Wingfield Skilled Nursing And Rehabilitation Cente

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) the activities care plan addressed a resident's visual impairment and the need for staff to support and assist the resident with personalized activities for 1 of 23 sampled residents (Resident #9). This deficient practice had the potential to prevent staff caring for the resident to be aware of the resident's personalized interests and how the staff could assist the resident to meet the resident's activity related goals. 2) A care plan was developed to address monitoring for a resident with bilateral lower extremity edema for 1 of 23 sampled residents (Resident #86). This deficient practice had the potential for the resident to suffer adverse health outcomes because of staff caring for the resident being unaware of the need to monitor for signs of leg swelling. 3) A care plan was developed for the use of bed rails for 1 of 23 sampled residents (Resident #208). This deficient practice had the potential…

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 Licensed Practical Nurse (LPN) performed the duties as outlined in the State Board of Nursing Nurse Practice Act with safe medication administration when the LPN failed to check blood sugar levels prior to the administration of insulin for 1 of 23 sampled residents (Resident #212). The deficient practice had the potential to expose the resident to medication errors resulting in additional health complications. Findings include: Resident #212 Resident #212 was admitted to the facility on [DATE], with a diagnosis including type two diabetes mellitus without complications. On 12/02/2024 at 2:17 PM Resident #212 explained while waiting for lunch on 12/02/2024, the resident was sitting with the resident's daughter and a nurse approached the table to check the resident's blood sugar levels. The nurse told the resident the nurse would be back to administer the resident's insulin and the nurse walked away. The nurse came back…

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 dependent upon staff for Activities of Daily Living (ADLs) had brief changes overnight for 1 of 23 sampled residents (Resident #36). This deficient practice had the potential to compromise resident hygiene, comfort, and dignity, and increase the risk of skin breakdown and infections. Findings include: Resident #36 Resident #36 was admitted to the facility on [DATE], with diagnoses including rhabdomyolysis, a disease which causes muscle pain and weakness and trouble moving arms and legs, repeated falls, muscle weakness, unsteadiness on feet, other reduced mobility, and pressure ulcer of sacral region, unspecified stage. On 12/02/2024 at 9:28 AM, Resident #36 verbalized the resident was ignored by the night shift staff and was only receiving a brief change once overnight. The resident explained the night shift staff should change the resident every two to three hours, however the staff only came in and changed…

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 visually impaired resident received individualized activities based on the resident's preferences and goals for 1 of 23 sampled residents (Resident #9). This deficient practice had the potential to result in a resident feeling a loss of independence and negatively impact the resident's psychosocial well-being. Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unqualified vision loss, both eyes and depression, unspecified. On 12/02/2024 at 9:08 AM, Resident #9 verbalized the resident would participate in group activities when the activities were accessible for the resident, but the resident did not have any activities the resident could do while the resident was by themself. An Activity Interview for Daily and Activity Preferences, dated 11/04/2024, documented it was very important to the resident to have mystery and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's medication for neuropathy (a nerve condition causing pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) was refilled timely to prevent the resident from missing eight doses of the medication for 1 of 23 sampled residents (Resident #9). This deficient practice had the potential to result in a resident experiencing unrelieved nerve pain the medication was prescribed to treat. Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including other chronic pain, pain, unspecified, pain in left ankle and joints of left foot, and pain in right knee. On [DATE] at 9:18 AM, Resident #9 verbalized the resident had not received a scheduled pain medication over the weekend. The resident explained the medication was usually given three times a day to prevent the resident from having pain in 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 interview, clinical record review, and document review the facility failed to ensure a resident's blood sugar levels were tested timely prior to the administration of insulin for a resident with type two diabetes mellitus for 1 of 23 sampled residents (Resident #212). This deficient practice had the potential to cause the resident to experience hypoglycemia or hyperglycemia symptoms related to blood sugar levels not being regulated. Findings include: Resident #212 Resident #212 was admitted to the facility on [DATE], with a diagnosis including type two diabetes mellitus without complications. On 12/02/2024 at 2:17 PM Resident #212 explained while waiting for lunch on 12/02/2024, the resident was sitting with the resident's daughter and a nurse approached the table to check the resident's blood sugar levels. The nurse told the resident the nurse would be back to administer the resident's insulin and the nurse walked away. The nurse came back over one hour later to administer the insulin to 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 observation, interview, clinical record review, and document review, the facility failed to ensure a resident did not have a bottle of over-the-counter medication unsecured on the resident's bedside table when the resident did not have an order for the medication or to keep medications at the bedside for 1 of 23 sampled residents (Resident #9). This deficient practice had the potential to result in the resident self-medicating and suffering adverse reactions or medication interactions. Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus with diabetic neuropathy, unspecified, type II diabetes mellitus with unspecified complications, and long term (current) use of insulin. On 12/03/2024 at 2:40 PM, a medication bottle was on the top of the bedside table to the left of the resident, in between the resident's bed and the curtain separating the resident from the resident's roommate. The label on 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 protect a resident from being kicked by another resident for 1 of 8 sampled complaint and Facility Reported Incident (FRI) residents (Resident #5). Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including cognitive communication deficit and major depressive disorder, recurrent, in partial remission. Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, vascular dementia, moderate, with agitation, and schizoaffective disorder, bipolar type. FRI #NV00070234, dated 01/16/24, documented Resident #5 reported to the Licensed Social Worker (LSW) the resident was kicked in the leg by Resident #6, resulting in a bruise on Resident #5's left knee. A social services progress note dated 01/16/24, in…

