Vista Hills Health Care Center

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 for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Residents #10) reviewed for care plans.The facility failed to have a comprehensive person-centered care plan for Resident #10 to address prescribed active Medications for pain, Tramadol 50 MG Take 1 tablet by mouth every 8 hours as needed pain, and Anxiety, Alprazolam 0.5 MG Take 1 tablet by mouth at bedtime.This failure could place residents at risk of not receiving care and services to meet individualized medical and nursing needs.Record review of Resident #10's face sheet dated 02/11/26 revealed a [AGE] year-old female with admission date 04/09/2025.Record review of Resident #10's health and physical progress note dated 02/10/26 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of eight residents ( Resident #58) reviewed for ADL care.The facility failed to ensure Resident #58's fingernails was clean and free from debris on 02/09/26. This failure could place residents who required assistance with ADL's at risk for unmet care needs.Findings included:Record review of Resident # 58's admission record dated 02/11/2026 revealed a [AGE] year old male admitted on [DATE] and readmitted on [DATE].Record review of Resident #58's History and Physical dated 01/13/2026, revealed a medical history of atrial fibrillation (heart condition where the top chambers of the heart quiver instead of beat causing irregular heartbeats).Record review of Resident # 58's five day MDS dated [DATE], revealed a BIMS score of 13 indicating intact cognition. Section…

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 residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 1 reviewed for quality of care. The facility failed to ensure staff acted in a timely manner to transfer Resident #1 to a hospital after radiologist confirmed a spiral femur fracture on 05/29/2025 at 11:51 PM and delayed response until 05/30/2025 at 06:32 AM. This failure resulted in the resident receiving delay in emergency care services for a fractured femur and placed the resident at risk of further harm and injury.Findings included: Record review of Resident #1's admission record dated 10/15/2025 revealed an [AGE] year-old female with an initial admission date on 09/22/2023 and readmission date on 06/03/2025. Resident #1 was discharged from facility at family's request on 06/09/2025. Record review of Resident #1 physical and health dated 06/05/2025 revealed the resident had a diagnoses of advanced dementia (a degenerative…

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 consult with the resident's physician when there was a significant change in the resident's physical status for one (Resident #1 ) of 4 residents reviewed for physician notification. -The facility failed to immediately consult with physician and/or Nurse Practitioner when the facility did not have 4 doses of the prescribed Entresto Oral Tablet on hand to administer to Resident #1 according to physician's orders. This failure could place residents at risk of delayed medical treatment. Findings Included: Review of the admission Record dated 04/20/25 revealed an [AGE] year old female that was admitted on [DATE]. Review of the Annual History & Physical dated 03/29/23 for Resident #1 revealed diagnoses of congestive heart failure (the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) and sick sinus syndrome(a type of heart rhythm disorder). Review of the optional state assessment MDS dated [DATE] for Resident #1,…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 4 residents reviewed for pharmacy services in that: -The facility failed to administer Entresto Oral Tablet to Resident #1 as ordered. This failure placed residents at risk of inadequate therapeutic outcomes and a decline in health due to not receiving medication as ordered. Findings included: Review of the admission Record dated 04/20/25 revealed an [AGE] year old female that was admitted on [DATE]. Review of the Annual History & Physical dated 03/29/23 for Resident #1 revealed diagnoses of congestive heart failure (the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) and sick sinus syndrome( a type of heart rhythm disorder). Review of the optional state assessment MDS dated [DATE] for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #8) of 3 residents reviewed for catheter care. The facility failed to ensure Residents #8s catheter leg strap was in place to secure the catheter. This failure could place residents with foley catheters at risk of catheter pulling causing pain. Findings included: Record review of Resident #8's face sheet dated 1/14/25 revealed a [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of retention of urine and neuromuscular dysfunction of bladder. Record review of Resident #8's significant change MDS assessment dated [DATE] revealed a BIMS score of 15, her cognition was intact and had and had indwelling catheter. Record review of Resident #8's physician order dated 10/16/24 revealed ensure catheter strap in place 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 interviews and record review, the facility failed to consider the views of the residents and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. The facility failed to demonstrate their responses and rational's for such response for 1 of 1 resident council. The facility failed to ensure concerns expressed in the resident council meetings for (the past 7 months) were reported to the administrator and designated department heads. This failure could lead to residents feeling unheard and unvalued in their place of residence. Findings included: In a confidential interview during the Resident Group revealed stated they felt the administrator did not make any efforts to address their concerns and grievances discussed in previous months at the resident council meetings. The residents stated they had requested copies of the Resident Council minutes from the previous meetings so that they could see what efforts had been made to resolve the grievances expressed by the residents but were denied a copy of the…

