Sunset Villa Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths or showers for 3 (R #1, R #2, and R #3) of 3 (R #1, R #2, and R #3) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are:Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths or showers for 3 (R #1, R #2, and R #3) of 3 (R #1, R #2, and R #3) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are:R #1A. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE] with the following diagnoses: 1. Fracture of pelvis (a…

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

Based on observation, record review, and interview, the facility failed to develop and implement an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections). This failed practice has the potential to affect all 96 residents living in the facility as identified by the census provided by the Administrator on 12/08/24. This deficient practice could likely result in the spread of infectious diseases. A. On 02/03/25 at 6:00 am, during a random observation of the facility, signs indicated enhanced barrier precautions were on the doorways of rooms 102, 109, 110, and 120. B. Record review of the facility's Infection Prevention and Control Program Policy and Process Surveillance and Reporting policy, revision date of 06/2020, revealed the following: 1. The Infection Preventionist coordinates the development and monitoring of the facility's established infection control policies and procedures. 2. Reporting information related to compliance with the facility's established infection control policies and…

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

Based on record review and interview, the facility failed to ensure staff implemented a comprehensive antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This failed practice has the potential to affect all 45 residents in the facility. Residents identified on the matrix provided by the Administrator on 02/03/25. This deficient practice could likely result in the inappropriate use of antibiotics that can lead to resistance of multi-drug resistant organisms. The findings are: A. Record review of the facility's Antibiotic Stewardship policy, revision date of 06/20 revealed The Infection Control Committee (ICC) will review infections and monitor antibiotic usage patterns on a regular basis. In addition, the ICC will obtain and review results from microbial cultures, resistant organisms, alerts and antibiograms from the lab for tends of resistance. B. On 02/05/25 at 2:30 pm during an interview with the Infection Preventionist (IP), he confirmed he does 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 develop and implement an accurate, person-centered comprehensive care plan for 3 (R #5, R #24, and R #34) of 6 (R #1, R #5, R #17, R #24, R #34, and R #39) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: R #5 A. Record review of R #5's admission Record revealed R #5 was admitted to the facility on [DATE] with multiple diagnoses including: 1. Diabetes Mellitus with Hyperglycemia (a chronic metabolic disorder characterized by high blood sugar), 2. Heart failure, 3. Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), 4. Cellulitis (deep inflammation of the tissues just under the skin; caused by infection) of unspecified part of limb, 5. Unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure staff revised the care plan for 2 (R #5 and R #24) of 6 (R #1, R #5, R #17, R #24, R #34, and R #39) residents reviewed for pain medication management. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R #5 A. Record review of R #5's admission Record revealed R #5 was admitted to the facility on [DATE]. B. Record review of R #5's electronic files revealed a physician order for oxycodone (pain medication) dated 01/29/25 to be administered every six (6) hours as needed for pain. C. Record review of R #5's Medication Administration Record (MAR) for the month of February 2025, revealed R #5 was not administer oxycodone but has an active order that is available to be administered. D. Record review of R #5's comprehensive care plan revised on 01/31/25 revealed the comprehensive care plan did not include the use of pain medications and interventions for 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 record review and interview, the facility failed to ensure residents who had completed and signed a consent form for influenza (flu, infection of the nose, throat and lungs caused by a virus) vaccine actually received the vaccination for 1 (R #9) of 5 (R #7, R #9, R #10, R #14, and R #27) residents reviewed for immunizations. If residents are not vaccinated appropriately for influenza, then they have a higher likelihood of contracting the illness and spreading the flu to other residents in the facility. The findings are: A. Record review of R #9's Electronic Health Record (EHR) revealed the following: 1. The last influenza vaccine was received on 09/21/22. 2. History of vaccinations indicated the last flu shot was given on 09/21/22. 3. R #9 signed a consent for the influenza vaccine on 11/28/24. The EHR did not indicate the resident received the vaccination. B. On 02/06/2025 at 12:40 pm, during an interview with the Director of Nursing (DON), she confirmed R #9 had not yet received influenza vaccination after consenting for the vaccination. She was unable to confirm why 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 record review and interview, the facility failed to offer COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccinations to 4 (R #7, R #9, R #10, and R #14) of 5 (R #7, R #9, R #10, R #14, and R #27) residents reviewed for COVID-19 vaccinations. This deficient practice could likely result in residents getting COVID-19. The findings are: R #7 A. Record review of R #7's Electronic Health Record (EHR) revealed the record did not contain any COVID-19 vaccine forms which indicated staff offered or administered the COVID-19 vaccine to the resident. B. On 02/06/24 at 12:40 pm, during an interview with the Director of Nursing (DON), she confirmed R #7's EHR does not contain any evidence that the facility offered the COVID-19 vaccination to R #7. R #9 C. Record review of R #9's EHR revealed the last COVID-19 vaccination that R #9 received was on September 21, 2022. D. On 02/06/24 at 12:40 pm, during an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review, the facility failed to ensure privacy was provided for 1 (R #1) of 1 (R #1) residents reviewed when they failed to ensure personal privacy while dressing in her room. This deficient practice is likely to cause residents to feel exposed and unimportant. The findings are: A. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE] with multiple diagnoses including: 1. Type 2 Diabetes Mellitus (a chronic disease that occurs when the body doesn't use insulin properly, resulting in high blood sugar levels), 2. Degenerative disease of nervous system, unspecified (a condition that causes nerve cells in the brain or spinal cord to die with no known reason), 3. Altered mental status, unspecified (a significant change in a person's mental function, affecting their awareness, cognition, and behavior with no known reason), 4. Need for assistance with personal care. B. Record review of R #1's admission Minimum Data Set (MDS; a federally mandated…

