Leisure Village Health Care Center

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure their medication rate was below 5% for 1 (Resident #83) of 8 residents observed for medication administration. Specifically, staff did not perform an insulin pen safety check before insulin administration which resulted in 2 medication errors of 27 opportunities. The facility's overall medication error rate was 7.41%.Findings included: A facility policy titled, Medication Administration and General Guidelines, revised 01/2026, indicated, Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. An undated facility document titled, Standardized Priming (Safety Test) Instructions, indicated, Priming is essential before every injection to remove air bubbles from the needle and cartridge, and to ensure the device is functioning correctly. The policy also indicated, 2. The Priming Step (Safety Test) 1. Dial the dose: Turn the dose selector to 2 units. 2. Position the pen: Hold the pen with the needle pointing…

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 ensure comfortable water temperatures were maintained for 5 of 5 shower rooms. The DON identified 79 residents received showers. Finding:On 01/27/26 at 3:23 p.m., an observation of the large South shower showed an initial temperature of the water flow out of the shower head to be 100.4 degrees F. Within 11 minutes the water temperature was observed to be 77.4 degrees F.On 01/28/26 at 8:42 a.m., an observation of the small East shower showed an initial temperature of the water flow out of the shower head to be 107.4 degrees F. Within eight minutes the water temperature was observed to be 85.2 degrees F.On 01/28/26 at 9:01 a.m., an observation of the large East shower showed an initial temperature of the water flow out of the shower head to be 97.6. degrees F. Within one minute the water temperature was observed to be 98.4 degrees F.On 01/28/26 at 9:15 a.m., an observation of the North shower showed an initial temperature of the water flow out of the shower head to be 81.3 degrees F. Within two minutes 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 observation and interview, the facility failed to ensure there were qualified dietary staff to meet the needs of the residents for 2 of 3 dietary staff reviewed for qualifications. The DON identified 81 residents received nutrition from the kitchen. The DM identified 11 staff members who worked in the dietary department. Findings:On 01/27/26 at 1:35 p.m., dietary aide #1 and dietary aide #2 were observed washing dishes in the low temperature dish machine and dietary aide #2 stopped the dish machine during the wash cycle and walked away.On 01/27/26 at 1:38 a.m., dietary aide #2 stated there were suds in the side tank and that was how they knew the water was not hot enough. They stated they waited awhile and tried running the dishwasher again. Dietary Aide #2 stated they had not been shown how to check the temperature with the gauge or use test strips on the machine. Dietary Aide #2 stated they had worked at the facility for about a month and were trained by another staff member but had not learned anything about testing the dish machine, even though they used it several…

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 ensure staff performed their duties in a manner that would ensure clean and proper sanitation of dishes during 2 of 2 kitchen observations.The DON identified 81 residents received nutrition from the kitchen. Findings:On 01/27/26 at 1:30 p.m., the low temperature dishwasher was observed being stopped mid-cycle by dietary aide #2. The dishwasher reservoir water was observed to have suds. The temperature gauge was observed and showed the dial between the green arrows marked on the gauge and water temperature was measured to be 140 degrees F.A facility policy titled Warewashing, dated 08/25/25, read in part, dishware shall be washed in (3) sink unit with sanitizer or disposable dishware shall be used if dish machine is not working or reaching regulatory requirements.test strips shall be available for the pot sink and low temp dish machine sanitizer. Results shall be checked and recorded daily.A facility log sheet titled Warewashing Log - Dishmachine, dated January 2026, showed lines marked through 01/21/26 with 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 record review and interview, the facility failed to ensure resident representatives were notified of a change in condition for 2 (#4 and #9) of 4 sampled residents reviewed for change in condition.The DON reported the census in the facility was 80. Findings: A facility policy titled Notification of Change in Condition, revised 02/06/25, read in part, The attending physician/physician extender (nurse practitioner, physician assistant, or clinical nurse specialist) and the resident representative will be notified of a change in resident's condition, per standards of practice and federal and/or state regulations.1. An admission record, dated 10/23/20, showed Res #4 had diagnoses which included congestive heart failure and obstructive sleep apnea.A nurse note, dated 12/05/24, showed Res #4 had complained of nausea and the physician had been notified and ordered Zofran 4mg (a medication used to prevent nausea) every four hours as needed. The note did not show the resident's representative had been notified…

