Santa Fe Care Center

Based on interview, record review, and facility policy review, the facility failed to have an Infection Preventionist (IP) that had completed specialized training in infection prevention and control. This deficient practice had the potential to allow staff to go without the proper knowledge and training of infection control practices for 87 census residents. Findings include: Review of the facility's policy titled, Infection Preventionist, revised September 2022, revealed Policy Statement: The infection preventionist is responsible for coordinating the implementation and updating of the infection prevention and control program .Specialized Training: 2. Evidence of training is provided through a certificate(s) of completion or equivalent documentation. During entrance conference interview on 07/08/24 at 9:00 AM, the Administrator indicated Minimum Data Set (MDS) 1 was the IP and had been the IP since February of 2024. Review of the certificates provided by the facility for the IP revealed there was no certificate presented for the IP named at entrance. During an interview on 07/09/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review, the facility failed to ensure the oxygen (O2) concentrators had a filter or dust free filters on the inlet where the air came into the machine for five of five residents (Resident (R) 7, R19, R16, R47, and R132) of 20 sample residents. This deficient practice had the potential to allow an increased chance of infection and unnecessary respiratory treatment. Findings include: Review of the facility's policy titled, Departmental (Respiratory Therapy)- Prevention of Infection, revised November 2011, revealed Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .Steps in the procedure: Infection control Considerations Related to Oxygen Administration .9. Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry . Review of the facility's policy titled, Oxygen Administration,…

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 a medication error rate of less than 5% with five errors out of 25 opportunities which resulted in a 20% error rate for three of three residents (Resident (R) 50, R48, and R56) observed for medication administration out of a total of 87 residents. The facility failed to ensure Lidoderm patches (used for neuralgic pain) were applied or removed as ordered by the physician for R50, levothyroxine (used to treat hypothyroidism) and lisinopril (used to treat hypertension) were administered as ordered by the physician for R48, and Vitamin B-12 was administered in the correct dosage for R56. This failure had the potential to affect resident medication safety. Findings include: Review of the facility's policy titled, Administering Medications, revised April 2019, revealed, .Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber 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.

Based on record review, interviews, and facility policy review, the facility failed to have written documentation of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) CMS [Centers for Medicare and Medicaid Services]-10055 for one of three residents (Resident (R) 27) reviewed for beneficiary notices of 20 sample residents. The facility failed to have written documentation to indicate R27 or their legal representative were notified in writing of the SNFABN, the reason why Medicare might not pay for services, and the estimated daily cost the resident would be responsible for should they choose to receive skilled services. By not having written documentation, the resident was unable to make an informed decision and was unaware of additional costs and services when skilled services are ending. Findings include: Review of the facility's policy titled, Medicare and Medicaid Benefits, revised April 2017, indicated, Residents are provided with information verbally and in writing about how to apply for and use Medicare and Medicaid benefits .Upon admission, 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, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure a Significant Change MDS Minimum Data Set was completed within 14 days of a significant change for one of one resident (Resident (R) 10) receiving hospice services of 20 sample residents. Specifically, R10 was admitted to hospice services on 03/18/24 and no significant change MDS was completed within 14 days of the significant change. By not ensuring completion of a significant change MDS, this failure could potentially place the resident at risk for unmet care needs being addressed. Findings include: Review of the MDS-3.0 RAI Manual-v1.17.1, October 2019, under section A0310A Coding Instructions for Significant Change in Status Assessment indicated, If a nursing home resident elects the hospice benefit, the nursing home is required to complete the MDS Significant Change in Status Assessment (SCSA). It further indicated, It is a CMS [Centers for Medicare and Medicaid Services] requirement to have an SCSA completed EVERY time the hospice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to complete a quarterly assessment for one of one resident (Resident (R) 43) reviewed for completion of Minimum Data Set (MDS) assessments out of 20 sample residents. The facility was overdue by 25 days in completing the quarterly assessment. Findings include: Review of the facility's policy titled, Resident Assessments, revised October 2023, revealed, .OBRA [Omnibus Budget Reconciliation Act]- Required Assessments are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. OBRA assessments include .Quarterly Assessment .Non-Comprehensive MDS assessments include a select number of items from the MDS used to track the resident's status between comprehensive assessments and to ensure monitoring of critical indicators of the gradual onset of significant changes in resident status .Non-comprehensive assessments include Quarterly assessments . Review of R43's admission…

