Gardnerville Health & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review the facility failed to ensure oxygen was administered according to a physician's order for 1 of 13 sampled residents (Resident #34). This deficient practice had the potential to cause worsening of the resident's diagnosed chronic obstructive pulmonary disease. Findings include: Resident #34 Resident #34 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified and chronic systolic (congestive) heart failure. On 04/28/2025 at 9:45 AM, Resident #34 was receiving Oxygen via a Nasal Cannula (NC). The resident's Oxygen concentrator was set at 2.5 liters per minute (LPM). On 05/01/2025 at 7:49 AM, Resident #34 was sitting on the edge of the resident's bed. A NC was hanging below the resident's chin. A Registered Nurse (RN) entered Resident #34's room and adjusted the resident's NC. The RN explained Resident #34 was supposed to be on two liters of Oxygen. 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 personnel record review and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) employed greater than one year had a performance review completed annually for 1 of 3 CNAs reviewed for completed performance review. This deficient practice had the potential to affect all residents when the facility did not identify areas of CNA performance in need of insevice education/training. Findings include: Employee #9 Employee #9 was hired on 08/31/2023 as a CNA. Employee #9's personnel record lacked documentation a performance review had been completed in 2024. On 04/30/2025 at 11:45 AM, the Director of Nursing verbalized having been responsible for completing CNA performance evaluations and confirmed Employee #9 had not received a performance review upon the employee's one year anniversary. The facility policy titled, Nursing Personnel Education and Training, published 11/2016, documented employee reviews were to be completed every 12 months and identify areas of improvement and competencies to be completed as needed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review the facility failed to ensure medications were administered with an error rate of less than five percent (%). There were 26 opportunities observed and two errors. The medication error rate was 7.69%. Findings include: Resident #38 Resident #38 was admitted to the facility on [DATE], with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery, intracardiac thrombosis, not elsewhere classified, and ventricular tachycardia, unspecified. On 04/30/2025 at 8:14 AM, a Registered Nurse (RN)1 began preparing medications for Resident #38. The RN1 verbalized some of the resident's ordered medications were out of stock in the medication cart and the RN1 would need to go to the medication storage room to see if there was additional stock of the medications available. On 04/30/2025 at 8:18 AM, while in the medication storage room, the RN1 accessed an automated medication dispensing system,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure a multi-dose vial was labeled with the date the vial was opened in 1 of 1 medication storage rooms inspected. This deficient practice placed residents at risk for injection with expired Tuberculin Purified Protein Derivative (PPD) solution and potentially inaccurate Tuberculin PPD skin test results. Findings include: On [DATE] at 3:39 PM, during an inspection of the medication storage room and in the presence of the Infection Preventionist (IP), a vial of Tuberculin PPD (Mantoux) 5 Tuberculin Units (TU)/ 0.1 milliliters (ml) was found in the medication storage refrigerator. The vial lacked a cap, and a puncture site was observed in the rubber stopper. The vial and the manufacturer box lacked an open date. The manufacturer box included instructions to discard the vial within 30 days of opening. The IP confirmed the vial of Tuberculin PPD solution was open and lacked an open date written on the vial and the box. The IP verbalized…

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 document review, the facility failed to ensure the Facility Assessment (FA) was reviewed, updated, included input from and was approved by facility leadership and management Quality Assessment and Assurance (QAA) Committee. The deficient practice could result in the facility not being able to determine what resources were necessary to care for its residents competently. Findings include: On 04/30/2025, a review of the FA presented by the Interim Executive Director (IED), dated 03/25/2025, lacked documented evidence of an attendance sheet indicating a review of the FA contents by facility QAA Committee. The previous FA was requested from the IED. However, the FA documented individuals involved in completing the FA, to include the following: -Administrator -Director of Nursing (DON) -Governing Body Representative -Medical Director -Direct Care Representative -Resident Representative. On 04/30/2025 at 8:40 AM, the IED presented the previous FA, dated 08/29/2024. The IED verbalized the previous FA was placed in the shred pile and had to be located by staff. The FA…

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, clinical record review, and document review the facility failed to ensure 1) As Needed (PRN) medications were documented timely for 1 of 6 residents observed for medication administration (Resident #7) and 2) a wound care order was entered into the Electronic Medical Record (EMR) for 1 of 13 sampled residents (Resident #12). This deficient practice had the potential for duplicate administration of PRN medications, accurate Medication Administration Records (MARs) to not be available for review during a change in condition or required transfer to the hospital, and for staff providing care to a resident to not be aware of physician ordered care. Findings include: Resident #7 Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including emphysema, unspecified and cervicalgia. On 05/01/2025 at 8:14 AM, during the AM medication administration pass, a Registered Nurse (RN) began preparing medication for Resident #7. The RN verbalized 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 interview, record review and document review, the facility failed to develop and implement at least one Performance Improvement Project (PIP) per year. This deficient practice had the potential to adversely impact each resident's well-being. Findings include: On 05/01/2025 at 5:12 PM, the Interim Executive Director (IED), Director of Nursing (DON) and the Lead Administrator of Nevada (LAN) revealed Quality Assurance Performance Improvement (QAPI) committee meetings were held monthly and usual attendees included the Administrator, the Medical Director, and the DON. On 05/01/2025 at 5:15 PM, the LAN explained the facility was unable to furnish documentation or describe a PIP completed within the past year due to the facility using an electronic system to document the PIP and after the former Administrator left, the Quality Assurance (QAA) committee, no longer had access. The IED was unsure and was not able to confirm if the facility had any current PIPs and was not able to provide documentation for one. The IED stated having been the Administrator at this facility for a short…

