Rocky Mountain Care- Clearfield

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined that the facility did not ensure that all drugs and biological's were labeled in accordance with currently accepted professional principles, were stored under proper temperature controls, and included the expiration date when applicable. Specifically, a resident had insulin pens at bedside with out storage to prevent access to the insulin by other residents. Medication was left at the bedside of a resident who was not assessed for self administration of medication. A multi use vials of medications were opened and available for use date indicated medications were expired and still available for use. The medication fridge indicated temperatures too cold for safe medication storage. Resident identifiers: 15, 21, and 92. Findings included: 1. Resident 21 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with diabetic polyneuropathy, chronic venous hypertension, acquired absence of right leg below knee. 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 and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food safety. Specifically, the facility did not label or date multiple food items in the walk-in fridge and refrigerator, there were physical food contamination hazards present in the kitchen, and kitchen staff did not prepare and serve food in a hygienic manner. Findings Include: On 4/8/24 at 8:54 AM, an observation was made of one of the facility's freezers. Inside was an undated tub of ice cream, a box of open undated Udi buns, undated pie crusts, a package of undated [NAME] Spunkmeyer cookie dough, a bag of undated whipped topping, 7 undated frozen pies, and 2 bags of undated frozen fruit. On 4/8/24 at 8:58 AM, an observation was made of a ceiling vent and the ceiling directly above a food preparation area. The vent was covered in dust and the ceiling paint was peeling and flaky. On 4/8/24 at 9:00 AM, an observation was made of the food dry…

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 did not ensure that for 3 of 55 sample residents, medical records were complete and accurately documented. Resident identifiers: 3, 19, and 46. Findings include: 1. Resident 46 was admitted to the facility on [DATE] with diagnoses that included right knee flail joint, morbid obesity, weakness, insomnia, schizoaffective disorder, depression, osteoarthritis, and chronic pain. Resident 46's medical record was reviewed from 4/8/24 through 4/17/24. Resident 46's progress notes indicated that on 2/25/24 a Psych (psychiatric) NP (Nurse Practitioner) eval (evaluation) done. per provider orders, discontinue seroquel, start ability 5mg (milligrams) QAM (every morning) x (for) 1 week then increase to 10 mg QAM. The psychiatric evaluation could not be located in resident 46's medical record. On 4/17/24 at 3:40 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that the psychiatric evaluation completed for resident 46 on 2/25/24 was not 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.

On 4/17/24 at 3:27 PM an interview with the Administrator was conducted. The Administrator stated that the QAPI team met at least quarterly but tried to meet monthly if possible. The Administrator stated that the QAPI team consisted of the Administrator, the Medical Director, the Dietary Manager, the Director of Nursing, the Resident Advocate, Social Work, Nurse Management, and Therapy. The Administrator stated that every month, members of the QAPI team would bring information including quarterly measures, grievances, infection control updates, among other assignments that the staff go over and determine what areas needed to be improved. The Administrator stated that once an improvement process had begun, monitors were put in place and were checked as needed. The Administrator stated that if the improvement process was not working, then they would change the process and continue to monitor until the improvement process met satisfactory levels. The Administrator stated that a recent process that the QAPI team worked on was increasing the Physician visits for residents. Based 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 interview and record review, it was determined, the facility did not ensure that each resident's medical record included documentation that indicated that the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations; and that the resident either received the influenza and pneumococcal immunizations or did not receive the influenza and pneumococcal immunizations due to medical contraindications or refusal. Specifically, for 3 sampled residents, the facility did not keep documentation within the residents' medical record regarding the residents' pneumococcal consent status or education of the benefits and potential risks associated with the immunization. Resident identifiers: 3, 15, and 19. Findings Included: 1. Resident 3 was admitted to the facility on [DATE] with the following diagnoses of polyneuropathy, unspecified fracture of left femur, type 2 diabetes mellitus without complications,…