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 reviews, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to accurately code the Minimum Data Set (MDS) for two of three residents (Residents (R) 7 and R10) receiving hospice services and one of three residents (R29) receiving Insulin of 20 sampled residents. By not ensuring the accuracy of the MDS these failures could potentially place the residents at risk for care needs not being addressed. Findings include: Review of the MDS-3.0 RAI Manual-v1.17.1, October 2019, under Section J1400 Prognosis: indicated Definition: Condition or chronic disease that may result in a life expectancy of less than 6 months; In the physician's judgement, the resident has a diagnosis or combination of clinical conditions that have advanced or will continue to advance to a point that the average resident with that level of illness would not be expected to survive more than 6 months. This judgement should be sustained by a physician note .Steps for Assessment:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review, the facility failed to ensure a comprehensive care plan was developed for three of 20 sample residents (Resident (R) 43, R47, and R67) reviewed for care plans to include dialysis with a central venous catheter (CVC) for R43, oxygen for R47, and Post Traumatic Stress Disorder (PTSD) for R67. This deficient practice had the potential for residents to not receive the care and treatment they needed. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person Centered, revised March 2022, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation .3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .7. The comprehensive,…

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 a medication order was written to include proper dosage for the prescribed medication per current standards of practice for one of three residents (Resident (R) 50) observed for medication administration out of a total of 87 residents. This had the potential to cause residents to receive the wrong dosage of ordered medications. Findings include: Review of the facility's policy titled, Medication Orders, revised November 2014, revealed .When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered . Review of R50's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R50 was admitted to the facility on [DATE] with diagnoses that included pain in right shoulder. Review of R50's Physician Orders, dated 07/01/24 and located under the Orders tab of the EMR, revealed an order for R50 to receive, Lidoderm External…

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 review of facility policy, the facility failed to assess the cause of a continual, gradual, and unintentional weight loss and failed to identify and implement interventions to prevent further weight loss for one of four residents (Resident (R) 12) reviewed for nutrition out of 20 sample residents. This had the potential to contribute to a significant to severe weight loss for R12. Findings include: Review of the facility's policy titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revised September 2017, revealed .The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparison over time .The staff and physician will .identify individuals with .weight loss .The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes . Review of R12's admission Record, located under the Profile tab of the electronic…

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 the resident did not receive an unnecessary medication when they failed to perform physician ordered blood pressure monitoring prior to the administration of lisinopril (a medication used to treat hypertension) and failed to withhold the blood pressure medication with low blood pressure readings according to the physician ordered parameters for one of five sampled residents (Resident (R) 48) reviewed for unnecessary medications out of 20 sample residents. This had the potential to cause R48 to suffer adverse consequences including hypotension. Findings include: Review of the facility's policy titled, Medication Utilization and Prescribing - Clinical Protocol, revised April 2018, revealed .The physician and staff will identify any situation in which a resident is taking medications associated with potentially significant medication related problems .The physician and staff will evaluate the effectiveness 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 interview, record review, and facility policy review, the facility failed to conduct physical and occupational therapy evaluations as ordered by the physician for one of one resident (Resident (R) 231) reviewed for rehabilitation services out of 20 sample residents. This had the potential to cause a physical decline for R231. Findings include: Review of the facility's policy titled, Scheduling Therapy Services, revised July 2013, revealed .Therapy services shall be scheduled in accordance with the resident's treatment plan . Review of R231's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R231 was admitted to the facility on [DATE] with diagnoses that included type two diabetes mellitus, major depressive disorder, muscle weakness, other reduced mobility, and the need for assistance with personal care and continuous supervision. Review of R231's Physician Orders, dated 06/27/24 and located under the Orders tab of the EMR, revealed orders for physical 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 record review and interview, the facility failed to revise and update the care plan for 1 (R #1) of 1 (R #1) residents reviewed for unwitnessed injuries. If the facility is not updating the care plan to reflect the resident's current care needs and treatments, then the facility may not be providing the appropriate care to meet the resident's needs. The findings are: A. Record review of R #1 face sheet, dated 07/02/24, revealed he was admitted to the facility on [DATE] with multiple diagnoses including: - Vascular dementia (a chronic decline in mental abilities and memory) with behaviors. - Major depression (overwheliming sadness). - Late onset cerebelar (a portion of the brain) ataxia (impaired muscular movements). - Cognitive communication deficits (difficulty in speech and language). B. Record review of R #1's daily care notes, dated 05/21/24, revealed R#1 had a bluish discoloration around his left second finger and fourth finger. C. Record review of R #1's Nurses Skin Check, dated 05/20/24, 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.

