Violet Springs Health Campus

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and policy review, the facility failed to ensure their medication error rate did not exceed 5%. The facility had two errors out of 30 opportunities for a medication error rate of 6.6%. This affected one resident (#61) of three residents reviewed for medication administration observations. Findings include: On 01/14/26 at 7:55 A.M., an observation of the medication administration pass revealed Licensed Practical Nurse (LPN) #330 was intending to administer the morning medications for Resident #58 that were due between the hours of 6:00 A.M. and 10:00 A.M. LPN #330 had pulled the medications out of the medication administration cart for Resident #58 that included numerous tablets/ capsules for the resident, as well as a Lidocaine 4% patch. She approached the resident that was in the back left corner of the room and informed her that she had her morning medications to give her. The resident was sleeping, but aroused easily when spoken to. LPN #330 informed 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, observations, and interviews, the failed to ensure medications were not kept at bedside without orders for Resident #21 and #43. This affected two residents (#21 and #43) of the three residents reviewed for medications. This facility census was 54.Findings include:1. Review of the medical record for Resident #43 revealed an admission date of 07/15/20 with a re-entry date of 03/04/25 with diagnoses to include but not limited to chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, morbid (severe) obesity due to excess calories, anxiety disorder, cellulitis of abdominal wall, type two diabetes mellitus with chronic kidney disease stage 3, hypertensive heart disease, and shortness of breath. Review of the quarterly MDS dated [DATE] revealed a BIMS of 12 which indicated moderate cognitive impairment. No current self-administration of medication evaluation was documented for Resident #43. 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.

Based on observation, interview, and medical record review the facility failed to prepare a vegetarian menu in advance and follow the menu for Resident #85. This affected one resident (#85) of five residents reviewed for dining. The facility census was 54.Findings include:Observation on 01/13/26 at 12:00 P.M. revealed Resident #85 received green peas, baked sweet potatoes, and a salad. She did not receive baked ham.Observation on 01/14/26 at 11:50 A.M. revealed Resident #85 received green beans and mashed potatoes from the kitchen. She did not receive chicken or noodles.Interview on 01/14/26 at 11:50 A.M. with Area Director of Food Services #317 verified Resident #85 did not receive the Entree. He reported they had vegetarian options and the always available menu which included meat free options and she should receive one of those.Interview on 01/15/26 at 9:38 A.M. with Resident #85's power of attorney (POA) verified the resident followed a vegetarian diet and she expected the resident to be receiving full meals.Interview on 01/15/26 at 10:00 A.M. with Culinary Support #250 revealed…

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 provide the appropriate diet texture as ordered for Resident #65 and #67. This affected two residents (#65 and #67) of twelve reviewed for dining. The facility census was 54.Findings include: 1.Review of Resident #67's medical record revealed an admission date of 11/13/25 with diagnoses including fracture of unspecified part of femur, chronic obstructive pulmonary disease, heart failure, anxiety disorder, Parkinson's disease, and unspecified convulsions. Review of Resident #67's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. She received antianxiety medication, antidepressants, anticoagulants, antibiotics, opioids, and anticonvulsants. Review of Resident #67's after visit summary dated 01/12/26 revealed the resident was at moderate risk for aspiration and the diet recommended for the resident was International Dysphagia Diet Standardization Initiative (IDDSI) level six (soft and bite…

