Life Care Center Of Reno

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review, the facility failed to develop a person-centered Comprehensive Care Plan for the needed care and services related to 1) a Foley catheter for 1 of 24 sampled residents (Resident #69), 2) bowel and bladder retraining for 2 of 24 sampled resident (Resident #9 and #54), and 3) pain management for 1 of 24 sampled residents (Resident #223). This deficient practice had the potential to delay adequate care and interventions to properly manage concerns related to Foley catheter care, bowel and bladder retraining, and pain management. Findings include: Resident #69 Resident #69 was admitted to the facility on [DATE], with diagnoses including retention of urine, unspecified, benign prostatic hyperplasia without lower urinary tract symptoms, and chronic combined systolic (congestive) and diastolic (congestive) heart failure. A physician's order dated 06/09/2025, documented indwelling catheter to straight drainage. Size : 16 French Bulb; 10 milliliter (ml).…

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 personnel record review, document review and interview, the facility failed to ensure an employee had current cardiopulmonary resuscitation (CPR) training. This deficient practice placed residents at risk from an employee not having completed all employment eligibility requirements. Findings include: Employee #9 Employee #9 had a hire date of [DATE] and a title of Certified Nursing Assistant. Employee #9's personnel record documented a CPR certification with an expiration date of [DATE]. On [DATE] at 8:39 AM, the Staff Development Coordinator, Registered Nurse (RN), verbalized having been responsible to ensure all staff received the required certifications and confirmed Employee #9's CPR certification had expired on [DATE]. The Staff Development Coordinator RN verbalized not having been sure if Employee #9 had current CPR training. Employee #9's job description, signed by Employee #9 on [DATE], documented the employee must have obtained CPR certification and the certification must remain current during…

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 communication was maintained between the facility and the hospice agency providing care to 1 of 1 hospice residents residing in the facility (Resident #27) This deficient practice had the potential to result in the facility not being updated regarding the care the resident was receiving from the hospice agency, changes in the resident's condition, changes to frequency of care, new physician orders, and instructions for new physician orders. Findings include: Resident #27 Resident #27 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy, paraplegia incomplete, and malignant neoplasm of the brain. A physician's order dated 02/22/2025, documented to admit Resident #27 to Hospice for a diagnosis of glioblastoma of the brain (a malignant neoplasm). Resident #27's Hospice Care Binder was located at the nurses' station. The Binder included a nurse visit progress 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 observations, interviews, clinical record reviews, and document reviews, the facility failed to ensure the environment was free from accident hazards by not assessing and addressing the risk of entrapment for 1 of 24 sampled residents (Resident #270). The resident's bed was positioned with the right side pushed up against an air conditioning unit, leaving a gap of approximately six to eight inches between the mattress and the window and wall. This deficient practice had the potential to result in serious injury, including entrapment, by placing the resident at risk for preventable harm. Findings include: Resident #270 Resident #270 was admitted to the facility on [DATE], with diagnoses including acute diastolic heart failure, muscle weakness, and cognitive communication deficit. On 06/24/2025 at 10:06 AM, Resident #270 was in bed and the right side of the resident's bed was pushed up against the air conditioning unit with approximately six to eight inches between the upper right side of 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 Resident #9 Resident #9 was admitted to the facility on [DATE], with a principal diagnosis of pneumonia due to other gram-negative bacteria. Resident #9's Minimum Data Set 3.0 (MDS) assessment dated [DATE], section H (Bladder and Bowel) documented the following: -A trial of a toileting program had not been attempted. -The resident was always incontinent of bladder. -The resident was always incontinent of bowel. -A toileting program was not being used to manage the resident's bowel incontinence. Resident #9's evaluation for bowel and bladder training dated 05/21/2025, documented the resident was a candidate for toileting and timed or scheduled voiding. On 06/26/2025 at 2:13 PM, the Director of Nursing (DON) verbalized the purpose of a bowel and bladder program was to increase the continence level of the residents. The DON explained the bowel and bladder evaluation was completed upon admission to determine the resident's continence status. Once the resident's continence status was determined the evaluation 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 resident with a known history of significant weight loss was monitored for further weight loss upon readmission to the facility for 1 of 24 sampled residents (Resident #74). This deficient practice had the potential to result in serious health complications for the resident. Findings include: Resident #74 Resident #74 was admitted to the facility on [DATE] and readmitted on [DATE] after transferring to the hospital on [DATE], with diagnoses including enterocolitis due to clostridium difficile, cognitive social or emotional deficit following cerebral infarction and type 2 diabetes mellitus. A Weight Summary for Resident #74 documented the resident weighed 181.4 pounds (lbs) on 04/11/2025 and weighed 168.0 lbs on 05/10/2025 indicating a significant weight loss of 13.4 lbs or 7.39 percent (%) body weight loss. The Weight Summary documented the resident's weight obtained on 5/30/2025, was 156.7lbs. This indicated 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 determine and document a resident's tolerable level of pain and administer pain medication according to a physician's order for 1 of 24 sampled residents (Resident #223). This deficient practice had the potential for unrelieved pain, discomfort, and inadequate pain management. Findings include: Resident #223 Resident #223 was admitted to the facility on [DATE], with diagnoses including encounter for surgical aftercare following surgery on the circulatory system and chronic pain syndrome. On 06/24/2025 at 9:05 AM, Resident #223 was lying in the resident's bed. The resident verbalized the resident had chronic pain and regularly took pain medication at home to manage the pain however, facility was not providing the same amount of pain medication the resident used at home. The resident verbalized the facility nurse had declined to administer the resident's usual dose of pain medication due to the resident's Blood Pressure (BP)…

