Silver City Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents received quality treatment and care for 1 (R #16) of 4 (R #4, R #5, R #16, and R #80) residents reviewed for wound treatment when staff failed to: 1. Document R #16 had a wound on his right elbow. 2. Notify the provider and obtain orders for wound treatment for R #16 wound on his right elbow. 3. Provide wound care for R #16's wound on his right elbow. These deficient practices could likely lead to residents needs not being met and/or a worsening of their wounds. The findings are: A. Record review of R #16's admission documents, no date, revealed R #16 was admitted to the facility on [DATE]. B. On 01/05/26 at 2:45 PM, during an observation of R #16 by the nurses' station, revealed the following: 1. R #16 had blood on his right elbow. 2. LPN #17 cleansed R #16's right elbow and placed a bandage over the wound. C. On 01/05/26 at 2:46 PM, during an interview, LPN #17 stated she was placing a bandage on R #16 wound on his…

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 respiratory care in accordance with professional standards for 1 (R #3) of 2 (R #3 and R #47) residents reviewed for respiratory care when staff failed to follow the physician's order for oxygen use. This deficient practice could likely result in residents receiving too much or not enough oxygen and can lead to worsening of their condition. The findings are: A. Record review of R #3's admission documents, no date, revealed the following: 1. R #3 was admitted to the facility on [DATE]. 2. R #3 had the following diagnoses: a. Chronic respiratory failure with hypoxia (a long-term condition where the lungs can't get enough oxygen into the blood, causing low blood oxygen). b. Chronic obstructive pulmonary disease (COPD, a progressive lung condition causing airflow obstruction, making breathing difficult). c. Tracheostomy (a surgical procedure that creates an opening (stoma) in the neck into the windpipe (trachea) to provide an airway).…

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

Based on interview and record review the facility failed to ensure residents obtained dental services for 1 (R #7) of 3 (R #5, R #7 and R #63) residents sampled for dental services, when they failed to ensure residents receive routine dental care to include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. The findings are: A. Record review of R #7's medical record revealed an admission date of 04/10/25. B. On 01/06/26 at 1:26 PM, during an interview with R #7's Family Member (FM) #1, he stated that R #7 had not been to see a dentist since she had been at the facility. R #7's FM #1 stated that R #7 does have missing teeth. C. On 01/09/26 at 11:55 AM, during an interview, R #7 stated that she had not been to the dentist. R #7 stated she would like to go to the dentist. D. On 01/09/26 at 12:02 PM, during an interview the Social Services…

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 CNAs received the required in-service training of 12 hours per year for 2 (CNA #16 and CNA #17) of 2 (CNA #16 and CNA #17) CNAs reviewed for required in-service training. This deficient practice is likely to result in the CNAs not receiving the necessary training to meet the care needs of the residents. The findings are: A. Record review of the employee files revealed the following: 1. CNA #16's hire date was 11/18/24. 2. The file did not contain any documentation of in-service trainings for CNA #16. 3. CNA #17's hire date was 09/20/24. 4. The file did not contain any documentation of in-service trainings for CNA #17. B. On 01/13/26 at 9:27 AM, during an interview, the administrator confirmed the following: 1. There was no documentation of in-service trainings for CNA #16 and CNA #17. 2. CNAs were expected to have at least 12 hours of in-service training annually.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to maintain proper infection prevention measures when staff failed to ensure facility staff follow transmission-based precautions (actions to prevent the spread of infectious agents from individuals who are suspected to be infected, such as (gloves, facemasks, and gowns) for residents diagnosed with 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) for 1(R #24) of 1(R #24) resident reviewed. Failure to adhere to an infection control program could likely cause the spread of infections and illness to all 72 residents in the facility (residents were identified by the resident census provided by the administrator on 11/05/25) when staff failed to properly dispose of a disposable isolation gown. The findings are: A. Record review of R #24's face sheet, no date…

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 the griddle, essential equipment (vitally important; absolutely necessary) was in safe operating condition for 69 residents of 72 residents who eat food from the kitchen (residents were identified by the resident matrix provided by the Administrator on 11/05/25) when the facility failed to ensure the kitchen griddle had knobs to control the gas burners. If knobs are not in working order, then it could likely affect temperature range, making it difficult or impossible to adjust the heat. The findings are:A. On 11/05/25 at 1:58 PM, during an observation of the facility kitchen revealed four out of four knobs on the gas griddle were missing. B. On 11/05/25 at 2:02 PM, during an interview, the Dietary Manager (DM) confirmed that the knobs were missing.

Based on observation and interview, the facility failed to safeguard resident's personal privacy and medical record information for 3 (R #12, R #13 and R #24) of 3 (R #12, R #13 and R #24) residents sampled for privacy and confidentiality of records when the facility failed to do the following: 1. Repair the privacy curtain between R #12 and R #13's room. 2. Keep resident's vital signs and name confidential for R #24. These deficient practices could likely result in the residents feeling that their privacy is not valued and their information could be viewed by unauthorized residents, visitors, and staff. The findings are: A. On 11/05/25 at 10:03 AM, during an observation of R #12 and R #13's room, the privacy curtain had a section that was off track, leaving an open gap at the top of the curtain. B. On 11/06/25 at 10:06 AM, during an interview, Nurse Aide (NA) confirmed the privacy curtain in R #12 and R #13's room was off track and not completely closed. The NA stated that the curtain had been like that for several months. C. On 11/06/25 at 11:12 am, during an interview, LPN #8…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure care plan revisions occurred for 2 (R #3 and R #8) of 6 (R #1, R #2, R #3, R #4, R #8, and R #9) residents reviewed for care plan accuracy when the staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #3 A. Record review of R #3’s admission record (no date) revealed R #3 was admitted to the facility on [DATE]. B. Record review of R #3’s progress notes revealed the following: 1. Nurse note dated 05/06/25 at 6:12 PM: “Guardian in to visit with resident. Resident voiced concerns of wanting to go home or possible assisted living. Guardian stated she educated resident that it is a process and will assist…

