Life Care Center Of South Las Vegas

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure weekly weights were obtained in accordance with physician's order for 1 of 24 sampled residents (Resident 3). The failure potentially delayed identification of a significant weight change, nutritional re-assessment by a Registered Dietitian (RD) and appropriate interventions by the inter-disciplinary team (IDT). Findings include: Resident 3 (R3). R3 was admitted on [DATE] with diagnoses including protein-calorie malnutrition and difficulty swallowing. The medical record revealed the following weights documented for R3: - on 05/20/2025 111 lbs. (pounds) - on 06/09/2025 95 lbs. Accounting for a 14.1% weight loss from 5/20/2025 to 06/09/2025. The medical record lacked documented evidence of any further weights obtained. A physician order dated 05/19/2025 documented to obtain weekly weights for one month and then monthly weights. On 06/12/2025 at 11:42 AM, a Certified Nursing Assistant (CNA) explained the CNAs on the unit were only…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to: 1) follow a physician order for intravenous (IV) site care and 2) obtain a physician order for the use or removal of IV access for 2 of 24 sampled residents (Residents 9 and 261). This deficient practice had the potential to result in infection, phlebitis, infiltration, and compromised venous access. Findings include: 1) Follow Physician order Resident #9 (R9) R9 was admitted on [DATE] with diagnoses including cellulitis of the left and right lower limb. On 06/10/25 at 9:13 AM, R9 was observed lying in bed, alert and oriented, with a midline IV access site located in the right inner bicep. The dressing was dated 05/21/25. A physician order dated 05/21/25 documented the following: - IV: Midline Catheter - Change needleless connector every day shift every 7 days. - IV: Midline Catheter - Change transparent dressing every day shift every 7 days. Change catheter securement device with dressing change. Measure external…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review the facility failed to ensure it was free of a medication error rate of less than five percent (%) for four residents (Resident 88, 29, 361, and 94). The deficient practice posed a potential risk of injury or harm to the resident. Findings include: On 06/12/2025 in the morning, a Medication Administration Pass observation was performed with 30 opportunities observed and revealed five errors. The medication error rate was 16.67%. Resident 88 (R88) R88 was admitted on [DATE] with diagnoses including malignant neoplasm of kidney, acute renal failure, and iron deficiency. On 06/12/2025 at 7:28 AM, during the Medication Administration Pass observation, a Registered Nurse (RN) prepared and administered the following medications for R88: - Carvedilol 25 milligram (mg) one tablet by mouth - Levetiracetam 500 mg one tablet by mouth - Ferosul 325 mg one tablet by mouth - Losartan 100 mg one tablet by mouth A physician order dated 05/05/2025 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.

Based on observation, interview and document review, the facility failed to dispose expired medications. This deficient practice has the potential to cause adverse reactions or worsened health conditions to residents. Findings include: On 06/13/2025 at 9:28 AM, the medication refrigerator contained five expired Covid-19 vaccines, 0.5 milliliter (mL) single dose pre-filled injectable syringes dated 06/08/2025. On 06/13/2025 at 9:35 AM, the medication cabinet contained five expired 3000 milliliter (mL) normal saline irrigation bags for a discharged resident dated 03/08/2025. On 06/13/2025 at 9:40 AM, the Unit Manager verified the medications were expired and should have been disposed. 06/13/2025 at 9:49 AM, facility policy titled destruction of medication dated 03/04/2025, documented the facility will destroy discontinued or outdated medications in accordance with federal, state, local laws and regulations for pharmaceutical waste disposal.