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 a comprehensive care plan was developed for 1 (#1) of 3 sampled residents whose care plans were reviewed. The DON identified 75 residents resided in the facility. Findings: A policy titled Signing out LOA [leave of absence], dated January 2016, showed each resident leaving the premises was to be signed out on the sign out register at the nurses' station. A policy titled Comprehensive Person Centered Care Plan, dated 01/23/19, read in part, Each resident will have a person centered plan of care to identify proems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. A care plan, dated 02/22/25, did not show the resident was able to sign themselves out for outings, enjoyed being outside on their motorized wheel chair, or that staff had to sign the resident out at times. An admission assessment, dated 02/24/25, showed Resident #1 had a diagnosis of hypertension and a brief interview for mental status score of 13, which indicated the resident was cognitively…

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 residents were free from abuse for one (#3) of three sampled residents for abuse. The DON identified 81 residents who resided at the facility. Findings: Review of an incident investigation, dated 09/04/24, revealed an allegation of verbal abuse by staff to Resident #3. The investigation completed by the administrator revealed the roommate of Resident #3 overhead the verbal abuse of the staff to Resident #3. The investigation revealed the administrator had reported the incident to OSDH in a timely manner and investigated the incident. The employee was terminated and all notifications were made. A QAPI dated 09/05/24, revealed the plan of action by the facility regarding a substantiated allegation of abuse. An in-service dated 09/05/24, documented education was provided to all staff regarding a substantiated allegation of abuse. On 09/23/24 at 12:30 p.m., CNA #1 stated they had been in-serviced recently on all abuse types, who to report incidents to and when to report. On 09/23/24 at 12:34 p.m., CNA #2 stated they 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.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was 5% or less during medication administration. A total of 25 opportunities were observed with three medication errors. The medication error rate was 12%. The DON identified 78 residents who resided in the facility who received medications. Findings: 1. Resident #24 had diagnoses which included GERD and constipation. A Physician's Order, dated 01/31/24, documented an order for docusate sodium 100 mg twice daily for constipation. A Physician's Order, dated 06/03/24, documented an order for famotidine 20 mg once daily for GERD. On 08/21/24 at 8:49 a.m., CMA #1 was observed to administer medications to Resident #24. Docusate sodium and famotidine were not medications CMA #1 administered during the medication pass. On 08/23/24 at 9:25 a.m., CMA #1 stated they did not know how they forgot to administer the docusate sodium or the famotidine. CMA #1 stated they remembered they had verified they had 15 pills in their medication cup and one patch to administer. CMA #1 stated they 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.

Based on observation, record review, and interview, the facility failed to ensure medications were labeled and dated when opened for four (north hall medication cart, east hall treatment cart, south hall medication cart, and south hall treatment cart) of four medication/treatment carts observed. The DON identified eight medication/treatment carts in the facility. Findings: 1. On 08/23/24 at 2:42 p.m., the north hall medication cart was observed with CMA #3. A bottle of house stock milk of magnesia was observed to be opened and not dated. CMA #3 stated they were to date medications when they were opened. 2. On 08/23/24 at 2:50 p.m., the east hall treatment cart was observed with LPN #1. LPN #1 stated they were to date medications when they were opened. The following items were observed to be opened and not dated: a. a bottle of glucometer check strips; b. a Novolog insulin pen for Resident #41; c. a Lantus insulin pen and a Humalog insulin pen for Resident #18; d. an Anoro inhaler for Resident #58; and e. an albuterol inhaler 90 mcg for Resident #4. 3. On 08/23/24 at 2:59 p.m., 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 observation, record review, and interview, the facility failed to maintain a resident's dignity, by using a privacy bag over an indwelling catheter bag, for one (#7) of two residents reviewed for dignity. The administrator reported a facility census of 78. A Quality of Life Dignity Policy dated 03/2017, documented in part, .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by helping the resident to keep urinary catheter bags covered if Resident wants . Resident #7 was admitted with diagnoses which included multiple sclerosis, anxiety, depression, urogenital implants, and chronic pain. A physician's order, dated 03/29/24, documented, verify dignity bag is in place every shift. The order documented a diagnosis of obstructive and reflux…

