Blue Mountain Care Center

Based on interview and record review it was determined the facility failed to ensure long term residents received physician visits every 90 days for 3 of 4 sampled residents (#s 1, 8 and 11) reviewed for unnecessary medications and nutrition. This placed residents at risk for unassessed needs. Findings include:1. Resident 1 admitted to the facility in 8/2023 with diagnoses including dementia and muscle weakness. A review of the clinical record indicated Resident 1 received telehealth (virtual, not in-person) physician visits and the last in-person physician visit was on 2/18/25. On 10/15/25 at 9:16 AM Staff 13 (Former Administrator) stated physician visits were completed via telehealth. On 10/16/25 at 9:16 AM Staff 1 (Administrator) stated she believed only telehealth physician visits were acceptable. Staff 1 acknowledged Resident 1's last face to face physician visit was on 2/18/25. 2. Resident 8 admitted to the facility in 11/2024 with diagnoses including dementia and hypertension. A review of the clinical record indicated Resident 8 received telehealth physician visits and 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 inform residents and/or resident's responsible party of the risks and benefits, and to ensure consent was obtained, for the use of psychotropic medications for 1 of 5 sampled residents (#6) reviewed for unnecessary medications. This placed residents at risk for lack of informed consent of psychotropic medications. Findings include:Resident 6 admitted to the facility in 2025 with diagnoses including depression and insomnia.An 8/19/25 and 9/25/25 physician order indicated the following medications to be administered to Resident 6:- Trazadone (antidepressant) for insomnia- Sertraline (antidepressant) for depression- Bupropion ((antidepressant) for depressionA review of the clinical record revealed no indication the risks and benefits of the antidepressant medication was reviewed, or consent was obtained from Resident 6.On 10/15/25 at 12:00PM Staff 1 (Administrator) stated she was unable to locate any information to indicate the risks and benefits was reviewed, or a consent was obtained by Resident 6, for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to offer the resident/representative the opportunity to participate in the care planning process for 4 of 5 sampled residents (#s 3, 5, 6 and 13) reviewed for care planning. These failures placed residents at risk for lack of knowledge and input for the care planning process. Findings include:1. Resident 5 admitted to the facility on [DATE] with diagnoses including diabetes. Review of Resident 5's clinical record revealed no indication a care conference was offered or completed since admission. On 10/15/25 at 1:35 PM Resident 5 stated she/he had never had a care conference to review her/his care plan and was interested in having a care conference if it was offered. On 10/16/25 at 2:07 PM Staff 4 (Social Services) stated she was unable to locate in the clinical records any indication care conferences were completed to review a residents' care plan. Staff 4 stated there was no process in place to involve residents in their plan of care. Staff 4…

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 an allegation of abuse to the State Agency (SA) within the mandated timeframe for 1 of 1 sampled resident (#10) reviewed for abuse. This placed residents at risk for abuse. Findings include:Resident 10 admitted to the facility in 2/2021 with diagnoses including stroke and weakness.The 7/28/25 Quarterly MDS indicated Resident 10 had a BIMS of 15, which indicated she/he was cognitively intact.On 10/16/25 between 10:50 AM and 11:16 AM Witness 1 (Anonymous Staff), Witness 2 (Anonymous Staff) and Witness 3 (Anonymous Staff) indicated there were concerns when Staff 12 (LPN) locked the door when Resident 10 went out of the facility and did not allow her/him to re-enter the building. Witness 3 stated Staff 12 told Resident 10, You are not the most important resident here. We can't stop what we are doing and open the door. Witness 3 indicated Resident 10 started crying, and the incident was reported to Staff 2 (DNS).On 10/16/25 at 11:07 AM Resident 10 stated about a month ago Staff 12 was working night shift…

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 thoroughly investigate allegations of abuse for 1 of 1 sampled resident (#10) reviewed for abuse. This placed residents at risk for abuse. Findings include:Resident 10 admitted to the facility in 2/2021 with diagnoses including stroke and weakness.The 7/28/25 Quarterly MDS indicated Resident 10 had a BIMS of 15, which indicated she/he was cognitively intact.On 10/16/25 between 10:50 AM and 11:16 AM Witness 1 (Anonymous Staff), Witness 2 (Anonymous Staff) and Witness 3 (Anonymous Staff) indicated there were concerns when Staff 12 (LPN) locked the door when Resident 10 went out of the facility and did not allow her/him to re-enter the building. Witness 3 stated Staff 12 told Resident 10, You are not the most important resident here. We can't stop what we are doing and open the door. Resident 10 started crying and the incident was reported to Staff 2 (DNS).On 10/16/25 at 11:07 AM Resident 10 stated about a month ago Staff 12 was working night shift and when the resident left the facility at 4:40 AM, Staff 12…

