Pershing General Hospital SNF

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 five percent (%). There were 29 opportunities and two medication errors. The medication error rate was 6.9%. Findings include: Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including heart failure, unspecified, dry eye syndrome of bilateral lacrimal glands, and abnormal results of other function studies of the eye. On 10/17/2024 at 8:08 AM, a Registered Nurse (RN) began preparing medications for Resident #6. The RN verbalized the physician ordered Restasis Ophthalmic Emulsion eye drops were not available in the facility and were on order from the pharmacy. The RN verbalized Resident #6's physician ordered medications for the morning medication pass included Metoprolol 12.5 milligrams (mg). The RN compared the bubble pack containing Metoprolol to the physician order on the 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 observation, interview, clinical record review, and document review the facility failed to ensure 1 of 5 residents reviewed for medication administration were free from significant medication errors (Resident #6). This deficient practice had the potential to cause worsening of the resident's diagnosed heart failure. Findings include: Resident #6 Resident #6 was admitted to the facility on [DATE], with a diagnosis of heart failure, unspecified. Resident #6's MAR documented Metoprolol Tartrate oral tablet 25 milligrams (mg), give one half tablet by mouth two times a day related to heart failure, unspecified and tachycardia unspecified. Nurse to hold medication if blood pressure is lower than 90/50 and/or heart rate is lower than 50. The order date was 09/10/2024. On 10/17/2024 at 8:08 AM, during medication pass observation, a Registered Nurse (RN) began preparing medications for Resident #6. The RN verbalized Resident #6's physician ordered medications for the morning medication pass included Metoprolol…

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 psychotropic behavior monitoring was documented on the Behavioral Health (BH) Record for 6 of 12 sampled residents (Resident #2, #5, #11, #12, #24, and #25) and records were accurate for 1 of 5 residents observed during medication administration (Resident #6). Findings include: Incomplete Records Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of major depressive disorder, recurrent, unspecified. A physician order dated 02/18/2024, documented behavior monitoring every day and night shift related to major depressive disorder, recurrent, unspecified. Resident #2's October 2024 BH Record documented behavior monitoring every day and night shift related to major depressive disorder, recurrent, unspecified. The BH record had blank spaces for behavioral monitoring during the day shift on 10/03/2024 and 10/13/2024. Resident #2's clinical record lacked documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review the facility failed to ensure the Restorative Nursing Program (RNP) was provided to 13 of 13 residents in need of restorative nursing services (Resident #1, #2, #3, #7, #10, #11, #12, #15, #16, #17, #20, #21, and #23). Findings include: On 04/09/2024 at 2:48 PM, the Restorative Nursing Aide (RNA) verbalized the facility's RNP had not been active since January 2024, when the Licensed Practical Nurse (LPN) providing restorative nursing care changed job duties due to short staffing. The RNA explained the RNP started back up when the RNA was hired on 04/08/2024. The RNA verbalized the RNA briefly spoke with the Physical Therapist (PT) on 04/08/2024, and referred to the restorative nursing binder for activities to do with the residents. The RNA verbalized the RNA was supposed to document RNP after working with the residents but had not had the opportunity to do so. On 04/09/2024 at 3:01 PM, the Director of Nursing (DON) verbalized the LPN…

