Alpine Skilled Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review, the facility failed to ensure an allegation of verbal abuse was investigated and reported to the State Agency (SA) for 1 of 11 sampled residents (Resident #11). This deficient practice had the potential to result in psychosocial harm due to allegations of abuse not being thoroughly investigated and protections not put in place to prevent future abuse. Findings include: Resident #10 Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of bipolar disorder, unspecified. Resident #10's care plan included a focus initiated on 12/05/2024, documenting Resident #10 demonstrated a potential for verbally aggressive behaviors as evidenced by yelling out related to a cognitive communication deficit and bipolar disorder. A nursing narrative note, dated 05/28/2025, documented Resident #10 walked past another resident's room. The other resident was on the phone and yelled at Resident #10 to get away. Resident #10 yelled…

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 with a history of nicotine dependence had a care plan to address the resident's stated plans to continue smoking for 1 of 11 sampled residents (Resident #2). This deficient practice had the potential to result in facility staff being unaware of a resident's behavior and stated desire to continue smoking while wearing oxygen with the potential for the resident to suffer severe harm or death from burns as the result of smoking with oxygen in use from lack of care planned interventions to prevent adverse outcomes associated with the behavior. Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including nicotine dependence, cigarettes, uncomplicated and chronic obstructive pulmonary disease, unspecified. A Facility Reported Incident (FRI), dated 06/06/2025, documented the resident's wheelchair was on fire in the facility parking lot 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 interview, clinical record review, and document review, the facility failed to ensure resident care plans were updated after a resident-to-resident altercation for 2 of 11 sampled residents (Residents #10 and #11). This deficient practice has the potential to result in a resident not receiving care and services to meet their needs and prevent further altercations and psychosocial harm. Findings include: Resident #10 Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of bipolar disorder, unspecified. A nursing narrative note, dated 05/28/2025, documented Resident #10 walked past another resident's room. The other resident was on the phone and yelled at Resident #10 to get away. Resident #10 yelled out a racial slur. The Nurse spoke with the other resident who confirmed the incident and verbalized doing their best to stay away from Resident #10, but Resident #10 kept coming back. The residents had a history involving the police. A communication note 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, clinical record review, and document review, the facility failed to ensure a resident with a history of nicotine dependence and stated plans to continue smoking was adequately supervised to prevent the resident from experiencing a preventable accident while smoking with oxygen in place for 1 of 11 sampled residents (Resident #2) and two residents were not near Resident #2 while the resident was smoking with oxygen in place (Resident #3 and #4). This deficient practice had the potential to result in residents suffering burns causing severe pain and a decline in quality of life. Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including multiple sclerosis, muscle weakness (generalized), and chronic obstructive pulmonary disease, unspecified. Resident #4 Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified and pain,…

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 comfortable ambient air temperature was provided to residents (Resident #59, #19, #76, #30, #123, #104, #1, #2, #106, and #41) using the communal shower rooms in 3 of 3 facility shower rooms with temperatures of 62.1 degrees Fahrenheit (F), 62.4 F, and 67.6 F. This deficient practice had the potential to cause residents widespread discomfort before, during and after showers. Findings include: Resident #59 Resident #59 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including need for assistance with personal care and polyneuropathy, unspecified. On 01/07/2025 at 8:03 AM, Resident #59 verbalized it was a little chilly in the shower room and it was not very comfortable. Resident #19 Resident #19 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including need for assistance with personal care and chronic obstructive pulmonary disease,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure expired medications were removed from 2 of 3 medication storage rooms, and a wound care cart containing potentially hazardous opened treatment items remained secured. The opened items in the unsecured wound care cart had the potential to be available to resident's in and around the 400 Hall and the 400 Hall nurses' station. Findings include: Expired Medication On 01/09/2025 at 7:59 AM, the following expired medications were located in the [NAME] medication storage room: -Geri Care Iron Liquid Supplement, one 16 ounce (oz) bottle, expired 12/2024. -Tubersol tuberculin purified protein derivative five tub (T) unit (U) per 0.1 milliliters vial, three vials, all vials opened and unmarked with a date of opening. On 01/09/2025 at 8:03 AM, the Unit Manager (UM) confirmed the Iron Liquid Supplement had expired 12/2024. The UM also confirmed none of the three vials of Tubersol were marked with a date of opening and would be considered expired as there 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 observation, interview, and document review, the facility failed to ensure the facility's electronic health record was not left open and accessible on a computer attached to a medication cart with a resident's identifiers and medication administration record visible while staff were not in attendance or sight of the cart for 1 of 21 residents residing on the 800 hall (Resident #15). This deficient practice had the potential to result in a resident's confidential information being accessed by unauthorized individuals including other residents or visitors without the resident's permission. Findings include: Resident #15 Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including major depressive disorder, recurrent, moderate and bipolar disorder, unspecified. On 01/06/2025 at 8:58 AM, a computer located on top of a medication cart on the 800-hall had information for Resident #15 including the resident's name, picture, and current medications with associated…

