Rio Rancho Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop and implement a complete baseline care plan within 48 hours of admission for 1 (R #3) of 1 (R #3) resident. If the facility fails to implement a complete baseline care plan within 48 hours of admission for residents with complex needs and high fall risk, then staff may lack necessary guidance to prevent injury, resulting in avoidable harm such as serious falls, hospital transfers, and worsening of clinical status. The findings are: A. Record review of R #3's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: - Nontraumatic acute subdural hemorrhage (leakage of blood between the membranes of the brain), - Hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body); - Generalized muscle weakness; - History of transient ischemic attack (TIA; mini stroke). B. Record review of R #3's Fall Risk Assessment, dated 05/08/25, revealed R…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to promote resident choices for 4 (R #14, 49, 59 and 71) of 4 (R #14, 49, 59 and 71) residents reviewed for choices when staff failed to: 1. Offer R #14, R #49 and R #59 showers per their preference 2. Offer R #71 to have his bed at his preferred height These deficient practices are likely to result in the resident's personal choices not being honored. The findings are: R #14 A. On 02/17/25 at 11:15 AM, during an interview with R #14, he stated, Showers are an issue; I haven't had a shower in a while. It's been bed baths, but I prefer showers. B. Record review of the shower schedule for R #14's hall revealed R #14 should get showers two times a week on Monday and Thursday. C. Record review of R #14's shower sheets dated December 2024, January 2025, and February 2025, revealed staff gave R #14 thirteen bed baths and no showers. D. On 02/20/25 at 11:45 AM, during an interview with the Director of Nursing (DON), she stated The expectation is that if 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 interviews, the facility failed to ensure staff revised the care plans for 6 (R #'s 4, 14, 31, 61, 104, and 108) of 6 (R #'s 4, 14, 31, 61, 104, and 108) residents reviewed when staff failed to: 1. Update R #4's plan of care to include Hospice Care. 2. Conduct a quarterly care plan meeting as required for R #14 in accordance with his admission date and Minimum Data Set (MDS)assessment. 3. Update R #31's plan of care to include dialysis (artificial way to eliminate waste and excess fluid from the body). 4. Ensure care plan was updated to reflect R #61's current diet. 5. Update R #104's plan of care to include diabetic management and insulin use, pain management and narcotic use, and oxygen (O2) use. 6. Update R #108's plan of care to include O2 use. This deficient practice is likely to result in staff not being aware of residents' care needs and preferences, and residents not receiving the needed care. The findings are: R #4: A. Record review of R #4's electronic medical record (EMR)…

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 drug regimen review were completed for 3 (R #7, R #27, and R #67) of 5 (R #7, R #13, R #27, R #67, and R #89) residents reviewed. The failure to review and consider resident medication regimens each month could result in residents receiving unnecessary or ineffective medications. The findings are: R #7 A. Record review of R #7's face sheet dated 02/24/25, revealed R #7 was admitted to the facility on [DATE] with the following diagnoses: -Diabetes mellitus (a chronic disease in which the body is unable to properly process sugars in the blood). -Pain. -Schizophrenia (a chronic psychiatric disease that affects a person's ability to think and feel rationally). -Bipolar Disorder (a chronic psychiatric disease that affects a person's mood). -Paranoid Personality (a psychiatric disease that causes a person to be suspicious and fearful without reason or cause). -Overactive Bladder. B. Record review of R #7's pharmacist recommendation dated 03/29/24,…

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.

Based on observation, record review and interview the facility failed to administer medications for 2 (R #49 and R #67) of 4 (R #49, R #67, R #85 and R #105) residents with an error rate less than 5%. The facility administered 15 of 33 observed medications late for an error rate of 45.45%. Failure to administer medications without error could result in residents not receiving maximum benefit of their prescribed medications. The findings are: R #49 A. On 02/21/25 at 8:34 am, during an observation of R #49 morning medications administration, R #49 received Methacarbamal (a medication prescribed to muscle spasms) 500 mg (milligram). B. Record review of R #49's Medication Administration Record (MAR) dated February 2025, revealed methacarbamal was to be administered at 7:00 am. C. On 02/21/25 at 8:34 am, during interview, Certified Medication Aide (CMA) #1 stated methacarbamal was to be administered at 7:00 am and the medication would be considered late if administered more than one hour after the assigned administration time. She confirmed giving the medication at 8:34 am would be late…

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

Based on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of at least 12 hours per year for 3 (CNAs #1, #3, and #4) of 5 (CNAs #1, #2, #3, #4, and #5) CNAs randomly reviewed for required in-service training. This deficient practice is likely to result in the nurses aides not receiving the necessary training to meet the care needs of the residents. The findings are: CNA #1: A. Record review of the facility staffing list revealed CNA #1 was hired on 06/06/22. B. Record review of CNA #1's annual in-service training, dated 06/06/23 through 06/06/24, revealed CNA #1 did not complete at least 12 hours of required in-service training. C. Record review of the facility staffing schedule, dated 01/25/25 through 02/25/25, revealed CNA #1 worked sixteen CNA shifts in the facility during that timeframe. D. On 02/25/25 at 10:22 am during an interview with the Nurse Educator (NE) #1, she confirmed CNA #1 did not complete the required 12 hours of in-service training, but should have. CNA #3: E. Record review of 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 safeguard clinical record information by leaving Private Health Information (PHI) where unauthorized persons had access to the PHI for 1 (R #49) of 1 (R #49) residents reviewed during random observation. If resident's clinical information is not sufficiently safe guarded, resident's PHI is likely to be viewed by unauthorized residents, visitors and staff. The findings are: A. On 02/24/25 11:15 am during observation Certified Medication Aide (CMA) #1 left the computer screen opened and the narcotic book was visible to R #49's personal information and she left an individual patient's narcotic record face up on the counter at the nurses station. B. On 02/24/25 at 11:16 am during interview, Licensed Practical Nurse (LPN) #1 confirmed the computer screen was opened and the narcotic book was left open and visible to unauthorized residents, visitors and staff. She further confirmed that a narcotic record was left face up at the nurses station. LPN #1 stated that none of these items should have been left out in the open to be viewed…

