Las Cruces Wellness & Rehabilitation LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to report the results of the investigation within 5 days of the incident to the State Agency for 2 (R #270 and R #271) of 2 (R #270 and R #271) residents sampled for abuse. If the facility fails to report the results of the investigations to the State Agency within five days, then corrective action may not be taken and residents could likely suffer serious bodily injury. The findings are: R #270 A. Record review of the facility's 5-day report (no date) revealed the following: 1. R #270 fell on [DATE], that resulted in an emergency room (ER) visit with a diagnosis of acute displacement of the left hip, that required surgery on 03/05/24. 2. The record did not contain any documentation that the follow up report was submitted to the state agency. R #271 B. Record review of the facility's 5-day report (no date) revealed the following: 1. R #271 sustained a fall on 03/05/24, that resulted in an ER visit and R #271 did not have a serious injury. 2. The record did…

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 resident's representative(s) of the transfer in writing for 4 (R #15, R #109, R #266, and R #269) of 4 (R #15, R #109, R #266, and R #269) residents sampled for hospitalizations when they failed to: 1. Notify the resident's representative(s) of the transfer to the hospital in writing and in a language and manner they understand for R #15, R #109, R #266, and R #269. 2. Include the name, phone number, and address (mailing and email) of the Office of the State Long-Term Care Ombudsman on the transfer notification form. 3. Send a written copy of the Transfer Notices for R #15, R #266, and R #269 to the Ombudsman. These deficient practices could likely result in the resident and/or their representative not knowing the reason for a transfer, and their rights to advocate and make informed decision regarding their healthcare. The findings are: R #15 A. Record review of R #15's medical record revealed R #15 was transferred to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that residents and their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 4 (R #15, R #109, R #266, and R #269) of 4 (R #15, R #109, R #266, and R #269) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: R #15 A. Record review of R #15's medical record revealed R #15 was transferred to the hospital on [DATE]. B. Record review of R #15's bed hold notice revealed the following: 1. Staff did not document how many days a bed would be held for the resident. 2. Staff did not document who was notified about the bed hold notice. 3. Staff did not document that the Bed Hold Notification was provided to the resident. 4. Staff did not document that the Bed Hold Notification form was provided to the resident's family. R #109 C.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to create a baseline care plan (healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours, that accurately reflected the resident's current condition for 4 (R #59, R #96, R #110, and R #163) of 5 (R #59, R #96, R #110, R #163 and R #266) residents sampled for baseline care plan when staff failed to: 1. Include physician's orders for R #59's antibiotic and use of oxygen. 2. Complete all sections of the baseline care plan and did not include physician's orders for R #96's antibiotic. 3. Complete all sections of the baseline care plan and did not include R #163's dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities)-mild (stage of dementia where cognitive impairment starts to become more noticeable to the patient, as well as friends and family members) diagnosis and physician's orders for R #163 taking an antipsychotic medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure care plans were complete for 3 (R #106, R #108, and R #265) of 3 (R #106, R #108 and R #265) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the needs of the residents. The findings are: R #106 A. Record review of R #106's medical record revealed R #106 was admitted on [DATE]. B. Record review of R #10's care plan dated 06/11/24, revealed the care plan did not address R #10's discharge plan and any referrals to the local contact agency. C. On 07/01/24 at 2:20 PM, during an interview, Social Services confirmed that if it is not documented on R #10's care plan for discharge she did not do it. R #108 D. Record review of R #108's medical record revealed R #108 was admitted on [DATE]. E. On 06/25/24 at 10:56 AM, during an interview with R #108, he revealed the following: 1. He had a urinary tract infection (UTI, an infection in any part of the urinary system) and was receiving…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure care plan revision and care plan meeting requirements occurred for 5 (R #1, R #2, R #5, R #74, and R #266) of 5 (R #1, R #2, R #5, R #74, and R #266) when the staff failed to: 1. Revise the care plan with the most current resident information for R #2, R #5, R #74, and R #266. 2. 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, and includes other appropriate staff or professionals in disciplines as determined by the resident's needs) members participate in the care plan meeting for R #1 and R #2. These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a resident who enters the facility with diagnosis of urinary tract infection (UTI) received appropriate treatment for 1 (R #59) of 2 (R #59 and R #96) residents reviewed for UTI when they failed to ensure that a resident received all doses of antibiotic as prescribed to treat the UTI. This deficient practice could result in residents being susceptible to worsening of infection or becoming septic (potentially life-threatening when the body responds to infection by damaging its own tissues) The findings are: A. On 06/25/24 at 10:31 AM, during an interview, R #59 laid in bed and reported she was discharged to the facility about a week ago due to being in the hospital for a urinary infection. B. Record review of R #59's face sheet revealed R #59 was admitted to the facility on [DATE]. C. Record review of R #59's hospital discharge instructions dated 06/19/24 revealed: 1. Diagnosis; urinary tract infection (UTI). 2. New medications, start…