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 related to the care of a Foley catheter for 1 of 28 sampled residents (Resident #123). This deficient practice had the potential to result in residents not receiving care and services to meet their needs related to indwelling devices. Findings include: Resident #123 Resident #123 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unstable burst fracture of first lumbar vertebra, subsequent encounter for fracture with routine healing and paraplegia, unspecified. On 01/06/2025 at 8:30 AM, Resident #123 had a Foley catheter in place. The drainage bag was secured to the bed frame, and clear yellow urine was in the bag. The resident verbalized the resident believed the drainage bag was not emptied often enough. A Minimum Data Set 3.0 (MDS) admission assessment, completed 11/06/2024, documented Resident #123 had an indwelling catheter. An MDS…

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 updated to include new interventions for the prevention of falls for 1 of 28 sampled residents (Resident #448). This deficient practice had the potential to result in residents not receiving care and services to meet their needs and help prevent falls. Findings include: Resident #448 Resident #448 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including metabolic encephalopathy and other osteonecrosis, right femur. Fall Risk Evaluations dated 12/20/2024, 12/28/2024, and 01/02/2025 documented Resident #448 was a high risk for falling. A progress note dated 12/20/2024, documented Resident #448 had a fall. The resident reported the resident slipped during transfer and agreed to ask for assistance with transfers in the future. A progress note dated 01/02/2025, documented Resident #448 had a fall. The resident sustained no injuries. Resident #448's Care Plan included a focus…

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 physician ordered wound care was performed for 1 of 28 sampled residents (Resident #448). This deficient practice had the potential for a resident's wound to worsen and/or delay healing. Findings include: Resident #448 Resident #448 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including metabolic encephalopathy and other osteonecrosis, right femur. On 01/06/2025 at 9:05 AM, Resident #448 had a dressing covering the resident's right elbow. The dressing had a date of 01/05/2025 written on it. A physician's order dated 01/01/2025, documented wound treatment: clean right elbow skin tear with Normal Saline (NS), pat dry, apply xeroform sheet to area, cover with silicone dressing daily and as needed (PRN) if dressing becomes soiled or dislodged, every day shift. Resident #448's January Treatment Administration Record (TAR) lacked documented evidence wound care was provided to the resident's…

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

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 requests for a dentist appointment to address broken teeth and pain with chewing food were addressed and efforts were made to schedule the resident for a dental appointment for 1 of 28 sampled residents (Resident #59). This deficient practice had the potential to result in a resident with dental concerns experiencing increased pain with chewing food or infection from cracked and broken teeth. Findings include: Resident #59 Resident #59 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including need for assistance with personal care, type II diabetes mellitus with other specified complication, and other specified sepsis. On 01/06/2025 at 8:33 AM, Resident #59 verbalized the resident had been asking to see a dentist since May of 2024. The resident explained the resident had chipped and broken teeth causing the resident to have difficulty with chewing food 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, document review, and interview the facility failed to demonstrate effective administration by not ensuring the Administrator and the Director of Engineering adequately addressed the low ambient temperatures in 3 of 3 shower rooms. Findings include: On 01/07/2025, the following shower room ambient temperatures were taken with facility Maintenance staff present to confirm findings: -7:29 AM Boundary Peak communal shower room: 62.1 degrees Fahrenheit (F) -7:37 AM [NAME] communal shower room: 62.4 degrees F -8:52 AM [NAME] Peak communal shower room: 67.6 degrees F On 01/07/2025 at 9:14 AM, the Administrator explained the Administrator was unaware of the shower room ambient temperatures registering so low and the Administrator would not feel comfortable taking a shower in a room at the same temperatures. The Administrator confirmed the Director of Engineering was responsible for facility maintenance oversight. On 01/07/2025 at 12:14 PM, the Director of Engineering explained becoming aware the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #198 Resident #198 was admitted to the facility on [DATE], with diagnoses including fusion of the spine, lumbar region, encounter for orthopedic aftercare, other spondylosis, lumbar region, and intervertebral dis disorders with radiculopathy, lumbar region. Resident #198's December 2024 Treatment Administration Record (TAR) documented wound treatment: clean left lower back surgical incision with normal saline, pat dry, apply skin, cover with island dressing every Monday, Wednesday, and Friday, and as needed if dressing becomes soiled or dislodged. The start date was 12/20/2024. There was no wound treatment documented for 12/23/2024. Resident #198's December 2024 TAR documented wound treatment: clean right lower back surgical incision with normal saline, pat dry, apply skin, cover with island dressing every Monday, Wednesday, and Friday, and as needed if dressing becomes soiled or dislodged. The start date was 12/20/2024. There was no wound treatment documented for 12/23/2024. Resident #198's January…

