Vista Center At The Ridge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure Resident #36 was reweighed according to facility policy and failed to have documented evidence the physician was notified of after an 8.7% weight loss in 30 days and failed to ensure Resident #37's weekly weights were obtained as ordered. This affected two residents (#36 and #37) of three residents reviewed for nutrition and had the potential to affect all 144 residents in the facility. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 06/04/20. Diagnoses included malnutrition, muscle weakness, prostate disorder, depression and diabetes. Review of Resident #36's weight record revealed on 12/04/24 Resident #36 weighed 322 pounds and on 01/03/2025 Resident #36 weighed 294 pounds which was a 8.70% weight loss in 30 days. There was no documented evidence the physician was notified of the weight loss and no documented evidence a reweight was obtained. Review of the care plan dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review, the facility failed to ensure Resident #128's oxygen was administered as ordered by the physician and failed to ensure Resident #128's oxygen tubing was changed as ordered. This affected one resident (#128) of three residents reviewed for oxygen administration and had the potential to affect four additional residents (#36, #60, #95, #128 and #443) identified by the facility as receiving oxygen therapy. The facility census was 144. Findings include: Review of the medical record for Resident #128 revealed an admission date of 09/26/24. Diagnoses included left rib fracture, chronic obstructive pulmonary disease (COPD), kidney disease, and history of stroke. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #128 was cognitively intact. She required supervision for eating and oral hygiene, partial to moderate assistance for personal hygiene and was dependent on staff for showering and toileting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure pre and post dialysis assessments were accurate and complete. This affected two residents (#37 and #83) of three residents reviewed for dialysis. The facility census was 144. Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 12/13/24. Diagnoses included congestive heart failure, diabetes, morbid obesity, kidney disease, dysphagia, anemia, and vitamin D deficiency. Review of the care plan dated 12/16/24 revealed Resident #37 received dialysis three days per week. Interventions included assisting with transfers to dialysis, checking for new orders upon return from dialysis, maintaining communication with dialysis staff and physicians, and monitoring the shunt for signs and symptoms of infection. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 was moderately cognitively impaired. She required supervision for eating and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of the facility policy, the facility did not have an individualized care plan with interventions regarding Resident #76's post-traumatic stress disorder (PTSD). This affected one resident (#76) of two residents reviewed for PTSD and had the potential to affect six residents (#15, #21, #38, #76, #194, and #293) that were identified by the facility diagnosed with PTSD. The facility census was 144. Findings include: Review of the medical record for Resident #76 revealed an admission date of 12/04/24 with diagnoses including PTSD, Bipolar disorder, major depression, congestive heart failure, and diabetes. Review of the admission packet dated 12/05/24 and completed by Registered Nurse (RN) #1288 revealed Resident #76 had experienced trauma in his life, but he did not have any triggers identified. Review of the care plan dated 12/10/24 revealed Resident #76 required assistance with activities of daily living (ADL) related to alcoholic cirrhosis of the liver, PTSD, 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 record review, interview and facility policy review, the facility failed to ensure pharmacist recommendations for Resident #36 were addressed by the physician. This affected one resident (#36) of three residents reviewed for unnecessary medication. The facility census was 144. Findings include: Review of the medical record for Resident #36 revealed an admission date of 06/04/20. Diagnoses included hypertension, anxiety, malnutrition, muscle weakness, prostate disorder, depression, and diabetes. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively intact. He required set-up help for eating, supervision for oral hygiene, substantial or maximum assistance for personal hygiene and was dependent for toileting and showering. Review of the physician's orders for February 2025 revealed an order for Lasix 20 milligrams (mg) (diuretic) once per day which began on 09/18/23 and an order for Hydroxyzine 50 mg (antihistamine) three times per day which began…

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 interviews and record review, the facility failed to ensure all medications were secured and stored in locked compartments that would limit access only to authorized personnel. This affected three residents (Residents #13, Resident #16 and Resident #95) out of 31 who residents resided on the 200-nursing unit. The facility census was 144. Findings include: 1. Resident #13 admitted on [DATE] with diagnoses including acute cystitis with hematuria, encephalopathy, morbid obesity with status post gastric sleeve, diabetes mellitus, methicillin susceptible staphylococcus aureus infection, and anxiety. Review of Resident #13's medical record dated 01/01/25 to 02/03/25 showed no physician order for self-medication or an assessment of ability to provide self-medication included in the care plan and Minimum Data Set (MDS) 3.0 assessment. Resident #13's clinical record indicated he had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) assessment score of ten,…

