Valley West Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determine the facility failed to transmit resident assessments in the required timeframe for 5 of 5 residents (#s 18, 47, 54, 55, and 56) reviewed for late assessments. Findings include: 1. Residents 18 was admitted in 2023 with diagnoses including a fracture. The clinical record indicated a discharge assessment dated [DATE] was completed but was not transmitted until 2/5/24. On 2/9/24 at 10:58 AM Staff 10 (Regional Director of Clinical Operations) stated the assessment was completed but was not transmitted in the required timeframe. 2. Resident 47 was admitted to the facility in 2023 with diagnoses including a fracture. The clinical record indicated a discharge assessment dated [DATE] was completed but was not transmitted until 2/5/24. On 2/9/24 at 10:58 AM Staff 10 (Regional Director of Clinical Operations) stated the assessment was completed but was not transmitted in the required timeframe. 3. Resident 54 was admitted to the facility in 2023 with diagnoses…

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.

2. Resident 168 was admitted to the facility in 2023 with a diagnosis of heart failure. A 11/20/23 admission MDS and associated CAAs revealed Resident 168 was assessed to have cognitive impairment. A 12/5/23 Incident Summary revealed on 12/5/23 Resident 168 alleged on the night shift of 12/4/23 she/he was restrained and two CNAs of the opposite gender messed with her/him. The facility investigated the incident and was not able to support the resident's allegations. Progress Notes from 12/5/23 through 12/11/23 did not include the staff monitored Resident 168 to ensure she/he did not have psychosocial outcome related to her/his allegations of abuse. On 2/8/24 at 10:43 AM Staff 2 (DNS) stated if a resident reported abuse, even when the allegation was not supported, staff were to monitor the resident for 72 hours to ensure the resident felt safe. Staff 2 stated the staff did not monitor the resident. Based on observation, interview, and record review it was determined the facility failed to follow physician orders, monitor for abuse and respond to changes in condition in a timely manner…

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

Based on observation, interview, and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 1 of 4 sampled residents (#33) and 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs. Findings include: Resident 33 was admitted to the facility in 2017 with diagnoses including heart failure. A 12/4/23 Significant Change MDS indicated Resident 33 was cognitively intact and required extensive assistance from staff for toileting and brief changes. Review of 8/17/23 Resident Council Notes revealed residents had long call light wait times. On 9/1/23 a public complaint was received which indicated on night shift at times the facility only had one CNA working for 47 residents, and call light wait times were an hour and a half to two hours long. On 8/25/23 Resident 33 waited for a brief change for one hour and 55 minutes. A review of the Direct Care Staff Daily Reports from 7/1/23 through 8/31/23 revealed the facility did not have sufficient CNA staff to meet the State minimum CNA to resident staffing…

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

Based on observation, interview, and record review it was determined the facility failed to ensure resident food preferences were honored for 1 of 1 facility reviewed. This place residents at risk for lack of honored preferences. Findings include: 1. On 2/5/24 at 4:10 PM Staff 18 (Social Service Assistant) stated he was working as the Dietary Manager for the past eight months until a few weeks ago. Staff 18 stated he was aware of residents' concerns related to not having food preferences honored. On 2/7/24 at 8:21 AM Staff 7 (CNA) served Resident 33's breakfast. Resident 33 stated that's not mine I never order scrambled eggs. Resident 33 stated this happened a lot and the kitchen did not give residents what they ordered. On 2/7/24 at 9:18 AM Staff 23 (Cook) was asked about how staff made her aware of residents' food preferences, if they had any residents who were vegetarian and what their process included. Staff 23 confirmed Resident 368's diet slip indicated she/he was a vegetarian. Staff 23 stated the kitchen did not have a good variety of vegetarian options and the resident was…

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

Based on observation, interview and record review it was determined the facility failed to implement consistent use of PPE in 2 of 5 halls and failed to perform hand hygiene when required while assisting dependent residents to eat in 1 of 2 dining rooms. This placed residents at risk for communicable diseases and spread of infection. Findings include: According to Oregon Health Authority Guidance staff caring for residents with suspect or confirmed COVID-19 are required to wear a fit-tested N95 respirator, eye protection, gown, and gloves. Public health may recommend unit-wide use of N95 and eye protection if facility is experiencing an outbreak to reduce the risk of transmission from asymptomatic or pre-symptomatic individuals. It may be appropriate to implement extended use of N95s and eye protection for the sequential care of a large volume of COVID-19 patients. Extended use should not be used when other organisms are present (e.g., multidrug-resistant organisms). Gowns and gloves are to be used for one resident, one encounter. Practice single use disposable PPE (one per 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.

