North Las Vegas Care Center

Based on interview and record review, the facility failed to ensure the facility assessment policy was reviewed and updated to reflect new guidance which included the active involvement of direct care staff, input from residents, resident representatives, family members and ensuring there were sufficient number of competent staff to meet the needs of each resident and failed to involve direct care staff in the development of the facility assessment. The deficient practice had the potential to result in an incomplete evaluation of resident population and facility resources, which could affect staffing decisions, training, and availability of services needed to meet resident needs. Findings include: A review of the facility assessment policy dated 2017 revealed the policy had not been updated to include new Centers for Medicare and Medicaid (CMS) guidance which included: active involvement of direct care staff and input from residents, resident representatives and family members in developing the facility assessment. The facility assessment tool did not include documentation to show…

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 had a Quality Assurance Performance Improvement (QAPI) plan. This deficient practice had the potential to negatively affect the outcomes of resident care and the quality of each resident's life.Findings include:On 08/29/2025 at 12:02 PM, the Administrator was not able to locate the facility specific QAPI plan. The Administrator explained that the facility was using the QAPI policy until the plan could be found.A facility policy titled, Quality Assurance and Performance Improvement Program Committee Guidelines, revised on 09/29/2021, did not identify the requirement of developing a facility specific QAPI Plan containing the processes that will guide the nursing home's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved. The QAPI Plan was used to guide the organizational and facility performance improvement efforts.

Based on observation, interview, and document review, the facility failed to maintain the laundry environment in a sanitary condition by allowing a non-operational dryer located in the clean area of the laundry to accumulate dust inside and on the exterior surfaces. The deficient practice had the potential to contaminate the clean linens and increase the risk of infection for residents.Findings include:On 08/29/2025 at 10:38 AM, the clean area of the laundry room revealed a bank of four commercial dryers. One dryer was non-operational and had visible dust and lint accumulated inside the drum, on exterior surfaces, and in the gap between machines. The dryer was in the clean area of the laundry where clean linens and clothes were processed and stored. On 08/29/2025 at 10:38 AM, the Director of Maintenance described the dryer as moderately dirty with lint and dust build up on inside and outside of machine.On 08/29/2025 at 10:40 AM, the laundry aide indicated the dryer had been broken for at least three years since the laundry aide began working at facility. The laundry aide verbalized…

