Spanish Hills Wellness Suites

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide a clean and sanitary homelike environment by ensuring proper floor cleaning procedures were performed in 16 of 90 residents' rooms (rooms 406 to 422). The deficient practice had the potential to increase infection risk and denied the residents the right to a safe and clean homelike environment. Findings include: 1) Residents' room cleanness: On 01/07/2025 at 9:30 AM, Resident #28 (R28) verbalized concerns related to the cleanness of the resident's room. R28 indicated the room had been cleaned on a daily basis but dust and debris remained on the edges between the wall and the floor at the baseboard. On 01/07/2025 at 10:00 AM, a housekeeping staff confirmed room [ROOM NUMBER] had been cleaned. The housekeeping staff acknowledged the edges between the wall and the floor at the baseboard were not cleaned. On 01/07/2025 at 10:12 AM, the housekeeping supervisor confirmed the observation and verbalized all the surfaces of the room…

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 Preadmission Screening and Resident Review (PASARR) level two referral was completed for 1 of 24 sampled residents (Resident 69). The deficient practice had the potential to deprive the residents of concern and other residents of necessary behavioral health services. Findings include: Resident 69 (R69) R69 was re-admitted on [DATE], with diagnoses including schizoaffective disorder, anxiety disorder, depression, and post-traumatic stress disorder. On 01/07/2025 in the afternoon, R69 stated was on the Resident Council and had been at the facility for about three years. The resident related had been in a bad accident, had post-traumatic stress disorder (PTSD) from it, and also has bipolar illness. A PASARR level one document dated 08/06/2021, revealed R69 did not have dementia, mental illness (MI), intellectual disability, (ID) mental retardation (MR) or any related condition (RC) and was deemed appropriate 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 baseline care plan was formulated to manage the resident's care with a nephrostomy tube for 1 of 24 sampled residents (Resident 98). This deficient practice could have led to an increased risk of complications related to improper management and a lack of continuity in care. Findings include: Resident 98 (R98) R98 was admitted on [DATE] and readmitted on [DATE] with diagnoses including palliative care, dysuria (painful or difficult urination), and malignant neoplasm of the prostate. On 01/07/2025 at 12:48 PM, R98 verbalized a complaint to a Registered Nurse (RN) about a peeling dressing. An RN checked the resident's back and confirmed the nephrostomy dressing had peeled off, appeared old and undated, and was soiled. R98 indicated a shower had caused the dressing to become wet, but it had not been changed. Complaints of itchiness on the surrounding skin were noted. The RN acknowledged R98 was receiving hospice…

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, record review, interviews and document review, the facility failed to: 1) implement a care plan for restorative hand splinting services to prevent contractures for 1 of 24 sampled residents (Resident 44), and 2) develop care plans for side rails, weight loss and pressure ulcer for 3 of 24 sampled residents (Residents 62, 87, and 129). The deficient practice placed the residents at risk for worsening health conditions related to contractures, injuries, malnutrition and pressure ulcers. Findings include: The facility policy titled Care Plan Process, Person-Centered Care dated 05/30/2023, documented the facility would develop and implement baseline and comprehensive care plan for each resident that include instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. 1) Implementation of a Care Plan: Resident 44 (R44) R44 was admitted on [DATE], with diagnoses including cerebrovascular accident (CVA) with weakness right side…

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 provide an ongoing program of activities designed to meet the interests of the residents for 2 of 24 sampled residents (Residents 26 and 117) and 7 unsampled residents. The deficient practice had the potential risk to cause psychosocial distress to the residents. Findings include: Resident #26 (R26) R26 was admitted to the facility on [DATE], with diagnoses including erythematous condition (unspecified), anxiety disorder (unspecified), and secondary hyperparathyroidism of renal origin. On 01/07/2025 in the morning, R26 explained had been at the facility for about 6 years and liked to come to activities and do single solitary activities like reading newspapers and magazines. R26 explained R26 would like to see more trips out of the facility to events and shopping places. R26 had an Activity Evaluation dated 04/09/2024 which documented the resident had identified needs where programming should be focused on community…

