Sunset Ridge Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review the facility failed to ensure a resident was kept safe from abuse for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential for the resident to experience emotional distress and physical harm. Findings include: Resident 1 (R1) R1 was re-admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, end stage renal disease, and heart failure. The facility reported incident (FRI) dated 02/03/2024 documented the following: -On 02/01/2025 in the PM, R1 reported to the Nurse that on Saturday 2/1/2025, a Certified Nursing Assistant (CNA) took R1's room phone away because the resident kept calling the desk. - Employee 1 (E1) was interviewed and admitted to taking the phone away from the resident because the resident had kept calling the front desk. -Conclusion: The allegation of abuse by E1 against R1 was substantiated. The facility investigation documented R1 was upset with E1…

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 abuse policies and procedures were implemented for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential to put residents at risk of physical or psychosocial harm. Findings include: Resident 1 (R1) R1 was re-admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, end stage renal disease, and heart failure. The facility reported incident (FRI) dated 02/03/2024 documented the following: -On 02/01/2025 in the PM, R1 reported to the nurse that on Saturday 2/1/2025, a Certified Nursing Assistant (CNA) took the resident's room phone away because the resident kept calling the desk. - Employee 1 (E1) was interviewed and admitted to taking the phone away from the resident because the resident had kept calling the front desk. The facility investigation documented the allegation of abuse by E1 against R1 was substantiated. The investigation also…

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 and interview, the facility failed to ensure a resident was treated with dignity and respect by facility staff directing the resident to urinate in their incontinence brief for 1 of 16 sampled residents (Resident 3). The deficient practice had the potential to negatively impact the resident's well-being. Findings include: Resident 3 (R3) R3 was admitted on [DATE] with diagnoses including hypertension, end stage renal disease with hemodialysis, and congestive heart failure. On 01/07/2025 at 9:22 AM, a Certified Nursing Assistant (CNA) verbalized the staff are not supposed to tell incontinent residents to go to the bathroom in their briefs, however it does occur. On 01/07/2025 at 9:32 AM, Resident 5 (R5) verbalized having been told to urinate on themselves in the past. R5 verbalized feeling upset about it and has heard other residents have been told the same but cannot speak for them. On 01/07/2025 at 3:52 PM, R3 verbalized one CNA on the night shift told the resident if had to wait for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to clarify discrepancies in the appeal decision resulting in a resident being discharged and lacked documented evidence of well-coordinated discharge planning for 1 of 16 sampled residents (Resident 4). The deficient practice had the potential for a resident not to receive the necessary skilled therapy to improve functional ability and provide the necessary provisions for continuation of care. Findings include: Resident 4 (R4) R4 was admitted on [DATE] and discharged on 11/21/2024 with diagnoses including difficulty in walking, chronic osteomyelitis of right ankle and foot, contracture of muscle right lower leg, and limitations of activities due to disability. The admission Minimum Data Set (MDS) dated [DATE] documented R4 had lower extremity (hip, knee, ankle, foot) functional limitations in range of motion with impairment on both sides. The Physical Therapy Evaluation and Plan of Treatment dated 08/23/2024 documented 100+ degrees flexion contracture…

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 1 of 16 sampled residents (Resident 14). The deficient practice had the potential to increase skin breakdown, infections, odor and bacteria buildup. Findings include: Resident 14 (R14) R14 was admitted on [DATE], with diagnoses of major vascular neurocognitive disorder- dementia. A Therapy to Nursing communication form dated 01/06/2024, documented the resident is front weight bearing with transfer and the resident had an assessed device of a rolling walker. The resident needed supervision for grooming, oral care, upper body dressing and footwear, moderate assistance with toileting, minimal assistance with showering and lower body dressing. The resident is independent with communication, vison and feeding. On 01/07/2025 at 4:50 PM, Director of Medical records provided two shower sheets which documented on 01/08/2024, the resident had a bed bath and on 01/16/2024 the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure two free standing portable oxygen cylinders were safely stored. The deficient practice had the potential to prevent avoidable accidents and increase concerns of potential harm to residents and the facility overall. Findings include: On 01/07/2025 at 8:42 AM in resident room [ROOM