Based on record review and interviews, the facility failed to ensure they had sufficient staff to meet the needs of 11 (R #2 through #12) of 11 (R #2 through #12) residents who resided in the facility that required a minimum of two staff members to provide a safe resident transfer. This deficient practice is likely to negatively impact resident safety and comfort. The findings are: A. Record review of the facility resident census/transfer list, dated 11/03/23, revealed 11 (R #'s 2 through 12) residents out of 80 residents in the facility required a minimum of two staff members for transfers. B. On 11/02/23 at 9:44 am, during an interview with a former staff member, they stated the facility was short staffed a lot of the time and would require them to transfer residents with a Hoyer lift (a patient lift device used by caregivers to safely transfer patients, particularly those with mobility limitations) by themselves at night. The former staff member said Hoyer transfers required two staff members. C. On 11/02/23 at 4:08 pm during an interview with Licensed Practical Nurse (LPN) #1,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 2 (R #'s 4 and 5) of 2 (R #'s 4 and 5) residents reviewed by not updating the care plan to include current wounds and wound care. This deficient practices is likely to result in residents care and needs not being addressed if care plans are not updated. The findings are: Findings for R #4: 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 physician orders, dated 07/20/23, revealed an order for dressing change every other day for two weeks. C. Record review of R #4's care plan, dated 08/08/23, revealed the record did not include a care plan for R #4's wounds or wound care. D. On 11/20/23 at 3:22 pm, during an interview with the Assistant Director of Nursing (ADON), he stated wounds and wound care should be care planned. E. On 11/21/23 at 2:11 pm during an interview, the Director of Nursing (DON) confirmed staff did not careplan R…

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

Based on record review and interview, the facility failed to ensure that residents received the necessary treatment and services to prevent the development of pressure ulcers (skin damage which results from unrelieved pressure on the body) for 2 (R #'s 4 and 5) out of 2 (R #'s 4 and 5) residents reviewed when staff failed to: 1. Receive a wound care treatment order, provide wound care treatment, and communicate a new wound for R #4. 2. Receive a wound care treatment order and provide wound care treatment for R #5. This deficient practice is likely to result in residents developing pressure ulcers and in wounds worsening without proper treatment and communication. The findings are: Findings for R #4: A. Record review of R #4's skin and wound evaluation, dated 08/01/23, revealed a surgical site on left hand index finger present on admission. Staff did not document any other wounds as present on R #4. B. Record review of R #4's wound evaluation, dated 08/03/23, revealed the resident had an abscess (a collection of pus) on left buttock which was acquired while at the facility . C.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the medical record was accurate for 3 (R #'s 1, 4, and 6) of 3 (R #'s 1, 4, and 6) residents reviewed when staff failed to: 1. Document embolic stockings (stockings used to prevent blood clots in lower extremities) use for R # 2. Document a daily skilled progress note and nursing progress note the same day R #4 was sent to the ER (Emergency room). 3. Document a daily skilled progress note and nursing progress note the same day R #6 was sent to the ER. This deficient practice is likely to result in staff confusion as to the services and treatment provided. The findings are: Findings for R #1: A. Record review of R #1's face sheet revealed resident was admitted to facility on 08/31/23. B. Record review of R #1's orders, dated 08/31/23, revealed an order for anti-embolic stockings (stockings used to prevent blood clots in lower extremities). C. Record review of R# 1's Medication Administration Record (MAR) and Treatment Administration Record (TAR),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the provider or Emergency Contact (EC) for 1 (R #6) of 1 (R #6) residents reviewed for changes of condition (new or worsening symptoms). If the facility is not notifying the provider or EC when the resident experiences a change of condition, then it is likely the provider or EC are unable to make decisions related to treatment and advocate for the resident's care. The findings are: A. Record review of R #6's face sheet revealed R #6 was admitted into the facility on [DATE] with the following diagnoses: 1. Iron deficiency anemia (deficiency of healthy red blood cells in blood). 2. Hypothyroidism (a condition resulting from decreased production of thyroid hormones). 3. Type 2 diabetes mellitus with diabetic neuropathy. 4. Major depressive disorder. 5. High blood pressure. 6. Other local lupus erythematosus (an autoimmune disease with systemic manifestations including skin rash, erosion of joints, or even kidney failure). 7. End stage renal disease…