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 expired biologicals were discarded and temperatures of medication refrigerators were monitored for 1 of 1 treatment cart and 1 of 1 medication room reviewed for medication storage. This placed residents at risk for reduced efficacy of medication. Findings include:1. On [DATE] at 1:56 PM Staff 3 (LPN) was observed to prepare Humalog insulin for Resident 11. The open date was [DATE]. The manufacturer's instructions indicated the medication was to be discarded 28 days after opening.On [DATE] at 1:56 PM Staff 3 acknowledged the Humalog was expired and was not discarded 28 days after opening.2. On [DATE] at 2:09 PM the medication refrigerator logs were reviewed with Staff 3 (LPN). There were no recorded temperatures for [DATE] or [DATE]. The medication refrigerator was observed to contain insulin and medications.On [DATE] at 2:09 PM Staff 3 stated night shift was responsible for completing the temperature logs and 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 ensure routine dental services were provided for 1 of 2 sampled residents (#3) reviewed for dental care needs. This placed residents at risk for unmet dental needs. Findings include:Resident 3 admitted to the facility in 9/2024 with diagnoses including heart failure.On 10/14/25 at 9:27 AM Resident 3 stated it had been one year since she/he had a dentist appointment and there were issues finding a dentist that accommodated residents who required wheelchairs.No evidence was found in the clinical record to indicate a dental appointment was made since the resident's admission.On 10/16/25 at 2:08 PM Staff 4 (Social Services) stated she started at the end of September 2025 and was just now learning what her role was supposed to be. She stated she was not involved in dental services and provided no additional information regarding when Resident 3's dental status was reviewed.

Based on interview and record review it was determined the facility failed to provide dental services for 1 of 2 sampled residents (#12) reviewed for dental services. This placed residents at risk for unmet dental needs. Findings include:Resident 12 admitted to the facility in 2015 with diagnoses including heart failure and diabetes.A review of the 7/28/25 Quarterly MDS indicated Resident 12's BIMS score was a four, indicating severe cognition impairment.On 10/14/25 at 9:40 AM Witness 5 (Family) stated she was involved in Resident 12's care at the facility. Witness 5 stated Resident 12 had three natural teeth remaining and did not receive routine dental cleaning in the past year. Witness 5 stated she wanted Resident 12 to receive routine dental cleanings.No evidence was found in the clinical record regarding Resident 12's dental cleaning history.On 10/16/25 at 2:08 PM Staff 4 (Social Services) stated she started at the end of September 2025 and was just now learning what her role was supposed to be. She stated she was not involved in dental services and provided no additional…

