Arcadia Valley Skilled Nursing And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interview, and policy review, the facility failed to ensure residents requiring assistance with Activities of Daily Living (ADLs) received nail care and showers as scheduled. This affected two residents (#33 and #44) of four residents reviewed for ADL assistance. The facility census was 37. Findings include:1.Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, type II diabetes, and dementia. Review of a care plan dated 07/03/25 revealed Resident #33 required assistance with ADLs related to cognitive impairment, dementia, and weakness. The goals were to continue to participate in ADLs as able and have no decline in ADLs through the review, and remain clean, dry, odor free and appropriately dressed through the review date. Interventions included but were not limited to requiring non-weight bearing assistance (including steadying, contact guard assistance or guided maneuvering) with shower, and staff will…

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 policy review, the facility failed to ensure the bowel protocol was followed when residents did not have bowel movements for three days or longer. This affected two residents (#37, #44) of five residents reviewed for unnecessary medications. Additionally, the facility failed to ensure a resident received physician ordered treatment for lymphedema. This affected one resident (#37) of one resident reviewed for lymphedema pumps. The facility census was 37. Findings include:1a.Record review revealed Resident #37 admitted to the facility on [DATE] with diagnoses including multiple sclerosis and chronic obstructive pulmonary disease. Review of a minimum data set assessment dated [DATE] revealed Resident #27's cognition remained intact, she had no behaviors, was dependent on staff for toileting hygiene, and was occasionally incontinent of bowel and bladder. Review of the bowel record revealed Resident #37 did not have a bowel movement from 03/01/26 through 03/06/26 or 03/08/26…

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, observation, and interview, the facility failed to ensure interventions to prevent pressure injuries were in place. This affected one resident (#6) of two residents reviewed for pressure injuries. The facility census was 37. Findings include: Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including dementia and hypertension. Review of an order dated 09/17/25 revealed Resident #6 had a pressure reducing mattress to bed. Review of a care plan dated 09/23/25 revealed Resident #6 was at risk for impaired skin integrity/pressure ulcers related to concussion and decreased mobility. Goals included skin to be free of breakdown and open areas will be healed without complications. Interventions included but were not limited to air mattress to bed at all times, elevate heels off mattress, inspect skin during routine daily care, liquid protein daily for wound healing, lotion to skin as needed, medications as ordered, pad and protect skin as needed, peri-care…

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 record review the facility failed to provide indwelling urinary catheter care. This affected one resident (#20) of six residents reviewed with indwelling urinary catheters. The census was 37.Findings include:Medical record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, dysphagia, chronic kidney disease stage 3, anemia, and supraventricular tachycardia.Review of Resident #20's admission minimum data set (MDS) assessment completed on 03/12/26 revealed the resident had an indwelling urinary catheter.Review of Resident #20's care plan dated 03/10/26 revealed the resident is at risk for infection or worsening infection due to indwelling medical devices, urinary catheter, and J-tube for nutrition.Review of Resident #20's care plan revealed completed on 03/10/26 revealed the resident has an alteration in elimination related to indwelling urinary catheter. Interventions include Foley catheter care every shift and as needed…

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 and interview, the facility failed to ensure residents received dental services. This affected one resident (#14) of three residents reviewed for dental services. The facility census was 37. Findings include:Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including dementia and anemia. Review of an order dated 08/27/24 revealed Resident #14 may see audiology, vision, dental, and podiatry. Review of a care plan revised on 03/26/25 revealed Resident #14 was at risk for oral/dental health problems related to natural teeth. The goal was to remain free from oral/dental complications through the next review date. Interventions included coordinate arrangements for dental care and transportation as needed/ordered (07/24/24); require oral inspections with oral care and report changes to a nurse (07/24/24); monitor/document/report to physician as needed signs and symptoms or oral problems needing attention: pain, abscess, debris in mouth, lips cracked 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, staff interview, and policy review, the facility failed to ensure a resident's indwelling urinary catheter's collection bag was maintained off the floor reducing the risk of infection. This affected one resident (#44) of two residents reviewed for indwelling urinary catheters. Findings include:Review of Resident #44's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a malignant neoplasm of an unspecified part of an unspecified bronchus or lung, malignant neoplasm of the vulva, neuromuscular dysfunction of the bladder, retention of urine, and difficulty walking. Review of Resident #44's physician's orders revealed the resident had an order to maintain an indwelling urinary catheter related to the diagnosis of retention of urine. The order had been in place since the resident was admitted to the facility on [DATE]. There was also an order to change her catheter bag every week on Tuesdays. Review of Resident #44's active care plans revealed 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 record review, observation, and interview the facility failed to ensure all mechanical, electrical, and patient equipment was in safe operating condition. This affected one resident (#37) of seven residents who are dependent on mechanical lifts for transfer. The census was 37.Findings include:Medical record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, chronic obstructive pulmonary disease, and muscle weakness.Review of Resident #37's minimum data set (MDS) assessment completed on12/02/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #37's minimum data set revealed the resident was dependent of staff for toileting, personal hygiene, and bed mobility and transfers. Observation on 03/26/26 at 8:51 A.M. revealed Resident #37 being transferred from bed to chair with a mechanical lift with Certified nurses aide (CNA) #128, and CNA#164. Upon lifting the resident from…

