Villa Toscana At Cypress Woods

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 18.52% based on 5 errors out of 27 opportunities, which involved three (Resident #26, Resident #37, and Resident #77) of seven residents reviewed for medication errors. 1. The facility failed to ensure that Resident 26's Ferrous Sulfate 300 (60 Fe) mg/5ml and Calcium-Vitamin D 600-200 mg were available at the time of observation and administered as ordered. 2. The facility failed to ensure that Resident 37's Glucosamine HCL 500 mg was available at the time of observation and administered as ordered. 3. The facility failed to ensure that Resident 77's Fish Oil 1000 mg was administered correctly as Resident 77 was administered Fish Oil 1200 mg. The facility failed to ensure that Resident 77's Super B-Complex Oral Tablet (B-Complex w/Biotin & Folic Acid) was administered correctly. Resident 77 was administered Vitamin B-Complex…

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 drugs and biologicals used in the facility must include the expiration date when applicable for five out of five residents (Resident #20, Resident #81, Resident #35, Resident #2, and Resident #299) reviewed for expired medication. The facility failed to ensure that Latanoprost eye drops (Latanoprost is used to treat certain types of Glaucoma and other causes of high pressure inside the eye) were labeled with expiration date for Resident #20, Resident #81, Resident #35, Resident #2, and Resident #299. This failure could place residents at risk of not receiving the intended therapeutic effects of prescribed medications or receiving potentially harmful side effects from prescribed medications. Findings include: Record Review of Resident 20's face sheet dated [DATE], revealed resident was a [AGE] year old female admitted to the facility on [DATE] with diagnoses including Paroxysmal Atrial Fibrillation (Irregular Heartbeat),…

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 food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for kitchen sanitation. -The facility failed to label, and date left over foods items in 1 of 1 walk in-cooler in the kitchen. -The facility failed to ensure that expired food products were not stored in the food pantry (dry goods area). These failures could place residents at risk for food-borne illness and food contamination. The findings include: Observation and interview with the Dietary Manager on 02/24/25 at 10:15AM, revealed- The cooler in the kitchen had the following expired food products: - sour cream half container of 5 Ibs dated best by -01/18/2025 Cottage cheese 3Ibs container half use dated best by -02/14/25. Half container of pimento cheese dated best by 02/21/25. Observation of the dry good storage area revealed the following:. -6 one quart of high calorie protein supplements dated used by 02/04/25. -4-8oz containers of chipotle dated used by 06/12/2023. 8 oz bottle of imitation…

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 pharmaceutical services to meet the needs of 1 (Resident #300) of 6 residents reviewed for pharmacy services. The facility failed to ensure that medications were administered to Resident #300 on 3/6/2024 when she was admitted to the facility. This failure could place residents at risk of not having appropriate therapeutic effects from prescribed medications. Findings include: Record Review of Resident 300's face sheet dated 2/28/25, revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Vascular Dementia (Dementia caused from impaired blood flow to the brain), Anxiety, Restlessness and Agitation. Record Review of Resident 300's Discharge-Summary - V3 dated 4/9/24 at 9:36 a.m. revealed Resident 300 was admitted to the facility on [DATE] and discharged on 3/26/24. Resident 300 was not admitted to the facility at the time of the investigation and was unable to be observed or…

