Oasis Nursing & Rehab Of Green Valley

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure a resident was kept safe from abuse for 1 of 5 sampled residents (Resident 4). The deficient practice had the potential for the resident to experience emotional distress and physical harm. Findings include: Resident 4 (R4) R4 was re-admitted to the facility on [DATE] with diagnoses including cerebral palsy, depression, anxiety disorder, and diabetes mellitus. The resident had a brief interview for mental status (BIMS) evaluation with a score of 15, denoting the resident's cognition is intact. Resident 5 (R5) R5 was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage, chronic respiratory failure, dementia, and depression. The resident had a brief interview for mental status (BIMS) evaluation with a score of 15, denoting the resident's cognition is intact. The facility reported incident (FRI) dated 02/19/2024 documented the following: -On 02/19/2025 at approximately 1:45 PM, R4 reported to 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 interviews, record review, and document review, the facility failed to ensure the wrong medication was not administered to a resident for 1 of 5 sampled residents (Resident 3). The deficient practice placed the resident at risk for kidney transplant complications. Findings include: Resident 3 (R3) R3 was admitted on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD), and kidney transplant status. A physician order dated 02/24/2022 documented to give Tacrolimus 0.5 milligram (mg), one capsule (a form of oral medication made of a gelatin or plant-based shell filled with powder, liquid, or granules) by mouth once a day for kidney transplant. (Tacrolimus- an anti-rejection medication prescribed to patients who receive organ transplant for the purpose of suppressing immune response). A medication error report dated 01/25/2025 revealed R3 was administered Cialis 5 mg tablet (a form of oral medication in solid form of compressed powder which may be coated, scored, or split)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure the residents' behavior was monitored and documented for residents receiving psychoactive medications for 6 of 25 sampled residents (Residents 44, 102, 5, 161, 4, and 99). This deficient practice could have increased the risk of adverse side effects, ineffective medication management, missed signs of worsening conditions, and compromised resident safety. Findings include: A facility policy titled Medication Monitoring and Management revised in November 2014, indicated the resident's medication regimen required monitoring for significant negative changes from baseline. Medications were to be ruled out as the cause of these changes, following the policy on detecting and preventing adverse consequences. Resident 44 (R44) R44 was admitted on [DATE], with diagnoses including depression, dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A Physician Order dated 09/01/2024,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure residents have a right to make choices about aspects of their life in the facility which are significant to the resident for 1 of 35 sampled residents and 3 unsampled residents (Residents #126, 14, 118 and 41). The failure to accommodate the residents' preferences and choices had the potential risk to cause psychosocial distress to the residents. Findings include: The facility is located off a minor street which leads to an entrance to the facility parking lot where the facility has a large, covered portico which joins a large wrap around porch area before the entrance to the facility. In this porch area before the facility's main entrance are numerous park benches to sit and enjoy the quiet view of the front flower garden of the facility. Resident 126 (R126) R126 was admitted to the facility on [DATE] with diagnosis of hypertension and chronic kidney disease. R126 had a Brief Interview for Mental Status (BIMS) score of 12…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure assessments were accurate, specifically for vision, hearing, and functional status impacting activities of daily living for 1 of 35 sampled residents (Resident 96). The deficient practice potentially deprived the resident of a person-centered plan of care ensuring the resident received adequate level of assistance with care needs. Findings include: Resident 96 (R96) R96 was admitted on [DATE] and readmitted on [DATE], with diagnoses including chronic vision loss, chronic hearing loss, Parkinson's disease and weakness. On 09/24/2024 at 8:38 AM, R96 laid in bed with eyes opened, an untouched breakfast tray was in front of the resident. After introduction, R96 requested surveyor to come closer and speak louder due to difficulty hearing. As the surveyor walked around the resident's bed to come closer to left side, the resident maintained frontal