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 complete a thorough investigation for an allegation of abuse for 1 (R #46) of 1 (R #46) residents reviewed for incidents. If the facility is not adequately investigating allegations of abuse, then corrective action is not implemented to prevent other residents from similar abuse which puts residents at risk of adverse serious outcomes. The findings are: A. Record review of R #46's face sheet revealed R #46 was admitted into the facility on [DATE]. B. On 02/21/25 at 1:17 pm during a lunch observation, R #46 told Certified Nursing Assistant (CNA) #2 that the night shift CNA from the night before (02/20/25) was hateful towards him and he was upset by that. C. On 02/21/25 at 1:19 pm during an interview with R #46, he stated the night shift CNA was hateful towards him and told him he could not use his call light for the rest of the night. R #46 confirmed he was upset by that, and he felt bad. D. On 02/21/25 at 1:21 pm during an interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide sufficient preparation for discharge for 2 (R #104 and #122) of 2 (R #104 and #122) residents reviewed by: 1. Not ensuring the referral for services had been received, accepted and was scheduled to provide care for the resident upon discharge home for R #104. 2. R #122 discharged without and not accepted back to the facility without notice or without other interventions for their behaviors. These deficient practices could likely result in resident not receiving needed services and having to navigate referral process for services unassisted. The findings are: A. Record review of R #104's face sheet revealed R #104 was admitted into the facility on [DATE] and was discharged on 02/12/25 with Home Health Services (medical care delivered in the patient 's home). B. Record review of R #104's physician orders dated 02/04/25, revealed R #104 was to discharge home with home health care services or outpatient therapy services to provide skilled nursing,…

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 meet professional standards of quality for 1 (R #46) of 1 (R #46) residents when hospice services (a type of compassionate care provided to individuals who are in the final stages of a terminal illness) were provided without physician orders. If the facility is not obtaining physician orders prior to initiating hospice services, then residents are likely to not receive the therapeutic benefits and care needed. The findings are: A. Record review of R #46's face sheet revealed R #46 was admitted into the facility on [DATE]. B. Record review of R #46's care plan dated 01/07/25 revealed R #46 was receiving hospice care services. C. Record review of R #46's physician orders revealed physician orders were not present for hospice care services. D. On 02/24/25 at 4:35 pm during an interview with the Director of Nursing (DON), she stated R #46 started hospice services on 02/01/25. The DON also stated that there should have been physician orders for hospice care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to ensure that 1 (R #114) of 1 (R #114) resident was provided treatment and care to maintain her overall well-being. The facility failed to ensure that resident's brief was changed and she was repositioned to prevent the development of a wound. The findings are: A. On 02/18/25 at 9:30 am during observation of the long term care unit, R #114 sat in her room, in her wheelchair with her son sitting next to her. She was non-responsive and slumped over to her right side while sitting in her wheelchair. B. Record review of R #114's Face Sheet dated 02/24/25 revealed R #114 was admitted to the facility on [DATE] with the following diagnoses: -Cerebral Infarction (stroke) due to embolism (blockage of a blood vessel). -Dysphagia (difficulty swallowing). -Encephalopathy (a brain disease that alters brain function or structure). C. Record review of R #114's Minimum Data Set (MDS:a set of assessments that provides an overall review of a resident's needs…

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 that 1 (R#58) of 1 (R #58) resident was provided with a device to reduce injury from falling. The facility failed to provide a fall mat (a soft cushion placed on the floor next to the bed to help absorb the impact of a fall and reduce injury) at the side of R #58's bed is likely to result in a resident incurring greater injury should he fall. The findings are: A. Record review of R #58's face sheet dated 02/25/25, revealed R #58 was admitted to the facility on [DATE] with the following diagnoses: -Diabetes Mellitus (failure of the body to properly mange blood sugars). -Repeated Falls. -Acquired Absence of Left Leg Above Knee (amputated left leg). B. Record review of R #58's daily care notes dated 12/10/24, 12/17/24, 01/22/25, 01/27/25 and 02/12/25, revealed R #58 had falls from his bed to the floor. C. Record review of R #58's care plan dated 12/12/24 revealed R #58's plan to prevent falls included a fall mat. D. On 02/18/25 at 10:06…

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

Based on record review and interview, the facility failed to ensure a portable oxygen tank was filled with oxygen for 1 (R #61) of 1 (R #61) residents reviewed for respiratory care (use of oxygen). This deficient practice is likely to affect residents with COPD (chronic obstructive pulmonary disease), shortness of breath and dependence on supplemental oxygen by not supplying enough oxygen in order to prevent hypoxia (decreased oxygen to the body). The findings are: A. On 02/17/25 at 11:22 AM, during an interview, R #61 stated the portable oxygen tank leaks, does not hold oxygen and he is unable to use it. He further stated he has mentioned the oxygen tank leak to several staff, but nothing has been done about it. He would like it to be available in case he were to need the oxygen. B. Record review of R #61's physicians order dated 02/01/25, revealed 2l (liters) via NC (nasal cannula-tube used to deliver the oxygen) to keep O2(oxygen) SATS (saturation-the percentage of oxygen in your blood) greater than 92% (percent) PRN (as needed). C. Record review of R #61's medical diagnosis…

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

Based on observation and interview, the facility failed to ensure medications were: 1. Stored properly 2. Narcotics given when signed out on the narcotic book. These deficient practices are likely to result in inaccurate medication counts and residents not getting the desired therapeutic results if medications are not administered as ordered. The findings are: A. On 02/24/25 at 11:01 am, during an observation of the south side medication cart revealed five unidentified loose pills on the bottom of the second drawer. During a count of the narcotic's kept in the medication cart there was a medication Pregabalin (used to treat pain) that had been signed out as administered to R #49 and medication was still present in the medication card. B. During interview with Certified Medication Aide (CMA) #, she confirmed there were five loose unidentified medications in medication cart and they should not be there, CMA #1 further confirmed that she had signed out the Pregabalin as administered to R #49 and she had not administered the medication as the Medication Administration Record (MAR)…

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

Based on observation and interview, the facility failed to ensure meals were served at an appetizing temperature for 1 (R #97) of 1 (R #97) residents reviewed for meal quality. This deficient practice may decrease the resident's quality of life and have the potential to cause weight loss due to the food not being the proper temperature. The findings are: A. On 02/18/25 at 1:18 pm, during an interview, R #97 stated the food is cold a lot of times for lunch when it is delivered to his room. B. On 02/24/25 at 1:22 pm, during an observation of lunch, revealed the following temperatures for the lunch test tray pulled for R #97: -Tamale was at 117 degrees Fahrenheit -Black beans was at 110 degrees Fahrenheit -Coleslaw was at 112 degrees Fahrenheit C. On 02/24/2025 at 1:22 pm, during an interview with the DC, she stated the temperatures taken for R #97 were not at the appropriate temperatures. D. On 02/24/25 at 1:22 pm, during an interview, the Dietary Manager (DM) confirmed the food tested for R #97 at 1:22 pm was not at the correct temperature. The DC confirmed the food should have been…