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 and interview, it was determined that the facility did not have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two. Specifically, there were numerous odors throughout the facility. Findings Include: On 4/8/24 at 10:30 AM an observation was made of the 200 hallway. There was a strong odor of bowel movement throughout the hallway. On 4/8/24 at 11:53 AM, an observation was made of the 300 hallway. There was a strong smell of urine throughout the entire hallway. On 4/10/24 at 8:22 AM, an observation was made of the 400 hallway. There was a strong odor of urine throughout the hallway. On 4/10/24 at 8:32 AM an observation was made in the 100 hallway. There was a strong odor of bowel movement throughout the entire hallway. On 4/10/24 at 8:42 AM, an observation was made of the 400 hallway. The strong odor of urine was still present. On 4/10/24 at 9:17 AM, an observation was made of the intersection between the 200 hall and the 300 hall. There 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 it was determined that the facility did not provide written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. Specifically, for 2 out of 55 sampled residents, residents did not receive written notice prior to the room change. Resident identifiers: 166 and 259. Findings Included: 1. Resident 166 was initially admitted to the facility on [DATE] and readmit to the facility on 1/25/2024 with the diagnosis of Periprosthetic fracture around internal prosthetic right hip joint, subsequent encounter, Acute kidney failure, Neoplasm of unspecified behavior of bladder, Fall on same level from slipping, tripping and stumbling without subsequent striking against object, subsequent encounter, Human immunodeficiency virus [HIV] disease. Resident 166's medical records were reviewed on 4/15/24. Resident 166's medical record was reviewed, and it documented resident 166 had been moved from room [ROOM NUMBER] A to room [ROOM NUMBER]…

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 it was determined, for 1 of 55 sampled residents, that the facility did not ensure that the resident had the right to send and receive mail including the right to privacy of such communications. Specifically, a resident received two letters via the postal service and facility staff opened the letters. Resident identifier: 26. Findings included: Resident 26 was admitted to the facility on [DATE] with diagnoses which consisted of cellulitis, orthopedic aftercare following surgical amputation, osteomyelitis, chronic kidney disease, acquired absence of right leg above knee, hyperlipidemia, hypertension, atrial fibrillation, peripheral vascular disease, gastroparesis, and type 1 diabetes mellitus. On 4/08/24 at 12:56 PM, an interview was conducted with resident 26. Resident 26 stated that the lady in the front office was opening his mail and it happened two times. Resident 26 stated that the mail was part of his divorce paperwork and dealt with his 401K. Resident 26 stated that he…

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 it was determined, for 2 of 55 sampled residents, that the facility did not ensure that the resident's right to formulate an advanced directive, including implementing the advanced directive per the facility policy was completed. Specifically, two residents' electronic medical records (EMR) documented that the residents' code status was Do Not Resuscitate (DNR) when the resident's Provider Order for Life-Sustaining Treatment (POLST) form documented full treatment. Resident identifiers: 19 and 92. Findings included: 1. Resident 92 was admitted to the facility on [DATE] with diagnoses which consisted of osteoarthritis, schizoaffective disorder, depression, anxiety disorder, hypertension, and chronic obstructive pulmonary disease. On 4/8/24, resident 92's medical records were reviewed. Resident 92's EMR dashboard documented DNR, and that the resident was a hospice patient. Resident 92's physician orders documented Resident POLST Status=FULL CODE. On 11/10/23, resident 92's POLST…

