Royal Springs Healthcare And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure physician's order for life-sustaining treatment (POLST) was made available to emergency personnel for a hospice resident and failed to maintain hospice paperwork in the facility in accordance with the facility policy and hospice agreement for 1 of 40 sampled residents (Resident 227). The deficient practice resulted in confusion among staff and emergency personnel and placed hospice residents at risk for advanced directives not being honored at end of life.Findings include: Resident 227 (R227) was admitted on [DATE] and readmitted on [DATE], with diagnoses including malignant neoplasm of the bronchus or lung. A POLST dated [DATE], revealed R227 did not have decisional capacity and a family member elected full code or attempt resuscitation in the event of cardiopulmonary arrest.A History and Physical dated [DATE], revealed R227 returned to the facility on [DATE] following hospitalization for acute chronic hypoxic respiratory…

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 sufficient number of nursing staff were scheduled to meet the needs of the residents during the weekends of December 2024 and January through February of 2025. The deficient practice placed the residents at risk for receiving inappropriate and delayed care. Findings include: The Centers for Medicare and Medicaid Services, Payroll-Based Journal (PBJ) Staffing Data Report, dated 07/01/24 through 09/30/2024, documented the facility had excessively low weekend staffing. This was the latest report available. The Daily Staffing Plan which was provided to the surveyors documented the facility staffing needs per unit. The Licensed Nursing and CNA schedule was maintained over two separate shifts; the 6:00 AM-6:30 PM (first shift) revealed five CNAs per unit and four licensed nurses for 100 unit and three licensed nurse each for the 200 and 300 units were needed. The 6:00 PM-6:30 AM (second shift) also revealed five CNAs per unit and four licensed nurses for 100 unit and three licensed nurse each for the 200…

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 review, and document review, the facility failed to remove discontinued and expired medications and supplies from the active supply in 2 of 3 medication rooms. This deficient practice had the potential to result in medication errors, including the unintentional administration of discontinued medications, posing a risk to resident safety and well-being. Findings include: On 02/13/25 at 9:11 AM, the medication room in 200 Hall was inspected, accompanied by a Licensed Practical Nurse (LPN1). The LPN indicated the Licensed Nurse on duty was responsible for monitoring expiration dates and discontinued medications, with the Unit Manager overseeing the process. The LPN explained expired and discontinued medications should have been separated or removed from the active supply for destruction or return to the facility. The LPN confirmed the following medications had been discontinued for discharged residents, and some had expired. The LPN explained these medications had already been removed from the active supply but was unaware of the reason for being…

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 Preadmission Screening and Resident Review (PASARR) level two referrals were completed for residents with newly identified psychiatric diagnoses for 5 of 35 sampled residents (Residents 24, 119, 110, 88 and 81). The deficient practice had the potential to deprive the residents of concern of necessary behavioral health services. Findings Include: Resident #24 (R24) R24 was re-admitted on [DATE], with diagnoses including congestive heart failure, type 2 diabetes mellitus, chronic pain syndrome, and bipolar disorder. A PASARR level one document dated 10/19/2018, revealed R24 did not have dementia, mental illness (MI), intellectual disability (ID), mental retardation (MR), or any related condition (RC) and was deemed appropriate for nursing facility (NF) placement. A review of the resident's medical notes revealed R24's bipolar disorder was diagnosed on [DATE], during an admit at an acute care hospital. A review of the recent…

