The Heights Of Summerlin, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5%, as required. This deficient practice placed residents at risk for adverse drug outcomes, decreased therapeutic effectiveness, and compromised safety.Findings include: Resident #191 (R191) was originally admitted on [DATE] and re-admitted on [DATE] with diagnoses including chronic pain syndrome.On 03/25/2026 in the morning, medication administration observations were conducted with R191 and a Registered Nurse. Medications administered included oxycodone hydrochloride (HCl) 10 milligrams (mg) and aspirin 81 mg (enteric coated), both administered orally.A review of the physician's orders revealed the following:Oxycodone HCl 10 mg oral tablet: give one tablet by mouth every 6 hours as needed for moderate to severe pain. The order did not document Oxycodone was to be the immediate release formulation that was administered.Aspirin 81 mg by mouth once daily for coronary artery disease. The order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review the facility failed to ensure medications were secured for 1 of 38 sampled residents (Resident 175) expired medication was disposed of. The deficient practice had the potential for the facility staff to administer expired and contaminated medications.Findings include: Resident 175 (R175) was admitted on [DATE] with diagnoses including spina bifida with hydrocephalus, chronic respiratory failure with hypoxia, paraplegia, type 2 diabetes mellitus and dysphagia. On 03/24/2026 at 10:56 AM, the refrigerator in Resident 175's (R175) room contained: -one opened bottle of Latanoprost Solution 0.005% eye drops dated 09/06/2025. -one opened bottle of Latanoprost Solution 0.005% eye drops dated 02/11/2026. On 03/24/2026 at 11:17 AM, a Licensed Practical Nurse (LPN) confirmed the medication bottles were in the resident's refrigerator and should have been kept securely in the medicine room refrigerator. On 03/27/2026 at 8:33 AM, the Director of Nursing (DON)…

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 there was sufficient number of kitchen personnel to provide the residents with meals delivered timely, and at proper temperature. The deficient practice placed residents at risk for negatively impacting quality of life.Findings include: The facility assessment tool updated 08/29/2025 and reviewed by the quality assurance committee on 12/30/2025, revealed the facility was licensed for 190 beds with an average daily census of 160 residents. The staffing plan was based on resident population and their needs for care and support, with sufficient staff to meet the residents needs which included: 1) a director of dining services 2) undetermined number of cooks to prepare all meals and snacks (one to four cooks per day) and dining services aides/servers were scheduled to set up, serve and clean up meals and snacks (one to five aides/servers per meal). Staffing levels were adjusted based on census or center needs.On 03/24/2026 in the morning, the facility's census was 170.On 03/24/2026 at 7:40 AM, there were…

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 food was not served late and at appropriate temperatures per facility policy. The deficient practice had the potential to negatively impact residents' quality of life.Findings include: On 03/24/2026 in the morning, the facility's census was 170.On 03/24/2026 at 7:40 AM, there were three kitchen staff members preparing meal trays for breakfast meal service. One staff member introduced themself as the Assistant Dietary Manager (DM) and indicated the other two were dietary aides.On 03/24/2026 in the morning, five residents in the 100-Hall, four residents in the 200-Hall and six residents in the 300-Hall complained about meals being served late, food was cold and often not good (unpalatable).On 03/27/2026 in the morning, the Dietary Manager (DM), cook and a dietary aide were on the service line where temperatures were taken for the following food items:Oatmeal: 197 degrees FahrenheitRegular Ham: 186 degrees FahrenheitPureed Ham: 183 degrees FahrenheitPancakes: 101 degrees FahrenheitThe Meal Delivery Times…

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 expired food items were discarded from 2 of 38 sampled resident refrigerators (Resident 151 and Resident 175). The deficient practice had the potential for expired foods to be consumed, which could lead to foodborne illness.Findings include:Resident 151 (R151) was admitted to the facility on [DATE] with diagnoses including epilepsy, pneumonia, dysphagia, type 2 diabetes mellitus, schizophrenia and dementia.On 03/24/2026 at 10:34 AM, the refrigerator in Resident 151's (R151) room contained:-one opened 1.89-liter bottle, Lucerne reduced fat milk, expired 03/19/26.-one unopened six-ounce container, Yoplait original yogurt, strawberry cheesecake flavored, expired 02/25/26. On 03/24/2026 at 10:45 AM, a Certified Nursing Assistant (CNA1) confirmed the expired findings in R151s refrigerator. CNA1 was unsure who removed expired food items from the resident refrigerators. CNA1 stated expired items would be discarded as the items were…

