Umpqua Valley Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to consistently and thoroughly monitor residents on psychotropic medications for 4 of 6 sampled residents (#s 4, 18, 52 and 77) reviewed for psychotropic medications and change of condition. This placed residents at risk for receiving unnecessary psychotropic medications. Findings include: 1. Resident 4 admitted to the facility in 2021 with diagnoses including depression and psychosis (mental disruptions of reality). A 1/10/24 physician order indicated to administer quetiapine (antipsychotic medication) to Resident 4 twice daily due to psychotic disturbances. A 1/11/24 physician order indicated to administer Zoloft (antidepressant medication) to Resident 4 daily due to major depression. The 3/2024 through 5/14/24 nursing Monitors for Resident 4 indicated to monitor for behaviors and side effects of medication which included: excessive sleepiness, verbal expression of sadness, distressing hallucinations (a false perception of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to implement EBP (Enhanced Barrier Precautions: implementation of personal protective equipment [gown, gloves, masks and/or goggles] when a resident has an indwelling medical device or wound) timely for 4 of 9 sampled residents (#s 6, 9, 32, and 127) reviewed for infection control and unnecessary medications. This placed residents at risk for cross-contamination. Findings include: 1. Resident 6 admitted to the facility 4/11/24 with a diagnosis of wound infection. Resident 6's Care Plan revealed she/he was not started on EBP for her/his chronic wound infection until 5/2/24. On 5/14/24 at 1:52 PM Staff 3 (IP) stated all new residents, prior to admission, were reviewed for the need for EBP. Staff 3 acknowledged EBP were to be implemented in nursing homes, effective 4/1/24, but the facility did not educate and implement the process until the end of 4/2024. Staff 3 acknowledged Resident 6 was not placed on EBP until 5/2/24. 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.

Based on interview and record review it was determined the facility failed to ensure antibiotic stewardship for 3 of 9 sampled residents (#s 1, 32, and 77) reviewed for infection control, UTIs and change of condition. Findings include: 1. Resident 1 admitted to the facility in 10/2023 with diagnoses including bladder cancer. A review of Resident 1's medical record revealed 4/19/24 orders to start Augmentin (an antibiotic) for 21 days. A review of Resident 1's labs revealed an 4/22/24 urine analysis (UA) with culture and sensitivity which grew pseudomonas aerugimosa (a type of bacteria), which was not sensitive to Augmentin. On 5/15/24 at 11:19 AM Staff 3 (Infection Preventionist) stated Resident 1's 4/22/24 UA was sent to the urologist. Staff 3 was unable to produce documentation of the urologist's review of the UA. A 5/15/24 review of Resident 1's medical record revealed no evidence for an antibiotic time-out. On 5/15/24 at 3:16 PM Staff 2 (DNS) and Staff 30 (Regional Director of Clinical) acknowledged an antibiotic time-out was not completed and pseudomonas aerugimosa was 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.

Based on interview and record review it was determined the facility failed to provide medication-related risk and benefits information to residents or resident representatives prior to administration for 2 of 6 sampled residents (#s 77 and 52) reviewed for medications. This placed residents and resident representatives at risk for lack of informed consent. Findings include: 1. Resident 77 admitted to the facility in 2023 with a diagnosis of stroke. A 6/18/23 physician order instructed staff to administer one tablet of Ativan (to treat anxiety) by mouth every eight hours PRN for anxiety and two tablets by mouth every eight hours PRN for anxiety. A 6/21/23 nurse practitioner order instructed staff to administer Escitalopram Oxalate (to treat depression and anxiety) one time a day for depression. A 6/23/23 nurse practitioner order instructed staff to administer buspirone (to treat anxiety) two times a day for anxiety. A 6/30/23 signed nurse practitioner order instructed staff to administer Seroquel (an antipsychotic to treat certain mental and mood disorders such as schizophrenia,…