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

Based on observation and interview, the facility failed to provide a comfortable and homelike environment that was in good condition for 1 (R #5) of 1 (R #5) resident reviewed for a homelike environment by not repairing the wall and the blinds in his room. Failure to maintain and provide a comfortable environment is likely to result in residents feeling unimportant and undervalued. The findings are: A. On 02/03/25 at 7:54 am, during an interview with R #5 he pointed to the sliding glass door in his room which had several broken and missing blinds and stated he has asked maintenance to fix them but hasn't heard anything. R #5 stated the blinds have been broken and missing for months, but could not remember exactly how long. B. On 02/05/25 at 3:16 pm, an observation of R #5's room revealed the following: 1. A section of the wall by the bed measuring approximately six feet by three feet had paint that was scrapped and was peeled. 2. The sliding glass door had several broken and missing blinds. C. On 02/05/25 at 3:46 pm, during an interview with the Maintenance Director (MD), he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) for 2 (R #34 and R #38) of 3 (R #24, R #34, and R #38) residents reviewed for care plans. If baseline care plans are not accurate then residents may not get the appropriate care which could lead to an adverse event (undesirable experience, preventable or non-preventable, that causes harm to a resident because of medical care or lack of medical care). The findings are: R #34 A. Record review of R #34's admission Record revealed R #34 was admitted to the facility on [DATE] with multiple diagnoses including: 1. Acute Respiratory Failure with Hypoxia (when the lungs are unable to adequately provide oxygen to the body, resulting in low blood oxygen levels (hypoxia) that occur suddenly and require immediate medical attention), 2. Urinary Tract Infection (UTI; an infection in any part of the urinary…

