Mesa Hills Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #36) of 8 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #36 was coded in the MDS for falls. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Record review of Resident #36's face sheet dated 05/06/25 revealed Resident #36 was admitted on [DATE] and was [AGE] years old. Resident #36 had diagnoses of Alzheimer's Disease (a progressive disease that affects memory, thinking, and behavior), muscle weakness, lack of coordination, and hemiplegia (paralysis or severe weakness on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) affecting left and right side. Record review of Resident #36's comprehensive care plan reflected: Resident #36 is at risk for…

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 observations, interviews, and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 Resident (Resident #91) of 8 residents reviewed for foot care. The facility did not provide adequate foot care for Resident #91. Resident #91's nails were greyish/black, thick, and long. The nail of her right big toe was curving and growing toward her second toe. This failure could put residents at risk for infection, impaired mobility, and poor foot health as well as a decline in their quality of life. The findings were: Record review of Resident #91's admission Record indicated Resident #91 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance (the loss of cognitive function that interferes with daily life and activities), type 2 diabetes mellitus (a disease in which your blood glucose, or blood sugar, levels are too high), muscle weakness, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents and failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 3 residents reviewed for accidents (Resident #97). The facility failed to provide adequate supervision to ensure Resident #97 did not obtain and keep cigarettes at his bedside. This failure could place residents who require supervision to prevent accidents and ensure their environment remains as free of accident hazards as possible, at risk for decreased quality of life or injury that could result in unnecessary hospitalization. Findings included: Record review of Resident #97's face sheet dated 05/04/25 indicated Resident #97 was a [AGE] year old male admitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus (body's inability to use insulin properly, leading to high blood sugar levels requiring insulin injections to manage) without Complications, Essential (Primary)…

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 observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 Resident out of 5 (Resident #42) reviewed for Enhanced Barrier Protections (EBP) for infection control practices. LVN A failed to follow Enhanced Barrier Precautions for an indwelling medical device (gastrostomy tube) for Resident #42. This failure could place residents at risk for cross contamination and the spread of infection. Findings included: Review of Resident #42's admission Record, dated 5/5/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a condition that affects one side of the body, usually caused by a stroke or other brain injury) and gastrostomy status (is the presence…

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 the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 4 of 10 (Resident #3, Resident #4, Resident #5, and Resident #6)) residents reviewed for environment. 1.The facility failed to ensure Resident #3's room was thoroughly cleaned, the walls and in good condition. 2.The facility failed to ensure Resident #4's room was thoroughly cleaned, and in good condition. 3.The facility failed to ensure Resident #5's room was thoroughly cleaned; and in good condition; and had privacy from the outside. 4.The facility failed to ensure Resident #6's door to bathroom did not have a hole and walls were painted and free from black spots. These failures could place residents at risk of living in an unsafe, unclean, and unsanitary environment which could lead to a decreased quality of life. The findings included: 1.Record review of Resident #3'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding, for one Resident (Resident #2) of two residents reviewed for feeding tubes, in that: Certified Nurse Aide (CNA) C was not competent in and did not follow facility protocols regarding feeding tube nutrition and care. CNA A adjusted Resident #2's feeding pump while providing Resident #2 with incontinent care. This failure could place residents with feeding tubes at risk for reflux, aspiration, nausea, vomiting, cramps, or diarrhea. Findings included: Review of Resident #2's Face sheet dated 4/17/25 revealed age [AGE] year-old female admitted on [DATE] with the diagnosis gastrostomy (opening in the stomach for food status. Record Review of Resident #2's Care plan dated 3/12/21 revealed: The resident requires tube feeding related to dysphagia and history of swallowing problem. Date initiated 3/25/24.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source were reported immediately to the State Survey Agency, within two hours, if the events that cause the allegation involve abuse or result in serious injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury for 1 resident (Resident #2) of 3 residents reviewed for abuse/neglect, The facility did not report the allegation of resident abuse to the State Survey Agency within the frame for Resident #1 who had been found with drug paraphernalia in his room. This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse and neglect. The findings included: Record review of Resident #2's face sheet dated 03/30/2025 reflected she was a [AGE] year-old male who was admitted to facility on 7/19/2023, relevant 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents reviewed for accidents. (Resident #3) The facility did not ensure Resident # 3's smoking supplies were stored at Nurses' station. This failure could place 4 residents who require supervision, at risk for a decreased quality of life or injury that could lead to an unnecessary hospitalization. Findings included: Record review of Resident #3's face sheet dated indicated Resident #3 was [AGE] years old male and admitted on [DATE] diagnoses of type 2 diabetes (the most common form of diabetes, characterized by the body's inability to use insulin properly, leading to high blood sugar levels, and often requiring lifestyle changes medication, or insulin injections to manage), anxiety disorder (a mental health condition characterized by persistent and excessive fear or worry that interferes with daily life, often accompanied by physical…