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 ensure an employee donned proper personal protective equipment (PPE) prior to entering a resident's room on isolation contact-based precautions for 1 of 2 residents on contact-based precautions (Resident #119). This deficient practice of lack of proper infection control practices had the potential to spread infection and affect all residents within the facility. Findings include: Resident #119 Resident #119 was admitted to the facility on [DATE], with diagnoses including methicillin-resistant staphylococcus aureus (MRSA), urinary tract infection, recurrent, major depressive disorder, unspecified, difficulty walking, and muscle weakness. On 01/06/2025 at 8:02 AM, a Social Services employee opened the door and walked into room [ROOM NUMBER], Resident #119's room. The room's door had a contact-based precautions sign posted on the outside of the door. The sign documented the room was on contact-based insolation…

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 was protected from verbal and physical abuse by a Certified Nursing Aide (CNA) when the CNA yelled at and threw an object at 1 of 5 sampled residents (Resident #1). This deficient practice had the potential to result in physical and psychosocial harm. Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of chronic hepatic failure without coma. A Resident Abuse Interview with Resident #1 dated 05/07/2024, documented the CNA was rude to Resident #1 when the CNA yelled at the resident, threw a pillow at the resident and shoved a pillow under the resident. Resident #1 was afraid to ask for help because of the way the resident was treated. A witness statement from Resident #1 dated 05/07/2024, documented the resident asked the CNA to assist with cleaning after a bowel movement but the CNA yelled at the resident don't tell me how to do…

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 resident with a stage four pressure ulcer was evaluated timely by the facility's Registered Dietician and a physician ordered nutritional supplement was administered to the resident (Resident #1). This deficient practice had the potential to result in a pressure ulcer to not receive the services and treatment to promote healing and prevention. Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified severe protein-calorie malnutrition and pressure ulcer of sacral region, stage four. A Physician Note dated 01/18/2024, documented Resident #1 had severe protein-calorie malnutrition and a stage four pressure ulcer of the sacral region. The plan included a dietary evaluation and Pro-Stat (a concentrated liquid protein drink). A Physician Order dated 01/22/2024, documented Pro-Stat, one drink per day with lunch. The order was created by…

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 was free from misappropriation of property when a Housekeeper asked for money from a resident for 1 of 11 Facility Reported Incidents (FRI) (Resident #1). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and anxiety. A Facility Reported Incident (FRI) final report dated 02/18/2024, documented a staff member had reported to the facility a Housekeeper had asked the resident to borrow money. The resident provided money to the Housekeeper and the Housekeeper had paid Resident #1 back and did not owe the resident anything. An investigation by the facility on 02/13/2024, documented 16 residents were randomly selected and verbalized they were not asked by staff to borrow funds. The Administrator verbalized the Housekeeper was terminated by the facility for a substantiated allegation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and document review, the facility failed to ensure a resident or resident representative gave informed consent prior to placing a resident's bed on the floor, against the wall and a resident had been provided with an informed consent for a psychoactive medication prior to the administration of the medication for 3 of 26 sampled residents (Resident #102, #40 and #87). Findings include: Resident #102 Resident #102 was admitted to the facility on [DATE], with diagnoses including anoxic brain damage, not elsewhere classified, muscle weakness (generalized), and unspecified mental disorder due to known physiological condition. On 01/29/24 at 10:10 AM, Resident #102 had two mattresses on the floor and one of the mattresses was placed against the wall. On 01/30/24 at 7:55 AM, Resident #102 was sleeping on the mattresses on the floor, placed against the wall. A progress note dated 12/28/23, documented the Director of Nursing (DON) spoke with the resident's Power of…