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 clinical record review, interview, and document review the facility failed to ensure 1 of 5 residents sampled for vaccinations (Resident #12) was offered timely pneumococcal vaccination to complete the recommended pneumococcal vaccine schedule. This deficient practice had the potential to result in residents contracting a preventable illness. Findings include: Resident #12 Resident #12 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus with other circulatory complications and chronic diastolic (congestive) heart failure. Resident #12's Immunization Audit Report documented the resident had received the 23-valent pneumococcal polysaccharide (PPSV23) vaccine on 06/17/2021, 12/03/2018, and 10/15/2013. The Immunization Audit Report and Resident #12's clinical record lacked documentation the resident previously received any other pneumococcal vaccines. The following vaccines were documented as pending immunization: PCV13, PPSV23, PCV15, and PCV20. A Resident…

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 clinical record review, interview, and document review the facility failed to ensure 1 of 5 residents sampled for vaccinations (Resident #4) received or declined an updated/booster dose of COVID-19 (Covid) vaccine after being screened for eligibility. This deficient practice placed residents wishing to receive the Covid vaccine at risk of not receiving the vaccine and experiencing severe or prolonged illness, hospitalization, or death as a result of infection with the Covid virus. Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus without complications and hypertension. Resident #4's Immunization Audit Report lacked documented evidence the resident had received any doses of the covid vaccine. The form documented a status of pending immunization for covid vaccine, entered by the Infection Preventionist (IP) on 04/13/2025. A Resident Multi-Vaccine Consent Form dated 04/13/2025, documented Resident #4 was eligible for the…

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

An initial report for FRI #NV00073619, with an allegation a Certified Nursing Assistant was verbally abusive toward a resident was submitted to the SA on 03/06/2025. A review of progress notes related to the incident revealed the incident occurred on 03/04/2025. Based on interview and document review, the facility failed to ensure an allegation of abuse, neglect and a fall resulting in serious bodily injury was reported to the State Agency (SA) within the required time frame for 7 of 10 Facility Reported Incidents (FRI). This deficient practice could result in allegations of abuse and neglect not being investigated by the facility and/or the SA timely. An initial report for FRI #NV00073584, with an allegation of Resident-to-Resident physical abuse was submitted to the SA on 03/03/2025. The report documented the alleged incident occurred on 02/25/2025. A resident grabbed another resident's shoulders and shook them to wake them up. An initial report for FRI #NV00073594, with an allegation of Resident-to-Resident sexual abuse was submitted to the SA on 03/03/2025. The report documented…

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, clinical record review, and document review, the facility failed to protect 1 of 24 residents sampled for Facility Reported Incidents (FRI) free from involuntary seclusion. The deficient practice had the potential to cause the resident psychosocial harm or emotional distress by placing the resident alone in the common dining room, closing the door, and leaving the resident isolated from others. Findings include: Resident #43 Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE], and discharged on 03/12/2025, with diagnoses including unspecified dementia, severe with other behavioral disturbance, anxiety disorder, unspecified, cognitive communication deficit, other seizures, and difficulty in walking, not elsewhere classified. A FRI, dated 03/06/2025, documented a Certified Nursing Assistant (CNA) entered Resident #43's room to assist the resident with a brief change. The resident became verbally agitated and began to exhibit signs of psychosis, signaling a Licensed…

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 document review, the facility failed to ensure initial elder abuse prevention training was completed timely for an agency contracted Certified Nursing Assistant (CNA) involved in and terminated as a result of an abuse investigation (Employee #24). This deficient practice had the potential to place all residents at risk for abuse and neglect. Findings include: Employee #24 Employee #24 was hired by the facility on 11/08/2024, and terminated on 03/05/2025, as a CNA. Employee #24's personnel record lacked documented evidence the employee had completed initial elder abuse training upon hire. A Facility Reported Incident (FRI), dated 03/06/2025, documented a Certified Nursing Assistant (CNA) entered Resident #43's room to assist the resident with a brief change. The resident became verbally agitated and began to exhibit signs of psychosis, signaling a Licensed Practical Nurse (LPN) to go to the resident's room to see what was happening. The CNA removed Resident #43 from the resident's room and transferred the resident to the community dining room. The resident had…