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 record review, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for dressing for 1 (R #1) of 1 (R #1) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: A. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE] with multiple diagnoses including: 1. Type 2 Diabetes Mellitus (a chronic disease that occurs when the body doesn't use insulin properly, resulting in high blood sugar levels), 2. Degenerative disease of nervous system, unspecified (a condition that causes nerve cells in the brain or spinal cord to die with no known reason), 3. Altered mental status, unspecified (a significant change in a person's mental function, affecting their awareness, cognition, and behavior with no known reason), 4. Need for assistance with personal 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 record review and interview, the facility failed maintain adequate hydration for 1 (R #24) of 1 (R #24) resident reviewed for dehydration when staff failed to: 1. Offer R #24 a drink when staff enter his room, 2. Document and monitor R #24's fluid intakes daily. If residents are not assisted with hydration support, then residents are likely to experience dehydration which could lead to other health problems. The findings are: A. Record review of R #24's admission Record revealed R #24 was admitted to the facility on [DATE] with the following diagnoses: 1. Alzheimer's disease, unspecified, 2. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), moderate, 3. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), severe with behavioral disturbance. 4. Cognitive Communication deficit (a communication difficulty that's caused by a cognitive impairment), 5. Essential…

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 labeled with a proper open date or expiration date. These deficient practices are likely to negatively impact the health of all residents, if staff administered or used potentially compromised or contaminated medications. The findings are: A. On 02/06/25 at 5:40 am, during an observation of the Medication Storage room, three opened bottles of generic throat spray was not labeled with an open date and a readable expiration date. B. On 02/06/25 at 5:45 am, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed the three bottles of throat spray were opened, the expiration date was unreadable and an open date had not been written on the bottles. She confirmed she was unable to determine when the throat sprays were opened and could not determine expiration because the manufacturers expiration dates were unreadable. She confirmed the expiration dates should be clear and readable. C. On 02/03/25 at 9:05 am, during an interview with the Director of Nursing (DON), she confirmed the opened…

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 all medication carts were locked while not in use. This deficient practice had the potential to affect all 19 people residing in rooms 100-111 as identified by the resident census provided by the Administrator on 06/06/24 by allowing unauthorized persons access to their medications and personal health information. The findings are: A. On 06/06/24 at 10:52 am, during a random observation of the facility, the medication cart located near the nurse's station was unlocked, and staff were not in the area. Further observation revealed R #3, R #4, and R #5 were present in the area. B. On 06/06/24 at 10:57 am, during an interview with the Director of Nursing (DON), he confirmed the medication cart was unlocked, and facility employees were not in the area. The DON stated an unattended, unlocked medication cart did not meet his expectations, because it should have been left locked if a nurse was not present and working out of it.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 2 (R #1 and #3) of 2 (R #1 and #3) residents reviewed for baseline care plans. This deficient practice could likely result in a decline in the residents' conditions due to staff not being aware of the care residents need. The findings are: R #1: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE]. B. Record review of R #1's baseline care plan, dated 04/07/24, revealed only the Social Services section was completed. Sections: Nursing Services, Rehabilitative Services, Nutritional Services, and Activities were blank and incomplete. C. On 06/06/24 at 6:07 pm, during an interview with the Regional Clinical Consultant (RCC), she confirmed R #1's baseline care plan was incomplete and should not have been. D. On 06/07/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to update and implement a comprehensive person-centered care plan for 1 (R #2) of 1 (R #2) residents reviewed for comprehensive care plans when the facility failed to have a current plan in place. Failure to have a current comprehensive person-centered care plan in place may result in staff not understanding and implementing the needs and treatments of residents. The findings are: A. Record review of R #2's Face Sheet revealed R #2 was admitted to the facility on [DATE]. B. Record review of R #2's care plan, dated 04/24/24, revealed all items listed as canceled which indicated the resident did not have a current care plan in place. C. On 06/06/24 at 6:24 pm, during an interview with Regional Nurse she stated she did not see a current care plan for R #2. She confirmed R #2 did not have a current, updated care plan to implement due to all items listed in the care plan were canceled.

Based on interview, the facility failed to have a qualified therapeutic recreation specialist or an activities professional direct the the activity program in the facility for all the residents who resided in the facility. If the facility is not providing activity programs for residents to participate in then residents are likely to get bored and their interests not being met. The findings are A. On 03/03/24 at 3:54 pm during an interview with the Administrator (ADM), she said the facility did not have an Activities Director since Valentine's Day weekend (02/11/24) to run the activity program. The ADM stated the Director Of Rehabilitation (DOR) provided some activities when he could, but she did not believe the DOR was certified as an activities professional. B. On 03/05/24 3:26 PM during an interview with the Regional Manager, he stated the facility's Activities Director did not work at the facility since February, and the facility did not have an Activities Director at this time. He stated the facility did not currently have an activity schedule or an organized activity program.