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 comprehensive care plans were revised to reflect new interventions, specifically, a nutrition care plan for 2 of 35 sampled residents (Residents 110 and 84) and a care plan for functional abilities and mobility for 2 of 35 sampled residents (Residents 156 and 67). The deficient practice had the potential to deprive residents of necessary interventions to maintain overall well-being. Findings include: Nutrition Care Plan Resident 110 (R110) R110 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction. Review of R110's medical record revealed R110 had a recorded weight of 172 pounds (lbs.) on 09/29/2024 and 157 lbs. on 12/29/2024 or a significant weight loss of 8.72 percent (%) over a three-month period. A physician's order dated 01/13/2025, documented R110 would be provided 1:1 assistance with meals at slow pace. On 02/12/2025 at 7:37 AM, R110 laid awake in bed with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure restorative nursing services were provided for 2 of 35 sampled residents (Residents 156 and 67) . This failure had the potential to result in increased pain, worsening contractures, reduced mobility, and a decline in the resident's overall quality of life. Findings include: Resident 156 (R156) R156 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left dominant side. On 02/11/2025 at 10:04 AM, R156 was awake and alert in bed. R156 expressed having issues with not receiving restorative nursing services because the facility only had one restorative nurse aide (RNA). R156 indicated receiving physical therapy (PT) and occupational therapy (OT) services on admission but when insurance stopped covering the PT/OT services, the resident was placed on RNA services which used to be provided three times a week. R156 indicated two RNAs quit in October 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, record review and document review, the facility failed to ensure feeding assistance was provided timely for residents with orders for one-on-one (1:1) feeding assistance with meals for 2 of 35 sampled residents (Residents 110 and 84). The deficient practice potentially contributed to the residents' significant weight loss. Findings include: Resident 110 (R110) R110 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction. Review of R110's medical record revealed R110 had a recorded weight of 172 pounds (lbs.) on 09/29/2024 and 157 lbs. on 12/29/2024 or a significant weight loss of 8.72 percent (%) over a three-month period. A physician's order dated 01/13/2025, documented R110 would be provided 1:1 assistance with meals at slow pace. On 02/12/2025 at 7:37 AM, R110 laid awake in bed with television on. A breakfast tray was observed on the bedside table which included scrambled eggs with melted cheese, pureed bread, a carton 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 Based on observation, interview, record review, and document review, the facility failed to ensure the enteral feeding was completely delivered as ordered or the duration of the order was clarified for 1 of 35 sampled residents (Resident 105), and the head of the bed was elevated during enteral infusion for 1 of 35 sampled residents (Resident 136). This failure could result in inadequate nutrition and hydration and an increased risk of aspiration pneumonia or other complications for residents. Findings include: Resident 105 (R105) R105 was admitted on [DATE], with diagnoses including bed confinement and gastrostomy. A Physician Order dated 09/16/2024 documented to infuse Jevity 1.2 tube feeding formula, volume: 1400 milliliters (ml), calories: 1680, rate: 70 ml per hour. A Care Plan dated 06/06/2022, documented R105 required tube feeding (TF) related to Pelizaeus-Merzbacher disease (a rare genetic condition that causes movement and coordination problems due to faulty nerve protection). The goal was to maintain…

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's order for Oxygen (O2) use and care orders were obtained and implemented, and Oxygen saturation was monitored for 1 of 35 sampled residents (Resident 68). This deficient practice had the potential to result in improper Oxygen administration, delays in necessary treatment, and potential harm to the resident's health and well-being. Findings include: Resident 68 (R68) R68 was admitted on [DATE], with diagnoses including shortness of breath and pulmonary disease. On 02/11/2025 at 8:51 AM, R68 was lying in bed with eyes closed. O2 was flowing at 2 liters per minute (LPM) via nasal cannula connected to the wall O2, and the humidifier bottle was undated and empty. No signs or symptoms of respiratory distress were noted. On 02/12/2025 at 10:25 AM, R68 was lying in bed, awake, and verbally responsive. O2 was flowing at 2 LPM via nasal cannula, and the humidifier bottle remained undated and empty. R68 indicated…