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 maintain completed dialysis communication forms for 3 of 24 sampled residents (Resident #2, #85 and #61). This deficient practice had the potential to result in a lack of critical information shared between the facility and the dialysis provider with the potential to have lead to delays or errors in care, adversely having affected resident health and safety. Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease and dependence on renal dialysis. A physician's order dated 03/21/2025. documented Resident #2 was to receive dialysis treatment at a dialysis center, every Tuesday, Thursday and Saturday for end stage renal disease. Resident #2's clinical record lacked documented evidence of a completed dialysis communication transfer form for the following dates: -03/29/2025, Saturday -04/01/2025, Tuesday -04/05/2025, Saturday…

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 all of a resident's medications were signed and dated during provider visits for 1 of 24 sampled residents (Resident #421). This deficient practice had the potential to result in medication errors, compromising the resident's health and safety. Findings include: Resident #421 Resident #421 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including bipolar disorder, depression, anxiety disorder unspecified, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident #421's physician's orders dated 06/18/2025, documented the following: -Acetaminophen tablet 325 milligram (mg). Give two tablets by mouth every four hours as needed for temperature above 101not to exceed three gram (gm)/24 hours. -Acetaminophen tablet 325 mg. Give two tablets by mouth every four hours as needed for pain scale one to three.…

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 social services staff assessed the impact of a room relocation on the resident's psychosocial status for a resident with a room change per facility policy for 1 of 24 sampled residents (Resident #171). This deficient practice had the potential to result in avoidable psychosocial harm. Findings include: Resident #171 Resident #171 was admitted to the facility on [DATE], with a primary diagnosis of unspecified nondisplaced fracture of surgical neck of right humerus, subsequent encounter for fracture with routine healing. A Resident Listing Report dated 06/22/2025, documented Resident #171 had a room change on 06/19/2025. Resident #171's clinical record lacked documented evidence of an assessment completed by social services regarding the resident's room change. On 06/23/2025 at 9:33 AM, Resident #171 verbalized approximately five days prior, the resident was evicted from their room in the other building of the same…

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 expired medications were removed from 2 of 3 medication carts inspected and a medication bottle was labeled with an expiration date in 1 of 3 medication carts inspected. This deficient practice had the potential to result in administration of expired medications, posing a risk to resident safety. Findings include: On 06/26/2025 at 11:30 AM, during an inspection of the station one front hall medication cart and in the presence of the Assistant Director of Nursing (ADON), the following items were found: -One box of Cranberry capsules 240 milligrams (mg) with capsules remaining in the box. The expiration date printed on the box and capsule packaging was 01/2023. -One box of Probiotic capsules with capsules remaining in the box. The expiration date printed on the box was 02/2025. The ADON verbalized if the expiration date was listed as a month and year the item expired at the end of the month. The ADON confirmed the expiration dates printed on the boxes of Cranberry and Probiotic capsules had passed. 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 clinical record review, personnel record review, document review, and interview, the facility failed to ensure compliance with the State of Nevada Revised Statute (NRS) 449.174 related to fingerprinting and Nevada Automated Background System (NABS) clearance for an employee having access to a sampled resident's record (Resident #83). This deficient practice placed residents at risk from an employee not having completed all employment eligibility requirements. Findings include: Resident #83 Resident #83 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side, muscle weakness (generalized), difficulty in walking, not elsewhere classified, attention and concentration deficit following cerebral infarction, memory deficit following cerebral infarction, cognitive social or emotional deficit following cerebral infarction, type 2 diabetes mellitus without complications, encounter for surgical…