Based on observation and interview, the facility failed to ensure food was stored, prepared, distributed, and served to residents in accordance with professional standards of food service safety when staff failed to: 1. Ensure all food items in the kitchen were stored properly. 2. Ensure the kitchen refrigerators were clean. 3. Ensure the drain under the stove and the side of the oven are free from grime and dirt. These deficient practices are likely to affect all 49 residents identified on the resident census list provided by the Administrator on 03/02/24. If the facility does not follow food safety guidelines, then they are likely to expose residents to food borne illnesses. The findings are: Food Storage findings: A. Observation on 03/04/24 at 7:42 am of the facility's food preparation area, revealed the following: 1. A two pound (lb.) frozen buffet ham wrapped in a plastic bag sat on a prep table and was thawing. 2. The refrigerator door in the kitchen was visibly dirty with drips and splatters, and the inside had spilled substances on the bottom of the refrigerator. 3. 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 record review and interview, the facility failed to provide behavioral health (the emotions and behaviors that affect your overall well-being) care training for 31 Certified Nursing Assistants (CNAs # 1-31) out of 31 (# 1-31) CNAs in the facility. This deficient practice could likely result in residents not receiving the services necessary to attain or maintain their physical, mental, and psychosocial (involving both psychological and social aspects) well-being. The findings are: A. Record review of the facility diagnosis report (list of residents), dated 03/06/24, revealed the facility had 26 residents diagnosed with a form of dementia or Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior). B. Record review of the facility in-services (multiple dates throughout 2023 and the beginning of 2024) and training sign-in sheet (form used to track staff attendance dated 06/05/23 and 06/06/23) for CNAs revealed the record did not contain any documentation to show the facility's 31 CNAs had behavioral health and dementia care-related…

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 residents' choices for 2 (R #'s 5 and 32) of 2 (R #'s 5 and 32) residents reviewed for choices when staff failed to: 1. Ensure medical appointments were not missed due to lack of transportation for R #5. 2. Ensure R #32 was taken outdoors per her preference. These deficient practices are likely to result in the resident's personal choices, needs, and preferences not being honored. The findings are: Findings for R #5: A. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE]. B. On 03/02/24 during an interview with R#5's daughter, she stated her mother missed appointments, because there was not a driver to take R#5. C. On 03/03/24 at 1:20 PM, during an interview with Director of Nursing (DON), she confirmed R #5 missed a podiatry appointment on 01/05/24 due to staffing. The DON stated they had to reschedule R #5's appointment to the podiatrist on 02/27/24, because there was not a driver to take the resident. D.…