NUMBER], two free standing portable oxygen cylinders were left unattended. On 01/07/2025 at 8:45 AM, the resident stated was not sure why the oxygen cylinders are in the resident's room. One oxygen cylinder was empty, and the other cylinder was half full. On 01/07/2025 at 8:45 AM, a Certified Nursing Assistant (CNA) explained was not sure why the oxygen cylinders were inside the room. The CNA confirmed the oxygen cylinders were placed correctly but the oxygen cylinders should be placed in the closet with other oxygen cylinders. The CNA stated was not aware if the oxygen cylinders were empty. On 01/07/2025 at 8:48 AM, a Registered Nurse (RN) expressed 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 record review, the facility failed to ensure medications were secured for 1 of 6 sampled residents (Resident #19). This deficient practice had the potential to result in other residents having access to the medication. Findings include: Resident 19 Resident 19 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus with diabetic neuropathy, surgery on the digestive system, dehydration, elevated white blood count, hypertension, hyperlipidemia, unspecified, acute kidney failure unspecified, chronic kidney disease stage three unspecified, and acute cholecystitis. On 1/07/2025 at 9:00 AM, a white/pink cream in a medication cup was left on Resident 19's dresser, unattended. On 1/07/2025 at 9:03 AM, the Registered Nurse verbalized the medication cup with the cream medication, should not have been placed and left in the resident's room. On 1/09/2025 at 10:23 AM, the Registered Nurse verbalized Resident #19 had an order for Moisture Barrier cream…

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

Based on observation, interview, and document review, the facility failed to ensure the menu was followed for a breakfast service. This deficient practice had the potential to affect all residents in the facility. Findings include: On 09/26/2024 at 8:31 PM, breakfast was delivered to residents in the Valley of Fire Unit to include cereal, fruit, pancakes and sausage. The Week At a Glance menu documented breakfast for Thursday would include assorted juice, choice of hot or cold cereal, cheesy eggs, hashbrowns, banana, toast, margarine or jelly, and milk or another beverage. The breakfast for Friday would include assorted juice, choice of hot or cold cereal, pancakes, sausage, fresh fruit cup, margarin or syrup, and milk or another beverage. On 09/26/2024 at 2:18 PM, the Dietary Manager (DM) verbalized breakfast on Thursday 09/26/2024 was swapped with the breakfast for Friday 09/27/2024 because the cook looked at the wrong day on the menu and began preparing for the breakfast for Friday instead of the breakfast for Thursday. The DM verbalized residents would be notified of this change…

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) a dietary aide's purse was not being stored with resident food in the dry storage area of the kitchen, 2) a hairnet was donned prior to entering the kitchen, 3) hand washing was performed when entering the kitchen or prior to donning gloves, 4) beverages were covered when traveling down hallways, 5) food was stored at safe temperatures, and 6) thermometers were properly sanitized between foods during the taking of temperatures. This deficient practice placed residents at risk for food-borne infectious illnesses. Findings include: 1. Storage of personal items: On 09/23/2024 at 12:56 PM, located on a shelf containing food for residents, was a staff members purse. On 09/23/2024 at 1:00 PM, the Dietary Aid confirmed the purse belonged to them and verbalized the Dietary Manager had previously spoke to the Dietary Aid on a few occasions about leaving the Dietary Aid's purse next to resident food. The Dietary Aid explained the purse…

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 4 of 4 dining rooms maintained a comfortable home-like environment by storing medical equipment in the dining areas. The deficient practice had the potential to affect all residents who wish to eat in the dining areas. Findings include: On 09/24/2024 at 7:54 AM, in the Lake [NAME] dining room, the following medical equipment was being stored: -One hoyer lift, -One vitals sign monitor, and; -One wheelchair scale. On 09/24/2024 at 8:06 AM, there was a resident eating breakfast in the Lake [NAME] dining room. The resident explained the medical equipment was always in the dining area, however, did not know how long the equipment had been there. On 09/24/2024 at 8:11 AM, a Certified Nursing Assistant (CNA) explained the medical equipment was supposed to be put away in the cubbies, located in each hallway, however staff would put the equipment in the dining area after use. The CNA confirmed the medical equipment was stored in the dining…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and document review, the facility failed to ensure 1) expired medications were removed from 1 of 5 inspected medication carts and 1 of 2 inspected medication storage rooms, 2) an unsealed medication was removed from 1 of 5 inspected medication carts, and 3) discontinued medications were removed from 1 of 5 inspected medication carts. This