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 written notification was provided to the State Agency (SA) when the facility had a change in Director of Nursing (DON). This deficient practice had the potential to result in lack of oversight to ensure the facility employed a qualified DON. Findings include: On 06/22/2025, the facility provided a list of staff currently employed by the facility. The list included the DON and documented a hire date of 10/07/2024. On 07/01/2025 at 9:13 AM, the Administrator denied the facility provided written notice to the SA when the facility last had a change in DON and explained the Administrator was unaware of the requirement to provide the written notice. On 07/01/2025 at approximately 10:00 AM, the Administrator provided a copy of a typed letter. The letter was dated 07/01/2025 and was signed by the Administrator. The letter documented the letter was formally notifying the SA of a change in DON at the facility. The start date for DON was 10/07/2024. The facility policy titled Changes in Executive Director and/or Director of…

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

Based on document review and interview the facility failed to maintain the required Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) committee members to include the Director of Nursing and the Medical Director. Findings include: The facility provided a list of QAPI Committee members. The list documented the QAPI committee was comprised of the Chief Executive Officer, the Chief Nursing Officer, the Medical Director or designee, the Infection Preventionist, and two other facility staff. On 07/01/2025 at 1:47 PM, the Administrator verbalized the QAPI committee required at a minimum the Administrator, the Director of Nursing, Medical Director or designee, the Infection Preventionist and two other staff members. The Administrator provided the QAPI sign in sheets for the following dates, the following noted QAPI members were not on the QAPI meeting sign-in sheet and were not in attendance: July 23, 2024 - Director of Nursing (DON) August 29, 2024 - DON September 27, 2024 - DON December 30, 2024 - DON January 2025 - DON, Medical Director (MD)…

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, document review, and interview, the facility failed to adhere to proper infection control protocols by allowing a resident's catheter tubing to drag on the floor while the resident was seated in a wheelchair for 1 of 24 sampled residents (Resident #69). This deficient practice had the potential to result in contamination of the catheter tubing, urinary tract infections and increasing the risk of other complications for the resident. Findings include: Resident #69 Resident #69 was admitted to the facility on [DATE], with diagnoses including retention of urine, unspecified, benign prostatic hyperplasia without lower urinary tract symptoms, and chronic combined systolic (congestive) and diastolic (congestive) heart failure. A physician's order dated 06/09/2025, documented indwelling catheter to straight drainage. Size: 16 French Bulb: 10 milliliter (ml). Change for clogging or dislodgement as needed for benign prostatic hyperplasia for infection, obstruction or when the…

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

Based on observation, interview, clinical record review and document review, the facility failed to ensure resident information was not visible on an unattended computer screen and at a nursing station facing a public area. This deficient practice had the potential for unauthorized access to residents' protected health information. Findings include: On 04/08/2025 at 9:35 AM, a consultation report was sitting on the counter of the 200-hall nursing station with patient information upright and exposed to anyone walking by. On 04/08/2025 at 9:37 AM, a Licensed Practical Nurse (LPN) approached the nursing station and flipped the resident consultation report over to cover patient information. The LPN confirmed the consultation report had resident information on it and needed to be covered or flipped over to ensure anyone walking by would not see the information. On 04/08/2025 at 11:01 AM, a computer screen on a medication cart in the 100-hallway displayed medication information for a resident. On 04/08/2025 at 11:01 AM, an LPN confirmed the computer was left on and displayed 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.