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

Based on interview and record review, the facility failed to assist or provide an opportunity for residents to organize a facility resident council for all 49 residents as listed on the Resident Census provided by the Administrator on 03/02/24. This deficient practice is likely to result in residents not feeling heard or feeling as if their concerns are not important. The findings are: A. Record review of resident council meeting minutes revealed the last resident council meeting occurred on 09/12/23. B. On 03/02/24 at 4:13 pm during an interview with Administrator (ADM) , the ADM stated the facility did not have an Activities Director, so the resident council did not meet on a regular basis. C. On 03/03/24 at 11:00 am during interview with R #s 8, 11, 26, 29, 43, and 47 at the Resident Council discussion, residents in attendance stated a resident council meeting was not scheduled for months. None of the residents in attendance could remember when the last meeting was held.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe, comfortable, and homelike environment. This deficient practice is likely to affect all 49 residents living in the facility as listed on the Resident Census provided by the Administrator on 03/02/24. Failure to maintain the building in a clean and comfortable manner is likely to prevent residents from enjoying everyday activities. The findings are: A. On 03/02/24 at 9:49 am during a random observation of R #5's room, there was a strong smell of urine, the floor was sticky, and there was an unknown dried substance on the floor. R #5's bed did not have sheets on it. The trash can was full of trash. B. On 03/04/24 at 11:14 am during a random observation of R #28's room, there was trash, dirt, and an unknown dried brown substance on the floor. The trash can was full of trash. C. On 03/02/24 at 10:16 am during an interview with Housekeeper (HK) #1, she stated she was not sure if staff cleaned R #28's room the day before (03/01/24), but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure resident care plans were revised for 5 (R #'s 29, 31, 34, 37, 44) of 5 (R #'s 29, 31, 34, 37, 44) residents reviewed for care plans when staff failed to: 1. Conduct quarterly care plan meetings as required for R #29. 2. Update a care plan to reflect antipsychotic medication (medications that mainly treat psychosis-related conditions and symptom) use and falls for R #31. 3. Update a care plan to reflect information regarding falls for R #37. 4. Update a care plan to accurately reflect information regarding falls, removal of catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid), and the use of fall mat (a mat placed on the floor beside a resident's bed in case a resident falls out of bed) for R #44. These deficient practices are likely to result in staff not being aware of residents' care needs and preferences, and residents not receiving the needed care. 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 observation, interview, and record review, the facility failed to meet professional standards of care for 1 (R #3) of 2 (R #'s 3 and 35) residents reviewed when staff failed to schedule an magnetic resonance imaging (MRI; medical imaging technique that uses a magnetic field and radio waves to create detailed images of the organs and tissues in your body) appointment for R #3 per physician orders. If the facility is not scheduling MRI appointments per physician orders, then residents are likely to not receive the therapeutic benefits and care needed. The findings are: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] with the following diagnoses: 1. Pain. 2. Osteoarthritis (Inflammation of one or more joints). 3. Muscle wasting and atrophy (A progressive and degeneration or shrinkage of muscles or nerve tissues). B. Record review of R #3's physician orders revealed the following: 1. Order dated 01/20/24 for non-contrast MRI of right hip for severe pain to rule…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide activities of daily living (ADL) assistance for baths and showers for 2 (R #'s 24 and 32) of 2 (R #'s 24 and 32) residents reviewed for ADL care when staff failed to: 1. Offer R #'s 24 and 32 at least three showers a week. 2. Document when a resident refused any bath or shower. These deficient practices are likely to affect the dignity and health of the residents. The findings are: A. Record review of shower schedule revealed residents occupying the A beds receive a bath/showers on Monday, Wednesday and Fridays. Residents occupying B bed receive a shower/bed bath on Tuesday, Thursday and Saturdays. R #24: B. Record review of R #24's face sheet revealed R #24 was admitted into the facility on [DATE] and resided in Bed-A. C. Record review of R #24's care plan, dated 04/17/23, revealed the following: - Focus: R #24's vision was highly impaired. She had a diagnosis of diabetic retinopathy (complication of diabetes where blood vessels…

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

Based on observation, record review, and interview, the facility failed to provide an on-going program of activities designed to meet the interests and well-being for 7 (R #'s 6, 9,16, 29, 30, 32, and 33) of 7 R #'s 6, 9,16, 29, 30, 32, and 33) residents reviewed for activities when staff failed to: 1. Offer one-to-one activities to residents that stay in their rooms or are bed bound for R #'s 6, 9,16, 29, 30, 32, and 33. If residents are not provided or encouraged to attend or participate in activities that meet their interests, are enjoyable, and enhance their social and emotional well-being, then they are likely to experience an increase in boredom, isolation, and depression. The findings are: A. Record review of the facility activity quarterly assessments revealed the following: 1. R #6's dated 02/06/24: Chooses not to participate in group activities (large/small) and Participates in: one-to-one visits. 2. R #9's dated 02/05/24: Participates in one-to-one programs and Participates in: one-to-one visits. 3. R #16's dated 01/10/24: Participates in one-to-one programs. 4. R #29's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident's hearing was maintained with functioning hearing aides for 1 (R #24) of 1 (R #24) resident. This deficient practice is likely to result in the resident not being able to understand when people communicate with her and her needs not being met. The findings are: A. Record review of R #24's face sheet revealed R #24 was admitted into the facility on [DATE]. B. Record review of R #24's care plan, dated 04/17/23, revealed the following: - Focus: R #24 had decreased social involvement due to hearing loss. She stated the feeling of unease being around others. She refused to participate with activities, often occasionally joining for a few minutes and assisting to go back to her room. - Interventions: Ensure that adaptive equipment (any tool used to help or assist a person to accomplish activities of daily living) that R #24 needed was provided and was present and functional. Staff will encourage and assist R #24 with the use…