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 and interview, the facility failed to store and prepare food in a sanitary manner. This had the potential to affect 42 of 42 residents at the facility. Findings included: Observation during an initial tour of the kitchen with Dietary Manager (DM) #142 on 05/13/24 at 8:54 A.M. revealed two bags of salad with a best by date of 05/12/24 in the refrigerator. DM #142 confirmed findings. Continuous observations of the lunch tray line were made on 05/15/24 from 12:14 P.M. to 12:44 P.M. revealed: 1. Dietary Aide (DA) #109 used the back of her right wrist to rub her nose. DA #109 did not change her gloves or wash her hands. 2. Seven trays were sent out to be served on the [NAME] hallway with bowls of grapes left open to air. 3. Dietary [NAME] (DC) #123 sorted meal tickets to be placed on trays. While sorting, DC #123 licked her fingers to help separate papers. The tickets then went onto resident trays. 4. DA #109 took her right glove off, wiped her right hand on her pants, then applied a new glove without performing hand hygiene. 5. DA #109 used the back of her right…

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 medical record review, review of beneficiary protection notification review form, interview, and policy review, the facility failed to ensure Resident #40 and #41 were provided appropriate liability notices when cut from Medicare Part-A services with benefit days remaining and remained in the facility. This affected two residents (#40 and #41) of two residents reviewed who remained in the facility after being cut from Medicare Part-A services. Findings included: 1. Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including acute bronchitis, need for assistance with personal care, muscle weakness, pain in thoracic spine, difficulty in waking, and altered mental status. Review of the beneficiary protection notification review form (undated) revealed Resident #40 was discharged from Medicare Part A with benefit days remaining on 02/18/24 and remained in the facility. The resident did not receive an Advance Beneficiary Notice (ABN) form CMS-10055 due to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents had privacy while in their room. This affected one resident (#38) of one resident reviewed for privacy. The facility census was 42. Findings included: Record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including hyperkalemia, gastrointestinal hemorrhage, acute kidney failure, and type II diabetes. Review of a quarterly minimum data set completed on 03/22/24 revealed Resident #38's cognition remained intact and she had no behaviors. 1. Review of a nursing note dated 04/11/24 at 11:06 A.M. by Director of Nursing (DON) revealed Resident #38 had declined a room change after being kept awake the previous night by her roommate. Review of an undated page of interventions for Resident #38's roommate revealed no interventions to prevent rummaging through Resident #38's belongings. Review of an updated sticky note revealed interventions for Resident #38's privacy to be maintained included cups with lids,…

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 and interview, the facility failed to ensure residents were invited to participate in care planning upon admission and quarterly reviews. This affected two residents (#15 and #22) of three residents reviewed for care planning. The facility census was 42. Findings included: 1. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, type II diabetes, and congestive heart failure. Review of an admission minimum data set (MDS) revealed Resident #22's cognitive function remained intact and she had no behaviors. Review of a Multidisciplinary Care Conference assessment dated [DATE] revealed a care conference was held via telephone and participants included administration, social worker, and Resident #22's family/friend. Interview on 05/13/24 at 11:29 A.M. with Resident #22 revealed she had not been invited to participate in a care conference and was not aware the facility had a social worker. Interview on 05/14/24 at 4:14 P.M.…