Based on observation, interview and document review, the facility failed to ensure medications were secured in 1 of 2 central supply rooms. The deficient practice had the potential risk of unauthorized access to medications, theft, or misuse of medication within the facility. Findings include: On 01/22/2025 at 10:28 AM, the central supply room, across from the nurse's station, on the 100-hall had the door propped open with a silver dumbbell weight. The central supply room contained a variety of items such as: medication and wound care dressings. There were two medication carts located on the right side as you enter the room. A brown medication cart was located under a wall mounted cabinet. The medication cart was unlocked with keys hanging out of the cart lock. The top drawer of the brown medication cart contained the following: - Vitamin C (nutritional supplement): five bottles. - Vitamin B12 (nutritional supplement): two bottles. - Coenzyme Q10 (nutritional supplement): three bottles. - Floranex (probiotic): seven bottles. The second drawer contained the following: - Benadryl…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to complete a nutritional assessment including food preferences within 72-hours of admission per facility policy for 1 of 2 sampled residents (Resident 2). The failure to honor resident food preferences could potentially cause residents to lose interest in eating their meals. Findings include: Resident 2 Resident 2 was admitted on [DATE] and discharged on 12/10/2024, with diagnoses including lupus and mild kidney injury. Review of the resident's medical record revealed a nutrtional assessment and food preferences were not documented. A physician's order dated 12/05/2024, documented a regular diet, regular texture, thin liquid consistency. On 01/22/2025 at 2:55 PM, the Dietary Director verbalized a dietary staff member would meet with a newly admitted resident within 24 hours to obtain the resident's food preferences. The information obtained about food preferences would be documented in the resident's medical record. On 01/22/2025 at 3:30…

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 a safe discharge was planned and occurred for 2 of 2 unsampled residents (R214 and R219). This deficient practice had the potential for residents to be placed in an improper home setting and not receive the required care. Findings include: Resident 214 (R214) R214 was admitted to the facility on [DATE], with a diagnosis including heart failure, unspecified dementia, mood disturbances, Type 2 diabetes, muscle weakness and difficulty walking. At the bottom of the Face Sheet under Miscellaneous Information, it was documented the resident was discharged to a private home/apt with home health services on 01/09/2024. A Discharge summary dated [DATE], documented the resident was discharged to Home and Other. The Summary detailed the group home address, transportation company, and reason for discharge which noted cleared for discharge. The summary further included the Home Health company name; telephone number listed along with…

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

Based on observation, interview, record and document review, the facility failed to ensure comprehensive care plans were implemented for the management of falls for 1 of 24 sampled residents (Resident 50). The deficient practice had the potential for staff not to provide personalized care for the resident. Findings include: Resident 50 (R50) R50 was a long-term resident at the facility, with diagnoses including cholecystectomy and dementia. R50's medical records revealed a fall at the facility on 03/10/2024 at 1:15 PM. R50's comprehensive care plan revised on 03/10/2024, addressed the resident's fall and goals and interventions. The comprehensive care plan lacked implementation to monitor and care for the resident fall management. R50's medical records revealed a physical therapy consultation was suggested in the care plan on 03/10/2024, to consult for strength and mobility. On 08/08/2024 at 1:10 PM, the director of rehabilitation (DOR) explained during the Clinical Inter Disciplinary Team (IDT) meeting, if it is suggested for a therapy screening, the screen request gets put into…

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 scheduled showers were provided to dependent residents for 1 of 24 sampled residents (Resident 246) and 2 unsampled residents (Residents 215 and 213). This deficient practice could potentially compromise resident hygiene and comfort, and increase the risk of skin breakdown and infections. Findings include: A facility policy titled Activities of Daily Living dated 02/12/2024, indicated residents would receive assistance as needed to complete activities of daily living (ADLs), including bathing. Any change in the ability to perform ADLs would be reported to the nurse. Resident 246 (R246) R246 was admitted on [DATE], with diagnoses including dementia, difficulty in walking, and muscle weakness. A Care Plan dated 07/24/2024, documented a self-care performance deficit for R246 related to dementia and disease process. Interventions included substantial assistance from one person. A Care Plan dated 07/25/2024, 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, interviews, record review, and document review, the facility failed to ensure a resident with a urinary catheter had appropriate diagnosis and a bladder training program was implemented for 1 of 24 sampled residents. The deficient practice had the potential for increased risk of infection. Findings include: Resident 203 (R203) R203 was admitted on [DATE] with diagnosis including benign prostatic hyperplasia (BPH) without lower urinary tract symptoms. On 08/06/2024 at 3:29 PM, R14 was sitting in room with catheter and verbalized being treated for wound on foot and was not able to explain why catheter was needed. An admission minimum data set (MDS) assessment dated [DATE], documented resident was admitted with indwelling catheter and was not participating in a bladder training program. On 08/09/2024 at 8:01 AM, the Director of Nursing (DON) indicated when resident was admitted with catheter, would ask for bladder training, urology consult. Diagnosis should be entered with the physician order…