deficient practice has the potential to place residents at risk of receiving medications that were no longer at a safe level of efficacy. Findings include: Expired Medication On 09/24/2024 at 2:35 PM, during an inspection of the medication room on the Valley of Fire unit in the presence of Licensed Practical Nurse (LPN)1, the following items were found: -Three intravenous (IV) solution bags containing Pantoprazole 40 milligrams (mg) in 100 milliliters (ml) of Normal Saline (NS). The use by date on the three IV solution bags was 09/06/2024. The IV solution bags were hanging on the wall of the medication room, with current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure residents were informed both orally and in writing prior to or upon admission of the rules related to leaving on pass. This deficient practice had the potential to affect the entire facility population of 129 residents. Findings include: Resident # 347 Resident #347 was admitted to the facility on [DATE], with a primary diagnosis of encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. On 09/23/2024 at 3:09 PM, Resident #347 verbalized the resident was unable to leave the premises. In the past, when Resident #347 wanted to go across the street for food or to the grocery store, Resident #347 was told by facility staff if the resident left, the facility would kick the resident out. Resident #347 verbalized being in the facility felt like being in a prison. On 09/24/2024 at 2:34 PM, during a resident council interview, 5 of 5 residents reported wanting to leave the premises…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, document review and interview, the facility failed to ensure a resident or resident representative was provided information about the right to formulate an advanced directive for 1 of 29 sampled residents (Resident #84). The deficient practice has the potential to deprive residents of their right for self-determination. Findings Include: Resident #84 Resident #84 was admitted to the facility on [DATE], with diagnoses including anoxic brain damage, acute respiratory failure with hypoxia, and severe persistent asthma with acute exacerbation. Resident #84's clinical record lacked documented evidence of an advance directive or information provided to the resident or the resident's representative about the right to formulate an advanced directive. On 09/26/2024 at 7:28 AM, the Director of Nursing confirmed the facility had not determined if Resident #84 had an advanced directive or if the resident or the resident's representative was provided information to formulate one. The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review and document review, the facility failed to ensure a care plan was developed for 1) a resident receiving hospice services (Resident #57), 2) a resident dependent on a respirator (Resident #69), and 3) a resident with anxiety (Resident #15) for 3 of 29 sampled residents. This deficient practice has the potential to deprive residents of receiving appropriate care. Findings include: Resident #57 Resident #57 was admitted to the facility on [DATE], with diagnoses including psychotic disorder with hallucinations due to a known physiological condition, cognitive communication deficit and depression, unspecified. On 09/24/2024 at 7:57 AM, Resident #57 verbalized being confused as to what care was being provided in the facility and could not verbalize if the resident was receiving hospice services. A physician's order dated 09/18/2024, documented admit to hospice on 09/18/2024. Resident #57's clinical record lacked documented evidence of a care plan for hospice. On 09/26/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to meet professional standards of medication administration and ensure medications were not left, unsecured, at a resident's bedside for 1 of 4 residents observed for medication administration (Resident #82). The deficient practice placed the patient at risk for not receiving needed medication. Findings include: Resident #82 Resident #82 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including other acute osteomyelitis, left ankle and foot and chronic obstructive pulmonary disease, unspecified. On 09/26/2024 at 9:04 AM, a Licensed Practical Nurse (LPN) began preparing medications for Resident #82. Included in the prepared medications was ClearLax 17 grams (gm), mixed in water, in a clear plastic cup. On 09/24/2024 at 9:17 AM, the LPN entered Resident #82's room and placed the resident's medications on the bedside table. The LPN stood at the resident's bedside while the resident took the oral tablet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review and document review, the facility failed to ensure a code status of do not resuscitate (DNR) was not documented as full code in the electronic health record for 4 of 29 sampled residents (Resident #57, #75, #40, and #347). This deficient practice had the potential to result in a resident with DNR status being given life-saving measures during an emergent event. Findings include: Resident #57 Resident #57 was admitted to the facility on [DATE], with diagnoses including psychotic disorder with hallucinations due to a known physiological