Based on observation, interview, and document review, the facility failed to ensure the outside receptacle area was kept free of trash, leaves, seepage from the receptacle container, leakage of an air conditioning hose causing a build-up of a thickened substance, and flies. Findings include: On 07/29/2024 at 8:38 AM, the outside gated facility receptacle area had an accumulation of leaf debris and gloves for medical care. The receptacle container had seepage causing a built-up dried puddle of liquid waste, accumulated over time and deposited on the cement. Another puddle (wet liquid) had accumulated within the gated area, in the corner. A vent and hose were present however, the source of the liquid could not be identified. The Certified Dietary Manager (CDM) was present and verbalized the receptacle area needed a spray down. The CDM was unable to identify the source of the liquid puddle. On 08/01/2024 at 1:50 PM, the outside gated receptacle area remained with an accumulation of leaf debris and gloves for medical care. The receptacle container had seepage causing a built-up dried…

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's Quality Assurance and Performance Improvement (QAPI) committee failed to identify the facility lacked a process to ensure bowel and bladder assessments were completed upon admission for determination of candidacy to a bowel and/or bladder retraining program and to offer a bowel and bladder retraining program for residents assessed to be candidates for a bowel and bladder retraining program resulting in the potential to affect residents' ability to maintain their highest continent status. Findings include: On 08/01/2024 at 11:33 AM, the Director of Nursing (DON) verbalized incontinence impacted a resident's quality of life and explained it was important for residents to be able to achieve or maintain the resident's highest level of continence. Incontinent residents were at risk of developing urinary tract infections, and skin breakdown. On 08/01/2024 at 11:34 AM, the DON verbalized the DON was not sure when the facility last had a Bowel and Bladder program and explained the DON had worked at the facility for approximately one year…

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 1) complete bowel and bladder assessments upon admission for determination of candidacy to a bowel and/or bladder retraining program for 12 of 24 sampled residents (Resident #26, #32, #39, #40, #68, #86, #94, #105, #117, #185, #440, and #442) and 2) offer a bowel and bladder retraining program for residents assessed to be candidates for retraining for 10 of 24 sampled residents (Resident #2, #12, #13, #51, #52, #55, #60, #76, #235, and #443). This deficient practice had the potential to affect residents' ability to maintain their highest continent status. Findings include: Lack of Complete Bowel and Bladder Assessments Resident #26 Resident #26 was admitted to the facility on [DATE], with a principal diagnosis of other specified local infections of the skin and subcutaneous tissue. Resident #26's Minimum Data Set 3.0 (MDS) assessment dated [DATE], section H (Bladder and Bowel) documented the following: -A trial of a toileting…

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 Controlled Drug Records (CDR) were correctly completed for 2 of 3 inspected medication carts to reflect an accurate reconciliation of controlled medications for 8 of 24 sampled residents (Resident #96, #5, #89, #93, #77, #102, #94, and #109). Findings include: Station One Front Hall Medication Cart Resident #96 Resident #96 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and dysarthria following cerebral infarction. A physician's order dated 05/30/2024, documented tramadol 50 milligram (mg), give one tablet by mouth every six hours as needed for a pain level of 4-10 (on a numeric pain scale of 0-10). On 08/01/2024 at 8:41 AM, the Station One Front Hall medication cart included a CDR for Resident #96. The last entry on the CDR, dated 07/31/2024 at 7:05 PM, documented eight 50 mg tablets of tramadol were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, interview, and document review the facility failed to ensure the bed controls for 1 of 24 sampled residents (Resident #94) was in working order and the resident was physically able to work the control, resulting in emotional distress and increased pain for the resident. Findings include: Resident #94 Resident #94 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus with other specified complication, difficulty in walking not elsewhere classified, diaphragmatic hernia without obstruction or gangrene, rectal prolapse, and age related debility. A History and Physical record for Resident #94, dated 06/30/2024, documented the resident had a surgical history of laminotomy and hernia repair. A physician's order dated 07/19/2024, documented Acetaminophen tablet 325 milligrams (mg), give two tablets by mouth every four hours as needed for a pain level of 1-3 on numeric pain scale of 0-10. A physician's order dated 07/19/2024, documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and document review the facility failed to provide the required documentation for discharge when a resident was emergently transferred to an acute care hospital for 1 of 24 sampled residents (Resident #76). Findings include: Resident #76 Resident #76 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, unspecified, acute pulmonary edema, and unspecified asthma, uncomplicated. A Minimum Data Set 3.0 (MDS) discharge assessment dated [DATE], Section A, documented Resident #76 had an unplanned discharge to a short term acute care hospital with return anticipated. A Resident Census Report for Resident #76 documented the resident was admitted to an acute care hospital on [DATE], and returned to the facility on [DATE]. A Nurse Progress Note dated 05/26/2024, documented Resident #76 was yelling out, and when the nurse entered the resident's room the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and document review the facility failed to submit for evaluation of the Pre-admission Screening and Annual Resident Review (PASRR or PASARR) level II to the state designated authority for 1 of 24 sampled residents (Resident #76) when the resident had a new diagosis of schizophrenia. The failure had the potential to deprive the resident of the care and services necessary to meet their mental health needs. Finding include: Resident #76 Resident #76 was admitted to the facility on [DATE], and readmitted on [DATE], and 05/29/2024, with a diagnosis of acute and chronic respiratory failure with hypoxia, bipolar disorder, current episode depressed, mild or moderate severity, unspecified. A diagnosis of schizophrenia, unspecified, was added when the resident was readmitted to the facility on [DATE], and was documented as present upon readmission. A PASRR Level I Identification Determination for Resident #76 was dated 02/11/2021. A Minimum Data Set 3.0 (MDS) admission assessment 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 Oxygen was administered as ordered for 1 of 24 sampled residents (Resident #442). Findings include: Resident #442 Resident #442 was admitted to the facility on [DATE], with diagnoses including other specified chronic obstructive pulmonary disease (COPD) and dependence on supplemental Oxygen. On 07/29/2024 at 3:55 PM, Resident #442 was lying in bed and was receiving Oxygen at six Liters Per Minute (LPM) via Nasal Cannula (NC). On 07/31/2024 at 9:46 AM, Resident #442 was lying in bed and was receiving Oxygen at five LPM via NC. A physician's order dated 07/26/2024, documented Oxygen at four LPM, continuously per NC, every shift for COPD. On 07/31/2024 at 9:50 AM, a Registered Nurse (RN) explained Resident #442 had an order for Oxygen to be administered at four LPM via NC for the resident's COPD. The RN entered Resident #442's room and confirmed the resident was receiving Oxygen at five LPM. The 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.

