Paloma Springs Healthcare LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Recite from 02/12/24 Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (a set of reasons or a logical basis for a course of action or a particular belief) for not following the consultant pharmacist's recommendation in the residents' medical record for 2 (R #45 and R #46) of 5 (R #9, R #45, R #46, R #62, and R #90) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). The findings are: R #45 A. Record review of R #45's face sheet no date revealed the following: 1. R #45 was admitted to the facility on [DATE], 2. R # 45 was diagnosed with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to keep residents free from psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for 2 (R #45 and R #46) of 5 (R #9, R #45, R #46, R #62 and R #90) residents reviewed for unnecessary medications when they failed to: 1. Carry out a gradual dose reduction (GDR; stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued) and failed to document clinical rationale to continue psychotropic medications for R #45 and R #46. 2. Ensure that as needed (PRN) psychotropic orders were limited to 14 days and ensure that if the prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for R #46. If consultant pharmacist recommendations and physician's orders are…

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

Based on observation and interview, the facility failed to provide a comfortable and homelike environment for 1 (R #1) of 3 (R #1, R #45, and R #78) residents sampled for environment, when staff failed to do the following: 1. Keep the residents' floor free of trash and orange peels. 2. Remove the residents' lunch tray after they had finished. 3. Empty and remove full urinal from the tray table. These deficient practices could likely cause residents to feel like they are not living in a comfortable home-like environment and like they are not valued. The findings are: A. On 04/21/25 at 2:15 PM, during an observation of R #1's room, revealed there were orange peels on the R #1's floor. There were food crumbs on the floor around R #1's bed. R #1's floor also had paper trash on the floor. On R #1's tray table, there was a lunch tray from lunch service (lunch was served at 12:00 pm). There was a full urinal on R #1's lunch tray. B. On 04/21/25 at 2:21 PM, during an interview, CNA #8 confirmed that there were orange peels, trash, and spills on the floor. CNA #8 confirmed that R #1's lunch…

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 Recite from 02/12/24 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 2 (R #32 and R #90) of 2 (R #32 and R #90) residents reviewed for hospitalization. This deficient practice could likely result in the residents and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: R #32 A. Record review of R #32's transfer notification, dated 04/16/25, revealed R #32 was sent to the hospital for cough and congestion. B. Record review of R #32's medical record, no date, revealed staff did not complete a written bed hold notification for R #90's transfer to the hospital on [DATE]. R #90 C. On 04/21/25 at 3:33 PM, during an interview, R #90 stated the following: 1. R #90 was sent to the hospital on [DATE], because the staff thought he was having heart issues. 2. Staff did not provide him with a written bed hold…

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 the Minimum Data Set Assessment (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) were accurate for 2 (R #9 and R #46) of 5 (R #9, R #29, R #46, R #62 and R #78) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: R #9 A. On 04/22/25 at 09:20 AM, during an interview, R #9 stated she did not have any teeth and needed dentures. B. Record review of R #9's admission record revealed R #9 was admitted on [DATE]. C. Record review of R #9's admission MDS dated [DATE] revealed: 1. Section L0200, Dental, check all that apply a. Staff did not check that R #9 had no natural teeth or tooth fragments (edentulous; the state of being without teeth). D On 04/25/25 at 11:03 AM, during an interview, the MDS Coordinator stated that she was unaware that R #9 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Recite from 02/12/24. Based on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 1 (R #90) of 2 (R #32 and R #90) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: A. Record review of R #90's admission record (no date) revealed the following: 1. R #90 was admitted to the facility on [DATE]. 2. Diagnosis of Edema (swelling caused by too much fluid trapped in the body's tissues). B. Record review of R #90's physician order dated 03/11/25, revealed an order for Furosemide (diuretic medication used to treat fluid retention (edema) and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions) 40 mg, once a day for edema. C. Record review of R #90's admission Minimum Data Set Assessment, dated 03/17/25, revealed Section N- Medications: N0415 High-Risk Drug Classes; Staff selected…

