La Vida Buena Healthcare

Based on record review and interview, the facility failed to report an investigation regarding allegations abuse and neglect within the required timeframe (2 hours) for 3 (R #'s 13, 14, and 17) of 4 (R #'s 13, 14, 16, and 17) residents reviewed for grievances.If the facility is not submitting the summary of the facility's investigation to the State Agency, then the State Agency is unable to appropriately triage (review) the allegation for further investigation.The findings are: A. Refer to F0610 for related findings. R #13: B. Record review R #13's neglect incident report provided by the facility dated 07/17/25 revealed the following:Details of Incident: During an audit of facility grievances, this incident is being reported that R #13 stated Nursing Assistant (NA) #1 came to change R #13 but left to get supplies and never returned to change R #13. Another staff member came to assist R #13. After Incident Actions: NA #1 was re-educated. Details of Interventions: Investigation is ongoing. Follow-up was reported to the SA on 07/22/25 at 10:34 am. No indication that the neglect…

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 complete a thorough investigation and report the investigation findings within five working days, for allegations of abuse and neglect for 3 (R #'s 13, 14, and 17) of 4 (R #'s 13, 14, 16, and 17) residents reviewed for grievances. If the facility is not completing an accurate and thorough investigation and submitting the summary of the facility's investigation to the State Agency, then the State Agency (SA) is unable to appropriately triage (review) the allegation for further investigation.The findings are: R #13: A. Record review of R #13's facility grievance dated 07/17/25 revealed the following:Subject: R #13 stated that Nursing Assistant (NA) #1 answered her call light but stated that she needed to go get more bed sheets and never returned to help R #13. R #13 pressed her call light again, and an unnamed Certified Nursing Assistant (CNA) came in to assist R #13. NA #1 returned to R #13's room and was laughing while the CNA was assisting R #13. Later that day, R #13 was in the shower, and NA #1 came into the shower room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 2 (R #'s 9 and 11) of 2 (R #'s 9 and 11) residents when the facility failed to:Remove R #9's scalp staples within 7 to 10 days as ordered by a physician. Provide physician orders for anticoagulant (blood thinner) complications (bruising, bleeding, pain, swelling, and dizziness) monitoring (daily nursing assessments) for R #11. If the facility is not following physician orders or providing medication monitoring orders, then residents are at risk of adverse outcomes and inadequate monitoring of treatment. The findings are:R #9: A. Record review of R #9's face sheet revealed R #9 was admitted into the facility on [DATE]. B. Record review of R #9's emergency room (ER) Discharge Instructions (Orders) dated 06/13/25 revealed R #9 was to have his staples that were located on his head, to close a laceration (a tear or ragged cut in skin or flesh), removed in 7 to 10 days. C. 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 Based on record review and interview, the facility failed to provide a program of activities sufficient to meet each resident's capabilities, interests and needs, for 1 (R # 5) of 3 (R #s 1, 2 and 5) residents reviewed for activities. This deficient practice has the potential to cause residents feelings of boredom, isolation and depression. The findings are: A. On 07/22/25 at 11:17 am during an interview with R #5 he stated that he would like to be integrated back into the community. He further stated that there are no facility outings scheduled by the facility and he would like to go outside to walk but he was told he was not to leave the facility without someone accompanying him. R #5 feels frustrated because he is not able to exercise his rights to be able to leave the facility to go to the store or to walk around the facility grounds. B. Record review of Activity assessment dated [DATE] revealed: Page 2 question 7. Go outside for fresh air when the weather is nice: 1) Very Important. C. 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 residents received the necessary treatment and services to prevent the development and worsening of pressure wounds (also called a pressure injury/pressure ulcer; skin damage which results from unrelieved pressure on the body) for 1 (R #15) of 1 (R #15) resident reviewed when staff failed to: Monitor for changes in R #15's coccyx (tailbone area; base of spine) pressure ulcer and timely notify the provider (physician and/or Nurse Practitioner) of R #15's pressure ulcer worsening and development of new pressure wound.Document and monitor wound progress (that includes measurements; to track effectiveness of wound care treatments and to prevent the progression of pressure ulcers) for R #15, so any pressure ulcer changes can be managed and/or treated without delay. These deficient practices likely resulted in R #15's pressure ulcer worsening with necrotic tissue (death of cells in tissue due to disease, injury, or failure of the blood supply) which…

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 utilize Nursing Assistants (NAs) appropriately by using NAs for more than 4 months, on a full-time basis to provide nursing and nursing related services for 2 (NAs #1 and 2) of 3 (NAs #1, 2, and 3) reviewed for staffing.If the facility is staffing NAs for longer than 4 months, then residents are likely to not receive the appropriate care, services and may not meet the needs of all residents.The findings are: NA #1: A. Record review of the facility staffing list reviewed on 07/24/25 revealed NA #1 was hired by the facility on 01/13/25 as a Nurse Aide in Training. B. Record review of the facility staffing schedule dated 07/21/25 through 07/24/25 revealed NA #1 worked on a unit as a Nurse Aide in Training.C. On 07/24/25 at 2:48 pm during an interview with NA #1, she stated that she just became a Certified Nursing Assistant (CNA) about one week ago, but prior to that, she was working at the facility as a Nurse Aide in Training for longer than 120 days. NA #2: D. Record review of the facility staffing list reviewed on 07/24/25…

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 ensure a resident was treated with respect and dignity for 1 (R #5) of 3 (R #1, 2 and 5) residents reviewed for dignity by:1. Not allowing the resident to leave the facility per his preference.2. Re-directing the resident back to the facility when he has wanted to leave to go for a walk or shopping and not offering the resident an alternate solution/plan. This deficient practice created frustration and confusion for the resident because he did not understand why he was unable to leave. The findings are:A. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE].B. On 07/22/25 at 10:51 AM- during a phone interview with R #5's Sister she stated He complains about not being able to leave whenever he wants. I was told that he needs someone to sign him out. I don't know what their policy is about him leaving on his own is but he capable of making his own decisions.C. On 07/22/25 at 11:17 AM during an interview with R #5, he…

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 staff revised the care plan for 1 (R #5) of 3 (R #1, 2 and 5) residents reviewed when staff failed to update the care plan to include R #5 not being able to leave the facility independently. This deficient practice is likely to result in residents' preferences and needs not being addressed if care plans are not updated. The findings are: A. On 07/22/25 at 11:17 am during an interview with R #5 he stated that he would like to be integrated back into the community. He further stated that the facility doesn't have any outings scheduled and he would like to go outside to walk but he was told he was not to leave the facility without someone accompanying him. R #5 feels frustrated because he is not able to exercise his rights to be able to leave the facility to go to the store or to walk around the facility grounds. B. Record review of Activity assessment dated [DATE] revealed: Page 2 question 7. Go outside for fresh air when the weather is nice: 1)…