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 food preference was followed for 1 (R#97) of 1 (R #97) observed for dining observation., This deficient practice could result in the resident not eating and losing weight. A. On 02/18/25 at 1:24 pm, during interview, R #97 stated I don't like eggs and they keep giving me eggs that are cold for breakfast. B. On 02/19/25 at 8:45 am, during an observation of R #97's breakfast, there were eggs on his breakfast plate which he had not eaten. C. Record review of R #97's meal ticket revealed the meal tick did not have any indication of R #97 disliking eggs. D. On 02/24/25 at 1:52 pm during an interview, Dietary Manager (DM) stated she interviews residents upon admission and she reviews their preferences every quarterly, or as needed. She confirmed that she did not know R #97 did not like eggs.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a record review and interview, the facility failed to ensure medical records were complete for 1 (R #89) of 1 (R #89) residents reviewed. This deficient practice is likely to result in staff not having the information they need to provide competent, comprehensive care and services to residents. The findings are: A. Record review of R #89's face sheet revealed R #89 was admitted into the facility on [DATE]. B. Record review of R #89's Electronic Medical Record (EMR) revealed a Pre-admission Screening and Resident Review (PASRR: a federally required screening of any individual who applies to or resides in a Medicaid-certified nursing facility) was not available for review in the EMR. C. On 02/20/25 at 11:32 AM, during an interview, the Director of Nursing (DON) confirmed there was not a PASRR in R #89's EMR available for review and PASSR should be included in any admission to a medicaid certified nursing facility.

Based on record review and interview, the facility failed to ensure there was collaboration between the facility and hospice services for 1 (R #4) of 1 (R #4) 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 residents not receiving the services needed. The findings are: A. Record review of R #4's admission Minimum Data Set (MDS: a set of evaluations and review that provide an overall picture of a persons needs and abilities) Section O, Special Treatments, Procedures and Programs revealed the resident was on hospice care. B. On 02/19/25 at 1:42 PM, during an interview, the Director of Nursing in Training (DON-IT) stated a hospice binder (a binder that contains written communication between the facility and the hospice provider to include the coordinated plan of care) should be kept at the nurse's station or in medical records for R #4 so that staff are aware of the care that's needed/provided by the hospice provider. C. On 02/20/25 at 11:40 AM, during an interview, the Director of…

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

Past Noncompliance Based on record review and interview, the facility failed to ensure that bathing/showering assistance was provided for 1 (R #1) of 1 (R #1) resident reviewed for ADLs (activities of daily living). This deficient practice could likely result in residents in need of this specialized care experiencing a decline in their ability to perform hygiene tasks and maintain good personal hygiene. The findings are: A. Record review of R #1's face sheet dated 10/02/23 revealed this as R #1's an initial admission date with the following list of diagnoses: -Unspecified dementia, (a group of symptoms dealing with affecting memory, thinking and abilities). -Unspecified urinary incontinence, (loss of bladder control). -Chronic respiratory failure with hypoxia, (low oxygen in the blood). -Nonrheumatic aortic (valve) stenosis (narrowing of the aortic valve). B. Record review of R #1's shower tracking sheet provided by the Director of Nursing (DON) revealed that the shower days for R #1 are scheduled for Mondays and Thursdays. The shower sheets also revealed that R #1 had not had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS - a standardized assessment tool that measures health status in nursing home residents ) for 1(R #3) of 3 (R #'s 2, 3 and 4 ) resident reviewed. If the MDS assessment is inaccurate, then residents are likely to not receive the services they need or have an accurate record of the services needed and received. The findings are: A. Record review of R #3's Face Sheet dated 09/11/24, revealed R #3's an initial admission date and included the following diagnoses: -Sepsis (an infection of the blood stream,), -Urinary tract infection (infection of any part of the urinary system), infection and inflammatory reaction due to indwelling urethral catheter (a thin flexible tube that is inserted into the bladder when there is an issue with voiding urine), -Benign prostatic hyperplasia (condition in which an overgrowth of prostate [organ in male reproductive system]) with lower urinary tract symptoms, -Obstruction 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, record review, and interview, the facility failed to ensure that residents receive their meals in accordance with the menu schedule for 2 (R #'s 2, and 5) of 3 (R #'s 2, 4 and 5) residents reviewed during meal observations. If the facility is not ensuring that meals are served timely as scheduled, then residents are likely to be at risk of malnutrition and frustration. The findings are: A. Record review of the Facility's Meal Schedule revealed, Breakfast: 7:15 am, Lunch: 12:00 pm, and Dinner: 5:15 pm. B. On 11/14/24 during a meal schedule observation revealed a lunch meal cart was delivered to one hall at 1:12 pm and another lunch meal cart was delivered to the neighboring hall at 1:27 pm. R #'s 2 and 3 were roommates, R #2 received one lunch meal tray at 1:28 pm, R #3 did not receive a lunch meal tray until 1:43 pm. C. On 11/14/24 at 1:36 pm during an interview with the Director of Nursing, she stated that the kitchen forgot to send a lunch tray for R #3 and that this does happen often. She further stated that meals are often served late. D. On 11/14/24 at…

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

Based on interview and record review the facility failed to have a Registered Nurse (RN) at least 8 hours during each 24 hour period. This deficient practice is likely to affect all 114 residents on the census list provided by the Administrator on 08/13/24. This deficient practice is likely to result in residents not receiving the services they required. The findings are: A. Record review of the facility's staffing schedule for the months of April, May, June, and July 2024 revealed there was not a Registered Nurse (RN) scheduled to provide direct patient care on the following days: 1. April 7, 13, 14, 21, 22, 27, 28. 2. May 11, 31. 3. June 3, 10, 24. 4. July 1, 2 16, 30. B. On 08/15/24 at 1:23 pm, during an interview, the Scheduling Manager and the Administrator stated they were aware they did not always have a Registered Nurse on schedule. The Scheduling Manger stated they have been short on nurses.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to meet professional standards of quality by not maintaining accurate weights for 1 (R #14) of 3 (R #13, 14 and #15) residents sampled for nutrition. This deficient practice could likely result in resident nutrition to not be accurately assessed, causing a potential for unidentified medical issues or weight gain or loss. The findings are: A. Record review of the face sheet for R #14 indicated the resident was admitted on [DATE] with the following diagnoses: - Altered mental status (abnormal state of alertness and awareness), - Parkinson's disease (is a progressive disorder that affects the nervous system in parts of the body controlling nerves), - Ulcerative chronic proctitis (inflammation to the rectum), - Vascular dementia (brain damage due to impaired blood flow to the brain), - Severe protein-calorie malnutrition (not enough nutrition). - R #14 was discharged on 02/24/24. - This is not an all inclusive list. B. Record review of the physician orders…

