Torrey Pines Post Acute And Rehabilitation

Based on interview and document review, the facility failed to ensure dementia training was provided for 3 of 11 employee files reviewed (Employees 4, 5, and 8) as outlined in Nevada Administrative Code (NAC) 449.74522 Findings include: NAC 449.74522 documented: 1. Except as otherwise provided in subsection 4, each person who is employed by a facility for skilled nursing which provides care to persons with any form of dementia, including, without limitation, dementia caused by Alzheimer's disease, who has direct contact with and provides care to persons with any form of dementia and who is licensed or certified by an occupational licensing board must complete the following number of hours of continuing education specifically related to dementia: (a) In his or her first year of employment with a facility for skilled nursing, 8 hours which must be completed within the first 30 days after the employee begins employment; and (b) For every year after the first year of employment, 3 hours which must be completed on or before the anniversary date of the first day of employment. 2. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure visitors and staff wore appropriate personal protective equipment (PPE) and hand hygiene had been performed when cleaning a room under transmission-based precautions (TBP). These deficient practices had the potential to expose residents, staff, and visitors to infectious agents and compromise the facility's infection prevention and control measures. Findings include: Resident 140 (R140) R140 was admitted on [DATE], with diagnoses including diabetes mellitus and osteomyelitis, left ankle and foot. On 06/24/2025 at 11:54 AM, a contact precaution sign was posted on R140's room door, instructing staff to perform hand hygiene before room entry and exit, and to wear a gown and gloves. PPE was available. R140 had a left foot infection and was on contact isolation for a methicillin-resistant Staphylococcus aureus (MRSA). R140's spouse was observed seated in bed assisting the resident, who was lying in bed, without wearing…

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 abuse training was provided in accordance with the facility assessment and facility policy for 3 of the 11 employee files reviewed (Employees 4, 5, and 8). The deficient practice had the potential to allow unqualified employees to provide care for residents. Findings include: On 06/26/25 at 09:23 AM, the Director of Staff Development (DSD) indicated abuse training was required to be completed upon hire and annually, on or before the employee's hire anniversary date. The personnel file of Employee 4 revealed the employee was hired as the Social Services Director (SSD) on 03/16/2024. The last recorded abuse training was dated 03/25/2024. The DSD confirmed that Employee 4's abuse training was overdue. The personnel file of Employee 5 revealed the employee was hired as the Registered Dietitian on 05/06/2019. The last recorded abuse training was dated 05/16/2019. The DSD confirmed that Employee 5's abuse training was overdue. The personnel file for Employee 8 revealed the employee was hired as a Certified Nursing…

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 kept safe from physical abuse for 1 of 5 sampled residents (Resident 2) and a resident was protected from abuse by another resident with increasingly aggressive behaviors for 1 of 5 sampled residents (Resident 4). The deficient practice had the potential for the residents to experience emotional and physical harm. Findings include: Resident 2 (R2) R2 was admitted on [DATE] with diagnoses including other specified disorders of bone density and structure of left ankle and foot, type 2 diabetes, and chronic obstructive pulmonary disease. Resident 3 (R3) R3 was admitted on [DATE] and discharged on 09/18/2024 with diagnoses including unspecified psychosis, schizophrenia, and unspecified dementia. The facility reported incident (FRI) dated 09/24/2024 documented the following: -On 09/18/2024 at approximately 7:00 PM, R3 was observed being physically aggressive with R2 and striking R2's body. - R2 and R3 were immediately…

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 medications left on top of a medication cart were secured. The deficient practice had the potential risk of unauthorized access to medications, medication errors, theft, or misuse of medication within the facility. Findings include: On 03/12/2025 at 12:24 PM, a medication cart with a medication card containing 20 tablets of Divalproex Sodium delayed release (DR) 500 milligram (mg) (a medication used to treat seizures), was parked unattended at the entrance of the northeast hallway in front of a resident room while staff, visitors and resident were in the hallway. On 03/12/2025 at 12:27 PM, a Registered Nurse (RN) exited a resident room and approached the medication cart. The RN acknowledged the card of pills stating should not have been left on top of the cart unattended as someone could get the pills and take them. On 03/12/2025 at 2:15 PM, the Director of Nursing (DON) stated medications were to be secured in the medication cart when not being administered. Leaving medications on top of the…

