Avamere Rehabilitation Of King City

4. Resident 15 was admitted to the facility in 6/24/24 with diagnoses including urinary tract infection and diabetes. The 12/29/24 Quarterly MDS indicated Resident 15 was cognitively intact and required substantial assistance with showering. On 1/9/25 at 1:08 PM Resident 15 stated her/his shower days were on Tuesdays and Fridays and was unsure if she/he missed any showers. Resident 15's December 2024 shower log revealed the resident received a shower on 12/13/24, refused a shower on 12/17/24, and received showers on 12/20/24 and on 12/27/24. Resident 15 went seven days between showers for two weeks. On 1/10/25 at 11:32 AM Staff 16 (CNA) stated Resident 15 did not receive a shower due to staffing shortage. Staff 16 stated Resident 15 was scheduled for a shower on 12/24/24, however, due to staffing shortage, no scheduled showers were completed on that day. On 1/10/25 at 12:16 PM Staff 2 (Regional RN) stated it was her expectation that all showers were completed as scheduled. If a shower was refused or missed, it would be completed at the next shift or next day. Staff 2 confirmed…

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 there were sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: On 7/25/24 the facility had a census of 62 residents. On 7/18/24, Staff 1 (Administrator) provided a list of residents who: -Required two-person mechanical lift transfers: 23; -Required one or two-person extensive or total assistance for bathing: 47; -Required one or two-person extensive or total assistance for toileting: 47; -Required one or two-person extensive or total assistance for dressing: 49; -Required two person assistance at all times for all care: 11; -Had behavioral healthcare needs which required monitoring: 28; -Were at risk for elopement: 5 and -Were considered high fall risks: 14 1. On 2/1/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs on all shifts resulting in residents not being toileted timely, long…

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 an ongoing person-centered activity program for 3 of 3 sampled dependent residents (#s 9, 24 and 47) reviewed for activities. This placed residents at risk of a decline in psychosocial well-being and diminished quality of life. Findings include: The facility's 2/2005 Activities Policy revealed the facility was to encourage each resident to maintain normal leisure activity. The facility would provide an activities program that addressed the intellectual, social, spiritual, creative and physical needs, capabilities and interests of each resident. The activity program would promote each resident's self-respect by providing activities that supported self-expression and choice. 1. Resident 9 was admitted to the facility in 5/2021 with diagnoses including major depressive disorder and dementia. Resident 9's 6/11/21 and revised 11/16/21 Activities Care Plan indicated the following: -Resident 9 liked music, pet therapy, visiting with the chaplain, gardening, flowers and birds. -Resident 9 was…

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

Based on observation, interview and record review it was determined the facility failed to ensure beverages were labeled and stored in a manner to minimize spoilage and bulk food items were stored in a manner to minimize cross contamination in 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk of foodborne illness. Findings include: On 7/15/24 at 9:49 AM during the initial tour of the kitchen dry storage area, a plastic scoop was observed to be partially buried in the bulk sugar. Staff 24 acknowledged the scoop was not stored appropriately and stated it should be in the provided holster above the sugar rather than in the supply of sugar, to minimize the risk of cross contamination. On 7/15/24 at 9:57 AM the following items were observed to be stored in the snack refrigerator in the facility's 100 hallway: -A previously-opened liter container of nectar-thick lemon water dated 6/23 -A previously-opened liter container of nectar-thick lemon water dated 6/4 -A previously-opened liter container of nectar-thick orange juice labeled Use by 6/26 Staff 24…