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 facility policy review, the facility failed to administer the pneumonia and Coronavirus-19 (Covid-19) vaccine to Resident #125. This affected one resident (#125) out of five residents reviewed for immunizations. The facility census was 144. Findings include: Resident #125 was admitted on [DATE] with diagnoses of malignant neoplasm of stomach, bipolar disorder, and feeding difficulties with gastrostomy, dysphagia, protein calorie malnutrition, and urinary incontinence. A review of Resident #125's medical record revealed Resident #125's signed request dated 11/11/24 revealed Resident #125 wanted to receive the pneumococcal and Covid-19 vaccinations. Review Resident #125's electronic medical record dated 11/08/24 through 02/04/25 revealed no provider orders for the pneumococcal or Covid-19 vaccination. Review of Minimal Data Set (MDS) 3.0 assessment for Resident #125 completed on 12/19/24 showed the pneumococcal vaccine was not offered, and Resident #125 was not up to date with…

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 maintain fall prevention interventions as ordered by the physician for Resident #112 to prevent further falls. This affected one resident (#112) of three residents reviewed for accidents. The facility census was 125. Findings include: Record review for Resident #112 revealed an admission date of 03/01/21. Diagnoses included encephalopathy, unspecified dementia with other behavioral disturbances, spinal stenosis, muscle weakness, difficulty in walking, unspecified psychosis, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #112 was rarely or never understood. Resident #112 had no impairment to the upper or lower extremities and used no mobility devices. Resident #112 required setup or cleanup assistance with meals, substantial/max assistance for toileting, and partial/moderate assistance for transfers. Resident #112 had no falls since admission.…

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 ensure an effective pest control program. This finding had the potential to affect 122 residents of 125 who eat meals from the kitchen as three residents (Residents #99, #103 and #108) received nothing by mouth. Findings include: Interview on 05/03/24 at 9:18 A.M. with Resident #73 revealed he had concerns with flying ants which were all over the place. Interview on 05/03/24 at 9:33 A.M. with Kitchen Aide #808 revealed the facility used a green liquid in the mop water for gnats in the kitchen but the facility still had a lot of gnats flying around the kitchen. Observation on 05/03/24 at 9:35 A.M. with Kitchen Aide #808 of the food cart located right outside of the kitchen doors revealed five to six black gnats flying around inside the food cart. Observation on 05/03/24 at 9:38 A.M. with Kitchen Aide #808 of the kitchen area revealed multiple gnats flying around the dishwasher and sink area of the kitchen. Interview on 05/03/24 at 9:47 A.M. with Maintenance Director #809 confirmed the facility had a gnat problem and he was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, review of the schedule and time clock punch report, record review, and review of facility policy revealed the facility did not ensure Resident #14's total parental nutrition (TPN) was administered in a safe manner including having a register nurse (RN) in the facility while it was infusing. This affected one resident (#14) out of one resident with an order for TPN. The facility census was 125. Findings Include: Review of the medical record for Resident #14 revealed an admission date of 01/4/24. He was discharged to the hospital on [DATE]. He was re-admitted on [DATE] (no longer on TPN). His diagnoses included sepsis, protein-calorie malnutrition, ileostomy status, acute kidney failure, and plasma-protein metabolism disorder. Review of the physician's order dated 01/05/24 revealed Resident #14 had the following TPN order: Amino acids (clinisol 15 percent) 110 gram (gm) per day, dextrose 330 milligram (mg) per day, Lipids (Intralipids 20 percent) 50 mg per day, sodium chloride 60…