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 note from the provider (physician or nurse practitioner) at the time of each visit for 1 (R #15) of 1 (R #15) residents reviewed for physician's visits This deficient practice could likely result in the resident's needs not being met due to facility staff being unaware of resident's status related to lack of written, signed, and dated progress notes at the time of the visit. A. Record review of R #15's Electronic Medical Record (EMR) revealed R #15 was admitted to the facility on [DATE]. B. Record review of R #15's physician's progress notes revealed the following: 1. History and Physical (H&P), dated 04/14/24, revealed the H&P note was a late entry entered on 06/20/24. 2. Provider progress note, dated 04/15/24, revealed the note was a late entry entered on 06/20/24. 3. Provider progress notes dated 04/16/24, revealed the note was a late entry entered on 06/20/24. 4. Provider progress notes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that residents had a physician visit at least every 30 days for the first 90 days after admission for 1 (R #15) of 1 (R #15) residents reviewed for physician's visits. This deficient practice could likely result in residents not receiving the required medical assessment which could cause a delay in care and treatment of medical conditions. The findings are: A. Record review of R #15's Electronic Medical Record (EMR) revealed R #15 was admitted to the facility on [DATE]. B. Record review of R #15's entire EMR revealed the medical record did not contain any documentation that R #15 was seen by the physician. C. On 07/01/24 at 2:35 PM, during an interview with the Administrator, she confirmed the following: 1. There was no documentation in R #15's medical record from the physician. 2. She was unable to determine if R #15 was seen by a physician. 3. She was unsure how frequently R #15's physician sees residents in the facility. 4. Her expectation is…

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 store medications properly for all 17 residents in rooms 135-151 (residents were identified by the Resident Matrix provided by the Administrator on 06/25/24), when they failed to ensure the medication cart did not contain loose medications. This deficient practice could likely result in residents obtaining or being administered medication not prescribed to them, receiving medications that are less effective and may result in adverse side effects. The findings are: A. On 06/29/24 at 2:55 PM, during an observation of the medication cart assigned to room's 135-151, one white oval tablet was loose between the medication cards (cardboard and foil packaging prefilled with prescription medication) in the second drawer of the medication cart. B. On 06/29/24 at 2:57 PM, during an interview with LPN #34, he confirmed there was a loose white tablet stating, I will remove it. C. Record review of the facility's Storage of Medication Policy dated September 2018, revealed Medications and biologicals are stored properly,…

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 medical records were complete and accurate for 1 (R #18) of 5 (R #1, R #18, R #109, R #110 and R #111) 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 #18's medical record dated 05/30/24 revealed R #18 has a diagnosis of Dysphagia (difficulty or discomfort in swallowing). B. Record review of R #18's care plan dated 06/02/24 revealed R #18's mouth needed to be checked after meals for pocketed (when food is held in the mouth for an extended amount of time without swallowing) food and debris. C. On 06/26/24 at 2:23 PM, during an interview, LPN #11 said that the nurses are the ones that will check to see if R #18 has pocketed food after meals. LPN #11 said that she does not document when she checks R #18 for pocketing after meals. LPN #11 said she doesn't know how to tell if R #18 is being checked after meals.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was completed within 14 calendar days after admission for 1 (R #266) of 4 (R #15, R #108, R #265, and R #266) 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 #266's admission record revealed an admission date of 06/08/24. B. Record review of R #266's admission MDS assessment revealed the admission MDS assessment was completed on 07/01/24. C. On 07/02/24 at 9:23 AM, during an interview with the MDS Nurse, she confirmed the following: 1. R #266 was admitted to the facility on [DATE]. 2. R #266's admission MDS assessment was not completed within 14 days of admission. 3. The expectation is for admission MDS Assessments to be completed within 14 days of admission.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to keep residents free from accidents for 1 (R #266) of 1 (R #266) resident reviewed, when they failed to ensure that skin creams were stored out of resident's reach. These deficient practices could likely result in residents obtaining medical equipment which can cause injury/death. The findings are: A. On 06/25/24 at 1:39 PM, during an interview with R #266's family member, she stated that R #266 had gone to the hospital on [DATE]. B. Record review of R #266's nursing progress note, dated 06/24/24, revealed R #266 was sent to the hospital after being found with white cream on her teeth and tongue. C. On 07/02/24 at 9:55 AM, during an interview with RN #21, the following was revealed: 1. On 06/24/24, R #266 was in her room and had white cream all over her mouth, tongue, and teeth. 2. There were two tubes of barrier cream (a topical formulation used to place a barrier between the skin and contaminants that may irritate the skin, typically used for…