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 foot care for 1 (R #1) of 1 (R #1) resident reviewed for foot care when staff failed to provide nail care for R #1's toenails or make an appointment to a podiatrist for foot care. This deficient practice could likely cause podiatric complications (foot and ankle health issues, often arising from underlying systemic diseases like diabetes or poor circulation, that can lead to problems such as ulcers, infections, nerve damage (neuropathy), and, in severe cases, amputation in residents with diabetes). The findings are: A. Record review of R #1's admission record, no date, revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 has a diagnosis of type 2 diabetes mellitus (a chronic metabolic condition characterized by insulin resistance, where the body's cells don't respond to insulin properly, and a gradual decline in the pancreas's ability to produce enough insulin) without complications. B. On 08/25/25 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 ensure medical records were complete and accurate for 2 (R #1 and R #8) of 6 (R #1, R #2, R #3, R #4, R #8 and R #9) residents reviewed for documentation accuracy when staff failed to: 1. Document blood pressure and heart rate readings for R #1. 2. Document the correct diagnosis on the medication administration record for R #8. This deficient practice has the potential to have a negative impact on the care staff provide to residents due to missing or inaccurate records and resident information. The findings are: R #1 A. Record review of R #1's admission record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 diagnoses included: a. Essential primary hypertension (HTN, abnormally high blood pressure that is often influenced by lifestyle factors and not the result of a medical condition). b. Paroxysmal atrial fibrillation (A FIB, episodes of rapid and irregular heartbeats that can last from a few minutes to several…

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, interview, and observation 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 1 (R #1) of 1 (R #1) resident reviewed for ADL care when staff failed to cut R #1's fingernails. This deficient practice is likely to negatively affect the dignity and health of the residents. The findings are: A. Record review of R #1's admission record, no date, revealed R #1 was admitted to the facility on [DATE]. B. On 08/25/25 at 1:16 PM, during an observation, some of R #1's fingernails were overgrown, some were jagged and uneven from breaking off. C. On 08/25/25 at 1:16 PM, during an interview, R #1 stated staff had not offered to cut her fingernails. R #1 said she did not have any clippers to cut them herself. D. Record review R #1's Quarterly MDS dated [DATE] revealed R #1 needs partial to moderate assistance with personal hygiene. E. On 08/25/25 at 2:25 PM, during an…

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

Based on record review and interview, the facility failed to ensure residents, their representatives, and the Ombudsman received a written notice of transfer as soon as practicable for 4 (R #8, R #9, R #11 and R #13) of 4 (R #8, R #9, R #11 and R #13) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative not knowing the reason or location the resident was discharged . The findings are: R #8 A. Record review of R #8's medical record revealed the following: 1. On 12/07/24, the facility transferred R #8 to the hospital for a fall. 2. On 12/08/24, the facility transferred R #8 to the hospital for evaluation of abdominal wound and fever 3. The record did not contain any written transfer notices. R #9 B. Record review of R #9's medical record revealed the following: 1. On 12/09/24, R #9 was sent to the hospital for abnormal lab results. 2. The record did not contain a written transfer notice. R #11 C. Record review of R #11's medical record revealed the following: 1. On 12/22/24, R #11 was sent to the hospital for…

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

Based on record review and interview, the facility failed to ensure residents or their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 4 (R #8, R #9, R #11 and R #13) of 4 (R #8, R #9, R #11 and R #13) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: R #8 A. Record review of R #8's medical record revealed the following: 1. On 12/07/24, the facility transferred R #8 to the hospital for a fall. 2. On 12/08/24, the facility transferred R #8 to the hospital for evaluation of abdominal wound and fever. 3. R #8's record did not contain a written notices of the bed hold notice. R #9 B. Record review of R #9's medical record revealed the following: 1. On 12/09/24, R #9 was sent to the hospital for abnormal lab results. 2. R #9's record did not contain a written notice of the bed hold notice. R #11 C. Record review of R #11's medical record revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure care plans were reviewed and revised for 3 (R #1, R #14 and R #17) of 4 (R #1, R #2, R #14, and R #17) residents reviewed for care plans when they failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #1 A. Record review of R #1's admission Record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 had a diagnosis of need for assistance with personal care (providing or assisting in performing daily living tasks and maintaining personal hygiene). B. On 01/22/25 at 7:29 PM, during an interview, CNA #1 stated that R #1 sometimes refuses her showers. C. Record review of R…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, 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 oral care, baths and showers for 3 (R #1, R #2, and R #17) of 3 (R #1, R #2, and R #17) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: R#1 A. Record review of R #1's admission record revealed R #1 was admitted into the facility on [DATE]. B. Record review of R #1's MDS Quarterly Minimum Data Set (a federally mandated assessment instrument completed by facility staff) dated 12/13/24 indicated R #1 required substantial/maximal assistance (staff lifts or holds trunk or limbs and provides more than half the effort) for showers. C. Record review of the facility's shower schedule revealed R #1 was scheduled for showers on Tuesdays and Fridays on the night shift. D. On 01/22/25 at 11:35 am, during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that facility staff followed physician's order for 2 (R #1 and R #13) of 5 (R #1, R #2, R #8, R #11 and R #13) residents reviewed for quality of care. Failure to follow physician orders could likely lead to facility staff and physician being unaware of changes in resident condition and could likely lead to worsening of resident's condition. The findings are: R #1 A. Record review of R #1's admission record (no date) revealed R #1 was admitted to the facility on [DATE]. B. Record review of R #1's physician orders revealed an order date 08/30/2024: Weight every day shift every seven (7) days, scheduled every Saturday for monitoring. C. Record review of R #1's Nutritional assessment dated [DATE] revealed the following: 1. Weight gain would be beneficial given very low body mass index (BMI;a tool that healthcare providers use to estimate the amount of body fat by using height and weight measurements and helps assess risk factors for certain health…