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 have competent (aware of each resident's current health status and regular activity) nursing staff that was aware of anticoagulant (blood thinner) use for 1 resident (R #11) of 1 resident's (R #11) reviewed for falls. If nursing staff are not aware of anticoagulant medications taken by residents; then this deficient practice is likely to result in medication administration errors, the lack of monitoring of the resident's condition, delays in treatment or interventions, and increased risk of serious injury or complications such as bleeding, following a fall. The findings are: A. Record review of R #11's face sheet revealed R #11 was admitted into the facility on [DATE]. B. Record review of R #11's physician orders dated 02/07/24 revealed R #11 was prescribed Xarelto (anticoagulant) 2.5 mg (milligrams), give one tablet by mouth twice a day related to heart disease.C. Record review of R #11's care plan dated 05/06/25 revealed that R #11 received…

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 promote resident choices for 1 (R #3) of 2 (R #'s 2 and 3) residents reviewed for choices when staff failed to offer R #3 showers per her preference. If the facility does not honor residents' choices, then residents are likely to experience a loss of independence and self-worth leading to feelings of frustration and depression. The findings are: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE]. B. Record review of R #3's care plan dated 01/28/25, revealed R #3 required Activities of Daily Living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance with baths/showers due to physical and cognitive impairments. C. Record review of the facility's shower schedule revealed R #3's bath/shower days were scheduled for Monday, Wednesday, and Saturday each week. D. Record review of R #3's documentation survey report (ADL tracking form located 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the facility providers (Nurse Practitioner, Physician) when there was a change of condition for 1 (R #1) of 1 (R #1) residents reviewed. This deficient practice is likely to result in a delay in treatment or inadequate treatment. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: 1. Encounter for surgical aftercare following surgery on the digestive system. 2. Peritoneal Abscess (a collection of pus or infected fluid located in the inner wall of the abdomen). 3. Malignant Carcinoid Tumor (rare type of tumor that grows slowly). 4. Colostomy (Connects the colon to the stoma at the abdominal wall. Bypasses or surgically removes part of the large intestine). - R #1 was discharged to the emergency room (ER) on 01/21/25. B. Record review of R #1's nursing progress notes dated 01/21/25 at 6:30 pm, revealed facility nursing staff received report that R #1 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medical records were updated and accurate for 1 (R #1) of 1 (R #1) resident reviewed, when the facility: 1. Failed to document a change in condition (CIC; sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) that required R #1 to go to the emergency room (ER). 2. Failed to document the reason R #1 was sent to the ER, including documentation that indicated a facility provider was notified of R #1 being sent to the ER on [DATE]. This deficient practice is likely to result in residents having an inaccurate medical record, which could result in the residents receiving less than optimal care and treatment. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: 1. Encounter for surgical aftercare following surgery on the digestive system. 2. Peritoneal Abscess (a collection of pus or infected…

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 conduct a through investigation and failed to report timely to the State Survey Agency for 1 (R #1) of 3 (R #1, 2, 3) residents reviewed for incidents/accidents. This deficient practice is likely to prevent the state agency from properly monitoring and investigating a facility and prevent such incidents in the facility. The findings are: A. Record review of R #1's daily care note dated 08/24/24, revealed the resident was being assisted to bed by Certified Nurses Aide (CNA) #1 when he fell to the ground. CNA #1 asked that Licensed Practical Nurse (LPN) #1 to come to the room and assist with R #1. When LPN #1 arrived in the room, LPN #1 noted R #1 was on the floor with a large cut above his left eye. R #1 laid in a puddle of blood on the floor. LPN #1 reported that while assisting R #1, he stated you did this, you hit me. R #1 was cleaned and transported to hospital for further evaluation and assistance. B. Record review of New Mexico Health Care Authority facility report #77137, the facility reported an incident dated…

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 deliver meals consistently and timely to 84 residents that received room trays or ate in the dining room, as identified on the facility census provided by the Administrator on 08/20/24. This deficient practice is likely to cause frustration and hunger. The findings are: A. Record review of the Concern/Grievance Reports revealed the following: - Dated 08/14/24, meals have been coming out late for weeks, and it is not okay. - Dated 08/14/24, food was always late. Not enough time for activities, because food came out late. - Dated 08/14/24, did not eat lunch in dining room. It was too late, and he (the resident) was hungry. He ate a donut in his room. - Dated 08/19/24, food late, food Cold. - Dated 08/19/24, food almost always cold. Food always late. Coffee in the mornings have to wait up to an hour to get some. B. Record review of the facility's meal times revealed the following: Breakfast was at 8:00 am, lunch at 12:00 pm, and dinner at 5:00 pm for all meals served in the facility to include dining room and…

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

Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to: 1. Properly label and store food items. 2. Maintain the facility kitchen free of dirt and grime. This deficient practice is likely to affect all 83 residents listed on the resident census list, provided by the Administrator on 08/02/24, and could likely lead to foodborne illnesses in residents if food is not being stored properly, safe food handling practices are not adhered to. The findings are: 1. Food storage A. On 08/02/24 at 10:15 am, observation of the facility kitchen area revealed the following: - Two, five pound bags of frozen chicken patties (2 ounces) sat outside of the freezer. They were open to air, not labeled, and not dated. - One, ten pound box of beef patties sat outside of the freezer. They were open to air, not labeled, and not dated. - One, six quart plastic container of apple sauce stored in a refrigerator and was not labeled or dated. - One, six quart plastic container of sliced cheese stored in a refrigerator and was not labeled or…

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

Based on observation and interview, the facility failed to maintain proper infection prevention measures when the facility experienced an outbreak of coronavirus disease (COVID; a contagious viral disease) and staff failed to: 1. Properly dispose of used personal protective equipment (PPE; protective masks, gloves and gowns used and disposed of when staff is exposed to a contagious disease). 2. Exchange and dispose of protective mask after contact with each contagious resident. These deficiencies are likely to affect all 83 residents of the facility as listed on the census provided on 08/02/24. The findings are: A. On 08/02/24 at 10:20 am during entrance to the facility through the main front doors, a sign indicated the facility had an outbreak of COVID, and all persons who entered were required to wear a protective mask. B. On 08/02/24 at 10:30 am during observation of the facility's halls, all staff wore protective masks as they walked about the unit and interacted with residents. Disposal of PPE C. On 08/02/24 at 1:18 pm during an interview, Certified Nurses Aide (CNA) #1 stated…

