Town Of Vici Nursing Home

Based on record review and interview, the facility failed to ensure the physician was notified of insulin being held for 1 (#19) of 5 sampled residents reviewed for notification. LPN #3 identified eight residents received insulin. Findings: A quarterly resident assessment, dated 11/22/24, showed Resident #19 had diagnosis which included diabetes mellitus and BIMS score of 14 (cognition intact). Resident #19's physicians order, dated 01/17/25, showed Lantus insulin (medication to control blood sugar) 50 U, subcutaneous daily. Hold for FSBS below 120. A MAR, dated March 2025, showed the Lantus insulin had not been administered on 03/03/25, 03/09/25, 03/11/25, 03/14/25, 03/21/25, 03/28/25 and on 03/29/25 due to the resident not eating breakfast. There was no documentation Resident #19's physician had been notified. On 04/08/25 at 12:21 p.m., LPN #1 stated they would hold insulin if a resident was not eating their meal or if their blood sugar was below 120. They stated they would notify the physician and document it in the progress notes. LPN #1 stated there was no documentation 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. BP monitoring for a PRN antihypertensive medication for 1 (#3); and b. medications were available for 1 (#11) of 5 sampled residents reviewed for medications. The administrator identified 37 residents resided in the facility. LPN #3 identified three residents had orders for clonidine. Findings: 1. Resident #3's quarterly resident assessment, dated 11/18/24, showed a diagnosis of hypertension and a BIMS score of five (severe cognitive impairment). A physician's order, dated 12/23/24, showed to administer clonidine (antihypertensive agent) tablet 0.1 mg three times a day as needed for SBP (the maximum blood pressure during contraction of the heart) greater than 160. A January 2025 MAR, showed Resident #3's BP had not been monitored three times daily on 01/01/25 - 01/31/25. A February 2025 MAR, showed Resident #3's BP had not been monitored three times daily on 02/01/25 - 02/28/25. A March 2025 MAR, showed Resident #3's BP had not been monitored three times daily on 03/01/25 - 03/31/25. An April 2025 MAR, showed…

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 nail care was provided for a dependent resident for 1 (#18) of 16 sampled residents reviewed for ADLs. The administrator identified 37 residents resided in the facility. Findings: Resident #18's significant change assessment, dated 02/10/25, showed diagnoses of congestive heart failure, BIMS was 15 (cognition intact), and they required substantial assistance for personal hygiene. On 04/07/25 at 12:54 p.m., Resident #18 was observed to have jagged fingernails and a brown substance under their fingernails. An undated document titled Nursing Care Standard for Orderlies and Aides, showed fingernails were to be clean and trimmed. On 04/07/25 at 12:57 p.m., Resident #18 was asked if staff provided nail care. They stated staff had not provided nail care in the past week. On 04/07/25 at 1:05 p.m., CNA #1 was asked when nail care was provided. They stated on shower days or when they were long and dirty. CNA #1 stated Resident #18's fingernails looked bad and needed done.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a comprehensive care plan for one (#4) of four sampled residents reviewed for care plans. Faciilty census was 43. Findings: Resident #4 was admitted to the facility on [DATE] and had diagnoses which included, pain, and high blood pressure. The clinical health record did not contain documentation a comprehensive care plan had been completed. On 06/25/24 at 9:03 a.m., LPN #1 was asked if Resident #4 had a comprehensive care plan. They stated it had not been completed they only had the care plan reference sheet.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure comprehensive MDS assessments were completed timely for three (#27, 38, and #140) of 12 sampled residents reviewed for assessments. The administrator identified 36 residents resided in the facility. Findings: A [MDS] and Care Plan policy, undated, read in part, .(MDS) will be completed upon each new admission within 14 days of admission. A MDS will also be completed upon .Annual Assessment . An admission Summary report, documented Resident #38 was admitted [DATE] and Resident #140 was admitted [DATE]. The facility's EHR documented Resident #27's quarterly assessment was completed 08/07/23. The resident's comprehensive assessment was due in November. The facility's EHR documented comprehensive assessments were not completed for Resident #27, 38, or #140. No copies were provided for Resident #27, 38, or #140. On 12/05/23 at 12:21 p.m., MDS coordinator #1 was asked how they ensured MDS assessments were completed timely. They stated they have a list…