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 provide therapy services for 1 of 1 sampled resident (#1) reviewed for nutrition. This placed residents at risk for functional decline. Findings include:Resident 1 admitted to the facility in 8/2023 with diagnoses including dementia and muscle weakness.A review of the 9/12/25 Annual MDS indicated Resident 1's BIMS score was a four, indicating severe cognition impairment. The MDS also indicated Resident 1 had swallowing issues including loss of liquids and/or solids from the mouth when eating and/or drinking along with coughing or choking during meals.A review of the 7/29/25 Nutrition at Risk (NAR) notes revealed concerns for increased risk of choking. The notes indicated Resident 1 was waiting for insurance authorization for a SLP evaluation. A review of the 8/7/25 Tele-Health Physician Provider Note revealed the resident had a recent diagnosis of lung cancer, was experiencing dysphagia and weight loss, and was awaiting a SLP evaluation.A review of the 8/28/25 Tele-Health Physician Provider Note revealed 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 interview and record review it was determined the facility failed to notify hospice services of the resident's death in a timely manner for 1 of 1 sampled resident (#16) reviewed for hospice. This placed residents at risk for a lack of coordination of care upon death. Findings include: A review of the facility [DATE] Hospice Services Policy and Procedure revealed the following:- Blue Mountain Care Center (BMCC) will coordinate with the State Recognized Hospice Program to provide support to terminally ill residents (and their families) that resides in the facility.- Hospice and BMCC will communicate with each other when any changes are indicated to the Plan of Care.- The Plan of Care will be consistent with the Hospice philosophy of care.-BMCC will comply with the hospice policies and procedures.On [DATE] a public complaint was received by the State Agency which alleged the facility failed to notify hospice services of Resident 16's death in a timely manner. Resident 16 was admitted to the facility 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 review it was determined the facility failed to maintain a medication error rate of less than five percent. There were five errors in 26 opportunities resulting in a 19 percent error rate. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 164 admitted to the facility in 8/2024 with diagnoses including diabetes. The 6/5/24 physician order indicated Resident 164 was to receive Novolin R (insulin) seven units before meals. The manufacturer instructions for Novolin R indicated to prime the insulin pen with two units prior to drawing up the insulin for administration. On 8/13/24 at 12:18 PM Staff 4 (RN) was observed to administer seven units of Novolin R via insulin pen to Resident 164. Staff 4 did not prime the insulin pen with two units prior to drawing up the insulin for administration. On 8/13/24 at 12:55 PM Staff 4 acknowledged she did not prime the insulin pen prior to administration and stated she was not aware the Novolin R insulin pen needed to be primed. 2. Resident 8 readmitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure professional standards were followed for 1 of 1 RN (Staff 2) reviewed for medications and pressure ulcers. This placed residents at risk for adverse medication reactions and worsening of wounds. Findings include: The Oregon State Board of Nursing Scope of Practice Standards for Registered Nurses (OAR [PHONE NUMBER]) outlined standards related to the Registered Nurse's responsibility for nursing practice implementation. Applying nursing knowledge . the Registered Nurse shall implement the plan of care by: - Implementing treatments and therapy, appropriate to the context of care, including emergency measures, interpretation of medical orders, medication administration, independent nursing activities, nursing, medical and interdisciplinary orders, health teaching and health counseling; - Documenting nursing interventions and responses to care in an accurate, timely, thorough, and clear manner. The Oregon State Board of Nursing…

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 nail care to dependent residents for 2 of 2 sample residents (#s 10 and 11) reviewed for ADLs. This placed residents at risk for lack of grooming and skin impairments. Findings include: 1. Resident 10 admitted to the facility in 2021 with diagnoses including kidney disease. The 7/26/21 Care Plan indicated Resident 10 required ADL assistance by staff for personal hygiene. Review of Resident 10's clinical medical record revealed no documented evidence for when the resident's nail care was to be provided. Observations made on 8/13/24 at 9:20 AM and on 8/14/24 at 9:30 AM revealed Resident 10 with long fingernails. Some of the fingernails were curved down, touching the nail bed. Resident 10 was unable to state when her/his fingernails were last trimmed. On 8/14/24 at 9:24 AM Staff 6 (CNA) stated resident nail care was to be done on shower days and as needed. Staff 6 stated nail care was documented in Tasks under personal hygiene and there was no specific place to document when nail care…

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 implement physician orders upon admission for 1 of 1 sampled residents (#164) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: Resident 164 re-admitted to the facility on [DATE] with diagnoses including post-surgical care for a toe amputation. The 8/2/24 hospital discharge orders indicated Resident 164 was to receive the following medications: -doxycycline (an antibiotic medication) 100 mg; 1 tablet BID. 8/3/24 PM dose was missed. -losartan (a hypertension medication) 25 mg; 1 tablet BID. 8/3/24 PM dose was missed. -pravastatin (a cholesterol medication) 40 mg; 1 tablet one time a day. 8/3/24 dose was missed. The MAR and 8/3/24 progress note indicated Resident 164 did not receive one dose of doxycycline, one dose of losartan, and one dose of pravastatin. An 8/3/24 at 4:58 PM progress note revealed Staff 5 (RN) was unable to resume many meds and documented in the progress note…

