The Heights at Medical Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 8 (room [ROOM NUMBER], #103, #104, #106, #110, #113, #116, and facility shower room) of 12 rooms observed for environment. The facility failed to ensure Resident rooms #102, #103, #104, #106, #110, #113, #116, and facility shower room were clean and sanitized. The facility failed to ensure Resident room [ROOM NUMBER]'s floor was repaired of cracks to prevent accidents. These deficient practices could place residents at risk of living in an unclean, unsafe and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 07/16/24 at 10:06 AM of Resident room [ROOM NUMBER] reflected the entry way into the resident's bathroom had a large crack in the floor and a piece of tile was broken off. On the floor, behind 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, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure food in the facility's refrigerator was labeled and dated according to guidelines. 2. The facility failed to ensure the ice machine in the kitchen area was thoroughly cleaned. 3. The facility failed to ensure food in the facility's freezer was labeled and dated according to guidelines. 4. The facility filed to ensure kitchen equipment in the kitchen area, was thoroughly cleaned. 5. The facility failed to ensure food in the facility's dry food area was labeled and dated according to guidelines. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 07/16/24 from 08:35 AM to 08:50 AM in the facility's only kitchen reflected: One large container of diced pineapples in 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 treat each resident with respect, dignity, and care in a manner and environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #51) of 5 residents reviewed for dignity. The facility failed to ensure LVN A closed the door and provided privacy obtaining Resident #51's blood sugar. This failure could place the residents at risk of not having their right to a dignified existence maintained. Findings included: Review of Resident #51's Face Sheet, dated 07/17/2024, reflected resident was a [AGE] year-old female admitted on [DATE]. Resident #51 was diagnosed with Type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar) without complication. Review of Resident #51's Quarterly MDS Assessment, dated 07/05/2024, reflected resident had a severe impairment in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated diabetes mellitus as one of resident #51's active…

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 assessments accurately reflected the resident's status for two (Resident #40 and Resident #43) of eight residents reviewed for Accuracy of Assessments. The facility failed to ensure Resident #40's Quarterly MDS Assessment accurately reflected that Resident #40 still had his g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach). The facility failed to ensure Resident #43's Quarterly MDS Assessment accurately reflected that Resident #43 still had his g-tube. The facility failed to ensure Resident #'s 43's Quarterly MDS Assessment accurately reflected that Resident #43 had impairment to his right hand. These failures could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings included: Resident #40 Review of Resident #40's Face Sheet, dated 07/16/2024, reflected…

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 reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for two (Resident #40 and Resident #43) of eight residents reviewed for Care Plans. The facility failed to ensure Resident #40 and Resident #43 were care planned for their g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) not being used for nutrition but was still connected to the residents. This failure could place the residents at risk of not receiving necessary care and services. Findings included: Resident #40 Review of Resident #40's Face Sheet, dated 07/16/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #40 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 interviews and record reviews the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 (Residents #26 and #63) of 2 residents reviewed for (ADLs) care provided to dependent residents. 1.The facility failed to ensure Resident #26 received scheduled showers reviewed for the past 30 days (06/16/24 - 07/16/24). 2. The facility failed to ensure Resident and #63 received scheduled showers reviewed for the past 30 days (06/16/24 - 07/16/24). These failures placed residents at risk of not receiving necessary services to maintain good personal hygiene and decreased self- esteem. Findings included: 1. Record review of Resident #26's Face Sheet, dated 07/17/2024, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included Kidney Failure and required ADL assistance. Record review of Resident #26's Quarterly Minimum Data Set (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 observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for one (Resident #44) of twelve residents observed for incontinent care . The facility failed to ensure that CNA D did not wipe from front to back while providing incontinent care to Resident 44 on 07/16/24. These failures could place the residents at risk of cross-contamination and development of urinary tract infections. Findings included: 1.Review of Resident #44's Face Sheet, dated 07/16/2024, reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included post COVID-19 condition and pneumonia. Review of Resident #44's Comprehensive MDS Assessment, dated 06/01/2024, reflected Resident #44 was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated Resident #44 was always incontinent for bowel and bladder. Review of Resident #44's Comprehensive Care…