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, observation, interview, and policy review the facility failed to ensure residents were assessed and provided activities per preference. This affected one resident (#247) of one reviewed for activities. Findings included: Record review revealed Resident #247 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including malignant neoplasm of bone, type two diabetes, diabetic retinopathy with macular edema unspecified eye, visual loss, anxiety, depression, spinal stenosis, arthritis, sleep disorder, and heart disease. Review of Resident #247's activity participation review dated 03/15/24 revealed the resident's activity preference was blank. The Minimum Data Set (MDS) assessment section indicated the resident was interviewed and it was somewhat important to do her favorite activities. Further review of Resident #247's medical record (paper and electronic) revealed no evidence the resident's activity preferences were reviewed or evidence a new assessment 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 record review, observation, interview, and policy review the facility failed to ensure fall interventions were in place per the resident plan of care. This affected one resident (#10) of one reviewed for falls. Findings included: Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including muscle weakness, dementia, macular degeneration, difficulty walking, lack of coordination, and fracture of right humerus. Review of Resident #10's nurses notes dated 05/2023 to 05/2024 revealed Resident #10 had fallen 07/17/23, 09/01/23, 01/20/24, and 04/25/24. Review the Resident #10's quarterly Minimum Data Set (MDS) dated [DATE] to 10/03/23 revealed no evidence the falls that occurred on 07/17/23 or 09/01/23 were captured on the MDS assessment. Review of Resident #10's fall plan of care initiated on 01/01/23 and revised on 01/18/24 revealed on 03/14/22 an intervention was added to have a low bed with mat on floor. On 02/15/22 a new intervention was added to place 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, observations, review of a resident's meal ticket, staff interview, and policy review, the facility failed to ensure a resident, who had a history of a significant weight loss, received nutritional interventions as ordered. This affected one resident (#35) of three residents reviewed for nutrition. Findings include: Review of Resident #35's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included morbid obesity, moderate protein-calorie malnutrition, muscle wasting and atrophy, dysphagia (difficulty swallowing), mild cognitive impairment of unknown etiology, schizo-affective disorder, heart failure, and major depressive disorder. Review of Resident #35's physician's orders revealed her diet included a consistent carbohydrate diet, regular texture, and regular consistency. She was also to receive super cereal and super potatoes (higher calorie foods) every day. Review of Resident #35's care plans revealed she had a care plan in place for 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 record review, observation, and interview, the facility failed to ensure medically related social services were provided to residents to monitor behavioral health concerns. This affected one resident (#10) of two residents reviewed for behaviors. The facility census was 42. Findings included: Record review revealed Resident #10 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, major depressive disorder, anxiety disorder, chronic obstructive pulmonary disease. Review of a quarterly minimum data set completed 04/03/24 revealed Resident #10 had moderately impaired cognitive skills, verbal behaviors one to three days, other behaviors one to three days, and refused care one to three days. Review of a care plan revealed Resident #10 had a behavior problem related to Alzheimer's disease, depression, and anxiety, is followed by [NAME] psych for frequently yelling out; Resident #10 has an alteration in mood with depression, anxiety, related to anxiety disorder with target behaviors…

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, family interview, and staff interview, the facility failed to ensure narcotic pain medication ordered on an as needed (prn) basis included parameters to direct the nurses on when to administer it and failed to administer another controlled narcotic medication for the reason it was ordered for. This affected one resident (#26) of five residents reviewed for unnecessary medications. Findings include: Review of Resident #26's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease, congestive heart failure (CHF), unspecified dementia without behavioral disturbances, emphysema, anxiety disorder, schizophrenia, unspecified psychosis, and psychotic disorder with delusions. Review of Resident #26's physician's orders revealed she had an order to receive Norco (controlled narcotic pain medication used for the treatment of moderate to severe pain) 5-325 milligrams (mg) by mouth (po) every four hours prn for pain. She also had an order 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 record review, observation, interview, and policy review the facility failed to ensure the medication error rate was less than 5%. There were 26 opportunities for error and two observed errors resulting in the medication error rate of 7.69 percent. This affected one resident (#33) of three residents observed for medication administration. Findings included: Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including hypothyroidism, low back pain, chronic pain, and fractures of the left femur, humerus, and sacrum. Review of Resident #33's current order dated 05/2024 revealed on 04/08/24 new orders were received to administer Synthroid 125 micrograms (mcg) early (4:00 A.M. to 6:00 A.M.) on Monday, Wednesday, and Friday. Further review revealed to administer Diclofenac Sodium external gel 1% four grams (gm) to knees, ankles, foot topically every shift for pain. Observation of Resident #33's medication administration with Licensed Practical Nurse (LPN) #126 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 record review, observation, interview, review of medication administration records, review of the pharmacy list for expiration dates for insulin, and policy review the facility failed to ensure medications were stored properly and medications were not expired. This affected one resident (#38) residing on the East unit. Finding included: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with a diagnosis including type two diabetes. Review of Resident #38's orders and medication administration record dated 05/2024 revealed on [DATE] the resident's insulin order was changed to Humalog pen inject per sliding scale. If blood sugar 0-300 no insulin required, blood sugar 301-400 give four units, blood sugar 401-600 give six units. Check blood sugar before meals and at bedtime. The resident did not receive the Humalog from [DATE] to [DATE]. Observation and interview on [DATE] at 2:21 P.M. and 3:00 P.M. of East medication cart with Licensed Practical Nurse…