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 expired medication was not administered to 1 of 7 unsampled residents (Unsampled Resident 02). The deficient practice had a potential for a non-viable medication to be administered to the resident. Findings include: Unsampled Resident 02 (UR2) UR2 was admitted to the facility on [DATE] with diagnoses of other sequelae of cerebral infarction, anxiety disorder (unspecified), chronic kidney disease stage 3 (unspecified), and dementia with mood disturbance (unspecified). On [DATE] at 09:45 AM, a punch card of Hydralazine HCL 10 milligram (mg) tablets for UR2 was observed expired on [DATE], in the 400-hall medication cart. On [DATE] at 09:46 AM, a Licensed Practical Nurse, confirmed the Hydralazine HCL 10mg tablets were expired and should have been discarded for resident safety. On [DATE] at 09:47 AM, the Assistant Director of Nursing, also verified the Hydralazine HCL 10mg tablets were expired and should have been…

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, record review, and interviews, the facility failed to place hand splint for contracture management for 1 of 24 sampled residents (Resident 44). The deficient practice placed the resident at risk to develop contractures, decrease hand functionality, and cause pain and discomfort. Findings include: Resident 44 (R44) R44 was admitted on [DATE], with diagnoses including cerebrovascular accident (CVA) with weakness right side of the body. On 01/07/2025 in the morning, R44 was lying on the bed clutching the right hand with the left hand. The resident indicated they could not move the right hand, and a splint was previously used but was not sure why the splint was no longer applied. A care plan developed on 04/20/2023 and updated on 12/18/2024, documented R44 should have received restorative nursing program (RNP) (a set of nursing interventions that help residents maintain or improve their ability to function independently) for right resting hand splint due to the increased risk to acquire 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 failed to ensure a physician's order had been obtained for the presence of the nephrostomy tube, the insertion site had been monitored, and dressing changes had been scheduled for 1 of 24 sampled residents (Resident 98). This deficient practice increased the risk of infection, complications from improper management, and a lack of continuity in care. Findings include: Resident 98 (R98) R98 was admitted on [DATE], and readmitted on [DATE], with diagnoses including palliative care, dysuria (painful or difficult urination) and malignant neoplasm of the prostate. On 01/07/2025 at 12:48 PM, R98 voiced a complaint to a Registered Nurse (RN) about a peeling dressing. The RN checked the resident's back and confirmed placement of a capped nephrostomy tube, with the nephrostomy dressing soiled, peeled off, and appearing old and undated. R98 indicated a shower had caused the dressing to become wet, but it had not been changed. The RN…

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, record review, document review, and interview, the facility failed to assess a resident's nutritional status during a period of substantial weight loss for 1 of 24 residents (Resident 87). The deficient practice had the potential to place the resident at risk of malnutrition and dehydration, compromising the residents' health and increasing susceptibility to further medical complications. Findings include: Resident 87 (R87) R87 was admitted on [DATE], with diagnosis including encephalopathy, nausea with vomiting, and drug induced subacute dyskinesia. A Malnutrition Screening Tool dated 09/09/2024, documented R87 was eating poorly due to decreased appetite. R87 scored positive for nutritional risk. R87's Vitals Report dated 09/07/2024, documented an initial resident weight of 150 pounds (lbs.) upon admission. The Vitals Report documented resident weight of 120.1 lbs. on 10/09/2024. R87 sustained weight loss of 29.99 lbs. or 19.93% of R87's total body weight between 09/07/2024 and 10/09/2024.…

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 the Dialysis Communication Record were completed, shunt or dialysis access assessments were conducted, and vital signs were obtained pre- and post-dialysis for 1 of 24 sampled residents (Resident 16). The deficient practice increased the risk of complications, including delayed detection of shunt malfunction, inadequate dialysis, hemodynamic instability, bleeding, and potential infection. Findings include: Resident 16 (R16) R16 was admitted on [DATE], with diagnoses including chronic kidney disease, hypertension, and dependence on renal dialysis. The Quarterly Minimum Data Set, dated [DATE], documented the brief interview of mental status with a score of 14/15, which indicated R16's cognitive status was intact and R16 was receiving dialysis treatment. A Physician Order dated 08/28/2024, documented dialysis on Monday, Wednesday, and Friday. A Care Plan dated 09/06/2024, and revised 12/05/2024, documented R16 was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, document review, and interview, the facility failed to obtain a physician order for the use of bed side rails for 1 of 24 residents (Resident 62). The failed practice had the potential to place the resident at risk of injury such as falls, entrapment, and broken bones. Findings include: Resident 62 (R62) R62 was admitted on [DATE], with diagnosis including Parkinson's disease without dyskinesia, chest pain, and syncope and collapse. On 01/07/2025 at 3:27 PM, R62 was observed sitting in a wheelchair at the resident's bedside. Bed side rails were observed up on bilateral sides of the bed. R62 reported side rails were put up to facilitate movement. A Side Rail Review and Consent dated 12/06/2024, documented the use of side rails was considered for syncope, status post fall, hypertension, and hypothyroidism to aid with repositioning, bed mobility and transfers. R62's medical record lacked documented evidence of a physician order for the use of side rails. On 01/10/2025 at 8:37…