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 Recite from 02/12/24. Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #90) of 1 (R #90) residents reviewed for documentation accuracy. 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. Record review of R #90's admission record (no date) revealed the following: 1. R #90 was admitted to the facility on [DATE]. 2. R # 90 had the following diagnoses: a. Diarrhea (loose, watery stools that occur more frequently than usual). b. Noninfective gastroenteritis and colitis (involves inflammation of your stomach and intestines). c. Cellulitis of abdominal wall (a rare sign of acute appendicitis that presents as aggressive intra-abdominal inflammation). d. Acquired absence of other parts of digestive tract (missing parts of your digestive organs due to an injury or operation). B. Record review of R #90'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.

Past noncompliance Based on record review and interview, the facility failed to prevent staff to resident exploitation when Activity Aide (AA) #1 used R #16's bank debit card to make an unauthorized (without the account holders permission) money withdrawals or purchases for 1 (R #16) of 3 (R #16, R #17, and R #18) residents reviewed for abuse, neglect, and exploitation. This deficient practice could likely result in residents not having money available when they need it, psychosocial distress, and a loss of trust in staff. The findings are: A. Record review of the facility's self report, dated 09/13/24, revealed the following: 1. The self-report was submitted to the State Agency due to allegations of misappropriation (wrongful use of another's belongings, money, etc.) of funds for R #16. 2. R #16's Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters) reported that R #16's bank account was missing nearly $3,000 and there were multiple suspicious (showing a cautious distrust) charges. 3. The police were called and started an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #1) of 2 (R #1 and #2) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: A. Record review of R #1's face sheet no date, revealed R #1 was admitted into the facility on [DATE]. B. Record review of R #1's Electronic Medical Record (EMR) revealed a fall risk evaluation (an evaluation to determine a residents risk of falls), dated 04/26/24, indicated R #1 was a high fall risk. C. Record review of R #1's baseline care plan,…

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

Based on record review and interview, the facility failed to ensure staff acted upon pharmacy recommendations for all 85 residents in the facility (residents were identified on the resident matrix provided by the Administrator on 02/05/24), when they failed to get the pharmacy recommendations back from the provider with instructions to accept or decline recommendations, within 30 days of the facility receiving the pharmacy recommendations. This deficient practice could likely result in residents being at a higher risk of adverse (undesired harmful effect resulting from medication) side effects. The findings are: A. Record review of the Pharmacy Recommendations, for November 2023, revealed the following: 1. The pharmacist conducted a facility wide Medication Regimen Review on 11/11/23. 2. The provider signed off on the recommendations from the pharmacist Medication Regimen Review on 12/15/23. B. Record review of the Pharmacy Recommendations, for December 2023, revealed the following: 1. The pharmacist conducted a facility wide Medication Regimen Review on 12/19/23. 2. The provider…

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 follow procedures in accordance with professional standards of food service safety, when they failed to: 1. Ensure the chemical sanitation solution was maintained at the correct concentration. 2. Properly label opened food items in the walk-in refrigerator and walk-in freezer. This failure had the potential to affect all 81 residents in the facility who eat food prepared in the kitchen. Residents were identified by the Resident Matrix provided by the Administrator on 02/05/24. If the facility fails to adhere safe food storage then residents are likely to be exposed to foodborne illnesses. The findings are: Sanitizer Solution A. On 02/05/24 at 10:05 AM, during an observation, the kitchen revealed the following: 1. The chemical sanitation solution, used during the rinse cycle of dishwashing, leaked from the container onto the counter. 2. The Dietary Director (DD) ran a sanitizer strip test, during the rinse cycle of dishwashing, but the sanitizer solution did not register on the test strip. B. On 02/05/24 at 10:05 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.