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

Based on interview, and record review the facility failed to treat residents with respect, dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 5 of 13 residents in the confidential group interview. The facility failed to provide privacy by conducting care plan meetings in resident rooms. These failures could place residents at risk of decreased feelings of self-worth and decreased quality of life. Findings included: In a confidential interview during the Resident Group revealed Care Plan reviews were being done in the residents' rooms in the presence of their roommates and staff members and/or visitors were able to go into the room and hear everything that was being discussed. The residents said this made them feel embarrassed and was a violation of their privacy. In an interview on 11/19/24 at 4:53 PM, with LVN MDS Nurse revealed resident care plans were conducted in resident room's and she was not aware if residents had voiced any concerns about this practice. In an interview with the Administrator on 11/20/2024…

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

Based on interview and record review, the facility failed to ensure the prompt resolution of all grievances to include all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed, any corrective action or to be taken by the facility as a result of the grievance, and the date when the decision was issued for 5 of 13 confidential residents reviewed for resident rights. 1. - The Activities Director failed to initiate grievance reports on behalf of the residents regarding grievances and concerns voiced during the Resident Council Meetings. 2. - The facility Administrator failed to document, resolve, and follow-up on grievances related to quality of care voiced by the residents during the Resident Council Meetings. 3. - The facility failed to ensure residents received responses to grievances and concerns voiced during the Resident Council…

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 a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #27) of 18 residents reviewed for assistance with ADLs. The facility failed to ensure Resident #27, who required assistance with ADLs, did not have long and dirty fingernails. This failure could affect residents who were dependent on assistance with ADLs and could result in poor care, lack of dignity, infection, and skin tears due to long nails. Findings include: Record review of Resident #27's admission Record, dated 11/18/24, reflected 61-year-female who was admitted on [DATE]. Record review of Resident #27's History and Physical dated 10/13/24, revealed diagnoses: intracerebral hemorrhage, non-verbal, limited range of motion and strength with hemiparesis (weakness on one side of the body). Record review of Resident #27's admission MDS dated [DATE],…

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 proper treatment and care to maintain mobility and good foot health in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 1 of 18 residents (Resident #27) reviewed for foot care. The facility failed to provide access to podiatrist for Resident #27. This failure placed residents at risk of poor foot hygiene and decline in residents' physical condition. Findings include: Record review of Resident #27's admission Record, dated 11/18/24, reflected 61-year-female who was admitted on [DATE]. Record review of Resident #27's History and Physical dated 10/13/24, revealed diagnoses: intracerebral hemorrhage and was non-verbal with limited range of motion and strength with hemiparesis (weakness on one side of the…

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

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of each resident for 3 (ADON L, RN A, and LVN C) of 4 licensed staff. The facility failed to ensure ADON L, RN A, and LVN C, signed off on the Controlled Drugs-Count Record after verifying all controlled substances in the medication cart were accounted for with the on-coming nurse at the change of shift. These failures could place residents at risk for not receiving the intended therapeutic response of prescribed medications and drug diversion of controlled substances. Findings include: Observation and Record Review on 11/18/24 at 9:42 AM, ADON L revealed she had already counted controlled substances at the change of shift with the nurse going off shift and had not sign the Controlled Drugs-Count Record right after she completed the count and had verified all controlled drug counts were correct with nurse going off shift. ADON L said…

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

Based on observation, interview, and record review, the facility failed to provide safe and secure storage of medications for 3 of 3 medication carts (halls E, B and C), 1 of 1 medication rooms checked for medication storage. 1. -The facility failed to ensure medications were stored according to routes of administration. 2. -The facility failed to ensure opened bottles of Acidophilus Probiotic Dietary Supplement were refrigerated after opening in 2 of 3 medication carts 3. -The facility failed to ensure medication cart drawers were clean and free of trash. These failures could affect residents that received medications from the facility and drug diversion. Medication Carts: Observation and interview on 11/20/24 at 3:20 PM with LVN H, on hall E revealed oral medications, and topical medications in a drawer were not stored according to routes of administration. LVN H, stated they had been trained to store medication in the medication cart according to route of administration. Observation and interview on 11/20/24 at 3:25 PM with Medication Aide J on hall B, revealed a bottle of…

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

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 1 of 1 diet test tray reviewed for food temperatures. 1. - The facility failed to maintain food hot on diet serve test tray. 2. - The facility failed to maintain cold foods in palatable temperatures of less than 41 degrees F. These failures could affect the residents by placing them at risk for malnutrition due to not providing appetizing temperature meal. Findings include: In a confidential interview with 13 of 13 residents revealed the meals were being delivered cold. Residents reported that this was an on-going problem, and nothing was being done to address their concerns. Food Temperature: In an observation and interview on 11/19/24 at 10:46 AM with the Director of Food and Nutrition revealed during food temperature checks revealed the Guacamole (a dip made from avocados) temperature was 43.3 degrees F. He said, The guacamole is not at the appropriate temperature, it should be less than 41 degrees F, so, I am going to put it in…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. 1. - The facility failed to keep metal shelving in the food preparation area free of food particles. 2. - The facility failed to discard expired perishable foods stored in the refrigerator. 3. - The facility failed to store food in refrigerators and freezers in sealed containers. 4. - The facility failed to label food containers stored in the refrigerators. 5. - The facility failed to keep the tile floor in the dry food storage area free of dust, white stains and food particles. 6. - The facility failed to keep food containers in the dry storage room free of dust, food particles and sealed. 8. - The facility failed to ensure Dietary Staff used gloves while taking food temperatures. 9.- The facility failed to ensure Dietary Staff sanitized the food thermometer in…