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 medication was administered timely to 1 of 3 sampled residents (Resident #2). The deficient practice had a potential for the intended use of the medication to be insufficient or ineffective with a possible cause of harm to the resident. Findings include: Resident #2 (R2) R2 was originally admitted to the facility on [DATE] with diagnoses of Parkinson's Disease without dyskinesia, chest pain, personal history of transient ischemic attack, and cerebral infarction without residual deficits. A physician order dated 06/07/2024 for Doxycycline Hyclate 100 milligram (mg) tablet was ordered for cellulitis and was to be given at 9:00 AM and 9:00 PM. The medication administration record (MAR) revealed the resident missed the 9:00 PM dose on 06/07/2024, both doses on 06/08/2024, and the first dose of the medication was administered on 06/09/2024 at 9:00 AM. The MAR documented the facility was awaiting delivery 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide pain medication as requested, assess, and document resident pain level accurately according to physician's order for 1 of 1 unsampled residents (Resident 4). The deficient practice placed the resident at risk for ineffective and inadequate pain control. Findings include: Resident 4 (R4) was admitted on [DATE] with diagnoses including angina pectoris, muscle wasting and atrophy, chest pain, absences of right and left leg below the knee, and pain. On 01/30/2025 at 10:23 AM, a Licensed Practical Nurse (LPN3) verbalized if medication is not available for a resident, a nurse should check the Omnicell (onsite medication dispensing machine) for the medication before waiting for the pharmacy to deliver the medication. On 01/30/2025 at 10:35 AM, the Registered Nurse Unit Manager (RN3) indicated the nurses use the Omnicell often to ensure resident do not go without medication. On 01/30/2025 at 10:42 AM, R4 was lying in bed, alert 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 complete a Preadmission Screening and Resident Review (PASARR) Level 2 evaluation for newly found changes or diagnosis for 4 of 32 sampled residents (Resident 115, 81, 139 and 119). The deficient practice had the potential to place residents at risk of not being evaluated for appropriate determination of necessary behavioral health services. Findings include: Resident 115 (R115) R115 was admitted on [DATE], with an admitting diagnoses including chronic pancreatitis and blindness. On 08/09/2024 at 9:00 AM, the resident was observed lying in bed. During the introduction, R115 stated not wanting to talk to anyone and sternly ordered to leave the room. On 08/10/2024 and 08/11/2024 in the morning, R115 was observed wheeling self along the hallways while constantly talking to self. R115 was observed stopping at other resident room doorways and continuously talking even with no one inside the room. R115's admission History 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 1) the physician was notified of a high Vancomycin trough level (laboratory monitoring of Vancomycin to maintain therapeutic blood levels and prevent serious side effects) prior to administration of next dose and, 2) there was a physician order to hold Vancomycin when the nurse decided to not administer the medication during subsequent shift for a resident who was being treated for bacterial pneumonia for 1 of 32 sampled residents (Resident 143). The deficient practice placed the resident at risk for ineffective antibiotic therapy and serious side effects. Findings include: Resident 143 (R143) R143 was admitted on [DATE] and readmitted on [DATE], with diagnoses including intracranial injury with loss of consciousness and bacterial pneumonia. A physician's order dated 09/08/2024, documented to give Vancomycin reconstituted solution 1,000 milligrams (mg) 1.25 grams, intravenously (IV) every eight hours at 8:00 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and document review the facility failed to ensure care orders were entered and carried out for a colostomy (a surgical opening in the abdomen which provides a means for the collection of waste from the colon) in accordance with the resident care plan and facility policy for 1 of 32 sampled residents (Resident 69). The deficient practice had the potential for introducing infection and negative outcome of residents with a colostomy. Findings include: Resident 69 (R69) R69 was admitted on [DATE] and readmitted on [DATE]. On 09/09/2024 at 11:30 AM, R69 verbalized receiving care from the Certified Nursing Assistant (CNA) regarding colostomy however was not sure when the last time the barrier wafer was last changed on the colostomy. The medical record lacked documented evidence of any physician orders for the care and management of colostomy. On 09/10/2024 at 9:45 AM a CNA indicated the CNA would provide basic cleaning care for residents with a colostomy. The CNA would…

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 gastrostomy (G-tube) care orders were entered and carried out in accordance with facility protocol for 1 of 32 sampled residents (Resident 79). The deficient practice placed the resident at risk for G-tube complications including but not limited to infection, malposition and discomfort. Findings include: Resident 79 (R79) R79 was admitted on [DATE] and readmitted on [DATE], with diagnoses including metabolic encephalopathy, gastroparesis and gastrostomy malfunction. On 09/09/2024 at 1:34 PM, R79 was awake and able to communicate. A bottle of Glucerna 1.5 and a water bag was hanging on a tube feeding (TF) pump with feeding tube looped around the machine. The Unit Manager indicated R79's enteral feeding schedule was to be started at 7:00 PM and terminated at 7:00 AM. A physician's order dated 05/24/2024, documented to give Glucerna 1.5 at 80 cubic centimeters (cc) per hour for 12 hours via percutaneous endoscopic…