Based on interview, document review, and personnel record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had a performance evaluation completed annually for 1 of 3 CNAs employed greater than one year sampled for personnel record review (Employee #13). Findings include: On 07/31/2024 at 10:30 AM, the Staff Development Coordinator (SDC) participated in an interview to confirm the accuracy of the Personnel Records Checklist completed by the facility for 20 employees. Employee #13 Employee #13 was hired as a CNA with a start date of 10/11/2022. Employee #13's personnel file documented a performance evaluation dated 03/08/2024. On 07/31/2024 at 10:44 AM, the SDC confirmed Employee #13 did not have a performance evaluation completed on or before the employee's anniversary date of 10/2023 and confirmed Employee #13's only performance review was completed on 03/08/2024. On 07/31/2024 at 1:21 PM, the Director of Nursing (DON) verbalized all CNAs were required to have a performance review annually. The DON verbalized it was a corporate directive to review all CNAs…

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 1) loose and unlabeled medications were removed from 2 of 3 inspected medication carts, and 3) medications were not left unattended and unsecured in a resident room for 1 of 24 sampled residents Resident (#40). Findings include: Medication Storage Carts On [DATE] at 9:56 AM, during an inspection of the Station Two Medication Cart, a small, white, round pill was found on the bottom of the cart's controlled substance drawer. An RN assigned to the medication cart was not able to identify the medication and/or who the medication belonged to. On [DATE] at 10:04 AM, the Staff Development Coordinator Registered Nurse (SDC RN) confirmed the medication found loose in the bottom of the Station Two Medication Cart's controlled substance drawer, should have been removed from the cart and confirmed the expectation was all medications in the medication cart would be labeled and in the appropriate containers. Station Two…

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 complete Treatment Administration Records (TAR) for the administration of a skin protective ointment for 1 of 24 sampled residents (Resident #2). Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], with a diagnosis of paraplegia. A physician's order dated 05/15/2024, documented skin protective ointment to perianal area at each brief change. Confirm every shift. Resident #2's TAR dated 05/20/2024, and 06/26/2024, lacked documented evidence the skin protective ointment had been administered per the physician's order. On 08/01/2024 at 1:29 PM, the Director of Nursing (DON) confirmed Resident #2's TAR dated 05/20/2024, and 06/26/2024, lacked documented evidence the skin protective ointment had been administered per the physician's order. The DON verbalized it was the DON's expectation nursing staff were to document in the resident's clinical record immediately upon administration of a medication or…