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 quarterly MDS assessments were completed timely for four (#15, 32, 19, and #2) of 12 sampled residents reviewed for assessments. The administrator identified 36 residents resided in the facility. Findings: A [MDS] and Care Plan policy, undated, read in part, .Quarterly reviews and updates will be completed as mandated . The facility's EHR documented Resident #15's last completed assessment was 07/28/23. It documented a quarterly assessment, dated 10/27/23, had not been completed. The facility's EHR documented Resident #32's last completed assessment was 07/09/23. It documented a quarterly assessment, dated 10/09/23, had not been completed. The facility's EHR documented Resident #19's last completed assessment was 07/26/23. It documented a quarterly assessment, dated 10/23/23, had not been completed. The facility's EHR documented Resident #2's last completed assessment was 08/31/23. It did not document another assessment had been completed. No copies were provided for Resident #15, 32, 19, or #2. On 12/05/23 at 12:21…

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 record review and interview, the facility failed to ensure MDS assessments were transmitted timely for seven (#15, 32, 19, 2, 27, 38, and #140) of 12 sampled residents reviewed for assessments. The administrator identified 36 residents resided in the facility. Findings: The facility's EHR documented comprehensive assessments were not completed for Resident #27, 38, or #140. The facility's EHR documented quarterly assessments were not completed for Resident #15, 32, 19, or #2. On 12/05/23 at 12:21 p.m., MDS coordinator #1 stated the EHR was not prepared when the new update for MDS assessments came out and it still wasn't working. They stated they haven't been able to complete MDS assessments after 10/01/23. They stated if they managed to get the assessments completed and locked, the assessments were being rejected.

Based on observation, record review, and interview, the facility failed to ensure dependent residents were assisted to be changed for one (#2) of two sampled residents reviewed for ADLs. The administrator identified 36 residents resided in the facility. Findings: Resident #2 has diagnosis which included dementia. A care plan, dated 08/31/23, documented Resident #2 required staff assistance with ADLs due to confusion and left below the knee amputation. It documented to assist Resident #2 with toileting every two hours. It documented the resident had occasional incontinence of bladder. On 12/05/23 at 8:39 a.m., Resident #2 was observed sitting up in their wheelchair in the sitting area. The resident's pants were observed to be wet from their lower abdomen, down their left inner thigh, to the knee area. From 12/05/23 at 8:39 a.m. to 10:52 a.m., Resident #2 was observed to sit in their wheelchair in the sitting area. The resident's clothes were observed to dry over time. Several staff were observed to walk by the resident during this time. Staff were not observed to check or change 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 implement a dementia focused care area on a comprehensive care plan for one (#140) of 12 sampled residents reviewed for care plans. The administrator identified 36 residents resided in the facility. Findings: Resident #140 had diagnosis which included dementia. A [MDS] and Care Plan policy, undated, read in part .a trigger sheet will be completed for each resident, identifying problems and potential problems .a care plan will be completed for each resident. A new admission's care plan will be completed within 21 days of admission . Resident #140's Care Plan, undated, did not document a focus problem for dementia care. On 12/05/23 at 12:34 p.m., LPN #4 was asked how do they ensured a focused care area was included on a care plan. They stated they followed the care areas triggered by the MDS. They were asked if there was a focus care area for dementia on Resident #140's current care plan. They stated, No.

Based on record review and interview, the facility failed to ensure laboratory orders were obtained per physician's orders for one (#38) of three sampled residents reviewed for laboratory orders. The administrator identified 36 residents resided in the facility. Findings: A Lab policy, undated, read in part, .This facility will provide, or obtain clinical laboratory services .This facility will be responsible for the .timliness [sic] of services . Resident #38 had diagnosis which included presence of aortocoronary bypass graft and cerebral infarction. A physician order, dated 11/01/23, documented to obtain a CBC and CMP in two weeks. On 12/05/23 at 9:00 a.m., LPN #2 was asked how staff ensured lab orders were obtained. They stated the facility had a lab tech who worked one day a week, and if the lab order needed to be obtained on a different day, the nurses would collect it, and take it to the lab. On 12/05/23 at 1:53 p.m., the DON was asked to provide Resident #38's lab results from the order on 11/01/23. She stated, They were not done.