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, medical record review, interviews and facility policy review, the facility failed to maintain appropriate infection control practices to prevent the potential spread of infection. This affected two residents (#91 and #93) of 22 sampled residents. The facility census was 54.Findings Include:1. Review of the medical record for Resident #93 revealed an initial admission date of 01/10/26 with the diagnoses including but not limited to acute respiratory failure, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, severe morbid obesity. right bundle branch block, bifascicular block, ventricular tachycardia, gout, Parkinson's disease, benign prostatic hyperplasia, hyperlipidemia, hypothyroidism, constipation and prediabetes. Review of the resident's admission observation and data collection dated 01/10/26 revealed the resident was admitted to the facility being alert, with impaired daily decision making. The assessment indicated the resident was admitted to the facility with an indwelling urinary catheter. Review of the plan of care dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review the facility failed to ensure Resident #49's call light was kept within reach. This affected one resident (#49) of five reviewed for environment. The facility census was 54.Findings include:Observation on 01/12/26 at 10:02 A.M., 1:42 P.M., and 2:25 P.M., on 01/13/26 at 1:30 P.M. and 3:36 P.M., on 01/14/26 at 8:49 A.M., and on 01/15/26 at 8:35 A.M. revealed the resident in her recliner with no call light. The call light was observed near her bed across the room.Interview on 01/15/26 at 8:35 A.M. with Certified Resident Care Associate (CRCA) #324 revealed the resident could use a call light. CRCA #324 verified the resident spent most of her time in the recliner and had no way to call for staff. She reported the facility did not have call light pendants and the regular wall call light did not reach to the recliner. She reported she knew extended cords could be obtained for the call light, but the resident did not have one.Review of Resident #49's medical…

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, medical record review, staff interview, and facility policy review, the facility failed to document and address a resident representative grievance timely. This affected one (Resident #54) of three resident grievances reviewed. The census was 52.Findings Include:Record review for Resident #54 revealed he was admitted to the facility on [DATE]. His diagnoses were peritoneal abscess, sclerosing mesenteritis, other disease of stomach and duodenum, other specified diseases of intestines, syncope and collapse, unspecified severe protein-calorie malnutrition, occlusion and stenosis of bilateral carotid arteries, hypertensive heart and chronic kidney disease with heart failure, congestive heart failure, chronic kidney disease, other ventricular tachycardia, atherosclerotic heart disease, hypo-osmolality and hyponatremia, nonrheumatic aortic (valve) stenosis, unspecified right bundle-branch block, old myocardial infarction, and hyperlipidemia. Review of his Brief Interview for Mental Status (BIMS)…

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 facility policy review, the facility failed to ensure fall interventions were in place for a resident at risk for falls. This affected one resident (Resident #54) out three residents reviewed for falls. The facility census was 52. Findings Include: Review of Resident #54's medical record revealed admission date [DATE] with the following diagnoses including but not limited to acute respiratory failure, congestive heart failure (CHF), cardiomegaly, atrial fibrillation, and history of hemorrhagic stroke. Resident #54 expired on [DATE]. Review of Resident #54's admission fall risk evaluation dated [DATE] revealed Resident #54 was at risk for falling related to poor mobility, history of stroke, and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 required assistance from staff for transfers, ambulation, and personal hygiene tasks and the resident had impaired cognition with Brief Interview Mental Status (BIMS) of 9 out 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 employee file review and staff interview, the facility failed to ensure State Tested Nursing Assistants (STNAs) received annual performance reviews. This had the potential to affect all residents residing in the facility. The facility census was 46 residents. Findings Include: Review of STNA #139's employee file revealed a date of hire of 05/30/23. STNA #139's file contained a 90-day evaluation dated 11/10/23. STNA #139's file did not include an annual performance appraisal as of 10/17/24. Interview on 10/17/24 at 10:25 A.M. with Business Office Staff (BOS) #136 confirmed there was no annual evaluation present in the employee file for STNA #139. BOS #136 stated they were not required to do evaluations after the 90-day evaluation. Interview on 10/17/24 at 12:00 P.M. with the administrator confirmed there was no annual evaluation in the employee file for STNA #139.

Based on record review and staff interview, the facility failed to ensure State Tested Nurse Aides (STNAs) completed the minimum required 12 hours of in-servicing a year. This affected one (STNA #139) of two STNAs reviewed for required in-services. This had the potential to affect all residents in the facility. The facility census was 46. Findings Include: Review of STNA #139's personnel record revealed a hire date of 05/30/23. The record revealed STNA #139 completed six hours of training as a new hire in orientation. STNA #139 was assigned 12 hours of inservice/ on-line training that had not been completed. Interview on 10/17/23 at 10:35 A.M., with Business office staff member #136 verified STNA #139 did not complete the required 12 hours of in-service training for the last year. Interview on 10/17/23 at 12:00 P.M., with the administrator verified the facility assigned 12 hours of on-line training but STNA #139 did not complete the training. The administrator agreed the minimum requirements for STNA staff was to complete 12 hours of in-servicing/training annually.