gaze and did not follow the surveyor's movement. R96 asked surveyor if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level 2 evaluation for displayed behavioral activity or diagnosis for 3 of 35 sampled residents (Resident 99, 135, and 72). The deficient practice had the potential to place residents at risk of not being evaluated for appropriate determination of necessary behavioral health services. Findings include: Resident #99 R99 was admitted on [DATE], with diagnoses including psychosis and bipolar. The PASRR level 1 utilized for R99's admission was dated 09/28/2020, documented diagnoses of dementia and Alzheimer. On 09/24/2024 at 9:30 AM and 09/26/2024 at 10:20 AM, R99 was observed lying in bed with day clothing. R99 was awake and would answer simple questions. R99 was noticed to mumble words to self when not spoken to. R99's care plan problem with a start date of 03/28/2023 documented: Resident is at risk for adverse consequence related to receiving psychotropic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and document review, the facility failed to ensure comprehensive care plans were created for the management of sleep apnea devices for 2 of 35 sampled residents (Resident 64 and 390). The deficient practice had a potential for staff not to provide person centered care for a resident. Findings include: Resident 64 (R64) R64 was admitted on [DATE] with diagnoses including open wound lower back and pelvis and hemiplegia after cerebral infarction. On 09/24/2024 at 1:43 PM, at R64's bedside table was breathing equipment. R64 indicated it was a CPAP (Continuous Positive Airway Pressure) machine (a device that helps treat sleep-related breathing disorders, such as sleep apnea, by keeping airways open while you sleep). R64 indicated using the CPAP at night and self manages the equipment and does the self-application of the nasal mask. R64 indicated bringing the equipment from home upon admission. Physician and nursing progress notes lacked documented evidence R64 was using 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, record review, and document review, the facility failed to ensure a deep tissue injury in a high risk resident was treated, and appropriate interventions were implemented and the weekly skin assessment was completed as scheduled for 1 of 25 sampled residents (R52). This deficient practice had the potential to lead to worsening of the pressure injury, increased risk of infection, delayed healing, further tissue damage, and a higher likelihood of complications such as sepsis or hospitalization. Findings include: Resident 52 (R52) R52 was admitted on [DATE], with diagnoses including diabetes mellitus, urinary tract infection, dysphagia (difficulty swallowing), and gastrostomy. The Braden Scale for Predicting Pressure Sore Risk dated 07/20/2024, documented a score of 10, which indicated a high risk for developing a pressure sore. The admission Skin assessment dated [DATE], documented R52 had a left heel, old wound. The Care Plan dated 07/14/2024 documented R52 was at risk for skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure a resident who was clinically blind was provided assistance with food and fluids for 1 of 35 sampled residents (Resident 96). The deficient practice potentially contributed to the resident's significant weight loss and hospitalization. The resident was sent to the hospital on [DATE] due to poor oral intake and weakness and on 09/27/2024 due to dehydration. Findings include: Resident 96 (R96) R96 was admitted on [DATE] and readmitted on [DATE], with diagnoses including chronic vision loss, chronic hearing loss, weakness, abnormal weight loss and nutritional deficiency. On 09/24/2024 at 8:38 AM, R96 laid in bed with eyes opened, an untouched breakfast tray was in front of the resident. After introduction, R96 requested surveyor to come closer and speak louder due to difficulty hearing. While the surveyor walked around the resident's bed to come closer to left side, the resident maintained frontal gaze and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure the physician orders for bolus tube feeding, water flushes, and gastrostomy tube care were obtained for 1 of 35 sampled residents (Resident 52). This deficient practice had the potential to result in improper nutrition, dehydration, increased risk of infection, gastrointestinal complications, delayed healing, and potential hospital readmission. Findings include: Resident 52 (R52) R52 was admitted on [DATE], with diagnoses including dementia, diabetes mellitus, urinary tract infection, dysphagia (difficulty swallowing) and gastrostomy. The admission Skin assessment dated [DATE], documented R52 had Percutaneous Endoscopic Gastrostomy (PEG) (a feeding tube inserted into the stomach through the abdomen for nutrition) tube in place. A Care Plan dated 07/14/2024, documented R52 