Based on interview and record review it was determined the facility failed to notify the physician for a change of condition for 1 of 1 sampled resident (#33) reviewed for change of condition. This placed residents at risk for delayed treatment. Findings include: Resident 33 was admitted to the facility in 2017 with diagnoses including heart failure. A 11/19/23 Administration Note instructed staff to administer Lisinopril two times a day for high blood pressure and hold for heart rate under 50. The note indicated vitals were outside of parameters and medication was not administered and the nurse was aware. A review of Resident 33's vital summaries from 11/1/23 through 11/18/23 revealed the following: -Pulse Summary: ranged between 56 to 88 beats per minute. -Respiration Summary: ranged between 14 to 20 breaths per minute. -O2 (Oxygen levels) Summary: Oxygen level was checked on 11/7/23 and was 92 percent. -Blood Pressure Summary: ranged between 134 systolic and 68 diastolic and 168 systolic 56 diastolic. A review of Resident 33's vital summaries on11/19/23 revealed the following:…

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 interview and record review it was determined the facility failed to ensure a comprehensive care plan was developed for 1 of 6 sampled residents (#50) reviewed for vision and medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 50 was admitted to the facility in 2023 with a diagnosis of dementia. a. A 1/11/23 admission MDS and 1/24/24 Annual MDS and associated CAAs revealed Resident 50 had a visual impairment and it placed the resident at risk for falls, decline in ADLs, decline in cognitive function and pain. The CAAs indicated a care plan was to be developed to ensure the resident's vision did not negatively impact the resident. Resident 50's care plan last revised 1/17/24 did not include a focused area to address the resident's impaired vision. On 2/8/24 at 11:05 AM Staff 2 (DNS) acknowledged Resident 50 was assessed to be at risk for impaired vision but a care plan was not developed. Refer to F685. b. A 1/24/24 Annual MDS and associated CAAs revealed Resident 50 had dementia with behavior disturbances and was administered Seroquel…

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

Based on observation, interview and record review it was determined the facility failed to involve residents in the care planning process and revise care plan interventions for 3 of 10 sampled residents (#s 8, 50 and 168) reviewed for care plans, restraints and medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 8 was admitted to the facility in 2017 with diagnoses including paraplegia (inability to move the lower parts of the body) and UTI. A 2/23/23 Care Management note revealed Resident 8 was involved in her/his care plan discussion and staff were present to hear her/his concerns. On 2/5/24 at 12:25 PM Resident 8 stated staff did not routinely involve her/him in the discussion of her/his care. Resident 8 last recalled a discussion of her/his care plan concerns with staff in 2/2023. On 2/9/24 at 12:39 PM Staff 3 (Social Services Director) confirmed discussions with Resident 8 about her/his plan of care were not completed quarterly as requested. 2. Resident 50 was admitted to the facility in 2023 with diagnoses of a finger fracture 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 interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 3 sampled residents (#317) reviewed for ADLs. This placed resident at risk for lack of personal hygiene. Findings include: Resident 317 was admitted to the facility in 2022 with diagnoses including chronic pain and muscle weakness. A 7/6/22 care plan indicated Resident 317 required one staff to assist with her/his shower or bed bath three times a week at night. The 8/2023 Documentation Survey Report indicated Resident 317 received bathing once on 8/4/23 for the entire month. There was no documentation Resident 317 refused bathing services. On 2/6/24 at 10:54 AM Resident 317 stated she/he did not receive bathing as expected in 8/2023 and staff continued to state her/his lack of bathing was related to the facility's lack of staffing. On 2/8/24 at 12:50 PM Staff 28 (CNA) indicated she cared for Resident 317 often, confirmed in 8/2023 the facility was routinely short of staff and the morning shift was to offer bathing the next day if…

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

Based on observation, interview and record review it was determined the facility failed to assist in vision care needs for 1 of 3 sampled residents (#50) reviewed for vision. This placed residents at risk for a decline in leisure activities. Finding include: Resident 50 was admitted to the facility in 2023 with a diagnosis of Parkinson's disease. A 1/11/23 admission MDS and 1/24/24 Annual MDS and associated CAAs revealed Resident 50 had impaired vision and it placed the resident at risk for falls, a decline in ADLs and overall decline in health. The assessment indicated the resident did not wear glasses, had blurred vision and preferred dim lighting. The resident was assessed to have a good memory. The CAAs indicated visual function and status would be addressed in the care plan. Resident 50's care plan did not address her/his visual impairment, need for glasses or other factors which impacted the resident's quality of life or quality of care due to poor vision. On 2/5/24 at 1:23 PM Resident 50 stated she/he had glasses but they broke at the facility, and she/he needed glasses.…

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 interview and record review it was determined the facility failed to implement physician orders related to a pressure ulcer for 1 of 2 sampled residents (#8) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 8 was admitted to the facility in 2017 with diagnoses including paraplegia (inability to move the lower parts of the body) and UTI. A 5/22/23 revised care plan revealed Resident 8 was at risk for skin breakdown due to chronic right hip wound which opened periodically. A 5/31/23 physician order indicated Resident 8's air mattress should be monitored every shift and settings kept at 2. A 6/14/23 clinic wound healing assessment indicated Resident 8 was assessed for a Stage 3 (full thickness tissue loss) right ischial (large bone in the lower part of the hip) pressure injury and her/his air mattress appeared to be improperly inflated and could be a potential cause for Resident 8's wound deterioration. The 1/2024 and 2/2024 TARs did not indicate Resident 8's air mattress was monitored. On 2/8/24 at 3:34 PM…