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 initially assess and monitor pressure ulcers for 2 of 2 sampled residents (#s 6 and 8) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers and unassessed treatment needs. Findings include: 1. Resident 8 admitted to the facility on 5/2024 with diagnoses including diabetes and a sacral fracture. The 5/20/24 admission Nursing Database indicated Resident 8 did not have any wounds present. The 5/20/24 care plan indicated the resident had a potential impairment to skin integrity related to diabetes and fragile skin. Interventions included to encourage and assist resident to change positions frequently; notify nurse of new skin issues; and follow facility protocols for treatment of injury. The 8/2024 TAR revealed the facility implemented a standing order for wound care on 8/10/24 for a wound to Resident 8's left buttock. The 8/11/24 at 4:36 AM progress note indicated wound care was completed to an open area on Resident 8's left buttock. It was noted there was no drainage, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to obtain ordered medications timely for 2 of 6 sampled residents (#s 1 and 7) reviewed for medications. This placed residents at risk for not receiving prescribed medications. Findings include: 1. Resident 1 admitted to the facility in 2018 with diagnoses including chronic kidney disease. The 8/9/24 physician order indicated Resident 1 had a UTI and to start Keflex (antibiotic) 500 mg TID for seven days. The 8/2024 MAR indicated Resident 1 did not receive Keflex on the following dates and times: -8/10/24 8:00 PM -8/11/24 7:00 AM -8/11/24 12:00 PM -8/11/24 8:00 PM -8/12/24 7:00 AM -8/12/24 12:00 PM On 8/15/24 at 12:29 PM Staff 2 (DNS) acknowledged Resident 1 did not receive Keflex as ordered on the identified dates. Staff 2 was observed to check the electronic medication dispensing system for availability of Keflex and stated he was unsure of how to check for inventory and availability of medication. Staff 2 stated he thought 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 address pharmacist recommendations in a timely manner for 3 of 5 sampled residents (#s 6, 8 and 12) reviewed for unnecessary medications. This placed residents at risk for unnecessary medication administration. Findings include: 1. Resident 8 admitted to the facility on 5/2024 with diagnoses including depression. A 7/8/24 Pharmacy Review indicated Resident 8 received mirtazapine (an antidepressant) 7.5 mg at bedtime. The recommendation was to discontinue this medication. On 8/6/24, (29 days later), the physician agreed with the pharmacy recommendation. A review of the 8/2024 MAR indicated Resident 8 received the last dose of mirtazapine 7.5 mg at bedtime on 8/6/24. On 8/15/24 at 3:11 PM Staff 3 (RNCM) stated the expectation was for the physician to address the pharmacy recommendations within two weeks and implement the recommendations. Staff 3 acknowledged Resident 8 had a pharmacy recommendation on 7/8/24 and it was not signed by the physician until 8/6/24. 2. Resident 6 readmitted to the facility in 2023…

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 medical records were accurate for 2 of 2 sampled residents (#s 6 and 8) reviewed for pressure ulcers. This placed residents at risk for inaccurate wound measurements. Findings include: 1. Resident 8 admitted to the facility on 5/2024 with diagnoses including diabetes and a sacral fracture. The 8/15/24 at 11:59 AM progress note by Staff 2 (DNS) indicated Resident 8 had a Stage 2 pressure ulcer on the left inner gluteal (muscles that make up the buttock area) that measured 1.2 inches long, .5 inches wide, and 0 inches deep with no visual drainage or odor. Four Stage 2 pressure ulcers to the left forearm were also identified and measured. The 8/15/24 at 12:49 PM Weekly Wound Observation Tool completed by Staff 2 indicated Resident 8 had a Stage 2 pressure ulcer on the left gluteal and left forearm, slough tissue was present (yellow/white material in the wound bed), and the wounds were facility acquired on 5/15/24. The measurements were 20 mm long, 13 mm wide, 02 mm deep and had minimal drainage 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.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 2 of 2 sampled CNA staff (#s 5 and 6) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include: On 5/16/23 at 10:18 AM Staff 1 (Administrator) was asked for the annual performance reviews for Staff 5 (CNA) and Staff 6 (CNA). Employee performance reviews indicated the following: -Staff 5 was hired 3/1995 and the last performance review was completed in 2021; -Staff 6 was hired 7/2020 and the last performance review was completed in 2021. On 5/16/23 at 2:31 PM Staff 1 acknowledged the last performance review for Staff 5 and Staff 6 was completed in 2021 and the annual performance reviews were not completed for 2022 for the identified CNA staff.

Based on interview and record review it was determined the facility failed to implement an antibiotic stewardship program for 1 of 1 facility reviewed for antibiotic stewardship. This placed residents at risk for developing antibiotic resistance. Findings include: On 5/17/23 at 9:52 AM a request was made for the antibiotic stewardship program documentation from Staff 2 (DNS/IP). On 5/17/23 at 9:52 AM Staff 2 stated the facility had no process to track antibiotic use and did not have an antibiotic stewardship program in place.