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, clinical record review, and document review, the facility failed to ensure the medication room and a medication cart did not contain expired COVID-19 testing supplies and narcotic medications were stored appropriately to prevent a resident's narcotic pain medication from going missing for 1 of 1 residents sampled for Facility Reported Incident (FRI) investigations (Resident #188). This deficient practice had the potential to result in residents tested with the expired products receiving inaccurate results, delays in residents receiving pain medication, and unauthorized individuals having access to narcotics without a prescription, leading to the misuse of prescription opioids. Findings include: Expired Testing Supplies On [DATE] at 11:13 AM, the facility's medication storage room contained a box of COVID-19 test kits with an expiration date of [DATE], documented on the side of each test kit box. The box contained 73 test kits. The Resident Care Manager confirmed the expiration…

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 document review, the facility failed to ensure an ice machine's cleanliness was maintained, food was discarded per facility policy, and hand hygiene was performed during trayline observation. This deficient practice had the potential to affect the entire facility census. Findings include: Ice Machine On 06/24/2024 at 8:14 AM, the ice machine in the kitchen had a hard, white, flaky substance around the outside and inside of the door of the machine. An ice machine task sheet, posted on the side of the ice machine, documented routine maintenance was completed on 06/04/2024, and included door gasket cleaning. The task sheet documented a contracted maintenance company would complete a six month deep clean on the ice machine. On 06/24/2024 at 8:16 AM, the Nutrition Services Supervisor confirmed the ice machine had a hard, white, flaky substance around the door, and believed the cleaning of the door was completed during the deep cleaning of the ice machine by the contractor. On 06/24/2024 at 8:26 AM, the Nutrition Services Supervisor verbalized not…

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

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a staff member performed hand hygiene between contact with residents and environmental surfaces, a glucometer was sanitized correctly between residents, clean laundry was stored and handled in a sanitary manner and was not placed on a floor cleaner to finish drying, and a fan was not blowing air from the dirty laundry side of the laundry room to the clean laundry side of the laundry room. This deficient practice had the potential to result in the spread of infection and illness to residents throughout the facility due to lack of appropriate infection control practices. Findings include: Hand Hygiene On 06/20/2024 at 9:16 AM, the Activities Director (AD) entered a resident room and leaned down to speak with the resident in the bed nearest the door. The AD touched the resident's hand and the resident's bedding. The AD then left the resident's room and walked down the hallway toward the nurse's station. The AD placed both hands on the counter of the nurse's station and then…

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, clinical record review and document review, the facility failed to ensure informed consents were obtained prior to administering two psychotropic medications for 1 of 13 sampled residents (Resident #288). Findings include: The facility policy titled Psychotropic Drugs, updated 08/2022, documented psychotropic drugs included anti-depressants and anti-anxiety agents. Resident #288 Resident #288 was admitted to the facility on [DATE], with diagnoses including unspecified dementia unspecified severity, obstructive sleep apnea, and anxiety disorder unspecified. The physician's orders for Resident #288 dated 06/18/2024, documented the following: -Amitriptyline Hydrochloride (HCl) oral tablet 25 milligrams (mg), give 25 mg by mouth one time a day for restlessness related to anxiety. -Buspirone HCl oral tablet 30 mg, give 30 mg by mouth two times a day for restlessness related to anxiety. The June 2024 medication administration record (MAR) for Resident #288 dated 06/25/2024, documented…

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, clinical record review, and document review, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 2 of 13 sampled residents (Resident #3 and #13). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including other cord compression, muscle weakness generalized, and contracture of muscle unspecified site. A physician's order dated 09/28/2019, documented Resident #3 required bilateral bed rails to increase safety and independence with bed mobility. Resident #3's care plan revised 10/10/2023, documented the resident had bilateral quarter size bed rails as it related to bed mobility and repositioning. An intervention documented the resident and the resident's family would understand the use of bed rails was for bed mobility and repositioning only. Resident #3's last quarterly MDS assessment dated [DATE], section P0100 (Restraints and Alarms - Physical Restraints) documented bed rails were used daily 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 interview, clinical record review, and document review the facility failed to develop a care plan for a resident with a Deep Vein Thrombosis (DVT) (Resident #13) and a resident with insomnia (Resident #20) for 2 of 13 sampled residents. Findings include: Resident #13 Resident #13 was admitted to the facility 09/11/2021, with diagnoses including Parkinsonism and unspecified dementia, unspecified severity, with other, behavioral disturbance. On 06/25/2024 at 10:39 AM a Licensed Practical Nurse (LPN) verbalized Resident #13 received an anticoagulant for a DVT. The LPN confirmed the resident did not have a care plan for DVT. A Nurse Practitoner Progress Note dated 07/24/2023, documented Resident #13 had a left lower DVT of superficial and common femoral vein. A physician's order dated 07/26/2023, documented Eliquis, 5 milligram (mg) tablet. Give 5 mg by mouth two times a day for DVT. Resident #13's June Medication Administration Record (MAR) documented Eliquis 5 mg tablet was administered twice daily from…