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 fed by enteral means received the appropriate treatment and services to prevent complications of enteral (intake of food through a tube in the gastrointestinal tract) feeding for one (Resident #43) of four residents reviewed for gastrostomy tube management. The facility failed to ensure that Resident #43 had orders to observe the g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) even though it was not used by the resident. The facility failed to ensure that Resident #43 had order to flush and check the placement of the g-tube every shift. These failures could place residents who had g-tube at risk for having a clogged g-tube. Findings include: Review of Resident #43's Face Sheet, dated 07/16/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #43 was diagnosed with dysphagia (difficulty in swallowing). 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 observations, interviews, and record review, the facility failed to ensure that Residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Residents #1) of four residents reviewed for respiratory care. The facility failed to ensure that Resident #1's mask for CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was properly stored. The facility failed to ensure that Resident #1's humidifier had water in it. This failure could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Review of Resident #1's Face Sheet, dated 07/16/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included pneumonia (inflammation of the lungs) and acute respiratory failure with hypoxia (insufficient…

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 assist a resident in obtaining routine dental care for one (Resident #31) of one resident reviewed for dental services. The facility failed to ensure assist Resident #31 with getting a dental appointment when requested by the responsible party in March 2024 This failure could place the resident at risk of not receiving required dental services to avoid complications with her eating. Findings included: Review of Resident #31's Face Sheet, dated 07/17/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included denture use. Review of Resident #31's Quarterly MDS Assessment, dated 04/20/2024, reflected that Resident #31 had a severe impairment in cognition with a BIMS score of 08 (moderate cognitive impairment). Review of Resident #31's Comprehensive Care Plan updated on 03/08/24 reflected that Resident #31 was care planned for Maintain adequate nutritional status and good oral hygiene daily and ongoing over…

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 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 #51) of twelve residents observed for infection control. The facility failed to ensure that LVN B and RA F changed their gloves and performed hand hygiene while providing incontinent care to Resident #51. This failure could place the residents at risk of cross-contamination and development of infections. Findings included: Review of Resident #51's Face Sheet, dated 07/17/2024, reflected resident was a [AGE] year-old female admitted on [DATE]. Resident #51 was diagnosed with sepsis (an infection of the blood stream). Review of Resident #51's Quarterly MDS Assessment, dated 07/05/2024, reflected resident had a severe impairment in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated that 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 ensure each resident had the right to personal privacy for 2 of 4 residents (Resident #2 and Resident #4) reviewed for dignity. 1. Resident #2's privacy curtain was not closed completely during wound care on 6/21/24. 2. Resident #4's privacy curtain was not closed completely during wound care on 6/22/24. These failures could affect residents by contributing to poor self-esteem and decreased self-worth and quality of life. Findings included: 1. Record review of Resident #2's Facesheet, dated 6/21/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Seizure (burst of uncontrolled electrical activity between brain cells causing temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness), GERD (digestive disease in which stomach acid or bile irritates the food pipe lining) , Muscle Weakness, Glaucoma (condition that can cause blindness by damaging the optic nerve)…

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

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 8 medication carts (the 100-hallway medication cart) reviewed for medication storage, The facility failed to ensure the 100-hallway medication cart was locked when it was left unattended in the common area in front of the nurses' station. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings were: In an observation on 6/19/2024 at 6:30 PM, the 100-hallway cart was observed unlocked and unattended in the common area near the nurse's station. The surveyor was able to open the drawers without staff intervening. The 100-hallway cart contained over-the-counter medications, prescription medications and glucose monitoring paraphernalia. Non-ambulatory residents were in the area. In an interview on 6/19/2024 at 6:35 PM, the DON stated the surveyor was the only visitor in the immediate…