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

Based on observation, interview, and record review the facility failed to follow proper infection control practices for 1 (R #74) of 2 (R #5 and R #74) residents identified during random observation when the facility failed to ensure resident's nasal cannulas (a device that delivers extra oxygen through a tube and into your nose) were labeled with the date that they were changed. This deficient practice could likely result in the spread of contagious and resistant illnesses to other residents. The findings are: A. On 06/25/24 at 1:31 PM, during an observation of R #74's room, the nasal cannula tubing was not dated to indicate when it was changed. B. Record review of R #74's physician's orders dated 06/05/24 revealed the following: 1. Oxygen titration 0-6L (liters) via nasal cannula to keep saturations > (greater than) 92% every shift for hypoxia. 2. Oxygen at 4 Liters Per Minute (LPM) via nasal cannula every shift. C. On 06/25/24 at 1:33 PM, during an interview with LPN #34 she confirmed the following: 1. Nasal cannula oxygen tubing did not have a date. 2. She stated tubing gets…

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 1 (R #11) of 4 (R #11, R #12, R #13, and R #14) resident reviewed for care plans when they failed to revise R #11's care plan to include refusals for offloading (minimizing or removing weight placed on an area to prevent and heal ulcers) and repositioning. This deficient practice could likely result in staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: A. Record review of R #11's medical record revealed the following: 1. R #11 was admitted on [DATE]. 2. R #11 had a Stage III pressure ulcer [Full thickness tissue loss. Subcutaneous (under the skin) fat may be visible, but bone, tendon, or muscle are not exposed. Slough (the yellow/white material in the wound bed) may be present but does not obscure the depth of tissue loss] present on admission. B. On 04/05/24 at 2:51 PM, during an interview, the Wound Care…

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 The following is a recite from a recertification survey on 03/14/23. Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 3 (R #1, R #21, and R #23) of 4 (R #1, R #2, R #21 and R #23) when they failed to: 1. Initiate wound care upon admission for R #1 and R #23. 2. Answer call lights in a timely manner for R #21. This deficient practice could likely lead to residents needs not being met and/or a worsening of their condition. R#1 A. Record review of R #1's admission Record (no date) revealed an admission date of 08/01/23 with diagnoses of unspecified open wound (injury involving an external or internal break in the skin which can lead to sharp, stabbing, burning and/or tingling pain) of left thigh and right thigh. B. Record review of R #1's convalescent care orders (physician's orders for admission to a nursing facility), dated 08/01/23, revealed: 1. Does the patient have wounds or surgical sites? Yes.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that the MDS accurately reflected the resident's status at the time of the assessment for 1 (R #1) of 3 (R #1, R #2 and R #11) 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 #1's admission MDS, dated [DATE], revealed Section I, Active Diagnoses, question I8000, Additional active diagnoses: Pressure ulcer of sacral region (skin injury on the lower back/spine area), stage 3 (pressure ulcer that has gone through the top two layers of skin, as well as fatty tissue). B. On 10/30/23 at 3:00 PM, during an interview, the Wound Care Nurse stated R #1 did not have a stage 3 pressure ulcer to her sacrum. C. On 10/30/23 at 3:52 PM, during an interview, the DON stated R #1's MDS diagnosis should not include stage 3 pressure ulcer. The DON confirmed that R #1 did not have a pressure ulcer. D. On 10/30/23 at 4:00 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.

Based on observation and interview the facility failed to properly store medications in the medication carts for all 41 residents (residents were identified by the resident matrix provided by the Administrator on 03/07/23) that were randomly sampled, when they failed to secure the medication carts on both units in the facility. This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects. The findings are: Unit 1 A. On 03/07/23 at 11:33 AM, during an observation of Unit 1 revealed the medication cart unlocked, no staff were present. B. On 03/07/23 at 11:40 AM, during an interview LPN #8 confirmed that the medication cart was unlocked. Unit 2 C. On 03/07/23 at 4:16 PM, during an observation of Unit 2 revealed the medication cart on was not locked. No staff were in the area. D. On 03/07/23 at 4:19 PM, during an interview RN #14 confirmed that the medication cart was unlocked. E. On 03/14/23 at 2:33 PM, during an interview the DON confirmed the medications cart should be locked when not in line of site.