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, clinical record review, and document review, the facility failed to meet professional standards for accurate recording per the Nevada Nurse Practice Act for a Registered Nurse (RN) when the Minimum Data Set Coordinator, Registered Nurse (MDS Coordinator) backdated a resident's care plan for deep vein thrombosis (DVT) by 11 months (Resident #13). Findings include: Resident #13 Resident #13 was admitted to the facility 09/11/2021, with diagnoses including Parkinsonism and unspecified dementia, unspecified severity, with other, behavioral disturbance. On 06/25/2024 at 10:39 AM a Licensed Practical Nurse (LPN) verbalized Resident #13 received an anticoagulant for DVT. The LPN confirmed the resident's Comprehensive Care Plan lacked a care plan for DVT or the anticoagulant. On 06/25/2024 at 10:40 AM, Resident #13's Comprehensive Care Plan lacked documented evidence of a care plan for DVT. A Nurse Practitioner Progress Note dated 07/24/2023, documented Resident #13 had a left lower DVT of superficial and common femoral vein. A physician's order dated 07/26/2023,…

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 document review, the facility failed to ensure nursing staff were trained and certified to perform Cardio-Pulmonary Resuscitation (CPR) in the event of a resident cardiac arrest for 2 of 5 sampled licensed nurses (Licensed Practical Nurse (LPN)1 and LPN2). The deficient practice could result in a negative outcome for a resident in cardiac arrest while awaiting the arrival of emergency medical personnel. Findings include: LPN1 LPN1 was hired on [DATE]. LPN2 LPN2 was hired on [DATE]. LPN1 and LPN2's personnel records lacked documented evidence of current CPR certifications. On [DATE], the Business Office Manager (BOM) confirmed responsibility for personnel record review conducted during the survey process. On [DATE] at 10:54 AM, during an interview for review of personnel records, the BOM verbalized being unsure about the policy for CPR training, including who was required to be certified and how often training was required. The BOM confirmed the personnel records for LPN1…

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, clinical record review, and document review, the facility failed to ensure a resident was not administered a pain medication outside physician parameters resulting in a resident receiving acetaminophen unnecessarily for 1 of 13 sampled residents (Resident #288). Findings include: Resident #288 Resident #288 was admitted to the facility on [DATE], with diagnoses including encephalopathy unspecified, hypothyroidism unspecified, and hypertension. A physician's order dated 06/18/2024, documented acetaminophen oral tablet. Give 650 milligrams (mg) by mouth every six hours as need for one to four moderate pain. Resident #288's care plan documented the resident had identified pain interfering with sleep, rehabilitation activities, and day to day activities related to migraines and headaches. An intervention revised on 06/25/2024, documented to administer analgesia as per orders. The June 2024 medication administration record (MAR) for Resident #288 dated 06/25/2024, documented the acetaminophen 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 Based on interview, clinical record review, and document review, the facility failed to ensure a psychotropic medication was prescribed to a resident with a diagnosed indication for use for 1 of 13 sampled residents (Resident #20). Findings include: Resident #20 Resident #20 was admitted to the facility on [DATE], with diagnoses including anxiety, unspecified and cellulitis of left lower limb. On 06/25/2024 at 10:29 AM, a Licensed Practical Nurse (LPN) verbalized Resident #20 received Trazadone for insomnia. The LPN confirmed the resident did not have a diagnosis of insomnia, for which the medication was to treat. A physician's order dated 03/12/2024, documented Trazodone Hydrochloride oral tablet 50 milligram (mg). Give one tablet by mouth one time a day for insomnia. Resident #20's June Medication Administration Record (MAR) documented Trazodone 50 mg tablet was administered once daily from 06/01/2024-06/25/2024. Resident #20's Comprehensive Care Plan lacked a care plan for insomnia. On 06/26/2024 at 9:16 AM,…

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, clinical record review, and document review, the facility failed to ensure 4 of 15 residents reviewed for vaccinations were offered a pneumonia vaccine upon admission (Residents #239, #88, #89, and #288) and 1 of 15 residents reviewed for vaccinations and residing in the facility during the 2023 to 2024 influenza (flu) season was offered a flu vaccine (Resident #33). This deficient practice had the potential for residents to become ill with a preventable illness due to lack of vaccinations. Findings include: Resident #239 Resident #239 was admitted to the facility on [DATE], with diagnoses including acute and chronic respiratory failure with hypoxia, type two diabetes mellitus without complications, and heart failure, unspecified. The clinical record for Resident #239 lacked documentation the resident was screened for or offered a pneumonia vaccine. Resident #33 Resident #33 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus without complications,…