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, observation, interview, and policy review the facility failed to maintain infection control practice while administering eye drops. This affected one resident (#6) of two observed for administration of eye drops. Finding included: Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including macular degeneration and dry eyes. Review of Resident #6's orders and medication administration records dated 05/2024 revealed to instill one drop of Artificial Tear Solution 1% in both eyes twice daily. Observation on 05/15/24 at 8:43 A.M. of Licensed Practical Nurse (LPN) #139 administering eye drops to Resident #6 revealed the LPN washed hands and applied gloves and administered artificial tears to Resident #6's left eye. The LPN removed her gloves and applied a new pair of gloves without performing hand hygiene. The LPN administered artificial tears to the right eye and removed her gloves and left the room without performing hand hygiene after removing 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 record review, review of a medication error report and the facility's related investigation, review of hospital records, staff interview, family interview, and policy review, the facility failed to ensure a resident was provided with a safe and orderly discharge as she was discharged home without clear discharge instructions. The resident was also given a medication belonging to another resident when the nurse had pulled the resident's medications from the medication administration cart and sent them home with the resident's husband without reviewing her medications. This affected one (Resident #46) of three residents reviewed for discharge. Findings include: A review of Resident #46's closed medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a UTI, altered mental status, and a psychotic disorder with hallucinations. A review of Resident #46's physician's orders revealed she was ordered to receive Cephepime HCL (an antibiotic) 2,000 milligrams (mg) intravenously…

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 and interview, facility failed to notify resident physicians and responsible parties when residents tested positive for COVID-19. This affected 11 residents (#2, #22, #27, #33, #40, #44, #66, #69, #77, #89, and #99 ) of 19 residents reviewed for COVID-19. The facility census was 40. Findings included: 1. Record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, type II diabetes, asthma, and major depression. Review of nursing note from 11/16/23 revealed Resident #66 tested positive for COVID-19, and the resident's physician was not notified. 2. Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, and hypertension. Review of nursing note from 11/17/23 revealed Resident #40 tested positive for COVID-19, but the resident's physician was not notified. 3. Record review revealed Resident #27 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 observation and interview, facility failed to wear personal protection equipment (PPE) including N-95 respirator masks appropriately in isolation rooms. This had the potential to affect all 40 residents residing in the facility. The facility census was 40. Findings included: Observation on 11/30/23 at 7:51 A.M. revealed State Tested Nursing Assistant (STNA) #133 entering room [ROOM NUMBER], which was a COVID isolation room, wearing a surgical mask underneath an N-95 respirator mask. This breaks the seal of the N-95 respirator mask. Interview on 11/30/23 at 8:01 A.M. with STNA #133 confirmed she was wearing a surgical mask under her N-95 respirator and she was unaware it could cause the seal of the N-95 to break. Observation on 11/30/23 at 9:00 A.M. revealed Housekeeper #199 entering room [ROOM NUMBER], which was a COVID isolation room, wearing a surgical mask underneath an N-95 respirator mask. This breaks the seal of the N-95 respirator mask. Interview on 11/30/23 at 3:34 P.M. with Director of Nursing…