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 report an allegation of abuse to the State Agency (SA) within the required timeframe. Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including cognitive communication deficit and major depressive disorder, recurrent, in partial remission. A social services progress note dated 01/16/24 at 9:25 AM, documented Resident #5 reported to the Licensed Social Worker (LSW) the resident was kicked in the leg by another resident. The initial Facility Reported Incident (FRI) #NV00070234 was submitted to the SA on 01/16/24 at 6:51 PM. The incident was documented as physical abuse. On 02/27/24 at approximately 3:00 PM, the Administrator verbalized all types of abuse were to be reported to the SA. The Administrator confirmed allegations of physical abuse were required to be reported to the SA within two hours of becoming aware of the allegation. The Administrator…

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 kitchen equipment temperature logs were completed daily and hand hygiene supplies were available for dietary staff to wash their hands at hand washing stations with the ability to affect 119 of 119 residents. Findings include: Temperature Logs On 02/27/24 at 8:50 AM, a tour of the kitchen was conducted, and for temperature logs were hanging on the side of a reach-in refrigerator. The following logs documented the most recent temperatures of kitchen equipment: -Fridge and Freezer temperature log last completed 02/21/24 -Front fridge temperature log last completed 02/24/24 -Front fridge temperature log last completed 02/20/24 -Dishwashing and rinsing temperature log last completed 02/21/24 On 02/27/24 at 9:34 AM, the Food Services Manager (FSM) verbalized the expectation was all the logs were to be completed daily to ensure proper functioning of the kitchen equipment and ensure the residents would not become ill from faulty equipment. The FSM confirmed the logs were not up to date and was unsure if all…