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

Based on observation and interview, the facility failed to ensure a blood glucose monitor with a used test strip was not left unattended on top of medication cart. The deficient practice had the potential to compromise the safety and well-being of residents by allowing exposure to blood borne pathogens. Findings include: On 03/12/2025 at 12:24 PM, a medication cart was parked unattended at the entrance of the northeast hallway in front of a resident room while staff, visitors and resident were in the hallway. A blood glucose monitor with a test strip inserted into the device, was lying on top of the medication cart. The testing strip had a dark red type of substance visible. On 03/12/2025 at 12:27 PM, a Registered Nurse (RN) exited a resident room and approached the medication cart. The RN acknowledged the glucometer had been used to obtain a resident blood sugar and the testing strip needed to be discarded, and the blood glucose monitor needed to be disinfected. The RN stated the glucometer should not have been left unattended. On 03/12/2025 at 2:15 PM, the Director of Nursing…

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 showers were provided as scheduled for 1 of 8 sampled residents (Resident 1). The deficient practice had the potential to negatively impact the resident's overall well-being. Findings include: Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The admission Minimum Data Set (MDS) dated [DATE], documented R1 had moderately impaired cognition and required partial to moderate assistance with supervision touch assist for bathing. Partial to moderate assistance was defined as helper lifts or supports trunk and limbs but helper provided less than half the effort. The shower schedule revealed R1 was scheduled to receive two showers a week on Tuesdays and Fridays by day shift staff. The medical record lacked documented evidence R1 was provided showers on 07/02/2024, 07/09/2024, 07/16/2024 and 07/19/2024. On 08/29/2024 in the…

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

Based on observation, interview and document review, the facility failed to ensure food items stored inside the stand-alone cooler and freezer were labeled, dated, and not expired; containers for juice machine were stored according to manufacturer instruction; items in the unit nourishment rooms were labeled, dated, and not expired. The deficient practice posed a potential risk to safety and health standards which could lead to contamination, inadequate storage, and place residents at risk of foodborne illness. Findings include: On 05/07/2024 at 8:00 AM, the initial tour of the kitchen was completed with the following findings: - in the stand-alone refrigerator a container of sour cream had expired on 05/01/2024. - in the stand-alone freezer there were several food items in Ziploc plastic bags which were not labeled or dated. Items consisted of meat, fruits, vegetables, and dessert items. - the oven/stove ventilation system's last service date was 12/26/2023 and should be cleaned every 90 days. - juice containers for drink machines were being stored in the dry storage area. There…