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, and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 1 of 1 laundry room, 2 of 2 linen closets and residents' rooms reviewed for environmental conditions. 1. - The facility failed to maintain wood linen closet shelves in clean linen closets and ensure the shelves were free from splintered edges. 2. -The facility failed to replace missing floor baseboards in the laundry room. 3. - The facility failed to maintain walls in the laundry room and ensure they remained free of holes and chipped paint. 4. -The facility failed to replace broken or missing tiles in the shower room. 5. -The facility failed to keep water drains in the shower room free of rust. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment. Findings included: Clean Linen Closets: In an observation on 11/20/24 at 3:14 PM with the Housekeeping Supervisor revealed multiple wood shelves edges in the clean linen closet were splintered in…

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 assessments accurately reflected the resident's status for 1 (Resident #5) of 7 residents whose records were reviewed for assessments. Resident #5 was not listed as having behaviors on her annual MDS assessment. This failure to ensure comprehensive and accurate assessments could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Findings included: Record review of Resident #5's face sheet dated 9/17/24 revealed a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses of generalized anxiety, major depressive disorder, and mild cognitive impairment. Record review of Resident #5's annual MDS assessment dated [DATE] revealed BIMS score of 15, indicating her cognitive was intact and the behaviors section revealed no history of any behavior. Record review of Resident #5's comprehensive care plan dated 8/27/24 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.

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, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #6) reviewed for care plans. The facility failed to ensure the a care plan was developed to include Resident #6's head of bed being elevated to 30 degrees due to continuous enteral feeding . This deficient practice could place residents at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings include: Record review of Resident #6's face sheet, dated 08/01/24, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #6 has diagnoses which included gastronomy status (medical procedure where a tube, often called a G-tube,…

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 a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 6 residents (Resident #6) reviewed for enteral feeding . The facility failed to ensure Resident #6's head of bed was maintained at 30 degrees elevated according to physicians' orders. The failure could place residents at risk of aspiration (when food or liquid goes into the lungs or airway). Findings include: Record review of Resident #6's face sheet, dated 08/01/24, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #6 has diagnoses which included gastronomy status (medical procedure where a tube, often called a G-tube, is inserted through the abdominal wall directly into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assure that one (Resident #5) of seven residents reviewed for enteral feeding, received appropriate treatment and services to prevent complications of enteral feeding. -The facility failed to ensure that Resident #5's feeding tube bags were labeled with name of resident, date, and time the administration began to ensure residents maintain nutritional status within optimal parameters. This failure could place residents receiving enteral feedings at risk of not being provided the correct enteral feeding and not receiving feeding care in a timely manner to prevent complications. Findings included: Record review of Resident #5's face sheet dated [DATE], revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Diagnosis included dysphagia (difficulty swallowing) and gastrostomy status (surgical procedure used to insert a tube through the abdomen and into the stomach). Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure that residents receive care, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 (Resident #2 and #5) of 7 residents reviewed for quality of care. 1. The facility failed on 02/12/2024 to ensure the pressure ulcer on Resident #2's sacrum was covered with a dressing as ordered. 2. The facility failed to ensure there were orders in place to provide treatment to Resident #2's right lateral great toe although treatment was being provided. 3. The facility failed to ensure Resident #5 had a pressure relieving mattress to prevent development of pressure ulcers. These failures could result in increased pain, infections, development of new pressure ulcers, and decline in quality of life for residents. Findings include: Resident #2 Record review of Resident #2's face sheet dated 02/14/2024 revealed he was [AGE] years old, was initially admitted to the facility…

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

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 1 of 2 treatment carts (North Side) checked for medication storage. 1. The facility failed to ensure Santyl Ointments stored in treatment cart had a prescription label. 2. The facility failed to store prescribed and over the counter external ointments separately and labeled with resident's name. 3. The facility failed to ensure oral swabs were not stored with external ointments in the treatment cart. 4. The facility failed to remove medications from treatment carts after residents were discharged from the facility. These failures could affect residents that received treatments at the facility by placing them at risk of not having prescribed medications and cross contamination. Findings include: Observation and interview on 02/12/24 at 11:08 AM, with the Treatment Nurse revealed facility had two treatment carts. An observation of Treatment Cart #1 (North Side) revealed multiple…