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 and interview, it was determined, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, for 5 out of 37 sampled residents, resident rooms were observed to be unclean with debris on the floor. In addition, Hoyer lifts for resident care were observed to be soiled. Resident identifiers: 7, 19, 26, 62, and 80. Findings included: 1. On 8/1/22 at 8:31 AM, an observation was made on the 300 hallway of a dirty Hoyer lift. The Hoyer lift was outside of room [ROOM NUMBER] and the base of the Hoyer lift was observed soiled. On 8/1/22 at 9:02 AM, an observation was made on the 100 hallway of a dirty Hoyer lift. The Hoyer lift was observed to be stationed outside of resident room [ROOM NUMBER]. The base of the Hoyer lift was observed to be soiled. The daily shower log documented that the walkers and wheelchairs were scheduled to be cleaned on Monday, Wednesday, and Friday on the night shift for the 300…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined, the facility did not ensure that residents who are unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, for 10 out of 37 sampled residents, residents who were dependent on staff for showers, did not receive showers on a consistent and regular basis. Resident identifiers: 19, 26, 29, 32, 54, 62, 63, 80, 81, and 84. Findings include: 1. Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute respiratory failure with hypoxia, constipation, pain, hypoglycemia, essential hypertension, and hemiplegia, unspecified affecting unspecified side. On 8/2/22 at 9:31 AM, an interview was conducted with resident 29. Resident 29 stated he was dependent on staff for assistance with his activities of daily living (ADLs). Resident 29 stated he can not bathe, dress, or transfer himself without help.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined, the facility did not have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, for 6 out of 37 sampled residents, resident showers were not being completed due to staffing, complaints from residents regarding staffing and not receiving cares, and long call light times were observed. Resident identifiers: 7, 32, 40, 52, 54, and 121. Findings included: 1. On 8/1/22 at 9:08 AM, an interview was conducted with resident 7. Resident 7 stated the facility was short staffed at night. Resident 7 stated there were three staff for the entire 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 interview and record review, it was determined, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance with F584, and F880 which were cited within the facility's 2020 recertification survey. In addition, the facility was found to be in non-compliance with F758 and F761 which were cited within the facility's 2017, 2019, and 2020 recertification survey. Findings included: An annual recertification survey was completed on 10/16/17. The following deficiencies included, but not limited to, F329 (F758) and F431 (F761). An annual recertification survey was completed on 1/10/19. The following deficiencies included, but not limited to, F758 and F761. An annual recertification survey was completed on 2/10/20. The following deficiencies included, but not limited to, F584, F758, F761, and F880. 1. Based on observation and interview, it was determined, the facility did not provide housekeeping 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 2. On 8/1/22 at 8:59 AM, an observation was made of Registered Nurse (RN) 1 and Nursing Student (NS) 1 exiting resident room [ROOM NUMBER] which had signage on the door indicating the resident was on droplet precautions. Door signage also included instructions for donning appropriate PPE and doffing PPE. Both nurses were observed not to sanitize their eye protection after exiting the room. An interview was conducted with RN 1. RN 1 stated that Centers for Disease Control and Prevention guidelines, for residents on quarantine, required staff to don a mask, eye protection, a gown, and gloves before entering a room, and doff the gown and gloves when exiting the room. RN 1 also stated staff should perform hand hygiene after exiting and sanitize the eye protection. RN 1 stated both staff should have sanitized their eye protection and they did not. 3. On 8/2/22 at 9:28 AM, CNA 1 was observed to enter resident room [ROOM NUMBER], where the resident was on contact precautions for a multi-drug resistant organism wound.…

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, it was determined, the facility did not review and revise the comprehensive care plan after each assessment. Specifically, for 1 out of 37 sampled residents, the care plan did not address a resident's intravenous (IV) hydration status. Resident identifier: 80. Findings included: Resident 80 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, pulmonary hypertension, type 2 diabetes mellitus, cognitive communication deficit, adult failure to thrive, pulmonary hypertension, hypothyroidism, celiac disease, benign prostatic hyperplasia, morbid obesity, hyperlipidemia, disorder of phosphorus metabolism, hypomagnesemia, major depressive disorder, essential tremor, hypertension, and obstructive sleep apnea. On 8/1/22 at 8:44 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 80 had an IV infusion of magnesium with normal saline (NS) every other day. On 8/1/22 at 11:41 AM, an interview 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, it was determined, the facility did not ensure that services provided met professional standards of quality. Specifically, for 1 out of 37 sampled residents, a percutaneous endoscopic gastrostomy (PEG) tube feeding did not have the bag labeled with the formula type, rate of infusion, resident identification information, date and time of administration, or the nurse initials who initiated the infusion. Resident identifier: 99. Findings included: Resident 99 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included [NAME]-Sachs disease, bipolar disorder, pseudobulbar affect, anxiety disorder, periodontal disease, hypotension, seizures, gastro-esophageal reflux disease, thrombocytopenia, dysphagia, moderate protein-calorie malnutrition, pain, muscle spasms, right artificial hip joint, and gastrostomy tube. On 8/1/22 at 8:44 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 99 had a tube feed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined, the facility did not provide necessary respiratory care and services consistent with the resident's care plan and goals. Specifically, for 1 out of 37 sampled residents, a resident's oxygen tubing and prefilled humidifier bottle were not changed as ordered by the physician, and the filter on the concentrator was not cleaned as ordered by the physician. Resident identifier: 14. Findings included: Resident 14 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, type 2 diabetes mellitus without complications, chronic systolic (congestive) heart failure, acute and chronic respiratory failure, morbid obesity, generalized anxiety disorder, post-traumatic stress disorder, borderline personality disorder, and unspecified psychosis. On 8/2/22 at 8:16 AM, an observation was made of resident 14 receiving oxygen at 4 liters per minute via nasal canula from an oxygen concentrator. The oxygen concentrator was observed…