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, resident council minute review, housekeeping checklist review, and facility policy review, the facility failed to provide a safe, clean, functional, sanitary, and comfortable environment. This affected one resident (#24) of three residents reviewed regarding environment and the poor condition of the shower chair had the potential to affect 32 of 43 all residents residing in the facility (11 residents received bed baths and did not go to the shower room (#4, #12, #13, #17, #21, #23, #27, #29, #30, #34, and #41) . The facility census was 43. Findings included: 1. Observation on 11/02/23 at 7:48 A.M. of the bedside commode beside Resident #24's bed revealed there was a yellow liquid with an ammonia odor and small brown formed substance in it. The ammonia odor was noted prior to looking in the bedside commode. Observation on 11/02/23 at 9:45 A.M. of the bedside commode beside Resident #24's bed revealed there was a yellow liquid with an ammonia odor and small brown formed substance…

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, resident record review and facility policy review, the facility failed to ensure a resident's room was maintained for easy mobility in a wheelchair. This affected one Resident (#24) of three residents reviewed for mobility. The facility census was 43. Findings included: Review of Resident #24's medical record revealed she was admitted to the facility on [DATE] with diagnoses including acute cystitis with hematuria, acute kidney failure, metabolic encephalopathy, difficulty in walking, essential hypertension, and dementia. Review of Resident #24's admission Minimum Data Set (MDS) 3.0 assessment, dated 09/09/23, revealed she was cognitively impaired and needed the supervision of one person for locomotion on the unit. Observation on 11/02/23 at 7:48 A.M. of Resident #24's roommate's bed near the window in the room. The bottom of the bed was two and one half feet from the bathroom entrance. There was also a bedside commode two feet from the bathroom door and directly in front of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, resident record review, facility Self-Reported Incident (SRI) review, time punch documentation and facility policy review, the facility failed to send two State Tested Nursing Assistants (STNAs) home after an allegation of sexual abuse by a resident. This affected one resident (#46) of three residents reviewed for sexual abuse and had the potential to affect Resident #3. The facility census was 43. Findings included: Review of Resident #46's closed medical record revealed an admission date of 10/04/23 with diagnoses including acute cerebrovascular insufficiency, type two diabetes, essential hypertension, hyperlipidemia and male erectile dysfunction. Resident #46 left the faciity on [DATE] against medical advice. Review of Resident #46's admission Minimum Data Set (MDS) 3.0 assessment, dated 10/10/23, revealed the resident had impaired cognition. Further review revealed he was dependent in toileting, personal hygiene and upper body and lower body dressing. Review of Resident #46's progress…

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, resident record review and facility policy review, the facility failed to ensure tube feeding was labeled when hung, orders for tube feeding were complete, and residents who received tube feedings were weighed appropriately. This affected three residents (#17, #47 and #48) of three residents reviewed for tube feeding. The facility census was 43. Findings included: 1. Review of Resident #17's medical record revealed she was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, moderate protein-calorie malnutrition, type two diabetes mellitus without complications, and dysphagia. Review of Resident #17's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/17/23, revealed she was cognitively impaired and had a feeding tube while a resident. Review of Resident #17's physician order, dated 10/13/23, identified she was to receive Diabeta Source enteral feeding every night shift at 80 milliliters (ml)/hour (hr) from 8:00 P.M. to 8:00 A.M. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, resident record review, and facility policy review, the facility failed to ensure a resident was free from unnecessary medication when the resident, who had pain level parameters for the administration of a controlled narcotic, did not receive the medication unless the pain level parameters were met. This affected one resident (#46) of three residents reviewed for medications. The facility census was 43. Findings included: Review of Resident #46's closed medical record revealed an admission date of 10/04/23 with diagnoses including acute cerebrovascular insufficiency, type two diabetes, essential hypertension, hyperlipidemia and male erectile dysfunction. Resident #46 left the faciity on [DATE] against medical advice. Review of Resident #46's admission Minimum Data Set (MDS) 3.0 assessment, dated 10/10/23, revealed the resident had impaired cognition. Further review revealed he had not received any scheduled or as needed pain medications in the last five days. Review of Resident #46's plan 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, resident record review, and facility policy review, the facility failed to ensure medications were administered as ordered by the physician and using standards of care resulting in a medication error rate greater than 5% (error rate of 14.81%). This affected one resident (#26) of two residents observed for medication administration. There were 27 opportunities for medication error and four medication errors resulting in a 14.81% medication error. The facility census was 43. Findings included: Review of Resident #26's medical record revealed she was admitted to the facility on [DATE] with diagnoses including pulmonary embolism, pleural effusion, dysphagia, and type two diabetes mellitus. Review of Resident #26's admission Minimum Data Set (MDS) 3.0 assessment, dated 10/03/23, revealed she was cognitively intact and did not have any coughing or choking during meals, or when swallowing and did not have complaints of difficulty or pain when swallowing. Review of Resident #26'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.