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 facility policy review, the facility failed to ensure food items were dated when initially opened, failed to ensure staff wore beard covers or hair nets while in the kitchen, and failed to ensure staff performed handwashing between glove use. These failures had the potential to affect 56 residents who consumed food prepared by the facility's kitchen. Findings include: Review of the facility's policy titled, Food Handling revised 06/15/18 revealed, .Once a product has been prepared or portioned, a new use by date is established. Review of the policy titled, Staff Attire revised 10/20/23 revealed, Policy: All employees wear approved attire for the performance of their duties. Procedures, 1. All staff will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained . Review of the facility policy titled, Hand Washing revised 10/01/19 revealed, Critical Elements.8. Uses clean, dry paper towel or air dryer to dry surfaces of fingers and hands. 9. Uses clean, dry paper towel to turn off faucet, without…

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, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one (R #28) of 33 residents reviewed for Minimum Data Set (MDS) had a quarterly assessment successfully transmitted and accepted within the allotted time frame. Findings include: Review of the October 2023 RAI Manual, page 2-35, showed: The Quarterly assessment is a .non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous .assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD .must be not more than 92 days after the ARD of the most recent .assessment of any type. Review of R28's admission Record, from the electronic medical record (EMR) under the Profile tab, showed a facility admission date of 01/11/20. Review of R28's annual MDS, with an Assessment Reference Date (ARD) of 01/21/24, showed medical…

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

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one (R #28) of 33 sampled residents reviewed for Minimum Data Set (MDS) assessment had a quarterly assessment successfully transmitted and accepted within the allotted time frame. Findings include: Review of the October 2023 RAI Manual, page 2-35, showed: The Quarterly assessment is an .non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous .assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD .must be not more than 92 days after the ARD of the most recent .assessment of any type. Review of R28's admission Record, from the electronic medical record (EMR) under the Profile tab, showed a facility admission date of 01/11/20. Review of R28's annual MDS, with an Assessment Reference Date (ARD) of 01/21/24,…

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

Based on interview and record review, the facility failed to ensure an accurate Level 1 Pre-admission Screening and Resident Review (PASARR) was completed after a new diagnosis for one of one sampled resident (R21) reviewed for PASARR. Findings include: Review of R21's admission Record, from the electronic medical record (EMR) under the Profile tab, indicated a facility admission date of 02/06/24, re-admission date of 07/19/24 for R21, and included diagnoses of anxiety, bipolar disorder, and major depressive disorder. Review of R21's PASARR Level 1 Screening Form, dated 02/06/24, revealed R21's diagnosis of anxiety was included on the screening. There were no recommendations related to the diagnosis. Review of R21's Diagnosis Record, from the electronic medical record (EMR) under the Diagnosis tab, indicated R21 had a diagnosis of bipolar disorder, unspecified dated 02/06/24, major depressive disorder recurrent moderate, dated 02/6/24, and anxiety disorder dated 02/06/24. On 09/18/24 at 11:55 AM during an interview , the Admissions Coordinator stated she was unaware the resident'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 record review, interview, and policy review, the facility failed to revise the care plan (CP) of one resident out of six residents (R8) reviewed for accidents/falls out of a total sample of 29 residents. This failure to revise the care plan of R8 by implementing interventions to prevent future falls has the potential to lead to serious adverse consequences. Findings include: Review of R8's Census tab located in the electronic medical record (EMR) revealed R8 was originally admitted on [DATE]. Review of R8's Medical Diagnoses tab located in the EMR revealed R8 had diagnoses including dementia, weakness, and unsteadiness on feet. Review of R8's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 92/24/24 and located in the EMR revealed R8 had a Brief Interview for Mental Status (BIMS) score of nine out of 15 indicating a moderate cognitive decline and no falls since admission in Section J. Review of the quarterly MDS with an ARD of 05/26/24 revealed R8 had a BIMS score of six out…