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 28 (R28) R28 was re-admitted on [DATE], with primary diagnoses including anxiety disorder, depression, bipolar disorder, schizophrenia, and a psychotic disorder (other than schizophrenia). On 05/07/2024 in the morning, R28 laid in bed with eyes on telephone with headphones on. R28 appeared lethargic and spoke stating R28 had been in the facility for a little while. The resident was able to make needs known asking about the ability to smoke marijuana in the facility and being able to use a power wheelchair in the facility. On 05/08/2024 in the afternoon, R28 laid in bed with eyes on telephone with headphones on and appeared lethargic. While talking to the resident about the facility's policy on no marijuana smoking, R28 was not able to talk in complete sentences and was not making sense. R28 was talking nonsensical. A PASARR level one document dated 03/14/2016, revealed R28 did not have dementia, mental illness (MI), intellectual disability, (ID) mental retardation (MR) or any related condition (RC) 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, interviews, record reviews, and document review, the facility failed to ensure the medication administration record was not signed off before the medications were administered for 2 of 20 sampled residents (Residents 75 and 246). The deficient practice could have the potential risk to resident safety, medication errors, missed doses, or incorrect dosages, and adverse health outcomes. Findings include: Resident 246 (R246) R246 was admitted on [DATE], with diagnoses including osteomyelitis and anemia. On 05/09/2024 at 8:48 AM, a Licensed Practical Nurse (LPN) in the Northeast Unit prepared eight medications, placed in medication cups, and promptly signed the medication administration record (MAR) to confirm the medications were completely administered. R246 refused two medications. The LPN explained the MAR had been signed off before the actual medication administration due to being preoccupied later and might forget to sign. On 05/09/2024 at 11:41 AM, the Assistant Director of Nursing (ADON)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and document reviews, the facility failed to ensure: 1) A resident's wound was cleansed, dressing was replaced or applied as ordered when the wound was soaked with urine and feces for 1 of 20 sampled residents (Resident 70), and 2) The wound treatment orders were obtained and transcribed before the treatment was provided for 1 of 20 sampled residents (Resident 55). The deficient practice could have the potential to cause delayed healing, worsened wounds, infection, and further complications. Findings Include: Resident 70 (R70) R70 was admitted on [DATE] and readmitted on [DATE], with diagnoses including pressure-induced deep tissue damage of the sacral region and the presence of a right artificial hip joint. A physician order dated 05/04/2024, documented wound care to the right buttock to cleanse with normal saline, pat dry, apply Medihoney, apply zinc paste, and cover with a clean dry dressing on day shift on Monday, Wednesday, and Friday for 30 days. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and document review, the facility failed to ensure: 1) The formula bag or container was labeled with the resident's name, TF rate, date/time, and nurse's initials as ordered, 2) A physician's order of the tube feeding (TF) rate was obtained and transcribed for 1 of 20 sampled residents (Resident 55) and, 3) The care orders for the gastrostomy (GT) site and dressing change were obtained, transcribed, and implemented for 1 of 20 sampled residents (Resident 55). These deficient practices could have led to complications such as ineffective nutrition, aspiration, or infection, jeopardizing the resident's health and well-being. Findings include: Resident 55 (R55) R55 was admitted on [DATE] and readmitted on [DATE], with diagnoses including dysphagia (difficulty swallowing) and gastrostomy malfunction. 1) On 05/07/2024 at 10:08 AM, R55 was lying in bed, awake with confusion. R55's TF Glucerna 1.2 was infusing at 70 milliliters (ml) with water flushes at 5 ml/hr. The TF…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure care and management orders were obtained, transcribed, and carried out for residents who were admitted with an intravenous (IV) access for 2 of 19 sampled residents (Residents 65 and 245). The deficient practice placed the residents at risk for an infection. Findings include: Resident 65 (R65) R65 was admitted on [DATE], with diagnoses including hydrocephalus, cardiomegaly, and status epilepticus. On 05/07/2024 at 9:42 AM, R65 laid in bed awake and alert. A double-lumen central venous catheter (CVC) was observed on R65's left upper chest with tape half off, exposing insertion site. R65 indicated the CVC was placed and used at the hospital but had not been used at the facility. R65 indicated staff flushed and replaced the catheter dressing at irregular intervals and no one had discussed with R65 whether the CVC was to be maintained or removed. A hospital radiology report dated 03/11/2024, revealed a dual lumen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and document review, the facility failed to ensure the resident's arteriovenous fistula (AVF) for dialysis access was assessed, a physician order was obtained, and the bruit/thrill was monitored for 1 of 20 sampled residents (Resident 70). This deficient practice posed a potential risk of infection and ineffectiveness in dialysis treatment. Findings include: Resident 70 (R70) R70 was admitted on [DATE] and readmitted on [DATE], with diagnoses including chronic kidney disease and dependence on renal dialysis. On 05/07/2024 at 1:41 PM, R70 was unavailable and out of the facility. A Registered Nurse (RN) indicated R70 was on dialysis. On 05/08/2024 at 1:00 PM, R70 was in bed, with eyes open and noted resident was blind. R70 had a permacath or tunneled catheter in the right upper chest covered with a dressing and arteriovenous fistula (AVF) in the left upper arm. The family indicated the AVF dialysis access site was placed approximately two months ago and explained…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and document reviews, the facility failed to ensure their medication error rate was below five (5) percent (%) when two errors were identified with 25 opportunities observed, calculating an error rate of 8 %. Failure to follow physician orders and timely administer medications posed a potential risk of injury or harm to the resident. Findings include: Resident 246 (R246) R246 was admitted on [DATE], with diagnoses including osteomyelitis and anemia. On 05/09/2024 at 8:48 AM, the LPN in the Northeast unit prepared eight medications, except Lactobacillus. A Physician order dated 04/29/2024, documented Lactobacillus oral capsules to give 1 capsule by mouth three times a day for gastrointestinal prophylaxis. The Medication Administration Record (MAR) dated 05/09/2024, documented the Lactobacillus was administered. On 05/09/2024 at 1:03 PM, a Licensed Practical Nurse (LPN) in the Northeast Unit confirmed the Lactobacillus was missed and was not administered timely.…