Based on record review and interview, the facility failed to notify residents of changes in treatment for 1 (R #246) of 1 (R #246) residents reviewed for notification of change, when they failed to notify R #246 of a change in her Anticoagulation medication (medicine used to reduce the risk of stroke and blood clots) and medical diagnosis. If the facility does not notify residents of the change in treatments or condition, then they will not have an opportunity to make decisions and/or advocate for treatment or care. The findings are: A. On 03/08/23 at 10:36 AM, during an interview with R #246, R #246 stated that she was told about having a blood clot (a gelatinous mass of fibrin and blood cells formed by the coagulation of blood) on 03/02/23 by a nurse when she was given more medication than usual, and asked why. B. Record review of R #246's MAR dated March 2023 revealed the following: 1. 02/22/23 start date Xarelto (a prescription medicine used to reduce the risk of stroke and blood clots) 2.5 mg day for dvt (a blood clot that develops within a deep vein in the body, usually in the…

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

Based on interviews, observations, and record reviews, the facility failed to ensure residents were protected from further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 12 (R #1, R#5, R #9, R #16, R #17, R #20, R #21, R #23, R #32, R#248, R #249, and R #250) of 12 (R #1, R#5, R #9, R #16, R #17, R #20, R #21, R #23, R #32, R#248, R #249, and R #250) residents randomly sampled. When the facility failed to remove LPN #13 after an allegation of abuse was made. This deficient practice could likely result in residents being at risk of continued abused. The finding are: A. Review of R #247's admission Record, revealed an admission date of 03/02/23. B. On 03/09/23 at 1:59 PM, during an interview with R #247, he stated that he was not sure of the date, but that while visiting with his daughter, a nurse made a comment about making a baby with him. R #247 gave the physical attributes of LPN #13 and gave a name very similar to LPN #13 (as he was unsure of her name). He responded to LPN #13 that he already had his kids and she replied 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 residents, their representatives, or the Ombudsman received a written notice of transfer as soon as practicable for 4 (R #5, R #20, R #40, and R #44) of 4 (R #5, R #20, R #40, and R #44) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative not knowing the reason or location that the resident was discharged . The findings are: R #5 A. Record review of R #5's Progress Notes revealed the following: 1. R #5 was transferred to the hospital on [DATE] for a fall. B. Record review of R #5's medical record revealed no written Transfer Notice. R #20 C. Record review of R #20's Medical Record revealed the following: 1) R #44 was sent to the hospital on [DATE]. 2) No written transfer notice was found. R #40 D. Record review of R #40's Progress Notes revealed the following: 1. R#40 was transferred to the hospital on [DATE] for high heart rate. E. Record review of R #40's 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.

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 their bed hold policy indicating the duration that the bed would be held for 4 (R #5, R #20, R #40, and R #44) of 4 (R #5, R #20, R #40, and R #44) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: R #5 A. Record review of R #5's Progress Notes revealed the following: 1. R #5 was transferred to the hospital on [DATE] for a fall. B. Record review of R #5's medical record revealed no written Bed Hold Policy Notice. R #20 C. Record review of R #20's Medical Record revealed the following: 1) R #44 was sent to the hospital on [DATE]. 2) No written Bed Hold Policy Notice was found. R #40 D. Record review of R #40's Progress Notes revealed the following: 1. R#40 was transferred to the hospital on [DATE] for high heart rate. E.…

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

Based on observation, record review, and interview, the facility failed to meet professional standards of quality for 1 for (R #7) of 4 (R #7, R #19, R #196, and R #197) residents observed during medication administration, when RN #1 held R #7's blood pressure medication without specific parameters (numerical or other measurable factor) from the medical provider. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication due to it not being administered. The findings are: A. On 03/10/23 at 8:40 AM, during observation of medication pass and interview, it was observed RN #1 did not administer Metoprolol Succinate (high blood pressure medication) ER (abbreviation for extended released meaning medication is released slowly over time) 50 MG. RN #1 stated she was holding the medication because R #7's blood pressure is 100/57 (number for blood pressure reading) B. Record review of R #7's Physician's orders revealed: Order Date 02/14/23; Metoprolol Succinate…