Based on observation, staff interview and review of facility policy the facility failed to ensure multi use vials of tuberculin purified protein derivative (PPD) were dated when they were opened. This had the potential to affect the 30 new admissions since 09/26/27 which included Residents #18, #38, #39, #40, #41, #42, #43, #132, #133, #134, #135, #136, #137, #138, #232, #234, #235, #236, #237, #239, #240, #241, #242, #243, #244, #245, #246, #247, #244 and #245. The facility census was 46. Findings Include: Observation on 10/17/24 at 10:08 A.M. of the 200 hallway medication room with the Director of Nursing (DON) revealed three open, used and unlabeled tuberculin purified protein derivative (PPD) solutions. Interview on 10/17/24 at 10:10 A.M. with the DON confirmed the tuberculin PPD solution was opened but neither the box nor the vials were dated as to when opened. The DON revealed the facility received the PPD solution on 09/26/24 confirming the medication was not past its possible use by date. The DON confirmed the opened vials should have been labeled with a date. Review 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 medical record review and staff interview, the facility failed to take vital signs in connection to an as needed blood pressure medication. This affected one (Resident #5) of five residents reviewed for unnecessary medications. Also, the facility failed to hold blood pressure medications and notify the physician when vital signs were outside safe/accepted parameters. This affected one (Resident #27) of five residents reviewed for unnecessary medications. The census was 46. Findings Include: 1. Resident #5 was admitted to the facility on [DATE]. Diagnoses included multiple fractures of pelvic with stable disruption of pelvic ring, pneumonia, type II diabetes, hypertensive heart and chronic kidney disease with heart failure, heart failure, chronic kidney disease (stage III), acute posthemorrhagic anemia, hypothyroidism, vitamin B deficiency, hypo-osmolality and hyponatremia, pure hypercholesterolemia, depression, unspecified hearing loss, gastroesophageal reflux disease (GERD), parasthesia of 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.

Based on record review, observation and interview the facility failed to ensure care planned interventions for falls were implemented for Resident #20. This affected one (Resident #20) out of four residents reviewed for falls. The facility census was 46. Findings Include: Review of the medical record for Resident #20 revealed an admission date of 06/14/23, with diagnoses including hydrocephalus, disorientation, altered mental status, hemiplegia, type two diabetes, depression, and anxiety. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, completed on 08/23/24, indicated that the resident was severely cognitively impaired and required assistance with ambulation. Review of the care plan, dated 06/16/23, revealed Resident #20 was at risk for falls related to impaired balance, left hemiparesis, right thalamic mass, medication side effects, incontinence and cognition deficits. Review of interventions for the falls care plan revealed an intervention, dated 07/26/23, for bed mat on the floor. Observation of Resident #20's room and bathroom on 10/15/24 at 9:23 A.M. and 4:39…

