Medina Valley Health & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for 1 of 2 residents (Resident #52) whose records were reviewed for PASRR services. The facility failed to recognize on the Level I PASRR screening that Resident #52 had the mental illness diagnoses of Post Traumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) which would qualify Resident #52 for a PASRR evaluation. This deficient practice could place residents with mental illness at risk for not obtaining the services needed to treat their mental health diagnoses. The findings include: Attempted to interview Resident #52 on 11/13/24, resident was a poor historian. Record review of Resident #52's admission sheet, dated 5/26/24, noted the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a movement disorder of the nervous system), Angina (a condition of insufficient oxygen in the blood…

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 revealed the facility failed to ensure the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 7 Residents (Resident #36 and Resident #15) whose records were reviewed for Care Plans. 1. Staff failed to ensure Resident #36's Care Plan reflected he was hearing impaired and used an amplifier as a hearing aid. 2. The facility failed to update Resident #15's Care Plan to reflect a history of UTIs with interventions for staff to monitor the resident for possible UTI symptoms. This deficient practice could affect any resident and result in residents not receiving the care and services they needed. 1. Review of Resident #36's face sheet, dated 11/15/24, revealed he was admitted to the facility on [DATE] with diagnoses including unspecified sequelae of cerebral infarction and Major Depressive disorder, recurrent severe without psychotic…

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 unable to carry out activities of daily living received the necessary services to maintain good personal and oral hygiene for 1 of 7 Residents (Resident #36) whose records were reviewed for activities of daily living. Nursing staff failed to brush Resident #36's teeth and wash his face for 1 of 4 survey dates, 11/14/24 and nursing staff failed to clip his nails for an undetermined amount of time. This deficient practice could affect residents who required assistance and could result in poor hygiene and feelings of dissatisfaction. The findings were: Review of Resident #36's face sheet, dated 11/15/24, revealed he was admitted to the facility on [DATE] with diagnoses including unspecified sequele of cerebral infarction and Major Depressive disorder, recurrent severe without psychotic symptoms. Review of significant change MDS assessment, dated 10/1/24, revealed Resident #36's BIMS was 11 reflecting moderate…

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 that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 (Resident #191 and Resident #15) of 2 residents reviewed for catheter care and or incontinent care. 1. The facility failed to ensure CNA L and CNA M did not leave stool on Resident #15 when performing incontinent care. 2. The facility failed to ensure CNA J and CNA K kept Resident #191's urine catheter bag below the level of the bladder during incontinent care. This failure could place residents at risk for urinary tract infections. Findings included: 1. Record review of the admission Record, printed 11/15/24, reflected Resident #15 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing an area of dead brain tissue), extended spectrum beta…

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 establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for two of ten residents (Resident #24 and Resident #41) reviewed for pharmacy services. The facility failed to ensure medication doses noted on the electronic Medication Administration Record (MAR) matched doses recorded on the Controlled Drug Reconciliation Log for Resident #24 and #41. This deficient practice could put residents at risk for pain, anxiety, misappropriation, and drug diversion. Findings include: Review of Resident #24's admission sheet, dated 8/18/24, noted the resident was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Anxiety Disorder, Dementia, Angina, Hypertension, Hyperlipidemia, and Major Depressive Disorder (MDD). Review of Resident #24's quarterly MDS assessment, dated 8/22/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all medications were labeled in accordance with currently accepted professional principles for one of ten residents (Resident #55) reviewed for medication labeling and storage. The facility failed to ensure Resident #55's insulin pen was labeled with the date it was opened. This deficient practice could place residents who receive medications at risk of not obtaining the therapeutic level of their prescribed medications. The findings include: Review of Resident #55's admission sheet, dated [DATE], noted the resident was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Anxiety Disorder, Dementia, Hypertension, Hyperlipidemia, and Major Depressive Disorder (MDD). Review of Resident #55's quarterly MDS assessment, dated [DATE], noted the resident BIMS was 8, indicating he had moderate cognitive impairment and a diagnosis of Type 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 (Resident #15 and Resident #191) of 8 residents reviewed for accuracy and completeness of clinical records. 1. The facility failed to timely document Resident #15's complaints of dysuria (a painful or uncomfortable feeling when urinating, often described as a burning, stinging, or itching sensation in the urethra or urethral meatus) on 11/03/24 and 11/11/24. 2. The facility failed to document a wound care order in active orders, when it was ordered on 11/12/24, and not active until 11/14/24, for wound care treatment for Resident #191 who developed a open reddened area to her gluteal folds after admission. This failure could affect any residents who have medical records and could result in misinformation about professional care provided. Findings included: Record review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 residents (Resident #191) reviewed for hospice services, in that: The facility failed to ensure Resident #191's most recent Physician Certification of Terminal Illness and Hospice Election form were completed and were part of the hospice documents at the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of the admission Record, dated 11/15/24, reflected Resident #191 was a [AGE] year-old female originally admitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 4 residents (Residents #15) reviewed for infection control 1. The facility failed to ensure CNA L and CNA M used appropriate hand hygiene between glove changes when providing incontinent care to Resident #15. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of the admission Record, printed 11/15/24, reflected Resident #15 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing an area of dead brain tissue), extended spectrum beta lactamase (ESBL) resistance ( enzymes that make…