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 range of motion services were provided to one (#21) of one sampled residents who were reviewed for range of motion. The DON identified 18 residents who had contractures. Findings: The undated Restorative Nursing Program policy, read in parts, .The interdisciplinary [NAME] has the primary responsibility for identifying restorative needs .A resident may be started on a restorative program when .during a after skilled therapy . Resident #21 had diagnoses which included contracture to right elbow, wrist, and hand. A PT Evaluation & Plan of Treatment, dated 03/30/24, read in part, .At this time pt is at PLOF and is not a candidate for skilled PT. Pt will benefit from restorative program for geri chair positioning and contracture management . A physician's order, dated 07/19/24, documented to place a hand roll to the left hand daily. On 08/21/24 at 12:54 p.m., Resident #21 was observed in the living room in their geri chair. Resident #21…

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 the urinary drainage bag was properly positioned for one (#59) of one resident observed for urinary catheter. The Resident Matrix, documented six residents who had a urinary catheter. Findings: On 08/20/24 at 8:21 a.m., Resident #59 was observed in bed on their left side with the urinary catheter bag on the floor. On 08/22/24 at 8:34 a.m., Resident #59 was observed in bed on their right side with the urinary catheter bag on the floor. On 08/22/24 at 8:36 a.m., CNA #2 stated the urinary catheter bag should not be on the floor. On 08/23/24 at 9:16 a.m., the DON stated the facility did not have a policy regarding positioning of a urinary catheter bag, but it should not have been on the floor.

Based on observation, record review and interview, the facility failed to ensure food items were labeled, dated, and stored according to facility policy. The administrator identified 77 residents received services from the kitchen. Findings: A policy titled Refrigeration, revised on 08/21/24, read in part, .all leftovers shall be labeled and dated with an expiration date . On 08/20/24 at 8:00 a.m., one unlabeled, undated zip lock freezer bag containing frozen biscuits, and one unlabeled, undated zip lock freezer bag containing frozen cookies were observed in the freezer. On 08/20/24 at 8:05 a.m., an opened, unsecured bag of lettuce was observed without a label or date. On 08/20/24 at 8:15 a.m., the DM stated all left over food should be securely closed and labeled with a date.

Based on observation and interview, the facility failed to ensure enhanced barrier precautions were used for one (#13) of one resident observed for peg tube care. The administrator identified one resident with a peg tube. Findings: Resident #13 had diagnoses which included dysphasia. On 08/20/24 at 9:34 a.m., enhanced barrier precautions signage was observed on Resident #13's door. EBP supplies were observed on the back of the door. On 08/20/24 at 9:40 a.m., LPN #3 was observed to administer medication to Resident #13 via the peg tube. The nurse was not observed to wear a gown. On 08/20/24 at 9:45 a.m., LPN #3 stated the resident was not on infection control precautions. On 08/23/24 at 9:12 a.m., the infection preventionist stated enhanced barrier precautions should be used when performing wound care, colostomy care, catheter care, port care, or providing peg tube care. On 08/23/24 at 11:35 a.m., the DON stated enhanced barrier precautions should be used when providing peg tube care, catheter care, incontinent care, or wound care. They stated an enhanced barrier precaution policy…

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 the required number of staff were present when the mechanical lift was operated for one (#3) of one resident reviewed for mechanical lift use. The DON identified 79 residents resided in the facility. Findings: Resident #3 had a diagnoses which included fracture of the left femur and dementia. A Care Plan dated 03/42/21 documented the resident required two person assist with transfers using a mechanical lift. A document titled Incident Report, dated 07/06/24, read in part, .this nurse was called to to room by CNA, resident was on the floor on her back next to the Hoyer Lift with the sling under her. On 07/06/24 a document titled Inservice 07/06/24 documented, .Staff to ensure that two staff members are always present during transfers with the Hoyer Lift or Sit to Stand. Make sure the correct size sling is used and is positioned properly. On 07/09/24 at 2:53 p.m., CNA #4 stated she has been inserviced on the use of a Hoyer Lift and you must use two staff members such as another CNA, CMA, or nurse. On 07/09/24 at 3:00…