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 it was determined the facility failed to provide a restorative program to prevent further decline in range of motion and to apply devices as ordered for 3 of 3 sampled residents (#s 17, 38, and 50) reviewed for ROM. This placed residents at risk for decline in their range of motion abilities. Findings include: 1. Resident 17 admitted to the facility in 2019 with diagnosis including contracture of the left hand. Physician orders signed 1/26/24 instructed staff to apply a left-hand splint in the evening and remove in the morning. A 1/2024 TAR instructed staff to apply a left-hand splint in the evening and remove in the morning. The following entries instructed the reader to review notes: -1/10/24 night shift. -1/13/24 night shift. -1/16/24 night shift -1/18/24 evening shift. -1/19/24 night shift. A review of Administration Notes for Resident 17's left hand splint from 1/13/24 through 1/20/24 revealed the following: -1/11/24 cannot locate. -1/14/24 splint not…

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 follow physician orders to maintain healthy parameters of nutritional status and monitor for weight loss for 2 of 4 residents (#s 24 and 61) reviewed for hydration and nutrition. This placed residents at risk for weight loss. Findings include: 1. Resident 24 was admitted to the facility in 2016 with diagnoses including dementia and depression. A 6/1/23 physician order indicated Resident 24 was to receive a supplement health shakes with each meal. A 6/5/23 care plan intervention for Resident 24's dementia indicated she/he was to receive one on one assistance with all meals. The Weight Summary for Resident 24 revealed the following: -6/1/23 -126.8 pounds -8/3/23 -128.8 pounds -9/1/23 -121 pounds -10/1/23 -120.6 pounds -1/4/23 -116.6 pounds The Documentation Survey Report revealed the following: -7/2023, Resident 24 received greater assistance than cueing (an indirect signal) to eat during 14 of 93 meals . -8/2023, Resident 24 received greater…

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 interview and record review it was determined the facility failed to address pharmacy recommendations for 1 of 5 sampled residents (#40) reviewed for medications. This placed residents at risk for ineffective medications and medication side effects. Findings include: Resident 40 was admitted to the facility in 2023 with diagnoses including PTSD and depression. On 12/1/23 the pharmacist recommended the facility complete an Abnormal Involuntary Movement Scale (AIMS) test to evaluate Resident 40 due to her/his use of antipsychotic medications. On 1/10/24 the pharmacist recommended the facility monitor the hours of sleep for Resident 40 due to the use of trazadone (antidepressant used for insomnia). There was no evidence in the clinical record an AIMS test was completed or the hours of sleep were monitored for Resident 40. On 2/9/24 at 12:31 PM Staff 2 (DNS) stated she could not locate an AIMS test and there was no information related to monitoring trazadone.

Based on interview and record review it was determined the facility failed to monitor the use of psychotropic medications for 1 of 5 sampled residents (#40) reviewed for medications. This placed residents at risk for ineffective medications and medication side effects. Findings include: Resident 40 was admitted to the facility in 2023 with diagnoses including PTSD and anxiety. A review of the 2/2023 MAR indicated Resident 40 received Seroquel (antipsychotic medication) and trazadone (antidepressant used to treat insomnia). There was no evidence in the clinical record an Abnormal Involuntary Movement Scale (AIMS) test was completed or the hours of sleep were monitored for Resident 40. On 2/9/24 at 12:31 PM the monitoring of antipsychotic and antidepressant medications was discussed with Staff 2 (DNS). Staff 2 stated she could not locate a completed AIMS test or monitoring for the effectiveness of trazadone.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The Life Care Centers of America Policy and Procedure: Lab Procedures and Diagnostics for Collecting a Stool Specimen dated 9/20/23 indicated the following: The facility will provide Collecting a Stool Specimen in accordance with professional standards of practice, as outlined by [NAME] through the procedure (helps nursing staff achieve clinical excellence, with access to the latest evidence-based clinical information). Because it it's possible to obtain stool specimens on demand, proper collection requires careful patient instructions to ensure an uncontaminated specimen. Special Considerations: Place stool specimens in a refrigerator used only for specimens. If testing for Clostridioides difficle (C. Diff), (a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon) that can be life-threatening, collect only diarrheal (unformed) stool unless you suspect ileus (decrease in flow of intestinal contents) due to infection. According to the CDC the C. Diff toxin is very unstable. The toxin…