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, clinical record review, and document review, the facility failed to ensure 4 of 15 residents reviewed for vaccinations were offered a COVID-19 vaccine upon admission (Residents #239, #88, #89, and #288) and 1 of 15 residents was offered an updated 2023 to 2024 COVID vaccine (Resident #30). This deficient practice had the potential for residents to become ill with a preventable illness due to lack of vaccinations. Findings include: Resident #239 Resident #239 was admitted to the facility on [DATE], with diagnoses including acute and chronic respiratory failure with hypoxia, type two diabetes mellitus without complications, and heart failure, unspecified. The clinical record for Resident #239 lacked documentation the resident was screened for or offered a COVID vaccination. Resident #88 Resident #88 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type two diabetes mellitus without complications, hyperlipidemia, unspecified, and essential (primary)…

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 laundry room was a safe and comfortable temperature. This deficient practice had the potential to result in staff experiencing adverse effects from working in unsafe temperatures while providing laundry services for residents of the facility. Findings include: On 06/26/2024 at 9:33 AM, during a tour of the laundry room, a fan was blowing air from the dirty side of the room to the clean side of the room. The Housekeeper confirmed the fan was in use to prevent the housekeeping staff from overheating as the room had not had air conditioning for the past year. On 06/26/2024 at 10:07 AM, the Administrator confirmed the laundry room was without air conditioning. On 06/26/2024 at 10:47 AM, the Maintenance Director verbalized the laundry room had been without out air conditioning off and on for the past year and the temperature should be maintained between 71- and 81-degrees Fahrenheit. On 06/26/2024 at 1:25 PM, the washing machine and dryers were not operating in the laundry room and the ambient temperature in 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 personnel record review, interview and document review, the facility failed to ensure annual elder abuse training was completed 1 of 20 sampled employees (Housekeeper). Findings include: The Housekeeper was hired on 09/17/2019. Employee #20's personnel record documented elder abuse training completed 05/04/2023, but lacked documented evidence elder abuse training was completed in 2024. On 06/25/2024, the Business Office Manager (BOM) confirmed responsibility for personnel record review conducted during the survey process. On 06/26/2024 at 10:54 AM, during an interview for review of personnel records, the BOM verbalized all staff were required to complete elder abuse training upon hire and annually thereafter. The BOM explained being unsure about the expected timeframes for elder abuse training. The BOM confirmed Employee #20's personnel record lacked elder abuse training in 2024. The facility policy titled Abuse Training, updated 10/2022, documented center staff were trained on abuse prevention, reporting, and intervention upon hire, annually and periodically thereafter.

Based on observation, interview, and document review, the facility failed to ensure a sufficient number of Certified Nursing Assistants (CNAs) were scheduled to perform resident care according to the Facility Assessment for 2 of 2 shifts during the weekends in January, February and March of 2023. Findings include: The Centers for Medicare and Medicaid Services, Payroll-Based Journal (PBJ) Staffing Data Report, dated 01/01/23 through 03/31/23, documented the facility had excessively low weekend staffing. On 08/28/23 at 9:40 AM, a CNA verbalized there were, on average, about two to three CNAs per shift. The CNAs were caring for about 14 residents each, per shift. The Facility Assessment Tool documented the facility capacity and staffing projections. The CNA schedule was maintained over two separate shifts; 6:00 AM-6:00 PM (first shift) projected three to four CNAs and 6:00 PM-6:00 AM (second shift) projected three to four CNAs. On 08/30/23 at 8:08 AM, the Administrator explained the Facility Assessment Tool staffing projections were based on an average daily census of 30. The Schedule…

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 document review and interview, the facility failed to ensure 1) tracking and trending of infections and antibiotic use was accurately completed and monitored with the potential to affect the facility's entire resident census of 34, 2) staff received education related to the Antibiotic Stewardship Program (ASP), and 3) tracking and reporting of employee infections was completed and the ASP policy included a process for tracking and reporting employee infections. Finding include: Tracking and Trending The facility form titled Line Listings for Infections by Resident, (Line Listing) included the following areas for documentation: -Resident name and age, -Resident room number, unit and date of admission, -Date of infection (onset) -Site of infection, -Symptoms present at admission -Pathogen/organism -Community or Healthcare associated (CAI/HAI) -Transmission Based Precautions (TBP) initiated (the word none was pre-populated into each line of this section every month) -Date resolved/comments The Line Listing did not include an area to document the prescribed antibiotic, ordered…