condition, cognitive communication deficit and depression, unspecified. Resident #57's electronic chart documented the resident was a full code and was to receive cardio pulmonary resuscitation (CPR) in an emergent event. Resident #57's Provider Order for Life-Sustaining Treatment (POLST) dated [DATE], documented the resident was on comfort-focused treatment and was a DNR. Resident #75 Resident #75 was admitted to the facility on [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure an ordered therapeutic diet was on the resident meal card and provided to 1 of 29 sampled residents (Resident #89). This deficient practice placed the resident at risk for not receiving an appropriate diet to maintain nutritional needs. Findings include: Resident #89 Resident #89 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of type two diabetes mellitus without complications. A physician order dated 08/06/2024, documented heart healthy consistent carbohydrate (CCHO) diet regular texture regular consistency. Resident #89's care plan included an intervention revised 08/18/2024, documenting prescribed diet was heart healthy CCHO diet. On 09/24/2024 at 10:19 AM, Resident #89 verbalized Resident #89 was diabetic. The facility served a lot of carbohydrates that did not taste very good, so Resident #89's family often brought meals Resident #89 liked better. The Week At 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 interview, clinical record review and document review, the facility failed to obtain Dialysis Communications forms for a resident receiving hemodialysis for 1 of 29 sampled residents (Resident #198). This deficient practice potentially places residents at risk for not receiving continuity of care. Findings include: Resident #198 Resident #198 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including end stage renal disease, other specified abnormal findings of blood chemistry, and heart failure, unspecified. A physician's order dated 09/22/2024, documented hemodialysis every Tuesday, Thursday, and Saturday. Resident #198's Care Plan initiated on 09/24/2024, documented the resident required renal dialysis related to renal failure and was to receive dialysis every Tuesday, Thursday and Saturday. Resident #198's clinical record lacked documented evidence dialysis communication forms were being sent with the resident to dialysis and obtained in the medical record. 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 interview, clinical record review, and document review the facility failed to discontinue a medication after receiving an order to discontinue the medication for 1 of 29 sampled residents (Resident #4). This deficient practice resulted in the resident receiving an unnecessary medication. Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region and neuromuscular dysfunction of bladder, unspecified. An Order Summary Report for Resident #4, dated 09/26/2024, documented the following: -Oxybutynin Chloride oral tablet, give one tablet by mouth BID for overactive bladder. The order date was 09/17/2024, with a start date of 09/18/2024. -Tolterodine Tartrate (Detrol) two mg tablets, give one tablet by mouth BID for urinary frequency, urgency, and incontinence. The order date was 09/17/2024, the start date was 09/18/2024. The September 2024 Medication Administration Record (MAR)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review, the facility failed to ensure a psychotropic medication's side effects were monitored, a psychotropic medication's related behaviors were monitored, and an as needed psychotropic medication was limited to 14 days for 1 of 29 sampled residents (Resident #15). This deficient practice placed residents at risk for not receiving appropriate medications for their overall health status. Findings include: Resident #15 Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of anxiety disorder unspecified. A consent for psychotropic medication dated 08/13/2024, documented Hydroxyzine 25 mg with an expected duration of 14 days. An active physician's order dated 08/13/2024, documented Hydroxyzine Pamoate capsule 25 milligrams(mg). Give one tablet via gastronomy tube every 12 hours as needed for anxiety. Resident #15's physician orders lacked evidence of side effect monitoring or behavior monitoring for Hydroxyzine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review the facility failed to ensure medications were administered with an error rate of less than 5 percent (%). There were 31 opportunities and 6 medication errors. The medication error rate was 19.35%. Findings include: Resident #48 Resident #48 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acute respiratory failure with hypoxia and other seizures. On 09/25/2024 at 7:47 AM, a Licensed Practical Nurse (LPN) explained medications were required to be administered within one hour before and one hour after the scheduled administration time on the Medication Administration Record (MAR). On 09/25/2024 at 10:13 AM, a Registered Nurse (RN) began preparing to administer medications to Resident #48. Among the medications prepared were the following: -Cholecalciferol D3 1000 units, two tablets were placed in a medication cup. -Docusate Sodium 100 milligrams (mg), one tablet was placed in a medication cup.