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 provide evidence to support pharmacy recommendations were reviewed in a timely manner. This affected three (Residents #5, #27, and #7) of five residents reviewed for unnecessary medications. Also, the facility failed to follow a pharmacy recommendation after the physician agreed to the recommendation. This affected one (Resident #7) of five residents reviewed for unnecessary medications. The census was 46. Findings Include: 1. Resident #5 was admitted to the facility on [DATE]. Diagnoses included multiple fractures of pelvic with stable disruption of pelvic ring, pneumonia, type II diabetes, hypertensive heart and chronic kidney disease with heart failure, heart failure, chronic kidney disease (stage III), acute posthemorrhagic anemia, hypothyroidism, vitamin B deficiency, hypo-osmolality and hyponatremia, pure hypercholesterolemia, depression, unspecified hearing loss, gastroesophageal reflux disease (GERD), parasthesia of 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 medical record review and staff interview, the facility failed to provide proper parameters for as needed and scheduled medications. This affected four (Residents #5, #27, #137, and #7) of five residents reviewed for unnecessary medications. The census was 46. Findings Include: 1. Resident #5 was admitted to the facility on [DATE]. Resident #5's diagnoses included multiple fractures of pelvic with stable disruption of pelvic ring, pneumonia, type II diabetes, hypertensive heart and chronic kidney disease with heart failure, heart failure, chronic kidney disease (stage III), acute posthemorrhagic anemia, hypothyroidism, vitamin B deficiency, hypo-osmolality and hyponatremia, pure hypercholesterolemia, depression, unspecified hearing loss, gastroesophageal reflux disease (GERD), parasthesia of skin, dysphagia, and need for assistance with personal care. Review of Resident #5's Minimum Data Set (MDS) assessment, dated 06/21/24, revealed Resident #5 was cognitively intact. Review of Resident #5's current…

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 medical record review, medication administration observation, staff interviews, and medication administration policy review, the facility failed to ensure a medication error rate of five percent or less. Two errors occurred in 35 opportunities for error. The medication error rate was 5.77 percent. This affected one resident (Resident #20) of four residents observed for medication administration. The facility census was 46. Findings Include: Review of the medical record for Resident #20 revealed an admission date of 06/14/23, with diagnoses that include hydrocephalus, disorientation, altered mental status, hemiplegia, type two diabetes, depression, and anxiety. The most recent Minimum Data Set (MDS) 3.0 assessment, completed on 08/23/24, indicated Resident #20 was severely cognitively impaired. Review of the care plan dated 08/08/23 revealed Resident #20 utilized anti-depressant and chemical interventions related to the signs and symptoms of depression. Review of physician orders for Resident #20 revealed the following orders: -Duloxetine capsule, delayed release, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to provide Resident #27 dignity related to the use of an indwelling urinary catheter when the urinary collection bag was observed uncovered. This affected one resident (#27) of two residents reviewed for dignity. Findings include: Review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including traumatic hemorrhage of cerebrum, other obstructive and reflux uropathy, benign prostatic hyperplasia, flaccid neuropathic bladder, type two diabetes mellitus, hyperlipidemia, depression, spinal stenosis and unspecified cord compression. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 06/10/22 revealed Resident #27 had moderately impaired cognition. The assessment did not reflect the use of a urinary catheter for the resident. Review of the plan of care, dated 07/27/22 revealed Resident #27 used a Foley catheter for a diagnosis 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 record review, facility policy and procedure review and interview the facility failed to ensure a potential incident of physical abuse was immediately reported to the Administrator and to the State agency as required. This affected two residents (#7 and #8) of two residents reviewed for abuse. Findings include: Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including hypertensive chronic kidney disease, acute cystitis, osteoarthritis, atherosclerosis, atherosclerotic heart disease, vascular dementia without behavioral disturbances, anxiety disorder, restlessness and agitation, major depressive disorder, and hypothyroidism. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/06/22 revealed the resident had significant cognitive impairment. Review of Resident #7's progress notes, dated 07/10/22 (late entry written on 07/11/22), revealed the nurse was passing medication and heard yelling from the dining area. She went to the dining area and found 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, facility policy and procedure review and interview the facility failed to provide a bed hold notice to Resident #42 and/or the residents representative at the time of discharge to the hospital. This affected one resident (#42) of two residents reviewed for hospitalization. Findings include: Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, respiratory failure, hypertensive heart and kidney failure, congestive heart failure, atrial fibrillation, morbid obesity, osteoarthritis, obstructive sleep apnea, type II diabetes, hyperlipidemia and dependence on supplemental oxygen. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/13/22 revealed the resident was cognitively intact. Review of Resident #42's medical record revealed she was discharged from the facility to the hospital on [DATE]. Record review revealed no evidence the resident or her responsible party were provided a bed hold notice at the time 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, record review and interview the facility failed to ensure Resident #243's peripherally inserted central catheter (PICC) line dressing was changed as ordered by the physician. This affected one resident (#243) of two residents reviewed for intravenous catheter lines. Findings include: Record review revealed Resident #243 was admitted to the facility on [DATE] with diagnoses including encounter for orthopedic aftercare following surgical amputation, acquired absence of right great toe, osteomyelitis, cellulitis of right lower limb, type two diabetes mellitus with diabetic peripheral angiopathy with gangrene, morbid obesity due to excess calories, type two diabetes mellitus with diabetic neuropathy and chronic obstructive pulmonary disease. Record review revealed a physician's order, dated 07/08/22 for IV- PICC dressing change every five days, measure external catheter length, enter in measurement med note. Review of the 07/15/22 admission Minimum Data Set (MDS) 3.0 assessment 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.