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 and interviews the facility failed to ensure they had sufficient staff to meet the needs of all 113 residents residing in the facility when staff failed to. 1. Offer baths or showers to residents as scheduled; 2. Answer call lights timely to meet the needs of the residents. These deficient practices are likely to negatively impact resident safety, comfort, and to impede processes such as timely incontinence care (assisting residents to the bathroom or changing adult briefs), regular turning schedules (moving or turning residents that need assistance and are unable to move on their own), showers, and appropriate assistance with meals. The findings are: Baths/Showers Findings: Findings for R #14: A. Record review of R #14's face sheet revealed R #14 was admitted to the facility on [DATE]. B. Record review of R #14's care plan, dated 07/05/23, revealed the following: - Focus: R #14 required assistance and was dependent for ADL care in bathing due to right hemiparesis (weakness of one side) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to promote residents choices for 5 (R #'s 16, 76, 94, 95, and 96) of 5 (R #'s 16, 76, 94, 95, and 96) residents reviewed for choices when staff failed to: 1. Offer R #16 showers per his preference. 2. Ensure medical appointments were not missed due to lack of transportation for R #'s 76, 95, and 96. 3. Ensure R #94 was provided clothing that fit and ensure she had clothing available. These deficient practices are likely to result in the resident's personal choices, poor hygiene, needs, and preferences not being honored. The findings are: Shower Preference Findings: R #16 A. On 02/13/24, at 4:02 pm, during an interview with R #16, he stated he did not get showers according to his shower schedule, and he did not refuse them. R #16 stated the last time he received a shower was 02/07/23, and he would like showers as scheduled. B. Record Review of shower schedule, dated 02/20/24, revealed R #16 was scheduled for showers on Monday, Wednesday,…

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 notify residents of the findings of their grievances. This deficient practice is likely to result in the facility not considering the needs of the residents. The findings are: A. On 02/14/24, at 9:11 AM, during an interview with Resident's Council (RC) members, residents present in the meeting stated the facility did not act promptly with grievance responses and many times they do not get a response at all. The RC members stated they did not know if grievances were acted upon. They said the facility staff tell them they are working on it or they are looking into it. The RC members stated that was where it ended. B. Record review of the resident grievance forms, dated 11/23 through 02/24, revealed the forms were blank under the resolution of grievance section, which indicated a resolution had not been completed for the grievance. C. On 02/19/24, at 11:58 AM, during an interview with Social Services Director (SSD), she stated grievances were written on a grievance form and given to each department to follow up on. The SSD…

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 did not ensure 2 (R #'s 92 and 107) of 3 (R #s 39, 92, and 107) residents reviewed for timely Beneficiary Protection Notification received the correct notifications form 10055: Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) . This deficient practice can result in confusion for the resident or their representative as to what services they have or do not have financial coverage for. The findings are: A. Record review of Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review for R #92 revealed the following: 1. The record did not contain documentation to show staff issued CMS (Center for Medicare/Medicaid Service) form 10055: Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to R #92 who intended to continue services. The facility provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. B. Record review of SNF Beneficiary Protection Notification Review for R #107 revealed the following: 1. The record did 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to conduct quarterly care plan meetings as required for 3 (R #'s 19, 25, and 73) of 3 (R #'s 19, 25, and 73) residents reviewed. This deficient practice is likely to result in staff not being aware of residents' care needs and preferences, and residents not receiving the needed care. The findings are: Findings for R #19: A. On 02/16/24, at 11:22 AM, during an interview with Social Services Director (SSD), the SSD stated the last care conference for R #19 was on 04/06/22. She further stated care conferences should be held quarterly, and R #19's care conference was not. Findings for R #25: B. Record review of R #25's face sheet revealed R #25 was admitted into the facility on [DATE]. C. Record review of R #25's care plan meeting progress notes revealed R #25's last care plan meeting occurred on 07/11/23. D. On 02/13/24 at 12:06 pm during an interview with R #25, she stated, I haven't had one of those [care plan meetings] in awhile. E. On 02/19/24 at 11:51…

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 quality for 5 (R #'s 8, 11, 14, 21, and 73) of 5 (R #'s 8, 11, 14, 21, and 73) residents when staff failed to: 1. Label, date, and change oxygen (O2; labeling and date as to when the O2 was replaced with new tubing) for R #'s 11, 14, and 73. 2. Ensure humidifier bottles (bottles with distilled water used to provide humidity) on O2 were full for R #8 and #21 If the facility is not changing and labeling oxygen tubingand not ensuring humidifier bottles were full then residents are likely to not receive the therapeutic benefits and care needed. The findings are: O2 Tubing Findings: Findings for R #11: 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 01/16/24, revealed an order to change oxygen tubing weekly. Label each component with date and initials every day shift, every Monday. C. On 02/13/24, at 6:10 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 record review and interview, the facility failed to ensure the resident's ability to perform activities of daily living (ADLs) was maintained for 2 (R #'s 14 and 42) of 2 (R #'s 14 and 42) residents reviewed for restorative therapy (therapy in which a patient trains on abilities they already have to perfect them and helps maintain physical abilities to perform ADLs.) If the facility does not ensure that residents receive restorative services, then the residents are likely to experience a decrease in their ability to walk, transfer (move from one place to another), and do other activities of daily living. The findings are: Findings for R #14: A. Record review of R #14's face sheet revealed R #14 was admitted into the facility on [DATE]. B. Record review of R #14's Occupational Therapy (OT) Evaluation, dated 10/24/23, revealed the resident was referred to OT due to decline in ability to move without pain and ADL participation. The resident was largely bed bound due to inability to efficiently self-propel…

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 an elopement risk assessment was completed for a resident with elopement risks. 3. Ensure the elopement book was updated to include R #34 These deficient practices are likely to put residents at risk of unsafe situations. The findings are: A. Record review of the local police department public alert, dated 10/2/23, revealed R #34 eloped from facility at 5:00 PM. B. Record review of R #34's medical record revealed the record did not contain an elopement assessment. C. Record review of the facility elopement book, dated 02/19/24, revealed R #34 was not in the elopement book. (An elopement book is used at a facility to identify high at risk residents who have potential to elope or have a history of elopement. Elopement book is typically kept at the nurses station or the front office, to alert staff of high risk elopement residents, and it typically contans a picture of the resident.) D. On 2/19/24 at 3:16 PM, during an interview with the Director of Nursing (DON), he stated R #34 had eloped from facility twice,…

