Altercare Of Navarre Ctr For Rehab & Nrsg Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Residents #3, #66 and #67's pressure ulcer wound care was completed as ordered and per best practice guidelines. This finding affected three (Residents #3, #66 and #67) of six residents reviewed for pressure ulcers. The facility census was 89.Findings include: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses including chronic cholecystitis, congestive heart failure, high blood pressure, renal insufficiency, diabetes, protein malnutrition, anxiety disorder, depression, atrial fibrillation, and chronic obstructive pulmonary disorder. Review of Resident #3's physician's orders revealed on 12/12/25 and order was written for Expedite (a liquid protein supplement) 30 milliliters (ml) twice a day for wounds. An order written on 03/09/26 to clean sacrum with wound cleanser as needed and on a weekly basis. No other wound healing supplements were ordered. Review of the comprehensive quarterly Minimum Data Set (MDS) 3.0 assessment for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of facility policy, the facility failed to provide safe transfer assistance utilizing a mechanical lift device for Resident #61. This affected one resident (#61) out of seven reviewed for accident hazards. The facility census was 89. Findings include: Review of the medical record for Resident #61 revealed an admission date of 10/07/24 with diagnoses including end stage renal disease, abnormalities of gait and mobility, reduced mobility, rheumatoid arthritis, acquired absence of left leg below knee, repeated falls, and history of transient ischemic attack and cerebral infarction. Review of the care plan dated 10/08/24 revealed Resident #61 had impaired ability to perform or participate in activities of daily living (ADL) care related to left below knee amputation, diabetes mellitus, tremors, use of assistive devices, dialysis, impaired range of motion of the left lower extremity, and medical co-morbidities. Interventions included provide assistance 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, record review, interview, and review of facility policy, the facility failed to ensure Resident #27's respiratory needs were ordered and the cleaning and storage of oxygen services were in place. This affected two residents (#27 and #89) out of four reviewed for respiratory care. The facility census was 89. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 01/05/26 with diagnoses including congestive heart failure, asthma, thrombocytopenia, end stage renal disease, history of pulmonary embolism, and obstructive sleep apnea. Review of the care plan, revised 01/05/26, revealed Resident #27 had the potential for alteration in respiratory function related to congestive heart failure, asthma, shortness of breath while lying flat or during exertion, anxiety, and obesity. Interventions included administer oxygen as ordered implemented 01/05/26. Review of the five day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had no cognitive…

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 on dialysis received ongoing assessment and monitoring to ensure health status and reduce complication of dialysis care. This finding affected three (Residents #26, #67, and #85) of five residents reviewed for dialysis. The facility census was 89.Findings include:1. Review of the medical record for Resident #26 revealed an admission date of 03/29/25 with diagnoses including congestive heart failure, type two diabetes mellitus, hypertension, and end stage renal disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had no cognitive impairment and received dialysis treatments. Review of the physician's orders for Resident #26 identified orders for dialysis every Monday, Wednesday and Friday at 5:30 A.M. effective 04/06/26, complete the pre-dialysis observation and vital signs on dialysis days at 4:30 A.M. effective 04/06/26, and completed the post-dialysis observation and vital signs 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 observation, record review and interview, the facility failed to ensure Resident #12 was free from significant medication error. This finding affected one (Resident #12) of six residents observed for medication administration. The facility census was 89.Findings include: Review of Resident #12's medical record revealed the resident was admitted on [DATE] with diagnoses including muscle weakness, need for assistance with personal care and chronic kidney disease stage 4.Review of Resident #12's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] the resident exhibited intact cognition.Review of Resident #12's physician orders revealed an order dated 04/11/26 for Buspirone 10 milligrams (mg) three times a day (due at 7:00 A.M. to 11:00 A.M., 1:00 P.M. to 2:30 P.M. and 6:30 P.M. to 10:30 P.M.; Ferrous Sulfate 325 mg twice daily with meals (due from 7:00 A.M. to 11:00 A.M. and 6:30 P.M. to 10:30 P.M.; Humalog KwikPen insulin 12 units subcutaneous with breakfast once a day at 7:00 A.M.; Lactulose…

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 medications were secured appropriately. This finding affected two of the three medication carts reviewed. The facility census was 89.Findings include: 1. Observation on 04/20/26 at 9:42 A.M. with Licensed Practical Nurse (LPN) #517 of the 400-hall medication cart revealed one loose white pill lying on the bottom of the second drawer of the medication cart. Interview on 04/20/26 at 9:45 A.M. with LPN #517 confirmed the above findings. 2. Observation on 04/20/26 at 9:55 A.M. with Registered Nurse (RN) #646 of the 300-Long medication cart revealed one loose green pill located on the bottom of the second drawer of the medication administration cart. Interview on 04/20/26 at 10:00 A.M. with RN #646 confirmed the above findings. Review of the Medication Storage in the Facility policy dated 05/2020 revealed medications were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply was accessible only to licensed nursing personnel, pharmacy personnel, 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.