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 care for 1 (R #6) of 4 (R #s 2, 3, 6, and 7) residents reviewed for care when staff failed to ensure the resident was sent out to the emergency room (ER) in a timely manner. If the facility is not sending residents to the emergency room (ER) as ordered then residents are likely to not get the care they need. The findings are: Findings for R #6 A. Record review of R #6's physician's progress note, dated 08/22/23, revealed the resident had a fractured left knee cap which the physician felt was not healing well. The physician documented for staff to send the resident to the emergency room. B. Record review of R #6's physician orders, dated 08/25/23, revealed an order to send R #6 to the ER for evaluation of a swollen, tender, left knee. C. Record review of R #6's face sheet revealed R #6 was sent to the ER on [DATE] at 4:19 pm. R #6 was not sent to the ER any other time after the 08/25/23 physician order. D. On 11/20/23 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 observation and interview, the facility failed to: ensure medications were stored properly, medication carts were locked and secured when not in use, and ensure that medications were not left on bedside tables in residents' rooms. These deficient practices are likely to result in resident injury, through dosing with medications that have been improperly stored, having access to medications not prescribed for them, and possible overdose. The findings are: A. On 05/18/23 at 9:50 am during observation of the medication cart for Wing 2 with the Director of Nursing present, it revealed four (4) unidentified loose pills that were on the bottom of the second drawer. During interview with the Director of Nursing (DON) she confirmed there were four (4) loose, unidentified medications in the second drawer of the Wing 2 medication cart. B. On 05/18/23 at 09:37 am during observation of the medication cart for Wing 4 with Registered Nurse (RN) #1 present, it revealed 1 pink oval unidentified loose pill on the bottom…

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 safe food preparation for all 82 residents as listed on the CMS 672 (Resident Census and Conditions of Residents) provided by the Administrator on 05/15/23, that could receive meals prepared in the kitchen. This failure could potentially cause food borne illnesses to be spread throughout the facility due to the unsanitary conditions. All 82 residents may be affected because they all get served eggs for breakfast The findings are: A. On 05/15/23 at 6:49 am during observation of the kitchen, on refrigerator #2 there were no temperatures documented for the day. B. On 05/15/23 at 6:55 am during observation of the kitchen, on free#1 there were no temperatures documented for the day. C. On 05/15/23 at 7:04 am during observation of the kitchen, there was a flat of eggs ( a flat of eggs is a 30 individual eggs in a carton) of raw shelled eggs resting on the hot grill, with no ice. The eggs were taken out prior to breakfast and not returned back to the refrigerator until after breakfast. D. On 05/15/23 at 6:55 am Assistant…

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 reasonably accommodate resident needs and preferences for 2 (R #'s 10 and 97) of 2 (R #'s 10 and 97) residents reviewed by: 1. Providing R #10 an assisted device used for beverages (sippy cup) without orders and asking R #10's preference. 2. Not honoring R #97's right to choose his own physician or canceling/re-scheduling R #97's physician appointment. If the facility is not honoring resident preferences, then residents are not able to make choices about aspects of their lives that are important to them. This could ultimately affect the residents' overall quality of life and lead to a loss of independence. The findings are: Findings for R #10: A. Record review of Dietary Meal Ticket dated 05/22/23 revealed that R #10's dietary order is Regular Puree Level 1, (foods that smooth and free of lumps, easy to swallow). B. On 05/22/23 at 12:30 pm during an observation of the lunch meal in the Main Dining Room, R #10 had a Regular Puree Diet with two (2) sippy cups (assisted device) for her drinks. C. Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that the care plan had been revised for 1 (R #1) of 1 (R #1) residents reviewed by not updating the care plan to include oxygen (O2) use. This deficient practices is likely to result in residents care and needs not being addressed if care plans are not updated. The findings are: 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 physician orders dated 02/05/23 revealed, oxygen continuous @ [at] 3L [Liters] d/t [sic] COPD [Chronic obstructive pulmonary disease- a chronic inflammatory lung disease that causes obstructed airflow from the lungs]. C. Record review of R #1's care plan dated 02/06/23 revealed O2 use was not care planned. D. On 05/15/23 at 11:21 am during an observation and interview with R #1, R #1 was observed wearing O2. R #1 confirmed he wears O2 daily. E. On 05/25/23 at 2:38 pm during an interview with the Director of Nursing (DON), she confirmed O2 was not 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.