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's Abuse Committee, to include the Director of Nursing, failed to understand and identify actual employee to resident verbal and physical abuse had occurred toward a resident for 1 of 13 sampled residents (Resident #3) and 2) the facility failed to ensure the Director of Nursing (DON) in charge of the facility's Restorative Nursing Program (RNP), had the knowledge and skills needed to manage the program. Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter, dysphagia, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and quadriplegia, unspecified. A Facility Reported Incident (FRI) dated 03/21/2024, and concluded on 03/25/2024, documented 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 clinical record review, interview and document review, the Administrator failed to ensure a Restorative Nursing Program (RNP) was maintained for residents with the potential to participate in the program and failed to ensure the Abuse Committee investigated allegations of employee to resident abuse by applying the current definition of abuse as per 42 CFR Chapter IV, Part 483, Section 12, Freedom from Abuse, Neglect, and Exploitation. Findings include: Restorative Nursing Program On 04/09/2024 at 2:48 PM, the Restorative Nursing Aide (RNA) verbalized the facility's RNP had not been active since January of 2024, when the Licensed Practical Nurse (LPN) providing restorative nursing care changed job duties due to short staffing. On 04/09/2024 at 3:01 PM, the Director of Nursing (DON) verbalized the LPN providing restorative nursing care changed job duties the week of 01/08/2024, due to short staffing. The DON confirmed from 01/08/2024, to 04/08/2024, nursing staff did not provide restorative care. On 04/15/2024 at 4:18 PM, the Administrator verbalized the facility failed 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.

Based on personnel record review, interview and document review, the facility failed to ensure 10 of 20 facility staff received training on the facility's Quality Assurance and Performance Improvement (QAPI) program. Findings include: The following employee records lacked documented evidence QAPI training had been completed: -Employee #2, with a title of Director of Nursing and a start date of 12/05/2023. -Employee #4, with a title of Registered Dietitian and a start date of 06/28/2017. -Employee #8, with a title of Certified Nursing Assistant and a start date of 06/03/2003. -Employee #16, with a title of Certified Nursing Assistant and a start date of 01/23/2024. -Employee #13, with a title of Registered Nurse and a start date of 12/13/2023. -Employee #15, with a title of Licensed Practical Nurse and a start date of 12/20/2021. -Employee #18, with a title of Dietary Aide/Cook and a start date of 11/20/2023. -Employee #19, with a title of Dietary Aide/Cook and a start date of 06/16/2017. -Employee #20, with a title of Housekeeper and a start date of 01/24/2023. -Employee #21, with 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 ensure a resident's right to be treated with respect and dignity was protected when a care plan was updated to include sexual behaviors of the resident, as the facility response to the resident experiencing abuse. A cognitively impaired, non-verbal resident without previously identified behaviors had a care plan initiated as part of their clinical record without evidence or assessment of a change in the resident's baseline, after facility staff observed physical and verbal abuse by a Certified Nursing Assistant (CNA1) toward the resident for 1 of 13 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter, dysphagia, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral…

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 a resident's Guardian gave informed consent prior to placing an air mattress on top of a resident's bariatric bed for 1 of 13 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter, dysphagia, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and quadriplegia, unspecified. On 04/08/2024 at 11:05 AM, Resident #3 was in a geri-chair next to the bed. The bed was a bariatric bed with an air mattress on the top of the bed. Resident #3's clinical record lacked a care plan addressing the air mattress on the top of the bariatric bed. Resident #3's clinical record lacked documented evidence…

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 protect a resident's right to be free from verbal and physical abuse by a Certified Nursing Assistant (CNA) for 1 of 13 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter, dysphagia, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and quadriplegia, unspecified. A Facility Reported Incident (FRI) dated 03/21/2024, and concluded on 03/25/2024, documented a Dietary Aid (Food Services Supervisor) had overheard a CNA1 tell Resident #3 I told you I would slap you if you did that again. The FRI was unsubstantiated by the facility for failure to prove Resident #3 experienced a negative psychosocial…

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 implement the facility's Abuse policies regarding identification, investigation, protection and reporting for an allegation of verbal and physical abuse toward a resident by a Certified Nursing Assistant (CNA) for 1 of 13 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter, dysphagia, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and quadriplegia, unspecified. A Facility Reported Incident (FRI) dated 03/21/2024, and concluded on 03/25/2024, documented a Dietary Aid (Food Services Supervisor) had overheard a CNA tell Resident #3 I told you I would slap you if you did that again. The FRI was…