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, it was determined, the facility did not ensure that pain management was provided to residents who required such services. Specifically, for 1 out of 37 sampled residents, a resident reported uncontrolled pain and missed pain medication administration. Resident identifier: 62. Findings included: Resident 62 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included non-ST elevation (NSTEMI) myocardial infarction, pneumonia, bipolar disorder, anxiety disorder, chest pain, hypotension of hemodialysis, end stage renal disease, congestive heart failure, gastro-esophageal reflux disease, hypothyroidism, paraplegia, morbid obesity, history of transient ischemic attack, pain, hyperlipidemia, type 2 diabetes mellitus, essential hypertension, pulmonary embolism, insomnia, major depressive disorder, colostomy, artificial opening of urinary tract, and pelvic inflammatory disease. On 8/1/22 at 12:27 PM, an interview was conducted with resident 62.…

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, it was determined, the irregularities noted by the pharmacist during the drug regimen review must be reported to the attending physician and the facility's Medical Director and Director of Nursing (DON), and these reports must be acted upon. Specifically, for 2 out of 37 sampled residents, a pharmacy recommendation to attempt a gradual dose reduction (GDR) on a resident's medication was not acted upon when the physician agreed with the pharmacy recommendation. In addition, . Resident identifiers: 7 and 62. Findings included: 1. Resident 7 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, cerebral palsy, dysphagia, anxiety disorder, bipolar disorder, Parkinson's disease, sleep disorder, convulsions, and pain. Resident 7's medical record was reviewed on 8/2/22. The Pharmacy Consultation Report dated 3/10/22, documented [Name of resident 7 removed] has a long standing order for Lamotrigine 150 mg [milligrams] twice daily. Please attempt 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined, the facility did not ensure each resident's drug regimen remained free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which would indicate the dose should be reduced or discontinued. Specifically, for 2 out of 37 sampled residents, a resident's medications were not administered per the physician's orders and medications were omitted and documented as not being administered at all. Resident identifiers: 62 and 80. Findings included: 1. Resident 62 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included non-ST elevation (NSTEMI) myocardial infarction, pneumonia, bipolar disorder, anxiety disorder, chest pain, hypotension of hemodialysis, end stage renal disease, congestive heart failure, gastro-esophageal reflux disease,…

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, it was determined, the facility did not ensure that a resident who used psychotropic drugs was not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, for 1 out of 37 sampled residents, a resident received one GDR on an antipsychotic medication for bipolar disorder that was initiated by the facility on 9/1/21. Resident identifier: 7. Findings included: Resident 7 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, cerebral palsy, dysphagia, anxiety disorder, bipolar disorder, Parkinson's disease, sleep disorder, convulsions, and pain. Resident 7's medical record was reviewed on 8/2/22. A physician's order dated 9/1/21, documented Latuda (lurasidone) tablet 20…

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 and interview, it was determined, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, included the accessory and cautionary instructions and the expiration date when applicable, and were stored in locked compartments. Specifically, observations were made of medications left unattended on top of the medication cart and a medication was found available for use without an expiration date or dosage visible. Findings included: 1. On 8/3/22 at 7:59 AM, an observation was made of Licensed Practical Nurse (LPN) 1 during morning medication administration on the 300 hallway. LPN 1 was observed to leave the following medications unattended on top of the medication cart while inside a resident room; Meropenem 500 milligram intravenous, Combigan 0.2-0.5 % drops, Dorzolamide 2 % drops, and Prednisone acetate 1% drops. On 8/3/22 at 8:05 AM, upon return to the medication cart with LPN 1 the above medications were observed missing from the top of the cart. An immediate interview 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, it was determined, the facility did not provide the special eating equipment and utensils for residents who needed them. Specifically, for 1 out of 37 sampled residents, the facility did not provide the resident with weighted utensils to assist with dining. Resident identifier: 80. Findings included: Resident 80 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, pulmonary hypertension, type 2 diabetes mellitus, cognitive communication deficit, adult failure to thrive, pulmonary hypertension, hypothyroidism, celiac disease, benign prostatic hyperplasia, morbid obesity, hyperlipidemia, disorder of phosphorus metabolism, hypomagnesemia, major depressive disorder, essential tremor, hypertension, and obstructive sleep apnea. On 8/1/22 at 9:24 AM, an interview was conducted with the Central Supply Manager (CSM). The CSM stated that resident 80 had refused his breakfast and was upset. The CSM stated that…