Based on observation, record review, and interview, the facility failed to meet professional standards of quality for 2 (R #'s 65 and 95) of 2 (R #'s 65 and 95) residents by: 1. Not following physician orders for wound care for R #65. 2. Providing R #95 an antidepressant without depression indications. If the facility is not providing wound care as ordered, and prescribing medications without indications, then residents are likely to not receive the therapeutic benefits as needed. The findings are: Findings for R #65 A. On 05/25/23 at 12:37 pm, during an observation of R #65 wound care and interview with the Director of Nursing (DON), she stated that nursing staff had been placing Calmoseptine (barrier cream) to the resident's coccyx (also known as the tailbone, is a small, triangular bone resembling a shortened tail located at the bottom of the spine). During the observation it was noted that the area was red, no open places, no optifoam was on the wound and only Calmaseptine was noted to be on the wound. B. Record review of the physician order dated 04/13/23 revealed; Wound care…

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

Based on record review and interview, the facility failed to ensure that 1 (R #73) of 2 (R #11 and 73) residents reviewed for dental care obtained routine and as needed dental care. If the facility is not ensuring that residents with identified dental issues receive timely dental care, then residents are likely to experience tooth decay, tooth pain, and difficulty chewing; which could also affect their nutritional well-being. The findings are: A. On 05/23/23 at 2:45 pm during an interview with R #73, she stated that a tooth on the right side of her mouth was tender and had been bothering her for a couple of weeks. Staff gave Tylenol 1 x (once a day) a day. R #73 further stated that she has mentioned to facility staff that she would like to see [name of her dentist] for dental care and for her tooth pain; but she has not gotten any reply back from the facility staff R #73 was not sure of the dates she had let staff know but, they have been aware of it because they have administered her pain medication for her tooth pain. R #73 stated her tooth pain adversely affects her eating 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 there was communication (exchanging of information) in the resident's record indicating the delivery of hospice services (services provided for a person experiencing an advanced, life-limiting illness) for 1 (R #37) of 1 (R #37) resident reviewed for Hospice Services. This deficient practice could likely lead to the resident not receiving the services needed due to lack of collaboration (to work jointly) and communication between the facility and hospice provider. The findings are: A. Record review of R #37's Physicians Orders revealed the following: 12/28/22 Admit to [Name of Hospice Provider]. B. Record Review of R #37's medical record's under Miscellaneous tab revealed no hospice notes for any of the dates of service. C. On 5/18/23 at 3:49 pm, during a phone interview with [name of Hospice Medical Records Clerk], she stated that she makes hospice binders for all [name of Hospice] hospice residents in the facility. The binders are taken to the facility with admission paperwork and blank visit notes. All hospice…