Based on record review and interview, the facility failed to obtain laboratory samples and results as ordered. This affected one resident (#85) out of six reviewed for unnecessary medications. The facility census was 89. Findings include: Review of the medical record for Resident #85 revealed an admission date of 01/23/26 with diagnoses including end stage renal disease, seizures, and history of cerebral infarction. Review of the physician's orders for Resident #85 identified orders for Levetiracetam (Keppra) 500 milligrams (mg) per 5 milliliters (ml) to give 500 mg twice daily effective 01/29/26. Review of the pharmacy recommendation dated 02/03/26 revealed a recommendation was made for a supplemental dose of Levetiracetam after each dialysis session. Nurse Practitioner (NP) #658 reviewed the recommendation on 02/26/26 and ordered to obtain a Levetiracetam level on the next lab day. Review of the laboratory documentation revealed NP #658 ordered for the bloodwork to be drawn on 02/27/26 and the lab did not collect the specimen because Resident #85 was at dialysis, which the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of facility policy, the facility failed to ensure staff followed infection control protocols for residents on contact isolation and droplet isolation. This affected three residents (#12, #17, and #40) out of five reviewed for infection control. The facility census was 89. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 08/23/25 with diagnoses including history of urinary tract infections, type two diabetes mellitus, end stage renal disease, congestive heart failure, and need for assistance with personal care. Review of the physician's orders for Resident #12 identified orders for contact transmission based precautions effective 04/11/26. Review of the progress note dated 04/11/26 at 3:20 P.M. revealed Resident #12 had returned from the hospital this day and was on contact isolation precautions due to a urinary tract infection with the presence of Extended-Spectrum Beta-Lactamase (ESBL), which are enzymes…

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 Resident #8's responsible party was notified of new orders and changes in Resident #8's condition. This affected one (Resident #8) of three residents reviewed for notifications. The facility census was 83. Findings include: Review of the medical record revealed Resident #8 was admitted on [DATE] with diagnoses that included Alzheimer's disease, hyperlipidemia, osteoporosis, hypothyroidism, hypotension, insomnia, adult failure to thrive, major depressive disorder, anxiety disorder, and hypertension. Review of a progress note dated 12/02/24 revealed Resident #8 was in isolation for Covid positive precautions. A progress note dated 12/14/24 revealed Resident #8 was administered an oral antibiotic for a urinary tract infection. Review of the physician orders revealed cephalexin 500 milligrams (mg) twice a day from 12/14/24 through 12/21/24 for a urinary tract infection. Review of physician orders revealed on 01/04/25 Resident #8 had new orders for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview and policy review the facility failed to prevent Resident #8 from receiving the wrong medication. This affected one (Resident #8) of three residents reviewed for medications. The facility census was 83. Findings include: Review of the medical record revealed Resident #8 was admitted on [DATE] with diagnoses that included Alzheimer's disease, hyperlipidemia, osteoporosis, hypothyroidism, hypotension, insomnia, adult failure to thrive, major depressive disorder, anxiety disorder, and hypertension. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #8 had severe cognitive impairment. Review of physician orders revealed on 01/04/25 Resident #8 had new orders for acetaminophen (for mild pain) 1000 milligrams (mg) every six hours as needed, albuterol sulfate (to prevent and treat difficulty breathing) inhaler two puffs every four hours as…