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 it was determined, the facility did not maintain records on each resident that were complete, accurately documented, and readily accessible. Specifically, for 2 out of 37 sampled residents, progress notes for a resident had notes from other residents located inside their medical record, and pharmacy monthly medication reviews were not located in the resident's medical record. Resident identifiers: 62 and 80. Findings included: 1. Resident 80 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, pulmonary hypertension, type 2 diabetes mellitus, cognitive communication deficit, adult failure to thrive, pulmonary hypertension, hypothyroidism, celiac disease, benign prostatic hyperplasia, morbid obesity, hyperlipidemia, disorder of phosphorus metabolism, hypomagnesemia, major depressive disorder, essential tremor, hypertension, and obstructive sleep apnea. On 8/4/22, resident 80's progress notes were reviewed and 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 it was determined, for 3 of 45 sampled residents, that the facility did not ensure that the medication error rate was not 5 percent or greater. Specifically, 4 medication errors were observed out of 31 observations with a medication error rate of 12.9%. Resident identifiers: 7, 99, and 330. Findings include: 1. Resident 330 was admitted to the facility on [DATE] with diagnoses which included quadriplegia C1-C4 complete, stage 3 pressure ulcer, hypertension, mood disorder, and pain. On 2/6/20 at 8:30 AM, Licensed Practical Nurse (LPN) 1 was observed to prepare and administer medications to resident 330. LPN 1 was observed to prepare an intravenous (IV) infusion of piperacillin-tazobactam (Zosyn) 3.375 grams (gm). The vial of powdered Zosyn was reconstituted into a bag of Normal Saline 100 milliliters (ml). LPN 1 was observed to attach the IV tubing to the reconstituted bag of Zosyn and the tubing line was primed to the end of the tubing. No excess liquid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 1 of 45 sampled residents, that the facility did not determine that the right to self-administer medications was safe and clinically appropriate. Specifically, a resident was observed to self administer insulin incorrectly and the entire dose was not dispensed. Resident identifier: 7. Findings include: Resident 7 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, altered mental status, acute kidney failure, type 2 diabetes mellitus, metabolic encephalopathy, and gastro-esophageal reflux disease. On 2/6/20 at 9:15 AM, Registered Nurse (RN) 5 was observed to prepare and administer medications to resident 7. RN 5 obtained resident 7's Lantus insulin pen from the medication cart. RN 5 dialed the pen to dispense 65 units and then gave the pen to resident 7 to self administer. Resident 7 was observed to press the tip of the pen to the abdomen while pressing the plunger of the pen. Resident 7's hands…

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, it was determined the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, residents complained of smoking odors and observations were made of residents smoking in close proximity to the facility. Findings include: On 2/4/20 at approximately 10:15 AM, an interview was conducted with a resident whose room was located on the 300 hallway. The resident stated it smells smoky in here and the facility was working on moving her to a different room. The resident further stated she wore a surgical mask because the facility smelled of cigarette smoke. On 2/4/20 at 1:47 PM, an observation was made in the television area located at the intersection of the 100 and 200 hallways. A resident was observed smoking directly outside of the door leading from the television area to the outdoor courtyard. On 2/4/20 at 2:40 PM, the 300 hallway was observed to smell of cigarette smoke. The Social Services Director (SSD) was observed walking down the 300 hallway and was immediately interviewed. The SSD stated it…