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

Based on observation and interview, the facility failed to use infection control protocols for the storage and cleanliness of nebulizers (a device that is used to administer medication in the form of a mist inhaled into the lungs) and a glucometer (a portable machine used to check blood sugar levels) for 2 (R #1 and 12 ) of 2 (R #1 and 12) residents reviewed for infection control. If the facility is not using proper infection control protocols, residents are likely to be exposed to airborne pathogens and infections. The findings are: Resident #1: A. On 05/15/23 at 11:21 am during observation, R #1's nebulizer mask was observed on top of a CD (compact disc) player on a chair. The nebulizer was not covered or sealed in a bag, and exposed to the open air. B. On 05/17/23 at 5:06 pm during observation, R #1 nebulizer was stored on R #1's night stand not bagged and exposed opened to air. C. On 05/17/23 at 5:08 pm during an interview with Hospitality Aide (HA) #1, she stated she did not know the protocol for storing nebulizers or nebulizer masks. Resident #12: D. On 05/16/23 at 1:12 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 record review and interview, the facility failed to ensure Certified Nurse Aides (CNA's) received the required in-service training of no less than 12 hours per year for 2 (CNA #12 and CNA #13) of 3 (CNA #12, CNA #13, and CNA #14) CNA's 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: For CNA #12: A. Record review of the facility staffing list revealed CNA #12 was hired on 12/07/21. B. Record review CNA #12's online training revealed CNA #12 had only completed 10.75 hours of training as of 03/09/23. C. Record review of the facility schedule dated May 2023 revealed CNA #12 had worked 19 shifts throughout the month. D. On 05/26/23 at 11:17 am during an interview with the Director of Nursing (DON), she confirmed CNA #12 did not have the 12 completed hours of training as required in order to work with residents. For CNA #13: E. Record review of the facility staffing list revealed CNA #13 was hired on 02/14/22. 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 interview and record review, the facility failed to ensure that 1 (R #87) of 1 (R #87) resident's records contained current documentation of code status (a directive regarding a resident's resuscitation [the action or process of reviving someone from unconsciousness or apparent death] wishes should a life threatening event occur). This deficient practice has the potential to deny residents the fulfillment of their end of life medical care choices and could result in unnecessary suffering for the resident and their significant others. The findings are: A. Record review of R #87's physician's orders dated [DATE] revealed an order for FULL CODE (full life saving measures to be initiated upon experiencing a life threatening event). B. Record review of R #87's care plan dated [DATE] indicated his code status as FULL CODE with life saving measures to include: Call 911 for ambulance transport, Contact MD (Medical Doctor) and POA (Power of Attorney), Perform CPR (Cardiopulmonary Resuscitation: can help save 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 record review and interview, the facility failed to document efforts to resolve a resident grievance for 1 (R #74) of 1 (R #74) resident with complaints against staff. This deficient practice is likely to result in the residents' rights not being honored. The findings are: A. Record review of R #74's social service progress notes dated 05/02/23 revealed, Note Text: This writer and BOM [Business Office Manager] went to the residents room to go over a [Name of discharge document] that his insurance had issued. I let the resident know the dates, the options of appeal and paying privately. He then stated that he 'will not be going anywhere' and that he was going to call his case manager. Some minutes later he approached this writer and BOM in the rotunda and stated that his case manager would be calling him back, he also said that he was not going to sign the document at all and that we shouldn't talk to him about private cost. All this was being said while also saying profanity to this writer. I let him know that he shouldn't be talking to me that way and that I'm not being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that 4 (R #'s 4, 17, 37, and 44) of 4 (R #'s 4, 17, 37 and 44) resident reviewed for Minimum Data Set (MDS) assessments, had MDS documents completed, submitted, and finalized in a timely manner. If MDS assessments are not completed and submitted in a timely manner, then residents are likely to receive less than optimal care. The findings are: Findings for R #4: 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 MDS Page located in the Electronic Health Record (EHR) revealed R #4's most recent MDS was a Quarterly assessment dated [DATE]. C. On 05/23/23 at 1:47 pm during an interview with the Director of Nursing (DON), she stated, She [R #4] should of had one [a completed MDS assessment] in March [2023]. Findings for R #17: D. Record review of R #17's Face Sheet revealed R #17 was admitted into the facility on [DATE]. E. Record review of R #17's MDS Page located in the EHR…

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 discharge MDS (Minimum Data Set) Assessment was accurate regarding change of condition and discharge for 1 (R #81) of 1 (R #81) resident reviewed for facility discharges. This deficient practice is likely to cause the resident to not receive the care and services needed to attain or maintain their highest practicable well-being. The findings are: A. Record review of R #81's progress notes revealed that R #81 was admitted on [DATE] for skilled level of care after hospitalization with the following diagnosis: 1. Infected L [left] total knee arthroplasty [Surgical procedure in which parts of left knee joint are replaced with artificial prosthetic parts] 2. PAROXYSMAL ATRIAL FIBRILLATION [Irregular and often rapid heart rhythm] 3. HYPERTENSION. [High blood pressure.] 4. HYPOTHYROIDISM. [Thyroid gland doesn't make enough thyroid hormone to meet body's need.] 5. ANEMIA. [ Lack of healthy red blood cells] 6. MAJOR DEPRESSIVE DISORDER [Persistent…