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

Based on interview and document review, the facility failed to ensure the facility assessment was reviewed and updated when staffing levels were reduced beginning October 2023, and the input of department heads were taken into consideration in accordance with the facility's policy. The deficient practice had the potential to ensure resident's care needs were met. Findings include: The Facility Assessment policy revised October 2018, documented a designated team would conduct a facility-wide assessment once a year and as needed to ensure resources were available to meet the specific needs of the residents. The facility assessment included a detailed review of the resident population which included resident acuity (severity of patient's illness or medical condition) as well as a detailed review of resources available to include staff type and staffing plan. The team would include the medical director, administrator, director of nursing services, infection preventionist, and all department heads (social services, dietary, activities, rehabilitation, environmental services). The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and document review, the facility failed to ensure 1 of 20 sampled residents (Resident 101) was free of abuse by a staff member, specifically, an incident involving a staff member who was witnessed to have pushed a resident, which resulted in a fall. The deficient practice had the potential to cause physical harm to the resident. Findings include: A facility policy titled Abuse Prevention Program (undated) documented the administration will protect residents from abuse by anyone to include facility staff. Resident 101 (R101) R101 was admitted on [DATE] and discharged on 04/01/2024, with diagnosis including bipolar disorder, unspecified psychosis, anxiety disorder, unspecified dementia, and altered mental status. A Brief Interview for Mental Status (BIMS; a tool used to screen and identify the cognitive condition of a resident) on 01/17/2024 documented a score of 11, which indicated moderate cognitive impairment. The facility reported incident (FRI) dated 02/01/2024, documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure a pre-admission screening and resident review (PASSAR) was completed prior to admission for 6 of 31 sampled residents (Residents #68, #4, #284, #79, #76 and #75) and 11 unsampled residents. The deficient practice potentially placed residents at risk for inappropriate placement with regards to required level of care. Findings include: The Medicaid Services Manual dated 05/01/2015, documented the provider must assure every resident was screened in accordance with state and federal PASSAR regulations. The provider must present to state and federal reviewers' proof of Level one (PASSAR I) and when indicated, PASSAR level two (PASSAR II) screenings were completed prior to admission and the most recent screening if the individual experienced significant change in physical and mental condition. The services manual documented, a Level I identification screening must be completed by a licensed health care professional for all nursing…

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 consent for a Do Not Resuscitate order was obtained from a person holding a legal power of attorney for medical decision-making for a resident with cognitive impairment for 1 of 31 residents (Resident #140). The deficient practice had the potential to deny the provision of emergency medical treatment, the right to request, deny, or discontinue treatment, and to formulate an advance directive. Findings included: Resident #140 (R140) R140 was admitted on [DATE], with diagnoses including dementia, altered mental status, acute kidney failure, poor appetite, and generalized weakness. On [DATE] at 10:30 AM, the resident had difficulty hearing and was confused. On [DATE] at 11:00 AM, a Licensed Practical Nurse (LPN) confirmed R140 was alert, oriented only to person, and confused. The medical record revealed a Minimum Data Set admission assessment dated [DATE], with a Brief Interview for Mental Status scoring 09 that…

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 the admission nursing assessment by reflecting the actual vision and hearing health impairments for 1 of 31 sampled resident (Resident #140). The deficient practice had the potential to deny the provision of vision and hearing services to improve the quality of life of the resident. Finding included: Resident #140 (R140) R140 was admitted on [DATE], with diagnoses including dementia, altered mental status, acute kidney failure, poor appetite, and generalized weakness. On 06/27/2023 at 10:30 AM, the resident had difficulty hearing and seemed to have vision impairment. R140 did not have eye glasses. Nursing Patient Evaluation (admission assessment) dated 06/21/2023, indicated R140 had adequate hearing bilaterally. admission falls risk assessment dated [DATE], documented vision status was adequate. Daily skilled nursing notes dated from 06/24/2023 through 06/28/2023, did not document R140's vision 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 ensure a baseline care plan included the actual vision and hearing impairment status for 1 of 31 residents (Resident #140). The deficient practice had the potential to deny the provision of vision and hearing services to improve the quality of life of the resident. Finding included: Resident #140 (R140) R140 was admitted on [DATE], with diagnoses including dementia, altered mental status, acute kidney failure, poor appetite, and generalized weakness. On 06/27/2023 at 10:30 AM, the resident had difficulty hearing and seemed to have vision impairment. R140 did not have eye glasses. Nursing Patient Evaluation (admission assessment) dated 06/21/2023, indicated R140 had adequate hearing bilaterally. admission falls risk assessment dated [DATE], documented vision status was adequate. Daily skilled nursing notes dated from 06/24/2023 through 06/28/2023, did not document R140 vision and hearing impairments. Psycho-social…