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

Based on record review and interview, the facility failed to ensure 1 (R #1) of 3 (R #1, #2 and #3) residents reviewed for pressure ulcers (a wound caused by prolonged pressure occurring in boney area of the body) received the necessary treatment and services to promote healing and prevent new ulcers from developing, when staff failed to conduct consistent pressure ulcer wound assessments with measurements. If the facility is not consistently assessing and measuring wounds, then resident's wounds are likely to worsen without appropriate intervention. The findings are: A. Record review of R #1's face sheet, dated 08/02/24, revealed she was admitted to facility on 08/08/19 with multiple diagnoses including: - Contractures (a shortening of muscles around joints causing joint stiffness and immobility) multiple sites. - Dementia (a chronic progressive disease that leads to memory loss and decline in mental ability.) B. Record review of R #1's daily care notes revealed the following: - Dated 05/15/24, R #1 had a new pressure sore on her coccyx (lower back and upper buttocks). It 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, interview, and observation, the facility failed to provide sufficient support staff to carry out the functions of food and nutrition services at the facility. This deficient practice is likely to result in the residents' dietary needs not being met, recieving food that is not stored approriately (open to air, not labeled and dated) and longer waits for meal service for all 80 residents residing at the facility. Reference F0809 and F0812

Based on observation, record review, and interview, the facility failed to deliver meals consistently and timely for all 80 residents in the facility. This deficient practice could potentially lead to frustration and hunger. The findings are: A. Record review of the facility meal times in the dining room revealed the following: 1. Breakfast: 8:05 am. 2. Lunch: 12:05 pm. 3. Dinner: 5:05 pm B. On 06/10/24, a lunch observation revealed the following: - At 12:24 pm, the main dining room was filled with residents, and lunch was not served. - At 12:57 pm, staff began to serve lunch. C. On 06/10/24 at 12:40 pm during an interview with Licensed Practical Nurse (LPN) #1, she stated staff were supposed to serve lunch in the dining room at 12:05 pm, but it was late. LPN #1 also stated staff have served meals late ever since the facility did not have a Dietary Manager (DM). D. On 06/10/24 at 2:19 pm during an interview with R #15, she stated staff often delivered the meals late in the main dining room. R #15 stated other residents were upset when meals are late. E. On 06/10/24 at 3:20 pm during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure food was stored, prepared, distributed, and served to residents in accordance with professional standards of food service safety when staff failed to: 1. Ensure all food items in the kitchen were labeled, dated, and stored properly. 2. Ensure refrigerated and frozen food was put away after a delivery and not left out for an extended period of time. 3. Ensure the kitchen walls, floors, and freezer floor were clean from dirt, grime, and unknown liquid. These deficient practices are likely to affect all 80 residents identified on the resident census list provided by the Administrator on 06/10/24. If the facility does not follow food safety guidelines, then they are likely to expose residents to food borne illnesses. The findings are: Food Storage Findings: A. On 06/10/24 at 10:39 am, an initial kitchen observation revealed the following: 1. One plastic tub of russet potatoes was not labeled or dated and stored in the dry storage. 2. One plastic tub…

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 provide reasonable accommodations of resident needs and preferences for 1 (R #12) of 1 (R #12) residents. If the facility is not honoring resident preferences then residents are not able to make choices about aspects of their lives which are important to them. This deficient practice is likely to result in the resident's life style, personal choices, needs, and preference not being met. The findings are: A. On 06/10/24 at 11:55 AM during an interview with R #12, she stated the residents get up when staff come in and get them ready. R #12 stated she would like to get up at 9:00 am, but staff get her up at about 6:00 am. B. Record review of R #12's admission Activity Assessment, dated 12/02/2021, revealed the resident preferred to get up at 9:00 am. C. On 06/12/24 at 11:24 AM during an interview with the Administrator, she stated residents should be accommodated to get up and go to bed when they wanted. She stated it was their choice. D. On 06/13/24 at 10:39 AM during an interview with Certified Nursing Assistant (CNA) #1,…

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 interviews the facility failed to provide a homelike environment for all 17 residents that ate their meals in the small dining room when staff failed to remove resident meals from the serving trays after they served the residents their meals. Residents were identified by the resident matrix provided by the Administrator on 06/10/24 and the seating chart for the small dining room provided by the Administrator on 06/12/24. This deficient practice could likely cause residents to feel depressed and anxious that they are not living in a comfortable home-like environment. The findings are: A. On 06/12/24 at 12:08 pm during an observation of the lunch meal in the small dining room, staff served the residents their lunch and left the food on the serving trays. Further observation revealed residents ate their meals with their plates, utensils, and cups still on the serving trays. B. On 06/12/24 at 12:13 pm during an interview with the Director of Nursing (DON), she stated They [residents that ate their meals in the small dining room] have always been served on trays.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a Minimum Data Set (MDS; a collection of health data that reflects a resident's functional capabilities) assessment for 1 (R #3) of 1 (R #3) residents reviewed for significant change resident assessments. This deficient practice could likely result in resident needs not being identified or treated, resulting in residents receiving less than optimal care. The findings are: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE]. B. Record review of R #3's physician orders, dated 03/12/24, revealed an order to discontinue hospice services. C. Record review of R #3's Electronic Health Record (EHR) revealed staff did not complete a significant change MDS assessment for R #3 when she discharged from hospice services. D. On 06/14/24 at 9:50 am during an interview with the MDS Coordinator (MDSC), she stated staff should have completed a significant change MDS assessment for R #3 when she discharged from hospice…

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 an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 3 (R #75, R #78, and R #386) of 3 (R #75, R #78, and R #386) residents reviewed for baseline care plans. This deficient practice could likely result in a decline in the residents' conditions due to staff not being aware of the residents' needs. The findings are: R #75 A. Record review of R #75's face sheet revealed he was admitted to the facility on [DATE]. B. Record review of R #75's baseline care plan, dated 03/14/24, revealed an incomplete document. The sections for Nursing Services, Social Services, Rehabilitative Services, and Nutritional Services were blank. C. On 06/13/24 at 1:06 pm during an interview with the Director of Nursing (DON), she confirmed R #75's baseline care plan was incomplete. She stated it was her expectation staff fully complete 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 observations, interviews, and record reviews, the facility failed to develop a comprehensive care plan for 3 (R #58, R #78, and R #386) of 3 (R #58, R #78, and R #386) residents reviewed for care plans. This deficient practice could likely result in residents not receiving the care and treatment needed due to staff being unaware of the needs of residents. The findings are: R #58 A. Record review of R #58's face sheet revealed she was admitted to the facility on [DATE]. B. On 06/12/24 at 11:24 am during an observation, R #58 wore a nasal cannula (a thin, flexible tube that goes around the head and into the nose that supplies additional oxygen) connected to the oxygen concentrator (a device that supplies additional oxygen) while in her room. C. Record review of R #58's physician orders revealed an order, dated 01/26/24, for oxygen via nasal cannula continuously at 2 liters (L). D. Record review of R #58's care plan, dated 02/19/24 revealed the care plan did not include R #58's order and use of oxygen. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers by the facility staff for 2 (R #'s 15 and 31) of 2 (R #'s 15 and 31) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: R #15: A. Record review of R #15's face sheet revealed R #15 was admitted into the facility on [DATE]. B. Record review of R #15's care plan, dated 02/19/24, revealed the following: - Focus: R #15 was at risk for skin breakdown due to bowel and bladder incontinence and decreased mobility. - Interventions: Shower per schedule. C. Record review of the facility's shower schedule revealed R #15 was scheduled to receive a shower every Tuesday, Thursday, and Sunday. D. Record review of R #15's ADL tracking form in her Electronic Health Record (EHR), dated 05/01/24…