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's order for dialysis was transcribed, the dialysis access was monitored, and vital signs were obtained and documented pre- and post- dialysis for 1 of 35 sampled residents (Resident 166). This deficient practice could have the potential to increase the risk of bleeding, infection, hypotension, and inadequate dialysis, compromising the resident's health and safety. Findings include: Resident 166 (R166) R166 was admitted on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease and dependence on renal dialysis. The Quarterly Minimum Data Set, dated [DATE], documented the brief interview of mental status for R166 with a score of 15/15, indicating cognitive status was intact and dialysis had been provided. On 02/11/2025 at 9:17 AM, R166 was verbally alert and oriented, seated in the wheelchair, with a dialysis port in place on the right chest. R166 indicated receiving dialysis…

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 updated to reflect accurate and current staffing needs of the facility and residents, and all required FA components were accurately documented. This deficient practice has the potential to deprive the residents of needed care. Findings include: The FA, updated 01/02/2025, lacked the following documentation: - The care required by the resident population, using evidence-based, data-driven methods which consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, or overall acuity - Services provided, such as physical therapy, pharmacy, behavioral health, and specific rehabilitation therapies - A facility-based and community-based risk assessment, utilizing an all-hazards approach - Active involvement of Nursing home leadership and management in the Facility Assessment process -Information on the staffing levels needed for specific shifts, such as day, evening, and night and adjusted as necessary based on changes to resident population On…

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

Based on interview and document review, the facility failed to ensure the Quality Assurance Performance Improvement Plan (QAPI) program 1) followed through on the facility's performance improvement project (PIP) for staffing shortage, 2) conducted a root cause analysis on the facility's high staff turnover rate, and 3) maintained oversight over low weekend staffing patterns. The deficient practice had the potential to negatively impact the quality of care provided to residents. Findings include: Staffing Shortage PIP The facility's QAPI plan reviewed January 2024, documented performance improvement projects were a concentrated effort towards a particular problem which may be on one area of the facility or facility wide. The PIP involved gathering information systematically to clarify issues, or problems and intervening to make improvements. The facility conducted PIPs to examine and improve care and services in areas which the facility has identified as needing attention. A PIP titled Staffing Shortage initiated on 12/31/2021, documented a root cause of pay rate and benefits. 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 observation, document review, and interview, the facility failed to prevent the following in a nourishment room: a staff member from consuming a drink, a trash can overflowed onto the floor, cubed ice placed inside a handwashing sink, and loose cubed iced on the bottom and around the food in a freezer. The failed practice had the potential to cause the spread of bacteria in the nourishment room. Findings include: On 02/11/2025 at 8:30 AM, in the 300 hall nourishment room, a staff member was observed sitting on a chair next to the handwashing sink and drank from a small cup filled with liquid, a clear bag with a knot tied on top filled with cubed ice was inside the handwashing sink, the trash can overflowed onto the floor, and loose cubed ice was covering the bottom of the freezer and around food products. On 02/11/2025 at 8:30 AM, the Food Service Director asked the staff member to exit the room, removed the chair, and advised the staff member they were not to drink in the nourishment room. The Food Service Director explained did not know why bagged ice was placed 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, record review, and document review, the facility failed to ensure a resident was treated with dignity and respect by facility staff not assisting with resident hygiene for 1 of 4 sampled residents. This had the potential to cause psychosocial distress to the resident. Findings include: Resident #2 (R2) R2 was admitted to the facility on [DATE], with diagnoses including traumatic hemorrhage of the cerebrum, type 2 diabetes mellitus, chronic obstructive pulmonary disease, muscle wasting and atrophy, and dysphagia. R2 was observed in bed wearing a clean medical gown with the covers pulled up to the chest. The resident was not shaven and had a beard covering the face. There was no wheelchair or assistive device on the resident's side of the room. On 10/23/2024 at 10:20 AM, R2 verbalized was admitted into the facility with very few clothes and the clothes which did come with the resident were too hot to wear so prefers to wear the gowns the facility provides. The resident 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 observation, interview, and document review, the facility failed to discard an expired food item and ensure 1 of 3 nourishment refrigerator temperatures were maintained. The deficient practice had the potential to place the residents at risk for a foodborne illness. Findings include: On 03/12/2024 at 7:44 AM, an initial kitchen tour was conducted with the Dietary Director. On 03/12/2024 at 8:01 AM, the walk-in refrigerator had 10 cartons of thickened dairy beverage with a best before date of 02/07/2024. The Dietary Director acknowledged the food item and best before date. On 03/12/2024 at 8:30 AM, the Dietary Director indicated there were three nourishment refrigerators in the facility. The 100-hall nourishment refrigerator internal thermometer read 49 degrees Fahrenheit and contained 24 individual servings of milk cartons. One milk carton was temped at 49.3 degrees Fahrenheit. The Dietary Director was present and acknowledged the temperature of the refrigerator and milk were out of range. On 03/13/2024 at 2:47 PM, the Dietary Director verbalized the Assistant Dietary…