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 determine the facility failed to honor a resident's right to refuse a transfer to another room for 1 of 2 sampled residents (#25) reviewed for positioning. This placed residents at risk for lack of honored choices. Findings include: Resident 25 admitted to the facility in 2023 with diagnoses including depression and seizures. An 4/3/24 Written Notice of Room Change indicated Resident 25 was asked to move to a semi-private room from a private room on 4/17/24 and Resident 25 refused to sign the room change notification. An 4/3/24 facility Daily Census indicated multiple vacant resident rooms were available on this date. An 4/25/24 Profile for Resident 25 indicated she/he was moved to a different room. On 5/13/24 at 3:53 PM Resident 25 stated she/he refused to sign the 4/3/24 Written Notice of Room Change because she/he had the right to remain in her/his room and did not want to move. On 5/14/24 at 3:33 PM Staff 5 (Social Services) acknowledged the 4/3/24 notification was given to Resident 25 because the facility was choosing to repurpose 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 issue a Notice of Medicare Non-Coverage (NOMNC) for 1 of 3 (#378) sampled residents reviewed for beneficiary notification. This placed residents at risk for lack of appeal information. Findings include: Resident 378 admitted to the facility with Medicare Part A services on 12/1/23 with diagnoses including cellulitis (an infection of the skin) of the right lower limb. A 1/12/2024 Social Services Note revealed Resident 378 had home health set up upon discharge from the facility, a ramp in place at home and Resident 378 was ready to discharge home once her/his IV antibiotics were completed. A 1/17/24 Progress Note revealed Resident 378's IV antibiotics were completed. Resident 378 discharged from the facility on 1/19/24. A 5/14/24 medical record review revealed no evidence the facility issued a NOMNC for Resident 378. On 5/14/24 at 1:24 PM Staff 35 (Social Service Director) confirmed Resident 378 discharged on 1/19/24 once her/his goals were met. Staff 35 stated Resident 378 was not issued a NOMNC prior to…

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

Based on observation, interview, and record review it was determined the facility failed to resolve a resident's report of missing clothing for 1 of 2 sampled residents (#6) reviewed for personal property. This placed residents at risk for missing items. Findings include: Resident 6 admitted to the facility in 2024 with diagnoses including a surgical infection. An 4/17/24 admission MDS revealed Resident 6 was cognitively intact. On 5/13/24 at 1:12 PM Resident 6 stated over one week prior she reported to the laundry staff her/his black jacket and a shrinker sock (special sock to wear over an amputation prior to placing a prosthetic) was missing. On 5/14/24 at 1:04 PM Staff 6 (Laundry) stated if a resident reported a missing item staff immediately looked for the item. If the item was not found, staff wrote the resident's name and missing item on a chalk board and also on a piece of paper to alert staff to look for the item. With Staff 6 the chalk board was observed to not have Resident 6's name or missing items listed. Staff 6 stated she did not see Resident 6's name on any paper to…

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

Based on interview and record review it was determined the facility failed to report allegations of abuse and misappropriation to the state agency or local law enforcement for 2 of 6 sampled residents (#s 1 and 47) reviewed for abuse and medications. This placed residents at risk for abuse. Findings include: 1. Resident 1 admitted to the facility in 10/2023 with diagnoses including quadriplegia. A review of a 2/22/24 grievance revealed Resident 1 had $160 go missing on 2/15/24, and the facility replaced the money on 3/21/24. A review of an 4/22/24 MDS revealed Resident 1 was cognitively intact. On 5/16/24 at 10:48 AM Staff 1 (Administrator) stated she did not think the money was missing to begin with. Staff 1 acknowledged the allegation of missing money was not reported to the state agency or to local law enforcement, and stated if there was a trend of missing money in the facility, it would have been reported. 2. Resident 47 admitted to the facility in 2021 with diagnoses including stroke and severe cognitive impairment. Resident 52 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.