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 ordered fluid restriction was followed for a dialysis dependent resident and the actual fluid intake or consumption was monitored for 1 of 24 sampled residents (Resident 14). The deficient practice could have the potential to result in adverse health outcomes, including fluid overload, increased blood pressure, and complications related to the resident's dialysis treatment. Findings include: Resident 14 (R14) R14 was admitted on [DATE], with diagnoses including end-stage renal disease, dependence on renal dialysis, atrial fibrillation, mitral valve insufficiency, and the presence of a cardiac pacemaker. A physician's order dated 08/01/2024, documented a fluid restriction of 1000 milliliter per day (ml/day). The distribution was as follows: 240 ml for breakfast, 240 ml for lunch, and 240 ml for dinner from Dietary; 140 ml for days and 140 ml for nights from Nursing, each shift, for managing R14's excessive fluid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to account for narcotics (opioid) signed out on the controlled drug record for one unsampled resident (R213). The deficient practice had the potential to delay a resident's pain management and increase the risk for physical and psychosocial harm. Findings include: Resident 213 (R213) R213 was admitted on [DATE] and discharged on 01/27/2024, with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left-dominant side, difficulty in walking, and muscle weakness. The physician's order dated 11/28/2023, documented Hydrocodone-Acetaminophen (a controlled substance/opioid) Oral Tablet 5-325 milligram (mg) give one tablet by mouth every four hours as needed for pain level 4-6 (moderate). On 08/07/2024 at 3:20 PM, the Assistant Director of Nursing (ADON) indicated the Controlled or Antibiotic Drug Record (narcotic log) for R213's Hydrocodone-Acetaminophen 5-325 mg for November 2023, December 20, 2023 to December…

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 a physician order to discontinue medication was completed for 1 of 24 sampled residents. The deficient practice had the potential for adverse effects on the resident and unnecessary medications. Findings include: Resident 14 (R14) R14 was admitted on [DATE] with diagnoses including end stage renal disease, dependence on renal dialysis. A pharmacist consultation report documented R14 medication regimen was reviewed on 07/23/2024 with the recommendation to discontinue the medication Spironolactone as it was contraindicated for residents on dialysis. A physician response dated 07/29/2024 documented agreement with pharmacist recommendation and indicated the medication would be discontinued on 07/29/2024. The medication administration record indicated Spironolactone was a current and active medication with the most recent dose given on 08/08/2024. On 08/08/2024 in the afternoon, a Licensed Practical Nurse (LPN) indicated R14 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, record review and document review, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater for one unsampled resident (Resident 37). Failure to administer medications as prescribed could have delayed the therapeutic treatment for the resident. Findings include: On 08/08/2024 in the morning, a Medication Administration Pass observation was performed with 27 opportunities observed and revealed two errors. The medication error rate was 7.41%. Resident 37 (R37) Resident 37 was admitted on [DATE], with diagnoses including chronic kidney disease, acute kidney failure, and polyneuropathy. On 08/08/2024 at 8:00 AM, during the Medication Administration Pass observation, a Licensed Practical Nurse (LPN) prepared and administered the following medications to R37: - Heparin 5,000 units subcutaneous (SQ/injection) - Budesonide Suspension 0.5 milligram (mg)/2 milliliter (ml) inhale orally - Cholestyramine one packet 4 grams by mouth - Famotidine 20…