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

Based on observation, interview, and record review it was determined the facility failed to ensure menus were followed for 2 of 5 sampled residents (#s 24 and 33) observed during dining observations. This placed residents at risk for lack of honored preferences and nutrition. Findings include: 1. Resident 33 was admitted to the facility in 2017 with diagnoses including heart failure. On 2/5/24 at 4:10 PM Staff 18 (Social Service Assistant) stated he was working as the Dietary Manager for the past eight months until a few weeks ago and was aware menus were not followed. On 2/7/24 at 8:21 AM Staff 7 (CNA) served Resident 33's breakfast. Resident 33 stated residents often did not receive what was on the menu. Resident 33 further stated she/he raised this concern during residential council, but nothing was ever resolved and staff continued to not follow the menu. On 2/8/24 at 11:30 AM a sample lunch tray was requested to include: country fried steak, cream gravy, mashed potatoes, confetti coleslaw, dinner roll, a chocolate chip bar, juice and a vegetarian option. Staff 19 (Cook) stated…

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

Based on observation, interview and record review it was determine the facility failed to ensure an ordered diet texture was provided as ordered for 1 of 3 sampled residents (#24) reviewed for nutrition. This placed residents at risk for unmet dietary needs. Findings include: The IDDSI (International Dysphasia Diet Standardization Initiative) for Easy to Chew texture indicated the following: -Do not provide fibrous foods. -Steak was to be avoided. -Make sure foods were soft enough to not regain its shape when pressed down firmly with a fork. Resident 24 admitted to the facility in 2017 with diagnoses including dementia and malnutrition. A 1/5/24 Speech Therapy Discharge Summary revealed Resident 24 required self-feeding with assistance due to dementia, and an Easy to Chew diet was recommended for the resident's safety. A 6/4/24 Nutrition: Quarterly Nutrition Data Collection indicated Resident 24 required assistance with meals. A 6/13/24 revised diet order for Resident 24 indicated she/he was to be provided Easy to Chew texture foods. A 6/25/24 revised care plan indicated Resident 24…

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 it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. On 11/29/22 at 10:17 AM Staff 7 (RN) stated that day was the first day she had two nurses on North Hall. On other days they were always short staffed on day and evening shifts and most weekends. Staff 7 stated she was unable to complete all of her daily assignments including: administering medications for 29 residents. Staff 7 stated she was not sure if or how often she made mistakes when passing medications due to being rushed and understaffed, and not always able to provide wound care treatments and complete charting for each shift. Staff 7 stated almost every other day she had to pass wound care treatments off to evening shift. Staff 7 stated she was not able to take breaks, administration was aware and did not provide support and told her she should…

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 interview and record review it was determined the facility failed to ensure the DCSDR (Direct Care Staff Daily Reports) were complete for 12 of 18 days reviewed for staffing. This placed residents and visitors at risk for lack of staffing information. Findings include: A review of DCSDRs from 1/11/23 through 1/29/23 revealed the following: -1/11/23 no census documented for evening shift. -1/12/23 no census documented for evening and night shift. -1/13/23 no census documented for night shift. -1/14/23 no census documented for night shift. -1/15/23 no census documented for day and evening shift. -1/16/23 no census documented for day and evening shift. -1/17/23 no census documented for evening shift. -1/20/23 no hours documented for CNAs day shift. -1/21/23 no census documented for day and evening shift. -1/22/23 no census documented for day and evening shift. -1/24/23 no census documented for evening shift. -1/27/23 no census documented for day shift. -1/28/23 no census documented for evening shift. On 2/1/23 at 9:30 AM Staff 1 (Administrator) confirmed the DCSDRs were…

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 it was determined the facility failed to maintain adequate room temperatures and clean and sanitary conditions on 2 of 2 halls (North and South) reviewed for environment. This placed residents at risk for lack of a clean and comfortable environment. Findings include: 1. During interviews with residents from 11/28/22 through 12/7/22 Residents 8, 31, 49 and 159 expressed concerns related to the building being too cold. Resident Council minutes from 9/2022, 10/2022 and 11/2022 contained concerns related to the temperature in the building being too cold. The 11/2022 meeting included residents felt the facility was warmer that week because the state surveyors were in the facility. On 11/30/22 at 11:45 AM Staff 9 (Director of Maintenance) stated he checked temperatures daily at the thermostats. The building heat fluctuated because it was an old building with older heating units. The thermostats were locked but some people are taking off the locks. The windows were 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.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 4 of 4 sampled CNA staff (#s 14, 15, 16 and 19) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include: On 12/6/22 at 9:50 AM Staff 1 (Administrator) provided the most recent performance reviews for Staff 14 (CNA), Staff 15 (CNA), Staff 16 (CNA) and Staff 19 (CNA). - Staff 14 was hired on 1/30/07, the provided performance review was dated 2/12/20 - Staff 15 was hired on 6/22/21, the facility was unable to provide a performance review - Staff 16 was hired on 3/10/2015, the provided performance review was dated 2/28/20 - Staff 19 was hired on 3/26/14, the provided performance review was dated 6/15/16 On 12/6/22 at 11:32 AM Staff 1 acknowledged the performance evaluations were not completed annually for Staff 14, Staff 15, Staff 16 and Staff 19.