Based on interview and record review it was determined the facility failed to complete thorough investigations for allegations of abuse for 2 of 6 sampled residents (#s 1 and 47) reviewed for abuse and medications. This placed residents at risk for abuse. Findings include: 1. Resident 1 admitted to the facility in 10/2023 with diagnoses including quadriplegia. A review of a 2/22/24 grievance revealed Resident 1 had $160 go missing on 2/15/24, the facility replaced the money on 3/21/24. A review of an 4/22/24 MDS indicated Resident 1 was cognitively intact. On 5/16/24 at 10:48 AM Staff 1 (Administrator) stated she did not think the money was missing to begin with, and acknowledged the allegation of missing money was not investigated. 2. Resident 47 admitted to the facility in 2021 with diagnoses including a stroke and cognitive impairment. Resident 52 admitted to the facility in 2023 with diagnoses including a stroke. A progress note dated 5/4/24 at 10:30 PM documented Resident 52 was sitting in her/his wheelchair on the 100 hall near the nursing station. Resident 47 was mobilizing…

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 safe and orderly discharge for 1 of 2 sampled residents (#77) reviewed for discharge. This placed residents at risk for unmet medications needs. Findings include: Resident 77 admitted to the facility in 2023 with a diagnosis of stroke. A 12/7/23 Discharge Orders and Instructions (discharge packet) revealed instructions for Resident 77 to continue medication on the Discharge Medication List and the medications were sent to pharmacy of choice. The signed Orders and Summary report included the following: Amlodipine (to treat high blood pressure), Atorvastatin (to treat high bad cholesterol), Baclofen (to treat muscle spasms), buspirone (to treat anxiety), clopidogrel (used to prevent heart attacks and strokes), Diclofenac (to treat mild to moderate pain and swelling), Docusate (to treat constipation), Escitalopram (to treat depression), Ibuprofen (to treat mild to moderate pain), Insulin (to treat diabetes), Levoxyl (to treat an underactive thyroid), Lisinopril (to treat high blood pressure), and…

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

Based on observation, interview, and record review it was determined the facility failed to ensure a resident was provided an activity program for 1 of 1 sampled resident (#63) reviewed for activities. This placed residents at risk for decreased quality of life. Findings include: Resident 63 admitted to the facility in 2023 with a diagnosis of chronic kidney disease. A 1/8/24 My Ways activity assessment revealed Resident 63 reported she he did not like group activities and did not want to be invited to church groups, really enjoyed short 1:1 visits, and appreciated the library cart when brought to her/him. A 1/31/24 Significant Change MDS revealed Resident 63 had memory issues. Activities Resident 63 identified as somewhat important included magazines, music, pets and being with groups of people. It was assessed Resident 63 thought it was very important to do her/his favorite activities. Resident 63's Care Plan revised on 2/8/24 revealed staff were to encourage ongoing family involvement, 1:1 bedside visits, reading, family visits, and rest. An 4/30/24 Nursing Note revealed staff…

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 respond to changes in condition in a timely manner and failed to follow physician orders for 3 of 9 sampled residents (#s 32, 52 and 77) reviewed for change of condition, pain, and medications. This placed residents at risk for delay of treatment. Findings include: 1. Resident 77 admitted to the facility in 2023 with a diagnosis of stroke. A 6/17/23 admission readmission Evaluation indicated Resident 77 was alert with orientation of person, place, and situation with appropriate verbal skills with slow speech. Resident 77 was continent of bladder and had moderate complaints of pain. A 6/18/23 Administration Note revealed the following: -6:44 AM Resident 77 was agitated and yelling and screaming out that she/he was in pain and was going to die. Resident 77 stated she/he was getting worse and not better. Resident 77 only had Tylenol (to treat mild to moderate pain) available. -7:34 AM indicated Resident 77 was still agitated and yelling about random things and less about pain. -9:16 AM the on-call provider…

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 appropriate foot care for 1 of 2 sampled residents (#77) reviewed for ADLs. This placed residents at risk for lack of nail care, pain, and increased infections. Findings include: Resident 77 admitted to the facility in 2023 with diagnosis of diabetes. A 6/30/23 care plan indicated Resident 77 had diabetes. Interventions included to refer to a podiatrist or foot care nurse, to monitor and document foot care needs and to cut long nails. No documentation was found in clinical record Resident 77 was referred to a podiatrist or foot care nurse. From 6/18/23 through 11/5/23 no documentation was found in clinical record Resident 77 received nail care to her/his feet. On 11/6/23 a Nursing Note indicated Resident 77 was provided nail care. From 11/7/23 through 12/11/23 no documentation was found in clinical record Resident 77 received nail care to her/his feet. A public complaint was received on 2/1/24 which indicated while Resident 77 was residing at the facility between 6/2023 and 12/2023 she/he did 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.