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 observations, interview, and document review, the facility failed to ensure preventative maintenance (PM - the regular inspection, cleaning, and servicing of medical equipment to ensure they are in good condition and can perform their intended function correctly) was completed for medical equipment (Oxygen concentrators, nebulizer machines and enteral feeding pumps) utilized in the facility. The deficient practice had a potential for unmaintained, inefficient, and unsafe medical equipment used for resident care. Findings include: On 03/12/2024 at 1:07 PM, observed at the bedside table of room [ROOM NUMBER]-B was a nebulizer machine. The PM sticker documented, Last PM 04/2022, Next PM 04/2023. On 03/12/2024 at 1:25 PM, observed at the bedside table of room [ROOM NUMBER]-A was a nebulizer machine. The PM sticker documented, Last PM 04/2022, Next PM 04/2023. Next to the bed was an Oxygen concentrator machine. The PM sticker documented, Last PM 02/2022, Next PM 02/2023. 03/14/2024 at 8:38 AM, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and document review the facility failed to ensure an advance directive acknowledgement was obtained for 2 of 35 residents (Residents 82, and 106)), and information was provided in a language the resident understands for 1 of 35 residents (Resident 276). The deficient practice had the potential to deny the resident of emergency medical treatment, the right to request, deny, or discontinue treatment. Findings include: Resident 82 (R82) R82 was admitted on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia and depression. The facility policy titled Advance Directives (revised 2016), documented upon admission the resident would be provided written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive. If the resident was unable to receive information about the right to formulate an advance directive the information would be provided to the legal representative. On 03/13/2024 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 interview record and document review, the facility failed to ensure beneficiary discharge notifications were followed per Medicare delivery of notices guidelines and issuance of advance beneficiary notices for residents who decided to remain at the facility after skilled services were terminated for 3 unsampled residents (Resident 216, 217 and 215). The deficient practice had a potential for a resident/resident representative to not be properly informed of the termination of Medicare coverage and the potential financial costs of services if to remain at the facility. Findings include: Resident 216 (R216) was admitted on [DATE]. R216 was issued a Notice of Medicare Non-Coverage (NOMNC) with a Last Cover Date (LCD) of 12/22/2023. R215's NOMNC notification notes documented the public guardian was notified via telephone calls and voice mails were left. There were three documented attempts: 12/20/2023 at 10:30 AM, 12/21/2023 at 10:47 AM, and on 12/22/2023 at 11:00 AM. The medical record lacked 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 and document review, the facility failed to ensure comprehensive care plans were revised for the management of edema (swelling) with the corresponding diagnosis for 1 of 35 sampled residents (resident 188). The deficient practice had a potential for staff not to provide personalized care for a resident. Findings include: Resident 188 (R188) R188 was admitted on [DATE], with diagnoses including venous insufficiency and fluid overload. On 03/12/24 on 12:56 PM, R188 indicated going for consultation visits to the cardiologist and having procedures to address the edema on the lower extremities. Observed R188 had left lower leg edema. R188's medical records revealed a cardiology consult dated 01/23/2024, documented Diagnosis: venous insufficiency. Findings: Successful vein ablation. Recommendations: The patient to return in one week. R188's medical records revealed cardiology consult dated 02/28/2024, documented diagnosis: Venous insufficiency and edema. Recommendations: 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 observations, interviews, record reviews, and document reviews, the facility failed to ensure the following: 1) The consultation recommendation was followed for 1 of 35 sampled residents (Resident 188). 2) The coagulation laboratory test order was transcribed and completed prior to percutaneous endoscopic gastrostomy (PEG) (a flexible feeding tube inserted through the abdominal wall into the stomach, allowing direct delivery of nutrition, fluids, and medications) tube removal as ordered for 1 of 35 sampled residents (Resident 99), and 3) The medications were given within the prescribed time for 2 of 35 sampled residents (Residents 117 and 182). The deficient practices could have led to complications such as bleeding or clotting, ineffective treatment, a lack of necessary care, and compromised health and safety of the residents. Findings include: 1) Resident 188 (R188) R188 was admitted on [DATE], with diagnoses including venous insufficiency and fluid overload. On 03/12/24 at 12:56 PM, R188 indicated…