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 ensure residents were free from accident hazards for 3 (R #15, #42, and #45) of 3 (R #15, #42, and #45) residents, when they failed to: 1. Use appropriate number of staff members to assist R #15 and R #45 while using a Hoyer lift (a patient lift or portable total body lift is a mobility tool designed to help individuals with mobility challenges). 2. Implement interventions to prevent falls after R #42 had repeated falls with injury. These deficient practices could likely result in residents being at risk of serious harm or injury. The findings are: Hoyer Lift Findings: A. Record review of the facility's Total Mechanical Lift (Hoyer lift) policy, dated June 2020, revealed at least two staff are to be present while resident is transferred with the mechanical lift. R #15: B. Record review of R #15's face sheet revealed R #15 was admitted into the facility on [DATE] with the following diagnoses: 1. Spastic quadriplegic cerebral palsy (stiff…

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 conduct a monthly Drug Regime Review for 1 (R #1) of 5 (R #1, R #29, R #37,R #45 and R #74) residents reviewed for unnecessary medications. This deficient practice is likely to result in irregularities not being communicated in a timely manner to the physician for review, evaluation, and possible intervention, which could result in delay of assessment or appropriate treatment. The findings are: A. Record review of R #1's physicians orders, dated 12/06/23, revealed duloxetine HCI (medication used for depression) delayed release sprinkle, 60 milligrams (mg). Give one capsule by mouth one time a day for depression. B. Record review of the facility's Medication Regime Review binder, dated from 01/01/24 through 06/12/24, revealed the binder did not contain R #1's documentation available for review. C. On 06/14/24 at 8:36 am during an interview with the Director of Nursing (DON), she stated. She gave the documents to medical records, and they could not locate the documents. She stated she was unable to locate any documents 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to monitor for the use of psychotropic medications (any medication that affects brain activity associated with mental processes and behavior) for 4 (R #'s 3, 11, 19, and 29) of 4 (R #'s 3, 11, 19, and 29) residents reviewed when staff failed to: 1. Attempt to gradually reduce the dose (lower dose/quantity of medication administered) for a psychotropic medication for R #3, #11, and #19. 2. Complete a psychotropic medication consent form prior to psychotropic medication use for R #29. These deficient practices are likely to result in residents being administered unnecessary medication or being over medicated. The findings are: R #3: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE]. B. Record review of R #3's physician orders, dated 09/11/23, revealed risperidone oral tablet, 4 milligrams (mg). Give one tablet by mouth two times a day for bipolar depression. C. Record review of R #3's pharmacist medication regimen…

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

Based on interview and record review, the facility failed to notify 2 (R #4 and #44) of 2 (R #4 and #44) residents when their balance was within or approached $200.00 of the maximum amount a Medicaid recipient could have in cash assets. If the facility is not notifying resident or residents' responsible parties when they are approaching the maximum amount then residents are likely to lose their eligibility of Medicaid benefits. A. Record review of the facility's Resident Statement Landscape (residents personal funds account) revealed R #4 and R #44 were above the eligible maximum amount. B. On 06/14/24 at 9:55 am during an interview with the facility Business Office Manager (BOM), he stated R #4's and R #44's accounts were above the maximum cash assets allowed amount for Medicaid recipients. He further stated the facility sent the residents' families a quarterly statement in April 2024, and they should have been aware the residents were approaching the maximum amount. He stated he did not send the families any other notifications, but the facility should notify the families when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to meet professional standards of care related to the use of oxygen for 1 (R #21) of 1 (R #21) residents. This deficient practice is likely to cause resident to have upper respiratory infections if oxygen monitoring is not done. The findings are: A. Record review of R #21's face sheet, dated 06/12/24, indicated R #21 was admitted to the facility on [DATE]. B. Record review of R #21's medical record revealed R #21 was admitted with the following diagnoses: 1. Chronic obstructive pulmonary disease (COPD; a chronic inflammatory lung disease that causes obstructed airflow from the lungs.) 2. Dysphagia (difficulty swallowing.) 3. Dementia (a group of symptoms affecting memory, thinking and social abilities.) 4. Hypertension [high blood pressure in the arteries (vessels that carry blood from the heart to the rest of the body).] C. On 06/13/24 at 9:26 am during random observation, an oxygen (O2) concentrator (a device that concentrates the oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to effectively manage pain for 1 (R #386) of 1 (R #386) residents reviewed for pain when staff did not provide pain treatment. This deficient practice likely resulted in R #386 experiencing pain without sufficient relief. The findings are: A. Record review of R #386's face sheet revealed she was admitted to the facility on [DATE]. B. On 06/10/24 at 3:21 pm during an interview with R #386, her husband, and her daughter, R #386 stated she had pain related to hemorrhoids, and her daughter brought cream from home for her to use. R #386's daughter stated she asked the facility for hemorrhoid cream on 06/07/24, but they did not bring any. The daughter stated she brought some cream from home and helped her mom to apply the cream on her hemorrhoids. C. Record review of R #386's current physician orders revealed the record did not contain orders for any type of medication or treatment for hemorrhoids. D. Record review of R #386's progress and nursing 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 1 (R #29) of 1 (R #29) residents reviewed for behavioral health concerns received necessary behavioral health care to meet their needs when staff failed to: 1. Ensure effective communication between the facility and psychiatric (psych) providers and provide consistent psychiatric services regarding R #29's psych service needs. 2. Document when facility Social Services Director (SSD) offered psych talk therapy to residents. These deficient practices are likely to result in the residents not receiving the behavioral or mental health care and assistance needed to improve mood and reduce depression and anxiety. The findings are: A. Record review of R #29's face sheet revealed R #29 was admitted into the facility on [DATE] with the following diagnoses: 1. Major depressive disorder (a mental disorder characterized by persistently depressed mood). 2. Anxiety. B. Record review of R #29's psychiatric individual therapy (talk therapy) notes, dated…