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, record review, and interviews, the facility failed to ensure activities were implemented for 3 (R #1, R #12 and R # 246) of 3 (R #1, R #12, and R # 246) residents reviewed for activities. This deficient practice could likely cause boredom, isolation, anxiousness and feeling helpless. The findings are: R #1 A. On 03/08/23 at 9:02 AM, during an interview, R #1 stated he wants to participate in activities but is not aware of any. R #1 did not state he refused activities. B. On 03/08/23 at 2:44 PM, during an interview with Social Services Assistant (SSA), she revealed that she tried to encourage R #1 to participate in activities, but he declines. SSA was asked if she documented R #1's refusals, she stated she had not documented the refusals. R #12 C. Record review of R #12's Care Plan dated 01/30/23 revealed the following: [Name of R #12] expects to have a short-term stay at this facility for rehab (rehabilitation). prefers independent activity . Activities will stop in to ensure I am content with my independent social and recreational contacts. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The following is a recite from a complaint survey on 10-31-22. Based on record review and interview, the facility failed to ensure call-lights were answered when a resident needed assistance for 3 (R #2, R #46 and R #247) of 3 (R #2, R #46 and R #247) residents reviewed for call-lights. This deficient practice could result in the residents' needs not being met, leaving them at risk for incontinence (lack of voluntary control over urination or defecation) and falls. The findings are: R #2 A. On 03/08/23 at 9:21 AM, during an interview, R #2 revealed that it takes about 30 minutes for staff to respond to his call light B. Record review of R #2's face sheet revealed an admission date of 02/20/23. C. Record review of R #2's MDS dated [DATE] revealed a BIMS (The Brief Interview for Mental Status is a structured evaluation aimed at evaluating aspects of cognition in elderly patients) score of 14 (Scores closer to 0 indicate severe cognitive impact and scores closer to 15 indicate an intact cognitive response). D.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to help maintain acceptable parameters of nutritional status, such as usual body weight for 1 (R #20) of 1 (R #20) residents sampled for nutrition, when they failed to conduct weekly weights for R #20 who had: a. a weight loss, b. physicians' orders to weigh weekly, and c. facility policy to weigh weekly. This deficient practice could likely result in residents losing weight without the facility being aware causing physical and mental health issues. The findings are: A. Record review of R #20's Care Plan dated 01/29/23 revealed the following: 1. - [name of R #20] has a potential nutritional problem r/t (related to) weakness and pain, at low BMI (Body mass index) and wound healing needs; had unplanned weight loss prior to admission. -Monitor/record/report to MD (Medical Doctor) PRN (as needed) s/sx (signs and symptoms) of malnutrition (lack of proper nutrition): . significant weight loss: 3 lbs (pounds) in 1 week, > (greater) 5% in 1 month, > 7.5% in 3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide pain management for 1 (R #46) of 2 (R #1 and R #46) residents reviewed for pain. Having a delay in delivery and administration of needed pain medication for R #46. This deficient practice likely resulted in residents experiencing unnecessary pain. The findings are: A. On 03/10/23 at 11:34 AM, during an interview, R #46 revealed she was not given her pain medications for several days after her admission when she was in pain. B. Record review of R #46's Electronic Medical Records (EMR) revealed: 1. admission [DATE] from [name of local hospital] Alert and Oriented x (times) 4 (someone who is alert and oriented to person, place, time and event), able to make needs known, .admitted for post -op (operation) right hip fracture care, to receive PT (Physical therapy), OT (Occupational therapy), and management of pain. 2. A BIMS (The Brief Interview for Mental Status is a structured evaluation aimed at evaluating aspects of cognition in elderly patients)…

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 nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs for 3 (CNA #11, CNA #12, and CNA #13) of 3 (CNA #11, CNA #12, and CNA #13) CNAs randomly 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 #11's personnel records revealed: 1) No CNA competency evaluation completed. B. Record review of CNA #12's personnel records revealed: 1) No CNA competency evaluation completed. C. Record review of CNA #13's personnel records revealed: 1) No CNA competency evaluation completed. D. On 03/14/23 at 11:22 AM, during an interview the Human Resources confirmed that the facility did not have CNA competencies for CNA #11, CNA #12, and CNA #13.

Based on observation, record review, and interview, the facility failed to ensure that the medication error rate was 5% or less for 2 (R #7 and R #196) of 4 (R #7, R #19, R #196, and R #197) residents observed during medication pass, when 1. R #7's blood pressure medication was held, and 2. Physician's orders were not followed for R #7 and R #196 medication administration. This deficient practice could likely result in residents not receiving the desired therapeutic effect and exposing residents to a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: R #7 A. On 03/10/23 at 8:40 AM, during observation of medication pass and interview, it was observed RN #1 did not administer Metoprolol Succinate (high blood pressure medication) ER (abbreviation for extended released meaning medication is released slowly over time) 50 MG (dosage of medication). RN #1 stated she was holding the medication because R #7's blood pressure is 100/57 (number for blood pressure reading). B. Record review of R #7's Physician's orders revealed: Order Date 02/14/23;…

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 ensure that residents are free of any significant medication errors for 1 (R #1) of 1 (R #1) residents reviewed for receiving medications, when they failed to administer medication per prescribers orders. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication due to it not being administered as prescribed. The findings are: A. Record review of R #1's Physician's orders revealed: Order Date 01/24/23; Norco (name brand of medication) 10-325 MG (strength of medication), Hydrocodone-Acetaminophen (generic name of combination medication used to relieve moderate to severe pain) Give 10 mg by mouth every 8 hours as needed for pain PS (abbreviation for pain scale) 5-10 (numbers on pain scale 1-10 indicating moderate to severe pain). B. Record review of R #1's Physician's orders revealed: Order Date 01/24/23; Tylenol (name brand of medication) 325 MG (strength of medication), Acetaminophen…