Based on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than 5%. There were 34 medication administration opportunities with 4 errors. The medication error rate was 11.76%. This placed residents at risk for decreased medication efficacy and/or adverse side effects. Findings include: Resident 11 admitted to the facility in 10/2021 with diagnoses including atrial fibrillation (irregular heart rate) and GERD (gastrointestinal reflux disease). Physician orders dated 10/19/21 and 12/16/21 indicated: omeprazole (to treat acid reflux) delayed release, magnesium oxide (supplement), vitamin D (supplement) and Seroquel (antipsychotic). On 12/6/22 at 10:06 AM Staff 31 (CMA) was observed to crush all medications, place them into applesauce and administer them to Resident 11. Resident 11 chewed the applesauce mixture. According to the Nursing Drug Handbook 2022 edition, omeprazole, magnesium oxide, vitamin D and Seroquel should not be crushed or chewed. On 12/06/22 at 10:30 AM Staff 31 was notified of the medication…

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 it was determined the facility failed to properly store and monitor food in 1 of 2 resident refrigerators and provide a clean exhaust hood for 1 of 1 kitchen. This placed residents at risk for an unclean preparation area and foodborne illness. Findings include: 1. On 11/30/22 at 12:02 PM the kitchen exhaust hood was observed with dark residue on the removable panels and dark sticky residue around the lip of the hood. A label with the date of 1/2022 was observed on the exhaust hood. Weekly Cleaning logs provided for 9/2022 and 11/2022 revealed no signature for the task of hood filters. No additional weekly documentation for cleaning of the hood filter during the last three months was provided. On 11/30/22 at 12:03 PM Staff 6 (Food Service Director) confirmed staff did not clean the removable panels and the exhaust hood was last cleaned when it was serviced in 1/2022. On 11/30/22 at 1:17 PM Staff 1 (Administrator) acknowledged the exhaust hood cleanliness was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 3 of 4 randomly selected staff members (#s 15, 16 and 19) reviewed for evidence of in-service training. This placed residents at risk for lack of competent staff. Findings include: On [DATE] at 9:50 AM Staff 1 (Administrator) provided the last 18 months of all completed training and in-services for Staff 15 (CNA), Staff 16 (CNA) and Staff 19 (CNA): - Staff 15 completed one in-service training, infection control - Staff 16 completed one in-service training, CPR - Staff 19 completed one in-service training, CPR On [DATE] at 11:32 AM Staff 1 acknowledged the required 12 hours of annual in-service training was not completed for Staff 15, Staff 16 and Staff 19.

Based on observation, interview and record review it was determined the facility failed to ensure care was provided in a manner that maintained and promoted dignity for 1 of 1 sampled resident (#20) reviewed for dignity. This placed residents at risk for receiving care that did not promote their dignity. Findings include: Resident 20 was admitted to the facility in 6/2022 with diagnoses including muscle weakness and chronic pain. Resident 20's care plan dated 7/6/22 indicated Resident 20 required one person assistance for ADLs, used a mechanical lift for transfers and required two staff for toileting. On 12/1/22 from 1:36 PM through 2:15 PM Resident 20's call light was observed activated. Staff were in the hall but did not answer the call light. On 11/30/22 at 11:36 AM Resident 20 stated she/he moved slow due to deficits in ROM. Resident 20 stated when staff bust in my room and try to take care of me quickly without treating me like a human, I feel humiliated and not treated with dignity. Staff treat me like an object, they are here for a paycheck. On 12/2/22 at 11:17 AM Staff 7…

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 interview and record review it was determined the facility failed to ensure residents were included in care planning for 1 of 2 sampled residents (#20) reviewed for care planning. This placed residents at risk for not being involved in the care planning process. Findings include: Resident 20 was admitted to the facility in 6/2022 with diagnoses including muscle weakness. On 11/30/22 at 9:33 AM Resident 20 stated she/he did not have a care conference and was not offered a copy of her/his care plan. Resident 20 stated she/he wanted to contribute to her/his care plan so her/his care would be consistent and accurate. On 12/5/22 at 12:33 PM Staff 2 (DNS) stated Resident 20 did not have a welcome care conference and was not given a copy of her/his care plan.

Based on interview and record review it was determined the facility failed to ensure preferences were honored for 1 of 1 sampled resident (#30) reviewed for choices. This placed residents at risk for lack of support for preferences. Findings include: Resident 30 was admitted to the facility in 4/2018 with diagnoses including visual loss and hypertension (high blood pressure). The 9/26/22 revised care plan revealed Resident 30 required one person to assist with bathing and staff were to encourage the resident to make her/his own decisions. Resident 30's 30 day ADL Task revealed showers were to be provided every Monday and Friday evening and from 10/18/22 through 11/18/22 and during this time one bed bath was received. No additional bathing was provided. On 11/28/22 at 1:16 PM Resident 30 stated staff only offered showers when she/he preferred bed baths during the day because she/he got cold in the evenings. Resident 30 confirmed she/he often refused bathing as a result. On 11/30/22 at 12:17 PM Staff 14 (CNA) stated she was aware Resident 30 preferred bed baths but did not inquire…