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 fall resulting in serious bodily injury was reported the State Agency (SA) for 1of 13 sampled residents (Resident #7). Findings include: Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance and wandering in diseases classified elsewhere. A Post Fall Evaluation dated 01/21/2024, documented Resident #7 fell in the facility's dining area. Resident #7 fell backward and struck the back of the resident's head on a door frame. Resident #7 lost consciousness for five seconds and was transferred to the emergency room (ER) for further assessment. On 04/11/2024 at 1:10 PM, the Administrator explained falls resulting in serious bodily injury were required to be reported to the SA. The Administrator verbalized the Administrator's understanding was a fall including the resident striking the resident's head with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interview, and document review, the facility failed to provide a discharge notification to the State Long Term Care Ombudsman for 1 of 3 discharged residents (Resident #26). Findings include: Resident #26 Resident #26 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus with other specified complications and chronic obstructive pulmonary disease, unspecified. A Nurse's Note dated 03/03/2024, documented the resident was found to have slurred speech and altered mental status. The resident was transferred to the hospital for consultation. The resident was discharged from the facility on 03/04/2024. Resident #26's clinical record lacked documented evidence a notification of discharge was provided to the State Long Term Care Ombudsman's office. On 04/09/2024 at 10:08 AM, the Minimum Data Set (MDS) Registered Nurse (RN) confirmed the MDS RN was responsible for notifying the State Long Term Care Ombudsman's office of discharges. The MDS RN confirmed…

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, interview, and document review the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 3 of 13 sampled residents (Resident #2, #15 and #17). Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic respiratory failure with hypoxia and vascular dementia, moderate, with mood disturbance. On 04/08/2024 at 1:06 PM, Resident #2 denied having an indwelling catheter in place currently or recently. Resident #2's MDS Section H - Bowel and Bladder, dated 03/11/2024, documented Resident #2 had an indwelling catheter. Resident #2's clinical record lacked any other documented evidence of the presence of an indwelling catheter. On 04/10/2024 at 3:35 PM, the MDS Coordinator confirmed Resident #2 did not have an indwelling catheter in place at the time the MDS dated [DATE], was completed and the indwelling catheter was marked in error. Resident #15 Resident #15 was admitted 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 clinical record review, interview, and document review the facility failed to ensure a care plan was developed and implemented related to 1) a resident's indwelling catheter (Resident #19), 2) a resident's end-of-life/comfort care (Resident #24), and 3) a resident's air mattress (Resident #3) for 3 of 13 sampled residents. Findings include: Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including unspecified sequelae of cerebral infarction and schizoaffective disorder, unspecified. A physician's order dated 04/07/2024, documented indwelling catheter. Resident #19's clinical record lacked a care plan related to the presence or care of the resident's indwelling catheter. On 04/10/2024 at 3:31 PM, the Minimum Data Set (MDS) Coordinator verbalized catheters and catheter care should be included in a resident's care plan when the resident had an indwelling catheter. The MDS Coordinator explained the care plan would include interventions such as signs and symptoms to monitor…