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 it was free of a medication error rate of five percent (%) or greater for one unsampled resident (Resident 58) and 1 of 32 sampled residents (Resident 61). The deficient practice placed other residents at risk for medication errors. Findings include: On 09/10/2024 in the morning, a Medication Administration Pass observation was performed with 32 opportunities observed and revealed three errors. The medication error rate was 9.38%. Resident 58 (R58) R58 was admitted on [DATE] and readmitted on [DATE], with diagnoses including type two diabetes mellitus. On 09/10/2024 at 8:21 AM, the Licensed Practical Nurse (LPN) prepared and administered the following medications to R58: - Metformin hydrochloride (HCl) 500 milligrams (mg), one tablet - Aspirin 81mg chewable, one tablet - Vitamin B12 500 micrograms (mcg), two tablets - Docusate sodium 100 mg, one tablet - Sennosides with docusate sodium 8.6 mg, two tablets - Thiamine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and document review, the facility failed to provide documented evidence influenza and pneumococcal vaccine was provided for 2 of 5 sampled residents (Resident 115 and 81). The deficient practice had a potential to prevent ensuring residents have had the necessary vaccines in fighting off diseases. Findings include: Resident 115 (R115) R115 was admitted on [DATE], with diagnoses including chronic pancreatitis and blindness. R115 Electronic Healthcare Records (EHR) under Preventive Health Care; Vaccinations, Tests & Results documented: No data available. Resident 81 (R81) R81 was admitted on [DATE], with diagnoses including significant for diabetes and neurocognitive disorder. R81 EHR under Preventive Health Care; Vaccinations, Tests & Results documented: No data available. On 09/11/2024 at 12:41 PM, reviewed the EHR with the Infection Preventionist (IP) and confirmed the vaccine records section of the residents were blank. The IP checked the physician's orders and 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 interviews, record review, and document review, the facility failed to provide documented evidence Corona Virus 19 (COVID 19) vaccine was provided for 2 of 5 sampled residents (Resident 115 and 81). The deficient practice had a potential to prevent ensuring residents have had the necessary vaccine in fighting off the specific viral disease. Findings include: Resident 115 (R115) R115 was admitted on [DATE], with diagnoses including chronic pancreatitis and blindness. R115 Electronic Healthcare Records (EHR) under Preventive Health Care; Vaccinations, Tests & Results documented: No data available. Resident 81 (R81) R81 was admitted on [DATE], with diagnoses including significant for diabetes and neurocognitive disorder. R81 EHR under Preventive Health Care; Vaccinations, Tests & Results documented: No data available. On 09/11/2024 at 12:41 PM, reviewed the EHR with the Infection Preventionist (IP) and confirmed the vaccine records section of the residents were blank. The IP checked the physician's orders…

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 verbal abuse or neglect allegation was reported to the abuse coordinator and state agency within the prescribed time for 2 of 7 sampled residents (Residents 1 and 2). The deficient practice could have the potential to put the residents at risk of further abuse or neglect, causing emotional distress and harm. Findings include: Resident 1 (R1) R1 was admitted on [DATE] and readmitted on [DATE], with diagnoses including bilateral hearing loss, weakness, difficulty in walking and abnormalities of gait and mobility and cognitive communication deficit. The Minimum Data Set, dated [DATE], documented a brief interview of mental status score of 5/15, which indicated R1's cognitive status was severely impaired. A facility report, dated 11/01/2023, documented verbal abuse or neglect had occurred on 10/28/2023 at 9:00 PM. A Certified Nursing Assistant 2 (CNA2) had reported Certified Nursing Assistant 1 (CNA1) had yelled and cursed at R1. 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 interviews, record reviews, and document reviews, the facility failed to ensure the allegations of verbal abuse and neglect were thoroughly investigated. The summary of the investigation, outcome or resolution, measures taken, and required documentation were not compiled and maintained for 2 of the 7 sampled residents (Residents 1 and 2). This deficient practice could potentially compromise the safety and well-being of the residents. Findings include: A facility report, dated 11/01/2023, documented verbal abuse or neglect had occurred on 10/28/2023 at 9:00 PM. Certified Nursing Assistant 2 (CNA2) reported hearing Certified Nursing Assistant 1 (CNA1) yell and curse at Resident 1 (R1). On the same night, Resident 2 (R2) had fallen and remained on the floor for an extended hour before the assigned CNA checked on R2. CNA1 was seen sleeping outside the room of the resident. A Licensed practical Nurse (LPN) walked by the R2's room and observed R2 almost falling again. Upon approaching the sleeping CNA about this issue, the LPN was ignored, and CNA1 returned to sleep. 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 a Preadmission Screening and Resident Review (PASRR) level II referral was completed for 8 of 31 sampled residents (Resident 26, 64, 88, 74, 32, 7, 15, and 4). The deficient practice did not identify residents with a potential need for specialized services after a diagnosis of mental disorder (a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior). Findings include: The facility's policy titled PASRR Documentation last revised on 11/01/2017, revealed the facility referred all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for PASARR level II review. Resident 26 (R26) R26 was initially admitted on [DATE] with medical diagnoses including dementia. A Nevada PASRR Level I Identification Determination dated 01/09/2020 documented R26 was appropriate for nursing facility placement. An admission Minimum Data Set (MDS) dated…