Based on observation, interview and record review it was determined the facility failed to ensure a resident's environment remained free from smoking hazards for 1 of 6 sampled residents (#57) reviewed for accidents. This placed residents at risk for a hazardous environment. Findings include: Resident 57 admitted to the facility in 2023 with diagnoses including COPD (Chronic Obstructive Pulmonary Disease) and chronic pain. A 3/2023 revised Physical Environment Facility with Independent and Supervised Smokers policy indicated residents deemed as independent smokers were to store smoking materials in an individual storage box located outside the resident's room. A 2/7/24 Nursing Smoking Screen indicated Resident 57 was safely able to smoke or vape (inhaled nicotine mist created by an electronic device) independently and had a history of hiding her/his smoking materials from staff. A 2/7/24 revised care plan indicated to notify the charge nurse if Resident 57 violated the facility smoking policy which included the storage of her/his smoking materials in her/his room. A 5/15/24 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 interview and record review it was determined the facility failed to ensure a resident was evaluated timely after weight loss for 1 of 5 sampled residents (#127) reviewed for nutrition. This placed residents at risk for continued weight loss. Findings include: Resident 127 admitted to the facility in 4/2024 with a diagnosis of a surgical infection. A 5/2/24 admission MDS revealed Resident 127 was obese, but weight loss was not a goal at that time due to calories required to heal from a surgical infection. Staff were to weigh the resident weekly and then monthly. Resident 127's 4/2024 and 5/2024 weight record revealed on 4/26/24, the resident weighed 232 lbs, on 4/29/24 239 pounds, and on 5/7/24 was 217 pounds. From 4/29/24 to 5/7/24 Resident 127 had a 9.21% weight loss. Resident 127's clinical record did not contain an assessment, re-weigh, or rationale for the 9.21% weight loss. On 5/15/24 at 11:03 AM Staff 3 (LPN Resident Care Manager) stated if a resident had a significant weight change, staff were to re-weigh the resident to ensure the recorded weight was accurate.…

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 the facility failed to provide pain management for 3 of 10 sampled residents (#s 32, 61, and 77) reviewed for pain management, change of condition and unnecessary medications. This placed residents at risk for lack of pain control. Findings include: 1. Resident 32 admitted to the facility in 2024 with diagnoses including surgical aftercare and disc degeneration in the lumbar region (age-related deterioration of the discs in the lower back). An 4/6/24 care plan revealed Resident 32 had pain, with interventions including evaluation of the effectiveness of the resident's pain management every shift, monitor and document the resident's pain characteristics; the quality, severity, anatomical location, onset, duration, aggravating factors, and relieving factors. An 4/11/24 MDS indicated Resident 32 was cognitively intact and had frequent pain presence which affected her/his sleep occasionally and affected therapy and day to day activities frequently. Resident 32 was at risk for uncontrolled pain, social isolation, and decline. An 4/2024…