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review and document review, the facility failed to ensure resident records were complete and accurate for 1 of 29 sampled residents (Resident #80). The deficient practice had the potential for the resident not receiving appropriate care and/or medications. Findings include: Resident #80 Resident #80 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic kidney disease, unspecified, unspecified severe protein-calorie malnutrition, and muscle wasting and atrophy, not elsewhere classified, multiple sites. Resident #80's weight record documented the following: -04/01/2024: used a sitting scale -04/08/2024: used a sitting scale -04/16/2024: used a sitting scale -04/23/2024: used a sitting scale -04/29/2024: used a sitting scale -05/06/2024: used a sitting scale -06/04/2024: used a sitting scale -07/03/2024: used a sitting scale -07/10/2024: used a sitting scale -07/12/2024: used weights taken during dialysis -07/18/2024: used weights…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review the facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for a resident with chronic wounds for 1 of 29 sampled residents (Resident #292) and hand hygiene was performed during medication administration for 1 of 4 residents observed during medication administration (Resident #82). The deficient practice had the potential for spreading infectious illnesses to all residents. Findings include: Resident #292 Resident #292 was admitted to the facility on [DATE], with diagnoses including localized swelling, mass and lump, lower limb, bilateral and chronic venous hypertension (idiopathic) with ulcer. On 09/23/2024 at 2:00 PM, Resident #292 was lying in bed with bilateral lower legs wrapped with elastic bandages. The resident explained the resident was admitted to the facility for care of a wound on the resident's leg. The resident recalled the wound was present for approximately four to five months. Resident #292's 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.

Based on employee record review, document review and interview, the facility failed to ensure an employee completed training on preventing, identifying, and reporting abuse, neglect, misappropriation of property, and exploitation (abuse training) for 1 of 35 sampled employees (Employee #8). The deficient practice had the potential to place residents at risk for abuse and neglect. Findings Include: Employee #8 Employee #8 with a title of Certified Nursing Assistant and a hire date of 10/17/2023. Employee #8's record lacked documented evidence abuse training had been completed. On 09/25/2024 at 1:19 PM, the Director of Human Resources confirmed Employee #8 was hired on 10/17/2023 and had not completed abuse training since hire. The facility policy titled, Freedom from Abuse, Neglect, and Exploitation, Preventing and Prohibiting Abuse, revised 09/13/2022, documented staff would receive training related to the prohibition and prevention, identifying and recognizing, and reporting of resident abuse, neglect, misappropriation of property, and exploitation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure pain medications were administered as prescribed for 1 of 15 sampled residents (Resident 1). This deficient practice had the potential to cause a resident to have uncontrolled pain and a diminished quality of life. Findings include: A facility policy titled Pain Assessment and Management revised in March 2020, documented interventions were developed to be consistent with the resident's goals and needs and to address the underlying causes of pain. The pain management interventions were required to be consistent with the resident's treatment goals, which were specially defined and documented. Implementing pain management strategies, including non-pharmacological interventions, may be appropriate alone, in conjunction with medications, or prescribed to manage pain. Implement the medication regimen as ordered, carefully documenting the results of the interventions. A facility policy titled Pharmacy Services-Medication…

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) the oven was maintained in sanitary conditions, 2) an expired meal product was discarded, 3) open meal products were labeled, 4) nourishment room was maintained in sanitary conditions, and 5) nourishment room food items in the refrigerator were labeled, dated, and expired items were discarded. The deficient practice had the potential to affect the residents' health by exposing them to potentially hazardous foods. Findings included: 09/20/23 07:50 AM, the following issues were identified during the initial tour to the kitchen: The top surface of the oven was tacky to touch with collection of food debris and dust. The inside of the oven was visibly soiled with golden-brown like grime stains. A food service worker verbalized the oven was cleaned about two months ago and was not sure how often it had to be cleaned. Expired meal products: a 5 pounds (Lbs.) container of peeled garlic expired on 09/16/2023 was found in the walk-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.