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 interviews, the facility failed to ensure they had sufficient staff to meet the needs of all 49 residents residing in the facility when staff failed to offer baths or showers to residents as scheduled. This deficient practice is likely to negatively impact the comfort, the dignity, and the health of the residents. The findings are: Bath/Shower Findings: R #24: A. Record review of R #24's face sheet revealed R #24 was admitted into the facility on [DATE]. B. Record review of R #24's care plan, dated 04/17/23, revealed the following: - Focus: R #24's vision was highly impaired. She had a diagnosis of diabetic retinopathy [complication of diabetes where blood vessels in the eye are damaged] related to diabetes. She was at risk for falls and injuries related to visual deficit. - Interventions: Give verbal reminders not to ambulate or transfer without assistance. Staff will announce themselves when entering room, talking to her when doing activities of daily living (ADLs),…

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 facility monitored for the use of psychotropic medications (any medication that affects brain activity associated with mental processes and behavior) for 1 (R #'s 17 and 37) of 3 (R #'s 17, 31, and 37) residents reviewed when staff failed to attempt to gradually reduce the dose (lower dose/quantity of medication administered) for a psychotropic medication. This deficient practice is likely to result in residents being administered unnecessary medication and being over medicated. The findings are: R #17: A. Record review of R #17's face sheet revealed R #17 was admitted into the facility on [DATE]. B. Record review of R #17's physician orders, dated 03/06/23, revealed an order for mirtazapine oral tablet, 7.5 milligrams (mg). Give one tablet by mouth at bedtime related to depression. C. Record review of R #17's pharmacy recommendations, dated 06/29/23, revealed gradual dose reduction attempt for mirtazapine, 7.5 mg. The Pharmacist…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications and other medical supplies were not expired. This deficient practice is likely to result in medications losing their potency. The findings are: A. On [DATE] at 2:39 PM, observation of the East Wing Medication Cart revealed the following: 1. One bottle of expired hand sanitizer with the expiration date of [DATE]. 2. Three Levemir FlexPens were past the manufacturer's recommended disposal date. The opened documented dates on the pens were: - Pen #1, [DATE]. The pen was 77 days past recommended disposal date. - Pen #2, [DATE]. The pen was 59 days past recommended disposal date. - Pen #3, [DATE]. The pen was 53 days past recommended disposal date. B. Record Review of the manufacturer disposal recommendation for Levemir FlexPens (medication used to control high blood sugar) revealed, Dispose after 42 days, even if there is insulin left in the pen or vial after opening. C. On [DATE] at 2:50 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.

Based on observation and interview, the facility failed to maintain confidential records by leaving medical information visible to other residents, visitors, and unauthorized staff for 25 (R #'s 2, 7, 10, 12, 13, 16, 17, 21, 22, 24, 29, 30, 31, 32, 33, 35, 36, 37, 39, 43, 44, 46, 47, 55, and 56) residents out of all 49 residents listed on the facility census provided by the Administrator on 03/02/24. This deficient practice would likely result in residents not having confidentiality of their medical information. The findings are: A. On 03/02/24 at 10:10 AM, during an observation of the medication cart on the [NAME] Wing, a clipboard with a list of all [NAME] Wing residents was face up and visible to anyone who walked by the unattended cart. The list on the clipboard contained the following protected health information (PHI; any information that relates to an individual's health status, medical history, or treatment): - Residents #2, 12, 16, 17, 21, 24, 30, 35, 36, 37, and 43 code status (treatment a person would or would not receive if their heart or breathing were to stop). -…