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

Based on observation and interview the facility failed to: 1. Ensure all medications were stored properly and in the original, labeled packaging. 2. Ensure medical supplies in the medication storage room were not expired. These deficient practices were likely to negatively impact the health of all residents, if staff administered or used potentially compromised or contaminated medications and medical supplies due to inappropriate storage. The findings are: A. On 6/10/24 at 10:37 AM during an observation of the A-Wing facility medication cart, five loose pills were at the bottom of drawer two. B. On 6/10/24 at 10:50 AM, Certified Medical Assistant (CMA) #1 stated there were unidentified loose pills on the bottom of drawer two, and they should not have been. CMA #1 further stated that nursing staff is responsible for cleaning the carts and disposing any loose medications or expired medications. CMA #1 further stated that the pharmacy comes in and will go through the medication carts and dispose of expired medications. C. On 6/10/24 at 10:55 AM during observation of the A-Wing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide food that accommodated resident preferences for 1 (R #15) of 1 (R #15) residents observed for food preferences. This deficient practice is likely to result in weight loss due to the resident not eating or an allergic reaction to the food being served to the resident. The findings are: A. Record review of R #15's face sheet revealed R #15 was admitted into the facility on [DATE]. B. Record review of R #15's care plan, dated 05/03/24, revealed the following: - Focus: Diet: Regular type. Regular with chopped meat. - Interventions: Use adaptive feeding equipment - Red foam built-up utensils, lip plate, and mug with spouted lid (sippy-cup) at all meals for improved self-feeding ability. Provide diet as ordered and honor food preferences. No beans. C. Record review of R #15's meal ticket, undated, revealed No beans. D. On 06/10/24 at 2:17 pm during an interview with R #15, she stated she had limited choices on meals to eat, and the…

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

Based on observation and interview, the facility failed to store foods under sanitary conditions by not: 1. Ensuring food items in the refrigerator and freezer were properly labeled and dated. 2. Ensuring food items in the refrigerator and freezer are properly covered. 3. Ensuring dry food items were properly stored, sealed, labeled, and dated in the dry storage room. 4. Ensuring raw eggs were kept on ice during preparation of meal service These deficient practices are likely to affect all 78 residents listed on the resident census list provided by the Director of Nursing (DON) on 04/03/23 and are likely to lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 04/03/23 at 9:32 am during the initial tour of facility kitchen, the following was observed in the kitchen freezers, kitchen refrigerators, and kitchen dry storage: 1. 1-2 pan that had frozen hamburger patties thawing out on top of a box of (24 count) of Iceberg Lettuce and was not labeled or dated and stored 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure that the care plan was developed and implemented for 2 (R #40 and #70) of (R #40 and #70) residents reviewed when: 1. The motion sensor alert was not turned on when R #70 was in bed per the care plan 2. The care plan did not identify that R #70 had glasses. 3. The care plan did not include the injury to R #40's leg If the facility is not developing and implementing resident care plans, resident may not get the care and assistance needed. The findings are: Findings related to motion sensor for R #70: A. Record review of care plan for R #70 dated 11/10/22 identified [Name of R #70] is at risk for falls because of inability to transfer safely and is unaware of safety needs. Interventions included 1/6/23 Ensure sensor alarm is in place and on 11/16/22 motion sensor alarm B. On 04/05/23 at 2:26 pm during interview with Certified Nurse Aide (CNA) #4, she identified that R #70 has motion sensor that triggers an alarm at nurses station if…

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 #40, 46 and 70) of 3 (R #40, 46 and 70) residents reviewed by not: 1. Not ensuring that care plan was revised to include R #40's injury to her right leg. 2. Not ensuring that care plan was revised to reflect R #46 was no longer receiving hospice services 3. Not ensuring the use of adaptive equipment was included in R #70's care plan If the facility is not updating the care plans to reflect the resident's current care areas and treatments, then the facility may not be providing the appropriate care and treatment to meet the residents' needs. The findings are: Findings for R #40 A. Record review of R #40 care plan dated 04/05/23 was not revised to indicated that the resident has had an injury to Rt.(right) leg. Injury occurred when resident was being transferred from wheelchair to bed on 03/06/23 B. On 04/05/23 at 6:59 pm, during an interview with the Director of Nurses (DON), she stated. That every injury should be on the…

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

Based on interview and record review, the facility failed to ensure that 1 (R #70) of 1 (R #70) resident reviewed for vision, received proper assistive devices to maintain her vision. If the facility is not assisting residents is accessing treatment and devices to maintain their vision, then residents could likely lose their ability to see and read. The findings are: A. On 04/03/23 at 4:59 PM during interview with R #70's daughter she stated She [R #70] is blind in the right eye and deaf in right ear. I had taken her to the doctor, but they said there's nothing they can do for her. They took her for her eyes to be tested, but not sure for glasses. She had a pair when she went in [was admitted to facility] but they were lost. She was ready for a renewal. B. Record review of Minimum Data Set (MDS)-11/07/22, 01/30/23 and 02/15/23 identified vision impaired and corrective lenses. C. Record review of the R #70's Care Plan dated 11/10/22 identified: has impaired vision. D. Record review of Personal Inventory sheet, dated 11/16/22 [date of admission] identified that resident had purple…

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 1. Ensure that residents received a safe transfer(without injury) using a hoyer lift (mechanical device designed to lift patients safely) during transfer for R #14 2. Ensure R #52's ordered wing mattress (mattress that is used to keep residents from rolling out of bed) was placed on his bed to prevent falls. These deficient practices are likely to result in residents suffering further injury. Findings for R#14 A. Record review of R #14's care plan dated 02/24/23 revealed: Focus: Resident has Cerebral Palsy (a disorder that affect movement, muscle tone, balance, and posture) and needs extensive assistance for all her ADLs (Activities of Daily Living). She is hard to understand but is able to communicate her needs. Goals: Resident will have all ADL's done with assistance from staff. Interventions: Two person assist for transfers. Hoyer lift for all transfers. B. On 04/04/23 at 11:36 AM during an interview with R #14 she stated that staff had hit her knees on the bed when they were transferring her from her wheelchair to her…