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 stored foods were labeled and dated and food items were stored properly. 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 08/06/2024 at 7:46 AM, open bags of green beans, asparagus, and peppers & onion mix were stored in the walk-in freezer without a date as to when the bag was opened. The Dietary Manager explained the open bagged items should have been dated as to when the bag was opened and then placed back in the freezer. On 08/06/2024 at 8:01 AM, a bottle of lemon juice, Jello packets, and canned pimentos were missing received on dates in the dry storage area. Also, silk, a milk substitute, was stored in the reach in cooler without a lid. The Dietary Manager explained the items in the dry storage area should have been dated as to when the items were received from the [NAME]…

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 fall prevention interventions were included in the baseline care plan of a resident who was at risk for falls for 1 of 10 sampled residents (Resident 7). The deficient practice potentially contributed to an actual fall. Findings include: Resident 7 (R7) R7 was admitted [DATE], with diagnoses including displaced mid cervical fracture of right femur. On 11/14/2023 at 10:00 AM, R7 was alert and sitting on the side of a low bed. A walker and bedside commode were observed on the right side of the resident's bed. R7 recounted having a recent fall while ambulating to the toilet with walker assist. According to R7, the walker got caught on the bedside commode and the resident landed on bottom. An alert charting dated 11/06/2023, revealed R7 was admitted to the facility following a right femur fracture sustained from a fall. A fall risk assessment dated [DATE], revealed R7 had one to two falls prior to admission and was at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and document review, the facility failed to 1) document evidence at discharge of medication education, instructions, and reconciliation, 2) follow-up for durable medical equipment (DME) recommendation, and 3) lacked a physician's discharge summary for 1 of 10 sampled residents (Resident 9). The deficient practice potentially contributed to the resident's lack of knowledge regarding their medication and delayed the resident from obtaining the recommended medical equipment. Findings include: R9 was admitted on [DATE] and discharged on 07/21/23, with diagnosis including atrial fibrillation, gout, and encephalopathy. Medication Education, Instructions and Reconciliation: A physician order dated 07/21/23, documented R9 was to go home with medications on hand and was to be provided instructions on medication administration. The medical record lacked documented evidence the resident and/or family was educated, or provided instructions for medication and medication reconciliation 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, interviews, record review, and document review, the facility failed to ensure a physician order was obtained prior to evaluation and admission to hospice, and there was a process in place to ensure communication between the facility and the hospice agency for 2 of 3 hospice residents. The deficient practice had the potential to have adverse effects on the resident's well-being and continuity of care. Findings include: Resident #9 (R9) R9 was admitted on [DATE] with diagnoses including end stage renal disease, dependence of renal dialysis. Brief Interview for Mental Status (BIMS) score was 15/15 indicating R9 was cognitively intact. The facility policy titled Hospice (revised 11/23/2022) documented if the resident or responsible party chooses to receive hospice services, the attending physician must write an order referring the resident to hospice. A physician order dated 05/22/2023 documented, Admit to hospice services as of 3/18/23 to Harbor Hospice Services. On 06/06/23 at 12:27 PM, 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, medical record review, and document review, the facility failed to ensure 1 of 22 residents (R72) could safely self-administer medications. The failed practice had the potential to affect the resident's health and well-being. Findings include: Resident 72 (R72) R72 was admitted on [DATE] with medical diagnoses to include displaced comminuted fracture of shaft of left tibia (shin bone) and unspecified fracture of shaft of humerus (upper arm bone) and left arm. On 06/08/2023 at 7:30 AM, observed on R72's bedside tray table were three bottles containing: calcium, magnesium, and zinc supplement, advanced hemp gummies 900 milligrams (mg), and gummies 400 mg. R72 informed they self-administered the supplement before meals and the gummies as needed for their pain, in addition to oxycodone administered by the facility. R72 identified the gummies as a tetrahydrocannabinol (THC) (cannabis) product. Licensed Practical Nurse (LPN) (LPN1) entered the room advising this was the first time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and document review, the facility failed to ensure an incident of misappropriation of property was reported to the state agency following the occurrence per policies and regulations for 1 of 22 sampled residents (Resident 15). This deficient practice could potentially lead to psychological harm to the resident, undermine rights, compromise safety, and jeopardize their well-being. Findings include: Resident #15 (R15) R15 was admitted on [DATE], with diagnoses including osteoarthritis and anemia. On 06/06/23 at 9:53 AM, R15 indicated missing $100 dollars the resident had kept in the wallet since admission. Resident indicated informing the Assistant Director of Nursing (ADON) about the missing money but has not heard anything back. R15 claimed it had been at least 2 weeks since the occurrence. The medical record lacked documented evidence an investigation was initiated with regards to R15's missing property. Review of the Inventory of the Personal Effects Record dated 05/09/2023,…