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 consistently monitor a dialysis access site for 1 of 1 sampled resident (#26) reviewed for dialysis. This placed residents at risk for dialysis complications. Resident 26 admitted to the facility in 2020 with diagnoses including stroke and end stage renal disease. An order dated 3/12/24 instructed staff to monitor the resident's dialysis access site for bruit (whooshing) and thrill (vibration) twice a day. A review of the clinical record revealed the site was monitored for bruit and thrill 11 of 39 opportunities in 3/2024, 14 of 60 opportunities in 4/2024, and one time in 32 opportunities in 5/2024. On 5/17/24 at 9:59 AM Staff 14 (LPN Unit Manager) was asked about dialysis monitoring. Staff 14 stated staff were expected to check the site for any bleeding, check bruit and thrill and to ensure there was a dressing in place. Staff 14 was asked about the lack of site monitoring. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure pneumonia vaccines were offered for 2 of 5 sampled residents (#s 42 and 67). This placed residents at risk for respiratory illness. Findings include: A 2/9/23 CDC shared Clinical Decision-Making tool revealed: If a resident over 65 completed the pneumonia vaccine series with PCV 13 AND PPSV23, PCV20 was not routinely recommended. Factors including residing in a nursing home or residents who had more than one chronic medical condition including heart and lung disease, diabetes and a weakened immune system should be evaluated for PCV 20 appropriateness. 1. Resident 42 admitted to the facility in 2021 with a diagnosis of heart disease. Immunization records revealed Resident 42 received two pneumonia vaccines. Resident 42 was eligible for but not assessed by the resident's physician for an additional vaccine. On 5/14/24 at 2:09 PM Staff 3 (IP) acknowledged Resident 42's pneumonia vaccines were complete but an additional vaccine could be administered after clinical evaluation. A request was made to Staff…

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 abuse training for 3 of 5 (#'s 26, 27, and 28) staff reviewed for abuse training. This placed residents at risk for abuse. Findings include: A review of the facility's in-service records identified the following issues: -Staff 26 (CNA) had no documentation of completing the annual abuse training. -Staff 27 (CNA) had no documentation of completing the annual abuse training. -Staff 28 (CNA) had no documentation of completing the annual abuse training. On 5/16/24 at 2:00 PM Staff 1 (Administrator) acknowledged the above staff did not complete their annual abuse training.

Based on interview and record review it was determined the facility failed to ensure food was served at the proper temperature to prevent avoidable burns for 1 of 4 sampled residents (#4) reviewed for food temperature. This placed residents at risk for oral burns. Findings include: Resident 4 admitted to the facility in 2022 with diagnoses including stroke and quadriplegia (paralysis of all four limbs). The 1/9/24 BIMS assessment score was 4 out of 15 which indicated severe cognitive impairment. The 1/1/24 Facility Investigation revealed Resident 4 sustained an injury which had discoloration, edema and blistering to the inner bottom lip of the mouth which measured 2 cm x 0.6 cm. The investigation revealed on 12/31/23 around 5:00 PM Staff 4 (CNA) obtained Resident 4's food tray directly from the kitchen tray line and brought it to the resident. Resident 4 grimaced and made a loud noise with the first bite of food. Staff 4 stated the food burned Resident 4 and proceeded to place a spoonful of the pureed food onto her own arm and determined the food felt too hot. At the time 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 the time between the start of the evening meal and the start of the breakfast meal did not exceed 14 hours without providing a substantial evening snack and snacks were suitable and available at non-traditional times for 1 of 1 facility, 1 of 3 facility snack refrigerators and 2 of 7 sampled residents (#s 29 and 35) reviewed for food and dining. This placed residents at risk for unmet nutritional needs and hunger. Findings include: 1. A review of the meal service times revealed dinner started at 4:30 PM and breakfast started at 7:30 AM, a span of 15 hours. On 2/7/23 at 9:28 AM the snack refrigerator was observed to contain three half sandwiches, two thickened cranberry juice cocktails and two milk substitutes. On 2/7/23 at 2:31 PM Staff 33 (CNA) stated the kitchen was supposed to stock the refrigerator at 1:00 PM. At times the items were not ready and the CNAs were asked to stock. Staff 33 added they were given puddings, cottage cheese and applesauce. There were no sugar free items…