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

Based on record review, observation and interview, the facility failed to ensure that residents maintain acceptable parameters of body weight for 1(R #45) of 1(R #45) resident reviewed for weight loss by not implementing new intervention to address continued weight loss over 6 month period and by not ensuring that R #45 received healthshake as ordered. This deficient practice could likely result in continued weight loss and poor clinical condition of residents. The findings are: A. Record review of the Dietary Interview Pre Screen form, dated 01/05/21 identified that R #45 is on a regular diet with regular food consistency with a supplement order for health shakes; fortified foods for weight management. B. Record review of the Weights and Vital Summary for R #45 identified the following weights: 1. 08/07/22: 119.4 lbs (pounds) 2. 09/01/22: 111.4 lbs 3. 11/05/22: 109 lbs 4. 01/04/23 99.1 lbs 5. 02/06/23: 93.9 lbs 6. 03/05/23: 87 lbs C. Record review of the Physician order Summary report revealed order dated 09/13/22 Ensure (nutrition drink) two times a day D. Record review of R #45'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 ensure that food was prepared in a form to meet the residents needed for 2 (R #5 and #82) of 2 (R #5 and 82) resident observed during random observation by ensuring that: 1. Mechanical Soft Diet was provided as ordered by a physician for R #5 2. R #82 was served pureed consistency. If the facility fails to provide foods in a consistency that residents are able to consume then residents are at risk for choking. The findings are: Findings for R #5 A. On 04/04/23 at 7:52 am during observation of breakfast tray, R #5 was observed to have a regular piece of sausage. R #5's meal ticket dated 04/04/23 revealed Mechanical Soft Diet (food that is mechanically altered into small pieces to prevent choking). B. On 04/04/23 at 7:53 am during interview Wound Care Registered Nurse (WCRN) confirmed the sausage on resident's (R#5) was regular consistency and should have been mechanical soft texture. C. Record review of Physicians orders dated 04/17/22 revealed Regular diet Mechanical Soft texture. Findings for R #82 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, record review and interview, the facility failed to provide food that accommodates resident allergies intolerance's and preferences for 3 (R #40, 52 and 81) of 3 (R #40, 52 and 81) resident's observed for food preferences. This deficient practice is likely to result in, an allergic reaction to the food being served to the resident and resident food preferences not being honored. The findings are: Findings for R #40 A. Record review of R #40's Physician Orders printed on 02/08/23 revealed, Allergies: Acidic foods. B. On 04/06/23 at 12:32 pm during an observation of lunch, R #40 was served Lettuce & Tomato on her plate. C. On 04/06/23 at 12:35 p.m. during an interview with Dietary Manager (DM), she stated that R #40 did have a slice of tomato on her plate. D. Record review of R #40's Care Plan revealed, R #40 has allergies to Lettuce, Tomatoes and Milk. E. Record review of R #40's dietary meal ticket dated 04/06/23, revealed R #40 was served Lettuce and Tomato Slices for lunch . Findings for R #52 F. On 04/04/23 at 10:28 am during an during an observation and…

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

Based on record review and interview, the facility failed to ensure that there was collaboration between the facility and hospice services for 1 (R #46) of 1 (R #46) residents reviewed for hospice services by not developing a coordinated plan of care for the resident. This deficient practice is likely to result in the resident not receiving the services that she needs. The findings are: A. Record review of R #46's admission Minimum Data Set (MDS), Section O, Special Treatments, Procedures and Programs and the residents admission Record/Face Sheet revealed the resident was on hospice care. B. On 04/05/23 at 4:57 PM during an interview with the Director of Nursing (DON), she stated that all hospice documentation are in the Medical Record under the miscellaneous section/tab. C. Record review of R#46's Medical Record revealed that the Coordinated Plan of Care was not present in the Medical Record. D. On 04/05/23 at 7:06 PM the DON confirmed that there was not a coordinated plan of care for hospice services.

Findings related to catheters: F. On 04/03/23 at 12:32 pm during observation, R #58 was being pushed in his wheelchair from the dining room to the hallway. Under the wheelchair the catheter bag was dragging directly on the floor. Registered Nurse (RN) #1 confirmed that the catheter bag should not be touching the floor. G. On 04/03/23 at 5:51 pm during observation, R #58 was sitting in his wheelchair near the Nurse's station. His catheter bag was observed to be dragging on the floor. H. Record review of the care plan for R #70 dated 03/14/23 identified [Name of R #70] has a foley catheter and is at risk for increased urinary tract infections. I. On 04/06/23 at 8:56 am and 10:38 am during observation, R #70 was laying in bed sleeping. His catheter bag was observed laying directly on the floor under the bed. J. On 04/06/23 at 10:40 am during interview with Licensed Practical Nurse (LPN) #1, she observed and confirmed that R #70's catheter bag should be hanging on the side of the bed and not laying directly on the floor. Findings related to masks: K. On 04/03/23 at 9:15 am during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that there is an appropriate diagnosis for the use of psychotropic medications for 1 (R #19) of 5 (R #15, 19, 32, 70 and 82) residents evaluated for unnecessary medications. If residents are prescribed psychotropic medications without proper diagnosis, then residents are likely to be administered unnecessary medications likely resulting in adverse side effects. The findings are: A. Record review of R #19's Current Diagnosis report reviewed on 04/06/23 identified that R #19 has been diagnosed with Alzheimer's, unspecified (A progressive disease beginning with mild memory loss possibly leading to loss of the ability to carry on a conversation and respond to the environment.) No other neurological or psychiatric disorders identified. B. Record review of the History and Physical (H&P) dated 08/26/21 for R #19 completed by Physician #2 identified Past Medical History to include anxiety depression but was not included in current assessment. No other…

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, observation, and record review, the facility failed to manage hydration for 1 (R #52) of 1 (R #52) resident reviewed for hydration. This deficient practice is likely to result in serious health complications for any resident without adequate hydration. The findings are: A. On 04/05/23 at 10:26 am during an observation and interview with R #52's sister. She stated that R #52 is on thickened liquids (a diet designed to prevent aspiration in patients) and very often R #52's thickened water is set on a table or on the bedside stand and R #52 is unable to reach it or even open it and drink it. During this observation the container of thickened water was observed to be sitting on the table. R #52's sister further stated that it had been left there earlier and they (R #52's sister and son) were waiting to see when staff would come in to hydrate R #52. B. Record review of Physicians orders dated 02/06/23 revealed Nectar consistency (a liquid that is altered to be thicken then water) to be provided daily and at meal times. C. On 04/05/23 at 4:38 pm during an interview…