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

Based on record review, observation, and interview, the facility failed to ensure a functioning call light system for 1 (R #28) of 1 (R #28) residents reviewed for call lights. If the facility fails to have call lights that are not functioning, residents cannot call staff in case of an emergency or get their needs met by the facility. The findings are: A. Record review of the Resident Council meeting minutes, dated 09/12/23, revealed the call light in R #28's room number was not working. B. On 03/02/24 at 9:15 AM during interview, R #28 stated his call light did not function for awhile but could not remember how long. R #28 stated the facility was aware the light was not functioning because it was discussed in a Resident Council meeting. C. On 03/02/24 at 9:24 AM during observation of R #28's room, the call light was activated by surveyor. The light outside of R #28's room did not light up, and there were not any other visible signs the call light was activated. D. On 03/04/24 at 9:52 am, during an interview and observation with the Maintenance Manager (MM), he stated all call…

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

Based on record review and interview, the facility failed to provide training for 2 certified nurse aides (CNAs #6 and #7) of 5 CNAs ( #1, 2, 5, 6, and 7) on the facility's policies and procedures for reporting abuse or neglect. This failure had the potential to affect all 49 residents as indicated on the facility census provided by the administrator on 03/02/24. This deficient practice is likely to result in staff not knowing what constitutes abuse or neglect or how to report abuse or neglect. A. Record review of the facility staffing list revealed the following: 1. CNA #6 was hired on 03/01/23. 2. CNA #7 was hired on 03/01/23. B. Record review of the facility in-services (multiple dates throughout 2023 and the beginning of 2024) and training sign-in sheet (form used to track staff attendance dated 06/05/23 and 06/06/23) revealed CNA #6 and CNA #7 did not receive the required the reporting of abuse, neglect, and exploitation training. C. Record review of the facility staffing schedule dated February 2024 revealed CNA #7 worked 15 shifts throughout the month. CNA #6 was on the…

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

Based on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of no less than 12 hours per year for 1 (CNA #5) of 5 (CNA #1, #2, #5, #6, and #7) CNAs randomly reviewed for required in-service training. This deficient practice is likely to result in the nurses aide's not receiving the necessary training to meet the care needs of the residents. The findings are: A. Record review of the facility staffing list revealed CNA #5 was hired on 03/01/23. B. Record review of the facility's CNA 12 hour in-service training revealed CNA #5 was not found on any in-service training, which indicated CNA #5 did not have the required 12 hours of annual in-service training. C. Record review of the facility staffing schedule, dated February 2024, revealed CNA #5 worked four shifts during the month. D. Record review of the facility staffing schedule, dated March 2024, revealed CNA #5 was scheduled to work four shifts throughout the month. E. On 03/06/24 at 11:07 am during an interview with the Regional Clinical Consultant (RCC),…

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 allow 1 (R #51) of 1 (R #51) resident to return to the facility after a hospitalization on 12/05/23. If the facility fails to allow a residents to return to the facility then residents are likely to feel unwanted and feeling as if they have no place to go. The findings are: A. Record review of R #51's face sheet revealed he was admitted on [DATE] with the following diagnoses: 1. Muscle wasting and atrophy, multiple sites [the wasting (thinning) or loss of muscle tissue]. 2. Dysphasia (A condition with difficulty in swallowing food or liquid). 3. Other symptoms and signs involving cognitive functions and awareness (problems remembering, difficulty speaking, and difficulty understanding). 4. Mixed receptive-expressive language disorder (a disorder that affects both receptive and expressive areas of communication). 5. Cerebral palsy, unspecified (a group of disorders that affect a person's ability to move and maintain balance and posture). 6.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to meet professional standards of care for 1 (R #32) of 1 (R #32) residents reviewed by not providing restorative physical therapy service devices as ordered by a physician. This deficient practice is likely to result in residents having a decreased in mobility and pain, causing psychosocial harm and despair. The findings are: A. Record review of R #32's face sheet revealed R #32 was admitted into the facility on [DATE]. B. Record review of R #32's care plan, dated 06/11/23, revealed the following: - Focus: R #32 required extensive assistance from staff for Activities of Daily Living (ADLs) and mobility. She was at risk for further ADL decline related to generalized health decline. - Interventions: Apply carrot (therapy device designed to be gently inserted into the hand and drawn into place with a plastic wand without causing discomfort) to left hand as tolerated. C. Record review of R #32's physician orders, dated 01/17/24, revealed…