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 interview and record review it was determined the facility failed to ensure residents were free from verbal and physical abuse for 1 of 3 sampled residents (#52) reviewed for abuse. This placed resident at risk for abuse. Findings include: Resident #52 admitted to the facility in 8/2022 with diagnoses including stroke with hemiplegia (paralysis of one side of the body), anxiety and major depressive disorder. On 8/18/22 at 10:13 AM Adult Protective Services (APS) called in a complaint to the state agency related to an incident which occurred on 8/7/22 at the facility. Staff 13 (CNA) took Resident 52 out to the smoking area. Staff 13 told Staff 16 (CNA) and Staff 48 (CNA) they were going outside and would need assistance to get back into the building. At approximately 9:45 PM the resident's ex-partner approached the smoking area from the street and began an altercation with the resident. The ex-partner approached the resident with a raised fist and was yelling, swearing and threatening the resident. The ex-partner hit the hat off the resident's head and grabbed cigarettes…

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 interview and record review it was determined the facility failed to report potential abuse to the state agency for 1 of 3 sampled residents (#52) reviewed for abuse. This placed resident at risk for abuse. Findings include: Resident #52 was admitted to the facility in 8/2022 with diagnoses including stroke with hemiplegia (paralysis of one side of the body), anxiety and major depressive disorder. On 8/18/22 at 10:13 AM Adult Protective Services (APS) called in a complaint to the state agency related to an incident which occurred on 8/7/22 at the facility. Staff 13 (CNA) took Resident 52 out to the smoking area. Staff 13 told Staff 16 (CNA) and Staff 48 (CNA) they were going outside and would need assistance to get back into the building. At approximately 9:45 PM the resident's ex-partner approached the smoking area from the street and began an altercation with the resident. The ex-partner approached the resident with a raised fist and was yelling, swearing and threatening the resident. The ex-partner hit the hat off the resident's head and grabbed cigarettes from 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 interview and record review it was determined the facility failed to complete thorough investigations related to abuse for 3 of 3 sampled residents (#s 19, 43 and 52) reviewed for abuse investigations. This placed residents at risk for abuse. Findings include: 1. Resident 19 was admitted to the facility in 8/2022 with diagnoses including dementia and frequent falls. An Incident Report dated 9/1/22 at 3:00 PM indicated a CNA assisted the resident to the floor after the resident attempted to transfer from the toilet back to the wheelchair. The resident grabbed the bathroom bar but her/his foot would not move so the resident was gently lowered to the floor since she/he could not transfer back to the wheelchair. No injuries were noted. The report included information that Resident 19 had a history of repeated falls, cognitive deficits and dementia. An Incident Report dated 9/21/22 indicated Resident 19 was complaining of pain from below the knee to the ankle on the right side. The resident was requesting an x-ray. The resident was refusing to work with therapy due to the pain.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to accurately code assessments for skin conditions and mood and behaviors for 3 of 11 sampled residents (#s 7, 26 and 42) reviewed for nutrition, pain and ADLs. This placed residents at risk for inaccurate assessments. Findings include: 1. Resident 42 was admitted to the facility on [DATE] with diagnoses including diabetic ulcer and diabetes. The 10/21/22 Quarterly MDS indicated Resident 42 did not have a diabetic foot ulcer. The 10/19/22 Wound Evaluation indicated Resident 42 had a diabetic foot ulcer on her/his left heel. On 12/5/22 at 3:20 PM Staff 12 (Regional RN) stated Resident 42's Quarterly MDS assessment should have identified her/his diabetic foot ulcer. 2. Resident 7 admitted to the facility in 2022 with diagnoses including Alzheimer's disease. A 7/20/22 Annual MDS indicated Resident 7 was rarely or never understood and the BIMS was completed by staff for Section C. Resident 7's 10/26/22 care plan indicated the following: -…

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 interview and record review it was determined the facility failed to develop and implement comprehensive care plans for 3 of 6 sampled residents (#s 14, 18 and 54) reviewed for accidents, behavior, and pressure injury. This placed residents at risk for unmet needs. Findings include: 1a. Resident 18 was admitted to the facility in 9/2019 with diagnoses including depression and adult failure to thrive. The 12/4/19 depression care plan indicated Resident 18 exhibited sad/tearful and frequently apologizing. On 3/3/22 interventions were revised and indicated staff to anticipate resident needs and provide education on effective coping strategies. The 8/22/22 Annual MDS cognitive loss dementia CAA indicated Resident 18 had mild depression, lost interest in prior activities and reported feeling bad about her/himself. The resident stated she/he had occasional thoughts of being better off dead. The 8/22/22 Annual MDS activity and mood CAA indicated Resident 18 reported depression regularly over the past 15 months. Resident 18's mood fluctuated, and she/he often apologized for 'being…