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 ensure residents were free from abuse for 4 (CR #1 and Resident #2, and Resident #6 and Resident #7) of 6 residents. The facility failed to protect Resident #6 from being slapped by CR#1 resulting in CR#1 being grabbed by Resident #7 on 1/26/24 at 9:15 am. The facility failed to supervise CR#1, who was on 1:1 supervision, when CR#1 hit Resident #2 on 1/26/24 at approximately 5:30 p.m. This failure placed residents at risk of harm and injury. Findings included: Resident #6 Record review of Resident #6's face sheet dated 1/26/24 revealed Resident #6 was an [AGE] year old female resident who admitted on [DATE]. Diagnosis included hypertensive heart disease, muscle wasting and atrophy, heart failure, difficulty walking, and anxiety. Record review of Resident #6's Nurse Event note dated 1/26/24 at 15:26 (3:26 p.m.) revealed Resident #6 said another resident came over to her and tried to hit her in the eye and she pushed her away. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 3 Residents (Resident #3, #4 and #5 ) observed for infection control, in that: MA A failed to sanitize blood pressure cuff after each use for Resident #3, and Resident #5 MA A failed to use proper hand hygiene while passing medications to Resident #3, Resident #4, and Resident #5. MA A failed to maintain a clean work space/med cart while passing medications to Resident #3, Resident #4 and Resident #5. These failures place residents at risk of cross contamination and infections. Findings included: Resident #3 Record review of Resident #3's face sheet dated 2/7/25 revealed Resident #3 was a [AGE] year old female resident who admitted on [DATE]. Diagnoses included chronic kidney disease, type 2 diabetes, hypertension 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 observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 5 residents (Resident #1) reviewed for call lights. The facility failed to have a call light within reach for Resident #1 to call for assistance. This failure could place residents at risk for a delay in care and services. Findings included: Record review of Resident #1's face sheet dated 1/28/2025 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: wrist drop-right wrist (weakness of the muscles that control wrist extension, resulting in the inability to lift the hand or extend the wrist properly), muscle weakness, lack of coordination, muscle wasting, hemiplegia (almost complete paralysis of one side, including loss of movement), and hemiparesis (partial weakness or reduced strength on one side but not complete paralysis) affecting left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure residents who are unable to carry out the activities of daily living received the necessary services to maintain grooming and personal hygiene care for 1 (Resident #1) of five residents reviewed for ADL care. -The facility failed to ensure Resident #1 was provided timely incontinent care. These failures could place residents who required ADL care at risk of not receiving personal care and services. Findings included: Record review of Resident #1's face sheet dated 1/28/2025 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: wrist drop-right wrist (weakness of the muscles that control wrist extension, resulting in the inability to lift the hand or extend the wrist properly), muscle weakness, lack of coordination, muscle wasting, hemiplegia (almost complete paralysis of one side, including loss of movement), and hemiparesis (partial weakness…

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 1 of 5 residents (Resident #1) reviewed for infection control. -CNA K and CNA T did not wear a gown when providing dressing, transferring and providing incontinent/peri care to Resident #1 who was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) on 12/19/24. This failure could place residents at risk of infections. Findings included: 1.Record review of Resident #1's face sheet dated 12/19/24 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnosis included Alzheimer's disease, aftercare following joint replacement surgery, osteoarthritis (the most common type of arthritis, it happens when the cartilage that lines…

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 immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complication) for 1 (Resident #1) of 15 residents reviewed for physician notification. The facility failed to consult with the physician when Resident #1 developed a rash on her arms, legs, and back. These failures could place residents at risk of not having their physician informed and residents not receiving adequate medical interventions, not having their care needs met, not being seen by physicians, and not receiving adequate and timely interventions, which could cause a decline in physical and psychosocial health and even death. Findings included: Record review of Resident #1's face sheet reviewed on 09/11/24 revealed an eighty-five-year-old woman who was admitted on [DATE]. Her admitting…

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 conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 (Resident #1) of 15 residents reviewed for comprehensive assessments in that. The facility did not complete 2 weeks of Weekly Skin Assessments for Resident #1, which resulted in the development of an unexplained rash. These failures could place residents at risk of not having all medical needs assessed and met in a timely fashion. Findings Included: Record review of Resident #1's face sheet reviewed on 09/11/24 revealed an eighty-five-year-old woman who was admitted on [DATE]. Her admitting diagnoses were dementia, anxiety disorder, malnutrition, and hypertension. Record review of Resident #1'sQuarterly MDS (comprehensive nurse assessment) Section C- Cognitive Patterns revealed that she had a score of 8 (moderately impaired) out of 15. Record review of Resident #1's care plan initiated 04/06/24…