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 Enhanced Barrier Precautions (EBP) were implemented for a resident with a chronic wound for 1 of 94 unsampled residents (Resident #26). Findings include: Resident #26 Resident #26 was admitted to the facility on [DATE], with diagnoses including unspecified open wound of abdominal wall, unspecified quadrant without penetration into peritoneal cavity, subsequent encounter and unspecified open wound, right thigh, subsequent encounter. On 07/29/2024 at 10:08 AM, Resident #26 verbalized the resident had wounds. The resident recalled having the wounds for at least seven months and verbalized facility staff were providing wound care. Resident #26's room lacked EBP signage and a Personal Protective Equipment (PPE) cart. A physician's order dated 07/06/2024, documented wound care: clean right medial thigh wound with Normal Saline (NS), pat dry, apply Xeroform, cover with clean dry dressing (CDD) every Monday,…

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 prevent a resident's roommate (Resident #2) from urinating on the floor regularly and to ensure the resident had a right to a clean, comfortable environment for 1 of 5 sampled residents (Resident #1). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including spontaneous bacterial peritonitis, sepsis, unspecified organism, other ascites, and unspecified severe protein-calorie malnutrition. An Event Note dated 12/12/23, documented Resident #1 was transferred to another room, per the resident's request. Resident #1's clinical record lacked documented evidence when Resident #1 had initially made the room change request. Resident #1's clinical record documented the resident as having been in room [ROOM NUMBER] with Resident #2, upon admission until Resident #1's room change request on 12/12/23. Resident #2 Resident #2 was admitted to the facility on [DATE], with diagnoses including…

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 coordinate a resident's care with the hospice provider for 1 of 5 sampled residents (Resident #1). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including spontaneous bacterial peritonitis, sepsis, unspecified organism, other ascites, and unspecified severe protein-calorie malnutrition. Resident #1's Care Plan dated 08/26/23, documented the resident had a terminal prognosis. An Admission/readmission Note dated 08/25/23, documented Resident #1 was admitted under Infinity hospice care, the physician was notified, and the order was verified. On 03/13/24 at 12:25 PM, the Executive Director (ED) verbalized the facility had no hospice records on-site for Resident #1 and would contact the hospice agency. On 03/13/24 at 1:01 PM, the Licensed Social Worker (LSW) confirmed having been the hospice coordinator. The LSW verbalized there was usually a binder for hospice documentation at the…

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

Based on observation, interview and document review, the facility failed to ensure a hand washing sink in the Kitchen was stocked with disposable hand towels. Findings include: On 03/13/24 at 9:30 AM, the hand washing sink near the walk-in refrigerator in the kitchen did not have disposable hand towels in the wall dispenser. On 03/13/23 at 9:35 AM, the [NAME] confirmed the hand towels at the hand washing sink near walk-in refrigerator had not been stocked in a couple of days. On 03/13/23 at 9:41 AM, the Executive Director confirmed the disposable hand towel dispenser had been empty and should have been stocked to ensure proper hand hygiene. The facility policy titled, Housekeeping Service, reviewed, 06/04/23, documented all sinks were to be well stocked with paper towels for hand washing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interview and document review, the facility failed to prevent resident to resident abuse for 2 of 5 sampled residents (Resident #1 and #2). Findings include: The Facility Reported Incident (FRI) #NV00069244 documented a Registered Nurse (RN) had heard a resident slapping another resident. Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including borderline personality disorder, anxiety disorder, depression, and cerebral infarction without residual deficits. Resident #1's Care Plan dated 06/23/23, documented the resident was often confused and at risk for change in mood or behavior due to medical conditions. Resident #2 Resident #2 was admitted to the facility on [DATE] with diagnoses including dysphagia, oropharyngeal phase, altered mental status, unspecified psychosis not due to a substance or known physiological condition, and dementia with other behavioral disturbance. Resident #2's Care Plan dated 09/28/22, documented the resident was at risk…