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

Based on observation, record review, and interview, the facility failed to provide assistive devices (special eating equipment and utensils) for 1 (R #50) of 1 (R #50) resident reviewed for use of assistive devices. This deficient practice is likely to result in residents not being able to eat meals independently unable to perform activities of daily living which could likely result in consuming less food. The findings are: A. Record review of Dietary Meal ticket dated 04/04/23 revealed foam grip utensils for all meals. B. On 04/04/23 at 12:34 pm, during an observation of lunch meal tray to identify if resident was provided foam grip utensils. R #50 was served breakfast and provided with regular utensils. C. On 04/04/23 at 12:35 during an interview with Certified Medical Assistant (CMA) #2, he confirmed R #50 should have foam grip utensils and he did not have any. D. Record review of Dietary meal ticket that was followed on 04/06/23 revealed, R #50 is to use foam grip utensils (foam tubing used to assist in patients with a weak grip).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to store and serve food under sanitary conditions by not: 1. Ensuring food items in the refrigerator and freezer were properly labeled and dated. 2. Ensuring food items in the freezer were properly stored. 3. Ensuring food items weren't stored on the kitchen and freezer floor. These deficient practices are likely to affect all 69 residents listed on the resident census list provided by the Administrator (ADM) on 02/28/22. If the facility fails to adhere to safe food handling practices residents are likely to be exposed to foodborne illnesses. The findings are: A. On 02/28/22 at 9:27 am during the initial tour of facility kitchen, the following was observed: 1. 1- 3.5 L (Liter) plastic container of sliced American cheese dated, 2/27 was not labeled and stored in the second refrigerator. 2. 1- 3.5 L of white sliced cheese dated 2/28 was not labeled and stored in the second refrigerator. 3. 1- Large plastic container of shredded cheese dated, 2/28 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.

Based on observation, interview and record review, the medical director of the facility failed to manage and coordinate resident care in a manner that would enable each resident to attain or maintain his or her highest practicable physical, mental, and psychosocial well being, which resulted in 3 (three) citations related to Pain Management, Physician visits, and Quality of Care. The cumulative effect of these systemic deficient practices resulted in contributing to poor resident outcomes with respect to quality-of-life, quality-of-care, health, safety and comfort. The findings are: Refer to F0684, F0697, and F0711 for findings pertinent to this citation. A. Record review of Medical Director Agreement Page 1 and 2 section 5 (duties) dated 07/20/19 and signed by the Facility Medical Director on 07/25/22 revealed: B. Participates in development of a system providing medical care pan for each patient, which covers medications, nursing care, restorative services, diet, and other services as appropriate, a plan for discharge. M. Be available for consultation in the development and…

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

Based on observation and interview the facility failed to maintain proper infection prevention measures for 2 (R #67's and R #64) of 2 (R #67's and R #64) residents identified during random observation when R 67 and R #64's 's Foley Catheters were resting on the bare floor. Failure to adhere to an infection control program is likely to cause the spread of infections and illness. The findings are: A. Record review of R #67's physician orders dated 02/28/22 revealed, Change 14F (Unit of measure used to determine the size of the catheter) Foley catheter. B. On 02/08/22 at 3:20 pm during an interview with R #67, R #67 is observed having a Foley catheter in place. R #67 confirmed she has had a Foley catheter for several days. R #67's Foley catheter is observed to be lying on the floor under R #67's bed. C. On 03/03/22 at 10:56 am during an interview with the Director of Nursing (DON), she stated, It [R #67's Foley catheter] should not have been laying on the floor. D. On 03/04/22 at 9:19 a, during random observation and interview with the DON, R #64 was observed in the hallway in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide a homelike environment, for 2 (R #'s 63 and 67) of 2 (R #'s 63 and 67) residents reviewed for homelike environment, by not maintaining an environment that is clean and free of clutter. If the facility fails to maintain resident rooms in a homelike environment, then residents are likely to feel uncomfortable and could exacerbate (make worse) health issues. The findings are: A. Record review of R #67's face sheet revealed R #67 was admitted into the facility on [DATE] and currently resides with R #63 in Room (RM) #302. B. On 02/28/22 at 3:35 pm during observation and an interview with R #67, approximately 17 large drops of Betadine (an antiseptic used for skin disinfection before and after surgery) were present on the floor next to R #63's bed. Several large pieces of trash were also present on the floor. R #67 confirmed the Betadine and trash had been on the floor since the morning. C. On 02/28/22 at 3:37 pm 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 record review and interview, the facility failed to provide an incident or a follow-up report to the State Survey Agency, for 2 (R #33 and R #67) of 2 (R #33 and #67) residents reviewed for falls and R #67 for not receiving her meal for dinner. If the facility fails to report incidents and/or falls with injury to the State Agency, then the State Agency is unable to ensure residents have a safe and hazard-free environment. The findings are: Findings for R #33: A. Record review of Nurse progress notes dated 02/07/22 at 4:43 am revealed, Resident was sent out for fall that occurred in dining area during dinner. At the time of fall, no injuries present and resident did have complaints of slight tenderness. PRN [as needed] Tylenol [pain medication] was administered by day shift with no relief. At the time that this nurse received report, resident stated she had severe pain to left side of body and head and requested she be sent out. MD [Medical Doctor] was notified and resident was sent to [Name of Local Hospital] via EMS [Emergency Medical Services] transportation. B. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for 2 (R #10, 51) of 6 (R #10, 18, 22, 33, 47, and 51) residents reviewed for care plans. Failure to develop and implement a resident-centered care plan is likely to result in staff's failure to understand and implement the needs and treatments of residents, resulting in decline in abilities and a failure to thrive. The findings are: R #10 A. Record review of R #10's physician order dated 09/18/21 revealed an order for Physical Therapy (PT) (treatment provided by trained therapists to assist with strengthening and motion) to evaluate and treat. B. Record review of R #10's care plan dated 01/04/22 revealed no current care plan for daily restorative care (therapy that is provided over a long term to encourage mobility and flexibility) C. On 03/03/22 at 8:32 am during interview with Physical Therapist (PT), she stated that restorative care is provided to any resident who might need daily…

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 their physician after each visit, and physician appointments were scheduled for residents 13 ( R #'s 4, 13, 16, 18, 26, 33, 37, 46, 48, 51, 52, 54 and 118) of 44 ( R #'s 1, 2, 4, 5, 6, 9, 10, 12, 13, 16, 18, 19, 20, 21, 22, 24, 25, 26, 29, 30, 32, 33, 34, 36, 37, 39, 41, 42, 43, 46, 47, 48, 50, 51, 52, 53, 54, 55, 57, 58, 64, 66, 68, and 118) residents reviewed for current physician progress notes and documentation. This deficient practice is likely to result in resident's needs not being accurately determined and met due to the lack of current documentation. A. Record review of the Facility Medical Director (FMD) resident tracking form dated 03/01/22 revealed the following residents with past due Physician Progress Notes/ History and Physicals: 1. R #26 Progress Note- 02/21/22 Past Due 2. R #13 Progress Note- 01/13/22 Past Due 3. R #46 Progress Note- 02/29/22 Past Due 4. R #16…