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 and interview, the facility failed to ensure wound care was completed as ordered for Residents #43, #51 and #77 and timely wound assessments were completed for Resident #77. This finding affected three (Residents #43, #51 and #77) of four residents reviewed for wounds. Findings include: 1. Review of #51's medical record revealed the resident was admitted on [DATE] with diagnoses including other acute osteomyelitis of the right ankle and foot, encounter for other orthopedic aftercare and end stage renal disease. Review of Resident #51's hospital report dated 12/09/24 revealed the resident had a right lower extremity non healing wound with osteomyelitis related to advanced peripheral vascular disease and insulin dependent diabetes. Review of Resident #51's care plans revealed an intervention dated 12/10/24 indicated to note amount and characteristics of any wound drainage, and observe effectiveness of ordered treatments. Notify the physician as needed. Review of Resident ##51'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, record review and interview, the facility failed to ensure Resident #77's pressure ulcer wound care was completed as ordered. This finding affected one (Resident #77) of four residents reviewed for wound care. Findings include: Review of Resident #77's medical record revealed the resident was admitted on [DATE] with diagnoses including other acute osteomyelitis of the left ankle and foot, diabetes and partial traumatic amputation of the left foot. Review of Resident #77's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed intact cognition. Review of Resident #77's podiatrist note dated 11/12/24 revealed the resident had a stage three pressure ulcer of the left heel. Review of Resident #77's physician orders revealed an order dated 12/02/24 (discontinued 12/23/24) to cleanse the left foot with normal saline, apply Iodoform packing and a dry dressing to the left foot, apply betadine wet to dry to left heel and silver alginate and an abdominal (ABD) dressing to the anterior…

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, review of resident diet orders, review of menus/spreadsheets, and interview, the facility failed to ensure proper portion sizes of food were served to residents on a carbohydrate controlled (CCHO)/low concentrated sweet (LCS) diet. This affected six (Residents #32, #35, #36, #39, #40, and #43) of 30 residents on the 200 hall who had trays served. Findings include: Review of the menu and spreadsheet for lunch on 08/27/24 revealed the only difference between the regular diets and carbohydrate controlled (low concentrated sweet) diet was the portion size. The regular diet included a #8 scoop (1/2 cup) of au gratin potatoes and four ounces of mixed vegetables. The carbohydrate controlled diet called for a #10 scoop (3/8 cup) of au gratin potatoes and a three ounce serving of mixed vegetables. On 08/27/24 between 11:22 A.M. and 11:40 A.M. observations were made of the tray line. All residents who received au gratin potatoes and mixed vegetables were provided the same amount with the same utensils utilized to measure out the food. On 08/27/24 at 11:35 A.M., Certified…

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, medical record review, and interview, the facility failed to monitor a resident's oxygen saturations in accordance with physician orders. This affected one (Resident #44) of three residents reviewed for respiratory care. The census was 87. Findings include: Review of Resident #44's medical record revealed diagnoses including chronic respiratory failure, congestive heart failure, obstructive sleep apnea, and atherosclerotic heart disease. A physician order dated 05/17/24 revealed Resident #44 had an order for continuous oxygen at two liters per minute via nasal cannula. Instructions revealed to check placement and record oxygen saturation every shift. The only oxygen saturation able to be located between 08/15/24 and 08/26/24 revealed one oxygen saturation level was recorded on 08/23/24 at 4:32 A.M. and recorded as 97%. Observations on 08/28/24 at 2:05 P.M. revealed Resident #44's oxygen saturation level was 98% with oxygen at two liters per minute via nasal cannula. During an interview on 08/27/24 at 2:24 P.M., Registered Nurse (RN) #110 verified she was unable…

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 resident medical record review, observation and staff interview the facility failed to ensure pressure ulcer wounds were accurately staged. This affected two (Residents #47 and #39) of five residents reviewed for pressure ulcers. The facility identified six residents (Residents #5, #8, #39, #47, #53 and #245) with current pressure ulcer wounds. Findings include: 1. Review of Resident #47's medical record revealed an admission date of 10/01/23 with diagnoses that included Parkinson's disease, Alzheimer's disease with dementia and anemia. Further review of the medical record including care plan, Minimum Data Set (MDS) 3.0 assessment and pressure ulcer risk assessment identified the resident at high risk for the development of pressure ulcer wounds. MDS 3.0 assessment with a reference date of 07/11/24 indicated Resident #47 had a severely impaired cognition level. A nursing note on 07/01/24 indicated Resident #47 was evaluated by the wound nurse practitioner for a new wound which the wound nurse practitioner indicated was a stage three pressure ulcer wound (full thickness skin…