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

Based on observation, interview and record review it was determined the facility failed to accurately assess a resident's cognition for 1 of 1 sampled resident (#47) reviewed for communication. This placed residents at risk for unassessed needs. Findings include: Resident 47 was admitted to the facility in 11/2023 with diagnoses including dementia. Resident 47's 11/27/23 admission MDS, 2/27/24 Quarterly MDS and 5/29/24 Quarterly MDS Assessments indicated the resident's preferred language was Vietnamese, and the resident needed or wanted an interpreter to communicate with a doctor or health care staff, was usually able to understand others and was usually able to make her/himself understood. Resident 47's 11/27/23 admission MDS, 2/27/24 Quarterly MDS and 5/29/24 Quarterly MDS Assessments indicated a BIMS interview was not attempted with the resident as the resident was rarely/never understood. No evidence was found in Resident 47's clinical record to indicate an interpreter was utilized to help assess the resident's cognition during the 11/27/23 admission MDS, 2/27/24 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 interview and record review it was determined the facility failed to ensure a Level I PASARR (Preadmission Screening for Individuals with a Mental Disorder and Individuals with Intellectual Disability) was completed for 1 of 1 sampled resident (#45) reviewed for PASARR. This placed residents at risk for inappropriate placement in a nursing facility and a lack of needed services. Findings include: Resident 45 was admitted to the facility in 6/2023 with diagnoses including stroke and schizophrenia (a mental disorder). A review of the resident's electronic health record revealed no evidence Resident 45 had a screening Level I PASARR completed prior to admission. On 7/17/24 at 11:13 AM Staff 11 (Medical Records) and Staff 1 (Administrator) confirmed they were unable to locate a screening Level 1 PASARR for Resident 45.

Based on observation, interview and record review it was determined the facility failed to ensure care plans were revised to accurately reflect the needs of residents for 2 of 7 sampled residents (#s 45 and 48) reviewed for ADLs and falls. This placed residents at risk for unmet needs. Findings include: 1. Resident 45 was admitted to the facility in 6/2023 with diagnoses including stroke and schizophrenia (a mental disorder). Resident 45's 6/14/24 Annual MDS indicated the resident required supervision or touch assistance for eating. Resident 45's current Care Plan indicated Resident 45 required one person assistance for eating. Observations from 7/15/24 through 7/18/24 between the hours of 8:00 AM to 4:30 PM revealed Resident 45 ate her/his meals without assistance. On 7/17/24 at 7:43 AM, 7:48 AM and 8:05 AM Staff 9 (CNA), Staff 10 (CNA) and Staff 16 (CNA) reported Resident 45 ate her/his meals without assistance. Staff 9 stated staff set-up Resident 45's tray and then the resident was independent with eating. On 7/19/24 at 8:43 AM Staff 3 (LPN-Care Manager) stated Resident 45 was…

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

Based on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services in the area of communication for 1 of 1 sampled resident (#47) reviewed for communication. This placed residents at risk for diminished quality of life and potential decline in their ability to carry out activities of daily living. Findings include: Resident 47 was admitted to the facility in 11/2023 with diagnoses including dementia. Resident 47's 11/27/23 admission MDS, 2/27/24 Quarterly MDS and 5/29/24 Quarterly MDS Assessments indicated the resident's preferred language was Vietnamese, and the resident needed or wanted an interpreter to communicate with a doctor or health care staff, was usually able to understand others and was usually able to make her/himself understood. Resident 47's 4/11/24 Communication Care Plan indicated the following: -Arrange translator for Vietnamese as necessary to communicate with the resident. -Use the iPad (a small touchscreen computer) at the nurse's station to log in and indicate the language needed. Resident 47'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 observation, interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 2 of 5 sampled residents (#s 19 and 28) reviewed for ADLs. This placed residents at risk for unmet ADL needs and loss of dignity. Findings include: Resident 19 was admitted to the facility in 1/2017 with diagnoses including respiratory failure with hypoxia (when the respiratory system can not provide adequate oxygen to the body) and major depressive disorder. Observations from 7/15/24 through 7/17/24 between the hours of 8:12 AM and 2:39 PM revealed Resident 19 had numerous hairs, approximately 1/2 inch long, on her/his upper lip and lower portion of her/his chin. Resident 19's 5/16/24 Quarterly MDS indicated the resident had severe cognitive impairment and required substantial to maximal assistance from staff for personal hygiene care which included shaving. On 7/16/24 At 2:39 PM Resident 19 indicated she/he did not like hair on her/his upper lip and chin and she/he wanted the hair removed. On 7/17/24 at 8:13 AM Staff 14…