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 review and document review, the facility failed to ensure hand rolls were applied as recommended for 1 of 35 sampled residents (Resident 70). The deficient practice had a potential for resident to develop further contractures of an extremity/joint. Finding include: Resident 70 (R70) R70 had an initial admission date of 08/08/2016, with diagnoses including traumatic brain injury with chronic respiratory failure and persistent vegetative state. On 03/12/2024 at 10:31 AM, R70 was observed with right hand and wrist contracture. No splint was applied. No splint was seen in the close vicinity or at the bedside stand. R70's Physician's order documented on the Special Instructions: Patient to have right hand towel roll and left hand towel roll, 6 to 8 hours per day, clean and dry hands - 6 days per week. R70's treatment administration record (TAR) or Medication Administration records (MAR) does not reflect the resident's special instructions. On 03/13/2024 at 2:29 PM, R70 was observed with no towel rolls in the hands. On 03/14/2024 at 10:40 AM, R70…

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 Neuro checks were completed and care plan updated following a resident's unwitnessed fall, for 1 of 35 Residents (Resident 138). The deficient practices had the potential to significantly increase the risk of injury from falls. Findings include: Resident 138 (R138) R138 was admitted on [DATE], with diagnoses including dementia, hypotension, and altered mental status. R138's Annual History and Physical dated 10/10/2023, documented R138 was noted to be confused with a past history of Alzheimer's dementia and altered mental status. R138 remained in the facility for long-term care, and the plan included fall precaution. The Clinical admission dated 10/28/2021, documented R138 was confused. The Quarterly Brief Interview of Mental Status dated 01/30/2024, documented a score of 3/15, which indicated R138's cognitive status was severely impaired. The Minimum Data Set, dated [DATE], documented R138's functional status with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure the suprapubic size 16 French urinary catheter was inserted or the order was clarified for 1 of 35 sampled residents (Resident 152). The deficient practice could have the potential to have caused trauma, severe discomfort, urinary complications, injury, or harm. Findings include: Resident 152 (R152) R152 was admitted on [DATE] and readmitted on [DATE], with diagnoses including acute pyelonephritis, acute kidney failure and neuromuscular dysfunction of bladder. The Clinical admission Evaluation dated 05/16/2023, documented R152 was admitted with suprapubic catheter and the catheter size was not mentioned or documented. The Internal Medicine Progress Note dated 08/26/2023, documented R152 had suprapubic catheter for neurogenic bladder with a plan to continue suprapubic catheter care. A Physician order dated 08/22/2023, dated suprapubic catheter size 16 x (times) 30 milliliters (ml) water balloon for neurogenic…