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 an expired punch card of medications was discarded. The deficient practice had a potential for a non-viable medication to be administered to the resident. Findings include: On [DATE] at 09:45 AM, a punch card of Hydralazine HCL 10 milligram (mg) tablets was observed expired on [DATE], in the 400-hall medication cart. On [DATE] at 09:46 AM, a Licensed Practical Nurse, confirmed the Hydralazine HCL 10mg tablets was expired and should have been discarded for resident safety. On [DATE] at 09:47 AM, the Assistant Director of Nursing, also verified the Hydralazine HCL 10mg tablets was expired and should have been discarded for resident safety. A facility policy titled Medication Storage: 8.2 General Guidelines for Storage of Medication and Biologicals revised [DATE], documented outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from…

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

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. hand hygiene was performed for 1 of 24 residents (Resident 16) and enhanced barrier precautions (EBP) were implemented for 2 of 24 residents (Residents 16 and 98) and 2. hand sanitizer was available in the resident care areas. These deficient practices could have led to potential cross-contamination and transmission of infectious diseases among residents and staff. Findings include: A facility policy titled Transmission-Based/Standard Precautions and Enhanced Barrier Precautions, dated 05/15/2023, documented the expansion of EBP to include the use of PPE, such as gowns and gloves, during high-contact resident care activities where opportunities for the transfer of MDROs to staff hands and clothing existed. EBP was required for all residents with wounds or indwelling medical devices, including urinary catheters. EBP was also required during high-contact resident care activities, such as dressing, transferring,…

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 establish and implement a baseline care plan for the care and management of an Aspen collar (neck support device to manage spinal fractures while healing) for 1 of 6 residents (Resident 3). The deficient practice had the potential to result in skin impairments for resident. Findings include: Resident 3 (R3) R3 was admitted on [DATE] with diagnoses including multiple fracture of ribs, left side; unspecified displaced fracture of second cervical vertebra; person injured in unspecified motor vehicle accident, nontraffic. The last treatment encounter for physical therapy dated 12/13/2023, documented a precaution/contraindications of cervical vertebra 2 fracture Aspen collar at all times for R3. An admission progress note dated 12/07/2023 documented R3 had a neck collar in place. There was no physician order documented for R3 to be wearing the neck (Aspen) collar. The picture of the resident (R3) on the facility face sheet showed the…

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

Based on interview, record review and document review, the facility failed to ensure a cervical (Aspen) collar was ordered as recommended for 1 of 6 sampled residents (Resident 3). The deficient practice had a potential for resident to heal incorrectly after a cervical fracture. Findings include: Resident 3 (R3) R3 had an admission date of 12/06/2023, with diagnoses including multiple fractures of ribs, left side; unspecified displaced fracture of second cervical vertebra; person injured in unspecified motor-vehicle accident. On 08/15/2024 at 9:30 AM, the facility face sheet picture for R3 showed the resident wearing a cervical (Aspen) collar in the picture. The neck (Aspen) collar is a neck motion limiting device used to manage spinal fractures by maintaining the neck in a proper position while healing. R3's Discharge Summary from the acute care facility, documented spine surgery was consulted who recommended non-operative management with Aspen collar on at all times for 8-10 weeks. There was no physician order documented for R3 to be wearing the neck (Aspen) collar. The medical…