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

Based on record review and interview, the facility failed to complete an annual performance review of 1 Certified Nurses Aide (CNA #14) of 5 (Certified Nurses Aide #12, #13, #14, #15, #16) randomly reviewed. If the facility is not maintaining the annual performance reviews then residents are likely to not receive the appropriate care, services and may not meet the needs of all residents. The findings are: A. Record review of the facility staffing list revealed CNA #14 was hired on 09/10/19. B. Record review of CNA #14's Nursing Assistant Clinical Skills Checklist and Competency Evaluation (CNA Annual Performance Review) was documented as being completed on 02/22/22. C. Record review of the facility schedule dated May 2023 revealed CNA #14 had worked 8 shifts throughout the month. D. On 05/26/23 at 11:19 am during an interview with the Director of Nursing (DON), she stated, She's [CNA #14] been here since 09/10/19. DON confirmed an annual performance review/competency evaluation should have been completed for CNA #14 prior to her working with residents and it was not.

Based on record review and interview, the facility failed to ensure that psychotropic medication (medication used to treat mental health conditions) orders included the appropriate indication (use for the ordered medication) and that the resident had an appropriate diagnosis (medical condition) for 1 (R #95) of 1 (R #95) resident reviewed for unnecessary psychotropic drugs. This deficient practice could likely place R #95 at an increased risk for undesirable side effects (increased thoughts of suicide, insomnia, fatigue, sexual dysfunction) associated with the use of these medications. The findings are: A. Record review of R #95's physician's orders dated 05/05/23 revealed the following order: TraZODone HCl (hydrochloride) (medication is used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) Oral Tablet 100 MG (Milligrams) Give 1 tablet by mouth at bedtime for Antidepressant (medications used to treat depression). B. Record review of R #95's Medical Diagnoses dated 05/05/23 failed to indicate that R #95 had a diagnosis 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 record review and interview, the facility failed to ensure that a medical record were accurate for 1 (R #95) of 1 (R #95) resident reviewed for accurate documentation by not accurately documenting the timeliness of R #95's medication administration. This deficient practice is likely to result in staff confusion as to the services and treatment needing to be provided to residents. The findings are: A. Record review of R #95's physician orders dated 05/05/23 revealed, traZODone HCl Oral Tablet 100 MG [milligram] (Trazodone HCl) Give 1 tablet by mouth at bedtime for Antidepressant. B. On 05/18/23 at 9:30 PM during interview with R #95 he stated he had been waiting a long time for his nighttime medication Trazodone (a medication used to treat depression a mood disorder that causes feelings of prolonged sadness or loss of interest. It can also treat depression related insomnia a common sleep disorder associated with depression). C. On 05/18/23 at 9:46 PM during observation and interview with Certified Nursing Assistant (CNA) #3, CNA #3 was observed walking into R #95's room to…

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

Based on observation and interview, the facility failed to store and serve food under sanitary conditions by not: 1. Ensuring food items in the refrigerator and freezer were properly labeled and dated. 2. Ensuring food items in the freezer were properly stored. 3. Ensuring the restorative (having the ability to restore health, strength, or a feeling of well-being) freezer was clean. These deficient practices are likely to affect all 55 residents listed on the resident census list provided by the Administrator (ADM) on 03/20/22. If the facility fails to adhere to safe food handling practices residents are likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 03/20/22 at 11:10 am during the initial tour of facility kitchen, the following was observed: 1. 1- plastic bag of breaded meat product with opened date of 03/09/22 was not labeled and stored in freezer 2. 2. 2- large plastic bags of frozen chicken breast dated 03/17 was not labeled and stored in freezer 2. 3. 1- large plastic bag 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 reasonable accommodations of resident needs and preferences for 3 (R #16, 20 and 52) of 3 (R #16, 20 and 52) residents reviewed by: 1. Not assisting residents to shower per their requested schedule 2. Not providing visitors a restroom within the building likely reducing the amount of time a visitor can stay and visit. These deficient practices are likely to result in the resident's life style, personal choices, needs and preference not being met, resulting in boredom, depression, poor hygiene and loss of dignity. The findings are: Not assisting residents to shower per their requested schedule A. On 03/20/22 at 3:34 pm during an interview with R #16, she stated, I don't remember the last time I got showered. I would like a shower every other day. B. On 03/22/22 at 1:32 pm during an interview with Certified Nursing Assistant (CNA) #2, she stated that the residents are showered according to their shower preference sheet. C. Record review of the Shower Preference sheet dated 12/01/21 revealed that R #16…