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 prevent a controlled substance medication from being diverted for 1 of 5 sampled residents (Resident #3). Findings include: The Facility Reported Incident (FRI) #NV00069388 documented a resident's liquid Lorazepam medication had been possibly diverted or missing. Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including secondary malignant neoplasm of brain, cerebral edema, anxiety disorder, mood affective disorder, and depression. A physician order dated 09/04/23, documented Lorazepam Concentrate, 2 milligram (MG)/milliliters (ML), give 0.25 ML by mouth every two hours as needed for anxiety as exhibited by agitation and panic attacks. Resident #3's Medication Administration Record dated September 2023, documented Lorazepam Concentrate, 0.25 ML was administered on 09/06/23. Resident #3's Controlled Drug Record for Lorazepam with a start date of 09/04/23, documented 0.25 ML was administered on…

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 gave informed consent prior to administration of a psychotropic medication for 2 of 22 sampled residents (Resident #535 and #81). Findings include: Resident # 535 Resident #535 was admitted to the facility on [DATE], with diagnoses including dysarthria following cerebral infarction, insomnia, and depression. A physician's order for Resident #535 dated 08/14/23, documented melatonin oral tablet 3 milligram (mg), give three tablets by mouth at bedtime for circadian rhythm maintenance. On 08/16/23 at 3:44 PM, the Nursing Supervisor confirmed a consent had not been documented for Resident #535's administration of melatonin as it was a supplement and not considered a psychotropic medication. Resident #81 Resident #81 was admitted to the facility on [DATE], with diagnoses including displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing. A physician's order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, document review and interview, the facility failed to ensure a baseline care plan was created timely for the use of melatonin medication, treatment, and care needs for 1 of 22 sampled residents (Resident #81) and use of oxygen, treatment and care needs for 1 of 3 closed records (Resident #538). Findings include: Resident #81 Resident #81 was admitted to the facility on [DATE], with a diagnosis of displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing. A physician's order for Resident #81 dated 07/20/23, documented melatonin oral tablet 3 milligrams (mg), give one tablet by mouth at bedtime for circadian rhythm maintenance. On 08/16/23 at 4:11 PM, the Licensed Practical Nurse confirmed Resident #81 lacked a baseline care plan for the use of melatonin. On 08/17/23 at 8:32 AM, the Director of Nursing (DON) verbalized the facility did not develop a care plan for the use of melatonin. On 08/17/23 at 9:13 AM, the Registered…

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 was care planned with interventions to ensure a resident's safety when the resident's bed was close to the wall and wall heater and a resident was care planned for the use of Intravenous (IV) antibiotics and Transmission Based Precautions (TBP) for 2 of 22 sampled residents (Resident #1 and #486). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including cerebral palsy, unspecified and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. On 08/14/23 at 3:27 PM, the left side of Resident #1's bed was close to the wall, with the bottom portion of the bed pressed against the air conditioner/heater wall unit and the upper portion of the bed approximately four inches from the wall. Resident #1 verbalized the staff would push the bed against the wall to create more space in the middle 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's bed was not pushed up against a wall heater and was far enough away from a wall to not create a potential entrapment risk for 1 of 22 sampled residents (Resident #1). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including cerebral palsy, unspecified and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. On 08/14/23 at 3:27 PM, the left side of Resident #1's bed was close to the wall, with the bottom portion of the bed pressed against the air conditioner/heater wall unit and the upper portion of the bed approximately four inches from the wall. Resident #1 verbalized the staff would push the bed against the wall to create more space in the middle of the room. On 08/16/23 at 10:37 AM, the Licensed Practical Nurse (LPN) for Resident #1 verbalized the resident had rolled out of bed…

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 oxygen was administered per a physician's order and following a plan of care for oxygen therapy for 1 of 3 closed records (Resident #538). Findings include: Resident #538 Resident #538 was admitted to the facility on [DATE], with diagnoses including sleep related hypoventilation in condition classified elsewhere, dependence on supplemental oxygen and cardiac murmur. Resident #538 expired on [DATE]. Resident #538's Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documented evidence of oxygen administration for [DATE] and [DATE]. Resident #538's clinical record lacked a physician's order for oxygen. Resident #538's care plan, provided undated, lacked a care plan related to the administration of oxygen therapy. Resident #538's oxygen saturation summary documented the following: -[DATE], 97% oxygen via nasal cannula -[DATE], 93% oxygen via nasal cannula -[DATE], 98%…