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 accurately document resident's records for 2 (R #1 and R #2) of 2 (R #1 and R #2) residents when they failed to document: 1. The administration of pain medication on R #1's Medication Administration Record (MAR) 2. R #2's bruising related to his anticoagulant medication (medication to reduce coagulation of blood) on the MAR. This deficient practice could likely result in staff being unaware of resident's current conditions resulting in injury. The findings are: R #1 A. Record review of R#1's Controlled Drug Record for Hydrocodone-Acetaminophen (combination medication is used to relieve moderate to severe pain) 10-325 mg (dosage of medication) revealed: 1. Medication was signed out on Controlled Drug Record as 02/07/23 at 3:05 AM. Upon further review the date of 02/07/23 was entered in error and medication was administered on 02/08/23 at 3:01 AM (according to the MAR below). 2. Medication was signed out on Controlled Drug Record on 02/13/23 at 9:00 AM. 3. Medication was signed out on Controlled Drug Record 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 that each resident received or was offered Pneumococcal (a bacteria that causes pneumonia infection of the respiratory tract) and Influenza (flu: disease caused by virus infecting the respiratory tract) for 3 for (R #1, R #28, and R #246) of 5 (R #1, R #20, R #28, R #40, and R #246) residents reviewed for immunizations. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents. The findings are: R #1 A. Record review of R #1's Electronic Medical Record (EMR) revealed 1. Consent form indicating the resident wanted the flu vaccine. 2. No documentation found in the EMR to indicate that resident received the flu vaccine. R #28 B. Record review of R #28's EMR revealed no documentation the flu vaccine was given or offered. R #246 C. Record review of R #246's EMR revealed no documentation the pneumococcal vaccine was given or offered. D. On 03/13/23 at 4:11 PM, during an interview, the Nurse Consultant confirmed that R #1'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 interview and record review, the facility failed to ensure that nursing staff have completed the mandatory Effective Communication training for 6 (CNA #11, CNA #12, CNA #13, LPN #11, LPN #12 and LPN #13) of 6 (CNA #11, CNA #12, CNA #13, LPN #11, LPN #12 and LPN #13) staff randomly sampled for staffing. This deficient practice could likely result in staff being unable to inform residents of their total health status and to provide notice of rights and services. The findings are: A. Record review of CNA #11's Online Training Transcript revealed: 1) No Effective Communication training completed. B. Record review of CNA #12's Online Training Transcript revealed: 1) No Effective Communication training completed. C. Record review of CNA #13's Online Training Transcript revealed: 1) No Effective Communication training completed. D. Record review of LPN #11's Online Training Transcript revealed: 1) No Effective Communication training completed. E. Record review of LPN #12's Online Training Transcript revealed: 1) No Effective Communication training completed. F. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a comprehensive assessment was completed within 14 days of admission for 1 (R #246) of 1 (R #246) resident sampled for activities. This deficient practice could likely lead to the residents' preferences and needs not being met. The findings are: A. Record review of R #246's admission Record revealed an admission date of 02/23/23. B. Record review of R #246's MDS dated [DATE] revealed it was not complete. C. On 03/09/23 at 1:52 PM, during an interview, the MDS Coordinator confirmed that the admission MDS for R #246 was not completed within 14 days of admission.

Based on record review and interview, the facility failed to have the attending physician document in the resident's medical record his or her rationale for not changing the medication that was identified for Gradual Dose Reduction (GDR) by the monthly Pharmacy Review for 1 (R #28) of 6 (R #5, R #20, R #28, R #31, R #42, and R #46) resident sampled for unnecessary medications. The facility failed to provide documentation of the physician's rationale to keep R #28's Citalopram (used to treat depression) dose unchanged after the pharmacy review recommended a GDR. This deficient practice could likely result in residents receiving higher doses of medication than is needed. The findings are: A. Record review of R #28 Pharmacy Review for February 2023 revealed the following: 1. A recommendation for a GDR Citalopram. 2. The provider checked a box Resident with good response maintain the current dose. 3. Important: Please add resident specific documentation to support the above action or check below if information was added to physician progress notes . No documentation after. B. 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, interview, and record review, the facility failed to ensure that residents were treated with respect and dignity for 2 (R #48 and R #205) of 2 (R #48 and R #205) residents randomly sampled for dignity, when the facility failed to: 1. Knock on R #48's door before entering their room. 2. Place a dignity cover (a cover that conceals fluid in the drainage bag to improve patient dignity) on R #48's catheter bag. 3. Change R #205's clothing after she spilled food on her hospital gown at mealtime. If the facility is not treating residents with respect and dignity, then residents are likely to feel embarrassed and that their feelings/preferences are unimportant to facility staff. The findings are: R #48 A. On 12/15/21 at 2:16 PM, during an observation in R #48's room, the Wound Care Nurse did not knock on R #48's door before entering the room. B. On 12/16/21 at 2:30 PM, during an interview with the Wound Care Nurse, she confirmed that she should have knocked on R #48's door before entering. C. On 12/15/21 at 2:16 PM, during an observation in R # 48's room, R #48's…