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 there were eight hours of consecutive Registered Nurse (RN) coverage for two of 30 days reviewed for staffing. This deficient practice could have allowed all 116 residents residing in the facility on the affected dates to go without proper assessments or certain cares RNs can perform. Findings include: Review of the facility nursing schedules and Registered Nurse Employee Timesheet for the affected dated revealed the following days where an RN was scheduled for less than eight consecutive hours: - on 12/02/23 an RN worked from Midnight until 6:31 AM for a consecutive total of six hours and 31 minutes, and an RN worked from 5:55 PM until Midnight on 12/03/23 for a consecutive total of six hours and five minutes worked. - on 12/03/23 an RN worked from Midnight until 6:31 AM for a consecutive total of six hours and 31 minutes, and an RN worked from 5:55 PM until Midnight on 12/04/23 for a consecutive total of six hours and five minutes worked. On 12/14/23 at 11:55 AM, the Director of Nursing (DON) verbalized the DON…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to resolve the reported grievances from a resident regarding physcian order not being followed and preferred for double portions of food to be served at each meal for 1 of 22 sampled residents (Resident #169). Findings include: Resident #169 Resident #169 was admitted to the facility on [DATE], with diagnoses including depression, unspecified, rhabdomyolysis and muscle weakness, generalized. Resident #169's diet order dated 11/28/23, documented regular diet, regular texture and double portions. On 12/11/23 at 12:23 PM, Resident #169 explained double portion sizes were supposed to be served at each meal. The resident often felt hungry after each meal because the double portion sizes were only served occasionally. The resident filed a grievance with the facility about not receiving double portion sizes on 12/05/23, however the resident had not received any follow up from staff relating to the grievance filed. The lunch meal ticket for Resident #169 dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and document review the facility failed to interview all persons involved in an investigation of misappropriation for 1 of 22 sampled residents (Resident #55). Findings include: Interview and Documentation Resident #55 Resident #55 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including spinal stenosis, lumbar region with neurogenic claudication, dependence on wheelchair, and cognitive communication deficit. Facility Reported Incident (FRI) #NV00069936, documented the following: On 11/28/23, Resident #55 notified the Administrator and Social Worker there was $1600.00 missing from the resident's room. The resident kept the money hidden in the resident's bedroom and had the money since March 2023 from the sale of a vehicle. The resident had counted the money weekly and found the money was missing when the resident went to count the money on 11/28/23. On 12/11/23 at 3:48 PM, Resident #55 explained someone had stolen the resident's money from 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 and clinical record review the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 22 sampled residents (Resident #23). Findings include: Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy and cognitive communication deficit. Resident #23's last quarterly MDS assessment dated [DATE], section E0200 (Behavioral Symptoms - Presence and Frequency) completed on 11/23/23, documented behavior not exhibited for item B (verbal behavioral symptoms directed towards others. Such as threatening, screaming, and/or cursing at others). Section E0800 (Rejection of Care - Presence and Frequency) documented the behavior, rejection of care, was not exhibited. A Psychiatric Evaluation note dated 11/16/23, documented Resident #23 became agitated and angry during the Brief Interview of Mental Status (BIMS) assessment and accused the clinician of checking to see if I am stupid. Resident #23 used foul language to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) care planned interventions for administering a resident's as needed (prn) pain medication were followed for 1 of 22 sampled residents (Resident #53), 2) a care plan related to wounds was complete and person centered for 1 of 22 sampled residents (Resident #81), and 3) a care plan related to anemia was complete and person centered for 1 of 22 sampled residents (Resident #40). Findings include: Resident #53 Resident #53 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pain, unspecified, muscle weakness (generalized), and difficulty in walking, not elsewhere classified. On 12/11/23 at 9:35 AM, Resident #53 verbalized the resident had been experiencing pain in the resident's left leg and the pain was constant. Order Audit Reports for Resident #53 documented the following medications were ordered for pain: - Acetaminophen tablet 325 milligrams (mg) tablets. Give 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 observation, interview, clinical record review, and document review the facility failed to ensure medications were administered prior to the expiration date for 1 of 10 residents observed during medication administration (Resident #29) and nystatin (a medicated powder) was applied by an individual with the required skills and training to administer medications for 1 of 22 sampled residents (Resident #23). Findings include: Resident #29 Resident #29 was admitted to the facility on [DATE], with diagnoses including unspecified asthma, uncomplicated and chronic respiratory failure with hypoxia. On [DATE] at 10:30 AM, Resident #29 asked a Licensed Practical Nurse (LPN) for an inhaler. The LPN administered two puffs of albuterol sulfate 90 micrograms (mcg) per actuation (act) to Resident #29. After the resident had taken the medication, the albuterol sulfate inhaler was noted to have an expiration date of 07/2018. On [DATE] at 10:36 AM, the LPN confirmed the albuterol sulfate inhaler was expired and had been…