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 meet professional standards of quality for 2 (R #62, and R #118) of 2 (R #62 and R #118) residents when staff failed to: 1. Ensure oxygen was not administered without a physician's order. 2. Ensure oxygen was administered in accordance with the physician's orders 3. Ensure BIPAP (machine that can help push air into lungs) was administered in accordance with physician's orders. If the facility is not administering oxygen as prescribed and without an order then the residents are likely to not get the therapeutic results as needed or administered if not needed. The findings are: Findings for R #62 A. On 02/13/24 at 11:29 am during random observation, R #62 sat in her wheelchair and used a portable oxygen tank via nasal cannula [NC; oxygen tubing with nasal prongs used to receive oxygen (O2) from an oxygen delivery device, such as a portable oxygen or oxygen concentrator.] B. On 02/13/24 at 11:30 am during interview with Licensed Practical Nurse (LPN) #3, she reviewed physician's orders for R #62 and confirmed…

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 staff communicated and collaborated with the dialysis (clinical purification of blood as substitute for normal kidney functioning) facility regarding dialysis care and services for 1 (R #94) of 1 (R #94) residents reviewed for dialysis. If the facility is unaware of the status, condition, or complications that arise during dialysis treatment then residents are likely not to receive the appropriate monitoring and care they need. The findings are: A. Record review of R #94's face revealed R #94 was admitted into the facility on [DATE]. B. Record review of R #94's dialysis schedule revealed R #94 had dialysis on Tuesdays, Thursdays, and Saturdays from 9:00 am to 1:30 pm. C. Record review of R #94's dialysis communication record (communication form used to communicate between the facility and the dialysis center about the patients status), dated 12/01/23 through 12/31/23, revealed the following: 1. Six dialysis communication records were provided…

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 #109) of 1 (R #109) resident's reconciliation (the process of ensuring the number on the medication log and the number of pills in the container are the same) of medication log was accurate. Failure to accurately document when medications are dispensed and administered are likely to cause medication errors resulting in over-dosing or under-dosing residents. The findings are: A. Record review of the controlled substance (drugs that are regulated by state and federal laws) records, dated 02/12/24, for the north wing medication cart revealed the following: Reconciliation of the controlled substance log for R #109's oxycodone immediate (a medication used for pain), 5 milligram (mg) tablet and the blister pack (a tamper-evident packaging where an individual pushes individually sealed tablets through the foil in order to take the medication) for the same medication did not match. The number on the blister pack was five and the number on the reconciliation sheet was six. B. On 02/12/24, at 12:50 PM, during 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 ensure 4 (R #34, 51, 65, 76) of 5 (R #9, 34, 51, 65, 76) resident's medications were reviewed by the pharmacist and physician and acted on. These deficient practices are likely to cause residents to receive unnecessary medications, experience potential unnecessary drug interactions or adverse side effects. The findings are: A. Record review of monthly pharmacy review, dated June 2023, revealed a pharmacist reviewed all residents' medications and made the following recommendations: 1. Findings for R #34 - Recommendation to reevaluate medications and consider reducing quetiapine (medication used to treat psychiatric disorders). - R #34 received amoxicillin (a medication to treat bacterial infections), but the medication did not have a stop date. Pharmacist recommendation was to document a stop date. - The monthly review form did not contain any indication the provider reviewed and responded to the recommendations. 2. Findings for R #51 - Resident cannot swallow medications whole and received omeprazole (a medication used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medications were administered as ordered by the Physician for 1 (R #110) of 2 (R #110 and 156) residents reviewed for medication administration. This deficient practice is likely to result in a resident failing to obtain maximum wellness and/or suffering prolonged illness. The findings are: A. Record review of R #110's face sheet, dated 02/19/24, revealed he was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus (DM) (a chronic disease that causes too much sugar in the blood). B. Record review of R #110's physician order, dated 02/08/24, revealed an order to adminster insulin (a hormone medication that helps control the sugar found in blood) lispro (a fast acting insulin) subcutaneous (below the skin) cartridge, 100 unit/milliliters (ml). Inject 6 units subcutaneously before meals for DM. C. Record review of R #110's care plan, dated 09/28/23, revealed the following: - Focus: resident has a diagnoses 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 observation and interview the facility failed to: 1. Ensure medications and other medical supplies were properly stored and not expired. 2. Ensure temperatures for medication room and refrigerators were monitored daily as per facility procedure. 3. Ensure medication carts were locked when not in use. This deficient practice is likely to result in medications losing their potency and affect the quality of specimens needed for lab tests. The findings are: Medication Cart and Medication Room Storage Findings: A. On 02/12/24 at 12:30 PM during observation of the South Medication Room revealed the following: - One box nicotine patches (used to reduce cravings for nicotine and to help prevent withdrawal symptoms) expired 1/24. - One bottle, 1.5 calorie, 33.8 ounce, peptide-based high protein Osmolite therapeutic nutrition expired 2/1/24. - One bottle gabapentin, 250 milliliters (ml), oral solution (medication used to help relieve nerve pain) expired 1/20/24. - One bottle omeprazole, 2 milligram (mg), oral…

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 for all 113 residents in the facility. This deficient practice could potentially lead to frustration and hunger. The findings are: A. Record review of mealtimes posted in the dining room revealed all food trays are scheduled to be served by : 1. Breakfast scheduled at 7:15 am. 2. Lunch scheduled at 12:00 pm. 3. Dinner scheduled at 5:15 pm. B. On 02/12/24 at 1:04 pm during observation of lunch, residents in their rooms and had not received their lunch meals. C. On 02/13/24 at 1:14 pm during observation of lunch, staff delivered South Unit meal trays to the unit. D. On 02/13/24 at 6:28 pm during observation of dinner, staff delivered South Unit meal trays to the unit. E. On 02/15/24 at 1:49 pm during observation of lunch, residents in their rooms and had not received their meals. F. On 02/15/24 at 1:50 pm during an interview with R #76, he stated, I'm starving and my stomach is growling. I came out to see when I was finally going to get my lunch. R #76 stated meals are…