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 dust free filters on the inlet where the air came into the machine for two of three residents (R29 and R43) of 25 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 policy titled Respiratory Equipment/Supply Cleaning/Disinfecting revised 07/15/21 revealed, . In addition to surface cleaning and disinfecting, perform the following.Oxygen Concentrators: Rinse and dry the external filter weekly and PRN [as needed] when visibly dusty. 1. Review of R29's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 03/29/19, a readmission date of 04/09/24, and indicated a diagnosis of heart failure. Review of R29's Physician Orders, dated 04/10/24 and located in R29's EMR under the 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 and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #14) of 3 (R #12, R #14, and R #15) residents reviewed for abuse. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: A. On 07/23/24 at 12:10 PM, during an interview, CNA #11 stated that R #14 had not had anything to eat for lunch or breakfast. CNA #11 said that R #14 had not eaten breakfast or lunch for a week. CNA #11 said that she had documented that R #14 was not eating. B. Record review of the CNA's documentation for ADL's (Activities of Daily Living) (meal task) dated 07/23/24 for R #14, revealed the following: 1. On 07/16/24 at 8:44 AM, staff did not document the amount of the meal intake. 2. On 07/16/24 at 1:07 PM, staff did not document the amount of the meal intake. 3. On 07/16/24 at 5:52 PM, staff did not document the amount of the meal intake. 4. On 07/17/24 at 8:44 AM, staff did not document the amount of the meal…

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 in accordance with professional standards of food service safety for 77 residents that eat food prepared in the kitchen in the facility (residents were identified on the resident matrix provided by the Administrator on 09/11/23), when they failed to: 1. Wear facial hair coverings and hairnets in the kitchen. 2. Store food in a sanitary manner. If the facility fails to adhere to safe food handling practices, hygiene practices, and safe food storage, residents could likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 05/06/24 at 12:41 PM, during an observation of the kitchen revealed the following: 1. Six frozen hamburger patties sitting on top of a microwave. The hamburger patties were not in a wrapper, or on a plate or in a container. 2. The Dietary Manager (DM) #11 did not have a facial net covering his moustache and he did not have a hairnet on. B. On 05/06/24 at 12:42 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to report to the State Survey Agency within five (5) days of the incident for 1 (R #21) of 1 (R #21) residents sampled for abuse. If the facility fails to report abuse to the State Agency, then corrective action may not be taken, and residents could likely continue to be abused and/or suffer serious bodily injury. The findings are: A. Record review of R #21's medical record revealed R #21 was admitted on [DATE] and discharged on 02/06/24. B. Record review of R #21's progress note, dated 01/27/24, revealed R #21 was stuffing trash in the toilet. When asked why, R #21 told staff, I hate this place and everyone in it, I don't want to be here. I have a gun at home and I just want to shoot up this place. I hope you die here and everyone, I wish my wife was here so she could kick you're ass, all of you. I'm going to call the police. I was a golden glove in the military, and I will kick you're ass and your workers, I also know how to use stuff to stab you guys…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to revise the care plan for 2 (R #11 and R #21) of 4 (R #11, R #12, R #13, and R #21) residents reviewed for care plans when they failed to: 1. Revise R #11's care plan to include her regular/liberalized dysphagia advanced diet (moist foods in bite-sized pieces). 2. Have the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose to set goals, make decisions, and share resources and responsibilities) members participate in the care plan meeting for R #21. This deficient practice could likely result in staff being unaware of changes in care provided and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #11 A. Record review of R #11's Speech Therapy (therapeutic treatment of impairments and disorders of speech, voice, language, communication, and swallowing) Evaluation dated 01/16/24 revealed dysphagia advanced diet due…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide metal health services for 1 (R #21) of 1 (R #21) residents reviewed for mental health concerns, when the facility failed to provide metal health services for R #21 after the provider placed an order for mental health services. This deficient practice could likely result in worsening of behaviors and worsening of behavioral or mental health conditions causing increased depression and anxiety. The findings are: A. Record review of R #21's face sheet revealed R #21 was admitted on [DATE]. B. Record review of R #21's medical diagnoses revealed R #21 had a diagnosis of dementia, depression, and anxiety. C. Record review of R #21's admission referral from hospital, dated 05/06/23, revealed the following: 1. R #21 took Depakote Sprinkles (medication used to treat mental/mood conditions) 125 milligram (mg, unit of measure) twice a day. 2. R #21 took Escitalopram (antidepressant medication used to treat depression and anxiety) 10 mg once a day. D.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide social services for 1 (R #21) of 1 (R #21) residents reviewed for behavioral/emotional health, when they failed to provide timely referrals for R #21 to other long term nursing facilities after R #21 requested to be transferred. This deficient practice could likely lead to residents to feel that their wishes are not important and not attaining, or maintaining, their highest practicable mental and psychosocial well-being. The findings are: A. Record review of R #21's face sheet revealed he was admitted to the facility on [DATE]. B. Record review of R #21's progress note, dated 06/05/23, revealed R #21 stated that R #21 wanted to be moved to [name town] near his wife. C. Record review of R #21's progress note, dated 08/07/23, revealed the following: 1. R #21 stated that he wanted to leave the facility. 2. R #21 stated that he wanted to go home and live with his wife. 3. R #21 stated that if he could not live with his wife he would like to go to 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 ensure residents did not receive psychotropic medications unless the medication was necessary to treat a specific psychiatric diagnosis and was documented in the medical record for 1 (R #12) of 3 (R #11, R #12 and R #13) residents reviewed for unnecessary psychotropic medications. This deficient practice could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: A. Record review of R #12's admission record, not dated, revealed an admission date of 10/15/21 for R #12. B. Record review of R #12's Physician's orders revealed an order, dated 02/05/24, for Risperidone (an antipsychotic medication used to treat schizophrenia and bipolar disease) tablet, 0.5 mg two times a day for psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). C. Record review of R #12's Medical Administration Record (MAR) for April 2024, documented R #12 was taking…