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 document review the facility failed to ensure the facility had a qualified Infection Preventionist (IP) with required specialized training working at the facility. Findings include: A typed list of IPs working at the facility between June 30, 2022 (date of the last recertification survey) and 08/28/23, provided by the Administrator, documented the following: -Employee #1 (E1) worked as an IP from 02/21/22 - 12/12/22 -E2 worked as an IP for the facility from 04/24/22 - 08/22/23 -E3 worked as an IP from 04/03/23 - 05/11/23 E1 A Personnal (Personnel misspelled on form) Action Form (PAF) dated 11/01/21 (original hire date), documented E1 transferred to the facility in the role of Director of Nursing Services (DNS) on 02/01/22. The form lacked documented evidence E1 worked as the facility's IP. Term date 12/xx/22, was hand written at the top of the form and did not include the last day worked. A Centers for Disease Control and Prevention (CDC) IP Training Certificate documented E1 completed specialized IP training on 01/13/21. E2 A PAF documented E2…

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 clinical record review, interview, and document review, the facility failed to ensure 1) residents receiving antipsychotic medications, antidepressants, an antibiotics had a care plan specifying the medications and addressing potential adverse reactions and side effects of the medications and interventions for all staff providing care to the resident to implement in the event of adverse reactions for 5 of 12 sampled residents (Resident #26, #27, #10, #6, and #21), 2) a care plan was developed for a resident's safety for leaning in bed for 1 of 12 sampled residents (Resident #8), 3) the creation of a care plan for residents prescribed insulin and opiates for 1 of 12 sampled residents (Resident #10), 4) a care plan related to wound care and the signs and symptoms (s/s) of infection was created for 1 of 12 sampled residents (Resident #9), 5) a care plan related to bathing needs and a decline in Activities of Daily Living (ADLs) was created for 1 of 12 sampled residents (Resident #21), and 6) a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, interview, and document review the facility failed to ensure a resident's privacy and dignity was maintained by not providing a privacy bag to conceal the resident's urinary collection bag for 1 of 12 sampled residents (Resident #137), and by providing bathing assistance to 1 of 12 sampled resident (Resident #21). Findings include: Resident #137 Resident #137 was admitted to the facility on [DATE], with diagnoses including flaccid neuropathic bladder, not elsewhere classified, encounter for fitting and adjustment of urinary device, and personal history of urinary (tract) infections. A physician's order dated 08/24/23, documented Resident #137 had a 16 French urinary catheter with a 5-10 cubic centimeter (cc) balloon. On 08/28/23 at 2:42 PM, Resident #137 was resting in bed. The resident's urine collection bag was hanging from the resident's bed frame and was not concealed in a privacy bag. The urine collection bag was facing towards the resident's open door and 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 Based on observation, interview, clinical record review, and document review, the facility failed to ensure the call light was within the reach of a residents for 1 of 12 sampled residents (Residents #27). Findings include: Resident #27 Resident #27 was admitted to the facility on [DATE], with diagnoses including unspecified fracture of upper end of right humerus, sequela, Alzheimer's disease, unspecified, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, preglaucoma, unspecified, bilateral and depression. On 08/28/23 at 9:21 AM, Resident #27 was sleeping in bed. The bed was located against the wall with the call light cord wrapped around the call light outlet and the cord draping down in between the wall and the bed. On 08/30/23 at 9:07 AM, Resident #27 was sleeping in bed. The bed was located against the wall with the call light cord wrapped around the call light outlet and the cord was draping down in between the wall and the bed. A Certified Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, clinical record review, and document review, the facility failed to ensure a comprehensive care plan for the use of bedrails was revised to include the correct and actual size of the bedrail for 1 of 12 sampled residents (Resident #4). Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], with diagnoses including other cord compression, neurofibromatosis, unspecified, muscle weakness (generalized) and contracture of muscle, unspecified site. On 08/28/23 at 11:20 AM, Resident #4 had two quarter size bedrails attached to one side of the bed. Resident #4 explained the resident preferred bedrails for mobility while in bed. A physician's order dated 09/28/19, documented the resident required bilateral bedrails to increase safety and independence with bed mobility. The physician's order did not indicate the size of the bedrails to be used. The Minimum Data Set (MDS) 3.0, Section P, dated 07/22/23, quarterly assessment documented the resident used bedrails…

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 clinical record review, interview, and document review the facility failed to ensure a resident was provided bathing or showering assistance two times per week per the facility's bathing schedule for 1 of 12 sampled residents (Resident #21). Findings include: Resident #21 was admitted to the facility on [DATE], with diagnoses including other intervertebral disc degeneration, lumbar region, cellulitis of left lower limb, and puritis. On 08/28/23 at 10:49 AM, Resident #21 verbalized the resident had been at the facility since 08/03/23, and was was upset the resident had only been provided one bath. Resident #21's Minimum Data Set 3.0 (MDS) assessment dated [DATE], documented Resident #21 required the extensive assist of two or more people for bed mobility and transfers and walking did not occur. Moving from a seated to standing position was documented as not steady and only able to stabilize with staff assistance. Self-performance for bathing and support provided for bathing was documented as did not…