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 appropriately assess residents who smoked upon admission/readmission, secure smoking materials, including lighters, and establish a policy outlining guidelines on how to address smoking among residents in a non-smoking facility, and ensure safety measures were implemented for 3 of 13 sampled residents (Residents 66, 104, and 65). This deficient practice had the potential to place residents at risk of self-inflicted burns, fire hazards, or other safety concerns. Findings include: Resident 66 (R66) R66 was admitted on [DATE], and readmitted on [DATE], with diagnoses including shortness of breath and heart failure. The Minimum Data Set, dated [DATE], documented R66's brief interview of mental status a score of 15/15, and R66 was a current tobacco user. The Nursing Progress Notes dated 03/06/2025, documented R66 expressed unwillingness to use the Nicotine patch and intention was to continue smoking. The Assistant Director 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.

Based on observation, interview, and document review, the facility failed to ensure snacks were available to residents outside of scheduled mealtimes. The failed practice had the potential to cause residents to remain hungry in between meals and the resident's nutritional needs not met. Findings include: On 03/12/2025 in the morning, the snack tray at the 1st floor east nursing station was observed empty. On the 2nd floor nursing station, the snacks refrigerator had a bottle of dark colored soda and no snacks available for residents. On 03/12/2025 in the morning, the Dietary Director reported resident snack refrigerators were replenished daily after breakfast and again in the afternoon. On 03/12/2025 in the morning, Resident 109 (R109) reported did not know how to request food alternatives or snacks. On 03/12/2025 at 12:17 PM, R74 reported had been at the facility for six years. R74 explained sometimes there were crackers available, however, there were no sandwiches or other snacks for residents between meals. R74 explained residents able to visit the kitchen could have requested 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 the accuracy of assessment reflected the resident's status regarding the harness and straps being used for safety rather than as a restraint for 1 of 31 sampled residents. This deficient practice had the potential to result in the improper use of restraints, restricted mobility, and diminished quality of care. Findings include: Resident 60 (R60) R60 was admitted on [DATE], and readmitted on [DATE], with the diagnoses including spastic quadriplegic cerebral palsy and epileptic seizures (episodes of abnormal electrical activity in the brain that cause sudden changes in behavior, movement, or consciousness). On 03/18/2025 at 7:50 AM, R60 was in the activity room seated in the tilted wheelchair. R60 was incoherent, non-verbal and appeared comfortable. The harness and straps were in place securing R60. A physician order dated 01/09/2025, documented to ensure harness and strap were secured and on properly while 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, record review, and document review, the facility failed to develop comprehensive care plans to reflect new interventions, specifically a smoking care plan for 1 of 13 sampled residents (Resident 65). The deficient practice had the potential to deprive residents of necessary interventions to maintain overall well-being. Findings included: Resident 65 (R65) R65 was admitted on [DATE] with diagnoses including anxiety disorder, muscle weakness, and nicotine dependence. Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/02/2024 indicated under J1300 Current Tobacco Use, R65 was a tobacco user. The assessment under Section I: Active Diagnoses indicated the resident had seizure disorder or epilepsy, anxiety disorder, and depression. Review of R65's Comprehensive Care Plan initiated on 03/26/2024, included a smoking care plan initiated on 09/27/2024. On 03/18/2025 at 2:59 PM, the Minimum Data Set (MDS) Nurse verbalized upon admission of a new…

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 or a bath, were provided as scheduled for 1 of 4 unsampled residents (Resident 471). The deficient practice had the potential to increase skin breakdown, infections, odor and bacteria buildup. Findings include: Resident 471 (R471) R471 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, anemia, left foot cellulitis, gastritis, and stroke. The Minimum Data Set (MDS) in section GG dated 12/24/2024, indicated partial/moderate assistance with showering and bathing self. Review of R471's Care Plan initiated on 12/19/2024, indicated resident was dependent for Activities of Daily Living (ADL) care. R471's medical record for December 2024 and January 2025 lacked documented evidence the resident received either a shower or bath on the following dates: - 12/21/2024 (Saturday) - 01/01/2025 (Wednesday) R471's medical record lacked documented evidence the resident refused a shower or bath…