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 have a discharge summary that includes a summary of the resident's stay at the facility for 1 (R #22) of 3 (R #21, R #22, and R #23) residents reviewed for discharge. Failure to provide a complete discharge summary that includes a description of the resident's stay at the facility could likely result in the receiving facility or home health or home health agency not having the most current information to provide care to the residents. The findings are: A. Record review of the progress notes revealed that R #22 was discharged on 04/22/24. B. Record review of R #22's Discharge summary, dated [DATE], revealed staff did not complete the following areas of the form: 1. Dietary recommendation. 2. Skin condition. 3. Current infections. 4. Hearing ability. 5. Vision ability. 6. Dental concerns. 7. Speech pattern. 8. Bowel and bladder continence. 9. Assistance levels. 10. Signs and symptoms of a change in condition for the resident. 11. Therapy services that…

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

Based on record review and interview, the facility failed to ensure that staff received the appropriate behavioral health training and have the skills to provide behavioral health services for 1 (R #21) of 1 (R #21) residents reviewed for behavioral health concerns. This deficient practice is likely to result in residents not getting the care and assistance they need. The findings are: A. Record review of R #21's progress notes, revealed the following: 1. On 01/26/24, R #21 was attempting to break into the ashtray in the smoking area using a metal fork, knife, and toenail clippers. R #21 was found taking things from other residents rooms and staff belongings. When staff discussed with R #21, he stated, I hate it here and want to leave, just let me leave out the door. Resident yelled at staff, you're a bitch and just want to keep me here for the money. When the nurse asked for the silverware, resident reluctantly gave it to the nurse and stated, I'm not going to stop, I plan on making everyone's life a living hell here. 2. On 01/27/24, R #21 was stuffing trash in the toilet. When…

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

Based on observation, record review, and interview the facility failed to provide a therapeutic diet (a diet ordered by a physician or delegated registered or licensed dietitian as part of treatment for a disease or clinical condition, or to eliminate or decrease specific nutrients in the diet) as ordered by a physician for 1 (R #11) of 3 (R #11, R #12, R #13) residents reviewed for dietary services. If the facility fails to provide a diet as ordered, then residents are likely to experience weight loss due to not receiving their prescribed nutritional caloric intake and may be at risk for choking. The findings are: A. Record review of R #11's physician order dated 01/25/24, revealed an order for regular/liberalized diet, dysphagia advanced texture (bite sized foods that are moist with the exception of crunchy, sticky or very hard foods). B. On 05/07/24 at 11:59 AM, during an observation, R #11's was served whole chicken nuggets, whole French fries (not chopped). C. On 05/07/24 at 12:15 PM, during an interview, CNA #11 confirmed that R #11 was served whole chicken nuggets and whole…

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 of a change in condition for 1 (R #1) of 3 (R #1, R #3, and R #4) residents reviewed for change of condition, when they failed to notify the facility provider about R #1's low blood pressure, low temperature, and abdominal pain. This deficient practice could likely result in residents not receiving necessary care or a delay in treatment. The findings are: A. Record review of R #1's admission record revealed R #1 was readmitted to the facility on [DATE], with the following diagnoses: 1. Sepsis (life-threatening medical emergency caused by your body's overwhelming response to an infection). 2. Urinary tract infection (UTI) 3. Dehydration B. Record review of facility's sepsis screening policy (review date 08/07/23) revealed: Patients with suspected or known infections will be monitored for signs and symptoms of possible sepsis, refer to sepsis algorithm (process of evaluating symptoms, vital signs, changes in patient condition to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to meet professional standards of quality for 1 (R #3) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for professional standards of care when the facility staff failed to monitor R #3's blood sugar. If the facility is not monitoring the resident and reporting to the provider, it may lead to a delay in treatment or changes in residents' health status may go untreated. The findings are: A. Record review of R #3's admission record revealed he was admitted to the facility on [DATE]. Further review of the admission record revealed diagnosis of type 2 diabetes (condition that happens because of a problem in the way the body regulates and uses sugar) with hyperglycemia (condition in which an excessive amount of glucose circulates in the blood, generally a blood sugar level higher than 200). B. Record review of R #3's physician's orders revealed an order for Humalog (insulin) inject 10 units with meals for diabetes (order included treatment of checking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 3 (R #1, R #2, and R #3) of 3 (R #1, R #2, and R #3) residents reviewed for accuracy of documentation. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records. The findings are: R #1 A. Record review of R #1's admission record revealed R #1 was readmitted to the facility on [DATE]. B. Record review of R #1's Treatment Administration Record (TAR), dated January 2024, revealed: Vital signs daily, every day shift, start date 06/20/23. Further review of the resident's TAR revealed staff did not document the resident's vital signs during day shift on the following dates: -01/06/24 -01/07/24 -01/11/24 -01/16/24 -01/25/24 -01/29/24 R #2 C. Record review of R #2's admission record revealed R #1 was readmitted to the facility on [DATE]. D. Record review of R #2's TAR, dated January 2024, revealed: Lantus (insulin)…

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 the MDS assessment accurately reflected the resident's status at the time of the assessment for 1 (R #3) of 4 (R #1, R #2, R #3, and R #4) residents sampled for MDS accuracy. This deficient practice could likely result in residents not receiving the care and treatment they need. The findings are: A. Record review of R #3's physician's orders revealed an order for Humalog (insulin) inject 10 units with meals for diabetes with a start date 01/03/24. Order discontinue date 01/04/24. B. Record review of R #3's admission MDS assessment, Section N: Medication, dated 01/08/24 revealed: Question N0350 Insulin: Record the number of days the physician changed the resident's insulin orders during the last 7 days was answered 0. C. On 02/07/2024, at 1:45 PM, during an interview with the MDS coordinator, she confirmed that the insulin had been discontinued and that the MDS assessment was not accurate because there were changes to R #3's insulin orders.