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

Based on observation and interview, the facility failed to provide food according to U.S. Food and Drug Administration (FDA) Food Code, 2022 edition, for 2 (R #8 and #9) of 2 (R #8 and #9) residents observed for hot food temperature. This deficient practice is likely to result in residents getting a foodborne illness or having weight loss. The findings are: A. On 02/12/24 at 4:14 pm, during and interview, R #8 stated the food was often served cold. R #8 would like her food to be served hot. B. On 02/13/24 at 2:34 pm during an interview with R #9, she stated the food was always cold. She said she liked to eat her food hot, and it was cold quite often. C. Record review of the menu for lunch meal on 02/15/24 revealed the following: 1. Turkey garden burger. 2. Creamy coleslaw. 3. Ranch style beans. 4. Beverage of choice. D. On 02/15/2024 at 1:49 pm, observation of food temperatures of the lunch meal room trays on the South Hall, taken by the Dietary Manager (DM), revealed the following: 1. Turkey Garden Burger measured 115.8 degrees (°) Fahrenheit (F), 2. Creamy Coleslaw measured 64° F…

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 offered COVID -19 (a highly infectious viral disease) vaccinations to 2 (R #'s 63 and 76) of 4 (R #37, #40, #63, #76, and #110) residents reviewed for COVID-19 vaccines. This deficient practice could likely result in residents at risk of exposure to COVID-19 related infections. The findings are: Findings for R #63: A. Record review of R #63's face sheet revealed R #63 was admitted into the facility on [DATE]. B. Record review of R #63's immunization record, located in the Electronic Health Record (EHR), revealed staff administered R #63's last COVID-19 vaccine on 10/21/22. C. On 02/13/24 at 2:46 pm during an interview with R #63, he stated he wanted the COVID-19 booster and asked for it for several months. R #63 stated the staff have not offered him the COVID-19 vaccine. Findings for R #76: D. Record review of R #76's face sheet revealed R #76 was admitted into the facility on [DATE]. E. Record review of R #76's immunization record,…

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

Based on record review, observation and interview the facility failed to properly inform 1 (R #93) of 1 (R #93) resident of treatment decisions by failing to utilize interpreter line (service used for communication) to communicate with resident in a language the resident could understand. If the facility is not able to communicate with residents then residents are likely not to get their needs met. The findings are: A. Record review of R #93's face sheet revealed an admission date of 10/12/23 to the facility with the following diagnoses: 1. Cyst of pancreas (saclike pockets of fluid on or in your pancreas) , 2. Major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), 3. Personal history of suicidal behavior (talking about or taking actions related to ending one's own life), 4. Ulcerative colitis (a chronic condition that happens when you have inflammation in your colon), 5. Age-related cognitive decline (normal age-related decline in thinking and memory). B. On 02/13/24 at 1:05 pm during an interview, the Social Services Director…

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 an environment that was clean, in good condition, and had basic toiletries (paper towels, etc) for 2 (R #'s 61 and 109) of 2 (R #'s 61 and 109) residents sampled for a homelike environment. Failure to maintain the building in a clean and comfortable manner is likely to result in unsafe conditions and prevent residents from enjoying everyday activities. The findings are: A. On 02/12/24, at 12:40 pm, during random observation of R #61 and R #109's room, the floor was sticky, dirty, and had debris on it. The resident's room did not have any paper towels available for residents or staff use. B. On 02/12/24, during interview with R #61 and R #109, both residents stated they did not have any paper towels in the bathroom for their use. They further stated the floor had not been mopped in several days, and it was sticky and dirty. Both residents stated they are unhappy about the dirty floor and not having paper towels to dry their hands. C. On 02/12/24, at 12:44 pm, during an interview with Housekeeper (HK) #1, she 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 observation, record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R # 40) of 1 (R #40) residents reviewed for pressure ulcers (localized damage to skin/tissue occurs as a result of pressure) and pain. This deficient practice is likely to result in residents experiencing pain or a worsened condition. The findings are: A. On 02/19/24 at 10:48 am during wound care observation and interview, License Practical Nurse (LPN) #3 removed R #40's brief, which revealed multiple small round blisters to R #40's lateral (the side of the body or a body part that is farther from the middle or center of the body) inner thighs, left lower abdomen, and right outer thigh. Further observation revealed the blisters bled and drained a clear fluid. LPN #3 stated she was unaware of these blisters. She said staff did not document the blisters, and they were not being treated at this time. LPN #3 stated she had not contacted the physician for orders, because she was unaware of the blisters. B.…

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 residents received foot treatment and care in accordance with professional standards of practice for 1 ( R #62) of 1 (R #62) residents reviewed for foot care and dressing changes. This deficient practice is likely to result in residents experiencing worsened wound conditions. The findings are: A. On 02/13/24, at 11:12 am, during observation, R #62 sat on her bed with the bandage to her left foot exposed. The bandage on R #62's left foot had a date of 02/11/24, which indicated staff last changed the bandage two days prior to the observation. B. Record review of R #62's physician orders, dated 01/27/24, revealed the following order for wound care: Cleanse second toe (toe to left of the big toe) of left foot with wound cleanser (antiseptic solution used to clean wounds), pat dry, and apply skin barrier (cream used to prevent skin breakdown) to peri-wound (around the wound) area. Apply betadine (antiseptic solution that kills and prevents the growth of bacteria) to injured toe, cover with a non-adherent…

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

Based on observation and interview, the facility failed to provide food according to the residents meal tickets for 4 (R #25, R # 32 , R #64, and R #93) of 4 (R #25, R # 32 , R #64, and R #93) residents observed during lunch. This deficient practice is likely to result in weight loss due to residents not meeting caloric intake goals. The findings are: Findings for R #25: A. Record review of R #25's meal ticket, dated 02/16/24, revealed a regular/liberalized diet (non-restrictive), gravy on the side when meat is served. Lunch: 6 ounce (oz) assorted beverage, 1/2 cup mixed vegetables, 1/2 cup seasonal fresh fruit, 1/2 creamy peanut butter and jelly sandwich, 1 chicken fillet on roll, and 1 oz ladle brown gravy. B. On 02/16/24 at 1:16 pm during lunch observation and an interview, staff served R #25 a chicken sandwich, steamed vegetables, and did not serve gravy. R #25 stated, I really wanted the gravy. C. On 02/16/24 at 1:17 pm during an interview with Licensed Practical Nurse (LPN) #2, she confirmed staff did not serve R #25 gravy on the side and should have. D. On 02/19/24 at 4:30 pm…