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

Based on interview, and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident through the means other than a postal service for 6 of 6 confidential residents reviewed for weekend mail delivery. The facility failed to ensure residents received their mail on the weekend. This failure could place residents at risk for not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life. Findings include: A confidential group interview was conducted on 11/29/2023 at 10:04 AM with six residents and one resident's family member who translated for the resident. All six residents denied receiving mail on Saturdays. A resident said the facility received mail on Saturdays, but it was stored in the office and given to residents on Monday mornings. Interview on 11/30/2023 at 1:12 PM with the AD, she said she had been employed for three years. The AD said her primary duties included implementation 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 each resident was provided a communication system to call for assistance for 5 (Resident #13, Resident #34, Resident #43, Resident #51, and Resident #70) of 16 residents reviewed for call light placement. -The call light was observed on the floor, under the bed, in a location inaccessible to the resident when in each resident's room. This failure could place the residents at risk for not being able to call for help when needed, contribute to falls and injury, and/or psychosocial decline. Findings include: Resident #13 Record review of Resident#13's admission record dated 11/29/2023 revealed an [AGE] year-old woman admitted on [DATE]. Her diagnoses included Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), difficulty in walking, schizophrenia (mental disorder characterized by delusions, hallucinations,…

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, which included measurable objectives and time frames to meet resident's medical, nursing, and mental and psychological needs that were identified in the comprehensive assessment for 1 out of 18 residents (Resident #21) reviewed for comprehensive care plans. -The facility failed to ensure Resident #21's use of bedrails was added to her individualized care plan. -The facility failed to ensure Resident #21's bed was in a low position. These failures could place residents at risk of not receiving care and services needed to maintain their highest practicable quality of life, and possible falls leading to injury. Findings include: Record review of Resident #21's admission record dated 11/28/2023 revealed an [AGE] year-old resident admitted on [DATE]. The record documented her diagnoses included aftercare following joint…

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 acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 6 residents (Resident #54) reviewed for nutritional status. The facility failed to remove Residents #54's mighty shake from her meal ticket in accordance with Dietitian recommendations and Physician orders. This failure could place residents at risk of weight gain. Findings include: Record review of Resident #54's admission record dated revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, cognitive communication deficit, hypertension (high blood pressure), epilepsy, and pain. Record review of Resident #54's quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 5 out of 15 which indicated severe…

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 was assessed and had consents for bed rails for 1 of 6 residents (Resident #21) reviewed for bed rails. -The facility failed to obtain consent prior to installing and utilizing bedrails for Resident #21. -The facility failed to complete an assessment prior to installing and utilizing bedrails for Resident #21. These failures could affect residents who utilized some type of bed rails in the facility and could put the residents at risk for potential injuries. Findings include: Record review of Resident #21's admission record dated 11/28/2023 revealed an [AGE] year-old resident admitted on [DATE]. The record documented her diagnoses included aftercare following joint replacement surgery, fracture of the neck of the left femur (break at the top of the long bone in the leg, just below the ball joint), lack of coordination, and dementia (a group of symptoms that affects memory, thinking, and interferes with daily life). Record…

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 2 of 2 facility refrigerators reviewed for food procurement. - The facility failed to discard expired and unlabeled food items in the kitchen and nourishment room refrigerators. -The facility failed to store food according to manufacturer instructions. These failures could affect residents who ate food from the facility kitchen and place them at risk of foodborne illness and cross-contamination. Findings include: Observation on 11/28/23 at 8:40 am revealed the walk-in refrigerator had a foul odor upon entry. Observed zucchini in a box labeled with 11/8 with fuzzy, white, mold-like substance on the stalk of the vegetables. Observed packaged fresh basil in a box labeled 11/1. The basil was discolored with dark brown leaves mixed among green leaves. Observed box of bagged, fresh collard greens. The box was labeled 11/1 and the bags of greens was dated with best by 11/13/23. The collard greens were…

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 infection for 1 of 18 residents (Resident #60) reviewed for infection. -The facility failed to ensure CNA JJ and CNA RRRR performed hand hygiene during incontinent care on Resident #60. -The facility failed to ensure CNA BB used hand hygiene when passing meals to residents. These failures could lead to the spread of infection to residents, resident illness, and/or resident distress. Finding include: Observation on 11/28/2023 at 12:43 PM, the memory care unit's meal trays arrived at 12:43 PM. CNA BB began to pass the trays to one of the two dining areas of the unit. CNA BB placed a tray on the table for a resident in the room. CNA BB then moved a resident's wheelchair into the dining room and parked the chair at a table. CNA BB…