Recite from 08/10/22 Based on observation and interview, the facility failed to ensure essential equipment (vitally important; absolutely necessary) was in safe operating condition when the facility failed to ensure: 1. The transportation vehicle (transportation van used by facility to transport residents to and from appointments as needed) had a working air conditioner, 2. The kitchen stove had knobs used to control the gas burners. If essential equipment is not in working order then residents could likely not be able to achieve the highest practicable well being because they are unable to go to medical appointments or get food prepared on the stove. The findings are: Facility Van A. On 09/12/23 at 8:47 AM, during an interview, R #42 reported he had a dental appointment tomorrow in town. R #42 stated he did not know if he was going to go because the facility is having transportation issues due to the van not having an operating air conditioner. B. On 09/12/23 at 10:35 AM, during and interview, R #18 reported he did not go to an eye appointment, because the van's air conditioner did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a safe and clean environment by not maintaining the facility's odor in the 200 Unit between room [ROOM NUMBER] and 208 and between 213 and 217. This has the potential to affect all 40 residents in the facility's 200 Unit (residents were identified by the Census provided by the Administrator on 09/11/23). This deficient practice could likely result in residents not maintaining their highest practicable well being in the facility. The finding are: A. On 09/11/23 at 1:07 PM, during an observation of the 200 Unit revealed a very strong odor of urine. B. On 09/12/23 at 9:29 AM, during an observation the 200 Unit revealed an odor of urine. C. On 09/18/23 at 10:36 AM, during an interview R #1 reported the strong smell of urine on the 200 Unit. D. On 09/18/23 at 3:40 PM, during an interview Housekeeper #22 stated the urine odor is from residents that remove their own brief and throw it in the trash can or throw it on the floor next to their bed. E. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed provide a written notice of the bed hold policy at the time of the transfer to the resident and their representative(s) for 2 (R #68 and R #178) of 2 (R #68 and R #178) residents sampled for hospitalizations. This deficient practice could likely result in the resident and their representative being unaware that the resident is permitted to return and resume residence in the nursing facility upon discharge from the hospital. The findings are: R #68 A. Record review of R #68's Electronic Medical Record (EMR) revealed: 1) R #68 was transferred to the hospital on [DATE] due to critical laboratory results (laboratory test results that are significantly outside the normal range and may indicate a life-threatening situation). 2) No notice of bed hold policy notice was found. R #178 B. Record review of R #178's EMR revealed: 1) R #178's was transferred to the hospital on [DATE] per his request due to uncontrolled pain. 2) No notice of bed hold policy notice was…

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

Based on record review and interview, the facility failed to ensure that a Minimum Data Set (MDS) assessment was completed every three months for 1 (R #37) of 1 (R #37) residents reviewed for MDS assessments. This failed practice is likely to result in resident assessments being outdated and residents not receiving care and treatment that meets their current needs. The findings are: A. Record review of R #37's Electronic Medical Record (EMR) completed on 09/14/23 revealed, R #37's most recent MDS was completed on 05/06/23. B. On 09/14/23 at 1:45 PM, during an interview, the MDS Coordinator confirmed that R #37's Quarterly MDS was past due and was completed more than 3 months ago. The MDS Coordinator stated she recently had computer issues and that may be the reason she had not been prompted to complete an MDS for R #37.

Based on observation, record review, and interview, the facility failed to meet professional standards of quality for 1 for (R #63) of 4 (R #1, R #58, R #63, and R #181) residents observed during medication administration, when CMA #1 held R #63's blood pressure medication without specific parameters (numerical or another measurable factor) from the medical provider. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication due to it not being administered. The findings are: A. On 09/14/23 at 8:16 AM, during observation of medication pass and interview CMA #1 did not administer Lisinopril (medication used to treat high blood pressure) 20 mg. CMA #1 stated he was holding the medication because R #63's blood pressure is 94/53 (number for blood pressure reading). Per CMA #1, he holds blood pressure medications if the blood pressure top number is lower than 110 or if the heart rate is 60 or lower. CMA #1 stated that he had already informed the Unit…

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

Based on record review and interview, the facility failed to provide an ongoing activity program for 2 (R #1 and R #55) of 4 (R #1, R #43, R #55 and R #179) resident reviewed for activities. If the facility does not ensure that all residents are receiving an ongoing activity program, documenting resident refusals, and making in-room activity accommodations, then residents are likely to demonstrate an increase in isolation and depression. The findings are: A. On 09/13/23 at 12:05 PM, during an interview, R #1 stated that there is only about four group activities offered in the activity room and the rest are resident room activities or room visits. She stated there are no out of the facility outings and some of the activities listed do not include everyone and no alternatives offered. B. On 09/12/23 at 9:09 AM, during an interview, R #55 stated he would like to have more group activities It's mostly just bingo and room visits are not really an activity they (activities staff) just come and check on us and see if we are okay and then they leave. Some card games, listening to music or…