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 resident's percutaneous endoscopic gastrostomy (PEG) (a flexible feeding tube inserted through the abdominal wall into the stomach, allowing direct delivery of nutrition, fluids, and medications) tube was monitored post removal, cleansed, and the dressing changed, and 2) The pre- and post-PEG tube removal orders were transcribed as ordered, nothing by mouth status and clear liquid diet were implemented as ordered for 1 of 35 sampled residents (Resident 99). The deficient practices could have the potential to result in significant harm or complications, such as infection, improper care, missed necessary treatments, or other adverse outcomes. Findings include: Resident 99 (R99) R99 was admitted on [DATE] and readmitted on [DATE], with diagnoses including dysphagia (difficulty swallowing) and gastrostomy status. 1) On 03/12/2024 at 12:15 PM, a Certified Nursing Assistant (CNA) was provided with the lunch tray…

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 review and document review, the facility failed to ensure medication timed with meals was administered and documented as coded in the medication administration record (MAR) for 1 of 35 sampled residents (Resident 16). The deficient practice had a potential for a resident to miss out on a medication and to properly document missed doses of a medication. Findings include: Resident 16 (R16) R16 had an initial admission date of 12/11/2019, with diagnoses of end stage renal disease and dependence with renal dialysis. On 03/12/2024 at 9:45 AM, R16 indicated had not yet received morning medications. R16 indicated at times nurses would bring the resident's phosphate binders (medication used to decrease the absorption of phosphate from food in the digestive tract) after mealtime. R16 indicated when nurses bring phosphate binder medication after mealtime, the resident had no choice but to refuse the medication due to it serves no more purpose. R16 confirmed eating breakfast more than an hour ago and still has not yet received morning phosphate binders.…

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 valid consent for the use of psychotropic medications was obtained for 1 of 35 sampled residents (Resident 57). The deficient practice had the potential for a resident/resident representative not being properly informed of the risk and benefits of a prescribed psychotropic medication. Findings include: Resident 57 (R57) R57 was admitted on [DATE] with diagnosis including unspecified psychosis, unspecified dementia, major depressive disorder, and generalized anxiety disorder. A Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) was not conducted as R57 was rarely/never understood, had short and long term memory problems, and had severely impaired cognitive skills for daily decision making. A physician order dated 11/28/2022 documented Zoloft tablet 50 milligrams (MG). Give three tablets totaling 150 MG by mouth one time a day for depression, sad facial expressions. A physician…

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 observations, interviews, record reviews, and document reviews, the facility failed to ensure their medication error rate was below five (5) percent (%) when two errors were identified with 27 opportunities observed, calculating an error rate of 7.41 %. Failure to follow physician orders and timely administer medications posed a potential risk of injury or harm to the resident. Findings include: 1) Resident 117 (R117) R117 was admitted on [DATE] and readmitted on [DATE], with diagnoses including asthma and malignant neoplasm of skin. A Physician order dated 02/20/2024, documented Cetirizine extended release (ER) tablet 120 milligrams (mg) to be administered daily at 7:00 AM. On 03/14/2024 at 7:42 AM, during medication pass observation, a Registered Nurse 1 (RN1) prepared R117's medications except Cetirizine 120 mg. RN1 indicated the Cetirizine was not administered due to unavailability. The Medication Administration (MAR) History dated 03/14/2024, documented the Cetirizine was not administered due 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 interview, record review, and document review, the facility failed to ensure blood thinner or anticoagulant medication had been held before percutaneous endoscopic gastrostomy (PEG) (a flexible feeding tube inserted through the abdominal wall into the stomach, allowing direct delivery of nutrition, fluids, and medications) tube removal as ordered for 1 of 35 sampled residents (Resident 99). The deficient practice could have the potential to cause serious bleeding complications. Findings include: Resident 99 (R99) R99 was admitted on [DATE] and readmitted on [DATE], with diagnoses including dysphagia (difficulty swallowing) and gastrostomy status. A Skin/Wound Care Progress Note, dated 03/07/2024, documented the wound care team, nurse practitioner, and wound physician at bedside for the removal of R99's PEG tube. The administration of blood thinners to R99 was held before removal and could be resumed after the procedure, as ordered. R99's medical record lacked documented evidence the physician's order 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.