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 the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this was not possible or resident preferences indicate otherwise for 1 of 17 residents reviewed for nutritional status (Resident #1). The facility failed to ensure Resident #1 did not have a significant weight loss in 3 months. The facility failed to follow the dietitian recommendations to Resident #1 who had experienced significant weight loss. These failures could place residents at risk for malnourishment, illness, skin breakdown, and decreased quality of life. Findings included: Record review of a face sheet dated 3/29/2025 indicated Resident #1 was a [AGE] year-old male who was initially admitted on [DATE] and readmitted on [DATE] with the diagnoses of bipolar disorder, current episode manic severe with psychotic features (a chronic mental health condition…

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, interviews and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #72 ) of three residents reviewed for dignity. The facility failed to promote Resident #72's dignity by not covering his catheter's urinary collection bag with a privacy bag. This failure could place residents with catheters at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings included: Record review of Resident #72's admission record dated 03/24/24, reflected Resident #72 was a [AGE] year-old-male admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnoses which included, schizophrenia (severe mental disorder that affects the way a person thinks), bipolar disorder (mental disorder characterized by periods of depression and abnormally elevated moods), metabolic encephalopathy…

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 provide services with reasonable accommodation of resident needs and preferences, for 2 of 8 residents (Resident #11 and Resident # 35) reviewed for accommodation of needs. The facility staff did not provide Resident #11 and Resident #35 with a call light that was within reach. This failure could place residents who utilized call lights at risk for not having his/her needs met. Findings included: 1)Record review of the admission record for Resident #11 dated 03/27/24 reflected Resident #11 was admitted to the facility on [DATE], was a [AGE] year-old female with diagnosis that included diabetes (sustained high blood sugar levels), morbid obesity (overweight), chronic obstructive pulmonary disease with acute exacerbation (lung disease), legal blindness and asthma (inflammatory disease of the airways of the lungs.) Record review of the admission MDS assessment dated [DATE] for Resident #11 reflected Resident #11's cognitive status was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 8 residents (Resident #11) reviewed for care plans in that: The facility failed to develop a care plan to address Resident #11's in-room activities. These failures could place residents at risk of not receiving individualized interventions for their care needs. The findings included: Record review of the admission record for Resident #11 dated 03/27/24 reflected Resident #11 was admitted to the facility on [DATE], was a [AGE] year-old female with diagnosis that included diabetes (sustained high blood sugar levels), morbid obesity (overweight), chronic obstructive pulmonary disease with acute exacerbation (lung disease), legal blindness and asthma (inflammatory disease of the airways of the lungs.) Record review of the admission 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure a resident who entered the facility with an indwelling catheter and is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for one of 8 residents (Resident #72) reviewed for incontinent care and catheter care, in that. The facility failed to obtain documented MD orders from re-admission from hospital for catheter use which included catheter size, balloon inflation parameter and frequency of care for Resident #72. This deficient practice could place residents at-risk for infection due to improper catheter care practices. Findings included: Record review of Resident #72's admission record dated 03/24/24, reflected Resident #72 was a [AGE] year-old-male admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnoses which included, schizophrenia (severe mental disorder that affects the way a person thinks), bipolar disorder (mental disorder characterized by periods…

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 ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 2 of 4 residents (Resident #77 and Resident #81) reviewed for enteral nutrition, in that: The facility failed to follow physician's orders to ensure that Resident #77 and Resident #81 received the appropriate amount of enteral nutrition. This deficient practice could affect residents receiving optimal enteral nutrition and place them at risk of health complications and decline. The findings include: Record review of care plan for Resident # 77 revealed: Resident is totally dependent on (1) staff for peg tube feedings. Patient is NPO . Initiated/revised 2/16/2024. Resident requires tube feeding r/t dysphagia. Refer to physician orders for peg tube care and feedings. Date initiated: 2/16/24. Record review of admission record/face sheet for Resident #77 revealed: Diagnosis of unspecified protein-calorie malnutrition and gastrostomy status. Record review of MAR revealed 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 observation, interview, and record review, the facility failed to ensure a prescribed medication was given for 1 of 5 residents (Residents # 25) reviewed for Medication Pass. The facility failed to prevent Resident #25 from missing his daily nose spray . These failures could place the residents at risk of not receiving the therapeutic dosage of medications prescribed by the physician. The findings included: Record review of Order Summary revealed Resident #25 ordered Fluticasone Propionate Nasal Spray 2 sprays in each nostril daily for Nasal Congestion. Record review of Resident #25's MAR revealed Fluticasone Propionate Nasal Spray not given on 3/26/24 with a numerical code of 9 = Other/See Nurse Notes. Nurse notes on medication order for Fluticasone Propionate revealed medication last order date 3/26/24. No other notes noted. Observation of Medication Pass on 03/26/24 at 07:31 AM with LVN H revealed Resident #25 did not receive his nasal spray. In an interview with LVN H on 3/26/24 at 7:40 am after the med pass for Resident #25 was complete, she stated that she needed 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 record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for one Resident (R#14) of nineteen residents whose medications were reviewed, in that: The facility's Pharmacy Consultant recommended that the physician review the use of duplicate antipsychotic therapy with Risperidone and Quetiapine. The facility failed to ensure the attending physician documented his rationale for making changes to Resident #14's antipsychotic therapy in Resident #14's medical record. These failures could place all residents receiving anti-psychotic medications at risk for adverse drug consequences. The findings were: 1) Record review of Resident #14's Physician's orders for March 2024 revealed Resident #14 was admitted to the facility on [DATE] and was a [AGE] year-old female with diagnosis that included schizophrenia (characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, 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, the facility failed to ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in 1 of 2 medication rooms (medication storage located in 100 hallway) reviewed for medication storage and labeling. The facility failed to ensure that all medical supplies in the medication storage room in the 100 hallway were not past their expiration date. The facility's failure could result in residents receiving expired medical supplies, such as formula, as well as those supplies not being maintained at their best therapeutic level. The findings include: Observation of medication storage room in the 100 hallway on 03/26/24 at 04:15 PM revealed 12 cartons of Diabetisource tube feed formula passed the used by date of March 11, 2024 were located among currently dated cartons of Diabetisource tube feed formula. Interviewed LVN G who witnessed the medication storage and labeling review…