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 maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 multi compartment sinks (Dishwashing Sink) reviewed for essential equipment. The facility did not ensure the dishwashing sink was not leaking and used a food safe repair sealant. This failure could place the residents at risk of foodborne illness for consuming food washed in potentially contaminated water. Findings included: During an observation on 11/14/24 at 4:48 p.m. the dishwashing sink middle compartment used to rinse dishes was leaking water from the bottom onto the floor. The sink had a soft, yellowish substance, along the inside of the bottom of the right side of the sink. The sink could not hold water for longer than 5 minutes. During an interview on 11/14/24 at 5:00 p.m. the DS stated she was not sure what to call the yellowish substance in the sink, but it was used to repair a leak in the sink. The DS stated that they did not know if the sealant used was food safe. The DS stated she had discussed…

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 interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily 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, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 2 of 8 residents (Residents #1 and #2) reviewed for reporting allegations of abuse and neglect. 1. LVN B and the Administrator heard an allegation of physical and sexual abuse on behalf of Resident #2 and failed to report…

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 interviews and record reviews the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 (Resident #1) residents reviewed for 2 person staff assistance with mechanical lift transfers. CNA C transferred Resident #1 by herself, with a mechanical lift, and caused Resident #1 transient head pain. Resident #1 was assessed as needing more than 1 staff assistance with all transfers. The non-compliance was identified as past non-compliance. The noncompliance began on 12/8/23 and ended on 12/11/23. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk for harm by neglecting to provide more than 1 staff assistance with mechanical lift transfers. The findings included: A record review of Resident #1's admission record dated 10/10/2024 revealed an admission date of 03/10/2017 with diagnoses which included Parkinson's disease with dyskinesia (a chronic brain disorder that causes movement…

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 interviews and record reviews the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 8 residents (Resident #3) reviewed for catheter care. The facility failed to ensure LVN A used a sterile technique when flushing Resident #3's urinary catheter. This failure could place residents at risk for infection. The findings included: A record review of Resident #3's admission record revealed an admission date of 08/22/2023 with diagnoses which included obstructive and reflux uropathy (a condition when urine can't drain through the urinary tract, causing it to back up into the kidneys) and retention of urine. A record review of Resident #3's quarterly MDS assessment dated [DATE], revealed Resident #3 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 15 which indicated no cognitive impairment. Further review 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.

Based on observation, interview, and record review the facility failed to ensure, in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts (Medication cart #1) reviewed for medication storage. The facility failed to ensure the Medication cart in the public area was locked. This failure could place residents at risk of medication misuse and drug diversion. Findings include: During observation and interview on 9/21/24 at 11:42 am, Medication cart #1 was observed to be unlocked and unattended by the state investigator and RN A. There were no staff at the nurses' station and there were six residents sitting in the public area where the unlocked medication cart was located. RN A said the medication cart was not supposed to be unlocked. RN A further stated it was important the medication carts were locked because otherwise both residents and visitors had access to medications. During an interview on 9/21/24 at 4:26…

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 that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or serious bodily injury for 1 (Resident #1) of 4 residents reviewed for freedom from abuse, neglect, and exploitation. The facility failed to report an allegation of resident neglect regarding Resident #1's unwitnessed fall with major injury to the State Agency within the allotted time frame of 2 hours. This failure could place all residents at increased risk for potential neglect due to unreported allegations of neglect. The findings included: Record review of Resident #1's face sheet, dated 07/26/2024, revealed Resident #1 was admitted on [DATE] and re-admitted on [DATE] with diagnoses which included: cerebral infarction (damage…

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 reviews, the facility failed to protect resident's clinical records for 2 of 6 residents (Residents #1 & #5) reviewed for clinical records, in that: MA A failed to lock and disable access to Resident #1's electronic health record while he walked away from his medication cart. LVN B failed to lock and disable access to Resident #5's electronic health record while she walked away from her medication cart. This failure could affect residents by having their records viewed and accessed by unauthorized personnel and violate the HIPAA. The findings included: Record review of Resident #1's face sheet, dated 11/15/2023, reflected an [AGE] year-old female with an admission date of 11/04/2023 and an admitting diagnosis of OTHER FORMS OF ACUTE ISCHEMIC HEART DISEASE (inadequate blood supply (circulation) to a local area due to blockage of the blood vessels supplying the area.) Record review of Resident #5's face sheet, dated 11/15/2023, reflected a [AGE] year-old female with an…