received nutritional support through a feeding tube with a risk of aspiration. Interventions included assessing tolerance, verifying tube…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure care orders were obtained, transcribed and carried out for a peripherally inserted central catheter (PICC) line for 1 of 35 sampled residents (Resident 96). The deficient practice placed the resident at risk for infection. Findings include: Resident 96 (R96) R96 was admitted on [DATE] and readmitted on [DATE], with diagnoses including urinary tract infection (UTI). On 09/24/2024 at 8:38 AM, R96 laid awake in bed with breakfast tray in front. Two intravenous (IV) ports were observed dangling from underneath the resident's right arm with sleeve covering the insertion site. On 09/24/2024 at 10:28 AM, the Licensed Practical Nurse (LPN) pulled up R96's right sleeve and removed a beige kerlix wrapped around R96's right upper arm which revealed a transparent dressing labeled 08/29/2024 PICC, a gauze pad covered the insertion site. The LPN explained PICC line dressing changes were performed weekly and as needed but there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure physician orders were obtained for the use of Oxygen (O2) and monitoring of O2 saturation for 1 of 35 sampled residents (Resident 155), and for the use of a CPAP machine (a device used to treat sleep-related breathing disorders, such as sleep apnea, by keeping the airways open during sleep) for 1 of 35 sampled residents (Resident 64). This deficient practice could have led to potential adverse health outcomes, including inadequate oxygenation and compromised respiratory management. Resident 155 (R155) R155 was admitted on [DATE], with diagnoses including pneumonia, respiratory tuberculosis, acute and chronic respiratory and dependence of supplemental O2. The Observation Report dated 08/28/2024, documented R155 had O2 flowing via nasal cannula and had experienced shortness of breath. On 09/24/2024 at 3:30 PM, R155 was in bed, breathing through the mouth. O2 was flowing at 5 liters per minute (LPM) via nasal cannula,…

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 ensure annual performance appraisals were completed for 4 out of 10 sampled employees (Employees 6, 7, 9 and 10). The deficient practice placed the residents at risk for receiving substandard quality of care from certified nursing assistants (CNAs). Findings include: The Personnel Records Checklist dated 09/26/2024 revealed the following: -Employee 6 was hired as a CNA on 06/23/2022. A review of the employee's file revealed there was no annual performance evaluation completed for Employee 6 for Year 2023 and Year 2024. -Employee 7 was hired as a CNA on 07/07/2022. A review of the employee's file revealed there was no annual performance evaluation completed for Employee 7 for Year 2023 and Year 2024. - Employee 9 was hired as a CNA on 08/19/2021. A review of the employee's file revealed there was no annual performance evaluation completed for Employee 9 for Year 2022, Year 2023 and Year 2024. -Employee 10 was hired as a CNA on 11/04/2021. A review of the employee's file revealed there was no annual…

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, document review and interview, the facility failed to ensure stored foods were labeled and dated, food items were discarded prior to the expiration date, nourishment refrigerators were keeping the proper temperature, and safe food handling was occurring during meal service. This deficient practice posed a potential risk to safety and health standards which could lead to contamination, inadequate storage, and place residents at risk of foodborne illness. Findings include: On 09/24/2024 in the morning, round scrambled egg patties were open in the walk-in cooler. These egg patties were not labeled or dated as to when the box was opened. The Food Service Manager explained the open boxed items should have been dated as to when the box was opened and then placed back in the freezer. On 09/24/2024 in the morning, one open corn muffin mix, and one unopened corn muffin mix, were being stored in the dry storage area had expired in 06/24. The Food Service Manager verified the items in the dry storage area should have been thrown away one year from the manufacturers date.…

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