Based on observation and interview, the facility failed to ensure residents were treated with respect and dignity for all 19 residents in the secured unit (residents were identified by the resident matrix provided by the Administrator on 02/05/24), when the facility failed to refer to residents in a dignified manner. This deficient practice could likely result in residents feeling embarrassed, angry, and that their feelings are unimportant to the facility staff. The findings are: A. On 02/05/24, at 12:11 PM, during an interview with LPN #11, she said the CNAs assist residents that need assistance with eating. LPN #11 said the secured unit had a lot of feeders. LPN #11 said they were supposed to refer to the residents as feed assists. B. On 02/12/24, at 11:38 AM, during an interview, the DON stated staff were not supposed to refer to residents as feeders. The DON said referring to residents as feeders was a dignity issue and was not acceptable. The DON said staff were corrected right away and educated if they refer to residents as feeders.

Based on observation, interview, and record review, the facility failed to ensure grievance (complaints over something believed to be wrong or unfair) were acted upon for 2 (R #1 and R #28) of 2 (R #1 and R #28) residents reviewed for grievances. This deficient practice could likely result in residents feeling unimportant and unsatisfied with the results of the grievance process. The findings are: R #1 A. On 02/05/24, at 1:01 PM, during an interview, R #1 stated a blue jacket with hot pink on it went missing on 02/03/24. R #1 said she told the laundry girl the jacket was missing. R #28 B. On 02/05/24, at 1:24 PM, during an interview, R #28 stated the following: 1. She had several pants that went missing roughly 7 months ago. 2. About two months ago one of her shirts got bleached in the laundry. She gave it to one of the laundry workers, but did not hear anything about it. 3. She was missing a pair of jeans and told laundry staff about them. C. On 02/08/24, at 2:27 PM, during an interview with Laundry Aide (LA) #1, she stated the following: 1. Any concerns about missing laundry…

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 keep residents free from involuntary seclusion for 5 (R #56, R #72, R #79, R #82, and R #193) of 5 (R #56, R #72, R #79, R #82, and R #193) residents sampled for elopement (an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment) risk, when they failed to implement and document the following: 1. The clinical criteria (rules or standards on which a decision or judgment is made to determine medical necessity) met for placement in the secured/locked area by the resident's physician along with information provided by members of the interdisciplinary team (IDT team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities). 2. Whether placement in the secured/locked area was the least restrictive approach that was reasonable to protect the resident and assure his/her health and safety. 3. The IDT consideration of the impact and/or reaction of the resident, if any,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure residents, their representatives, and the Ombudsman received a written notice of transfer as soon as practicable for 3 (R #1, R #16, and R #28 ) of 3 (R #1, R #16, and R #28) 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 #1 A. On 02/05/24, at 1:11 PM, during an interview, R #1 stated she went to the hospital about three weeks ago. B. Record review of R #1's transfer documents revealed the following: 1. The facility transferred R #1 to the hospital on [DATE]. 2. The transfer notice was an electronic form in the resident's electronic medical record (EMR), and the EMR did not contain evidence to show the resident received the transfer notice in writing. 3. Transfer notice did not have information regarding: a. How the resident or the resident representative can appeal 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 provide written information to the resident or resident representative that specified the bed hold policy and the number of days the facility will hold a bed for the resident at the time of the transfer for 3 (R #1, R #16, and R #28) of 3 (R #1, R #16, and R #28) residents sampled for hospitalizations, when they failed to: 1) Use a written Bed Hold Notice that included the number of days the facility will hold a bed for the resident at the time of the transfer for R #1 and R #28. 2) Provide written information to the resident or resident representative that specified the bed hold policy and the number of days the facility will hold a bed for the resident at the time of the transfer for R #16. This deficient practice could likely result in the resident and/or their representative being unaware of the resident ability to return to their previous room or the next available room upon return from the hospital. The findings are: R #1 A. On 02/05/24, at 1:11…

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 record review and interview, the facility failed to ensure staff completed a comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff, which included the traditional care of the resident, the prevention and early detection of disease, and rehabilitation) assessment within 14 calendar days after admission for 1 (R #56) of 5 (R #56, R #72, R #79, R #82, and R #193) residents reviewed for completion of a comprehensive MDS assessment. This deficient practice could likely result in residents' preferences and needs not being met. The findings are: A. Record review of R #56's medical record revealed an admission date of 01/20/24. B. Record review of R #16's medical record revealed staff did not complete an admission MDS assessment as of 02/12/24. C. On 02/12/24, at 11:30 AM, during an interview, the MDS Coordinator confirmed R #56's admission MDS was not completed within 14 days of R #56's admission to the facility. The MDS Coordinator said that the admission MDS's should be completed within 14 days.

Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 6 (R #16, R #50, R #56, R #79, R #82, and R #193) of 6 (R #16, R #50, R #56, R #79, R #82, and R #193) residents reviewed for comprehensive care plans. Failure to develop a person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being. The findings are: A. On 02/12/24 at 11:00 AM, during an interview with the DON, she confirmed resident care plans should be person centered and should include correct information about resident care so the nurses are aware of how to care for the residents. R #16 B. On 02/05/24 at 2:47 PM, during an observation of R #16's room, it was observed that that R #16 had a dialysis catheter to the left chest. C. On 02/06/24 at 2:22 PM, during an interview with R #16, he confirmed the following: 1. He received dialysis on Mondays, Wednesdays, and Fridays through the dialysis catheter in his left chest. 2. He…

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

Based on record review and interview, the facility failed to revise the care plan for 1 (R #1) of 1 (R #1) resident reviewed for care plans. 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: A. On 02/05/24, at 1:09 PM, during an interview, R #1 stated she lost weight due to irritable bowel syndrome (an intestinal disorder causing pain in the belly, gas, diarrhea, and constipation). B. On 02/05/24, at 1:09 PM, during an observation, R #1 appeared very thin. C. Record review of weights log revealed the following: 1. On 07/04/23 - 101.2 lbs. 2. On 08/02/23 - 98.4 lbs. 3. On 09/05/23 - 92.8 lbs. 4. On 10/06/23 - 88.8 lbs. 5. On 11/06/23 - 90.4 lbs. 6. On 12/11/23 - 79.0 lbs. 7. On 12/25/23 - 82.4 lbs. 8. On 01/08/24 - 80.8 lbs. 9. On 01/08/24 - 80.8 lbs. 10. On 01/15/24 - 84.4 lbs. 11. On 01/22/24 - 82.6 lbs. 12. On 01/26/24 - 93.8 lbs. 13. On 01/29/24 - 81.4 lbs. 14. On 02/12/24 - 78.2 lbs. 15. On 02/15/24 - 81.8 lbs. E.…

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

Based on interview, observation, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight for 1 (R #1) of 1 (R #1) residents sampled for nutrition, when they failed to: a. Update the care plan to reflect actual weight loss. b. Follow dietitian's recommendations. These deficient practices could likely result in residents losing weight without the facility being aware causing physical and mental health issues. The findings are: A. On 02/05/24, at 1:09 PM, during an interview and observation with R #1, she stated she lost weight due to irritable bowel syndrome (an intestinal disorder causing pain in the belly, gas, diarrhea, and constipation). R #1 appeared very thin. B. Record review of R #1's Medical Record revealed R #1's medical diagnoses: 1. Anorexia nervosa (an eating disorder that causes a severe and strong fear of gaining weight), onset date 0 9/03/21. 2. Unspecified protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function),…