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 the dignity of a resident was maintained during and following perineal care for one (#1) of five sampled residents reviewed for abuse. A midnight census report, dated 07/01/24, documented 75 residents resided in the facility. Findings: A facility Resident Rights policy, dated 04/26/24, read in part, The Facility shall treat Residents with kindness, respect, and dignity and ensure Resident Rights are being followed. Resident #1 had diagnoses which included age related cognitive decline and dementia. On 07/02/24 at 2:03 p.m., CNA #1 stated on 06/27/24 on the evening shift they had provided perineal care to Resident #1. They stated they had attempted to clean Resident #1's vaginal area by picking off dry material with their hands instead of cleaning with wipes and cleanser. They stated the resident became upset, told CNA #1 to stop the care, and began crying. They stated they themselves became upset and assisted the resident put on their briefs then departed the room. They stated they did not otherwise assist 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 a CNA provided perineal care in accordance with accepted standards of care for one (#1) of five sampled resident reviewed for abuse. A midnight census report, dated 07/01/24, documented 75 residents resided in the facility. Findings: A facility Incontinent Care policy, dated 07/21/22, read in part, Cleanse Perineal Area with a Perineal Cleanse. Females: Separate the labia, Cleanse one side and then the other, Cleanse center of the Labia wiping towards the Rectal Area. On 07/02/24 at 2:03 p.m., CNA #1 stated they had been asked by CNA #2 to watch the memory care unit while they took a break. CNA #1 stated while on the unit they made a visual inspection of the residents and found Resident #1 laying on their bed fully clothed. They stated they smelled something foul and asked the resident if they could remove their jeans. They stated they removed the resident's jeans and instructed the resident to remove their briefs and found that the resident was dry. They stated they did see vaginal discharge. They stated they asked…

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 provide showers for two (#5 and #6) of two sampled residents reviewed for assistance with activities of daily living. The administrator identified 76 residents resided in the facility. Findings: 1. Resident #5 had diagnoses which included COPD and Parkinson's disease. Resident #5's quarterly assessment, dated 05/24/24, documented Resident #5's cognition was intact. On 06/18/24 at 2:14 p.m., Resident #5 stated they have not had a shower in over a week. They stated they feel dirty. The staff tells them they don't have enough staff to get showers done. On 06/18/24 at 2:14 p.m., Resident #6 stated they had not had a shower in over a week. They stated they only get a shower when they have a doctor's appointment. On 06/19/24 at 2:10 p.m., CNA #6 stated they can't always get baths done because they run out of time. On 06/19/24 at 3:00 p.m., CNA #5 stated the documentation for showers is very inconsistent and documents showers were done when they were not done because they didn't know how to document correctly. On 06/19/24 at 3:30…

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 answer call lights in a timely manner for three (#2, #3 and #4) of three residents reviewed for sufficient staff to meet the needs of residents. The administrator identified 76 residents resided in the facility. Findings: A document dated January 2024, titled Resident Council Minutes, stated in part .A. Nursing - call lights not being answered. Number of residents who share the concern: 10. A document dated February 2024, titled Resident Council Minutes, stated in part .B. Nursing - answering call lights and not retuning. Taking too long to answer call lights. A document dated March 2024, titled Grievance/Missing Property Monthly Tracking Log, stated in part .call lights not answered timely. A document titled Device Activity Report dated 06/01/24 through 06/03/24 documented the following: A) on 06/01/24 the call light was activated for 23 minutes in room [ROOM NUMBER]; B) on 06/01/24 the call light was activated for 23 minutes in room [ROOM NUMBER]; C)…

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 infection control practices were followed during the administration of medication. The administrator identified 76 residents resided in the facility. Findings: On 06/19/24 at 10:20 a.m., CMA #1 was observed popping pills into a medication cup then using bare fingers to break the potassium pill in two before giving to a resident. O 06/19/24 a.m., CMA #1 stated they should have used gloves and a pill cutter.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a thorough investigation for one (#5) of three residents reviewed for allegations of abuse. The DON identified 10 allegations of abuse since August of 2023. Findings: Resident #5 was admitted with diagnoses which included cerebral infarction, chronic obstructive pulmonary disease, and tobacco use. A progress note, dated 07/25/23, documented social services visited with Resident #5 and completed a smoking assessment which documented no supervision was required. An Incident Report Form, dated 08/07/23, documented an allegation of abuse for Resident #5. The form documented an un-named department head reported to the administrator an allegation the activities director was yelling at and belittling Resident #5. The form documented the activities director was immediately suspended pending the investigation. Review of the investigation revealed interviews with six alert and oriented residents who were chosen at random throughout the facility. 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 observation, record review, and interview, the facility failed to ensure timely incontinent care for one (#4) and failed to maintain infection control during incontinent care for one (#10) of four sampled residents reviewed for incontinent care. The DON identified 55 residents who were incontinent. Findings: The Incontinent Care policy, dated 07/21/22, read in parts, .The Facility will Provide Incontinent Care as Directed by the Plan of Care .Cleanse perineal area with perineal cleanser .Remove Gloves, Perform Hand Hygiene [and] Apply Clean Gloves .Apply Clean Brief . 1. Resident #4 had diagnoses which included Alzheimer's disease. The Care Plan, revised 11/16/23, documented the resident had bladder incontinence related to Alzheimer's disease and was to be assisted with toileting before meals, after meals, and at bedtime. The Care Plan documented the resident was incontinent of bowel and was to receive peri care after each incontinent episode. The quarterly assessment, dated 11/29/23, documented the resident was moderately impaired in cognition for daily decision making 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.