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 nystatin (a medicated powder) was applied by an individual with the required skills and training to administer medications for 1 of 22 sampled residents (Resident #23). Findings include: Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy, unsteadiness on feet, generalized weakness, difficulty walking, not elsewhere classified, and acute respiratory failure with hypoxia. A physician's order dated 12/05/23, documented nystatin external powder 100000 units/gram (gm), apply to bilateral breast fold topically in the morning for dermatitis for seven days and apply to bilateral breast fold topically at bedtime for dermatitis for seven days. An alert note dated 12/08/23, written by a Licensed Practical Nurse (LPN) documented Resident #23 had a shower on 12/08/23, and after the shower a Certified Nursing Assistant (CNA) patted the area dry and applied nystatin…

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 medications were not left unsecured in a resident's room by allowing a resident access to self-administer a medication and creating a potential accident by leaving a medication unsecured for 1 of 22 sampled residents (Resident #74). Findings include: Resident #74 Resident #74 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including cognitive communication deficit, need for assistance with personal care, and chronic obstructive pulmonary disease, unspecified. On 12/11/23 at approximately 11:00 AM, during a tour of the facility, an inhaler of Breztri Aerosphere was unsecured on Resident #74's bedside table. The door to the resident's door was open. A physician's order dated 11/16/23, documented Breztri Aerosphere Inhalation Aerosol 160-9-4.8 microgram (MCG) (Budesonide-Glycopyrrolate-Formoterol Fumarate). Inhale two puffs orally in the morning and two puffs at bedtime 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, clinical record review, interview, and document review the facility failed to ensure a resident's portable oxygen tank was not empty and oxygen tubing on the portable oxygen tank was changed per a physician's order for 1 of 22 sampled residents (resident #23). Findings Include: Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy and acute respiratory failure with hypoxia. Empty Oxygen Tank A physician's order dated 09/20/23, documented to administer oxygen at 2 liters per minute (LPM) continuously via nasal cannula for shortness of breath and hypoxia. On 12/11/23 at 2:53 PM, Resident #23 was wearing a nasal cannula conected to an empty portable oxygen tank on the back of the resident's wheelchair. On 12/11/23 at 3:00 PM, a Licensed Practical Nurse (LPN)1 confirmed Resident #23's oxygen tank was empty and should have been replaced or the resident should have had oxygen connected to the resident's oxygen concentrator. On 12/14/23…

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 as needed (prn) pain medications were administered as ordered and non-pharmacological interventions were attempted prior to medicating a resident with a prn pain medication for 1 of 22 sampled residents (Resident #53). Findings include: Resident #53 Resident #53 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pain, unspecified, muscle weakness (generalized), and difficulty in walking, not elsewhere classified. On 12/11/23 at 9:35 AM, Resident #53 verbalized the resident had been experiencing pain in the resident's left leg and the pain was constant. Order Audit Reports for Resident #53 documented the following medications were ordered for pain: - Acetaminophen tablet 325 milligrams (mg) tablets. Give two tablets (650 mg) every four hours as needed for severe pain. The medication's start date was 09/18/23. - Tramadol 50 mg tablet. Give one tablet by mouth every six…