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 allegations of abuse, neglect or mistreatment, including injuries of unknown origin was reported immediately, but not later than 2 hours after the allegation is made for 1 (Resident#28) out of 4 residents reviewed for reporting alleged abuse and neglect. -The facility failed to report Resident#28's fracture of lumber spine that was discovered on 11/08/2023 to the state agency. This failure could place residents at risk for not having incidents reported as required and continued abuse and neglect which could result in diminished quality of life. Findings include: Record review Resident#28 face sheet (undated) revealed she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included cognitive communication deficit (difficulty with thinking and how someone uses language), Parkinson disease (a progressive disorder that affects the nervous system and the parts of the body controlled by…

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 ensure the comprehensive care plan is reviewed and revised by an interdisciplinary team after each assessment for 1 (Resident #24) of 6 residents reviewed for care plan revisions, in that: -Resident # 24's care plan did not reflect the use of foley catheter. This failure could place residents at risk for not receiving appropriate interventions to meet their current needs. The findings include: Record review of Resident # 24 face sheet (undated) revealed a [AGE] year-old male with admission date of 09/23/2023 and re-admitted on [DATE]. His diagnoses included functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), fusion of spine (this procedure connects two or more bones in the spine) and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage).…

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 incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 resident (Resident #60) reviewed for incontinent care. -The facility failed to ensure CNA JJ and CNA RRRR properly cleaned Resident #60 during incontinent care. This failure could place residents at risk for urinary tract infections (UTI), urethral erosions, discomfort, skin breakdown, and a decreased quality of life. Findings include: Record review of the admission sheet (undated) for Resident #60 revealed an [AGE] year old female admitted to the facility on [DATE] with diagnoses which included contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), weakness (the state or condition of lacking strength) and parkinson disease ( a progressive disorder that affects 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 observations, interviews, and record reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 1 (Resident #23) of 4 residents reviewed for respiratory care, in that: -Resident #23's Nebulizer mask was not changed in over 14 days. This failure could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. Findings Include: Record review of Resident #23's Face Sheet (undated) revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included acute respiratory failure with hypoxia (occurs when the lungs can't release enough oxygen into your blood) pulmonary fibrosis (serious lung disease that causes lung scarring and shortness of breath) and hypoxemia (low levels of oxygen in your blood). Record review of Resident #23's Comprehensive MDS assessment dated [DATE] revealed she was assessed as…

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 drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 (skilled unit nurses' cart) of 4 medication carts reviewed for controlled drugs. The facility failed to document that one of Resident #47's ten morphine syringes contained 0.5 mL instead of 0.25 mL. The 0.5 mL syringe was rubber banded together with the 0.25 mL syringes. This failure could result in a medication error or drug diversion. Findings include: Record review of Resident #47's face sheet dated 12/1/23 revealed a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Alzheimer's disease, pain, and depressive disorder. Record review of Resident #47's annual MDS assessment dated [DATE] revealed she had a BIMS score of 6 out of 15 which indicated severe cognitive impairment. She required assistance from staff with ADL care. Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7%, based on 2 errors out of 26 opportunities, which involved 1 (Resident #57) of 6 residents reviewed for medication errors in that: -MA E administered Celecoxib (a medication used to treat pain or inflammation) to Resident #57 without a physician's order and did not administer Vitamin D to Resident #57 as ordered by the physician. These failures could place residents at risk of inadequate therapeutic outcomes. Findings include: Resident #57 Record review of Resident #57's face sheet dated 12/1/23 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included age-related osteoporosis (a condition when bone strength weakens and is susceptible to fracture), fracture of right femur, subsequent encounter for closed fracture with routine healing, dementia, and muscle weakness. Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours if the alleged violation resulted in serious bodily injury, to the administrator of the facility and to the State Survey Agency for 1 of 17 residents (CR#1) reviewed for abuse, neglect, and injuries of unknown origin. Record review to CR#1 clinical file dated 08/01/23 revealed that CR#1 had a fall but the clinical file did not reveal that the administrator, DON, NP, nor the RP were notified. Therefore the facility failed to report CR#1's injury of unknown source from an unwitnessed fall on 8/1/23. Also there was a review of Tulip on 08/04/23 and it revealed that the incident had not been reported to the state. This failure could affect residents by placing them at risk of not having incidents of abuse or neglect, reviewed, and investigated in a timely manner by the facility and Health and Human Services.…

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.