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 interview, record review, and document review, the facility lacked documented evidence a thorough investigation of a misappropriation of property following the occurrence was completed for 1 of 22 sampled residents (Resident 15). The failed practice had the potential to create an environment where abuse or neglect could occur unchecked, affecting all residents. Findings include: Resident #15 (R15) R15 was admitted on [DATE], with diagnoses including osteoarthritis and anemia. On 06/06/23 at 9:53 AM, R15 indicated missing $100 dollars the resident had kept in the wallet since admission. Resident indicated informing the Assistant Director of Nursing (ADON) about the missing money but has not heard anything back. R15 claimed it had been at least 2 weeks since the occurrence. The medical record lacked documented evidence an investigation was initiated with regards to R15's missing property. Review of the Inventory of the Personal Effects Record dated 05/09/2023, revealed the resident had five twenty-dollar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and document review, the facility failed to ensure a baseline care plan to manage the resident's pain was formulated following admission, to provide effective and person-centered care for 1 of 22 sampled residents (Resident 230). This deficient practice could potentially result in complications, poor outcomes, and a diminished quality of life for the resident. Findings include: Resident 230 (R230) R230 was admitted on [DATE], with diagnoses including sepsis, repeated falls, pressure ulcer, cognitive communication deficit, and difficulty walking. The Nursing assessment dated [DATE], documented R230's acceptable pain level was 3/10 (with a pain scale of 1 - 10). R230 had a pressure wound on the coccyx stage 2. No history of opioid addiction or disorder. A Physician order dated 05/23/2023, documented Percocet oral tablet 5-325 milligrams (mg) to give 1 tablet by mouth every 6 hours as needed (PRN) for pain. A Physician order dated 05/26/2023, documented Acetaminophen tablet of 325…

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, medical record review, and document review, the facility failed to clarify blood pressure medication instructions for 1 of 22 residents (R380). The failed practice had the potential to affect the resident's health and well-being. Findings include: Resident 380 (R380) R380 was admitted on [DATE] with medical diagnoses to include end stage renal disease, hypertension, diabetes type II, and chronic obstructive pulmonary disease. On 06/06/23 at 10:37 AM, R380 shared had refused the second dose of blood pressure medication when a nurse offered the resident medication, advising the resident's blood pressure was 121/54. R380 indicated did not feel blood pressure reading was high. A physician's order documented: -Clonidine 0.1 mg tablet. Give one tablet by mouth three times a day for hypertension. Hold for systolic blood pressure greater than 110 or heart rate less than 90. Started on 06/05/2023. -Clonidine 0.2 milligrams (mg) tablet. Give one tablet by mouth every six hours as needed for…

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

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 low bed position, or a hazard-free environment was timely implemented for 1 of 22 sampled residents. This deficient practice could lead to an increased risk of falls and potential injuries for the resident. Findings include: Resident 86 (R86) R86 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease and a fracture of the left femur (thigh bone). The Nursing Fall Risk Evaluation dated 06/02/2023, documented R86 had a history of falls and had experienced a change in cognitive status in the last 90 days. R86 was moderately impaired with limited vision. Assistance was required for elimination, and ambulation was problematic. The resident had three or more risk factors present and was taking three or more medications, which put R86 at risk for falls. A Care Plan dated 06/05/2023, documented R86 was a fall risk with an intervention to ensure a call light was within reach and orient 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: 1) the correct size of an indwelling urinary catheter (Foley) was followed as ordered or clarified; 2) the Foley catheter assessment was completed; and 3) Foley use was care planned for 1 of 22 sampled residents. The deficient practices could lead to potential urinary tract infections (UTIs), an increased risk of catheter-associated complications, dehydration, blockage, and discomfort or pain for the resident. Findings include: Resident 86 (R86) R86 was admitted on [DATE], with diagnoses including hyperplasia (enlargement of an organ or tissue) without lower urinary tract, benign prostatic disease, and a fracture of the left femur. On 06/06/2023 at 10:23 AM, R86 was in bed, incoherent, and the family was at the bedside. The family indicated R86 was admitted to the facility with a Foley catheter from the hospital. R86's Foley, 16 French catheter was in place, anchored, and draining with 175 cubic centimeters (cc)…