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 medication was administered with an error rate of less than five percent (%). There were 37 opportunities and five medication errors. The medication error rate was 13.51%. Findings include: Resident #29 Resident #29 was admitted to the facility on [DATE], with diagnoses including unspecified asthma, uncomplicated and chronic respiratory failure with hypoxia. On [DATE] at 10:30 AM, a Licensed Practical Nurse (LPN)1 administered two puffs of albuterol sulfate 90 micrograms (mcg) per actuation (act) to Resident #29. After the resident had taken the medication, the albuterol sulfate inhaler was noted to have an expiration date of 07/2018. On [DATE] at 10:36 AM, LPN1 confirmed the albuterol sulfate inhaler was expired and had been administered to Resident #29. An Order Review History Report for Resident #29 documented the following: -albuterol sulfate hydrofluoroalkane inhalation aerosol solution 108 (90 base)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review the facility failed to ensure 1)unsecured medications were not left in a resident's room for 1 of 22 sampled residents (Resident #74), 2) an open date was written on a multi-dose vial in 1 of 1 sampled medication storage rooms, 3) expired medications were removed from 1 of 3 sampled medication carts, and 4) medication labels included an expiration date for 2 of 3 sampled medication carts. Findings include: Resident #74 Resident #74 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including cognitive communication deficit, need for assistance with personal care, and chronic obstructive pulmonary disease, unspecified. On 12/11/23 at approximately 11:00 AM, during a tour of the facility, an inhaler of Breztri Aerosphere was unsecured on Resident #74's bedside table. A physician's order dated 11/16/23, documented Breztri Aerosphere Inhalation Aerosol 160-9-4.8 microgram (MCG)…

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, observation, clinical record review, and document review, the facility failed to provide meals based on resident's preferences for 1 of 22 sampled residents (Resident #169). Findings include: Resident #169 Resident #169 was admitted to the facility on [DATE], with diagnoses including depression, unspecified, rhabdomyolysis and muscle weakness, generalized. On 12/11/23 at 12:23 PM, Resident #169 explained double portion sizes were supposed to be served at each meal. The resident often felt hungry after each meal because the double portion sizes were only served occasionally. The resident filed a grievance with the facility about not receiving double portion sizes on 12/05/23. The lunch meal ticket for Resident #169 dated 12/11/23, documented the resident would be receiving a cheeseburger and would be getting double portions. The resident verbalized there was one cheeseburger on the plate. A Grievance/Complaint Report dated 12/05/23, documented Resident #169 was supposed to be receiving double…

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 2 of 5 residents sampled for vaccinations (Resident #63 and #74) were screened for eligibility to receive a COVID-19 vaccine, education regarding the vaccine was provided to the resident and/or the resident representative, and the vaccine was offered and either administered or declined. Findings include: Resident #63 Resident #63 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified sequelae of cerebral infarction, type 2 diabetes mellitus without complications, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Resident #63's state immunization record downloaded and printed on 12/13/23 at 11:16 AM, by the [NAME] President (VP) of Clinical Services lacked documented evidence the resident was administered a COVID -19 vaccine in 2023. The vaccine record documented the second dose of a COVID-19 vaccine was administered on 01/14/22.…

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 Certified Nursing Assistant (CNA) borrowed money from a resident and failed to pay the money back to the resident for 1 of 17 sampled residents (Resident #7). Findings include: Resident #7 Resident #7 was admitted to the facility on [DATE], and discharged on 09/22/23, with diagnoses including unspecified acquired deformity of right lower leg, dorsalgia, unspecified and other chronic pain. A Facility Reported Incident (FRI) dated 08/11/23, documented Resident #7 had reported to the facility, the resident had let a CNA borrow $100.00 to go toward the CNA's nursing degree; however, the CNA failed to return the money to Resident #7. A Complaint Form dated 08/14/23, documented Resident #7 filed a grievance explaining the resident had let a CNA borrow $100.00, however the CNA made no attempt to pay the money back to the resident. The employee was put on leave…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interview and document review, the facility failed to provide supervision to prevent two residents (Resident #8 and #9) from elopement from the facility. Findings include: FRI #NV00068634 documented on 05/21/23, a resident was found at a hardware store across the street from the facility. Resident #8 Resident #8 was admitted to the facility on [DATE], with diagnoses including traumatic subdural hemorrhage with loss of consciousness of unspecified duration, cognitive communication deficit, and impulsiveness. An Elopement Risk Evaluation dated 05/12/23, document the resident was at low risk for wandering. A Brief Interview for Mental Status dated 05/15/23, documented the resident was severely impaired, with a score of two. A Daily Skilled Charting Progress Note dated 05/16/23, documented the resident had multiple episodes of confusion and was attempting to open exit doors in hallways. An Incident Progress Note dated 05/21/23, documented the resident's family member had called 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.