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 and interview, the facility failed to ensure Resident #30's expired Lantus long-acting insulin was discarded as appropriate. This finding affected one (Resident #30) of two residents who receive insulin on the 100 A medication cart. Findings include: Review of Resident #30's medical record revealed the resident was admitted on [DATE] with diagnoses including major depressive disorder and type two diabetes. Review of Resident #30's physician orders revealed an order dated [DATE] for Lantus insulin 56 units once daily due from 7:00 A.M. to 11:00 A.M. Observation on [DATE] at 7:40 A.M. with Assistant Director of Nursing (ADON) #401 of the 100 A medication cart revealed Resident #30's Lantus long-acting insulin Kwikpen was dated [DATE]. Interview on [DATE] at 7:45 A.M. with ADON #401 confirmed Resident #30's Lantus long-acting insulin Kwikpen was expired and should have been discarded. Review of the Highlights of Prescribing Information (for Lantus) revised 06/23 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 observation, record review, interview and policy review, the facility failed to ensure appropriate infection control procedures were maintained while completing Resident #193's wound care. This finding affected one (Resident #193) of five residents reviewed for pressure wounds. Findings include: Review of Resident #193's medical record revealed the resident was admitted on [DATE] with diagnoses including cellulitis of the right lower limb and pressure ulcers to the right and left heels. Review of Resident #193's physician orders revealed an order dated 07/15/24 to apply liquid skin prep/barrier film to the affected area, cover with an abdominal wrap and kerlix daily and as needed; and an order dated 07/15/24 to apply liquid skin prep/barrier film to the affected area, cover with an abdominal pad and wrap with kerlix daily and as needed. Review of Resident #193's left heel pressure wound skin grid dated 07/15/24 authored by Licensed Practical Nurse (LPN) Wound Care Supervisor #375 revealed an unstageable…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, investigation review and policy review the facility failed to prevent misappropriation of resident medication. This affected three residents (#10, #11 and #12) of three residents reviewed for misappropriation. The census was 86. Findings include: 1. Review of Resident #10's medical record revealed an admission date of 03/30/24 and a discharge date [DATE]. Diagnoses included status post triple aortic repair, peripheral vascular disease, and acute respiratory failure. Review of Resident #10's April 2024 physician orders revealed an order for Oxycodone 5 milligrams (mg) as needed for moderate pain, severe back pain, or breakthrough pain to be given every four hours. Review of the discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was receiving an opioid. The assessment was not completed due to the residents' short stay in the…

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

Based on review of receipts, observations, and interviews, the facility failed to provide an adequate supply of supports for daily living. This affected two residents (#19 and #16) of three residents reviewed for incontinence care. This had the potential to affect 37 residents in the facility who are dependent on staff for the provision of incontinence care. Findings included: Observation on 01/26/24 at 1:40 P.M. during a tour of the supply areas in the facility with Maintenance Assistant (MA) #133 revealed the supply closet on the 200 hall did not have any wipes available and the shower room had four boxes of wipes, each box contained 12 packages of 64 wipes. An additional five packages of wipes were also in the shower room. In the 300 hall supply closet there were zero wipes available but eight washcloths were available on a linen cart. On the 100 and 400 halls, there were zero washcloths or wipes available in the supply rooms. In the laundry room, there were 17 washcloths . MA #133 confirmed the findings on 01/26/24 at 1:56 P.M. MA #133 stated the facility tried to do away 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 medical record review, review of resident Matrix, policy review, and interviews the facility failed to ensure wound care was provided per orders. This affected one resident (#70) of three reviewed for skin alterations. Findings included: Record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including non-pressure chronic ulcer of other part of left lower leg with fat layer exposed, non-pressure chronic ulcer of other part of right foot with fat layer exposed, abrasion, left lower leg, heart failure, kidney failure, unstageable pressure ulcer to left, deep tissue injury to the right heel, diabetes, and weakness. Review of the Matrix dated 01/26/24 revealed Resident #70 did not have pressure ulcers. Review of Resident #70's current orders and treatment administration records (TAR) dated 12/01/23 to 01/2026 revealed: All the following treatments were supposed to be administered from 7:00 A.M. to 3:00 P.M. A. On 12/06/23 a new order to cleanse the left heel and left…