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

Based on interview and document review, the facility failed to ensure grievances and complaints documented from Resident Council meetings related to missing and misplaced laundry were addressed and acted upon for 5 of 10 months of Resident Council meeting minutes. Findings include: On 01/31/24 at 10:01 AM, during the Resident Council Interview, seven of seven Resident Council members verbalized the facility had not responded to grievances or complaints discussed in recent Resident Council meetings. The Resident Council members explained the complaints were regarding missing laundry, and the facility had yet to respond with a solution. The Resident Council Meeting Minutes, dated 06/20/23, documented residents' complaints were related to missing personal items from laundry. The Resident Council Meeting Minutes, dated 09/19/23, documented the residents' complaints were related to missing personal laundry. The Resident Council Meeting Minutes, dated 11/21/23, documented the residents' complaints were related to missing personal laundry. The Resident Council Meeting Minutes, 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 observation, interview, clinical record review, and document review, the facility failed to ensure a care plan was developed 1) for a psychotropic medication (Residents #87), 2) to address a resident's phantom limb sensations and pain (Resident #322), 3) for the use and management of an anticoagulant (Resident #45), 4) regarding wound care and the care of a skin graft (Resident #96), and 5) the administration and monitoring of oxygen and the use of siderails (Resident #79) for 5 of 26 sampled residents. Findings include: Resident #87 Resident #87 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified sequelae of cerebral infarction, attention and concentration deficit following cerebral infarction, and muscle weakness (generalized). The medication orders for Resident #87 included documentation of the following: - Quetiapine fumarate tablet 25 milligrams (mg), give one tablet by mouth at bedtime for schizophrenia/bipolar disorder. The order date 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 observation, clinical record review, interview and document review, the facility failed to follow a physician's order for respiratory care for 1 of 26 sampled residents (Resident #49). Findings include: Resident #49 Resident #49 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, and major depressive disorder. On 01/29/24 at 12:55 PM, Resident #49 was in bed. An oxygen concentrator was next to the bed, turned on and administering oxygen via nasal cannula to the resident. The oxygen concentrator flow was four liters per minute (LPM) with the humidification bottle empty. On 01/30/24 at 10:15 AM, Resident #49 was in bed. An oxygen concentrator was next to the bed, turned on and administering oxygen via nasal cannula to the resident. The oxygen concentrator flow was four LPM with the humidification bottle empty. A physician's order dated 11/03/22, documented administer oxygen at four LPM via nasal cannula continuously. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with phantom limb sensations and severe pain had non-pharmacological interventions to manage the resident's pain for 1 of 26 sampled residents (Resident #322). Findings include: Resident #322 Resident #322 was admitted to the facility on [DATE], with diagnoses including complete traumatic amputation at level between left hip and knee, subsequent encounter, pain, unspecified, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. On 01/29/24 at 10:58 AM, Resident #322 verbalized the resident could still feel sensations in the resident's left foot. The resident verbalized the resident thought some of the medications the resident was receiving might have been for the phantom limb sensations but was unsure if the medications were effective. On 01/31/24 at 11:52 AM, Resident #322 verbalized the resident's pain level was frequently as high as an 8 out of 10. 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 alternatives were attempted and informed consent was obtained prior to installation of side rails for 1 of 26 sampled residents (Resident #79). Findings include: Resident #79 Resident #79 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease unspecified, repeated falls, and muscle weakness generalized. On 01/29/24 at 3:27 PM, Resident #79's bed had half side rails up on both sides and was in the lowest position. On 01/31/24 at 2:48 PM, Resident #79 verbalized using the side rails to assist with getting out of bed. Resident #79's physician's order dated 11/28/23, documented half side rails on both sides of the bed. Resident #79's Side Rails for Consideration Assessment, dated 11/30/23, documented the resident was unable to get in and out of bed safely with side rails. Resident #79's clinical record lacked documented evidence alternatives were attempted and informed consent was obtained…