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 standard food safety practices were followed for 1 of 1 kitchen and 2 of 2 unit refrigerators. This placed residents at risk for food borne illnesses. 1. On 2/6/23 the documented dinner time for residents began at 4:30 PM. On 2/6/23 at 3:05 PM the kitchen steam table was observed with cooked food on the steam table line including: whole black beans and a container of pureed green food. Three additional unidentified food containers sat in the steam table covered with foil. On 2/6/23 at 4:08 PM Staff 38 (Dietary Aide) stated he was the designated cook for dinner and started to prepare the puree foods around 12:30 PM and placed them on the steam table beginning at 1:00 PM. Staff 38 stated he understood food was not to be on the steam table line earlier than two hours prior to the meal service. On 2/8/23 at 11:20 AM Staff 29 (RD) stated foods should not be on the steam table line earlier than 30 minutes prior to meal service. 2. On 2/7/23 at 9:28 AM the ICF (Intermediate Care Facility)…

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 provide a homelike dining experience for 2 of 2 dining rooms reviewed for dining. This place residents at risk for a lack of homelike dining. Findings include: On 2/7/23 at 8:06 AM 19 residents were observed in the dining room for breakfast. The tables lacked table clothes, centerpieces or condiments. Trays were served to various residents at four different tables. The plates remained on the trays and plate covers were left on the tables next to the residents. Two female residents were served at their table while the remaining two residents sat approximately 10 minutes while waiting for their meals to be served. On 2/7/23 at 8:26 AM another table was observed with three student nurses standing while assisting residents with their meals. A facility CNA was seated at the same table assisting another resident. On 2/7/23 at 2:50 PM Staff 33 (CNA) stated staff were supposed to serve the entire table at the same time but the carts were disorganized and staff were told not to leave trays sitting too long. Staff 33…

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 revise comprehensive care plans for 5 of 10 sampled residents (#s 4, 35, 42, 65 and 81) reviewed for weight loss, pain management and positioning and mobility. This placed residents at risk for unmet needs. Findings include: 1. Resident 42 was admitted to the facility in 2022 with diagnoses including hip fracture and difficulty swallowing. The medical record documented a weight loss of 16 percent from 8/26/22 to 2/5/23 indicating severe weight loss. A review of Resident 42's nutrition care plan revealed a problem related to high body mass index (signifying overweight status), therapeutic diet, hip fracture, arthritis, low sodium levels and gastroesophageal reflux disorder (GERD). The care plan goal was for no significant weight loss and interventions included to provide diet as ordered and refer to the RD PRN. On 2/7/23 at 10:10 AM Resident 42 stated prior to admission she/he was not on a special diet but there were things she/he could not eat. Resident 42 indicated some foods caused…

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 1. Based on observation, interview and record review it was determined the facility failed to follow proper infection control techniques during wound care for 1 of 1 sampled resident (#61) reviewed for pressure ulcers. This placed residents at risk for cross contamination. Findings include: Resident 61 was admitted to the facility in 12/2021 with diagnoses including diabetes and Stage 4 pressure ulcer (wound reaching muscle, ligaments, or bones). On 2/8/23 at 2:57 PM Staff 13 (Unit Manager) was observed to perform a dressing change on Resident 61. Staff 13 removed the dirty dressing from the wound and then proceeded to clean the wound with dirty gloves. Staff 13 donned clean gloves and used a sterile Q-tip to place calcium alginate (natural fiber dressing to promote wound healing) inside the wound, cleaned around the wound and retrieved and opened a package of clean bandages without changing her gloves. Staff 13 acknowledged she did not change her gloves after she removed the soiled dressing and should have…

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 dignity and respect for 1 of 1 sampled resident (#2) reviewed for dignity. This placed residents at risk for lack of dignity and respect. Findings include: Resident 2 was admitted to the facility in 2019 with a diagnoses including quadriplegia, traumatic brain injury, speech and language deficits. A 7/10/22 Dehydration and Fluid Maintenance CAA revealed Resident 2 was at risk for dehydration and was a one to one feeder. A 7/20/22 comprehensive care plan indicated Resident 2 had a potential fluid deficit and was a one-to-one person feeder. On 2/7/23 at 8:28 AM three nursing students were observed assisting three different residents to eat. Staff 16 (Nursing student) was standing over Resident 2 as she assisted her/him to eat. On 2/8/23 at 12:13 PM Staff 11 (CNA) stated residents who required assistance with eating or drinking were called assisted feeders. On 2/9/23 at 8:33 AM Staff 10 (CNA) stated they separated the residents in the dining room to feed the feeders. On 2/9/23 at 10:12 AM…