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 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 1(North Side) of 2 treatment carts checked for cross contamination, and in one (Room F-108) of seven resident rooms checked for cross contamination. 1. The facility stored a used wound vac (a machine that removes drainage from a wound) in the treatment cart. 2. The facility had multiple self-adhesive dressing rolls that were not stored in sealed container in the treatment cart. 3. The facility failed to ensure oral swabs were not stored with external ointments in the treatment cart. 4. The facility failed to ensure used resident gowns were not placed in garbage cans. These failures could result in increased risk of infection to residents. Findings include: Observation on 02/12/12/2024 at 11:55 AM revealed a yellow cotton hospital gown on top of a trash can inside room F-108. In 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 observations, interview and record review, the facility failed to consult with the physician when the resident experienced a change in condition for 1 of 7 residents (Residents #4) reviewed for resident rights, in that: The facility failed to ensure the treatment nurse notified the physician when Resident #4 had a change in skin integrity. This deficient practice could place residents at risk of a delay of medical treatment. Findings included: Record review of Resident #4's admission record dated 02/12/2024 revealed Resident #4 was an [AGE] year-old woman admitted to the facility on [DATE]. Record review of Resident #4's History & Physical dated 09/27/23 revealed Resident #4 was an [AGE] year-old female transferred from foster home. Past Medical History; dementia, depression, and insomnia. Skin: No rash. No skin breakdown. Record review of Resident #4's MDS assessment dated [DATE] revealed she rarely made herself understood; had short-term memory problems. Her cognitive skills for Daily Decision Making…

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 to meet a resident's medical, nursing, and mental and psychosocial needs that describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #3) of seven residents reviewed for comprehensive person-centered care plans. The facility failed to develop and implement a care plan to address Resident #3's behavior of scratching. This failure put residents at increased risk of discomfort, impairment of skin integrity, and infection. Findings included: Resident #3 Record review of Resident #3's face sheet dated 02/15/2024 revealed she was [AGE] years old, was initially admitted to the facility on [DATE], and readmitted on [DATE]. Record review of Resident #3's History and Physical (H&P) dated 1/10/2024 revealed she was nonverbal and had diagnoses including 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, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #4 & #3) of three residents reviewed for quality of care. The facility failed to ensure treatment nurse transcribed the physician treatment order to treat Resident #4's rash on groin area. The facility failed to identify and treat Resident #3's rash and behavior of scratching. This failure placed residents at risk for delays in treatment, developing infections and deterioration of skin condition. Findings included: Resident #4 Record review of Resident #4's admission record dated 02/12/2024 revealed Resident #4 was an [AGE] year-old woman admitted to the facility on [DATE]. Record review of Resident #4's History & Physical dated 09/27/23 revealed Resident #4 was an [AGE] year-old female transferred from foster home. Past Medical History; dementia,…

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, interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 7 residents (Residents #4) reviewed for resident rights. The facility failed to ensure the treatment nurse documented she notified the physician when Resident #4 had a change in skin integrity. This deficient practice could place residents at risk of a delay of medical treatment. Findings included: Record review of Resident #4's admission record dated 02/12/2024 revealed Resident #4 was an [AGE] year-old woman admitted to the facility on [DATE]. Record review of Resident #4's History & Physical dated 09/27/23 revealed Resident #4 was an [AGE] year-old female transferred from foster home. Past Medical History; dementia, depression, and insomnia. Skin: No rash. No skin breakdown. Record review of Resident #4's MDS assessment dated [DATE] revealed she rarely made herself understood; had short-term memory problems. Her cognitive skills for Daily Decision Making…

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 were free from any physical restraints imposed for the purposes of convenience and not required to treat the resident's medical symptoms for two (Resident #2 and Resident #4) of 7 residents reviewed for restraints. The facility failed to ensure a scoop mattress (a mattress with built up sides that create a barrier to help stop residents from rolling or sliding out of bed) was not used with Resident #2 and Resident #4 without any medical indication. This failure could result in residents having physical restraints used that limited their movement without being evaluated for the medical need for this. Findings include: Resident #2 Record review of Resident #2's face sheet dated 02/01/24 revealed admission on [DATE] to the facility. Record review of Resident #2's facility history and physical dated 09/27/23 revealed an [AGE] year-old female diagnosed with Dementia. Record review of Resident #2's quarterly MDS dated [DATE]…