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 physician orders were followed for 1 of 5 sampled residents (#24) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include: Resident 24 was admitted to the facility in 10/2023 with diagnoses including dementia A 12/7/23 Physician Order indicated Resident 24 was prescribed a lidocaine 4% pain patch to be applied to the resident's lower back, one patch once daily. The lidocaine 4% pain patch was to be on for 12 hours and off for 12 hours. A review of Resident 24's 7/1/24 through 7/31/24 MAR indicated the resident's lidocaine 4% pain patch was not administered according to the physician orders on the following days: -7/6/24, 7/8/24, 7/9/24 and 7/10/24. On 7/18/24 at 12:17 PM Staff 7 (CMA) stated there were no lidocaine 4% pain patches available in the facility on 7/10/24, so she was unable to provide Resident 24 with her/his lidocaine pain patch. On 7/18/24 at 12:27 PM Staff 8 (Maintenance Director) stated he was responsible for ordering…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident 25 admitted to the facility in 10/2022 with diagnoses including history of falls, and stroke with hemiplegia and hemiparesis (paralysis and weakness of one side of the body). The quarterly MDS, dated [DATE], showed a BIMS score of 15 which indicated she/he was cognitively intact, and required minimal assistance from one staff for eating and oral/personal hygiene, maximal assistance from one to two staff for ADLs/cares, and she/he was dependent on one to two staff for wheelchair mobility and transfers. The resident's care plan, updated 4/6/23, revealed that she/he was at moderate risk for falls and needed a restorative care program to prevent decline in level of function. Interventions were updated on 6/6/24 to include a detailed ROM plan with monthly reviews. On 7/15/24 at 1:11PM Resident 25 demonstrated her/his ability to move arms effectively, and inability to move their legs effectively. Resident 25 stated they were supposed to receive restorative therapy three times a week, she/he received…

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 appropriate diet texture was followed for 1 of 2 sampled residents (#10) reviewed for nutrition. This placed residents at risk for choking. Findings include: Resident 10 was admitted to the facility in 12/2016 with diagnoses including dysphagia (difficulty swallowing). The facility's 9/2019 Food Size & Testing Methods Form defined a regular, easy to chew diet as the following: -No restrictions to food piece size. -Normal, everyday foods of soft and tender texture. -Foods must break apart easily and pass the fork pressure test. Resident 10's 5/2/24 Annual MDS revealed the resident experienced short-and-long-term memory loss, was moderately impaired for decision making, required supervision or touch assistance with eating and was edentulous (without teeth). Resident 10's 7/2024 Physician Orders directed the resident to receive a regular, easy to chew diet. On 7/15/24 at 11:53 AM Resident 10 was observed to eat in bed. The resident's meal tray sat on top of an overbed table 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 observation, interview and record review it was determined the facility failed to implement care plan interventions in the area of dining and nutrition for 1 of 2 sampled residents (#10) reviewed for nutrition. This placed residents at risk for unmet nutritional needs. Findings include: Resident 10 was admitted to the facility in 12/2016 with diagnoses including dysphagia (difficulty swallowing). Resident 10's 5/2/24 Annual MDS revealed the resident experienced short-and-long-term memory loss, was moderately impaired for decision making, required supervision or touching assistance with eating and was edentulous (without teeth). Resident 10's 5/16/24 Nutrition at Risk Care Plan indicated staff were to ensure the resident was in an upright position of 75 to 90 degrees during meals as the resident was considered at risk to aspirate. On 7/15/24 at 11:53 AM Resident 10 was observed to eat in bed. The resident's head-of-bed was elevated to approximately 45 degrees. On 7/17/24 at 8:07 PM Staff 10 (CNA) and at 8:27 PM Staff 19 (CNA) stated they were unsure of any positioning…

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 written information to residents concerning the right to formulate an advance directive for 5 of 5 sampled residents (#s 2, 7, 20, 23 and 50) reviewed for advance directives. Findings include: Records reviewed for Residents 2, 7, 20, 23 and 50 revealed no documentation of an advance directive or documentation to indicate the residents were informed of or provided written information concerning their right to formulate an advance directive. On 4/5/23 at 2:39 PM Staff 6 (Social Services Coordinator) stated she asked about a POLST (Physician Orders for Life Sustaining Treatment) upon admission but not advance directives. Staff 6 stated the facility had no process for discussing advance directives upon admission and was unable to provide documentation to verify residents were notified of their right to formulate an advance directive or to ensure a copy was obtained if a resident had an advance directive.