Based on observation, record review, and interview, the facility failed to prevent misappropriation of a controlled substance for one (#70) of one sampled resident reviewed for misappropriation of property. The Resident Census and Conditions of Residents report, dated 07/19/23, documented 78 residents resided in the facility. Findings: An Abuse Prevention policy, dated 10/21/22, read in parts .Misuse of Fund/Resident Property .The misappropriation or conversion for any purpose of a consumer's funds or property by an employee or employees without the consent of the consumer . A Controlled Medications-Administration policy, undated, read in parts, .At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and/or one nurse and a CMA, QMAP, Med tech or equivalent and is documented on an audit record . Resident #70 had diagnoses which included, anxiety, dementia and hypertension. A Physician Order, dated 05/19/23, read in part .Lorazepam 2mg/ml give 1 mL PO/SL q 4 hr prn for anxiety . An Individual Patient Narcotic Record, documented 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 observation, record review, and interview, the facility failed to provide assistance for activities of daily living (bathing, incontinent care, and nail care) for three (#35, 59 and #28) of five sampled residents reviewed for ADL care. The Resident Census and Condition of Residents report, dated 07/19/23, documented 15 residents were dependent for bathing, census was 78. Findings: An Incontinent Care policy, dated 07/21/22, read in parts, .The Facility will Provide Incontinent Care as Directed in the Plan of Care . A Nail Care policy, dated 07/21/22, read in parts, .the purpose of nail care is to clean the nail bed, trim nails .nail care includes daily cleaning and regular trimming, and report to the charge nurse ingrown nails, infection, pain, or nails that are thick and difficult to trim . 1. Resident #35 had diagnoses which included pressure ulcer of left heel stage 3, dementia, muscle weakness and need for assistance with personal care. A Care Plan, revised on 12/06/22, read in parts, .Broda chair r/t lower contractures .Check nail length and trim and clean on bath day…

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 provide proper cleaning and storage of a suction machine for one (#37) of one resident reviewed for cleaning and storage of a suction machine. The Resident Census and Condition of Residents report, dated 07/19/23, documented 78 residents resided in the facility and no Residents required suction. Findings: Resident #37 had diagnoses which included sepsis, pneumonia, acute respiratory failure with hypoxia, hypercapnia, and dysphagia. A Care Plan, dated 06/21/23, read in parts, .monitor, document, and report PRN any s/sx of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth . A Physician Order, dated 06/21/23, documented suction at bedside as needed. A admission Assessment, dated 06/23/23, documented Resident #37 used suction while not a resident in the facility. The clinical health record did not contain an order or an assessment for Resident #37 to self suction. On 07/13/23 at 4:18 p.m., a suction canister was observed on the bedside table. There was no cover on the Yankauer that was hung…

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 ensure a care plan intervention (low air loss mattress) was in place for pressure ulcer prevention for one (#35) of four residents reviewed for pressure ulcers. The Resident Census and Condition of Residents report, dated 07/19/23, documented eight residents had pressure ulcers. The census was 78. Findings: Resident #35 had diagnoses which included pressure ulcer of left heel stage three, dementia, muscle weakness and need for assistance with personal care. A Physician Order, dated 02/22/23, read in part .Pressure offloading to BLE with use of positioning pillows every shift . A Quarterly Assessment, dated 04/19/23, documented Resident #35 had moderate cognitive impairment, and had a pressure reducing device for their bed. A Care Plan, revised 05/12/23, read in parts .Maintain my LAL mattress settings at my weight parameter .offload area as I will allow .Pressure offloading to BLE with use of positioning pillows . A Physician Order, dated 06/30/23, read in part .Left Heel Wound Cleanse with NS, pat dry, apply…