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 observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to label and date frozen food items in one of one walk in freezers. These failures could residents at risk for food contamination and food-borne illness and impact the health and nutrition of residents. Findings included: Observation on 03/25/24 at 9:02 am of the walk-in freezer revealed frozen food items, 10 bags of peas, 5 bags of green beans, 10 bag of corn, 5 bags of beef, 3 bags of pork and 2 bags of chicken that were undated. Interview on 03/25/24 at 9:15 am with the Dietary Manager revealed all the listed frozen food items had not been dated when they were received and placed in the walk-in freezer because he would keep inventory of food items placed in the freezer and made sure those items were used first and then he would order more food items to place in the freezer. The Dietary Manager said the freezer temperature…

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, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #72 ) of 8 residents reviewed for accurate medical records. The facility failed to correctly transcribe the physician orders for Resident #72 related to indwelling catheter and document the treatment orders for catheter care. This failure could place resident at risk of not receiving needed care or treatments by misleading care providers regarding what care or treatment resident should receive. The findings include: Record review of Resident #72's admission record dated 03/24/24, reflected Resident #72 was a [AGE] year-old-male admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnoses which included, schizophrenia (severe mental disorder that affects the way a person thinks), bipolar disorder (mental disorder…

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 ensure residents received services with reasonable accommodations of resident needs and preferences for 2 (Resident # 17, Resident #19) of 15 residents reviewed for accommodations of needs. The facility failed to ensure Resident #17's and Resident's 19's call light was within reach. This deficient practice could place residents at risk of injury or harm due to not being able to call for assistance. The findings were: Record review of Resident #17's admission Record indicated Resident #17 was a [AGE] year-old admitted to facility on 02/22/22 with diagnoses of anemia (condition in which the blood doesn't have enough red blood cells), hypertension (abnormally high blood pressure), and chronic kidney disease, stage 5 (the kidneys are getting very close to failure or have already failed). Record review of Resident #17's MDS quarterly assessment dated [DATE], revealed Resident #17: -understood and was understood by others, -was moderately…

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 medications were stored and labeled in accordance with currently accepted professional principles on 1 of 3 medication carts (200) reviewed for medication storage in that: 1 liquid medication and 2 ointments found in 200 hall carts were not marked with the date they were opened and accessed. 1 ointment medications in the 200-hall medication cart were past the expired date. The failure could place residents receiving medication at risk for administration of medication incorrectly or that are ineffective resulting in exacerbation of the disease being treated or the introduction of infection from contamination. Findings include: During observation of 200 hall cart (back cart) on 02/03/23 at 09:33 AM revealed undated and expired medications. Findings include the medication Pink Bismuth regular strength -used for upset stomach reliever. Pink Bismuth was noted opened and used with no opened date. An antibiotic ointment…

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 the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one of 8 residents (Resident #10) reviewed for care plans in that: Resident #10's comprehensive person-centered care plan did not address the resident's behavior of removing her nasal cannula used (O2 tubing) for oxygen therapy. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings included: Record review of the admission record dated 02/02/23 for Resident #10 indicated Resident #10 was a [AGE] year-old female who was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #10's diagnosis…

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 provide pharmaceutical services that assure acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of one (Resident #50) of 10 residents whose medications were reviewed for pharmacy service. -LVN A prepped medications for Resident #50 and placed them unsecured in a medicine cup on the top drawer in the 300 hall medication cart to administer at a later time. This failure could place residents at risk of medication errors. The findings included: 1.) Record review of Resident #50's face sheet dated 02/03/2023 indicated Resident #50 was a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with the diagnoses of Acute and chronic respiratory failure with hypercapnia, pulmonary fibrosis, chronic obstructive pulmonary disease, type 2 diabetes mellitus, gastroparesis, dysphagia, cognitive communication deficit, hypertension, tracheostomy, and depressive disorder. Record review of 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.