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

Based on observation, clinical record review, interview and document review the facility failed to ensure an active physician's order was in place prior to providing wound care to a resident for 1 of 12 sampled residents (Resident #9). Findings include: Resident #9 Resident #9 was admitted to the facility with diagnoses including sepsis, unspecified organism, mild protein calorie malnutrition, nutritional anemia, unspecified, and weakness. A progress note dated 08/08/23, documented during care a redden/purplish, non-blanchable discoloration to Resident #9's sacral/coccyx region and upper bilateral buttocks was noted. The skin was intact and the resident denied pain. The provider was notified and orders were received. A physician's order dated 08/08/23, documented wound care to buttocks, cleanse with wound cleanser, pat dry, apply skin prep to peri wound, apply hydrogel to wound base, open skin only, cove with sacral foam dressing. Report worsening condition or signs and symptoms of infection to the provider, one time per day for open wound and as needed for soiled or dislodged…

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, clinical record review and document review, the facility failed to ensure a resident was assessed for risk of entrapment when the resident's bed was placed against the wall for 1 of 12 sampled residents (Resident #27). Findings include: Resident #27 Resident #27 was admitted to the facility on [DATE], with diagnoses including unspecified fracture of upper end of right humerus, sequela, Alzheimer's disease, unspecified, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, preglaucoma, unspecified, bilateral and depression. On 08/28/23 at 9:21 AM, Resident #27 was sleeping in bed. The bed was located against the wall with no spacing between the wall and the bed. A care plan, last revised on 10/04/22, documented the resident was on sedative/hypnotic therapy related to circadian rhythm regulation. Interventions included to monitor, document and report as needed for following adverse effects of sedative/hypnotic therapy, such as day…

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, clinical record review, interview, and document review the facility failed to ensure a resident's oxygen humidifier bottle was changed when empty, causing the resident discomfort for 1 of 12 sampled residents (Resident #25). Findings include: Resident #25 Resident #25 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, mild intermittent asthma with status asthmaticus, and emphysema, unspecified. A physician's order dated 05/31/22, documented to administer oxygen at 2 liters per minute (LPM) via nasal cannula to keep oxygen saturations greater than 90 percent as needed for shortness of breath. On 08/28/23 at 9:38 AM, Resident #25 was resting in bed. The resident's oxygen concentrator was running at 2 LPM but the resident was not wearing the oxygen. Resident #25 explained the resident took the oxygen off because it was causing the resident's nose to burn and hurt. The water humidifier…

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 personnel record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had a performance evaluation completed annually for 1 of 2 CNAs employed greater than one year sampled for personnel record review (Employee #8). Findings include: On 08/29/23 at 10:32 AM, the Business Office Manager and Divisional Director of Clinical Operations (DDCO) participated in an interview to confirm the accuracy of the Personnel Records Checklist completed by the facility for 20 employees. On 08/29/23 at 11:23 AM, the Personnel Records Checklist was given back to the DDCO for a double check and confirmation of discrepancies documented by the facility. Employee #8 Employee #8 was hired as a CNA with a start date of 03/25/21. The CNA's last performance evaluation was documented as completed on 08/25/22. On 08/29/23 at 1:01 PM, the Administrator provided the revised Personnel Records Checklist without revision to Employee #8's date of last performance evaluation. The Administrator was unable to provide evidence the CNA had an annual performance evaluation…

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 document review, the facility failed to ensure drug regimen reviews were completed monthly and pharmacy recommendations were addressed for 2 of 5 residents reviewed for unnecessary medications (Resident #6 and #26). Findings include: Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including chronic atrial fibrillation, unspecified, anxiety disorder, unspecified, and major depressive disorder, single episode, mild. The facility lacked documented evidence a monthly Medication Regimen Review (MRR) was conducted for Resident #6 in December 2022. Resident #6's MRR note, dated 01/05/23, completed by the Consultant Pharmacist, documented the manufacturer's packaging for finasteride (Proscar) and dutasteride (Avodart) should not be handled by women of child-bearing age. Women who were pregnant or may get pregnant must not handle broken or crushed tablets. Exposure to whole tablets was not expected to cause harm unless swallowed. The MRR lacked documented evidence the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and document review, the facility failed to ensure medications were administered with an error rate less than 5 percent (%). There were 28 opportunities and 16 medication errors. The medication error rate was 57.14 %. Findings include: Resident #20 Resident #20 was admitted to the facility on [DATE], with a diagnosis of fibroblastic disorder, unspecified. Resident #20's Order Summary Report documented the following active medication order: -Vitamin B-12 (cyanocobalamin) give 5000 micrograms (mcg) one time per day for supplement. Resident #20's Medication Administration Record (MAR) for August 2023, documented the following: -Vitamin B-12 (cyanocobalamin) give 5000 mcg one time per day for supplement. The scheduled administration time was 8:00 AM. On 08/29/23 at 8:59 AM, during a medication administration pass, a Registered Nurse (RN) was not able to find vitamin B-12 in the medication cart. The LPN verbalized the LPN would look for the medication at a later…