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 resident's prescribed Foley size order was followed or clarified and monitored for signs and symptoms of infection, and the physician was notified promptly for the presence of sediments and odorous urine for 1 of 31 sampled residents (Resident 16). This deficient practice had the potential to result in complications such as urinary tract infections (UTIs), discomfort, catheter-associated infections, and other related health risks. Findings include: Resident 16 (R16) R16 was admitted on [DATE] and readmitted on [DATE], with diagnoses including hydronephrosis and urinary retention. A Physician order dated 10/24/2024, documented 16 French by 10 milliliters (ml) water balloon for neuromuscular dysfunction of the bladder. The Minimum Data Set, dated [DATE], documented a score of the brief interview of mental status as 14/14, which indicated R16's cognitive status was intact. R16 had an indwelling catheter. A Care…

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 PT-INR (prothrombin time-international normalized ratio, a blood test measuring how long it took for blood to clot) was completed as ordered, and the level was monitored, documented in the Medication Administration Record and reported to the physician for 1 of 31 sampled residents (Resident 12). This deficient practice had the potential to result in adverse health outcomes, including an increased risk of bleeding or clotting complications and potential harm due to inadequate monitoring of anticoagulation therapy, and 2) A pain medication was administered despite a documented reported pain level of zero for one of 13 sampled residents (Resident 13). This deficient practice had the potential to over-medicate the resident with pain medication when not in pain, unnecessarily administer medication, and further worsen the resident's opioid dependency. Findings include: 1) PT-INR Resident 12 (R12) R12 was admitted…

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, and record review, the facility failed to ensure medicated wound care barrier cream were secured for 1 of 16 sampled residents (Resident 2). The deficient practice had the potential risk of unauthorized access to medication, or misuse of medication within the facility. Findings include: Resident 2 (R2) was admitted to the facility on [DATE] with a diagnosis including atherosclerotic heart disease, chronic diastolic heart failure, and fracture around the right hip joint. On 01/16/2025 at 4:03 PM, a clear medication cup with an iridescent white cream was observed on R2's overbed tray table. On 01/16/2025 at 4:12 PM, a Licensed Practical Nurse (LPN) confirmed the iridescent white cream was a medicated cream used by the wound care team. The LPN confirmed the medicated cream should not have been left in R2's room. On 01/17/2025 at 8:37 AM, a Wound Care Nurse confirmed the iridescent white cream the wound care team used was Triad Hydrophilic Wound Dressing used to help maintain 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.

Based on observation, interview and document review, the facility failed to ensure food items stored inside the walk-in cooler and walk-in freezer were labeled, dated, and not expired; the janitor closet located inside the kitchen was maintained in a sanitary condition; bottles of hand soap were not stored over the disposable ware and food item on a shelving unit in the Dry Storage Room; a meal tray was served to the correct resident for 1 of 34 sampled residents (Resident 113); and temperature logs were monitored and maintained for 3 of 4 nourishment refrigerators (First floor East Wing, 300 Hall, and 200 Hall). The deficient practices had the potential to place the residents at risk for a foodborne illness and had a resident served with incorrect diet. Findings include: Food items not labeled and dated and were expired. On 02/27/2024 at 8:17 AM, the following food items were observed inside the walk-in cooler and walk-in freezer: - Individual servings of chocolate pudding, chocolate cake, and pureed cake inside the walk-in cooler were not labeled and dated. There were no dates…

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 final report which included documentation of investigation findings and any corrective actions taken by the facility regarding an allegation of verbal abuse was submitted to the state agency for 1 of 34 sampled residents (Resident 54). The deficient practice which included failure to notify the resident of concern of the outcome of the investigation, had the potential to discourage residents from reporting incidences of potential abuse. Findings include: Resident 54 (R54) R54 was admitted on [DATE], with diagnoses including diabetes and chronic kidney disease. On 02/27/2024 at 10:08 AM, R54 laid in bed watching television. R54 indicated having multiple bad experiences with rude and disrespectful staff but the resident no longer reports such incidents ever since the facility ignored the resident's report of verbal abuse by a certified nursing assistant (CNA) last year. R54 recounted a CNA used profane language to the resident…