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 interview and record review it was determined the facility failed to revise care plans for 2 of 3 sampled residents (#s 16 and 42) reviewed for care planning and hospitalization. This placed residents at risk for unmet needs. Findings include 1. Resident 16 was admitted to the facility in 10/2012 with diagnoses including stroke. On 11/13/22 Resident 16 had an unwitnessed fall from the toilet. The current care plan indicated the resident required moderate assistance by one staff for toileting. No information was found in the care plan related to Resident 16's fall on 11/13/22. On 12/5/22 at 12:29 PM Staff 3 (LPN-Unit Manager) confirmed Resident 16's care plan was not revised after her/his fall. 2. Resident 42 was admitted to the facility in 4/2022 after hospitalization for a major infection that resulted in a below the knee amputation. An 4/14/22 Late Entry Physician Note indicated Resident 42 was re-admitted after hospitalization for staphylococcal (skin infection), blood clot and suicide attempt while in the hospital. The 5/25/22 psychosocial care plan goal indicated…

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

Based on observation, interview and record review it was determined the facility failed to provide showers and personal hygiene for dependent residents for 2 of 6 sampled residents (#s 36 and 40) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: 1. Resident 40 was admitted to the facility in 3/2022 with diagnoses including repeat falls and depression. The 7/2022 Documentation Survey Report revealed Resident 40 received three of eight scheduled baths during the month. The 7/5/22 Quarterly MDS revealed Resident 40 required one person assist for personal hygiene and bathing. The current bedside care plan revealed Resident 40 was to receive bathing on Wednesday and Sunday evenings. There was no indication of shaving care needs for Resident 40. On 11/29/22 at 8:50 AM Resident 40 was observed with gray chin whiskers approximately two inches long. Resident 40 stated she/he was not able to use her/his dominate hand to shave without staff assistance and the whiskers were unbecoming. Resident 40 stated bathing support was especially bad on weekends and lack…

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

Based on observation, interview and record review it was determined the facility failed to monitor edema for 1 of 1 sampled resident (#16) reviewed for oxygen. This placed residents at risk for unmet needs. Findings include: Resident 16 was admitted to the facility in 10/2022 with diagnoses including altered mental status and falls. A physician's order dated 1/14/22 indicated staff were to elevate Resident 16's legs throughout the day. Observations from 11/28/22 through 12/1/22 on day and evening shifts revealed Resident 16 sat in her/his wheelchair with edema to both feet, and her/his legs were not elevated. Resident 16 had her/his shoes on her/his lap and stated her/his edema had become worse. Resident 16 stated the edema made the neuropathy (pain from nerve damage) in her/his feet painful and staff were not addressing this. On 12/5/22 at 12:04 PM Staff 2 (DNS) stated the physician's order indicated staff were to elevate the resident's legs throughout the day. Staff 2 stated the resident did not have compression stockings, wraps for her/his feet and was not on a diuretic. Staff 2…

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 it was determined the facility failed to ensure skin and wounds were accurately and routinely assessed for healing for 2 of 4 sampled residents (#s 18 and 260) reviewed for pressure ulcers. This placed residents at risk for new and worsening pressure ulcers. Findings include: The 2019 National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide indicated the following recommendations regarding pressure ulcer assessment: - Document the results of all wound assessments. - Assess and document physical characteristics including location, category/stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. - Select a uniform, consistent method for measuring wound length, width, depth or wound area to facilitate meaningful comparisons of wound measurements across time. - Ensure pressure ulcers are correctly differentiated from other skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to provide adequate foot care for 3 of 5 sampled residents (#s 26, 42 and 47) reviewed for ADLs. This placed residents at risk for increased foot problems. Findings include: 1. Resident 47 was admitted to the facility in 11/2022 with diagnoses including diabetes and stroke. On 11/29/22 at 10:24 AM Witness 5 (Emergency Contact) stated she visited the resident regularly. Witness 5 said initially the facility took good care of the resident and kept her/him clean and groomed. However, the last few times she was in the facility the resident was dirty and soiled. The staff were not taking care of the resident's feet or toenails. The resident's feet had very flaky skin and her/his toenails were not trimmed. The resident had skin tears on her/his shins and ankles and it looked like the toe nails may have torn open the skin. On 12/1/11 at 12:00 PM an observation of Resident 47's feet was conducted. The resident had multiple scabs on…

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

Based on observation, interview and record reviewed it was determined the facility failed to provide ROM services for 3 of 3 sampled residents (#s 23, 43 and 40) reviewed for ROM. This placed residents at risk for decreased ROM. Finding include: 1. Resident 23 was admitted to the facility in 4/2019 with diagnoses including stroke and muscle weakness. The 6/3/20 ADL care plan indicated staff were to provide ROM one to five times a week to lower upper extremities, fingers, wrist, elbow and shoulder. Staff were to provide ROM one to two times a week to lower leg extremities. The Restorative Nursing Program Plan was last revised 9/14/20. An 10/19/22 Restorative Nursing Communication Tool revealed Resident 43 was to receive ROM services one to four times each week to increase lower extremity strength and coordination. The 11/2022 Restorative Record indicated Resident 23 was unable to receive ROM two days of the month. No additional documentation was provided. The 12/1/22 Quarterly MDS revealed Resident 23 had upper and lower extremity impairment and the resident did not receive ROM…