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, interview, and document review, the facility failed to follow physician's orders for insulin therapy for 2 of 13 sampled residents (Resident #9 and #13). Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], with a diagnosis of type II diabetes mellitus with unspecified complications. A physician's order dated 10/10/2023, documented NovoLOG Insulin FlexPen subcutaneous solution pen-injector 100 unit/milliliters (ml), (Insulin Aspart). Inject as per sliding scale subcutaneously before meals and at bedtime related to type II diabetes mellitus with unspecified complications: - if blood sugar was between 150 - 200, inject two units; - 201 - 250 = four units; - 251 - 300 = six units; - 301 - 350 = eight units; - 351 - 400 = ten units; - 401 - 450 = 12 units. Give insulin as directed and call provider. Resident #9's Medication Administration Record (MAR) dated February 2024, documented the resident's blood sugar was over 400 on the following 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 observation, clinical record review, interview and document review, the facility failed to assess an air mattress for entrapment and restraint for 1 of 13 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter, dysphagia, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and quadriplegia, unspecified. On 04/08/2024 at 11:05 AM, Resident #3 was in a geri-chair next to the bed. The bed was a bariatric bed with an air mattress on the top of the bed. Resident #3's clinical record lacked a care plan addressing the air mattress on the top of the bariatric bed. Resident #3's clinical record lacked documented evidence the risk and benefits were explained to the resident's Guardian 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 interview, clinical record review, and document review the facility failed to ensure 1) a resident with an indwelling catheter had orders in place for ongoing care of the catheter, 2) catheter care provided to a resident was documented in the resident's clinical record, and 3) a care plan was developed and implemented related to an indwelling catheter for 1 of 13 sampled residents (Resident #19). Findings include: Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including unspecified sequelae of cerebral infarction and schizoaffective disorder, unspecified. Resident #19's admission Record documented on 04/04/2024, the onset of the diagnoses of other symptoms and signs involving the genitourinary system and retention of urine, unspecified. A physician's order dated 04/07/2024, documented indwelling catheter. On 04/10/2024 at 3:11 PM, a Certified Nursing Assistant (CNA) verbalized the catheter care CNAs provided to residents included emptying the catheter bag, recording…

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, clinical record review, and document review the facility failed to ensure 1) a multidose vial was discarded by the use by date, 2) discontinued medications were disposed of timely and 3) the temperature of a refrigerator containing medications was logged daily for 1 of 1 sampled medication rooms. Findings include: Multidose Vial On 04/09/2024 at 4:23 PM, during an inspection of the medication storage room in the presence of a Registered Nurse (RN), a vial of tuberculin purified protein derivative, diluted aplisol 5 tuberculin units (TU)/0.1 milliliters (ml) was located in a refrigerator. The vial was inside the manufacturer box, 11/28 was written on the box. The box contained the following instruction: Once entered, vial should be discarded after 30 days. The RN confirmed the date written on the box was 11/28 and the vial should have been discarded prior to 04/09/2024. On 04/10/2024 at 10:05 AM, the Director of Nursing (DON) explained the expectation of nursing staff when a multidose vial was opened was to write the date opened on the vial. The vial…

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 assist a resident in obtaining dental services after a resident experienced bleeding gums for 1 of 13 sampled residents (Resident #10). Findings include: Resident #10 Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of cerebellar stroke syndrome. On 04/08/2024 at 2:36 PM, Resident #10's Guardian explained the resident had dental issues in the past and there was supposed to be a follow-up appointment but the Guardian did not know if a dental appointment was made. A physician's order dated 11/22/2021, documented the facility may arrange for podiatry, dental, psychiatric, audiology and vision consultations as needed. A care plan initiated 04/07/2023, and revised 10/12/2023, documented the resident had oral/dental health problems related to poor oral hygiene, needing supervision with oral care, and history of cavities. The care plan documented an intervention to coordinate arrangements…

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 resident's allergy restrictions were accommodated related to lactose intolerance for 1 of 13 sampled residents (Resident #17). Findings include: Resident #17 Resident #17 was admitted to the facility on [DATE], with a diagnosis of lactose intolerance, unspecified. On 04/08/2024 at 10:28 AM, Resident #17 verbalized the resident could not eat cheese because the resident was lactose intolerant. The resident explained the resident sometimes received cheese with the resident's meals and the resident was served eggs with cheese on top for the resident's breakfast on the morning of 04/08/2024. Resident #17's physician's orders documented the following: -Order date 05/31/2023, resident to dairy-free products as a replacement for whole milk. -Order date 02/18/2024, regular diet, regular texture, thin consistency, related to lactose intolerance, unspecified. Resident #17's comprehensive care plan initiated 08/10/2023, 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, clinical record review and document review, the facility failed to ensure a resident's clinical record was complete when an Minimum Data Set 3.0 (MDS) assessment was not completed for a resident upon discharge from the facility for 1 of 1 resident selected for Resident Assessment (Resident #22) and care provided related to a resident's indwelling catheter was documented in the resident's clinical record for 1 of 13 sampled residents (Resident #19). Findings include: Resident #22 Resident #22 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy and major depressive disorder, recurrent, unspecified. A Transfer/Discharge Report documented Resident #22 was discharged from the facility on 11/20/2023. Resident #22's clinical record lacked a discharge MDS assessment. On 04/09/2024 at 9:26 AM, the MDS Coordinator verbalized the facility was required to complete MDS assessments upon a resident's entry to the facility, with any changes in condition, and upon…