Based on interview and document review, the facility failed to ensure the views and recommendations of the resident group were acted upon, and the response and rationale were communicated back to the resident group. The failed practice had the potential to affect the quality of life and health status of residents. Findings include: The Resident Right to Organize and Participate in Resident Groups in the Facility policy dated July 2018, documented the facility would consider views of the residents and act promptly upon the grievances and recommendations of resident group concerning issues of resident care and life in the facility. The facility should be able to demonstrate the facility's response and rationale for the response in relation to expressed grievances and recommendations from the group. On 09/21/23 at 2:15 PM, eight residents attended the resident council meeting. The residents reported food concerns discussed in previous meetings had not been addressed and remained unresolved. Specifically, residents indicated food would sometimes be served late, cold, nasty, did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to securely store medication in the hallway and six resident rooms in 3 of 3 hallways in the Valley of Fire unit. The deficient practice had the potential for residents, visitors, and staff members to gain unauthorized access to medications and for residents to self-administer medication that could interact with facility prescribed medication, which can adversely affect a resident's health. Findings include: On [DATE] at 8:22 AM, an intravenous piggyback (Piperacillin and Tazobactam), was unattended on top of a locked medication cart stationed outside of resident room [ROOM NUMBER]. The staff member was inside resident room [ROOM NUMBER] and the medication cart was not within their sight. A Licensed Practical Nurse (LPN) exited resident room [ROOM NUMBER] and explained the medication was an antibiotic and should not have been left unattended. The medication should have been stored inside the medication cart. The LPN verbalized someone 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 and interview the facility failed to inform a resident of the medical justification for placing the resident on transmission-based precautions (TBP) for 1 of 31 sampled residents (Resident 10). The deficient practice led to miscommunication, the lack of residents' knowledge of their care arrangements, and had the potential for psychosocial harm. Findings include: Resident 10 (R10) R10 was admitted on [DATE] with diagnoses including bacteremia (bacteria in the bloodstream). On 09/20/2023 at 10:04 AM, a contact precaution sign was posted outside of R10's door. On 09/21/2023 at 1:15 PM, the contact precaution sign was no longer posted outside of R10's door. On 09/21/2023 at 1:44 PM, R10 explained they noticed the contact precaution sign, labeled with Methicillin-resistant Staphylococcus aureus (MRSA) (type of bacteria that was resistant to several antibiotics), was placed outside of their door on 09/20/2023 and taken off on 09/21/2023. R10 inquired four times with various staff members and have…

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 facility had a process in place to identify and refer residents for pre-admission screening and resident review (PASARR) level two for 1 of 31 sampled residents (Resident 30). The deficient practice had the potential to deprive residents with appropriate behavioral health services. Findings include: The PASARR Screening Coordination policy dated July 2018, documented the facility would refer to the appropriate state-designated authority, any resident with newly evident or possible serious mental disorder, intellectual disability, or related condition. Resident 30 (R30) R30 was admitted on [DATE], with diagnoses including bipolar disorder and pneumonia. R30's indicators included not having a PASARR level two with diagnoses. On 09/20/2023 in the morning, R30 was awake in bed with a tracheostomy tube, but was able to verbalize needs. A PASARR level one dated 07/31/2018, revealed R30 had no mental illness, no mental…