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 record review and interview, the facility failed to notify Resident #99's responsible party of the presence of bed bugs and subsequent room change. This affected one (#99) of three residents reviewed. The census was 133. Findings include: Review of the medical record for Resident #99 revealed an admission date of 08/21/14 with diagnoses including schizoaffective disorder, major depressive disorder, hypothyroidism, and lymphedema. Review of the resident contacts revealed Resident #99 was not her own responsible party. Further review of the medical record revealed there was no documentation of Resident #99's Responsible Party being notified of a room change due to bed bug treatments on 11/03/23. On 12/01/23 at 2:05 P.M., interview with Resident #99's Responsible Party stated he was never notified of anything related to bed bug treatments. On 12/01/23 at 2:40 P.M., interview with the Administrator verified Resident #99 was moved to another room on 11/03/23 due to bed bug treatment. He also confirmed that Resident #99's Responsible Party was not notified of the room change or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #23's advance directive was ordered per his preference. This affected one resident (#23) out of three residents reviewed for advance directives. The facility census was 126. Findings include: Review of Resident #23's medical record revealed an admission date of 03/21/18 with diagnoses including hepatic failure, encephalopathy, and chronic obstructive pulmonary disease. Review of Resident #23's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was cognitively intact and required supervision of one staff member for transfers and supervision with locomotion on unit. Resident #23 used a wheelchair. Review of Resident #23's DNR (Do Not Resuscitate) Identification Form, signed by Resident #23 and dated 10/26/18, revealed Resident #23's advance directive order was Do Not Resuscitate Comfort Care (DNRCC) indicating the resident would receive care that eases pain 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 record review, interview, policy review and review facility Self-Reported Incidents (SRIs), the facility failed to implement its policy to thoroughly investigate one incident of neglect and one incident of resident to resident abuse. This affected three residents (#50, #116 and #283) out of nine reviewed for abuse. The facility census was 126. Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of 06/04/20 with diagnoses including diabetes, pancreatitis, obesity, and kidney failure. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 had intact cognition. He required extensive assistance of two staff for bed mobility, toilet use and transfers, extensive assistance of one staff for hygiene, and was totally dependent on two staff for dressing. 2. Review of the medical record for Resident #116 revealed an admission date of 10/20/22 with diagnoses including dementia and heart disease. Review of the comprehensive MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, policy review and review facility Self-Reported Incidents (SRIs), the facility failed to thoroughly investigate one incident of neglect and one incident of resident to resident abuse. This affected three residents (#50, #116 and #283) out of nine reviewed for abuse. The facility census was 126. Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of 06/04/20 with diagnoses including diabetes, pancreatitis, obesity, and kidney failure. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 had intact cognition. He required extensive assistance of two staff for bed mobility, toilet use and transfers, extensive assistance of one staff for hygiene, and was totally dependent on two staff for dressing. 2. Review of the medical record for Resident #116 revealed an admission date of 10/20/22 with diagnoses including dementia and heart disease. Review of the comprehensive MDS 3.0 assessment dated…

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

Based on record review, interview, and facility policy review the facility failed to ensure a safe and complete discharge for Resident #123. This affected one resident (#123) of three reviewed for discharge. The facility census was 126. Findings include: Review of the medical record for Resident #123 revealed an admission date of 11/03/22 and a discharge date of 11/10/22. Diagnoses included a fracture of the left shoulder and gastro esophageal reflux disease (GERD). Review of a progress note dated 11/08/22 revealed Resident #123 told the facility she would not be returning to the facility after the appointment she had scheduled for the following day. The social worker was notified. Review of the medical record revealed no evidence of a physician's order for discharge, the resident received a discharge summary, or follow-up instructions. Interview on 01/12/23 at 9:48 A.M. with Social Services Designee (SSD) #622 confirmed there was no physician's order for discharge or discharge follow-up for Resident #123 once they were informed she would not be returning. Review of the undated…