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 there was a process in place to identify and refer residents with newly identified psychiatric diagnoses for pre-admission screening and resident review (PASARR) level two for 2 of 34 sampled residents (Residents 91 and 69). The deficient practice had the potential to deprive residents of necessary behavioral health services. Findings include: Resident 91 (R91) R91 was admitted on [DATE] and readmitted on [DATE], with diagnoses including major depressive disorder, anxiety disorder, and brief psychotic disorder. A minimum data set (MDS) dated [DATE], documented a brief interview for mental status (BIMS) score of 06 which indicated there was a significant cognitive deficit. On 02/28/2024 at 2:55 PM, R91 was present during the resident council meeting sitting in wheelchair, slouched, and sleeping for most of the meeting. When R91 was alert, speech was unclear and primarily used gestures for communication. 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 and document review, the facility failed to ensure comprehensive care plans were developed for: 1) monitoring and managing edema for a resident (Resident 74) and 2) a dialysis access catheter currently in use was care planned (Resident 128). The deficient practice had a potential for staff not to provide personalized care for residents. Findings include: 1) Managing edema Resident 74 (R74) R74 was admitted on [DATE], with diagnoses including displaced condyle fracture of the lower end of the right femur, closed reduction, and hypertensive heart disease. A Practitioner's Note dated 02/26/2024 at 7:38 PM, documented on 2/22 noted bilateral lower extremity swelling for which the patient would like ACE (All Cotton Elastic) wraps. A physician's order dated 02/22/2024, documented ACE wrap bilateral lower extremities one time daily. On 02/27/2024 at 10:45 AM, observed R74 with bilateral lower leg edema (swelling). The left lower leg was noted to have an ace bandage wrapped 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) prescribed orders to monitor and manage edema (swelling caused by too much fluid trapped in the body's tissues) were completed as prescribed for 1 of 34 sampled residents (Resident 74), 2) physician's order for fluid restriction was followed and discussed with the resident for 1 of 34 sampled residents (Resident 12). The deficient practices placed the residents at risk for fluid overload, missed edema management and non-compliance with physician orders. Findings include: Resident 74 (R74) R74 was admitted on [DATE], with diagnoses including displaced condyle fracture of the lower end of the right femur, closed reduction, and hypertensive heart disease. A Practitioner's Note dated 02/26/2024 at 7:38 PM documented, on 2/22 noted bilateral lower extremity swelling for which the patient would like ACE (All Cotton Elastic) wraps. A physician's order dated 02/22/2024, documented ACE wrap bilateral lower extremities one…

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 record review, the facility failed to ensure wound care treatments were provided per the physician's orders for one unsampled resident (Resident 177). The deficient practice had the potential for the worsening of the resident's skin condition. Findings include: Resident 177 (R177) R177 was admitted on [DATE] and discharged on 01/28/2024, with diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA) infection and limitation of activities due to disability. Review of R177's medical record which contained the physician's orders and Treatment Administration Record (TAR) for January 2024 revealed the following: 1) The physician's order dated 01/05/2024, documented Wound care: Cleanse coccyx with Normal Saline Solution (NSS), pat dry, apply TRIAD paste one time a day for redness/moisture-associated skin damage (MASD). The TAR for January 2024 lacked documented evidence the resident received the treatment on the following dates per the physician's order: - 01/08/2024 - 01/09/2024 -…

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 interview, record review and document review, the facility failed to ensure the restorative nursing services were provided per the therapy recommendation for 1 of 34 sampled residents (Resident 104). The deficient practice had the potential for the resident's further decline in physical functioning/mobility. Findings include: Resident 104 (R104) R104 was admitted on [DATE], with diagnoses including difficulty in walking, need for assistance with personal care, and history of falling. On 02/27/2024 at 9:16 AM, R104 was lying in bed, alert and oriented. R104 revealed the preference to be up in bed and perform exercises. R104 indicated not receiving therapy or restorative nursing services. The Physical Therapy (PT) Discharge summary dated [DATE], documented R104's dates of service for PT were from 07/20/2023 to 09/01/2023. R104 was seen for six days during the 08/19/2023 to 09/01/2023 progress period. The discharge recommendations included 24-hour care and Restorative Nursing Program (RNP). The prognosis…