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 This was cited as past non-compliance Based on record review and interview, the facility failed to ensure 1 (R #5) of 1 (R #5-9) residents reviewed for elopement risks received the appropriate supervision to prevent or minimize the risk of elopement (an unauthorized departure of a patient from an around-the-clock care setting.) This deficient practice could likely put residents of elopement. The findings are: A. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE]. B. Record review of R #5's Care Plan revealed: 1. On 05/26/23, R #5 exhibited wandering behavior that put him at risk for injury. He had diagnosis of dementia. 2. Initiated 07/25/23 and revised 09/10/23: R #5 was at risk for elopement related to impaired safety awareness, wandered in the afternoon and early evenings, knocked on doors and looked for his brother and/or the bathroom. No observed attempts at exit seeking; easily redirected. C. Record review of R #5's Elopement Risk Evaluation, dated 07/31/23, revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents obtained routine dental care for 1 (R #30) of 1 (R #30) residents reviewed for dental services. This failure is likely to result in the resident experiencing pain and potential weight loss. The findings are: A. On 03/02/24 at 2:52 PM, during an interview with R #30's power of attorney (POA), he stated R #30 had one denture (could not remember if it is upper or lower) and natural teeth. He further stated R #30 did not go to the dentist since her admission to the facility on [DATE]. B. Record review of the Social Services Director (SSD) Note, dated 02/09/24, revealed a referral for dental services was sent to [name of dental service used by facility] for R #30. C. On 03/03/24 at 4:43 PM, during an interview with SSD, she stated a dental referral was sent on 02/09/24 to [name of dental service used by facility], and she is waiting for an update. The SSD stated she made a follow-up call on 02/10/24 and was told the person in charge of…

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

Based on observation, record review and interview, the facility failed to provide assistive devices for 1 (R #28) of 1 (R #28) residents reviewed during dining observation. If residents are not provided special eating equipment as needed, then residents might be unable to consume their meals and beverages and is likely to result in weight loss, malnutrition, and dehydration. The findings are: A. Record review of R #28's meal ticket, dated 03/02/24, revealed staff to serve R #28 food in a divided plate (plate that is separated into sections). B. Record review of R #28's current physician orders revealed an order for use of a divided plate to facilitate self-feeding. C. On 03/03/24 at 12:05 PM during a random observation, R #28 ate lunch in the dining room, but R# 28 did not have a divided plate. D. On 03/03/24 at 12:18 PM during an interview with Licensed Practical Nurse (LPN) #2, he stated staff did not serve R #28's lunch on a divided plate, and a divided plate should have been provided.

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 1 (R #35) of 5 (R #'s 2, 6, 21, 29, and 35) 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: A. Record review of R #35's face sheet revealed R #35 was admitted into the facility on [DATE]. B. Record review of R #35's immunizations in the Electronic Health Record (EHR) revealed R #35's last COVID-19 vaccine was on 09/21/22. C. Record review of R #35's miscellaneous page in the EHR revealed the record did not contain any COVID-19 vaccine forms which indicated staff offered or administered the vaccine to the resident after 09/21/22 . D. On 03/02/24 at 2:44 pm during an interview with R #35, he stated he had a history of respiratory infections and was not offered a COVID-19 vaccine within the past year. R #35 stated he would receive a COVID-19 vaccine if…

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