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

Based on observation, record review, and interview, the facility failed to provide reasonable accommodations of residents needs and preferences for 2 (R #109 and R #204) of 2 (R #109 and R #204) residents reviewed during random observation when the facility failed to have the call lights (a device used by a patient to signal his/her need for assistance from staff) accessible for residents. This deficient practice could likely result in residents feeling that their preferences are unimportant and could likely results in residents being unable to call for assistance while they need help. The findings are: R # 109 A. On 12/20/21 at 11:07 AM, an observation of R #109's room revealed resident was sitting in his wheelchair, his call light was attached to a pillowcase, the pillow was on top of his bed upside down away from R #109's access. B. Record review of R #109's Nurses Notes revealed diagnosis of weakness. C. On 12/20/21 at 11:07 AM, during an interview CNA #3 confirmed that R #109 did not have access to his call light. R #204 D. On 12/15/21 at 10:04 AM, during an interview, R #204…

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 include necessary care/treatment, and services with goals in the baseline care plan for 3 (R #101, R #107, and R #206) of 3 (R #101, R #107, and R #206) residents reviewed for baseline care plans, when the facility failed to initiate a baseline care for: 1. R #101's ADL's (Activities of Daily Living), 2. R #107's Insulin (a protein hormone that is used as a medication to treat high blood glucose) 3. R #206's Activities, Lorazepam (Sedative, it can treat seizure disorders, such as epilepsy. It can also be used before surgery and medical procedures to relieve anxiety), Risperidone (Antipsychotic, it can treat schizophrenia, bipolar disorder, and irritability caused by autism) and Enoxaparin Sodium Solution (an anticoagulant that helps prevent the formation of blood clots). This deficient practice could likely result in residents not receiving the care and services need to obtain their highest quality of life. The findings are: R #101 A. Record Review of R #101's Face Sheet revealed admission date of 12/17/21. B. 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 record review and interview, the facility failed to develop and implement an effective discharge planning process that had resident's discharge goals for 3 (R #105, R #109 and R #206) of 3 (R #105, R#109 and R #206) residents reviewed for discharge planning. This deficient practice has the potential to complicate or prevent smooth and safe transitions from the facility to the residents' post-discharge settings. The findings are: R #105 A. Record review of R #105's Face Sheet revealed admission date of 11/28/21. B. Record review of R #105's Progress Notes revealed no documentation on a Discharge Plan. C. Record review of R #105's Care Plan revealed, no Discharge Plan. D. On 12/20/21 at 2:43 PM, during an interview, the Director of Clinical Services confirmed that no Discharge Plan was in place for R #105. R #109 E. Record review of R #101's Face Sheet revealed admission date of 12/17/21. F. Record review of R #101's Nurses Notes revealed no discharge documentation was found. G. Record review of R #101's Care Plan revealed no documentation for discharge was found. H. 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 keep residents free from unnecessary psychotropic medications for 1 (R #206) of 1 (R #206) resident sampled for unnecessary medications, when they: 1. Failed to have an end date for R #206's PRN (as needed) psychotropic (medication affecting the mind, emotions and behaviors) medication Lorazepam (medication used to treat anxiety), 2. Prescribe Risperidone (an antipsychotic drug used to treat certain mental/mood disorders (such as schizophrenia, and bipolar disorder) with the incorrect diagnosis of depression, 3. Failed to obtain consent for using anti-anxiety (medication to treat anxiety) and antidepressant (medication to treat depression) medications until 7 days after the treatment was initiated (12/08/21) and 4. Failed to perform AIMS (Abnormal Involuntary movement scale) (Clinical rated scale to assess severity of facial movements and body movements after use of psychotropic medications) assessment after administering medication Risperidone. These deficient practices could likely result in resident receiving…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to properly store medications for residents on the Unit One.(residents were identified by the resident matrix provided by the Administrator on [DATE]) when they failed to: 1. Date open medication bottles, and 2. Have medications inside of the treatment cart close to open packages of Medihoney (medication to decrease bacterial growth within the wound) and Hydrofera (used for wound protection and prevent bacteria and yeast growth) . This deficient practice could likely result in residents obtaining medications not properly stored, or expired, resulting in adverse side effects. The findings are: A. On [DATE] at 3:30 PM, during an observation of Unit One's medication cart revealed the following: 1. Hydrolyzed liquid protein (supplement used to provide individuals with additional protein) bottle open with no date. The medication was rubbed all over outside of the bottle. B. On [DATE] at 3:35 PM, during an observation of Unit One's treatment/wound care cart…