Based on observation, interview, and facility policy review, the facility failed to ensure Dakins Solution half strength used for wound care was dated when opened. This had the potential to affect three residents who had an active skin wound (#13, #24, and #26). The facility census was 43. Findings included: Observation on 11/02/23 at 10:42 A.M. of the wound supply cart revealed one bottle of one-half strength Dakins Solution which was open and almost empty and one bottle of one-half strength Dakins Solution which was open and almost full, each bottle with no documentation on the bottle to note when it was opened. Interview at the time with Registered Nurse (RN) #148 verified the bottles were not dated when opened and they should be. She verified multiple dose bottles expire 30 days after they are opened. Review of the facility policy titled, Medication Storage, Storage of Medication, undated, revealed medication and biologicals are stored properly, following manufacturer or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug…

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 facility policy review, the facility failed to ensure food storage and food handling was completed in a sanitary manner, failed to ensure pest control in the kitchen, failed to ensure food service equipment was clean, and failed to maintain documentation of food temperatures prior to serving, dishwasher sanitation requirements being met, and sanitation bucket requirements being met. This had the potential to affect 42 of 43 residents receiving food from the kitchen. Facility documentation revealed Resident #42 did not receive any food by mouth. Findings included 1. Observation on 08/21/23 at 7:45 A.M. of the right reach in refrigerator revealed approximately six ounces of possibly bologna which was opened and not labeled or dated, approximately eight ounces of roast beef which was opened and not dated, and a single hot dog which was in an unsealed bag and was also not dated. Observation on 08/21/23 at 7:47 A.M. of the left reach in refrigerator revealed one half of a large bag of lettuce which was open and not dated. The lettuce in the bottom 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 observation, interview, and facility policy review, the facility failed to ensure staff wore appropriate personal protective equipment when the facility was in COVID-19 outbreak, performed hand hygiene, did not touch items with soiled gloves, and cleaned and disinfected a glucometer used by multiple residents. This affected Residents #7, #27, and #29 and had the potential to affect all 43 residents. Findings included: 1. Observation on 08/21/23 at 7:30 A.M., upon entrance into the facility, of a sign on the exterior main entrance door which informed anyone entering the building the facility was in a COVID-19 outbreak. Observation on 08/21/23 at 7:31 A.M. of Licensed Practical Nurse (LPN) #95 and Registered Nurse (RN) # 100 sitting at the east nurses' station not wearing any masks. An interview at the time revealed the facility was in COVID-19 outbreak and per their facility policy they should be wearing N-95 masks. Neither LPN #95 of RN #100 were wearing eye protection. Observation on 08/21/23 at 7:32 A.M. of Housekeeping Aide #101 delivering meals to residents sitting 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.

Based on observation, interview, resident record review, and facility policy review, the facility failed to ensure pressure ulcer wound treatments were completed as ordered. This affected one resident (#37) of three residents reviewed for pressure ulcer care. The facility census was 43. Findings included: Review of Resident #37's medical record revealed an initial admission date of 04/16/23 and a readmission date of 03/30/23 with diagnoses including nondisplaced intertrochanteric fracture of the right femur, moderate protein-calorie malnutrition, muscle weakness, and repeated falls. Review of Resident #37's significant change Minimum Data Set (MDS) 3.0 assessment, dated 07/17/23, revealed he was cognitively intact and was always incontinent of bowel and bladder. Further review revealed he had one Stage 3 pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss) which was present upon…