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 nursing staff was able to explain the correct procedure for sanitizing an insulin pen when preparing to administer insulin to a resident for 1 of 3 residents observed for medication administration (Resident #193). Findings include: Resident #193 Resident #193 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type two diabetes mellitus with diabetic peripheral angiopathy with gangrene and local infection of the skin and subcutaneous tissue, unspecified. On 08/16/23 at 7:42 AM, a Licensed Practical Nurse (LPN) began preparing a Humalog insulin pen for Resident #193. The LPN attached the needle to the pen but did not scrub the rubber septum with alcohol prior to attaching the needle. The LPN verbalized the LPN had always been told the rubber septum was the sterile part of the syringe, so it did not need to be wiped with alcohol. On 08/16/23 at 2:06 PM, the Director of…

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

Based on interview and Personnel Record Review, the facility failed to ensure Certified Nursing Assistants employed greater than one year had a performance review completed annually for 3 of 3 CNAs reviewed for completed performance review. Findings include: CNA1 had a start date of 02/10/22. CNA2 had a start date of 03/28/22. CNA3 had a start date of 06/25/18. On 08/15/23 at 2:35 PM, the Administrator and Staff Development Coordinator confirmed CNA1, CNA2, and CNA3 had not had a CNA annual performance review completed timely in 2023. The Personnel Records Checklist completed by the facility, documented the three CNAs received performance reviews on 08/14/23.

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 did not receive unnecessary psychotropic medications when the facility lacked monitoring of the behaviors associated with the psychotropic medications, and monitoring for adverse side effects for 3 of 22 sampled residents receiving psychotropic medications (Resident #535, #537 and #81). Findings include: Resident #535 Resident #535 was admitted to the facility on [DATE], with diagnoses including dysarthria following cerebral infarction, insomnia, and depression. A physician's order for Resident #535 dated 08/14/23, documented melatonin oral tablet 3 milligram (mg), give three tablets by mouth at bedtime for circadian rhythm maintenance. Resident #535's care plan, provided undated, documented Resident #535 had disturbed sleeping patterns related to circadian rhythm. Interventions included providing medications or sleep aids as ordered, notifying physician of significant change in sleep pattern, and offer…

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 medications were not left unsecured on top of a medication cart. Findings include: On 08/16/23 at 7:27 AM, a medication card containing the medication, Bumex, was on top of a medication cart outside of room [ROOM NUMBER]. The door to the room was closed and there was no staff in the hallway or within sight of the medication cart. On 08/16/23 at 7:30 AM, the Licensed Practical Nurse (LPN) exited room [ROOM NUMBER] and confirmed the medication card had been left on top of the cart, out of sight of staff, and the medication card should not have been left on top of the cart. On 08/16/23 at 2:11 PM, the Director of Clinical Services (DCS) verbalized medications should not have been left on a medication cart when the cart was not within sight of a nurse. The DCS verbalized unattended medications would be a safety concern as another resident could have taken the medication. The United States Food and Drug Administration (FDA) defined…

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 employees wore the appropriate hair restraints in the kitchen. Findings include: On 08/16/23 at 12:00 PM, a Dietary Aid was observed walking through the kitchen during lunch tray line, without a hairnet. On 08/16/23 at 12:01 PM, the Dietary Aid verbalized hairnets were required to be worn in the kitchen. The Dietary Aid confirmed the Dietary Aid did not don a hairnet prior to walking through the kitchen and should have. On 08/16/23 at 12:02 PM, the Food Services Director (FSD) verbalized the expectation was all staff would wear hairnets in the kitchen. The FSD confirmed the Dietary Aid had walked through the kitchen during tray line without a hair net. Facility policy titled Associate Conduct and Dress Code, dated 03/28/23, documented dietary staff must wear hair restraints to prevent hair from contacting food.

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 1) sterile technique was correctly performed when changing a Peripherally Inserted Central Catheter (PICC) line dressing for 1 of 22 sampled residents (Resident # 228), 2) an insulin pen was disinfected prior to administering insulin to 1 of 3 residents observed for medication administration (Resident #193), and 3) appropriate Presonal Protective Equipment (PPE) was worn by staff when entering the room of a resident on contact isolation (Resident #107). Findings include: PICC Line Dressing Change Resident #228 Resident #228 was admitted to the facility on [DATE], with diagnoses including methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, bacteremia, and long term (current) use of antibiotics. Resident #228's physician's orders documented change PICC line transparent dressing weekly, every Thursday. Measure upper arm circumference (10 centimeters (cm) above…

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.