Based on observation, interview and document review, the facility failed to ensure a dining room was not overcrowded with residents and staff members for 1 of 4 dining rooms. The deficiency practice placed the residents and staff in uncomfortable environment and at risk for accidents. Findings included: On 06/14/23 at 12:01 PM, a total of 27 residents, most of them with wheelchairs and walkers and nine employees were observed in the unit 1 dining room for the noon meal. Due to the room size, staff were observed having difficulty moving between tables to assist the residents and serve the meal. The dining room did not have a sign indicating the actual occupancy capacity. On 06/14/2023 at 12:15 PM, a Certified Nursing Assistant (CNA) was assisting two residents with their meals standing in between the residents. At the next table, another CNA assisted a resident with the meal also in standing position. On 06/14/2023 at 12:30 PM, a CNA moved a resident twice from the table while eating their meal to gain access to the beverage cart that was behind the resident. The CNA apologized to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review the facility failed to ensure an assessment was completed for the self-administration of medication for 2 of 35 sampled residents (R417 and R69). The deficient practice had the potential to have adverse medication side effects detrimental to the safety of the residents of the facility. Findings include: Resident #417 (R417) R417 was admitted on [DATE] with diagnoses including vascular dementia, and post-traumatic stress disorder. On 06/16/23 at 11:11 AM, during medication pass observation the Licensed Practical Nurse (LPN) indicated R417 would keep the Advair medication in their room for self-administration. The LPN verbalized they were not aware of the resident having been previously assessed to be able to self-administer medications and was not familiar with any facility policy regarding self-administration of medications. On 06/16/23 at 11:12 AM, R417 verbalized they prefer to keep the medication in room and self-administer. R417 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review the facility failed to ensure a comprehensive care plan was completed on splint application for the management of contractures for one of 35 sampled residents (Resident #81). The failure of the development of a resident centered care plan inhibited consistent care of the resident throughout the different care disciplines. Findings include: Resident #81 (R81) R81 was admitted on [DATE] with diagnoses including cerebral infarction and age-related physical debility. On 06/14/2023 at 1:25 PM, the resident was observed sleeping in bed with no hand splint. A posting on the resident's wall indicated R81 was supposed to have a right-hand splint applied. On 06/15/2023 at 1:07 PM, R81 was awake and conversive. The resident indicated the right hand splint was not being applied on daily basis. R81's physician's orders dated 02/16/2023, documented CNA to don and doff right resting hand splint after 1-5 hours of wear as tolerated. Once every morning. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident 134 (R134) R134 was admitted on [DATE], with medical diagnoses to include a history of falling and diabetes mellitus type II. On 06/14/2023 at 09:29 AM, R134 complained their knee was not working correctly and requested to be seen by a physician. On 06/14/2023 at 10:04 AM, Licensed Practical Nurse 1 (LPN1) was informed R134 requested to be seen by a physician for their knee. LPN1 advised this was the first time hearing of any knee/leg concern for R134 and would follow up on the matter. On 6/16/2023 at 11:16 AM, Licensed Practical Nurse 2 (LPN2) verbalized were not aware of any recent complaints regarding R134 knee/leg. LPN2 reviewed electronic medical records and confirmed R134 had a right knee x-ray completed on 05/31/2023, with no findings, and there was documentation that a physician was recently paged for R134's knee but contact was pending. If LPN2 was waiting for a response from a physician and did not get in contact, LPN2 would follow up with the physician in two hours. As LPN2 could not confirm…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure application and documentation of a splint application for two of 35 sampled residents (Resident #81 and #39). The failure of application of splints could increase resident's contractures leading to decrease mobility and increase of pain during movements. Findings include: Resident #39 (R39) R39 was admitted on [DATE] with diagnoses including Parkinson's Disease and non-traumatic intracranial hemorrhage. On 06/14/2023 at 3:40 PM, R39 was observed with a left hand contracture. There was no hand splint noted within the close vicinity of resident. R39 physician's order dated 02/01/2023, documented certified nurse assistants (CNA) will don/doff the left-hand roll splint to the patient for 7X/week for 3 to 4 hours. Special Instructions: CNA will apply the left resting hand splint to the patient for 7X/week for 3 to 4 hours. Once every morning at 6:00 AM. R39's comprehensive care plan with a start date of 11/08/2017, last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to follow physician orders for peripherally inserted central catheter (PICC) dressing changes and flushes, for 1 of 35 sampled residents (Resident #217) and failed