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 document review, the facility failed to ensure temperature logs for the medication refrigerator were completed by each shift and failed to ensure unpackaged and unlabeled medications were removed from the medication cart. Findings include: Temperature Logs On 08/29/23 at 1:18 PM, during an inspection of the facility's medication storage room the temperature log for the medication refrigerator was reviewed and lacked documented evidence the temperature was monitored and recorded as follows: -The medication refrigerator temperature log (temperature log) for May 2023 did not document a temperature for 29 of 31 days and did not document a temperature during night shift for 29 of 31 night shifts. -The temperature log for June 2023 did not document a temperature during day shift for 5 of 30 days, and did not document a temperature during night shift for 9 of 30 night shifts. -The temperature log for July 2023 did not document a temperature during day shift for 8 of 31 days, and did not document a temperature during night shift for 10 of 31 night…

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 keep the refuse area clean. Findings include: On 08/28/23 at 8:13 AM, there were two dumpster areas. The first dumpster area had an open bag of trash, with the trash spewed throughout the area. The second dumpster area had used Personal Protective Equipment (PPE) and soiled bodily wipes throughout the area on the ground. On 08/28/23 at 8:19 AM the Food Services Manager verbalized trash was to be located inside of the dumpsters, with the lids closed, at all times. The Food Service Manager confirmed the accumulation of trash on the ground in both dumpster areas. On 08/29/23 at 9:39 AM, the Administrator explained dumpster lids were to be closed at all times with all trash contained within the dumpsters. There should not be a time where trash or debris were located on the ground or outside of the dumpsters because it was an infection control concern. The facility policy titled, Garbage and Rubbish Disposal, published July 2008, documented the outside dumpsters were to be kept closed and free of litter around the dumpster area.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the Facility Assessment included an Infection Preventionist (IP) and the hours required to complete the task assigned to an IP. Findings include: The Facility assessment dated [DATE], lacked documented evidence for the role of an IP and the hours needed to complete the infection control task. On 08/31/23 at 1:54 PM, the Administrator confirmed the Facility Assessment staffing plans did not include an IP and the hours needed to complete infection control task the IP was responsible for.

Based on interview and document review the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify 1) completion of person centered care plans (see tag F656), and 2) the Antibiotic Stewardship Program (ASP) lacked a facility wide system for monitoring and tracking infection trends and antibiotic use (see tag F881). Findings include: On 08/31/23 at 3:22 PM, the Administrator confirmed the QAPI committee did not identify or address the following concerns: -creating person centered care plans -the Antibiotic Stewardship Program (ASP) did not include a facility wide system for tracking and trending infections, and monitoring use of antibiotics On 08/31/23 at 3:27 PM, the Administrator verbalized the QAPI committee could have identified concerns related to creating person centered care plans. A lack of tracking and trending of antibiotics and infections could have been identified by asking the Director of Nursing and the Administrator if the facility had the necessary tools to manage the facility's Infection Control and ASP requirements including…

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 document review, the facility failed to ensure an Infection Preventionist (IP) attended the Quality Assurance and Performance Improvement (QAPI) committee meetings over the last 12 months. Findings include: The following QAPI sign-in sheets lacked evidence the IP attended and participated as a committee member in the QAPI meetings: - 07/29/22 - 09/22/22 - 12/22/22 - 03/16/23 - 04/26/23 - 06/16/23 - 07/20/23 - 08/25/23 On 08/31/23 at 3:22 PM, during the QAPI interview with the Administrator, the Administrator reviewed the QAPI sign-in sheets and confirmed the facility did not have an IP attend the QAPI committee meetings from July 2022 - August 2023.

Based on interview, personnel record review and document review, the facility failed to ensure staff were trained on the prevention of elder abuse for 3 of 20 sampled personnel records reviewed (Employee #10, #11, and #12). Findings include: On 08/29/23 at 10:32 AM, the Business Office Manager (BOM) and Divisional Director of Clinical Operations (DDCO) participated in an interview to confirm the accuracy of the Personnel Records Checklist completed by the facility for 20 employees. On 08/29/23 at 10:39 AM, the BOM and DDCO verbalized elder abuse training was required upon hire, annually, and as needed (PRN). On 08/29/23 at 11:23 AM, the Personnel Records Checklist was given back to the DDCO for a double check and confirmation of discrepancies documented by the facility. Employee #10 Employee #10 was hired as a Certified Nursing Assistant (CNA) with a start date of 12/23/22. The CNA's elder abuse training was completed on 01/05/23. Employee #11 Employee #11 was hired as a Physical Therapist (PT) with a start date of 02/01/23. The PT's elder abuse training had not been completed.…

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.