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 recommendation from a drug regimen review had a follow up response or rationale from the prescriber for 2 of 26 sampled residents (Resident #87 and #79). Findings include: Resident #87 Resident #87 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified sequelae of cerebral infarction, attention and concentration deficit following cerebral infarction, and muscle weakness (generalized). The medication orders for Resident #87 included documentation of the following: - Quetiapine fumarate tablet 25 milligrams (mg), give one tablet by mouth at bedtime for sleep. The order date was 11/27/23. A Consultant Pharmacist Recommendation to Physician, dated 12/18/23, documented the current diagnosis (sleep) was not an approved diagnosis for antipsychotic therapy. Consider a trial of tapering quetiapine to 12.5 mg nightly, with potential to discontinue after 14 days if well tolerated.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review, the facility failed to ensure a psychotropic medication was prescribed to a resident for an appropriate indication for 1 of 26 sampled residents (Resident #87). Findings include: Resident #87 Resident #87 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified sequelae of cerebral infarction, attention and concentration deficit following cerebral infarction, and muscle weakness (generalized). The medication orders for Resident #87 included documentation of the following: - Quetiapine fumarate tablet 25 milligrams (mg), give one tablet by mouth at bedtime for schizophrenia/bipolar disorder. The order date was 05/15/23 and was discontinued on 05/23/23. - Quetiapine fumarate tablet 25 mg, give one tablet by mouth at bedtime for agitation. The order date was 05/23/23 and was discontinued on 05/26/23. - Quetiapine fumarate tablet 25 mg, give one half tablet by mouth at bedtime for agitation for three days…

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 unsecured medications were not left in a resident's room for 1 of 26 sampled residents (Resident #10) and failed to ensure expired medications were removed from 1 of 6 medication carts. Findings include: Resident #10 Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including multiple sclerosis, need for assistance with personal care, and acute and chronic respiratory failure with hypoxia. On 01/29/24 at 12:36 PM, next to Resident #10's bed, on the side table, was an albuterol inhaler. The resident explained the inhaler was the resident's inhaler and was in the resident's room at all times. On 01/29/24 at 12:44 PM, the Registered Nurse (RN) explained Resident #10 was not to self-administer medications, except for the albuterol inhaler because the resident has a self-administering physician's order. The RN could not locate a self-administering physician's order 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 observation, interview, clinical record review, and document review, the facility failed to ensure a resident with a peripherally inserted continuous catheter (PICC) line had the PICC line dressing changed per facility policy for 1 of 26 sampled residents (Resident #319). Findings include: Resident #319 Resident #319 was admitted to the facility on [DATE], with diagnoses including cellulitis of left lower limb, sepsis, unspecified organism, and local infection of the skin and subcutaneous tissue, unspecified. On 01/29/24 at 10:32 AM, Resident #319 had a PICC line in the resident's left upper arm. The PICC line insertion site was covered with a transparent dressing with tape covering the top and bottom edges. The dressing was not dated or initialed. The resident verbalized he could not recall when the dressing was last changed or when the dressing was due to be changed again. On 01/31/24 at 11:57 AM, the PICC line dressing on Resident #319's left upper arm had the same appearance from the dressing…

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 training related to communication was provided to 2 of 20 sampled employees (Certified Nursing Assistant (CNA) CNA1 and CNA2). Findings include: A Personnel Records Checklist completed by the Human Resources Director (HRD) documented the following employees' personnel records lacked documented evidence the employees were provided Communication training: CNA1 CNA1 had a start date of 10/24/23. On 02/06/24 at 3:49 PM, the HRD confirmed CNA1's personnel record lacked documented evidence of communication training. CNA2 CNA2 had a start date of 02/01/22. On 02/06/24 at 3:51 PM, the HRD confirmed CNA2's personnel record lacked documented evidence of communication training.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review the facility failed to administer medications per a physician's order for 2 of 7 sampled residents (Resident #2 and #3). Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including vitamin D deficiency, unspecified and mild protein-calorie malnutrition. On 12/21/23 at 8:53 AM, a Licensed Practical Nurse (LPN) began preparing medications for Resident #2. One of the medications prepared was one tablet of Calcium Citrate-Vitamin D 400 milligrams (mg)-12.5 micrograms (mcg). On 12/21/23 at 8:56 AM, the LPN administered the prepared medications to Resident #2. An Order Review History Report for Resident #2 documented the following: -Calcium Citrate-Vitamin D oral tablet chewable 500-10 mg-mcg. Give one tablet by mouth one time a day for supplement. On 12/21/23 at 1:39 PM, the LPN reviewed Resident #2's medication orders and confirmed the resident's order was for Calcium…

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.