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 2 (R #13 and R #16) of 3 (R #13, R #16, and R # 193) residents sampled for dental services, when they failed to: a. Ensure residents received 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. b. Ensure residents received emergent dental services when indicated. These deficient practices are likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. The findings are: R #13 A. Record review of R #13's medical record revealed an admission date of 08/11/23. B. On 02/06/24, at 10:01 AM, during an interview with R #13, he said his front teeth were missing, and he would like to have them replaced. R #13 said he talked to staff and his guardian, but they did not make him an appointment. R #13 said he had not been to the dentist since he has been at the facility. C. B. On 02/07/24, at 1:16 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 accurately document in the resident record for 1 (R #60) of 5 (R #1, R #49, R #60, R #78, and R #82) residents sampled for unnecessary medications. This deficient practice could likely cause staff to be unaware of residents' current conditions if they are not documenting accurately in the medical chart. The findings are: A. Record review of R #60's Physician's Orders revealed the following: 1) Soliqua (a fixed-dose combination medication that combines insulin glargine and lixisenatide and is used to treat diabetes.) pen-injector. (Insulin Glargine-Lixisenatide) Inject 15 units, in the morning related to Type 2 diabetes. Hold if blood sugar is less then 150. B. Record review of R #60's TAR, for January 2024, revealed staff documented they gave R #60 Soliqua on the following dates: 1) On 01/01/24 with a blood sugar reading of 139. 2) On 01/02/24 with a blood sugar reading 145. 3) On 01/07/24 with a blood sugar reading 142. 4) On 01/31/24 with a blood sugar reading 120. C. Record review of R #60's TAR, for February 2024,…

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 medications properly for all 20 residents in rooms 219 through 230 (residents were identified by the resident matrix provided by the Administrator on 02/05/24) randomly sampled residents, when they failed to dispose of one loose tablet in the medication cart on the 200 unit. This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects. The findings are: A. On 02/08/24, at 12:55 PM, during an observation, the medication cart on 200 unit revealed one loose tablet in the medication cart. B. On 02/08/24, at 12:55 PM, during an interview, CMA #5 confirmed there was one loose tablet in the medication cart. C. On 02/12/24, at 12:14 PM, during an interview, the DON confirmed medications should not be loose in the medication cart.

Based on record review and interview, the facility failed to ensure the medical records contained documentation each resident received or staff offered the pneumococcal (a bacteria that caused pneumonia infection of the respiratory tract) vaccination for 1 (R #60) of 5 (R #09, R #10, R #28, R #60, and R #86) residents reviewed for immunizations. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents. The findings are: A. Record review of R #60's medical record revealed the following: 1. Staff documented R #60 declined the pneumococcal vaccination, undated. 2. Influenza/Pneumococcal Vaccination consent form, dated 10/04/23, revealed R #60 gave consent for the pneumococcal vaccination. 3. The record did not contain any other consent forms. C. Record review of R #60's all staff Progress Notes, from admission through review, revealed the record did not contain documentation staff administered the pneumococcal vaccination, R #60 declined the pneumococcal vaccination, or that staff provided…

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

Based on interview and observation, the facility failed to: 1. Ensure residents participating in Resident Council knew where the most recent survey was located, 2. Update the binder with the most recent survey for residents/family's access. This could affect the 9 (R#7, R#8, R#16, R#33, R#36, R#47, R#57, R#59 and R #68) of 9 (R#7, R#8, R#16, R#33, R#36, R#47, R#57, R#59 and R #68 ) residents sampled in Resident Council. If residents are unable to locate the latest survey conducted by State Surveyors, then residents, representatives, and visitors are unable to know how the facility is doing and make decisions accordingly. The findings are: A. On 10/28/22 at 2:00 PM, during the resident council interview, R#7, R#8, R#16, R#33, R#36, R#47, R#57, R#59 and R #68 revealed: 1. Residents were not aware that they have access to the most recent Survey. 2. The residents did not know where the latest survey is located. B. On 10/28/22 at 10:15 am, during an observation of the front lobby revealed a displayed Survey binder. C. Record review of the Survey Binder revealed the last survey on display…