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, personnel record review and document review, the facility failed to ensure infection control training was provided timely to 1 of 20 sampled employees (Employee #9). Findings include: Employee #9 Employee #9 was hired as the Minimum Data Set (MDS) Coordinator on 08/16/2021. Employee #9's personnel record documented infection control training was last completed on 01/25/2023. The employee's personnel record lacked documented evidence infection control training had been completed for 2024. On 04/15/2024 at 3:17 PM, the Human Resources (HR) Generalist verbalized infection control training was required to be completed upon hire and annually. The HR Generalist confirmed Employee #9 had not completed infection control training timely. The facility policy titled Long-Term Care Staff Continuing Education, reviewed 04/13/2023, documented all permanent nursing department employees shall receive infection control educational programs yearly.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review and document review, the facility failed to ensure residents were treated with dignity when residents felt bother, annoyed, or harassed by other residents' comments and behaviors for 2 of 15 Facility Reported Incident (FRI) residents (Resident #2 and #3). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus with unspecified complications and acquired absence of right leg above knee. Resident #2 Resident #2 was admitted to the facility on [DATE], with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. FRI #NV00069712 documented on 10/23/23, Resident #1 was in the dining room getting coffee when Resident #2 walked by and stated you guys need to get Resident #1 black glasses, so I don't have to see them looking at me. A staff member encouraged Resident #1 to keep walking. Within hearing of 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 interview and document review, the facility failed to ensure a non-verbal resident was not verbally abused by a staff member for 1 of 15 Facility Reported Incident (FRI) residents (Resident #12). Findings include: Resident #12 Resident #12 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela, quadriplegia, unspecified, paraplegia, unspecified, and aphasia following unspecified cerebrovascular disease. FRI #NV00070158 dated 01/03/24, documented Resident #12 was receiving a beverage in the dining room on the morning of 12/28/23, when a Dietary Aide (DA) overheard a Certified Nursing Assistant (CNA1) say shut the (expletive) up to the resident. The DA reported the incident to the Dietary Manager on 01/03/24, and an investigation was initiated. Resident #12's clinical record lacked any documentation of the incident. Resident #12's Minimum Data Set 3.0 Assessment (MDS), Section…