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 ensure staffing ratios were met to provide supervision and assistance as needed for one (#73) of six residents reviewed for staffing. The Resident Census and Conditions of Residents report, dated 07/19/23, documented 27 residents were dependent on staff for toileting and transfers, 34 residents required assistance of one or more staff for transfers, and 44 residents required assistance of one or more staff for toileting. The census was 78. Findings: A Emergency Staffing Protocol policy, dated 03/01/21, read in part, .The facility is committed to providing the residents with the safest environment possible . 1. A Daily Staffing sheet, dated 07/18/23, documented four staff on the 10:00 p.m. to 6:00 a.m. shift with a census of 78. The minimum staffing requirements for the night shift is one staff to 15 residents. For a census of 78, there should be five to six staff members. On 07/19/23 at 5:05 a.m., LPN #1 was asked, how many staff are in the building at this time. They stated there is one aide for East hall,…

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 a medication was available to administer as ordered by the physician for one (#132) of five sampled residents reviewed during medication pass observation. The Resident Census and Conditions of Residents report, dated 07/19/23, documented 78 residents resided in the facility. Findings: A Medication Administration and General Guidelines policy, undated, read in part .Medications are administered in accordance with written orders of the attending physician . Resident #132 had diagnoses which included unspecified intestinal obstruction, and partial intestinal obstruction, and unspecified abdominal pain. A Physician Order, dated 07/07/23, read in part, .Psyllium Oral [NAME](Psyllium) Give 1 packet by mouth two times a day related to PARTIAL INTESTINAL OBSTRUCTION . Resident #132's Medication Administration Record, dated 07/01/23 to 07/31/23, documented the resident had been administered the morning dose of Psyllium from 07/09/23 until…

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 monitor for side effects related to the use of psychotropic medications for four (#42, 54, 61, and #78) of five sampled residents reviewed for unnecessary medications. The Resident Census and Condition of Residents report, dated 07/19/23, documented 24 residents received antianxiety medications, and 51 residents received antidepressant medications. The census was 78. Findings: An undated, Monitoring of Antidepressants policy, read in part, .Residents receive an antidepressant medication routinely only when medically necessary. Every effort is made to ensure that resident who use antidepressants receive the intended benefit of the medication and to minimize the unwanted effects of the antidepressant medications . 1. Resident #42 had diagnoses which included GERD, depressive disorder, and high blood pressure. A Physician Order, dated 05/12/23, documented to administer Venlafaxine 75 mg one tablet by mouth one time a day. A TAR, dated May 2023, did not contain any documentation Resident #42 had been monitored for side effects…

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 ensure medication pass was less than five percent error rate for two (#132 and #16) of five residents reviewed during the medication pass observation. The medication pass error rate was 11.11%. The Resident Census and Conditions of Residents report, dated 07/19/23, documented 78 residents resided in the facility. Findings: A Medication Administration and General Guidelines policy, undated, read in parts .Medications are administered in accordance with written orders of the attending physician .If it is safe to do so, medication tablets may be crushed or capsules emptied when a resident has difficulty swallowing or is tube-fed . 1. Resident #132 had diagnoses which included unspecified intestinal obstruction, and partial intestinal obstruction, and unspecified abdominal pain. A Physician Order, dated 07/07/23, read in part .Psyllium Oral Packet (Psyllium) Give 1 packet by mouth two times a day related to PARTIAL INTESTINAL OBSTRUCTION, UNSPECIFIED AS TO CAUSE . On 07/18/23 at 7:53 a.m., CMA # 2 was observed to…

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

Based on observation, record review, and interview, the facility failed to serve a mechanically altered diet for one (#42) of three sampled residents reviewed for diets. A Resident Census and Condition of Residents report, dated 07/19/23, documented 24 residents received mechanically altered diets for pureed/chopped and census was 78. Findings: An undated, Diet Summary policy, read in parts, .This consistency modified diet is for individuals with limited or difficulty in chewing regular textures food . Resident #42 had diagnoses which included GERD, depressive disorder, and high blood pressure. A Physician Order, dated 01/19/23, read in part, .Regular diet, Regular texture, Thin consistency, cut up meat for nutrition . An Annual Assessment, dated 05/31/23, documented Resident #42 was cognitively intact. A Nutritional Assessment, dated 06/20/22, read in part .Regular cut up meat . A Diet Slip, dated 07/18/23, documented regular diet and thin liquids. The diet slip did not contain documentation for chopped meats. On 07/18/23 at 1:10 p.m., Resident #42 was observed to have five chicken…

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.