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

Based on observation, interview, and record review, the facility failed to maintain 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 4 staff (RN A) reviewed for infection control. During Resident wound care, RN A failed to perform hand hygiene appropriately. This failure could affect residents and place them at risk for infection. Findings included: Observation of wound care on 6/23/24 at beginning at 11:06 am, revealed RN A entered the resident's bathroom and washed his hands for 4 seconds prior to gathering wound care supplies. RN A then placed wound care supplies on the resident's bedside table and returned to the bathroom, RN A washed his hands for 3 seconds. Once RN A complete wound care, he entered the bathroom and washed his hands for 2 seconds. During an interview on 6/23/24/24 at 11:35 am, RN A said he was expected to wash his hands for 15-20 seconds. RN A further stated hand hygiene was to be performed after…

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 maintained the right to receive visitors of his or her choosing at the time of his or her choosing for 1 of 1 facility reviewed for resident rights. The facility failed to ensure all residents had the right to receive visitors between 7:00 PM and 7:00 AM. This deficient practice placed residents at risk of isolation, decreased emotional well-being, and diminished quality of life. The findings included: Observation on 05/22/2024 at 11:10 AM revealed a sign on the front door entrance that read visiting hours are from 7:00 AM to 7:00 PM. Record review of Resident #11's assessment, dated 03/09/2024 reflected an [AGE] year-old female, admitted on [DATE] with a primary diagnosis of chronic respiratory failure with hypoxia (a long-term condition that occurs when the airways to the lungs become damaged and narrow, limiting the movement of air and oxygen into the body). Interview on 05/22/2024 at 4:07 PM, Receptionist V stated she…

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 the comprehensive care plan was reviewed and revised by an interdisciplinary team for one (Resident #1) of one resident reviewed for revised Care Plan. The facility failed to ensure Resident #1's care plan was revised to reflect discontinued foley catheter. This failure could place the resident at risk of current needs not being met. Findings included: Review of Resident #1's Face Sheet dated 04/19/2024 reflected that the resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included altered mental status (a change in mental function), muscle wasting and atrophy (decline in muscle strength and energy), obstructive and reflux uropathy (when urine is unable to drain through the urinary tract and causes urine to back up into the kidneys), and chronic kidney disease (a condition where the kidneys lose their ability to filter blood and remove wastes). Review of Resident #1's Comprehensive MDS assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for one (Resident #1) of one resident reviewed for hospice services. The facility failed to maintain required hospice forms and documentation to ensure Resident #1 received adequate end-of-life care. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #1's Face Sheet dated [DATE] reflected that the resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included altered mental status (a change in mental function),…

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 allow the resident to obtain a copy of the records upon request and upon two working days advance notice to the facility for 1 of 5 residents (Resident #1) whose records were reviewed in that: The facility failed to provide a Resident #1's RP with a copy of Resident #1's medical records after a request was submitted to the facility. This deficient practice could affect residents and could contribute to a delay in the due legal process for residents. The findings were: Record review of Resident #1's electronic medical record, reviewed on [DATE], revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of gastro-esophageal reflux disease without esophagitis [acid reflux], hypomagnesemia [high magnesium levels in the blood], other hyperlipidemia [high fat levels in the blood], and unspecified atrial fibrillation [an abnormal heartbeat]. There was no RP designated in this section of the electronic medical record. 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 immediately notify a resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 1 residents (Resident #1) reviewed for notification of changes in that: The facility failed to ensure Resident #1's RP was notified when Resident #1 was transferred to a local hospital on 7/27/23. This deficient practice could place residents at risk of not having their family or legal representative notified when having a change of condition. The findings were: Record review of Resident #1's electronic medical record, reviewed on 3/25/24, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of gastro-esophageal reflux disease without esophagitis [acid reflux], hypomagnesemia [high magnesium levels in the blood], other hyperlipidemia [high fat levels in the blood], and unspecified atrial fibrillation [an abnormal heartbeat]. There was no RP designated in this section of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 2 of 6 residents (Residents #8 and 13) reviewed for gastrostomy tube management, in that: 1. Staff N failed to check the placement of Resident #8's gastrostomy tube prior to administering feeding. 2. Staff E failed to check the placement of Resident #13's gastrostomy tube prior to medication administration. These failures could place residents with gastrostomy tubes at risk of aspiration, medical complications, and a decline in health due to inappropriate gastrostomy tube care and management. The findings included: 1. Record review of Resident #8's face sheet dated 10/12/23 revealed he was admitted on [DATE] with diagnoses that included cerebral infarction (an area of the brain that dies due to lack of blood flow), gastrostomy (artificial external opening into the stomach for nutritional support),…