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

Based on observation, interview, resident record review and facility policy review, the facility failed to ensure incontinence care was provided timely. This affected one resident (#27) of three residents reviewed for incontinence care. The facility census was 43. Findings included: Review of Resident #27's medical record revealed an initial admission dated of 07/05/18 and a readmission date of 12/01/20 with diagnoses including multiple sclerosis, type two diabetes, morbid obesity, and generalized muscle weakness. Review of Resident #27's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/04/23, revealed she was cognitively intact. The assessment indicated she needed extensive assistance of two plus persons for physical assistance with toilet use and she was frequently incontinent of bladder and always incontinent of bowel. Review of Resident #27's plan of care, dated 07/09/18, revealed she had an alteration in elimination, was frequently incontinent of bladder and occasionally incontinent of bowel. Added on 07/29/19 was that she was always incontinent of bladder.…

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, resident record review and facility policy review, the facility failed to ensure they maintained a medication error rate of less than 5%. This affected three residents (#7, #20, and #29) of five residents observed for medication observation and resulted in a medication error rate of 13.95%. There was total of 43 opportunities for error during the medication administration observation and the facility had a total of six medication errors resulting in a medication error rate of 13.95%. The facility census was 43. Findings included: 1. Review of Resident #20's medical record revealed she was admitted to the facility on [DATE] with diagnoses including unspecified fracture of the unspecified lumbar vertebra, malignant neoplasm of the unspecified site, dementia in other disease classified elsewhere, Alzheimer's disease, anxiety disorder, and essential hypertension. Review of Resident #20's admission Minimum Data Set (MDS) 3.0 assessment, dated 07/09/23, revealed she was severely…

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 facility policy review, the facility failed to ensure liquid medications were stored in a way to prevent contamination. This affected one resident (#4) of five residents observed for medication administration. The facility census was 43. Findings included: Observation on 08/21/23 at 12:14 P.M. as Registered Nurse (RN) #100 prepared medications for Resident #4. RN #100 poured Resident #4's liquid Carafate medication in a plastic medication cup and then sat the cup on the top of the medication cart. She then lowered herself, so she was at eye level with the medication cup to check the amount. RN #100 had poured more than what was ordered for Resident #4 into the medication cup. RN #100 then picked up the medication cup with the Carafate in it and poured some of the liquid medication back into the medication bottle the medication was originally poured from. This action resulted in contamination of the bottle of medication. Interview on 08/21/23 at 12:25 P.M. with RN #100 verified she should not have returned the liquid Carafate she over poured into…

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 observations, staff interview, and facility policy review, the facility failed to store and date food in a safe manner. This had the potential to affect 44 of 44 residents in the facility. Findings include: Observations on 05/09/22 from 8:25 A.M. to 8:35 A.M. revealed the following items were open and undated as to when they were opened or when they should be discarded, in the facility freezer: chicken wings, country friend steak, chicken patties, and sausage patties. Interview with Dietary Manager #138 on 05/09/22 at approximately 8:35 A.M. confirmed the items listed above were opened and undated. She stated she was not aware that items within the freezer had to be dated with either the date they were opened or the date in which they should be discarded. Review of facility Food Storage policy, dated March 2022, revealed all foods should be covered, labeled, and dated. All foods would be checked to assure that foods would be consumed by their safe used by dates or discarded.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident financial record review, staff interview, and facility policy review, the facility failed to adequately notify residents and/or representative of the possibility of lost Medicaid eligibility for reaching and exceeding the maximum amount within their resident funds accounts. This affected two (Resident #34 and Resident #48) of six residents whose financial records were reviewed. The census was 44. Findings include: 1. Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses were quadriplegia, other recurrent depressive disorders, osteoarthritis, aphasia, epilepsy, glaucoma, and car driver injured in collision, with other type car in traffic accident. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/01/22, revealed Resident #34 was deemed to have a severe cognitive impairment. Review of Resident #34's financial records revealed the following quarterly balances: Second quarter 2021 was $5369.83, third quarter 2021 was $5402.63,…