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 provide pharmaceutical services to meet the needs for 1 (Resident #3) of 7 residents reviewed for pharmacy services. The facility did not provide Resident #3's Clozapine (used to treat severely ill patients with schizophrenia who have used other medicines that did not work well). The medication was not available as the facility pharmacy was not contacted regarding the refill of the medication. The facility did not have pharmacy recommendations for Gradual Dose Reduction forms for Resident #3, that were signed and reviewed from the physician. This failure could place residents at risk for a delay in medication administration and could place residents at risk of medical complications due to missed doses and reviewed pharmacy gradual dose reductions forms. Findings include: Record review of Resident #3's face sheet dated 01/30/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #3's facility history 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 interviews and record review the facility failed to provide or obtain laboratory services only when ordered by the physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State Law, including scope of practice laws and promptly notify the ordering physician of the results for 1 (Resident #3) of 7 residents reviewed for labs. Resident #3's labs were not drawn monthly as ordered by the physician. This failure could place residents at risk of a delay in receiving the necessary interventions to treat their medical condition. Findings include: Record review of Resident #3's face sheet dated 01/30/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #3's facility history and physical dated 01/04/24 revealed a [AGE] year-old female diagnosed with schizophrenia (a serious mental disorder in which people interpret reality abnormally). Record review of Resident #3's quarterly MDS dated [DATE] revealed no impairment of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation. 1. Facility Staff and Dietary Staff were not wearing hair nets or beard guards when entering or working in the kitchen. This failure could affect residents by placing them at risk of food borne illness. Findings include: Observation and interview on 01/30/24 at 11:00 AM, the Maintenance Director was observed going into the kitchen without a hair net or beard guard. The Maintenance Director stated it was okay to go into the kitchen without a hair net or beard guard. In the back in the kitchen Dietary [NAME] did not have his hair net or beard guard on. The Maintenance Director stated the Dietary Manager had in-serviced all of the facility staff of what should be worn when in the kitchen. During an interview on 01/30/24 at 11:20 AM with Dietary Cook, he stated a hair net and beard guard…

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 provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of one (Resident #2) of seven residents reviewed for availability of medications. The facility failed to obtain and administer Lyrica (pain medication) nine time between 12/01/23 and 12/05/2023 as per physician's orders to Resident #2. This failure puts residents at risk of not receiving prescribed medications and experiencing pain or other symptoms of diagnosed conditions. Findings included: Record review of Resident #2's face sheet dated 12/12/2023 revealed he was [AGE] years old, was initially 06/30/2023 and readmitted on [DATE]. Record review of Resident #2's History and physical dated 07/03/2023 revealed he had bilateral foot deformities with osteomyelitis (swelling in the bones usually due to an infection), and amputation of his left big toe and other left toes. He 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 interview and record review the facility failed to implement written policies that prohibit and abuse, neglect, and exploitation of residents and to investigate any such allegations for one (Resident #1) of 7 residents reviewed for implementation of written abuse, neglect, and exploitation policies: The facility failed to follow the facility policy on reporting allegations of all alleged violations to the Administrator, State agency and other officials in accordance with state law on and to investigate any such allegations on 12/05/23 when Resident # 1 had bruises on left groin of unknown origin. This failure could place all residents at the facility at risk for abuse. Findings included: Record review of admission record dated 12/09/2023 revealed Resident #1 was a [AGE] year-old woman admitted to the facility on [DATE]. Record review of Resident #1's Annual History and Physical 10/03/2023 revealed she was non-verbal, not alert to surroundings and on hospice care. Patient requires total assistance with…

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, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 1 (Resident #1) of 7 residents reviewed for abuse. -LVN C failed to immediately notify the Administrator on 12/05/23 Resident #1 had bruising left groin of unknown origin. - Facility failed to report an injury of unknown origin to the State Survey Agency within 24 hours of being reported to Administrator on 12/05/23. This failure could place residents at risk for abuse and neglect. Findings Included: Record review of admission record dated 12/09/2023 revealed Resident #1…

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 the transfer or discharge is documented in the medical record for 1 (Resident #1) of 7 residents reviewed for clinical records. The facility failed to complete Transfer/Discharge Form on 12/12/23 when Resident #1 was sent for Evaluation to the Emergency Room. This failure could put residents at risk of arriving at the emergency room without information regarding their medical conditions or needs. Findings included: Record review of admission record dated 12/09/2023 revealed Resident #1 was a [AGE] year-old woman admitted to the facility on [DATE]. Record review of Resident #1's Annual History and Physical 10/03/2023 revealed she was non-verbal, not alert to surroundings and on hospice care. Patient requires total assistance with ADLs (activities of daily living). Patient bed-bound, gastrostomy tube (feeding tube inserted directly through the abdominal wall into the stomach). Past Medical History: Dementia of the Alzheimer's Type, and Depression.…