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 gastrostomy tube (G-tube) feeding and water flush bag were labeled with the name of the resident, room number, infusion rate, and date and time the feeding and water flushes started for one unsampled resident (Resident 129). The deficient practice had the potential for the resident receiving expired or incorrect G-tube feeding, and inaccurate rate of feeding and water flushes. Findings include: Resident 129 (R129) R129 was admitted on [DATE], with diagnoses including gastrostomy and cognitive communication deficit. The physician's order dated [DATE], documented enteral feed order: Isosource 1.5 Cal at 250 milliliter (ml) via gastrostomy tube (G-tube) four times a day (QID) bolus. If Isosource 1.5 was unavailable, provide Glucerna 1.2 Cal at 325 ml QID via G-tube. On [DATE] at 9:23 AM, R129 was lying in bed and eyes closed. A G-tube feeding pump was placed on R129's bedside. A container of G-tube feeding formula…

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 peripheral intravenous (IV) line dressing was dated for 1 of 34 residents (Resident 21), and a midline (an 8 - 12 centimeter length IV catheter inserted in the upper arm with the tip located just below the axilla) catheter dressing was changed for 1 of 34 residents (Resident 133). The deficient practice poses an IV access site infection risk for the resident. Finding include: Resident 21(R21) R21 was admitted on [DATE], with diagnoses including aftercare surgery on the digestive system and chronic obstructive pulmonary disease. On 02/27/2024 at 10:17 AM, R21 was observed to have an IV line in the right forearm. The transparent dressing on the IV line had no date on dressing. R21 physician's order dated 02/17/2024, documented: - Peripheral IV Site Transparent Dressing change: at bedtime every 7 day(s) with site change and every 12 hours as needed: - Peripheral Catheter Site Change and needleless connector 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, record review and document review, the facility failed to ensure staff received training and obtained a physician's order for a continuous positive airway pressure (CPAP - a machine that uses mild air pressure to keep the airway open during sleep) device utilized within the facility for 1 of 34 sampled residents (Resident 288), The deficient practice had a potential for staff not to be aware and properly care for a resident with a specialized medical device. Findings include: Resident 288 (R288) R288 was admitted on [DATE], with diagnoses including cardiomyopathy and obstructive sleep apnea. On 02/27/2024 at 11:01 AM, observed at R288's bedside was a medical device, attached to the device was a flexible hose and at the end was a transparent plastic nasal mask with straps. R288 confirmed the medical device was a CPAP machine which was brought in by family upon admission. R288 indicated self-managing the device and at times might need assistance from staff with proper donning 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 1) dialysis access catheter was assessed and monitored and, 2) refusal of dialysis treatment interventions were documented for 1 of 34 residents (Resident 128). The deficient practice had a potential for the dialysis access not to be monitored for adverse reactions and education regarding dialysis complications were discussed. Resident 128 (R128) R128 was admitted on [DATE], with diagnoses including chronic kidney disease and rheumatoid arthritis. 1) On 02/27/2024 (Tuesday) at 10:50 AM, R128 was seen leaving the facility for dialysis treatment. R128 was in the wheelchair and indicated the usual schedule for dialysis treatment was Monday, Wednesday, and Friday (MWF) and was going today due to missing yesterday's treatment due to not feeling well. R128 indicated current dialysis access was through a permanent catheter (permcath) located at the right groin. R128 indicated having a left arm arterio-venous fistula (AVF -…

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) a consent was obtained prior to administering the psychotropic medication for 1 of 34 sampled residents (Resident 80), 2) a valid consent (with signature of the resident or representative) for the use of psychotropic medication for 1 of 34 sampled residents (Resident 91) was obtained, and 3) a consent for the use of psychotropic medication was obtained for 1 of 34 sampled residents (Resident 150). The deficient practice had a potential for a resident/resident representative not being properly informed of the risk and benefits of a prescribed psychotropic medication. Findings include: Resident 80 (R80) R80 was admitted on [DATE] with diagnoses including type 2 diabetes with foot ulcer and chronic kidney failure, severe stage 4. On 02/27/2024 on 2:47 PM, R80 indicated still waiting to see primary physician to inform of a history of schizophrenia. R80's medical record revealed no diagnosis for schizophrenia or any…