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 medical record review and staff interview, the facility failed to revise Pre-admission Screening and Resident Review (PASRR) records when the initial PASRR document was not correct. This affected two (Resident #7 and Resident #29) of three residents reviewed for PASRR. The census was 44. Findings include: 1. Medical record review revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses were end stage renal disease, muscle weakness, difficulty walking, cognitive communication deficit, major depressive disorder, schizoaffective disorder, anxiety disorder (12/13/21), muscle wasting and atrophy, dementia, hypothyroidism, hypertension, type II diabetes, chronic kidney disease (stage IV), schizophrenia, mild intellectual disabilities (10/17/20), generalized anxiety disorder (10/17/20), and unspecified protein-calorie malnutrition. Review of Resident #7's Minimum Data Set (MDS) 3.0 assessment, dated 04/15/22, revealed Resident #7 was deemed to have a significant cognitive impairment. Review 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 medical record review and staff interview, the facility failed to inform the state mental health agency of a significant change in Pre-admission Screening and Resident Review (PASRR) records. This affected two (Resident #7 and Resident #29) of three residents reviewed for PASRR. The census was 44. Findings include: 1. Medical record review revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses were end stage renal disease, muscle weakness, difficulty walking, cognitive communication deficit, major depressive disorder, schizoaffective disorder, anxiety disorder (12/13/21), muscle wasting and atrophy, dementia, hypothyroidism, hypertension, type II diabetes, chronic kidney disease (stage IV), schizophrenia, mild intellectual disabilities (10/17/20), generalized anxiety disorder (10/17/20), and unspecified protein-calorie malnutrition. Review of Resident #7's Minimum Data Set (MDS) 3.0 assessment, dated 04/15/22, revealed Resident #7 was deemed to have a significant cognitive impairment.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy, the facility failed to identify and monitor bruises for Resident #27 in a timely manner. This affected one of four residents reviewed for non pressure skin impairment. The facility census was 45. Findings include: Review of the medical record for Resident #27 revealed an admission date of 10/12/21 with diagnoses including chronic obstructive pulmonary disorder, osteoarthritis, malignant neoplasm, and history of thrombus. Review of the annual Minimum Data Set (MDS) dated [DATE] indicated Resident #27 was cognitively intact and required extensive assistance of two persons for activities of daily living. Resident #27 had no skin impairments noted. Review of the plan of care dated 04/18/22 revealed Resident #27 had bruising noted throughout her skin due to bumping self against various items in her room. The interventions included to inspect skin during routine daily care, and skin assessment as ordered. Observations on 05/09/22 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review, the facility failed to ensure a palm guard was offered and passive range of motion was completed for Resident #43. This affected one of three residents reviewed for range of motion. The facility census was 45. Findings include: Review of the medical record for Resident #43 revealed an admission date of 06/15/19 with diagnoses including Parkinson's disease, muscle wasting and atrophy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was cognitively intact, required assistance with activities of daily living, and had impaired range of motion to one side of upper extremities. Review of the plan of care dated 03/03/22 revealed Resident #43 had a contracture of the left hand and refused therapy, the brace, a carrot, and fingernail care. Resident #43 would at times accept cleaning of the hand and put tissues in the hand. Interventions included to report pain to the nurse and therapy restorative…

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 medical record review and staff interview, the facility failed to implement pharmacy medication regimen review recommendations approved by the physician in a timely manner for Resident #45. This affected one (Resident #45) of five residents whose pharmacy recommendations were reviewed. The census was 44. Findings include: Medical record review revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses were congestive heart failure, morbid obesity, difficulty walking, sleep apnea, type II diabetes, encephalopathy, major depressive disorder, myocardial infarction, anxiety disorder, acute and chronic respiratory failure, Alzheimer's disease, anemia, osteoarthritis, atherosclerotic heart disease, hypertension, and weakness. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/23/22, revealed Resident #45 was deemed cognitively intact. Review of Resident #45's pharmacy recommendation, dated 12/01/21, revealed a recommendation for the physician to review the quantity and frequency 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 medical record review, staff interview, and policy review, the facility failed have proper parameters for as needed pain medications for Residents #45 and #27, and failed to provide medications as written per the physician for Resident #45. This affected two (Resident #45 and Resident #27) of five residents reviewed for unnecessary medications. The census was 44. Findings include: 1. Medical record review revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses were congestive heart failure, morbid obesity, difficulty walking, sleep apnea, type II diabetes, encephalopathy, major depressive disorder, myocardial infarction, anxiety disorder, acute and chronic respiratory failure, Alzheimer's disease, anemia, osteoarthritis, atherosclerotic heart disease, hypertension, and weakness. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/23/22, revealed Resident #45 was deemed cognitively intact. Review of Resident #45's pharmacy recommendation, dated 12/01/21, revealed the pharmacy…

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.