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, policy review, review of the skill competency form for catheter care, observation, and interviews the facility failed to ensure infection control practices were maintained during urinary catheter care. This affected one resident (#24) of one resident observed for urinary catheter care. Findings included: Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including prostatic hyperplasia, urinary retention, sepsis, and metabolic encephalopathy. Review of Resident #24's plan of care for alteration in elimination related to Foley catheter (dated 01/22/24) revealed to perform catheter care every shift and/or per policy and to maintain dignity when checking/providing incontinence care for the resident. Review of Resident #24's current order revealed an order dated 01/22/24 for catheter care every shift. Review of Resident #24's indwelling catheter assessment dated [DATE] revealed the resident had a diagnosis of urinary retention. The resident required…

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 Center of Disease Control (CDC) information and guidance, review of infection control log, review of email, policy review, observation, and interviews the facility failed to ensure isolation protocols were discontinued timely. This affected three residents (#10, #63, and #70) of four residents reviewed for isolation. Finding included: 1. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including scabies, muscle weakness, urinary tract infection, aftercare following joint replacement, cellulitis, diabetes, respiratory and kidney failure, and heart disease. Review of Resident #10's order dated 01/15/24 revealed the resident was in contact isolation for scabies. Review of Resident #10's history and physical note dated 01/15/24 revealed staff reported the resident had a rash all over his back and they were concerned it was scabies. Assessment plan for the acute scabies was to treat him with permethrin 5% once now and repeat in seven…

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 review of pictures, observation, and interviews the facility failed to ensure a safe path of egress on the 300 hall. This had the potential to affect 27 residents (#8, #14, #15, #18, #19, #29, #34, #38, #39, #46, #50, #52, #55, #59, #60, #62, #70, #71, #74, #82, #85, #86, #87, #89, #91, #94, and #100) of 106 residents residing in-house during the time of the survey. Findings included: Observation on 01/26/24 at 10:07 A.M. of 300 hallway from room [ROOM NUMBER] to 321 revealed there was six wheelchairs sitting along the left side of the hall, five yellow caution signs randomly placed down the hallway, and one isolation cart blocking the path of egress. Review of two pictures provided from an anonymous source on 01/26/24 at 10:09 A.M., revealed two different pictures of wheelchairs lined down the left side of the hallway facing the egress doors from rooms 307 to 321. Interviews on 01/26/24 from 10:09 A.M. to 4:22 P.M., with a resident (who would like to remain anonymous) and an anonymous staff member…

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, staff interview, and policy review the facility failed to ensure proper storage of food items. This had the potential to affect all residents receiving food items from the facility kitchen. The facility identified one resident (Resident #5) who did not receive any food items from the facility kitchen. The facility census was 97. Findings include: Initial tour of the facility kitchen on 06/06/22 at 8:25 A.M. revealed the following food storage concerns within the walk-in cooler: Two undated large bags of mixed salad open directly to the air and one undated large bag of shredded cheddar cheese open directly to the air. Also, in the walk-in cooler was a small pushcart with several containers of sandwich items stored incorrectly: shredded cheddar cheese, sliced bologna, and tomato slices covered partially with plastic wrap open to the air and undated. Bread slices in a personal waxed single use bag open to the air and undated. Leaf lettuce, Swiss cheese slices, hard boiled eggs, pickles, turkey breast slices, American cheese slices, and sliced onions with no…

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 policy review the facility failed to ensure meal tickets accurately reflected renal diets and residents who were ordered renal diets received meals as ordered. This finding affected three (Resident's #15, #59 and #75) of four residents reviewed for renal diets. The facility census was 97. Findings include: 1. Review of Resident #75's medical record revealed he was admitted to the facility on [DATE] with diagnoses including end stage renal disease with dialysis, endocarditis, and muscle weakness. Review of Resident #75's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited moderate cognitive impairment Review of Resident #75's physician orders revealed an order dated 05/02/22 for a renal diet with low concentrated sweets and thin liquids. The instructions indicated to limit oranges, orange juice, bananas, and potatoes. Review of Resident #75's breakfast meal ticket dated 06/08/22 indicated a diet with low concentrated sweets with a regular…