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 medications were administered timely for 2 of 31 sampled residents (Resident 73 and 128). The deficient practice had the potential to impact treatment efficacy. Findings include: The facility's policy titled Medication Management Program last revised on 05/05/2023, revealed medications were administered no more than one hour before, to one hour after the designated medication pass time. Resident 73 (R73) R73 was admitted on [DATE] with medical diagnoses including pain, severe protein calorie malnutrition, and on hospice. On 08/30/23 at 9:15 AM, R73 indicated pain medications were consistently administered late by nursing staff. A review of physician orders revealed the following medications were ordered for pain management: - Fentanyl patch, 50 micrograms (mcg) per hour transdermal (through the skin), once every three days with a scheduled administration time of 10:00 AM - Methadone 10 milligrams (mg), 1 tablet every six hours…

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 podiatry follow up was completed for 1 of 31 sampled residents (Resident #61). Failure to identify the need for foot care could put the resident at risk of developing a wound or infection and a decrease of sense of well-being. Findings include: Resident 16 (R16) R16 was admitted on [DATE], with diagnoses including muscle wasting, atrophy, and weakness. On 08/30/2023 at 12:16 PM, R16 was observed with bilateral toenails to be long and unkept. R16 was wearing bilateral foot/lower extremity boots and indicated having a history of foot ulcers. The resident indicated the staff were very good in applying the splints but hasn't said or have done anything about the toenails. R16 indicated routinely going out for podiatry visits but hasn't gone for a while. Review of R16's medical record revealed a podiatry consult visit dated 03/15/2023. The consult note documented a follow up appointment with Podiatry in 2 weeks dated for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure the restorative nursing services were provided per the therapy recommendations for 1 of 31 sampled residents (Resident 130). The deficient practice had the potential for the resident's further decline in physical functioning. Findings include: Resident 130 (R130) R130 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, other abnormalities of gait and mobility, and other lack of coordination. The Physical Therapy (PT) Discharge summary dated [DATE], documented R130 had reached maximum potential with skilled services. The discharge reason was highest practical level achieved. The discharge recommendations included to refer R130 to restorative program for strengthening exercises on both lower extremities. The Occupational Therapy (OT) Discharge summary dated [DATE], documented R130 had reached maximum potential with skilled services. The discharge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an unused intravenous (IV) - lock (a thin, flexible tube placed in a vein in your hand or arm) was discontinued for 1 of 31 sampled residents (Resident #318). The deficient practice had the potential to be a portal of access for any microbial organism causing tissue infection at the insertion site. Finding include: Resident 318 (R318) R318 was admitted on [DATE], with diagnoses including epilepsy and cerebral infarction. On 08/30/2023 at 9:31 AM, R318 was observed with a right forearm IV lock with a double lumen extension. The dressing on the IV lock was dated 08/18/23. R18 nodded no when asked if the IV lock was still being used. There was no IV pump at the bedside. R318's medical record lacked documented evidence of any medications requiring an intravenous access. On 08/31/2023 at 9:01 AM, R 318's right forearm IV lock was still present. A licensed practical nurse (LPN) confirmed the resident was admitted on [DATE] at 10:25PM.…