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 interview and record review it was determined the facility failed to ensure care planned interventions and facility smoking policies were followed, and investigations were thorough for 3 of 4 sampled residents (#s 16, 40 and 54) reviewed for accidents. This placed residents at risk for injuries. Finding include: 1. Resident 16 was admitted to the facility in 10/2012 with diagnoses including stroke and difficulty walking. Review of the 3/14/20 care plan indicated the resident was at risk for falls due to stroke with right sided deficits, deconditioning, gait and balance problems, weakness, pain and history of falls. The resident had potential for falls related to cognitive loss, altered safety awareness and history of falls. The interventions were to anticipate and meet the resident's needs, assist with ADLs and place the call light button within reach. Review of a 11/13/22 fall incident report indicated the resident was heard screaming and staff ran into her/his room to find the resident fell off of the toilet hitting the right side of her/his head on a transfer pole and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident 162 was admitted to the facility in 6/2022 with diagnoses including chronic heart failure, kidney disease and COVID-19. On [DATE] at 9:49 AM a Communication with Physician included the following: Situation: The resident's oxygen (O2) saturation (sat) was 69 percent on two liters via nasal cannula. Background: The resident with active COVID-19. Assessment (RN)/Appearance (LPN): Resident was lying flat and coughing when O2 sat was 69%. This LN raised head up to 90 degrees and increased O2 to 3L. O2 sat increased to 72%. O2 was then increased to 4L and resident's O2 sat increased to 80%. O2 was then increased to 5L and resident began to sat between 93-95%. Resident's lungs continue to be congested with adventitious lung sounds noted in all lobes. Resident has no orders for medications to assist with breathing. On [DATE] at 2:59 PM an Orders Administration Note indicated: Oxygen at two liters per minute continuously via nasal cannula. Resident increased to five liters per minute related to oxygen…

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

Based on observation, interview and record review it was determined the facility failed to manage residents' pain for 1 of 2 sampled residents (#43) reviewed for pain. This placed residents at risk for unmanaged pain. Findings include: Resident 43 was admitted to the facility in 6/2022 with diagnoses including three Stage 4 pressure ulcers (full tissue loss) chronic pain and muscle weakness. The 6/23/22 Admission/readmission Skin Assessment indicated Resident 43 admitted from the hospital with three open area/wounds on her/his buttocks. The wounds were dry, intact, and bandages were changed by the wound nurse at the hospital. The resident complained her/his pain was a 7/10 and stated the Oxycodone (narcotic pain medication) was ineffective. The 6/23/22 care plan indicated Resident 43 had sacral pain that was not controlled with current pain medications. A 6/25/22 Physician Note indicated Resident 43 had pelvic pain. Pain medication during wound care was not enough and there was an absolute need for pain clinic referral. The 6/29/22 admission MDS indicated Resident 43 was alert 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 interview and record review it was determined the facility failed to ensure a resident was not given psychotropic medications without an appropriate diagnoses and adequate monitoring for 1 of 5 sampled residents (#42) reviewed for medications. This placed residents at risk for receiving unnecessary medications. Findings include: Resident 42 admitted to the facility in 10/2019 with diagnoses including depression. A 5/23/22 physician's order indicated staff were to administer trazodone (antidepressant medication) PRN for insomnia. A 9/13/22 Pharmacy Consultation note indicated Resident 42's trazodone PRN had no stop date. A 9/15/22 Pharmacy note indicated Resident 42 required PRN trazodone nightly to promote quality of life and it was PRN so that she/he may determine when she/he wanted to retire to bed. A 11/7/22 Pharmacy Consultation note repeated a 10/16/22 recommendation to discontinue the order for PRN trazodone with no stop date. On 11/16/22 the Physician indicated Resident 42 had trouble sleeping due to anxiety and would reassess the need for trazodone. A 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.

Based on observation, interview and record review it was determined the facility failed to ensure an effective system for resident food preferences for 1 of 2 sampled residents (#40) reviewed for food . This placed residents at risk for meal prefererences not being honored. Findings include: Resident 40 was admitted to the facility in 3/2022 with diagnoses including repeat falls and depression. A 7/12/22 Quarterly Nutrition Review revealed Resident 40's goal for weight maintenance with gradual weight reduction was acceptable. Resident 40's clinical record revealed no indication of food preferences. The 10/7/22 Resident Council Minutes revealed resident concerns related to food preferences that were not followed and lack of menu variety. On 11/29/22 at 9:22 AM Resident 40 stated she/he spoke to someone on admission related to her meal preferences but there was no follow through after the initial conversation. Resident 40 indicated she/he was concerned about healthy food alternatives and limited information was available regarding menu alternatives. On 11/30/22 at 11:08 AM and 12:49…

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.