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) clean and sanitary kitchen floors, walls, kitchen equipment, and ice machine in 1 of 2 nourishment rooms, and 2) temperatures were within appropriate range for a food item and reach-in freezer in 1 of 2 nourishment rooms. The deficient practice had the potential to compromise food safety, lead to cross contamination of harmful substances to food, or cause foodborne illnesses to resident. Findings include: On 01/09/2024 at 7:39 AM, an initial tour of the kitchen with the Dietary Director revealed the following: 1) Areas observed with food crumbs, dust, debris, and/or soiled with grease included: -floor area under deep fryer. -internal components of stove range. -floor area under and the wall behind preparation tables which were leaned against the wall. -wall area behind the dishwasher. -separate serving kitchen area had food debris and white water-stained buildup on the floors, counter, and inside cabinets. -ice machine in…

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 the staff provided privacy and dignity to the residents by knocking on the door and introducing themselves prior to entering the residents' rooms for 3 of 24 sampled residents (Resident 91, 86, and 44) and 6 unsampled residents (Resident 54, 56, 76, 31, 62, and 289). The deficient practice had the potential for the residents' rights to be violated. Findings include: On 01/09/2024 at 2:02 PM, Resident 91 (R91) voiced concerns related to individuals entering the resident's room without announcing and introducing themselves. R91 explained not knowing if the person who was entering the room was a staff member or a resident. On 01/10/2024 at 11:52 AM, a Resident Council Meeting was conducted with nine alert and oriented residents in attendance. The following residents revealed the staff were not knocking on the door and introducing themselves before entering the residents' rooms. The residents stated how they felt if staff 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 interview, record review and document review, the facility failed to ensure there was a process in place to identify and refer residents for pre-admission screening and resident review (PASARR) level two for 3 of 24 residents (Residents 20, 80, and 85) with psychiatric diagnosis. The deficient practice had the potential to deprive residents of necessary behavioral health services. Findings include: The facility policy titled PASARR Documentation Policy, last revised 06/09/20023, documented any resident with newly evident or possible serious mental disorder, intellectual disability or a related condition must be referred, by the facility to the appropriate state-designated mental health or intellectual disability authority for review. Resident 20 (R20) R20 was admitted on [DATE] with diagnosis including mood disorder due to known physiological condition with mixed features and depression. An admission Minimum Data Set (MDS) dated [DATE], documented active diagnosis including depression with no additional…

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 establish and implement a baseline care plan for the care and management of an ostomy (surgical opening) site for 2 of 24 residents (Resident 49 and Resident 232). The deficient practice had the potential to result in poor outcomes for residents. Findings include: Resident 49 (R49) R49 was admitted on [DATE] and readmitted on [DATE] with diagnoses including non-pressure chronic ulcer of skin of other sites with fat layer exposed, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A discharge assessment dated [DATE] documented acknowledgment of colostomy site. An admission assessment dated [DATE] documented R49 had colostomy. The medical record lacked documented evidence of a care plan for colostomy. A physician order dated 01/06/2024 documented to perform colostomy care every shift. The medical record lacked documented evidence of any further care orders or wound orders for care 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 care and management of a resident's ileostomy device was included in the resident's comprehensive care plan for 1 of 24 sampled residents (Resident 232). The deficient practice placed the resident at risk for complications related to the ileostomy device. Findings include: Resident 232 (R232) R232 was admitted on [DATE], with diagnoses including diverticulitis of large intestines with perforation and abscess and surgical aftercare following surgery of the digestive system. On 01/09/2024 at 9:43 AM, R232 laid in bed, awake and alert, wearing a gown which was pulled up and revealed an ostomy pouch secured around a stoma (an opening in the abdominal wall) with undated dressing. R232 clarified the pouch was an ileostomy device which was placed by the surgeon on 12/11/2023. The resident indicated Certified Nursing Assistants (CNAs) emptied the bag upon the resident's request or when filled with stool and gas. R232 could…