Based on interview and record review it was determined the facility failed to provide quarterly statements in writing of Personal Incidental Funds (PIF) for 2 of 2 sampled residents (#s 3 and 5) reviewed for PIFs. This placed residents at risk of being uninformed of financial statements. Findings include: 1. Resident 3 admitted to the facility in 2018 with diagnoses including dementia. On 5/15/23 at 8:47 AM Witness 1 (Complainant) stated the facility was in charge of Resident 3's finances including managing her/his PIF (Personal Incident Fund) of 30 dollars a month. Witness 1 stated she used to receive quarterly statements of Resident 3's PIF account but not longer received the statement and was unaware of how much Resident 3 had in her/his account. On 5/15/23 at 12:08 PM Staff 3 (Social Services) stated she was unsure if a quarterly statement was sent of Resident 3's PIF account. Staff 3 stated the account was managed by Staff 4 (Accountant). On 5/15/23 at 1:28 PM Staff 4 stated she managed Resident 3's finances including her/his PIF account. Staff 4 stated she did not sent out…

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 comprehensive assessments for 1 of 5 sampled residents (# 6) reviewed for medication. This placed residents at risk for unassessed needs. Findings include: Resident 6 admitted to the facility in 3/2023 with diagnoses including anxiety disorder and depressive disorder. The 4/2023 MARs indicated Resident 6 received the following medications: -trazodone (antidepressant medication) once daily; -bupropion (antidepressant medication) once daily; -buspirone (antianxiety medication) BID. The 4/7/23 Psychotropic Drug Use CAA was blank. The CAA failed to identify resident behaviors, history of the use of psychotropic medications, current psychotropic medication use, interventions or monitoring in place related to the resident's use of the medications. On 5/16/23 at 10:32 AM Staff 1 (Administrator) acknowledged Resident 6's Psychotropic Drug Use CAA was blank and was not comprehensive as identified.

Based on interview and record review it was determined the facility failed to assess and treat diabetic ulcers for 1 of 1 sampled resident (#1) reviewed for pressure ulcers. This placed residents at risk for worsening skin conditions. Findings include: Resident 1 admitted to the facility in 2018 with diagnoses including stroke and diabetes. A 4/1/23 progress note indicated Resident 1 had a wound on her/his right great toe, it was swollen and an open area was noted to be a 2 cm round wound. Wound Care notes indicated the resident had a diabetic ulcer to the right great toe measuring as follows: -4/5/23 0.70 cm x 1.0 cm. Topical care: cleanse with wound cleanser; apply skin prep to peri-wound; primary dressing: therahoney to wound base; secondary dressing: 2 x 2 Allevyn (foam dressing); change every week and PRN if it falls off. -4/12/23 0.80 cm x 0.80 cm [no changes to treatment]. -4/19/23 0.50 cm x 0.50 cm [no changes to treatment]. Plan to schedule to return in one month. There was no indication the wound care orders from the 4/5/23 wound consult were implemented. Resident 1's…

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

Based on interview and record review it was determined the facility failed to assess and treat pressure ulcers for 1 of 1 sampled resident (#1) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 1 admitted to the facility in 2018 with diagnoses including stroke. A 3/29/23 progress note indicated Resident 1 had a 1.4 cm x 0.8 cm x 0.3 cm wound to the left gluteal fold. The area was cleansed with wound cleanser and gauze, and covered with dressing. Wound Care notes indicated the Stage 3 pressure area to the left buttock was assessed and measured as follows: *4/5/23 0.9 cm x 1.5 cm x 0.1 cm. Topical care: cleanse with wound cleanser; apply skin prep to peri-wound; primary dressing: therahoney to wound base; secondary dressing 2 x 2 Allevyn. Change twice weekly and PRN if soiled or falls off. *4/12/23 0.9 cm x 1.5 cm x 0.1 cm (no changes to treatment). *4/19/23 0.9 cm x 1.5 cm x 0.1 cm (no changes to treatment). Plan to schedule to return in one month. The 4/6/23 and 5/4/23 physician orders indicated Allevyn dressing 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to have an order in place for the use of a catheter for 1 of 2 sampled residents (#119) reviewed for catheters. This placed residents at risk for urinary tract infections. Findings include: Resident 119 admitted to the facility on [DATE] with diagnoses including failure to thrive. The 4/19/23 admission Summary indicated Resident 119 had a Foley catheter when she/he admitted to the facility. No initial physician order for the catheter was located in Resident 119's clinical record. Resident 119's 4/24/23 hospice orders indicated the following: -Foley catheter to down drain; replace every six weeks or by order. May irrigate with 60 cc normal saline PRN. The 4/2023 and 5/2023 TARs did not indicate orders to irrigate the catheter and did not include monitoring of the catheter. On 5/15/23 at 9:11 AM, 12:53 PM and 2:23 PM Resident 119's catheter bag and tubing were observed to be hanging on the bed. A review of the clinical record…