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 assess residents for safe self-administration of medication for 1 of 5 sampled residents (#53) reviewed for unnecessary medications. This placed residents at risk for unsafe medication administration. Findings include: Resident 53 admitted to the facility in 2021 with diagnoses including end stage kidney disease. An 10/25/22 Physician order revealed orders for sevelamer carbonate oral tablet (a medication to decrease phosphate levels in patients with kidney disease). A 11/23/22 Annual MDS revealed Resident 53 had a BIMS of 11 which indicated moderate cognitive impairment. On 2/6/23 at 11:39 AM Resident 53 was observed in bed asleep and there was a white pill in a medication cup on her/his overbed table. On 2/6/23 at 11:45 AM Staff 3 (LPN) and Staff 31 (LPN Unit Manager) confirmed the medication was sevelamer carbonate and stated Resident 53 was alert and oriented and cleared to self-administer medication. On 2/6/23 at 11:47 AM Resident 53 stated the nurses gave her/him sevelamer carbonate upon…

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 keep call lights within reach of 3 of 3 sampled residents (#s 3, 28 and 68) reviewed for call lights. This placed residents at risk for not being able to call for assistance. Findings include: 1. Resident 68 was admitted to the facility in 6/2022 with diagnoses including fractured leg. The 6/14/22 care plan indicated staff were to ensure Resident 68's call light was within reach. On 2/6/23 at 12:07 PM Resident 68 sat in her/his room on the side of her/his bed. Resident 68's call light was wrapped around the wheel of the bed not in reach of the resident. Resident 68 reached for her/his call light for assistance to the restroom. The resident bent down, tried to grab the call light, and fell back on the bed due to being dizzy. On 2/6/23 at 12:10 PM Staff 41 (CNA) viewed Resident 68's call light underneath her/his bed and stated Resident 68's call light should be within reach of the resident. On 2/8/23 at 11:59 AM Staff 13 (Unit Manager) stated she expected Resident 68 to have her/his call light…

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 in a timely manner for 1 of 5 sampled residents (#31) reviewed for medications. This placed residents at risk for unmet needs. Findings include: Resident 31 was admitted to the facility in 2019 with diagnoses including heart failure and history of mini strokes. A 1/16/23 signed physician order instructed staff to administer Xarelto (prevents blood clots) every evening for blood clot prevention. A 1/2023 MAR instructed staff to administer Xarelto by mouth for blood clot prevention. From 1/22/23 through 1/31/23 Resident 31 refused the medication. A 2/2023 MAR instructed staff to administer Xarelto by mouth for blood clot prevention. From 2/1/23 through 2/8/23 Resident 31 refused the medication. No documentation was found in the clinical record the physician was notified of Resident 31's refusals of taking Xarelto. On 2/9/23 at 10:19 AM Staff 13 (Unit Manager) stated the physician was notified on 2/9/23 about Resident 31's refusal of taking Xarelto. Staff 13 stated she expected staff to…