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: 1. Ensure that food items in the pantry are labeled and dated, and 2. Keep the deep freezer's floor clean and free from clutter. These deficient practices could lead to foodborne illnesses that could affect all 37 residents in the facility (residents were identified on the census list provided by the Administrator on 12/15/21) who eat food prepared in the kitchen. The findings are: Pantry A. On 12/15/21 at 10:07 AM, an observation of the Kitchen revealed the following open items with no expiration or use by date: 1. One package of Beef flavor gravy. 2. One package of instant mash potatoes. 3. Two packages of vanilla pudding. 4. One package of Almonds. 5. Three bags marshmallows. 6. One package of raisins. 7. Three packages of jello mix. 8. Two packages of cake mix. 9. One package of biscuit mix. 10. One bag of macaroni. Deep Freezer B. On 12/15/21 at 10:07 AM, during an observation of the kitchen revealed the floor in the deep freezer had food particals/paper and in need of being swept and mopped. C. 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 provide an opportunity for residents to form a resident council for 2 (R #107 and R #211) of 25 residents (residents were identified by the documents provided by the Administrator on 12/15/21) randomly sampled for resident council. This deficient practice could likely affect residents that want to participate in a resident council meeting and express their concerns or grievances. The findings are: A. Record review of the document provided by the Administrator no date and no title revealed the following: Because we are a short-stay facility and our average length of stay is below 20 days most months, the facility does not have a Resident Council President. B. On 12/17/21 at 11:30 AM, during an interview with the Administrator stated, Our admission team is in charge of providing an end of stay questionnaire to the residents about their experience and stay in this facility, but we have not been very consistent with the questionnaires. Facility used end of stay questionnaires to provide an opportunity for resident's council,…

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 provide an ongoing activities program designed to meet the interests and well-being of residents for 1 (R #206) of 1 (R #206) resident randomly sampled for activities, by not providing meaningful individualized activities based upon residents' interests. If residents are not provided or encouraged to attend/participate in activities that meet their interests, are enjoyable, and enhance their social and emotional well-being, then they are likely to experience an increase in boredom, isolation, and depression. The findings are: A. On 12/15/21 at 10:52 AM, during an observation, R #206 was observed in his room sitting in his wheelchair. B. On 12/15/21 at 10:53 AM, during an interview R #206 stated since the day of admission the facility only offered him to play Bingo once, no other activities being offered. C. Record review of R #206's admission records revealed he was admitted to the facility on [DATE]. D. Record review of R #206's Progress…

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 provide proper care for pressure wounds (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for 1 (R #152) of 1 (R #152) resident sampled for pressure wounds, when they failed to follow proper infection control practices while performing wound care for R #152's pressure wound. This deficient practice could likely result in the spread of bacteria and could cause residents to develop infections. The findings are: A. Record review of R #152's Physicians Order revealed the following: 1. 12/20/21 . Cleanse wound with normal saline (solution used to clean wounds) and 4x4 gauze (soft and absorbent pads for wound cleaning) apply Medihoney (medication to decrease bacterial growth within the wound) to wound base and cover with dressing daily. B. On 12/20/21 at 1:07 PM, during an observation of wound care for R #152 revealed the following issues: 1. Wound Care Nurse (WCN) performed pericare (cleaning the private area) and wiped resident's bowel movement (stool pass). She (WCN) failed 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, interview and record review, the facility failed to provide the necessary care to effectively manage pain for 1 (R #152) of 1 (R #152) resident sampled for pain management, when they failed to manage R #152's pain properly before performing wound care. Failure to assess and treat pain could likely result in residents experiencing unnecessary increased discomfort. The findings are: A. On 12/20/21 at 1:07 PM, during an observation of wound care for R #152's pressure wound (injury to the skin resulting from prolonged pressure on the skin) expressed high level of pain and discomfort to her hip and wound to the coccyx (bone at the base of spine) area, stating I am hurting, I can not take this pain anymore, why is taking so long to finish this wound care? She complained of pain to the wound site while the Wound Care Nurse (WCN) was cleaning the area with normal saline (solution used to clean wounds) and gauze (soft and absorbent pads for wound cleaning). R #152 was observed moaning, grimacing (facial expression that usually suggests pain) and crying while she was…

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

Based on record review and interview the facility failed to ensure documents in resident record was complete and accurate for 1 (R #205) of 15 (R #35, R #40, R #48, R #50, R #105, R #106, R #151, R #152, R #153, R #154, R #167, R #205, R #206, R #207 and R #208) residents reviewed for Advanced Directives (legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity [physical or mental inability to do something or to manage one's affairs]) . This deficient practice could likely result in staff not knowing the status of resident's medical intervention wishes resulting in a delay or lack of care for residents. The finding is: A. Record review of R #205's Medical Orders for Scope of Treatment (MOST) form (legal document detailing the wishes of medical intervention [action that alters the course of a disease, injury, or condition by initiating a treatment or performing a procedure] during an emergency) dated 12/16/21 revealed the Signature of Physician section was not…

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