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 had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 3 of 3 residents (Resident #61, #82 and #40) observed for physical restraints in that: 1. The facility failed to obtain a consent for Resident #61 to wear a wander guard. 2. The facility failed to obtain a consent for Resident #82 to wear a wander guard. 3. The facility failed to obtain a consent for Resident #40 to wear a wander guard. This failure placed residents at risk of unnecessary restriction of their freedom of movement and diminished quality of life. The findings included: 1. Record review of Resident #61's face sheet, dated 09/21/23 documented a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included psychotic disorder with delusions due to known physiological…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility failed to ensure proper dating was used on dry and refrigerated items. 2. The facility failed to ensure dry food was stored in a proper container. 3. The facility failed to ensure there was paper towels at the hand washing sink. 4. The facility failed to ensure raw meat was thawed properly. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: 1. During an observation on 09/21/23 at 9:32 a.m. a bag of chocolate pudding was in inside of a plastic container with a label butterscotch pudding, Dated: 7/24-8/24. A box next to the plastic container of pudding read CHO PUDDING 06/08/23. No date was on the bag of chocolate pudding. A box of vanilla pudding read VAN PD 06/07/2023. A sticker label on the front of the box of vanilla pudding contained a bar code, item number, item name,…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Resident #76 and #43) reviewed for infection control practices, in that: 1. CNA C and RN D did not utilize appropriate hand hygiene during incontinent/peri care to Resident #76 2. LVN A placed a medication into the palm of her ungloved hand intended for Resident #43 These failures could place residents at risk of infection or a decline in health. The findings included: 1. Record review of Resident #76's face sheet, dated 9/22/23 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included urinary tract infection, lack of coordination and stage 3 chronic kidney disease (kidneys are damaged and can't filter blood the way they should).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible, for 1 of 2 Residents (Resident #76) reviewed for perineal/incontinent care, in that: CNA C failed to clean between Resident #76's vaginal folds during incontinent/peri care This deficient practice could place residents at risk of increased urinary tract infections due to improper care. The findings included: Record review of Resident #76's face sheet, dated 9/22/23 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included urinary tract infection, lack of coordination and stage 3 chronic kidney disease (kidneys are damaged and can't filter blood the way they should). Record review of Resident #76's most recent quarterly MDS assessment, dated 6/23/23 revealed the resident was moderately cognitively…

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 licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, and described in the plan of care for 4 of 7 residents (Resident #19, #80, #24, and #20) reviewed for nursing competencies, in that: LVN A failed to administer 7 medications outside of acceptable parameters for safe medication administration for Residents #19, #80, #24 and #20 and stored 2 medication cups with loose pills inside the medication cart. This failure could place residents at risk for not receiving their medications, not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: Record review of the nursing competency dated 7/25/23 for LVN E revealed she had satisfied the requirements for medication administration that included executing the 5 rights of medication administration (right patient, right medication, right dose, right time, right…

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 that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 32% based on 8 out of 25 opportunities, which involved 5 of 7 Residents (Residents #43, #19, #80, #24, and #20) reviewed for medication administration, in that: LVN A allowed Resident #43 to self-administer his inhaler without a physician's order or assessment and failed to administer 7 medications outside of acceptable parameters for safe medication administration for Residents #19, #80, #24 and #20. This failure could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: 1. Record review of Resident #43's face sheet, dated 9/21/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (not enough…

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 that residents are free of any significant medication errors for 2 of 7 residents (Resident #19 and #24) observed during medication administration in that: LVN A failed to administer Resident #19's insulin and Resident #24's insulin and seizure medication as prescribed by the physician. These deficient practices placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. The findings included: 1. Record review of Resident #19's face sheet, dated 9/21/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] and 3/24/23 with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with agitation, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and type 2 diabetes (a chronic, long-lasting 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.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly, for 1 of 2 dumpsters in that: Dumpster #1 had the side door open with garbage items visible and garbage on the ground outside the dumpster. This deficient practice could place residents who reside at the facility at risk of unsanitary conditions that could result in the attraction of vermin and rodents and expose them to germs and diseases carried by vermin and rodents. The findings were: Observation on 09/22/23 at 9:50 a.m. revealed Dumpster #1 had a side door and a glove and mask behind the dumpster on the ground. During an Interview with the DM on 09/22/23 at 9:50 a.m. the DM stated the dumpster side door should be closed after use. The DM stated the entire facility staff has access to this dumpster and she normally makes sure it is closed. The DM stated it should be closed to keep rodents out of the dumpsters. During an Interview with Administrator on 09/22/23 at 5:17 p.m., the Administrator stated the dumpsters should not be open, all staff have access to them,…

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.