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 develop and implement comprehensive person-centered care plans that included measurable objectives and time frames, to meet a resident's medical and nursing needs, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Resident #1) reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #1's interventions for falls, including a fall mat, and bed being in a low position, and for activities of daily living. This deficient practice could place residents, in the facility, at risk of not receiving the necessary care or services and not having personalized plans developed to address their needs. Findings included: Resident #1 Record review of Resident #1's face sheet, dated 12/18/23, revealed admission on [DATE] and readmission on [DATE] to the facility. Record review of Resident #1's hospital history and physical, dated 11/12/23,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, 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 1 (Resident #1) of 5 residents reviewed for accuracy and completeness. The facility failed to complete a SBAR for Resident #1's significant change in condition. The facility failed to accurately document wound description after each wound care provided to Resident #1. This failure could place residents at risk of not having accurate and complete information available to those providing their treatment and care. Findings included: Record review of Resident #1's face sheet dated 10/17/23 revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of encephalopathy (any disease that affects the whole brain and alters its structure or how it works, and causes changes in mental function), sepsis (life-threatening complication of an infection), acute kidney failure (kidneys suddenly can't…

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 the resident/ RP has the right to be informed of, and participate in, his or her treatment for one (Resident #1) of 5 reviewed for resident rights and RP rights, in that: Resident #1's RP was not notified or provided any information on Resident #1's discovered necrotic tissue on 09/22/23. The RP was denied the opportunity to participate on Resident #1's treatment options. This failure could place residents at risk of not being aware/informed to treatment options. Findings included: Record review of Resident #1's face sheet dated 10/17/23 revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of encephalopathy (any disease that affects the whole brain and alters its structure or how it works, and causes changes in mental function), sepsis (life-threatening complication of an infection), acute kidney failure (kidneys suddenly can't filter waste from the blood), and dysphagia (swallowing difficulties). Family member was placed…

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 for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 (Resident #3) residents reviewed for comprehensive care plans, in that: Resident #3 care plan did not include Hospice care. This failure could place residents at risk of not receiving the appropriate care and needs not being met. Findings include: Record review of Resident #3's face sheet dated 10/19/23 revealed a [AGE] year-old female who was re-admitted to facility on 10/02/23 with diagnoses of bed confinement status, dementia, moderate protein calorie malnutrition, type 2 diabetes, and anxiety. Record review of Resident #3's MDS quarterly assessment dated [DATE] revealed a BIMS score of 04, indicating she was severely cognitive impaired. Record review of Resident #3's local hospice medication report dated 09/05/23 revealed admission date…

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 describing the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for three residents (Resident #7, Resident #10 and Resident #89) of 27 residents reviewed for comprehensive care plans. The facility failed to ensure that Resident #7 ' s care plan accurately reflected her impaired vision or need for assistance with dining. The facility failed to ensure that Resident #10 ' s care plan accurately reflected her wandering and exit seeking behavior. The facility failed to ensure that Resident #89 ' s care plan reflected his visual impairment and resulting care needs. These failures put residents at risk of not having their unique care needs met, and experiencing diminished physical, mental, and psychosocial well-being. Findings include: Resident #7 Record review of Resident #7 ' 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 provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for four (Residents #29, #79, #89, and #212) for 27 residents reviewed for an ongoing program to support residents in their choice of activities. - The facility failed to provide individualized activities for Residents #29 and #79 who were bedbound. -The facility failed to provide Resident #89 with individualized activities reflecting his impaired visual status or preferences. -Resident #212 was not provided in room-activities, since it was his preference to stay in his room. This failure places residents at risk of feelings of isolation 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 that a resident who is incontinent of bladder received appropriate treatment and Foley care to prevent urinary tract infections for 2 (Resident #29, and Resident #79) of 4 residents reviewed for urinary incontinence, in that: The facility staff failed to provide Foley catheter care very shift as scheduled for Resident #29, and Resident #79. This deficient practice could place residents with catheters at increased risk for residents of urinary tract infections. Findings include: Resident #79 Record review of Resident #79's face sheet dated 09/20/23 revealed Resident #79 was admitted on [DATE] to the facility. Record review of Resident #79's history and physical dated 08/30/23 revealed a [AGE] year-old male diagnosed urinary retention, cystitis (inflammation of the bladder) and malignant neoplasm of prostate (prostate cancer). Record review of Resident #79's quarterly MDS dated [DATE] revealed resident could not make himself…

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 (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. The facility failed to perform controlled drug destruction with pharmacist and an allowed witness (DON, Administrator, Agent of the state board of Pharmacy) in accordance with state requirements from February 2023 until [DATE]. The facility failed to have a pharmacist available to perform controlled drug destruction from [DATE] to [DATE]. These failures could put residents at risk of drug diversion. Findings include: Record review of the drug destruction records…