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 separately locked compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 1 medication rooms, in that, Controlled medications in the narcotic waste box were accessible to any employees who had the code for the medication room. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings included: During an observation of the medication room on 10/12/23 at 2:52 pm with Staff L present revealed, the narcotic waste bin was attached to the Passport (Medication dispensing machine). It contained a slot on the top of the box for disposal of controlled medications. The box was full, and medications could be accessed without unlocking the box. Staff L was observed pulling medications out of the narcotic waste bin without unlocking the box. During an interview on 10/12/23 at 2:53 pm, Staff L verified that 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 observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment; including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior, with clean bed and bath linens that are in good condition, for 1 of 2 shower rooms (200-300 hall shower room), reviewed for a clean and homelike shower room, in that: The facility failed to ensure one of 2 facility shower rooms (200-300 hall shower room) did not present with a dirty shower bed, holes in the wall, a missing shower valve, and trash. This failure placed residents at risk for infections, injuries, and demoralization. The findings included: During an observation on 05/02/2023 at 10:21 AM, revealed the 200 / 300 Hall shower room presented with a Polyvinyl chloride (PVC) shower bed. The shower bed featured a blue nylon mesh bed, with a white vinyl foam cushion on top of the blue nylon mesh. Further observation revealed the foam bed presented with tears to the vinyl covering and dark colored areas of accumulated residue.…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility failed to ensure a bagged part of lettuce in the refrigerator dated 04/11/2023 and was not beyond the 72 hours discard time. 2. The facility failed to ensure the dietary aide did not bring rack of dirty meal trays through the kitchen during meal prep instead of the dishwashing room door. 3. The facility failed to ensure the cook while serving soup did not have gloved thumb inside the bowl resulting in soup touching thumb. These failures could place residents who received meals from the kitchen at risk for food borne illness. The findings included: An observation and interview with the DM on 05/02/2023 at 9:20 a.m. revealed a partially used head of lettuce in the refrigerator with the date of 04/11/2023. The DM stated it should have been removed and thrown out after three days. Observation on 05/03/2023 at 9:55 a.m. revealed the DA taking a rolling rack 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 residents have a right to personal privacy for 1 of 6 resident (Resident #9) reviewed for privacy, in that: The facility failed to ensure CNA A and CNA B completely closed Resident #9's privacy curtain while providing catheter care and incontinent care for the resident. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #9's face sheet, dated 05/04/2023, revealed an admission date of 03/03/2023, with diagnoses which included: History of sepsis(blood poisoning), History of urinary tract infection(infection of any part of the urinary system), Schizophrenia(serious mental disorder in which people interpret reality abnormally), Hypothyroidism(decrease production of thyroid hormones) and, Hypertension (high blood pressure). Record review of Resident #'9's admission MDS, dated [DATE], revealed the resident had a BIMS score of 13 indicating…

