubing on the floor due 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, interviews, and record review the facility failed to treat residents with respect and dignity for 1 (R #53) of 1 (R #53) resident sampled for dignity, when they failed to clean R #53, who is dependent on staff for assistance, after breakfast leaving him with food and nasal discharge in the common TV room. This deficient practice could cause resident to become depressed and anxious if residents do not get the help cleaning themselves after meals. The findings are: A. Record review of R #53's Care Plan dated 07/14/22 revealed the following: 1) [Name of R #53] exhibits decreased ability to perform ADL (Activities of Daily Living)(s) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to: History of CVA (Cerebrovascular Accident Stroke) . B. On 11/15/22 at 12:24 PM, during observation in the dining room, prior to being served lunch, R #53 was covered with a black fleece blanket that was draped over his lap and was visibly dirty with white stains that looked like dried food. C. On 11/16/22 at 8:53 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 observation, the facility failed to make prompt efforts to resolve grievances the resident may have for 1 (R #3) of 1 (R #3) residents sampled for missing property, when staff were made aware of R #3's missing remote for his TV and did not assist him in finding it until the next day. This deficient practice could likely result in emotional anguish for resident whom having missing property and are unable to find them. The findings are: A. On 11/15/22 at 2:08 PM, during an interview R #3 stated the remote to his TV was missing, and he told staff about it being missing. B. On 11/15/22 at 2:08 PM, during an observation of R #3's room no TV remote was visible. C. On 11/17/22 at 8:32 AM, during an interview the Social Services Director (SSD) confirmed that R #3 had told the Activities Director who then told her on 11/16/22. The SSD stated that she was going to look into finding R #3's remote because she had not yet done so. D. On 11/17/22 at 11:02 AM, the SSD stated she had found R #3's TV remote.

Based on interview and record review, the facility failed to report allegations of abuse to the State Agency within 2 hours for 1 (R #22) of 1 (R #22) residents review for abuse. This deficient practice could likely result in resident continuing to be abuse if allegations go unreported. The findings are: A. On 11/15/22 at 10:38 AM during an interview R #22 stated that 2 CNAs verbally abused her. R #22 stated that she did report the incident to the facility. R #22 was not sure of when and to whom she reported the allegation to. B. On 11/15/22 at 11:06 AM during an interview with the Administrator he stated that the facility was not aware of the allegation of verbal abuse regarding the two CNAs. The Administrator stated that the facility will investigate. C. Record review of the facility incident report dated 11/15/22 showed a time stamp of 3:58 pm (almost 5 hours after the facility was made aware). D. On 11/16/22 at 2:06 PM, during an interview the Administrator confirmed that the facility did not report the allegation of abuse within 2 hours. E. On 11/16/22 at 2:13 PM, during 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, and interview, the facility failed to revise the care plan for 3 (R #14, R #26, and R #36) of 3 (R #14, R #26 and R #36) resident reviewed for care plans, when they failed to: 1) Revise R #14's care plan to discontinue the use of Heperin (an anticoagulant A substance that is used to prevent and treat blood clots in blood vessels and the heart. Used to decrease the clotting ability of the blood and help prevent harmful clots from forming in blood vessels blood thinner). 2) Revise R #26's care plan to add weekly counseling. 3) Revise R #36's care plan to add any ADL(Activities of Daily Living). This deficient practice could likely result in the care plan not reflecting resident's current goals and care needs preventing residents from gaining and/or maintaining their highest practicable level of well-being. The findings are: R #14 A. Record review of R #14's Face Sheet revealed she was readmitted to the facility on [DATE] after being hospitalized . B. Record review of R #14's 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.

Based on record review and interview the facility failed to have the attending physician document his or her rationale in the resident's medical record when responding to the pharmacy recommendations for 1 (R #3) of 5 (R #3, R #14, R #28, R #46, R #47) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications longer than needed. The findings are: A. Record review of R #3's Pharmacy Recommendations for September 2022 revealed the following recommendations: 1) R #3 receives three or more CNS active (drugs that work on the Central Nervous System) medications . Hydroxyzine . risperidone . recommendation to reduce R #3's risperidone from 0.5 mg twice a day to 0.25 mg every morning and 0.5 mg in the evening. The decline box was handwritten as selected and written below decrease hydroxyzine to 25 mg every 8 hrs. No rationale documented. Provider signature dated 09/30/22. DON noted on 10/10/22. 2) R #3 receives three or more CNS active medications . Hydroxyzine . risperidone . recommendation to reduce R #3's risperidone…

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.