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 Abnormal Involuntary Movement Scale was completed per the facility's policy (AIMS/a rating scale designed to measure involuntary movements known as tardive dyskinesia which could develop as a side-effect of an antipsychotic medication) for 2 of 31 sampled residents (Resident 77 and 84); and a consent for psychotropic medications was obtained for 2 of 31 sampled residents (Resident 84 and 32). The deficient practice had the potential to result in adverse consequences for the resident's health and well-being. Findings include: Resident 77 (R77) R77 was admitted on [DATE], with diagnoses including history of drug induced subacute dyskinesia and schizoaffective disorder, bipolar type. The following were the physician's orders for R77's Risperdal (an antipsychotic medication): - 07/30/2023, Risperidone (Risperdal) tablet two milligrams (mg) one tablet via gastric tube at bedtime (qhs/every night at bedtime). - 08/16/2023…

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 two multidose medications were labeled accordingly for 1 of 3 medication rooms. The failure to properly identify a discard date of a medication could result in administration of a sub-potent medication. Findings include: On 08/31/2023 at 12:22 PM, observed inside the medication room refrigerator in 300 Hall, was two opened multi-dose vials of Tubersol (Tuberculin PPD) 5 Tuberculin Units (TU)/0.1 milliliters (mL) Solution for injection; (1) lot # 62371 and expires on 10/24, and (2) lot# 57594 and expires on 05/24. Both vials were not labeled as to the open and discard date. On 08/31/2023 at 12:31 PM, the licensed practical nurse (LPN) assigned to the unit confirmed the finding and indicated the opened multi-dose vials of medicine should have been dated with an open and discard date. The LPN indicated multi-dose vials were only valid for use 28 days after opening. On 08/31/2023 at 3:33 PM, the Director of Nursing (DON) acknowledged multidose vials should always be labeled with open and discard date once…

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

Based on observation, interview, and document review the facility failed to ensure the refrigerator in 1 of the 3 nourishment rooms was within the recommended temperature to keep cold foods cold. The deficient practice had the potential to impact the well-being of the residents through potential consumption of hazardous food items. On 08/30/2023 at approximately 8:05 AM, the refrigerator in the 200-hall nourishment room had an internal temperature of 48 degrees Fahrenheit. The Dietary Director confirmed the temperature. The refrigerator contained the following food items: - Three small apple sauce containers - Four milk cartons - Three medium sized plastic bags containing resident specific food items One apple sauce container was pulled from the refrigerator which had an internal temperature of 47 degrees Fahrenheit. The Dietary Director confirmed the temperature. On 08/31/2023 at approximately 12:30 PM, the Dietary Director indicated the Dietary Aides were responsible for checking the refrigerator temperatures in the nourishment rooms and reporting any issues. The Dietary Director…

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 Record of Death and Mortician's Receipt form was completed for 1 of 3 sampled close records reviewed (Resident 157). The deficient practice had the potential for the facility failing to maintain an accurate and complete record to release the body of a deceased person to the appropriate entity and the resident's record of death. Resident 157 (R157) R157 was admitted on [DATE] and discharged on [DATE], with diagnoses including encounter for orthopedic aftercare following surgical amputation, burns involving less than 10% of body surface, and poisoning by unspecified narcotics, accidental (unintentional), initial encounter. The Discharge summary dated [DATE], documented R157 was found unresponsive in bed, emergency medical services (EMS) were called while nursing performed cardiopulmonary resuscitation (CPR). EMS arrived and continued to revive the resident but was unsuccessful, and the resident was later pronounced deceased .…

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 record review, the facility failed to ensure immunizations were provided and recorded for 5 of 6 sampled residents. (Resident #98, #8, #109, #148 and #139). The failure to administer vaccines poses a risk of a resident to contract communicable diseases. Findings include: 1) Resident 98 (R98) R98 was admitted on [DATE], with diagnoses of osteomyelitis of the vertebrae and major depressive disorder. R98 Preventative Health Care section of the Electronic Health Record (EHR) lacked documented evidence an influenza and pneumococcal vaccine was provided or offered. 2) Resident 8 (R8) R8 was admitted on [DATE], with diagnoses of hemiplegia and unspecified voice and resonance disorder. R8 Preventative Health Care section of the EHR lacked documented evidence a pneumococcal vaccine was provided or offered. 3) Resident 109 (R109) R109 was admitted on [DATE], with diagnoses of enterocolitis and depression. R109 Preventative Health Care section of the EHR lacked documented evidence 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.