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 showers were provided as scheduled for a resident who required assistance with showers for 1 of 24 sampled residents (Resident 234). The deficient practice resulted in the resident expressing feelings of discomfort and embarrassment. Findings include: Resident 234 (R234) R234 was admitted on [DATE], with diagnoses including cerebral infarction affecting left dominant side. On 01/09/2024 at 10:59 AM, R234 was seated in wheelchair with contracted left arm. R234 indicated not being provided a shower for at least two weeks and was feeling uncomfortable and gross. The resident explained shower days were scheduled every Monday and Thursday by the day shift, but these were not being provided or re-offered. R234 indicated staff would wipe other body parts after incontinent care such as the back and front side but R234 verbalized bed baths were not thorough and were not sufficient substitution for a shower. On 01/09/2024 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 observation, interviews, and document review, the facility failed to ensure medications were administered in accordance with physician orders for 1 of 24 sampled residents (Resident 44). The deficient practice had the potential to have ineffective results with medication administration. Findings include: Resident 44 (R44) R44 was admitted on [DATE] with diagnosis including hypertension (high blood pressure). A physician order documented to give Isosorbide Dinitrate 20 milligrams 2 tablets every 12 hours. On 01/11/2024 at 8:12 AM, during medication administration observation, the Registered Nurse (RN) was observed dispensing one tablet of Isosorbide Dinitrate to medication cup and placing medication pack back in medication cart. On 01/12/2024 at 12:51 PM, the registered nurse indicated it was important to double check resident information and drug information including dosage and route to ensure correct medications were given correctly. The RN indicated the wrong dosage would have been given if 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 review and document review, the facility failed to ensure skin checks and skin assessments were completed and the rashes, redness, bruising, and open area on the resident's leg were reported and treated in a timely manner for 1 of 24 sampled residents (Resident 61). The deficient practice had the potential for the worsening of the resident's skin condition. Findings include: Resident 61 (R61) R61 was admitted on [DATE], with diagnoses including pruritus, long term (current) use of anticoagulants, and repeated falls. The physician's order dated 05/01/2023, documented weekly skin check by licensed nurse once a day on Monday. The Point of Care History record for August 2023, documented the following electronic charting by certified nursing assistants (CNAs) of R61's skin problem/condition and its location: - 08/15/2023 at 3:03 AM, clear/no skin problem - 08/16/2023 at 5:24 AM, redness and bruising on leg - 08/17/2023 at 12:30 AM, open area on leg - 08/18/2023 at 11:23 PM, rashes on leg -…

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 physician orders for care and management of a 1) colostomy and 2) ileostomy were obtained for 2 of 24 sampled residents (Resident 49 and Resident 232). The deficient practice had the potential for inappropriate care and negative outcomes of ostomy sites. Resident 49 (R49) R49 was admitted on [DATE] and readmitted on [DATE] with diagnoses including non-pressure chronic ulcer of skin of other sites with fat layer exposed, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A discharge assessment dated [DATE] documented acknowledgment of colostomy site. An admission assessment dated [DATE] documented R49 had colostomy. The medical record lacked documented evidence of a care plan for colostomy. The medical record lacked documented evidence of any care orders or wound orders for care of ostomy site, or appliance change for colostomy as well as frequency of change. On 01/12/24 at 9:31…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review the facility failed to ensure medications were administered per physician order for 1 of 3 sampled residents (Resident 1). The deficient practice had the potential to cause harm and delay resident treatment outcomes. Findings Include: Resident 1 (R1) R1 was admitted on [DATE] and discharged on 05/15/2023, with diagnoses including cellulitis of right lower limb, acquired absence of right leg below knee, urinary tract infection, status post kidney transplant, and prolonged antibiotic use. Review of the medical record documented a physician order dated 05/01/2023 for CellCept, administer one tablet twice a day for anti-transplant rejection of kidney. Review of the medication administration record (MAR) documented CellCept was not administered due to item unavailability on the following dates: -05/11/2023 at 9:00 AM -05/12/2023 at 9:00 AM On 08/24/2023 at 4:35 PM, The Director of Nursing (DON) confirmed the medication was not administered per physician order on 05/11/2023 and…

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 1) a medication cart was locked and 2) A normal saline flush was not left on top of a medication cart. The deficient practice had the potential for residents and visitors to gain unauthorized access to medications and treatment items. Findings include: On 08/24/2023 at 11:30 AM, a medication cart in the 100 hall was unlocked and unattended in the hallway outside a resident room. A 10 milliliter (ml) normal saline flush was on top of the medication cart. Visitors and residents were observed walking past the unattended medication cart. On 08/24/2023 at 11:34 AM, the Licensed Practical Nurse (LPN) responsible for the medication cart indicated the cart should be locked. The LPN confirmed the 10 ml saline flush should not be left on top of the cart and should be locked up. The LPN reported medications are locked to prevent residents and visitors from obtaining medications. On 08/24/2023 at 2:07 PM, the Director of Nursing (DON) confirmed the expectation for all medication carts to be locked when…

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.