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

Based on observation, interview and record review it was determined the facility failed to follow physician orders and follow the comprehensive care plan for 2 of 7 sampled residents (#s 61 and 65) reviewed for ROM and nutrition. This placed residents at risk for unmet needs. Findings include: 1. Resident 61 was admitted to the facility in 12/2021 with diagnoses including diabetes and altered mental status. A physician order dated 12/5/22 indicated, staff were to cleanse the residents hands with soap and water, dry thoroughly, place palm grip in hands and remove at HS. The revised care plan dated 12/6/22 indicated Resident 61 was to wear palm protectors in the morning and to be removed at night to bilateral hands to prevent skin breakdown related to hand contractures. Random observations from 2/7/23 through 2/9/23 during day and evening shifts revealed Resident 61's hands were in a fist, her/his nails dug into her/his palms and the resident was not wearing her/his palm protectors. On 2/8/23 at 2:57 PM Staff 44 (CNA) verified Resident 61 was not wearing her/his palm protectors. 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 implement mobility devices to ensure residents maintained ROM for 1 of 1 sampled resident (#41) reviewed for range of motion. This placed residents at risk for a decline in their range of motion and functional abilities. Findings include: Resident 41 was admitted to the facility in 2020 with diagnoses including a stroke. A review of the facility's 6/2018 Restorative Nursing Program policy revealed the following: - The facility provides services, care and equipment to assure that a resident maintains and/or improves his/her level of range of motion and mobility unless a reduction is clinically unavoidable. - Residents will be routinely assess for the need of a formalized Restorative Nursing program. - Restorative Nursing programs will be developed and/or formalized by a supervising nurse, contain measurable objective (s) and be included in the resident's care plan. - Restorative Nursing will be re-evaluated periodically by a licensed nurse and updated as necessary. A 12/3/22 Quarterly MDS…

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 accurately assess smoking and ensure residents' environment was free of smoking hazards for 3 of 4 sampled residents (#12, 43 and 53) reviewed for smoking. This placed residents at risk for smoking hazards. Findings include: A review of the 5/2018 Facility's Independent and Supervised Smokers policy revealed the following: - Smoking would occur in designated areas only. - Residents who wished to smoke would be assessed for smoking safety by nursing. - Residents deemed safe to be independent in smoking would have their personal smoking paraphernalia locked in a secure area, not in the resident's room. - Residents who are independent smokers would obtain their smoking paraphernalia staff upon request and residents would return items for storage after smoking. 1. Resident 12 admitted to the facility in 2022 with diagnoses including dementia and nicotine addiction. A review of Resident 12's progress notes revealed the following: - On 9/21/22 Resident 12 was observed smoking in a non-designated…

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 palatable meals for 1 of 3 sampled residents (#12) reviewed for food. This placed residents at risk for impaired nutrition. Findings include: Resident 29 admitted to the facility in 2021 with diagnoses including type 2 diabetes. A review of the 1/4/23 Interdisciplinary Team Care Plan Conference/Welcome meeting evaluation revealed Resident 29 stated the soups were too soupy. Staff 27 (Dietary Manager) was listed as an attendee. On 2/6/23 at 1:15 PM Resident 29 stated the chicken noodle soup tasted like, warm water with guts in it. Resident 29 stated she/he notified the dietary manager but nothing was done about it. On 2/8/23 at 12:52 PM the chicken noodle soup was sampled. The soup was warm but the broth tasted like water. On 2/10/23 at 1:00 PM Staff 27 confirmed she was notified during the week of 1/30/23 the chicken noodle soup tasted watered-down and acknowledged she did not inform the cook until after the meal was sampled on 2/8/23.

Based on observation, interview and record review it was determine the facility failed to address and honor food preferences for 2 of 7 sampled residents (#s 12 and 34) reviewed for food. This placed residents at risk for lack of honored preferences and meal satisfaction. Findings include: 1. Resident 12 was admitted to the facility in 4/2022 with diagnoses including diabetes and dementia. The 12/24/22 care plan indicated Resident 12 was independent for meals and food preferences were to be honored. A 2/1/23 IDT (Interdisciplinary Team) Care Plan Conference/Welcome Meeting Form indicated Resident 12 complained her/his meat at meals was tough. On 2/6/23 Resident 12 stated she/he complained to the dietary department the meat at meals was tough but there was no follow up on her/his concern because meat at meals continued to be tough. Resident 12 also stated she/he often did not receive the food she/he ordered. On 2/8/23 at 12:57 PM Staff 37 (CNA) stated Resident 12's tray lacked a food item. Resident 12's meal tray was observed and compared to her/his meal ticket which revealed…

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