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 PRN (as needed) orders psychotropic medications were limited to 14 days unless the prescribing practitioner provided written rationale for extending the order for 2 (R #18 and 22) of 5 (R #18, 22, 33, 47, and 67) residents reviewed with PRN psychotropic medications ordered. This deficient practice is likely to result in residents being administered unnecessary medication and being over medicated. The findings are: R#18 A. Record review of R #18 face sheet dated 03/04/22 revealed she was admitted to the facility on [DATE] with multiple diagnoses including Major Depressive Disorder (symptoms of sadness and despair). B. Record review of R #18 physician orders revealed the following: Active order #1 dated 12/14/21 administer Haloperidol (an antipsychotic medication administered to reduce psychotic symptoms) tablet 0.5 mg (milligrams) by mouth every 4 hours as needed for agitation/nausea. Active order #2 dated 12/14/21 administer Haloperidol…

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

Based on observation and interview the facility failed to: 1. Ensure that medications in the medication cart were not expired. 2. Ensure that all medications were properly labeled and stored. These deficient practices are likely to affect all 69 residents listed on the resident census list provided by the Administrator(ADM) on 02/28/22 by dosing with expired medications and dosing with medications that have been improperly stored. The findings are: A. On 03/04/22 at 10:21 am during an observation of the B Wing medication cart and interview with the Registered Nurse (RN) #1 and Certified Medication Assistant (CMA) #1, the following was observed: 1. 1 bottle of Hyosyne oral drops (medication for stomach/intestinal problems) was expired on 02/22 2. 1 bottle of Lovastatin (medication used to treat elevated blood cholesterol) was expired on 02/09/13 3. 5 unidentified loose pills were found on the bottom of the first drawer of the medication cart. 4. 2 unidentified loose pills were found on the bottom of the second drawer of the medication cart. 5. 4 unlabeled 4% (per cent) Lidocaine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure resident had access to call light for 1 (R #59) of 1 (R #59) residents reviewed for call light access. This deficient practice is likely to result in the residents not being able to notify staff of their needs or alert staff during emergent (urgent) situations. The findings are: A. Record review of R #59's face sheet revealed R #59 was admitted into the facility on [DATE]. B. On 03/03/22 at 12:49 pm during an observation and interview with R #59, she stated, Help me! Please get me in bed. I can't call them [staff] because the light is all the way over there. R #59 was observed to be sitting in her wheelchair while her call light was observed to be tied to R #59's bed, out of reach from the resident. C. On 03/03/22 at 12:53 pm during an interview with Certified Nursing Assistant (CNA) #1, she stated, Her [R #59's] roommate called me and said she [R #59] needed help going back to bed. She's [R #59] a two person assist and I told her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to revise the care plan for 1 (R #67) of 1 (R #67) residents reviewed for Foley catheter (flexible tube inserted through the urethra and into the bladder to drain urine) use. If the facility is not updating the care plan to reflect the resident's current care areas and treatment, then it is likely the facility may not be providing the appropriate care and treatment to meet the residents' needs. The findings are: A. On 02/08/22 at 3:20 pm during an observation and interview with R #67, R #67 is observed with a Foley catheter in place. R #67 confirmed she's had a Foley catheter since she arrived into the facility (02/07/22). B. Record review of R #67's Face sheet revealed R #67 was admitted into the facility on [DATE]. C. Record review of R #67's Clinical admission Evaluation Progress Note dated 02/07/22 revealed, Resident has a 14F Foley catheter in place that was placed on the 26th [01/26/22] due to resident being unable to urinate by self.…

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 ADL (Activities of Daily Living) assistance for baths/showers for 1 (R #54) of 3 (R #'s 33, 54, and 67) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: A. Record review of R #54's face sheet revealed R #54 was admitted into the facility on [DATE]. B. Record review of the facility 200 unit shower schedule revealed R #54 should be offered a shower/bath every Sunday, Wednesday, and Friday. C. Record review of R #54's care plan dated 11/16/21 revealed, Focus- [Name of R #54] is at risk for further decline in ADL's due to physical/cognitive impairments (difficulties with eating, dressing bathing and other ADL's also confusion or memory and loss). He has moments of forgetfulness. Interventions- Assist resident with shower. Allow resident to help as much as possible to promote independence. D. Record review of R #54's Documentation Survey Report dated…

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

Based on observation, record review, and interview, the facility failed to ensure that 1 (R #44) of 1 (R #44) resident received proper assistive devices to maintain his vision. If the facility is not assisting residents in accessing treatment and devices to maintain their vision, then residents could likely lose their ability to see and read. The findings are: A. On 03/01/22 at 11:29 am during interview with R #44, when asked if he had any problems with his vision, he stated I should wear glasses. They broke over a year ago and haven't been replaced or a new pair has not been ordered. B. Record review of the Minimum Data Set (MDS): Section B Hearing, Speech, Vision for R #44 dated 01/16/22 revealed that R #44 has impaired vision. C. Record review of the miscellaneous section of R #44's medical record revealed the last time R #44 had an eye doctor appointment was on 11/06/18 and at that appointment R #44 received a new glasses prescription. There were no further appointments or notes documented in the residents chart. It also revealed an admission Data Collection sheet dated 02/28/19…

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 resident specific physician orders and ongoing communication and collaboration (different persons/groups working together) with the dialysis (clinical purification of blood as substitute for normal kidney functioning) facility regarding dialysis care and services for 1 (R #42) of 1 (R #42) residents reviewed for dialysis. If the facility is unaware of the status, condition, or complications that arise during dialysis treatment, then residents are likely to not receive the appropriate monitoring and care they need. The findings are: A. Record review of R #42's face sheet dated 03/04/22 revealed she was admitted to the facility on [DATE] with multiple diagnoses including: End Stage Renal Disease (a progressive disease of the kidneys) Dependence of Renal Dialysis (use and dependence on dialysis to clean and purify blood) B. Record review of R #42's electronic medical record revealed there was no physician order for R #42 to attend dialysis. C.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure there was collaboration between the facility and hospice services (services provided for a person that is experiencing an advanced, life-limiting illness) for 1 (R #18) of 1 (R #18) resident reviewed for hospice services, by not having documentation in the resident's record indicating the delivery of hospice services, and for hospice failing to visit the resident as often as required. This deficient practice of not ensuring that there was an appropriate collaboration between the facility and hospice services is likely to result in the resident not receiving the services that they need. The findings are: A. Record review of R #18's face sheet revealed R #18 was admitted into the facility on [DATE]. B. Record review of R #18's care plan dated 12/15/21 revealed, Focus-[Name of R #18] requires Hospice Care. (A decline is expected as the disease progresses). C. Record review of R #18's physician orders dated 12/20/21 revealed, Admit to [Name 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.