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

Based on record review and interview, the facility failed to ensure residents received adequate and timely transportation to each vision appointment for 3 (R #18, R #25, and R #28) of 3 (R #18, R #25, and R #28) residents reviewed for timely transport to vision appointments. If the facility is not assisting residents in accessing treatment to maintain their vision, then residents are likely to lose their ability to see, which will compromise their quality of life. The findings are: R #18 A. On 09/12/23 at 10:35 AM during and interview, R #18 stated he was not able to go to his eye appointment due to issues with the facility's transportation van's air conditioner not working. B. Record review of R #18's Care Plan revealed: [name of resident] has vision impairment related to needing glasses to read fine prints. C. On 09/13/23 at 12:57 PM, during an interview Social Services (SS) stated that she was not aware of an appointment for R #18. SS stated that they are not doing transportation to [name of town] because of the van's broken air conditioner. She stated that she will call the eye…

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 resident's received appropriate treatment and services to prevent further decrease in range of motion for 2 (R #19 and R #59) of 2 (R #19 and R #59) residents reviewed for restorative therapy, when they failed to initiate restorative nursing care (nursing service that often follows skilled rehabilitation services provided by physical or occupation therapists with the goal to maximize function and prevent functional decline in residents dependent on staff for certain actions). This deficient practice could likely result in decreased mobility or a decrease in residents' abilities to participate or perform their own ADL's (activities of daily living). The finding are: R #19 A. Record review of R #19's MDS (Minimum Data Set; comprehensive assessment) dated 06/30/23 revealed R #19's declined with bed mobility, transfers and toileting and now required extensive assistance as compared to MDS dated [DATE] in which she required only…

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

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services for Foley Catheter tubing/Collecting bag (soft plastic or rubber tube that is inserted to the bladder to drain the urine and is connected to a collecting bag) care for 1 (R #8) of 1 (R #8) residents sampled for Urinary Catheter, when they failed to keep R #8's Foley catheter and tubing off the floor. This deficient practice could likely result in residents getting infections. The findings are: A. On 09/12/23 at 9:27 AM, during an observation of 100 Unit revealed R #8's catheter tubing was dragging on the floor while sitting in her wheelchair near the nurse's station. B. On 09/12/23 at 9:28 AM, during an interview, the Unit Manager (UM) #11 confirmed that R #8's foley tubing was dragging on the floor and that the tubing should not be on the floor. C. On 09/13/23 at 10:09 AM, during an observation of the Restorative Dining Room, R #8's catheter tubing was dragging on the floor while sitting in her wheelchair. D. On 09/13/23 at 10:11 AM, during an interview, RN #11…

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

Based on interview and record review, the facility failed to provide social services for 1 (R #3) of 1 (R #3) residents reviewed for behavioral/emotional health, when they failed to refer R #3 to veterans facility after he requested to be transferred. This deficient practice could likely result in a resident experiencing anxiety and depression because their concerns with the facility have not been addressed or resolved. The findings are: A. On 09/12/23 at 1:17 PM, during an interview, R #3 stated that he wants out. He said he is a Veteran and wants to go to a Veterans Home. B. Record Review of R #3's Care Plan dated 07/08/22 revealed [Name of R #3] is unsure if he will be staying in facility long-term or transitioning back to the community . Make referrals to community-based agencies, providers, and services communicating the residents/patients needs and barriers to care. C. Record review of a Social Services Assessment and Documentation revealed the following: 1. 01/12/23, Section E Discharge Planning revealed R #3 asked about a possible transition to a Veterans Home but is unable…

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 pharmaceutical services (the direct, responsible provision of medication-related care) were met for 1 (R #178) of 1 (R #178) residents reviewed for medications when they failed to provide routine medications to residents. This deficient practice could likely lead to unresolved infections, worsening of infection or uncontrolled pain. The findings are: A. Record review of R #178's Physician's orders revealed: Order date 03/16/23, order start date 03/17/23 vancomycin (antibiotic medication used to treat serious bacterial infections) intravenous (antibiotic given through the vein) use 1.25 gram every 12 hours for MRSA (methicillin-resistant staphylococcus aureus; infection caused by specific bacteria that are resistant to commonly used antibiotics) septicemia (serious blood stream infection) and osteomyelitis (infection in the bone) R (right) BKA (below knee amputation) stump (the end of a body part after the rest is removed) until 04/17/2023 B.…

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

Based on record review and interview, the facility failed to ensure that pharmacy recommendations were followed after the Physician accepted them for 3 (R #19, R #28 and R #68) of 5 (R #19, R #28, R #48, R #55 and R #68) residents reviewed for unnecessary medications. This deficient practice could likely result in residents being at a higher risk of adverse side effects. The findings are: R #19 A. Record review of Pharmacy Consultation Report Recommendation, dated 07/31/23, revealed: 1.Please monitor valproic acid [medication is used to treat mental/mood conditions such as manic phase (over-the-top level of activity or energy, mood or behavior) of bipolar disorder (serious mental illness characterized by extreme mood swings)] trough concentration (lowest concentration of medication in blood just prior to the administration of the next dose) 2. Please monitor a fasting lipid panel (lipid panel is a panel of blood tests used to find abnormalities in lipids, such as cholesterol and triglycerides) . 3. The form was marked I accept the recommendation . 4. The form was signed by 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 did not receive antipsychotic medications unless the medication was necessary to treat a specific psychiatric condition or diagnosis and was documented in the medical record for 1 (R #19) of 5 (R #19, R #28, R #48, R #55, and R #68) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications without a clinical indication (medical reason) and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: A. Record review of R #19's physician's orders revealed: Order start date 06/06/22, Risperdal (antipsychotic medicine that works by changing the effects of chemicals in the brain used to treat mental/mood disorders such as schizophrenia or bipolar disorder) solution (liquid form of medication) Give 0.5 ml by mouth two times a day for dementia with behaviors (condition that causes problems with thinking, memory and reasoning that can include behaviors of confusion, sleep deprivation and wandering).…