Based on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours for 16 of 40 days reviewed for RN coverage. This placed residents at risk for delayed nursing assessments. Findings include: A review of the DCSDR (Direct Care Staff Daily Reports) revealed the following: In 7/2022 12 days were reviewed and revealed eight days without RN coverage on 7/20/22, 7/21/22, 7/25/22, 7/26/22, 7/27/22, 7/29/22, 7/30/22 and 7/31/22. In 8/2022 12 days were reviewed and revealed seven days without out RN coverage on 8/7/22, 8/12/22, 8/13/22, 8/14/22, 8/19/22, 8/20/22 and 8/21/22. In 10/2022 16 days were reviewed and revealed one day without RN coverage on 10/27/22. On 4/7/23 at 2:16 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the lack of RN coverage for 7/2022, 8/2022 and 10/2022. Staff 1 stated they were working to ensure the facility had appropriate RN coverage.

Based on observation and interview it was determined the facility failed to store food in a sanitary manner for 1 of 1 facility kitchen reviewed for sanitary food storage. This placed residents at risk for food-borne illness and contaminated food. Findings include: On 4/3/23 at 9:15 AM during the initial tour of the facility's walk-in refrigerator and dry storage room the following were observed: Walk-in refrigerator: -An open and undated bag of sliced cheese; -An open and undated container of chocolate pudding covered with plastic wrap; -An open and undated bottle of teriyaki sauce; and -An open and undated bottle of sesame dressing. Dry storage room: -An open and undated package of turkey powder gravy mix; -An open and undated package of chicken powder gravy mix; -An open and undated package of brown powder gravy mix; -An open and undated bag of spaghetti; and -Two open and undated bags of cereal. On 4/3/23 at 9:18 AM Staff 24 (Cook) confirmed the above items were not appropriately dated and stated it was policy for food items to be dated immediately after initial use. On 4/4/23…

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 a resident's bathroom was clean and free of persistent odor for 1 of 4 sampled residents (#31) reviewed for environment. This placed residents at risk for lack of a clean, homelike environment. Findings include: On 4/5/23 at 11:10 AM there was a strong odor of urine in Resident 31's bathroom. A pile of crumpled paper towels and a large puddle of liquid were observed on the floor near the toilet. On 4/5/23 at 11:19 AM Staff 23 (Housekeeper) was asked about the process for cleaning resident rooms. Staff 23 stated it was divided between shifts and every room including bathrooms and showers was cleaned daily. When asked about Resident 31's room Staff 23 indicated the resident frequently urinated on the floor and her/his room was a priority for cleaning. Resident rooms were not cleaned during meal times and he had not cleaned the resident room yet that day. He stated when he cleaned the resident's room he mopped the floor around the bed working his way to the bathroom. He stated the resident often tracked…

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 representative was able to file a grievance in a timely manner for 1 of 1 sampled resident reviewed for grievances (#31). This placed residents at risk for unresolved concerns. Findings include: Resident 31 was admitted to the facility in 2020 with diagnoses including bipolar disorder and vascular dementia. On 4/4/23 at 1:32 PM Witness 4 (Family) stated the facility sent a grievance form by email but she was not able to open the attachment. She wanted to follow up on concerns about a missing cell phone. According to a social services progress note dated 1/5/23 by Staff 6 (Social Service Coordinator) Witness 4 reported the missing cell phone and stated she wasn't able to video chat with the resident. The note indicated the facility would check on the lost items. A Social Services progress note by a different staff member dated 1/9/23 stated Witness 4 was told we have to file a grievance to get the phone replaced. A 4/6/2023 at 11:32 AM Social Services Note indicated a copy of a blank…