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 facility policy review the facility failed to ensure Resident #125 was given all his medications upon discharge. This affected one resident (#125) of three residents reviewed for discharge. The facility census was 126. Findings include: Review of the medical record for Resident #125 revealed an admission date of 09/20/22 and a discharge date of 10/05/22. Diagnoses included diabetes, hyperglycemia, chronic kidney disease, hypercholesterolemia, and atrial fibrillation. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #125 had moderately impaired cognition. Review of the physician's orders for October 2022 revealed Resident #125 was taking Vitamin D3 (supplement), Lasix (diuretic) 20 milligrams (mg), Acetaminophen (pain reliever) 650 mg, Ferrous Sulfate (iron supplement) 325 mg, Apixaban (anticoagulant) 2.5 mg, Pravastatin (medication to treat high cholesterol) 80 mg, Potassium Chloride extended release (ER) (supplement) 20…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Resident #275 received physician ordered catheter care. This affected one resident (#275) out of one resident reviewed for catheter care. The facility census was 126. Findings include: Review of Resident #275's medical record revealed an admission date of 12/30/22. Diagnoses included hypotension, kidney failure, obstructive reflex uropathy, and benign prostatic hyperplasia (BPH) with lower tract symptoms. Continued review of the medical record revealed the resident was admitted with a Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine), but there was no documented evidence the resident was receiving Foley catheter care. Review of Resident #275's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #275's January 2023 Physician orders revealed an order for Foley catheter care per policy twice daily 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 observation, interview, record review, and review of the facility policy the facility failed to ensure Resident #427 was administered oxygen per physician orders. This affected one resident (#427) out of three residents reviewed for oxygen administration. The facility census was 126. Findings include: Review of Resident #427's medical record revealed an admission date of 08/28/15 with diagnoses including congestive heart failure, acute respiratory failure with hypoxia, and atrial fibrillation. Review of Resident #427's physician orders dated 10/13/22 revealed an order to discontinue oxygen at one to six liters per minute via nasal cannula to maintain oxygen saturation levels above 92 percent. Further review of Resident #427's physician orders from 10/13/22 through 01/04/23 did not reveal orders for oxygen administration. Review of Resident #427's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #427 was cognitively intact and did not use oxygen. Review of Resident #427's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy the facility failed to ensure Resident #115's psychotropic medication was administered as ordered. In addition, the facility failed to ensure Resident #124 had a diagnosis for a prescribed antipsychotic medication. This affected two residents (#115 and #124) of five residents reviewed for unnecessary psychotropic medications. The facility census was 126. Findings include: 1. Review of Resident #115's medical record revealed an admission date of 10/09/22 with diagnoses including fracture of the neck of the left femur, end stage renal disease, and dementia. Review of Resident #115's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #115 was cognitively intact and required extensive assistance of two staff members for bed mobility and transfers and required the assistance of one staff member for toilet use. Review of Resident #115's physician orders dated 10/21/22 revealed an order for Risperidone tablet…

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 record review the facility failed to maintain a medication error rate of less than five (5) percent (%). The medication error rate was calculated to be 8% and included two medication errors of 25 medication administration opportunities. This affected two residents (#46 and #31) of five residents observed during medication administration. The facility census was 126. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 01/08/15. Diagnoses included schizoaffective disorder, anxiety disorder, and major depressive disorder. Review of Resident #46's January 2023 physician's orders revealed Resident #46 had an order to receive Deplin 15-90.314 milligram (mg) capsule by mouth in the morning for hormone replacement. Observation on 01/11/23 at 7:40 A.M. of Registered Nurse (RN) #620 passing medications to Resident #46 revealed, RN #620 was unable to administer Resident #46's Deplin 15-90.314 mg. Interview on 01/11/23 at 8:07 A.M. RN #620 confirmed that the facility has not reordered Resident #46's Deplin…

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 ensure Resident #427 with symptoms of COVID-19 was tested timely. This affected one resident (#427) out of three residents reviewed for oxygen administration. The facility census was 126. Findings include: Review of Resident #427's medical record revealed an admission date of 08/28/15 with diagnoses including congestive heart failure, acute respiratory failure with hypoxia, and atrial fibrillation. Review of Resident #427's physician orders dated 10/13/22 revealed an order to discontinue oxygen at one to six liters per minute via nasal cannula to maintain oxygen saturation levels above 92 percent. Further review of Resident #427's physician orders from 10/13/22 through 01/04/23 did not reveal orders for oxygen administration. Review of Resident #427's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #427 was cognitively intact and did not use oxygen. Review of Resident #427's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Resident #1 and Resident #119's call lights were within reach. This affected two residents (#1 and #119) of three residents reviewed for call lights. The facility census was 126. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 02/15/18. Diagnoses included frontal lobe and executive function deficit, impulsiveness, and impulse control disorder. Review of Resident #1's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition and needed extensive assistance for bed mobility and transfers. Observation on 01/10/23 at 9:06 A.M. revealed Resident #1 lying in bed with his call light device located out of his reach under his bed. The resident was yelling out for staff requesting more food. Observation on 01/10/23 at 4:30 P.M. Resident #1 was observed again lying in his bed. His call light remained in the same position under his bed. Interview 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.