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

Based on interview, record review and document review, the facility failed to ensure a Facility Reported Incident (FRI) was completed and submitted timely to the State Agency (SA) for allegations of abuse for 1 of 15 FRIs. Findings include: FRI #NV00069839 with the allegation of resident to resident abuse was submitted to the SA on 11/14/23. The allegation was made on 11/12/23. On 02/28/24 at 4:19 PM, the Chief Nursing Officer confirmed the FRI was submitted late and outside of the required timeframes. On 2/28/24 at 2:41 PM, the Administrator verbalized allegations of abuse and neglect were to be reported to the SA within two hours if bodily harm occurred, 24 hours for all other allegations of abuse and neglect, and the final report was to be submitted within five working days of the incident. The facility policy titled Abuse Prevention and Prohibition, last revised 08/25/23, documented the abuse investigation team would report suspected abuse via the Facility Reported Incident form for all alleged violations of abuse, neglect, exploitation, mistreatment, and misappropriation 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 interview, record review and document review, the facility failed to 1) ensure an allegation of employee to resident verbal abuse was thoroughly investigated and documented for 1 of 15 Facility Reported Incident (FRI) residents (Resident #12) and 2) report investigation results within five working days of the for 2 of 15 FRIs (NV00070209 and NV00070124). Findings include: Employee to Resident Altercation Resident #12 Resident #12 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela, quadriplegia, unspecified, paraplegia, unspecified, and aphasia following unspecified cerebrovascular disease. FRI #NV00070158 dated 01/03/24, documented Resident #12 was receiving a beverage in the dining room on the morning of 12/28/23, when a Dietary Aide (DA) overheard a Certified Nursing Assistant (CNA) say shut the (expletive) up to the resident. The DA reported the incident to the Dietary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review, the facility failed to ensure a care plan was developed and implemented related to 1) post-traumatic stress disorder and psychotic disorder with hallucinations for 1 of 15 Facility Reported Incident (FRI) investigated residents (Resident #14), 2) following an investigation for employee to resident verbal abuse for 1 of 15 FRI investigated residents (Resident #12), and 3) inappropriate behaviors for 2 of 15 FRI investgated residents (Resident #1 and #4). Findings include: Resident #14 Resident #14 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including post-traumatic stress disorder (PTSD), chronic, altered mental status, unspecified, and psychotic disorder with hallucinations due to known physiological condition. Resident #14's physician order dated 04/18/23, documented the following: Cymbalta oral capsule delayed release particles 60 milligrams (mg), give one capsule by mouth one time a day for anxiety 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 clinical record review, interview, observation, and document review, the facility failed to protect a resident from abuse and harassment by another resident and prevent further abuse and harassment for 2 of 12 sampled residents (Resident #2 and Resident #6) and ensure a resident was not verbally and physically abused by a Certified Nursing Assistant (CNA) when providing peri-care for 1 of 12 sampled residents (Resident #20). Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], with diagnoses including major depressive disorder and mild cognitive impairment of uncertain etiology. Resident #2's Communication Note dated 10/09/23, documented by an Activities Aide, documented after a Resident Council meeting, Resident #2 went into the activity office for a personal conversation. Resident #2 started crying because after the Resident Council meeting, Resident #6 balled out Resident #2 for not telling the truth regarding meals being served in a timely manner. During the conversation…

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, clinical record review, and document review, the facility failed to submit an initial Facility Incident Report to the State Agency within two hours for 1 of 1 Facility Reported Incidents (FRI). Findings include: On 10/18/23 at 3:40 PM, CNA1 confirmed witnessing CNA2 forcefully rolling a resident in bed to provide morning peri-care. CNA1 did notified the Director of Nursing of the incident until the afternoon of 08/24/23. The facility's documented timeline indicated the Social Worker received the allegation of employee to resident abuse on 08/24/23 at 3:30 PM. An initial FRI #NV00069288 was submitted to the State Survey Agency on 08/24/23 at 8:38 PM, with the allegation of employee to resident abuse, three hours late. On 10/19/23 at 10:59 AM, the Administrator verbalized the Administrator was part of the facility Abuse Prevention Team (Abuse Investigation Team). The Administrator confirmed the initial report for alleged employee to resident abuse was not reported to the State Agency within the two-hour required timeframe. The facility policy titled Reporting…

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 a care plan was developed following employee to resident abuse for 1 of 12 sampled residents (Resident #20). The failure had the potential to delay implementation of appropriate resident care interventions. Findings include: Resident #20 Resident #20 was admitted to the facility on [DATE], with diagnoses including unspecified sequelae of cerebral infarction, contracture of muscle and mild cognitive impairment of uncertain or unknown etiology. An initial Facility Reported Incident (FRI) dated 08/24/23, documented an employee to resident abuse on 08/24/23, at 3:30 PM. The FRI documented a Certified Nursing Assistant (CNA) witnessed another CNA forcefully push Resident #20 to the edge of the bed to provide peri-care. Resident #20 met with the Social Worker alleging employee to resident abuse. Resident #20's Comprehensive Care Plan lacked a care plan related to the employee to resident abuse. On 10/19/23 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.