Based on record review and interview the facility failed to a. ensure an antibiotic was started in a timely manner for one (#14) of two sampled residents reviewed for antibiotic use, and b. assess, intervene and consult the physician for a resident with a rash for one (#2) of two sampled residents reviewed for impaired skin integrity. The Resident Census and Condition Report, dated 10/16/22, documented 39 residents resided in the facility. Findings: 1. Resident #14 had diagnoses which included, high blood pressure, unspecified dementia, and personal history of urinary tract infections. A physician order, dated 09/21/22 at 3:30 p.m., read in parts, .N/O send to [facility name] for eval and tx .N/O to obtain clean catch U/A .C/S if indicated . A Nurse progress noted, dated 09/21/22 at 3:50 p.m., read in part, .LE at 1522 [3:22 p.m.] office staff reported to this nurse, resident has been in office talking about harming self . A urinalysis lab report, dated 09/21/22 at 5:12 p.m., read in parts, .Nitrite positive .Leukocyte Esterase 3+ .WBC TNTC . A physician order, dated 09/21/22 at…

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

Based on record review, observations, and interview, the facility failed to ensure: a. staff wore appropriate PPE for residents in isolation and while performing COVID-19 testing on the residents, b. infections were tracked to identify any trends, c. ensure blood pressure cuff and stethoscope were sanitized between resident use for three (#12, #25, and #2) of four sampled residents observed during medication administration, d. staff were monitored and screened for COVID-19 signs and symptoms for three (CNA #3, LPN #3 and CMA #3) on entrance to the facility, and e. residents were screened every shift for COVID-19 signs and symptoms for 15 ( #31, #27, #25, #12, #16, #34, 33, #40, #17, #20, #29, #3, #14, #18, and #30) of 17 sampled residents reviewed for COVID-19 screenings. The Resident Census and Conditions report, dated 10/16/22, documented 39 residents resided in the facility. Findings: The facility's Infection Control Tracking Tool policy, dated 11/11/04, read in parts, .Use the building diagram on the reverse side to color cold [sic] infection type and location of infection .Use…

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 honor a resident's choice by performing CPR when the resident had a DNR and ensured staff were aware of code status, immediately, when a resident had no breathing or pulse for one (#42) of 16 sampled residents reviewed for advance directives. The DON identified 28 residents had DNRs. Findings: An undated facility policy, titled Residents Right to Self Determination, read in part, .Advance Directions will be documented on the Minimum Data Set, the front of resident chart, and other chart areas as appropriate .There will be an updated list of those with Advance Directives, DNR, etc. available. This list will be placed on the Front Wing and the [NAME] Wing. All employees will be aware of placement of these cards through orientation. The Charge Nurse will carry a listing of names in his/her pocket, if they wish . Resident #42 had was admitted to the facility on [DATE] with diagnoses which included diverticulitis, hypertension, and chronic kidney disease…

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 staff were tested for COVID-19 and results documented during outbreak testing for two (CMA #3 and LPN #3) of five staff reviewed for COVID-19 testing. The Resident Census and Condition Report form, dated 10/16/22, documented 39 residents resided in the facility. Findings: A P&P titled, [Facility Name] Policy and Procedure, revised 08/12/21, read in parts, .The policies and procedures are implemented for that purpose and are subject to change as more is learned about the illness and with the guidance of the CDC and OSDH . On 10/19/22 at 10:45 a.m., the Administrator was asked how many residents are currently COVID positive. They stated, 12. They were asked how many staff are currently COVID positive. They stated, eight. They were asked how often they are testing staff. They stated, twice weekly Mondays and Thursdays are testing days. On 10/19/22 at 3:18 p.m., The Administrator was asked who reviewed the weekly staff testing. The Administrator stated the administrator had been reviewing the testing. A staff line list…

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.