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 #68 (R68) R68 was readmitted on [DATE] with diagnoses including urinary tract infection and chronic wound. On 06/06/23 at 11:56 AM, observed R68's left upper arm PICC line had no date and resident was not able to say when was the last dressing change was completed. The IV pole had three bags of 100 milliliter (ml) IV antibiotics attached to a dial-a-flow (a medical device that is used when regulating the flow of a liquid or fluid through an IV) tubing with no dates. There was a .45 normal saline (NS) one liter bag with an attached tubing with no date on the bag and tubing. Observed three partially used NS 10 ml flushes at the desk with no caps. Review of R68's physician's orders and medication administration record (MAR) revealed there was no care and maintenance orders for the left upper arm PICC line. On 06/06/23 at 11:51 AM, the wound care nurse confirmed the observation and agreed IV lines should have been dated and discarded within 24 hours. IV lines should have been dated, and NS saline should…

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 was obtained and care orders were transcribed and implemented before the administration of Oxygen (O2) for 2 of 22 sampled residents (Residents 7 and 9). The deficient practice could lead to the potential risk of administering incorrect or inappropriate oxygen levels to residents, compromising their respiratory health and overall well-being. Findings include: A facility policy titled Oxygen Administration, Safety, Storage, and Maintenance, dated revised 10/07/2022, documented Oxygen would be administered in accordance with physician orders and current standards of practice. Change O2 supplies weekly and when visibly soiled. Equipment should be dated when set up or changed out. Resident 7 (R7) R7 was admitted on [DATE], with diagnoses including pneumonia, emphysema, asthma, and acute respiratory failure with hypoxia (low levels of oxygen) and hypercapnia (high levels of carbon dioxide 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to 1) label a multi-dose vial with an open and discard date. The failure can lead to administering a nonviable medication to resident or staff member and 2) ensure supplements and recreational medications were safely stored for 1 of 22 residents (R72). The failed practice had the potential for resident to self-administer medication that could interact with facility prescribed medication. Findings include: 1) On 06/07/23 at 4:02 PM, inside the medication refrigerator of the medication room at 100 and 200 Hall, was an opened Tubersol (Tuberculin PPD) 5 Units/0.1 milliliter solution for injection, with a lot #61619, expiration date of 09/2024. The vial had no open date and discard date. A nurse confirmed the finding and acknowledged the vial should have been labeled with an open and discard date. The nurse indicated a multi-dose vial was only safe to be administered for 28 days once opened. The facility policy titled Storage and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure transmission-based precautions were correctly implemented based on medical indication for 1 of 22 sampled residents (Resident 336). The deficient practice could lead to potential breaches in infection control. Findings include: A review of the facility's policy titled Transmission- Based Precautions and Isolation Procedures last revised on 05/24/2023 revealed contact precautions were intended to prevent transmission of pathogens which were spread by direct person- to- person contact. The policy indicated enhanced barrier precautions were used when exposure to blood and body fluids was anticipated such as during device care or use of central lines, urinary catheters, feeding tubes, and tracheostomy/ ventilators. Resident #336 (R336) R336 was admitted to the facility on [DATE] with medical diagnoses including dementia. On 06/06/2023 at 9:51 AM, a sign outside of R366's room indicated the resident was on contact precautions. The Assistant Director of Nursing (ADON) was observed donning…

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.