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 policy review the facility failed to store opened medications per facility protocol in three of four medication carts reviewed for medication storage. This affected six (Resident's #21, #36, #11, #26, #73, and #60) residents and had the potential to affect all 97 residents residing in the facility. Findings include: Observation on 06/07/22 at 11:40 A.M. of the 300-hall red key medication cart revealed insulin pen for Resident #21 was opened with no date listed as to when it was opened. A Victoza (anti-diabetic medication) pen for Resident #11 and a Tuojeo (insulin) pen for Resident #36 were also undated when opened. Interview during the observation with Licensed Practical Nurse (LPN) #321 confirmed the findings. Observation on 06/07/22 at 12:18 P.M. of the 300-hall yellow key medication cart revealed two bottles of eye drops prescribed to Resident #26 were opened with no date and one bottle of eye drops prescribed to Resident #73 was also opened with no date. Interview during the observation with LPN #321 confirmed the findings. Observation 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 observation, record review, and interview the facility failed to ensure Resident #353's wound care was completed as ordered. This finding affected one (Resident #353) of three residents reviewed for general skin conditions. The facility census was 97. Findings include: Review of Resident #353's medical record revealed he was admitted to the facility on [DATE] with diagnoses including end stage renal disease with dialysis, muscle weakness, and diabetes. Review of Resident #353's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited intact cognition. Review of Resident #353's physician orders revealed an order dated 05/20/22 for negative pressure therapy (wound vac or vacuum-assisted closure of a wound to help wounds heal) to the right lateral foot with the wound vac machine set at 125 mmHg (millimeters of mercury or a measurement of pressure) continuously. Prepare the peri-wound with Skin Prep (forms a protective film to help reduce friction during removal of tapes and films), apply a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #75's pressure ulcer wound care was completed as ordered. This finding affected one (Resident #75) of three residents reviewed for pressure ulcer wound care. The facility census was 97. Findings include: Review of Resident #75's medical record revealed he was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, muscle weakness, and chronic obstructive pulmonary disease. Review of Resident #75's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited moderate cognitive impairment. Review of Resident #75's physician orders revealed an order dated 05/31/22 to apply a wound vac machine (vacuum-assisted closure of a wound to help wounds heal) to the left heel with suction to be placed at 125 mmHg (millimeters of mercury or a measurement of pressure). The wound vac was to be changed every Monday, Wednesday, and Friday and as needed. Review of Resident #75's physician orders…

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, medical record review, resident interview, and staff interview the facility failed to ensure restorative range of motion and splint devices were implemented as ordered by the physician for residents identified with contractures of joints. This affected one (Resident #49) of one resident reviewed for joint limitation. The facility census was 97. Findings include: Observation of Resident #49 on 06/06/22 at 9:29 A.M. revealed contractures to the bilateral elbows and wrists with no splint device in use. Additional observations on 06/07/22 at 10:11 A.M. and 06/08/22 at 7:56 A.M. also revealed contractures with no evidence of splint devices in place. Review of Resident #49's medical record revealed an admission date of 02/22/20 with admission diagnosis that included quadriplegia and contracture of multiple joints. Review of physician's orders dated on 05/18/22 indicated restorative Passive Range of Motion (PROM) to the bilateral upper and lower extremities times 15 repetitions per session twice daily and a restorative splint program which indicated to apply 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 observation, interview, record review, and policy review the facility failed to ensure one (Resident #69) received tube feeding that was not expired of one resident reviewed for tube feeding. The facility census was 97. Findings include: Review of the medical record for Resident #69 revealed an admission date of [DATE]. Diagnoses included cerebral infarction, dysphagia, and cognitive communication deficit. Review of physician's orders for Resident #69 revealed an order dated [DATE] to administer Isosource 1.5 (enteral feed) at 20 milliliters (ml) per hour daily from 8:00 P.M. to 8:00 A.M. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #69 had severe cognitive impairment. Resident #69 required extensive one-staff physical assistance for eating. Review of the care plan for Resident #69 dated [DATE] revealed Resident #69 received enteral feeding as a primary source of nutrition. Interventions included to administer enteral feeding and flush per physicians' orders.…

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 the facility infection control logs, review of facility policy and procedure, and staff interview the facility failed to implement an effective antibiotic stewardship program to ensure antibiotics were not used unless residents met the criteria to treat an infection. This affected three residents (Resident's #10, #33, and #35) of five residents reviewed for antibiotic stewardship. This had the potential to affect all 97 residents in the facility. Findings include: 1. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses of stage four pressure ulcer (deep wound that reaches the muscles, ligaments, or bone) to the left buttock, osteomyelitis, chronic obstructive pulmonary disease, quadriplegia, spinal cord injury, insomnia, history of urinary tract infections (UTI), and neurogenic bowel and neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had…

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.