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 medication was available during the medication pass for 1 of 31 sampled residents (Resident 341). 2) The Medication Administration Record (MAR) was not signed off before medication administration for 1 of 31 sampled residents (Resident 341) occurred. These deficient practices had led to a missed medication dose, and the failure to accurately document the medication administration could potentially have resulted in medication errors, falsified medication records, altered therapeutic benefits, medication underdosing or overdosing, and adverse reactions. Findings include: Resident 341 (R341) R341 was admitted on [DATE], with diagnoses including severe protein-calorie malnutrition and gastrostomy status. 1) A Physician order dated 09/06/2023, documented Folic acid tablet 1 milligram (mg) via percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube used to deliver nutrition directly to the stomach). 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 interview, record review, and document review, the facility failed to ensure a newly identified pressure ulcer was reported to the physician and treatment orders were obtained and carried out for 1 of 31 sampled residents (Resident #437). The deficient practice placed the resident at risk for wound complications such as infection or worsening of the pressure ulcer. Findings include: Resident #437 was admitted on [DATE], with diagnosis including encounter for surgical aftercare following surgery of the circulatory system, heart failure, and limitation of activities due to disability. A Wound Assessment Details Report dated 04/21/23, documented a facility acquired coccyx wound was identified on 04/21/23. There was no documented evidence in the clinical record the physician was notified of the wound, the care plan was updated, skin assessments were completed, wound care orders were obtained, and the resident was provided treatment for the wound identified on 04/21/23. On 09/21/23 at 2:30 PM, the Wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a spray bottle of chemical cleaner, a bottle of wound cleanser, and a portable oxygen cylinder were safely stored. The deficient practice had the potential to prevent avoidable accidents and increase concerns of potential harm to residents and the facility overall. Findings include: On 09/20/2023 at 11:30 AM, a spray bottle of Sani2 chemical cleaner was unattended in a cubby area across from the elevators, at the entry of the Valley of Fire unit. Three residents and a staff member walked past the area. A Maintenance Assistance staff member walked by, confirmed the spray bottle of Sani2 chemical cleaner was unattended and advised the spray bottle of Sani2 chemical cleaner was not safe to leave unattended. On 09/20/2023 at 12:55 PM, in resident room [ROOM NUMBER] was a bottle of wound cleanser on top of the dresser drawer. On 09/20/2023 at 12:59 PM, a Unit Manager confirmed the bottle of wound cleanser was inside resident room [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 physician orders for the utilization and size of an indwelling Foley catheter were obtained and transcribed for 1 of 31 sampled residents (Resident 23), and the correct Foley size order was verified and inserted as ordered for 1 of 31 sampled residents (Resident 47). This deficient practice could potentially increase the risk of catheter-related complications, including urinary tract infections, patient discomfort, trauma, and pain. Findings include: Resident 23 (R23) R23 was admitted on [DATE], with diagnoses including urinary tract infection and severe dementia with agitation. A Care plan dated 09/08/2023, documented R23 had altered urinary function, requiring the use of an indwelling Foley catheter for obstructive neuropathy. R23's medical record lacked documented evidence a physician order was obtained for the utilization of the indwelling Foley catheter, including specifying its size. On 09/20/2023 at 11:01…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to complete timely assessments and interventions addressing resident's weight loss and a physician was notified for one of the 31 sampled residents (Resident 47). This deficient practice could have potentially led to a deprivation of essential care and a deterioration in overall health. Findings include: Resident 47 (R47) R47 was admitted on [DATE], with diagnoses including dysphagia, diabetes mellitus and chronic kidney disease. The Brief Interview of Mental Status dated 08/03/2023, documented a score of 14/15, which indicated R47's cognitive status was intact. On 09/20/2023 at 10:51 AM, R47 indicated was diabetic and had wounds. R47 