Based on record review and interview the facility failed to ensure pre and post hemodialysis assessments were completed for Resident #14. This affected one resident (#14) of one resident reviewed for hemodialysis. Findings include: Review of the medical record for Resident #14 revealed an admission date of 05/29/22 with diagnoses including encephalopathy, end stage renal disease with dependence on renal dialysis, hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side, hyperlipidemia, gastro-esophageal reflux disease, disorientation, and unspecified convulsions. Review of the physician's orders, dated 05/30/22 to 06/01/22 revealed an order for hemodialysis every Monday, Wednesday and Friday. A Dialysis Center Communication Observation was to be completed under 'other clinical observation' and sent with the resident. On 06/01/22 a physician's order revealed hemodialysis every Monday, Wednesday and Friday. A Dialysis Center Communication Observation was to be completed under 'other clinical observation' and sent with resident. Dialysis was scheduled…

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 maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 12.90% and included four medication errors of 31 medication administration opportunities. This affected one resident (#293) of three residents observed for medication administration. Findings include: Record review revealed Resident #293 was admitted to the facility on [DATE] with diagnoses including moderate protein-calorie malnutrition, atherosclerosis of aorta, asthma, hyperlipidemia, irritable bowel syndrome without diarrhea, dysphagia, dysphonia, adult failure to thrive, hypertension, gastro-esophageal reflux disease, constipation and shortness of breath. Review of physician's orders revealed the following oral medication orders, dated 07/13/22: Aspirin tablet delayed release/ enteric coated (DR/EC) 81 milligrams (mg) oral once a day for blood thinning. Metoprolol succinate (blood pressure and angina medication) extended…

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, record review and interview the facility failed to prepare and serve pureed foods in a manner to ensure they were served at the proper temperature and to ensure palatability. This had the potential to affect two residents (#241 and #244) of two residents identified to be on a pureed diet. The facility census was 48. Findings include: Review of the medical record for Resident #241 revealed an admission date of 06/21/22 with diagnoses including fracture of unspecified part of neck of left femur, encephalopathy, sepsis, anxiety disorder, dysphagia, adult failure to thrive, and restlessness and agitation. Resident #241 had a physician's order, dated 07/08/22 for a regular diet with a puree consistency Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 07/13/22 revealed Resident #241 had intact cognition, was on a mechanically altered diet and had a feeding tube providing 51% or more of calories and 501 cubic centimeters (cc's) or more of fluid a day. Review of the medical record for Resident #244 revealed an admission date of 07/15/22 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 and interview the facility failed to ensure Resident #5 was provided assistive devices at meals as ordered. This affected one resident (#5) of three reviewed for nutrition. Findings include: Review of the medical record for Resident #5 revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, atherosclerotic heart disease, unspecified psychosis not due to a substance or known physiological condition, delirium due to known physiological condition, other bipolar disorder, post-traumatic stress disorder, auditory hallucinations and gastro-esophageal reflux disease. Review of the physician's order revealed an order, dated 03/29/21 for Resident #5 to use a divided plate at all meals for increased ability to self-feed during meals. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/29/22 revealed Resident #5 had severe cognitive impairment and required the supervision of one…

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.