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

Based on observation and interview, the facility failed to ensure a garbage can was covered and not placed in a food storage area. This practice had the potential to affect all 113 residents, as listed on the facility census provided by the Administrator on 02/12/24, by attracting insects and rodents into the facility. The findings are: A. On 02/12/24 at 12:35 pm, an observation of the kitchen, revealed one garbage can, located in the kitchen's dry storage room, was full of trash and did not have a lid. B. On 02/12/24 at 1:15 pm during an interview with the Health Care Service District Manager (DM), she confirmed the uncovered garbage can should not be in the dry food storage area.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide proper infection control practices when staff failed to: 1. Wash hands before and change gloves after performing peri-care (cleaning the private areas of a resident) and prior to cleaning wound. 2. Change gloves after administering wound care. 3. Ensure clean bandages did not touch a non-clean surface (bed). 4. Dispose of soiled bandages in proper receptacle for items that contain biohazards waste and not disposing in resident rooms If the facility is not using proper infection control practices the residents are likely to acquire infections. The findings are: Findings for R #40 A. On 02/19/24 at 10:48 am, observation of wound care for R #40 revealed the following: 1. LPN #3 did not wash her hands before putting on her gloves to perform pericare. 2. LPN #3 did not change her gloves after performing pericare and before cleaning R #40's wound. 4. LPN #3 did not change her gloves after cleaning R #40's wound, or before she applied…

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 discharge was properly documented in the resident's medical record and provide a completed discharge plan for 2 (R #'s 2 and 3) of 2 (R #'s 2 and 3) residents reviewed for discharge. This deficient practice is likely to result in residents not having what they need for a safe discharge. The findings are: Findings for R #2: A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE] and discharged on 06/04/23. B. Record review of R #2's progress notes, dated 06/03/23, revealed, Calling [Name of out of facility healthcare provider] because patient [R #2] never returned after leaving with [Name of out of facility healthcare provider] on Friday [06/02/23]. Was told by Unit manager to call [Name of out of facility healthcare provider] and confirm where patient [R #2] is,. Patient may have been discharged without knowing. Patient [R #2] is still on chart, but is not here. At shift report I was told this information,…

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 #1) of 2 (R #'s 1 and 3) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: Findings for R #2: A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE] and discharged on 06/04/23. B. Record review of R #2's Minimum Data Set (MDS), Section G- Functional Status, dated 06/04/23, revealed, Physical help in part of bathing activity. C. Record review of R #2's Documentation Survey Report (ADL Tracking Form), dated 05/24/23 - 05/31/23, revealed staff did not assist R #2 with a bath/shower during that time. No shower sheets were available for the time period. D. Record review of R #2's Documentation Survey Report, dated 06/01/23 - 06/04/23, revealed staff did not assist R #2 with a bath/shower during that time. No shower sheets were available for the time period.…

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 by not assisting residents with showers per their requested schedule and preference for 1 (R #4) of 1 (R #4) residents reviewed for choices . This deficient practice is likely to result in the resident's personal choices, poor hygiene, needs, and preferences not being honored. The findings are: A. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE]. B. Record review of R #4's care plan, dated 05/10/23 revealed, Focus: While in the facility, [Name of R #4] states that it is important that She has the opportunity to engage in daily routines that are meaningful relative to Her preferences. Interventions: It is important for me to choose between a shower, bed bath, or sponge bath. C. On 09/06/23 at 1:27 pm, during an interview, R #4 stated, I want three showers a week [Monday, Wednesday, and Friday]. There's been times when I had to go without it [showers]. I was stinky and upset. R #4…

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 honor residents' rights by discharging a resident to hospital without providing proper notice and planning to one (R #1) of one (R #1) residents reviewed for discharge and planning. This deficient practice is likely to result in the resident experiencing feelings of frustration, fear and anxiety about where they will be residing after discharge from facility. A. Record review of facesheet revealed R #1 was admitted to facility on 01/17/22 with the following diagnosis: 1. Schizophrenia, unspecified (Mental condition that involving breakdown between thoughts, emotion and behavior, leading to faulty perception) 2. Anxiety disorder, unspecified (Mental illness that causes distressing and disruptive thoughts) 3. Major depressive disorder (Tendency of an individual to suffer recurrent episodes of depressed B. Record review of R #1's nurses progress notes, dated 06/14/23 at 1:32 PM, revealed officers arrived at facility to transport R #1 to hospital for a psychiatric evaluation. R #1 requested the writer of progress note, along…

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 medications were administered as ordered by the Physician, for 1 (R #5) of 1 (R #5) resident reviewed for medication administration. This deficient practice is likely to result in a resident failing to obtain maximum wellness and/or suffering prolonged illness. The findings are: A. Record review of R #5 face sheet reveals he was admitted to facility on 02/14/22 with multiple diagnoses including but not limited to: - Schizotypal Disorder (a personality disorder characterized by thought disorder, paranoia, social anxiety); - Delusional Disorders (a psychiatric disorder characterized by unrealistic thoughts and fears); - Type 2 Diabetes Mellitus (a chronic condition in which the body fails to properly regulate blood sugars). B. Record review of R #5's physician orders revealed orders to administer the following medications daily: - Amlodipine (a medication that helps reduce blood pressure) oral tablet, 5 mg (milligrams), by mouth one time a day for HTN (hypertension; a medical condition of high blood pressure); -…

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, record review, and facility policy review, the facility failed to ensure the nourishment refrigerator in the South Unit was maintained at a cold enough temperature to prevent the potential spread of foodborne illness to 58 residents who resided on the South Unit out of 99 total residents residing in the facility. Findings include: A. Review of the Food Storage: Cold Foods policy dated April 2018 revealed, All time/temperature control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA [Food and Drug Administration] Food Code . All perishable foods will be maintained at a temperature of 41 [degrees] F or below, except during necessary periods of preparation and service . An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. B. Review of the Refrigerator Temperature Log, included with the Food Storage: Cold Foods policy dated April 2018, revealed for all temperatures above 41 degrees F, corrective action was to be…

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, record review, and review of the facility's policy, the facility failed to ensure residents were free from abuse for one resident's (Resident (R) 80) of four residents reviewed for abuse. R80 was physically abused by a facility staff member. This failure had the potential to cause physical injury or pain as well as mental anguish, for R80. Findings include: Review of R80's undated admission Record, located in the Profile tab of the electronic medical record (EMR) revealed R80 was admitted to the facility on [DATE] with diagnoses of brain tumor, anxiety, depression, and dementia. Review of R80's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/24/22, located in the MDS tab of the EMR, revealed R80 suffered from short-term and long-term memory problems and severely impaired cognition. R80 exhibited mood symptoms of feeling depressed or down and poor appetite occasionally and she wandered daily. R80 required supervision and setup help with transfers and locomotion…