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 assessment accurately reflected the resident's status for 1 of 18 residents (Residents #50) whose assessments were reviewed, in that: The facility failed to ensure Resident #50's Annual MDS assessment did not incorrectly document the resident as receiving an anticoagulant. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments. The findings were: Record review of Resident #50's face sheet, dated 05/05/2023, revealed an admission date of 03/21/2023 with diagnoses that included: Metabolic encephalopathy (disease affecting brain structure or function), Type 2 diabetes mellitus(blood glucose, also called blood sugar, is too high.), Hypertension (high blood pressure) and, Vascular dementia(problems with reasoning, planning, judgment, memory caused by brain damage from impaired blood flow to the brain). Record review of Resident #50's physician order for March 2023 revealed orders for: Clopidogrel…

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 revise the comprehensive person-centered care plan to reflect the current condition for 2 of 12 residents (Resident #36 and Resident #44) reviewed for care plan revisions 1. The facility failed to update Resident #36's care plan to only reflect the DNR code status and resolve Full Code status care plan. 2. The facility failed to update Resident #44's care plan to only reflect the DNR code status and resolve Full Code status care plan. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1. Record review of Resident #36's face sheet, dated 05/04/2023, revealed she was admitted to the facility on [DATE] with diagnoses which included: cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, vascular dementia, type 2 diabetes mellitus without complications, other hypoglycemia, dysphagia following unspecified cerebrovascular…

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

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents (Resident #9) reviewed for incontinent care, in that: The facility failed to ensure CNA A separated Resident #9's labia to clean between the labia during catheter and incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #9's face sheet, dated 05/04/2023, revealed an admission date of 03/03/2023, with diagnoses which included: History of sepsis(blood poisoning), History of urinary tract infection(infection of any part of the urinary system), Schizophrenia(serious mental disorder in which people interpret reality abnormally), Hypothyroidism(decrease production of thyroid hormones) and, Hypertension (high blood pressure). Record review of Resident #'9's admission MDS assessment, dated…

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

Based on observations, interviews, and record reviews, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to 1 of 3 medication carts (200-hall medication cart) reviewed for medication storage, in that: The facility failed to ensure the 200-hall medication cart was not left unlocked, unattended, and presented with a medication atop. This failure placed residents at risk for misappropriation of property and /or injury by misapplication of drugs. The findings included: During an observation, on 05/02/2023 at 03:03 PM, revealed the 200-hall medication cart unlocked, unattended, and unsupervised by a resident's room. Observation of the medication cart revealed a bottle of sertraline [a drug that can treat depression, obsessive-compulsive disorder (OCD), anxiety disorder, and panic disorder]. The bottle was labeled sertraline 60ml; 20mg/ml. The medication was labeled with Resident #17's name. Observation of the room…

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 clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 6 residents (Resident #50) observed for accuracy of medical records in that: The facility failed to discontinue Resident #50 isolation precaution order. This deficient practice could place residents at risk for errors in care and treatment. The findings were: Record review of Resident #50's face sheet, dated 05/05/2023, revealed an admission date of 03/21/2023 with diagnoses that included: Metabolic encephalopathy (disease affecting brain structure or function), Type 2 diabetes mellitus(blood glucose, also called blood sugar, is too high.), Hypertension (high blood pressure) and, Vascular dementia(problems with reasoning, planning, judgment, memory caused by brain damage from impaired blood flow to the brain). Record review of Resident #50's physician order for March 2023 revealed an order for:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews 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 of 16 residents (Resident #11) reviewed for infection control, in that: The facility failed to ensure LVN D and CNA I practiced glove changes and hand hygiene during incontinent care for Resident #11 This failure could place residents at risk for infections and health declines. The findings included: A record review of Resident #11's quarterly MDS assessment, dated 01/25/2023, revealed Resident #11 was a [AGE] year-old male who was admitted on [DATE]. Resident #11 was assessed with a 13 BIMS score, indicating intact cognition. Resident #11 was diagnosed with obstructive uropathy and neurogenic bladder [a bladder which is not able to release urine]. Resident #11 had a colostomy [a surgical operation in which a…

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.