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 ensure a thorough medication regimen review was completed by the pharmacist monthly for 2 of 2 sampled residents (#s 2 and 4) reviewed for antibiotic use. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 4 admitted to the facility on [DATE] with diagnoses including multiple sclerosis. The 3/2/23 physician orders indicated Resident 4 received cephalexin 500 mg once daily for UTI prophylaxis. The order indicated the initial start date was 5/25/22. A review of the resident's clinical record revealed no evidence the resident's use of cephalexin was reviewed by a pharmacist. On 5/16/23 the state survey team requested a rationale for Resident 4's use of cephalexin. A log note from the physician was received that indicated appears [she/he] is on daily Keflex [cephalexin] for UTI prophylaxis given [her/his] frequent UTIs previously. On 5/17/23 at 12:28 PM Staff 8 (Pharmacist) stated she looked…

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 psychotropic drug reviews for 2 of 5 sampled residents (#s 2 and 8) reviewed for medications. This place residents at risk for unnecessary medications. Findings include: 1. Resident 8 admitted to the facility in 2021 with diagnoses including chronic pain, dysthymic disorder and epilepsy. The 4/8/21 Care Plan indicated Resident 8 used antidepressant medication related to the diagnoses of dysthymic disorder. Interventions included to monitor side effects and effectiveness of the medication. Review of the provided February, March and April 2023 psychotropic reviews entitled Pharmacist Recommendations/Review indicated a 30 day review was completed with no recommendations. No other documentation related to a psychotropic drug review were indicated. The form included signatures of the pharmacist and the physician only. On 5/16/23 at 10:16 AM and 5/17/23 at 11:16 AM Staff 1 (Administrator) stated the facility did not complete psychotropic drug meetings for any residents including Resident 8. 2. 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 ensure medical records were complete and accurate for 1 of 6 sampled residents (#8) reviewed for medications. This placed residents at risk for incomplete medical records. Findings include: Resident 8 admitted to the facility in 2021 with diagnoses including chronic pain, dysthymic disorder and epilepsy. 7/13/22 physician orders indicated CMP (comprehensive metabolic panel) and CBC (complete blood count) labs were to be completed annually (February) and the dilantin level (tests level of dilantin [seizure medication] in the blood) every 6 months (February and August). The orders indicated Resident 8 received 100 mg of phenytion (dilantin) BID related to seizures. A progress note dated 2/8/23 indicated Resident 8's blood was drawn for CMP, CBC and dilantin level and sent to the lab. Review of Resident 8's medical record revealed results for from the CBC lab and no documentation of the results for the CMP or dilantin labs were found. On 5/17/23 at 11:03 AM Staff 1 (Administrator) acknowledged the lab results…

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 it was determined the facility failed to ensure proper placement of a resident's catheter to prevent infection for 2 of 2 sampled residents (#s 4 and 119) randomly observed for infection control. This placed residents at risk for infection. Findings include: 1. Resident 4 admitted to the facility in 5/2022 with diagnoses including multiple sclerosis. On 5/15/23 at 10:35 AM Resident 4's catheter bag and tubing were observed uncovered hanging on the bed with the lower part of the bag lying on the floor next to the resident's bed. On 5/15/23 at 2:18 PM Resident 4's catheter bag was observed uncovered hanging on the recliner with the lower part of the bag touching the floor. On 5/15/23 at 2:29 PM Staff 2 (DNS) confirmed Resident 4's catheter bag was touching the floor and expected it to be off the floor for infection control. 2. Resident 119 admitted to the facility in 2023 with diagnoses including failure to thrive. On 5/15/23 at 9:11 AM, 12:53 PM and 2:23 PM Resident 119's catheter bag and tubing were observed uncovered hanging on the bed with 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.