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 or develop a comprehensive care plan for 1 of 5 sampled residents (# 16) reviewed for medications. This placed residents at risk for unmet needs. Findings include: Resident 16 was admitted to the facility in 2022 with diagnoses including stroke and thrombophilia (blood clots too easily). Resident 16's 10/17/22 CAAs indicated the resident had a history of recurrent strokes secondary to thrombophilia. Resident 16 had INR (blood test to determine dosing for anticoagulant medication) testing ordered and was followed by hematology (treatment of blood disorders) as an outpatient. Resident 16's 4/2023 physician's orders included warfarin (anticoagulant medication) once daily for thrombophilia. Resident 16's 4/2023 care plan did not include safety interventions and monitoring for bruising or bleeding related to anticoagulant use. On 4/10/23 at 9:46 AM Staff 16 (CNA) stated he would have to ask the nurse or medication…

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

Based on observation, interview and record review it was determined the facility failed to revise care plans in the areas of nutrition and ADLs for 1 of 1 sampled resident (#309) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include: Resident 309 was admitted to the facility in 3/2023 with diagnoses including stroke and hemiplegia (paralysis of one side of the body). Resident 309's 3/15/23 Physician Orders revealed the resident received a pureed texture diet and was able to feed herself/himself with guidance and supervision for safety. Resident 309's 3/16/23 Care Plan revealed the following interventions: -Close supervision and some physical help with eating; -Alternate between solids and liquids; -Encourage the resident to remain in an upright position for at least 30 minutes after meals; -Ensure the resident completed swallowing without pocketing foods; and -Instruct the resident to chew slowly and not to talk while chewing or swallowing. Resident 309's 3/20/23 admission MDS revealed the resident was cognitively intact and required set-up…

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 residents with limited range of motion received equipment to prevent further decrease in range of motion for 1 of 3 sampled residents (#32) reviewed for position and mobility. This placed residents at risk for worsening contractures. Findings include: Resident 32 was admitted to the facility in 8/2019 with diagnoses including Alzheimer's disease. Resident 32's 3/9/23 Quarterly MDS revealed the resident was severely cognitively impaired, required extensive assistance from staff with dressing, personal hygiene and eating and had upper extremity impairment on one side. Resident 32's 3/7/23 Care Plan indicated the resident was to have bilateral inflatable cone shaped splints (called carrots) placed in both hands. The Care Plan indicated the carrot splints were okay to be removed when the resident participated with eating and dressing. Observations of the resident from 4/3/23 to 4/7/23 between 8:35 AM to 4:20 PM revealed the resident's right thumb was tucked in under the remaining four…

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 withhold a blood pressure medication according to physician ordered parameters for 1 of 5 sampled residents (#49) reviewed for medications. This placed residents at risk for low blood pressure. Findings include: Resident 49 was admitted to the facility in 10/2022 with diagnoses including paroxysmal atrial fibrillation (an irregular heart rate that commonly causes poor blood flow). Resident 49's 3/11/23 Physician Orders included metoprolol tartrate (treats high blood pressure, chest pain and heart failure) twice daily and to hold the medication if the resident's systolic (the upper number in a blood pressure reading) blood pressure was less than 100 or if the resident's heart rate was less than 70. Resident 49's 3/2023 and 4/2023 MARs revealed the metoprolol tartrate was administered on 3/12/23, 3/14/23, 3/18/23, 3/20/23, 3/21/23, 3/23/23, 3/26/23, 3/27/23, 3/29/23, 3/31/23, 4/1/23 and 4/4/23 when the resident's heart rate was less than 70. On 4/7/23 at 10:15 AM Staff 22 (CMA) reviewed Resident 49's 3/2023…

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 observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent for 1 of 6 sampled residents (#309) reviewed for medication administration. There were five errors in 29 opportunities resulting in a 17.24% error rate. This placed residents at risk for adverse medication consequences. Findings include: Resident 309 was admitted to the facility in 2023 with diagnoses including stroke. Resident 309's 3/15/23 physician's orders included: - crush medications in a teaspoon of puree (a smooth blended food) - aspirin chewable - multivitamin with minerals - atorvastatin (cholesterol lowering medication) - levetiracetam (used to treat seizures) - tamsulosin (urinary retention medication) Resident 309's March and April 2023 MARs and TARs did not include the physician's order for the resident's medications to be crushed. Resident 309's 3/16/23 Care Plan included an aspiration precaution intervention to crush medications in applesauce or pudding. On 4/6/23 at 9:25 AM Staff 22 (CMA) was observed to administer…

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.