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 in 1 of 1 kitchen reviewed for professional standards for food service safety. - 1 bag with various vegetables found in the refrigerator opened to air and without a label of its ' contents. -2-gallon sized bottles of pancake syrup were unlabeled with the date they were opened. - 1 container of sugar unlabeled with date it was opened, as well as the label of the container ' s contents. These failures could place residents at risk of food-borne illness. Findings include: Observations on 09/18/23 at 8:03 AM of the refrigerator revealed a bag with various vegetables opened to air and unlabeled. The bag was not labeled with a label of its contents. Observations on 09/18/23 at 8:09 AM of the dry storage area revealed two 1-gallon bottles of pancake and waffle syrup that were found unlabeled with date they were opened. There was also a bin with sugar that was found to be unlabeled with the date it 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 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 one (Resident #29) of 9 resident reviewed for infection control, two (A Hall Linen Cart and F Hall Linen Cart) of two linen carts reviewed were not covered and sealed, and that one linen closet (D Hall Linen Closet) of one linen closet was kept closed. The facility failed to ensure that 2 linen carts were covered The facility failed to ensure that 1 linen closet was kept closed. The facility failed to provide safe, sanitary care and follow g-tube 20-22 French declogger (a device used to clear obstructions in gastrotomy tubes) packaging indication to discard after each use to prevent contamination. These deficient practices could place residents at risk for infection due to improper care practices. Findings include: Linen Carts…

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, observations, and record reviews the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced dignity and respect for 2 (Resident #24 and #79) of 9 residents reviewed for care that maintained or enhanced their dignity. -The facility failed to maintain Resident #24 ' s sense of dignity by not proving change in brief in a timely manner leaving resident soiled (wet) in the lobby area with other residents. -The facility failed to maintain Resident #79's sense of dignity by leaving a portion of his left side of his body exposed during transportation to the shower. These failures could place residents who require assistance with bathing and changing their clothing at risk of decreased self-esteem affecting their dignity. Findings included: Record Review of Resident #24 face sheet dated 09/19/23 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Record Review of Resident #24 ' s History and Physical dated 08/30/23…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident ' s right to formulate advance directives for two (Resident #62 and Resident #29) of 27 residents reviewed for enactment of advance directives. Resident #62 had both an out-of-hospital DNR order (tells health care providers not to do cardiopulmonary resuscitation) and a physician ' s order for full code (meaning if her heart stopped beating and/or she stopped breathing, all resuscitation procedures will be provided to keep her alive) in her medical record. Resident #29 had both an out-of-hospital DNR form and a physician ' s order for full code in his medical record. The failures could put residents at risk of not having their end of life wishes honored. Findings include: Resident #62 Record review of Resident #62 ' s face sheet dated 09/19/2023 revealed she was [AGE] years old and admitted to the facility on [DATE]. Record review of Resident #62 ' s history and physical dated 08/24/2023 revealed that she had diagnoses including…

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 conduct initially and periodically an accurate assessment of each resident's status capacity for 1 (Resident #89) of 27 residents reviewed for accurate assessment of resident ' s functional capacity. The facility failed to correctly assess and document on the MDS that Resident #89 had a severe vision impairment. This failure put residents at risk of not receiving services based on their actual functional capacity. Findings included: Record review of Resident #89 ' s face sheet dated 09/20/2023 revealed he was [AGE] years old and was initially admitted to the facility on [DATE] and again on 06/07/2023. Record review of Resident #89 ' s electronic Medical Diagnosis listing accessed 9/21/2023 revealed he had diagnoses including anoxic brain damage (brain damage due to lack of oxygen). Impaired vision was not listed as a diagnosis. He had a gastrostomy tube (tube into the stomach for feeding) and a tracheostomy (tube into the neck 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 observation, interview and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services for 1 of 8 residents (Resident # 207) reviewed for enteral feeding. -Resident #207 ' s ' s enteral feeding (nutrition given through a feeding tube) formula was not labeled with time of administration, date it was hung, and the rate the formula was given. This failure could place residents receiving enteral feedings at risk of malnutrition if feedings were to be given incorrectly. Findings include: Review of Resident #207 ' s face sheet dated [DATE] revealed a [AGE] year-old male with an admission date to the facility of [DATE]. Review of Resident #207 ' s electronic Medical Diagnosis list revealed dysphagia (difficulty swallowing). Review of Resident #207 ' s History and Physical dated [DATE] revealed dysphagia and revealed Resident #207 had a PEG tube (tube attached into the stomach through a small insertion in the abdominal wall that allows…

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 a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #207) of 3 residents observed for oxygen management. -Resident #207 utilized oxygen in his room and did not have an oxygen sign posted outside of the room. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings include: Review of Resident #207 ' s face sheet dated 09/20/2023 revealed a [AGE] year-old male with an admission date to the facility of 09/01/2023. Review of Resident #207 ' s electronic Medical Diagnosis list revealed acute respiratory failure with hypoxia (low oxygen) and tracheostomy (incision on the neck to allow for breathing). Review of Resident #207 ' s History and Physical dated 09/08/2023 revealed Resident #207 had a tracheostomy and was to receive oxygen to maintain an oxygen reading greater…