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

Based on observation and interview, the facility failed to properly store medications, when they failed to: 1. Dispose of loose tablets stored in the medication carts for the 100, 200, and Memory Care Units. 2. Ensure medication was not expired in the medication refrigerator. 3. Document temperatures for the 100 Unit medication refrigerator. This could affect all 81 residents in the facility (Residents were identified by the resident matrix provided by the Administrator on 09/11/23). These deficient practices could likely result in residents obtaining medications that are no longer effective or that are not prescribed to them resulting in adverse side effects. The findings are: 100 Unit Medication Cart A. On 09/18/23 at 10:47 AM, during an observation of the 100 Unit Medication Cart revealed the following: 1. Ten loose tablets in the medication cart, 2. One loose capsule in the medication cart. B. On 09/18/23 at 10:54 AM, during an interview, CMA #1 confirmed the there were ten loose tablets and one loose capsule in the medication cart. 100 Unit medication storage room C. On…

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

Based on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for 80 residents that eat food prepared in the kitchen in the facility (residents were identified on the resident matrix provided by the Administrator on 09/11/23), when they failed to: 1. Keep the deep freezer and kitchen floors clean, 2. Wear facial hairnets in the kitchen, 3. Failed to keep the stoves and surrounding areas clean from grease, 4. Ensure that spices in the kitchen are labeled and dated, 5. Ensure that food and spices are sealed properly after opening. If the facility fails to adhere to safe food handling practices, hygiene practices, and safe food storage, residents could likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 09/11/23 at 11:03 AM, during an observation of the kitchen revealed the following: 1. The floors in the freezer and kitchen had food particles, paper, fluids, and were sticky, 2.…

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

Based on record review and interview, the facility failed to ensure documents were complete and accurate for 1 (R #43) of 1 (R #43) residents who were reviewed for documentation, when they failed to accurately document R #43's participation in activities. This deficient practice could likely result in staff not having the information they need to provide competent, comprehensive care and services if vital information is missing from the documents. The findings are: A. Record review of R #43's Care Plan, revision date 09/07/23, revealed the following: 1. Encourage R #43's participation in activities, 2. Provide R #43 with opportunities for choice during care/activities to provide a sense of control. B. Record Review of R #43's Activity Participation Log, dated September 2023, revealed the following: 1. Independent engagement for 09/14/23, staff documented as limited involvement, 2. Individual Engagement for 09/14/23, staff documented as minimal to no response, 3. Room to Room for 09/14/23, staff documented as sleeping, 4. Independent Engagement for 09/15/23, staff documented as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a discharge summary that included a recapitulation (a summary describing the resident's course of treatment while residing in the facility) was completed for 1 (R #75) of 1 (R #75) residents sampled for discharge from the facility. This deficient practice could likely lead to the receiving facility or hospital not knowing what the current care needs and significant medical history are for the resident. The findings are: A. Record review of R #75's Electronic Medical Record (EMR) revealed: 1. R #75 was transferred to the hospital on [DATE] due to abnormal vital signs (blood pressure, heart rate, temperature, respiratory rate and/or oxygen levels that deviate from the normal range and can indicate a possible health problem) and altered mental status (change in mental function that can stem from illness or injury and leads to changes in awareness, movement and/or behaviors). 2. As of 09/13/23, #75 had not returned to the facility. 3. Recapitulation…

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 require that physician visits were made by the physician personally for 1 (R #59) of 1 (R #59) residents reviewed for pressure ulcer/injury when R #59 was seen by the attending physician via telemedicine (the remote diagnosis and treatment of patients by means of telecommunications technology) and not face to face. This deficient practice could likely result in residents not receiving the required medical assessment and review resulting in resident receiving less than optimal care. The findings are: A. Record review of R #59's face sheet revealed R #59 was admitted into the facility on [DATE]. B. Record review of R #59's History and Physical dated 05/25/23, revealed that this was the initial visit and care was provided by the physician utilizing telemedicine. C. On 09/19/23 at 3:45 PM, during an interview, the DON confirmed R #59's initial visit was done via telemedicine. The DON stated physician comes to the facility once a month and if there is an…

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

Based on record review and interview the facility failed to schedule an appointment for dental services for 1 (R #42) of 3 (R #32, R #42 and R #68) residents sampled for dental services. This deficient practice could likely result in residents' continued dental pain. The findings are: A. Record review of R #42's admission record revealed an admission date of 12/20/22. B. On 09/12/23 at 8:47 AM, during an interview, R #42 stated he had a dental appointment the following day on 09/13/23 in [name of town]. The resident did not know if he was going to the appointment, because the facility was having transportation issues. C. On 09/13/23 at 1:45 PM, during an interview, Social Services stated staff did not take R #42 to his dental appointment due to the transportation issues, and staff have not rescheduled the appointment . D. On 09/19/23 at 2:25 PM during an interview, the Administrator confirmed that resident should be going to their appointments regularly.