to obtain orders for PICC line care that included flushing, dressing changes and monitoring for signs of infection or complications, for 1 of 35 sampled residents (Resident #40). This deficient practice placed the residents at risk of complications including but not limited to catheter dislodgement, insertion site infection, phlebitis, and blood infection. Findings included: Resident #217 (R217) R217 was admitted on [DATE], with diagnoses including acute infection of a stage 4 decubitus ulcer, sepsis resolved and status post urinary tract infection. On 06/14/2023 at 9:00 AM, a PICC line was observed in R217's right upper arm. The PICC line insertion site was covered with a transparent dressing dated 06/04/2023. A nursing progress note dated 06/07/2023, revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure a physician order for Lidocaine patch pain medication was clarified, and the manufacturer's instructions for administration were followed as directed for 1 of 35 sampled residents (Resident 167). This deficient practice could potentially lead to inadequate pain management, compromised therapeutic outcomes, increased discomfort, adverse reactions, undermine the overall effectiveness of the medication, hinder the resident's recovery process, and affect physical and psychosocial health. Findings include: Resident 167 (R167) R167 was admitted on [DATE], with diagnoses including cellulitis of the right lower limb, osteomyelitis of the right tibia and fibula, joint replacement therapy, the presence of the right artificial knee joint and pain in the right lower leg. A Physician order dated 06/13/2023, documented Lidoderm 5 percent (%) patch to be applied in affected areas in the morning for osteoarthritis of the knee. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failure to ensure hemodialysis access catheter was assessed for patency for 1 of 35 sampled residents (R135). The deficient practice placed the resident at risk of complications of the AV fistula such as stenosis (abnormal narrowing of a blood vessel) that could cause problems with the quality of the hemodialysis treatment, persistent bleeding following punction and pain. Resident #135 (R135) R135 was admitted on [DATE], with diagnoses including end stage renal disease. On 06/15/2023 at 8:13 AM, it was observed R135 had a failed arteriovenous (AV) fistula ( a connection created between an artery and a vein used as access to perform hemodialysis) at the left upper arm. On the right upper arm, R135 had an AV access and still had a pressure gauze from dialysis center from the previous day Wednesday (06/14/2023). The resident stated some nurses checked the access, but it was not consistent. A care plan dated 12/09/2022, 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, record review, and document review, the facility failed to ensure the Nicotine patch was timely delivered and available as ordered following the resident's admission for 1 of 35 sampled residents (Resident 167). This deficient practice could potentially lead to negative health outcomes, hinder smoking cessation efforts, compromise overall well-being and quality of life, increase nicotine cravings, exacerbate withdrawal symptoms, impede the resident's progress towards a smoke-free lifestyle and adversely affect their physical health. Findings include: Resident 167 (R167) R167 was admitted on [DATE], with diagnoses including acute kidney failure, anemia, cellulitis of the right lower limb, joint replacement therapy and pain in the right lower leg. The Brief Interview of Mental Status dated 06/16/2023, documented a score of 15/15, which indicated R167's cognitive status was intact. On 06/15/2023 at 11:16 AM, R167 was in bed, verbally alert and oriented times four. R167 indicated 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, and document review, the facility failed to ensure (1) an open med cart was not left unattended for 1 of 6 med carts, (2) medication was not left at bedside (R69 and R127), and (3) monitoring of temperature for medication refrigerator and room was completed, and medical supplies for residents were properly disposed. Findings include: 1) On [DATE] at 8:50 AM, a medication cart parked in between rooms [ROOM NUMBERS] was observed with an open lock. The nurse was nowhere in the vicinity of the opened medication cart. At 8:58 AM, a non-clinical staff member was observed to pass the medication cart. At 9:08 AM, a certified nursing assistant was observed to pass the medication cart. At 9:12 AM, a licensed practical nurse (LPN) returned to the cart and confirmed the medication cart was unlocked and was unattended. The LPN indicated medications carts should always be kept locked to ensure the security of the stored medications especially narcotic medications. On [DATE] at 10:45 AM, an LPN…

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.