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 medical records were accurately documented for one (Resident #94) of 5 residents reviewed for accurate documentation of medical records. The facility failed to correctly document the administration of Fentanyl 50 mcg/hour patches every 72 hours to Resident #94 and instead documented that she was administered Fentanyl 25 mcg/hour patches every 72 hours. These failures could put residents at risk of incorrect records of medications administered. Findings include: Record review of Resident #94 ' s face sheet dated 06/20/2023 revealed she was [AGE] years old, and was initially admitted to the facility on [DATE] and again on 06/29/2023. Record review of Resident #94 ' s hospital history and physical dated 05/23/2023 revealed she had a diagnosis of oropharyngeal carcinoma (throat cancer). It was noted that she was administered several pain medications which were not effective. Record review of Resident #94 ' s initial admission…

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 reasonable accommodation of needs for 1 of 8 residents (Resident #1) reviewed for accommodation of needs: -Residents #1's push button call system was not adequate to meet the needs of the residents who required padded call light button. -Resident #1's call system was not placed within reach of the resident. This failure could place residents at risk of not being able to have their needs met. Findings included: Record review of Resident #1's face sheet dated 09/08/2023, revealed a [AGE] year-old male, with a readmission date of 05/03/2023 and initially admitted to the facility on [DATE]. Resident #1's diagnoses included: anoxic brain damage (a process that begins with the cessation of cerebral blood flow to brain tissue), tracheostomy status (surgically created hole in windpipe that provides an alternative airway for breathing), hypertension (high blood pressure), dysphagia (difficulty or discomfort in swallowing, as a symptom of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Residents #1) reviewed for assistance with ADLs in that: -Resident #1 had long fingernails that were dirty and had a black substance underneath them. This failure could place residents who required assistance with showering and maintaining good personal hygiene at risk for not receiving care and services to meet their needs and avoid ADL decline. Findings include: Record review of Resident #1's face sheet dated 09/08/2023, revealed a [AGE] year-old male, with a readmission date of 05/03/2023 and initially admitted to the facility on [DATE]. Resident #1's diagnoses included: anoxic brain damage (a process that begins with the cessation of cerebral blood flow to brain tissue), tracheostomy status (surgically created hole in windpipe that provides 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 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 5 (Resident #2) residents reviewed for foley catheter. -The facility failed to ensure Resident #1 had foley catheter secured on her thigh. This failure could place residents with foley catheter at risk of catheter pulling causing pain and/or infection. Findings include: Record review of Resident #2's face sheet dated 09/08/2023, revealed a [AGE] year-old female who was readmitted to the facility on [DATE] and was initially admitted on [DATE]. Resident #2's diagnoses included: acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), altered mental status (a change in mental function), overactive bladder (a problem with bladder function that causes the sudden need to urinate), anxiety disorder (a mental health 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 interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must (i) Be developed within 48 hours of a resident's admission for 1 of 5 (Resident #2) residents reviewed for baseline care plans. The facility failed to ensure a baseline care plan was developed with 48 hours for Resident #2 readmission on [DATE] and 8/2/23. This failure could have placed newly admitted residents at risk of not receiving the care and services and continuity of care. Findings include: Record review of Resident #2's face sheet dated 8/22/23 revealed an [AGE] year-old female who was readmitted on [DATE] with diagnoses of dementia and anorexia. Record review of Resident #2's MDS quarterly assessment dated [DATE] revealed a BIMS score of 3, she was severely cognitive impaired. Skin condition section 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview, and record review the facility failed to ensure each resident received adequate supervison and assistance devices to prevent accidents for 1 of 5 (Resident #4) residents reviewed for repositioning. The facility failed to ensure Resident #4 was repositioned using a drawsheet, CNA E grabbed Resident #4 right elbow to assist with scooting up to bed of head. This failure could place residents at risk of bruising, pain, or possible injury. Findings include: Record review of Resident #4's face sheet dated 08/22/2023 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of anoxic brain damage, dysphagia, muscle wasting ad atrophy. Record review of Resident #4's MDS quarterly assessment dated [DATE] revealed BIMS score of 0, he as severely cognitive impaired. Record review of Resident #4's care plan dated 07/17/2023 revealed focus care for ADLs with interventions of bed mobility required total assistance of 2 staff . During observation and interview 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 observation interview, and record review the facility failed to ensure 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 5 (Resident #4) residents reviewed for foley catheter. The facility failed to ensure Resident #4 had foley catheter secured on his thigh. This failure could place residents with foley catheter at risk of catheter pulling causing pain and/or infection. Findings include: Record review of Resident #4's face sheet dated 08/22/2023 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of anoxic brain damage and muscle wasting ad atrophy. Record review of Resident #4's MDS quarterly assessment dated [DATE] revealed BIMS score of 0, he as severely cognitive impaired and had an indwelling catheter. Record review of Resident #4's care plan dated 07/17/2023 revealed focus care for foley catheter with interventions of use a stabilizer…

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.