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 written notice of transfer as soon as practicable to residents and the ombudsman when residents were transferred to the hospital for emergency services for 3 (R #4, R #45, and R #56) of 5 (R #4, R #42, R #45, R#56 and R #66) residents. This deficient practice could likely result in residents or their representatives and the ombudsman being unaware of the reason for the transfer and the right to appeal. The findings are: R #4 A. Record review of R #4's Medical Record revealed the following: 1) R #4 went to the hospital on [DATE]. B. Record review of R #4 Transfer Notice dated 10/04/22 revealed R #4 did not sign until he returned to the facility on [DATE]. C. On 11/02/22 at 1:13 pm, during an interview the SSD (Social Service Director) confirmed that R #4 did not get a Transfer Notice until R #4 came back to the facility on [DATE]. R #45 D. Record review of R #45's Medical Record revealed the following: 1) R #45 went to the hospital on [DATE]. E.…

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

Based on record review and interview, the facility failed to ensure that pharmacist recommendations were reviewed by a physician and implemented after repeated monthly recommendations for 2 (R #56 and R #66) of 5 (R #4, R #23, R #32, R #52, R #56 and R #66) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions or adverse side effects. The findings are: R #56 A. Record review of Pharmacy Recommendation for R #56 dated 06/12/22 revealed: 1. The resident has an order for Fentanyl (powerful opioid drug used in the treatment of severe pain), Tramadol (opioid analgesic used to help relieve moderate to moderately severe pain), Codeine-Guaifenesin liquid (combination of an opioid cough suppressant and an expectorant cough syrup used to reduce cough and loosen mucus), and Acetaminophen-Codeine (opioid combination medication used to help relieve mild to moderate pain). Please add the standing order for PRN (as needed) Naloxone (Narcan; medicine 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 have complete and accurate documentation in the medical record for 1 (R #50) of 1 (R #50) resident when they failed to: 1) Document the plan for treatment from the NP (Nurse Practitioner) for R #50 after her labs came back with a recommendation to repeat sample and labs, 2) Document the cancellation of R #50's eye surgery appointment. This deficient practice could likely result in residents being unaware of their plan of care or upcoming appointments cause anxiety and depression. The findings are: Labs A. Record review of R #50's Physicians Orders revealed the following: 1) 09/28/2022 Culture, Urine. 2) 09/29/2022 Culture, Urine (a separate order). B. Record review of the lab results revealed the following: 1) The sample could have been contaminated and asks the facility to resubmit a new sample. 2) Handwritten at the bottom revealed NP notified on 10/03/22 at 16:48. (4:48 pm) C. Record review of R #50's Medical Record revealed the following: 1) No documentation of what the NP wanted to do about the lab request for a new…

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 that residents were treated with respect and dignity for 1 (R #52) of 1 (R #52) residents randomly sampled, when the facility did not have any pants or bottom covering for R #52 who's lower body was uncovered exposing her brief. This deficient practice could likely result in residents becoming depressed, anxious, and lacking self-worth. The findings are: A. On 10/26/22 at 10:52 AM, during observation of the Memory Care Unit, R #52 was observed laying in the bed closest to the door, the curtain and the door were open. R #52 had a shirt but was not covered with a blanket. R #52 did not have pants on and her brief was completely exposed. B. On 10/26/22 at 10:55 AM, during an interview CNA #21 confirmed the resident was not covered and she covered her. C. On 10/31/22 at 3:50 PM, during observation of R #52's room and interview with the Maintenance Director (MD), R #52 was observed uncovered and her brief was exposed. The MD confirmed that R #52 had a shirt on but was uncovered from the waist down exposing…

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 the facility Bed-hold notice upon transfer for 1 (R #45) of 1 (R #45) residents sampled for bed hold. This deficient practice could likely cause resident frustration and anxiety about not knowing if the facility will hold their bed while away. The findings are: A. Record review of R #45's Medical Record revealed the following: 1) R #45 went to the hospital on [DATE]. 2) No documentation of a bed hold notice was found. B. On 11/01/22 at 5:05 PM, during an interview with the Business Office Manager (BOM) and the Administrator, the BOM stated that R #45 was not given a bed hold policy. The BOM and Administrator stated that the facility tried to contact R #45 family and R #45 but could not get a hold of them. The Administrator did confirm that there was documentation of the facilities attempts to contact R #45 or his family.