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

Based on record review and interview, the facility failed to ensure that grievances received by both the Resident Council and individual residents are responded to timely for 2 (R #39 and 52) of 2 (R #39 and 52) residents reviewed. If the facility is not ensuring that grievances are responded to timely, then residents are likely at risk of continued repeat concerns and feeling as though their concerns are unimportant to the facility. The findings are: A. Record review of the Grievance Decision Reports revealed the following: 1. Grievance dated 12/19/21 from R #39 regarding shower preferences revealed date of notification of the grievance response was provided 01/10/22. 2. Grievance dated 12/06/21 from R #39 regarding shower preferences revealed date of notification of the grievance response was provided 01/10/ 22. 3. Grievance dated 02/08/22 from R #53 regarding staffing revealed date of notification of the grievance response was provided 03/03/22. 4. Grievance dated 02/08/22 from R #53 regarding nurses and doctors listening to residents revealed date of notification 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.

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 2 (R #39 and 56) of 2 (R #39 and 56) residents reviewed by: 1. Not labeling and dating oxygen (O2) tubing per physicians orders for R #39. 2. Administering O2 without physician orders for R #56. If the facility is administering O2 without physician orders, and not following physician orders to label and date O2 tubing, then residents are likely to not get the therapeutic results of medication/treatment needed. The findings are: Findings for R #39: A. Record review of R #39's face sheet revealed R #39 was admitted into the facility on [DATE]. B. Record review of R #39's physician order dated 02/01/22 revealed, Change O2/Nebulizer tubing Weekly and clean filter every night shift every Sun [Sunday] for Ensure Infection Control. C. On 03/20/22 at 1:25 pm during an interview with R #39, she stated, I wear it [O2] all the time and I wear it [O2] even in the shower. R #39's O2 tubing is observed 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 observation, record review, and interview, the facility failed to ensure that residents maintain acceptable parameters of nutritional status for 1 ( R #54) of 1 (R #54) resident reviewed for weight loss by not: 1) Monitoring for weight loss following 8.5% weight loss in one month for R #54 2) Identifying weight loss for R #54 and implementing interventions. This deficient practice is likely to result in continued weight loss and resident decline. The findings are: A. Record review of Dietician note dated 02/08/22 revealed: Dietary Nutrition at Risk, Note Text: 1st week of discussing in NAR/IDT (Nutrition Assessment Risk/Interdisciplinary Team): Resident triggered for a significant wt. (weight) loss of -8.5% in the last month and -11.3% in the last 3 months. She also had a non-significant variance of -7% in the last 6 months AEB (as evidenced by) the following recorded weights 02-01-22 140 lbs. 01-01-22 153.0 lbs. 12-01-21 156.6 lbs. 11-01-21 157.8 lbs. 10-01-21 155 lbs. 09-01-21 153.4 lbs. 08-01-21…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure 1 (R #48) of 1 (R #48) resident's Advance Directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were accurately reflected in the Electronic Medical Record (EMR) (a medical record which is accessible by computer) for resident. This deficient practices are likely to result in residents wishes for emergency medical care not being honored. The findings are: A. Record review of R #48's face sheet dated 03/21/22 revealed she was admitted to the facility on [DATE] with multiple diagnoses including: Ischemic Cardiomyopathy (heart disease) Chronic Kidney Disease (a long term decline of kidney function) Atherosclerotic Heart Disease of Native Coronary Artery (clogged and closed arteries of the heart) Delusional Disorders (disorders of thinking that cause imagined thoughts and beliefs) S-T…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide a homelike environment, for 1 (R #39) of 1 (R #39) residents reviewed for homelike environment, by not maintaining an environment that is clean and free of clutter. If the facility fails to maintain resident rooms in a homelike environment, then residents are likely to feel uncomfortable and could exacerbate (make worse) health issues. The findings are: A. Record review of R #39's face sheet revealed R #39 was admitted into the facility on [DATE]. B. On 03/20/22 at 1:35 pm during an interview and observation with R #39, two bed pans (one bed pan was in a plastic bag under the bathroom sink and the other was not in a plastic bag and stored on the bathroom towel rack) were observed to be in R #39's bathroom. R #39 stated, Those [bed pans] aren't mine. They [bed pans] are my past roommates. I don't like them there [in bathroom]. C. On 03/20/22 at 1:45 pm during an interview with Lead Certified Nursing Assistant (LCNA) #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.