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 resident with wandering behaviors was re-assessed for wandering and elopement behaviors for 1 of 31 sampled residents (Resident #79) and 2) a resident with swallowing issues who required one-on-one assistance with meals was provided assistance for 1 of 31 sampled residents (Resident #235). The deficient practice placed the residents of concern and other residents at risk for unsafe wandering, elopement, and aspiration. Findings include: Resident #79 (R79) R79 was admitted on [DATE], with diagnoses including neurocognitive disorder with behavioral disturbances, (for which the patient is being followed by psychiatry), severe debility, and hypertension. On 06/27/2023 at 9:00 AM, R79 was observed wandering in the 100-hall unit. R79 entered other resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]). A Certified Nursing Assistant (CNA) observed the situation and re-directed the resident. The CNA indicated R79…

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 clarification orders were obtained for a resident's peripheral intravenous (IV) access which was no longer in use and maintenance care orders were consistently provided for the resident's IV line prior to removal. The deficient practice placed the resident at risk for phlebitis (site infection). Findings include: Resident #235 (R235) R235 was admitted on [DATE], with diagnoses including renal calculi (stones) and dehydration. On 06/27/2023 at 11:00 AM, R235 sat in wheelchair with a right forearm peripheral IV access with dressing dated 06/26/2023. The resident's representative explained the resident was being treated for dehydration through IV fluids but R235's representative indicated being uncertain whether the line was to be maintained or removed because the resident's representative had not received communication regarding the IV access. A laboratory document dated 06/09/2023, revealed R235 had a critical blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure a physician's order was followed for oxygen therapy for 1 of 31 sampled residents (Resident #334). The deficient practice had the potential to impact the well-being of the resident. Findings include: Resident #334 (R334) R334 was admitted on [DATE] with medical diagnoses including respiratory failure with hypoxia (low levels of oxygen) and chronic obstructive pulmonary disease (disease causing airflow blockage in the lungs). On 06/27/2023 at approximately 9:15 AM, R334 was lying in bed using their phone. R334 was on 1.5 liters of oxygen therapy via nasal cannula. R334 indicated they were on 3 liters of oxygen and since being in the facility, nursing staff turned their oxygen on and off. A Physician Order dated 06/14/2023 revealed the following: - Administer oxygen at 3 liters per minute via nasal cannula continuously every shift for respiratory failure with hypoxia. On 06/28/23 at 12:30 PM, a Registered Nurse (RN)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure dietary orders were followed for a resident with mechanically textured diet and a history of weight loss for 1 of 31 sampled residents (Resident #15). This deficient practice placed the resident at risk for choking and weight loss. Findings include: Resident #15 (R15) was admitted on [DATE] and readmitted on [DATE] with diagnoses including mild protein-calorie malnutrition, anorexia and dysphagia, oropharyngeal phase. The resident had a loss of or no teeth and a history of weight loss. The Nutritional Care Plan dated 05/26/23, indicated the resident was at risk for nutritional problem related malnutrition, nutritional deficiency disorder, and poor intake by mouth. The goal was to maintain adequate nutritional status including the consumption of at least 75-100% of all meals daily through review date. Interventions included monitoring, documenting, reporting as needed any sign/symptoms of dysphagia (including several…

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 products were labeled, proper sanitation was being utilized for three-compartment sink and juice beverage station, dishwasher was properly cleaned, and nourishment room was free from pests. The failure had the potential to put residents at the facility at risk for receiving contaminated food or drinks. On 06/27/2023 at 7:40 AM the stand alone freezer contained a food product which was removed from box and sitting on shelf in plastic, dated, no label to identify product. On 06/27/2023 at 7:45 AM, the dietary aide was working at the three compartment sink and was not able to describe correct sequence for cleaning the dishes using the three compartment sink. There was no sanitizer being utilized and only had water with soap in the middle section of the sink. On 06/27/2023 at 7:48 AM, the Dietary Manager (DM) indicated there should be one sink used for soap, one sink for rinse water, and third sink should be full of sanitizer. The DM confirmed sink had used dishes not yet cleaned in all sections 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.