indicated the diabetic diet had been discussed but was not provided. R47 expressed concerns about significant weight loss, and nobody within the facility had discussed this concern. R47 indicated became aware of the weight loss during a weighing session and had to inquire with the CNA about 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 Resident 42 (R42) R42 was admitted on [DATE] with diagnoses including anoxic brain damage, acute respiratory failure with hypoxia, and dysphagia following cerebral infarction. A physician's order dated 07/31/2023, documented Glucerna with Carbsteady 1.2 calories at 85 cubic centimeters (cc) per hour for 20 hours from 6:00 PM to 2:00 PM via percutaneous endoscopic gastrostomy (PEG) tube to provide 1700mL/2040kcal. A quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) (screening measure for cognitive condition) score of 00, which meant R42 was severely impaired. On 09/20/2023 at 11:27 AM, R42 was lying in bed with the head of bed elevated. The tube feed pump was on and running with a formula of Glucerna with Carbsteady 1.2 calories, infusing at 85 cc per hour. A physician's order dated 09/20/2023, documented Glucerna with Carbsteady 1.2 calories at 90 cc per hour for 20 hours from 6:00 PM to 2:00 PM via PEG tube to provide 1800mL/2160kcal. On 09/21/2023 at 9:05 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure the peripherally inserted central catheter (PICC) or midline dressing was changed as scheduled for four sampled residents (Residents 8, 47, 79, and 390). This deficient practice could potentially lead to serious complications, such as bloodstream infections, clot formation, or other adverse health outcomes. Findings include: Resident 8 (R8) R8 was admitted on [DATE], with diagnoses including diabetes mellitus and osteomyelitis of left ankle and foot. The Brief Interview of Mental Status (BIMS) dated 09/01/2023, documented a score of 12/15, which indicated R8's cognitive status was intact. On 09/20/2023 at 12:30 PM, R8 lay in bed, verbally alert and oriented. An empty bag of intravenous antibiotics hung at the bedside. R8's left arm had a PICC line inserted; the transparent dressing was soiled and dated 09/07/2023. A Physician order dated 09/03/2023, documented changing the transparent dressing (every Sunday 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, interview, record review and document review, the facility failed to ensure an intravenous antibiotic was administered as scheduled following a physician's order for 1 of 31 sampled residents (Resident 132). The deficient practice had the potential to cause adverse effects related to toxic levels of the medication. Findings include: Resident #132 (R132) R132 was admitted on [DATE] with diagnoses including right mandible abscess and osteomyelitis. On 09/20/2023 at 9:10 AM, R132 stated a nurse administered an intravenous (IV) antibiotic at the wrong time. The resident denied any adverse reaction after the administration. A physician's order dated 09/04/2023, documented Zosyn (piperacillin sodium/tazobactam sodium 3-0.375 grams), intravenously every eight hours for osteomyelitis for 20 days. A physician's order dated 08/31/2023, documented Cubicin (Daptomycin) 600 milligrams (mg) IV (Daptomycin) one time a day for facial cellulitis. The Medication Administration Record (MAR) for September…

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 transport clean linen in a sanitary manner for one unsampled resident and follow their Transmission-Based Precaution (TBP) practice for 1 of 31 sampled residents (Resident 10). The deficient practice had the potential to contaminate clean linen and spread communicable infections or organisms that can affect the well-being of residents. Findings include: On 09/20/2023 at 8:39 AM, a Physical Therapy Assistant (PTA) was observed carrying clean folded linen in between their right arm and against their clothing/body down the 1100 hallway into a resident room [ROOM NUMBER]. The PTA was observed unfolding and fanning the linen over a resident in the B bed. On 09/20/23 at 8:41 AM, the PTA verbalized it was probably not okay to transport clean linen against their body due to the concern of contamination of the clean linen. The PTA did not know the importance of not fanning linen over a resident after it was transported in such a manner. 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.