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, record reviews, and review of the facility's policy, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for two residents (Resident (R) 80 and R31) of four residents reviewed for abuse. Additionally, the facility failed to ensure allegations of abuse for two residents (R80 and R12) of four residents reviewed for abuse were reported to the State Survey Agency within required time frames. These failures had the potential to contribute to continued potential abuse in the facility for these three residents. Findings include: A. Record review of R80's undated admission Record, located in the Profile tab of the Electronic Medical Record (EMR) revealed R80 was admitted to the facility on [DATE] with diagnoses which included brain tumor, anxiety, depression, and dementia. B. Record review of R80's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/24/22,…

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, record reviews, and facility policy review, the facility failed to ensure allegations of abuse for three residents (Resident (R) 80, R31, and R12) of four residents reviewed for abuse were thoroughly investigated. This failure had the potential to contribute to further abuse in the facility for these three residents. Findings include: Findings R80 A. Record review of R80's undated admission Record, located in the Profile tab of the Electronic Medical Record (EMR) revealed R80 was admitted to the facility on [DATE] with diagnoses which included brain tumor, anxiety, depression, and dementia. B. Record review of R80's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/24/22, located in the MDS tab of the EMR, revealed R80 suffered from short-term and long-term memory problems and severely impaired cognition. R80 exhibited mood symptoms of feeling depressed or down and poor appetite occasionally and she wandered daily. R80 required supervision and setup help with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to develop and implement an effective discharge planning process for one resident (Resident (R) 45) of two residents reviewed for community discharge. This failure had the potential to result in depression and/or a feeling of helplessness in R45 related to his desire to return to the community and lack of involvement of the resident in his discharge plan. Findings include: A. Review of R45's undated admission Record found in the Profile tab of the Electronic Medical Record (EMR), R45 was admitted to the facility on [DATE] with diagnoses which included kidney disease, major depressive disorder, and anxiety. B. Review of R45's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/24/22, revealed the facility assessed R45 to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R45 was cognitively intact. There was no active discharge planning for R45. C. 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 observations, staff interviews, and record review, the facility failed to ensure an individualized program of activities was implemented for one (Resident (R) 37) of two residents reviewed for activities. This failure had the potential to cause boredom, isolation, and feelings of helplessness for R37. Findings include: A. Record review of R37's undated admission Record, located in the Profile tab of the Electronic Medical Record (EMR), revealed R37 was admitted to the facility 01/29/21 with diagnoses which included dementia, major depression, and macular degeneration. B. Record review of R37's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/08/22, located in the MDS tab of the EMR, revealed staff assessed R37 with short- and long-term memory problems and severely impaired cognition. She exhibited the mood symptoms of poor appetite and little interest or pleasure in doing things occasionally but did not exhibit any behavioral symptoms. C. Record review of R37's annual MDS with an ARD of 02/05/22 revealed R37's felt it was very important to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure two of nine residents reviewed for accidents (Resident (R) 3 and R44) out of a total sample of 28 residents received adequate supervision and assistive devices to prevent accidents by the following: 1. R3 was transported to the facility from the hospital by an employee of the corporation (of which the facility was part of); R3's wheelchair was not strapped in, and she sustained a fall during transportation. R3 sustained injuries from the fall such as a bump to her forehead and bruises. 2. The facility failed to conduct neurochecks, complete a thorough investigation, and maintain adequate documentation concerning R3's fall and the investigation. 3. Additionally, R44 utilized a positioning rail on the left side of her bed. There was no current physician's order or assessment of the rail for safety. The facility determined the bed rail caused skin injuries to R44's forearm. The facility failed to implement…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 14) reviewed for bowel and bladder incontinence out of a total sample of 28 residents received necessary services to promote her ability to remain continent of urine as much as possible. Findings include: A. Review of the Continence Management policy dated 06/15/22, provided by the facility revealed, Patients will be assessed for the need for continence management as part of the nursing assessment process. A urinary incontinence assessment and/or bowel incontinence assessment will be completed upon admission or readmission and with a change in condition or change in continence status. Continence status will be reviewed quarterly as part of the care planning process .Purpose - To provide appropriate treatment and services for patients with urinary incontinence to minimize urinary tract infections and restore continence to the extent possible . Identify patient's continence…

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, record review, and facility policy review, the facility failed to identify target behaviors for monitoring of effectiveness of antipsychotic medication for two residents (Resident (R) 80 and R12) of five residents reviewed for unnecessary medications. This failure had the potential to contribute to unnecessary antipsychotic medication use in R80 and R12, who both used the medication to treat behavioral symptoms of dementia. Findings include: R80 A. Record review of R80's undated admission Record, located in the Profile tab of the Electronic Medical Record (EMR), revealed R80 was admitted to the facility on [DATE] with diagnoses which included brain tumor, anxiety, depression, and dementia. B. Record review of R80's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/24/22, located in the MDS tab of the EMR, revealed staff assessed R80 to have short- and long-term memory problem and severely impaired cognition. She exhibited mood symptoms of feeling…

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 facility policy review, the facility failed to ensure medication, medication carts, and treatments cart were secured when unattended. This had the potential for medications to become diverted or for a cognitively impaired resident to potentially take the medications. Findings include: A. Review of the facility's policy titled, 5.3 Storage and Expiration Dating of Medications, Biologicals revision date 07/21/22, provided by the facility, reflects in part, Store all drugs and biologicals in locked compartments, including the storage of Schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access. B. During an observation on 11/03/22 at 9:14 AM, revealed the medication cart in the south hall, parked between room [ROOM NUMBER]-156. Certified Medication Aide (CMA) 2 and Registered Nurse (RN) 1 both were working out of medication cart and walked into room [ROOM NUMBER] leaving the medication cart unlocked…

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, record review, and facility policy review, the facility failed to ensure one resident (Resident (R) 11) of three residents reviewed for dental services received assistance in obtaining routine dental care. This failure contributed to R11 requiring a mechanically altered diet for ease of chewing and a potential for negative emotional effects of having no teeth. Findings include: A. Record review of R11's undated admission Record, located in the Profile tab of the Electronic Medical Record (EMR), revealed R11 was re-admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure, major depression, and post-traumatic stress disorder. B. Record review of R11's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/08/22, located in the MDS tab of the EMR, revealed the facility assessed R11 to have a Brief Interview for Mental Status, score of 12 out of 15, which indicated R11 was moderately cognitively impaired. The facility…

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.