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

Based on observation, interview, record review and document review, the facility failed to ensure 1) a resident had orders and assessment for self-medicating and medications were properly secured in the resident's room for 1 of 34 sampled residents (Resident 94). and 2) biologicals such as vaccines were stored in accordance with manufacturer's guidelines. The deficient practices had a potential for a resident to improperly administer and store medications and improper vaccine storage could potentially affect the potency and effectiveness of the medications. Findings include: 1) Self medication administration Resident 94 (R94) On 02/27/2024 at 2:22 PM, observed two eye medications at R94's bedside table, one bottle of Artificial Tears and one bottle GenTeal Tears. R94 indicated self-administering the medication. On 02/27/2024 at 2:38 PM, the nurse caring for R94 was not aware the resident had medications at the bedside. The nurse was not aware if the resident had a self-administering assessment completed. The nurse confirmed medications should be secured if kept at the bedside. R94's…

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 concerns raised by the resident group regarding call light response times were communicated to the Administrator, the facility's response and actions were communicated back to the resident group, and the resident group response was obtained and documented in accordance with the facility's policy. The deficient practice potentially denied the facility's leadership from verifying, tracking, and developing meaningful interventions to address the resident's ongoing issues regarding call light response times. Findings include: 1) On 11/30/2023, in the morning, Resident 17 (R17) was alert and oriented and answered questions appropriately. R17 revealed being the President of the Resident Council. R17 explained on the second Tuesday of every month, residents gathered to discuss how things could be improved for all residents. The discussions were recorded by a staff member. R17 revealed at each Resident Council meeting for the last six months, and probably more, residents had complained of experiencing delayed response to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure a resident was not restrained to the bed frame for 1 of 14 sampled residents (Resident 5). The deficient practice had the potential to cause the resident physical, emotional and mental distress. Findings include: Resident 5 (R5) R5 was admitted on [DATE], with diagnoses including unspecified dementia, schizoaffective disorder, and senile degeneration of the brain. A facility document dated 03/27/2023 revealed a Certified Nursing Assistant (CNA) found R5 restrained to the bed by a medical gown which ran across the resident's hip with strings loosely tied to the metal frame of the bed underneath the mattress. The CNA who had just started shift made the discovery on 03/27/2023 at 6:45 AM and immediately reported the incident to the charge nurse, Director of Nursing (DON) and the Administrator. The investigation report revealed the night shift CNA admitted to tying down R5 on the bed due to being agitated throughout the night 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to provide necessary services for personal hygiene for 1 of 14 sampled residents (Resident 12) who was unable to carry out activities of daily living including elimination. The deficient practice had the potential to cause adverse physical and mental outcomes such as skin damage and loss of dignity. Resident 12 (R12) R12 was admitted on [DATE] and readmitted on [DATE] with diagnoses including fracture of the sacrum, and multiple other fractures, and difficulty walking. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident required assistance of two persons to transfer, assist of one person to ambulate, and required the assistance of one person for toileting and hygiene care. Care plans dated 05/19/2023 indicated the resident had problem of impaired mobility and required assistance of staff to perform activities of daily living (ADLs). On 11/28/2023, at 1:15 PM, R12 was alert and oriented and answered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure an admission social services assessment was completed for 1 of 14 sampled residents (Resident 3) and failed to ensure there were sufficient number of social services staff members in accordance with the facility assessment. The deficient practice had the potential for the facility not meeting the social services needs of the residents. Findings include: Resident 3 (R3) R3 was admitted on [DATE], with diagnoses including spinal fusion and heart failure. The Social Assessment policy revised July 2014, documented a social assessment shall be completed within 14 days of the resident's admission to the facility. The assessment would be used to identify the resident's personal and social situation, needs and problems and serve the purpose of helping staff develop a personalized plan of care. Components of a social assessment included physical factors such as sight, hearing and vision, cognitive factors, mood and behavior, personal…

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.