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, it was determined, for 2 of 45 sampled residents, the facility did not make prompt efforts to resolve grievances the residents may have. Specifically, grievances filed by the residents were not addressed by the facility in a timely manner. Resident identifiers: 6 and 112. Findings include: 1. Resident 6 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, pain, insomnia, major depressive disorder, hypertension, dysphagia, anoxic brain damage, and dystonia. On 2/4/20 at 10:35 AM, an interview was conducted with resident 6. Resident 6 stated she had several personal items that were missing and she notified facility staff. Resident 6 further stated her laptop went missing two weeks prior, and more and more jewelry was missing every day. Resident 6 further stated her missing items had not been replaced and the facility had not followed up with her about her missing items. The facility's grievance binder was reviewed and documented the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 of 45 sampled residents, that the facility assessment did not accurately reflect the resident's status. Specifically, a resident who did not require an anticoagulant medication was coded as receiving anticoagulants. In addition, a resident with a Preadmission Screening Resident Review (PASRR) Level II was coded as currently not considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Resident identifiers: 9 and 64. Findings include: 1. Resident 64 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia, dysphagia, chronic obstructive pulmonary disease, diabetes mellitus type 2, bipolar disorder, and epilepsy. On 2/4/20 at 12:28 PM, an interview was conducted with resident 64. Resident 64 was asked if she had received her blood thinning medication as ordered by the physician and in a timely manner by staff. Resident 64…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 1 of 45 sampled residents, that the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, a resident with a contracture did not receive range of motion services in order to prevent further decrease in range of motion. Resident identifier: 80. Findings include: Resident 80 was admitted to the facility on [DATE] with diagnoses which included disorientation, pain, hypertension, bipolar disorder, major depressive disorder, encephalopathy, dysphagia, and anxiety disorder. On 2/4/20 at 1:26 PM, an observation was made of resident 80. Resident 80 was observed laying in bed, and her right hand was contracted into a closed position. Furthermore, resident 80 was not observed to have a splint, brace, or other device in place. On 2/4/20 at 2:53 PM, a follow up observation was made of resident 80.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 2 of 45 sampled residents, that the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, one resident was not provided with assistance and interventions to prevent falls in accordance with her plan of care and a second resident was burned by a steam table located in the dining room. Resident identifiers: 6 and 112. Findings include: 1. Resident 6 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, pain, insomnia, major depressive disorder, hypertension, dysphagia, anoxic brain damage, and dystonia. On 2/4/20 at 10:35 AM, an interview was conducted with resident 6. Resident 6 stated she fell many times since admitting to the facility, and most recently fell in the bathroom. Resident 6 further stated the facility had not put anything in place to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 1 of 45 sampled residents, that the facility did not ensure that the licensed nurses had the specific competencies and skill set necessary to care for the residents' needs. Specifically, an observation was made of Licensed Practical Nurse (LPN) 1 administering intravenous (IV) medications improperly and the LPN did not have the credentials that documented competency in IV infusions. Resident identifier: 330. Findings include: Resident 330 was admitted to the facility on [DATE] with diagnoses which included quadriplegia C1-C4 complete, stage 3 pressure ulcer, hypertension, mood disorder, and pain. On 2/6/20 at 8:30 AM, an observation was made of LPN 1 during morning medication administration. LPN 1 was observed to prepare an IV infusion of piperacillin-tazobactam (Zosyn) 3.375 grams (gm). The vial of powdered Zosyn was reconstituted into a bag of Normal Saline 100 milliliters (ml). LPN 1 was observed to attach the IV tubing to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 of 45 sampled residents, that the facility did not establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determine that all drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled. Specifically, the facility did not have a narcotics reconciliation process in place and the Narcotic Record Log did not match the Medication Administration Records (MAR). Resident identifiers: 31 and 50. Findings include: 1. Resident 31 was admitted to the facility on [DATE] with diagnoses which included paraplegia, anxiety, orthostatic hypotension, unstable burst fracture, rib fracture, depressive disorder, mono-neuropathy, and chronic pain. On 2/5/20 at 1:45 PM, resident 31 was interviewed. Resident 31 stated that he had chronic back pain and that he received multiple pain medications for pain control. Resident 31 stated that…

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, it was determined the facility did not ensure that as needed (PRN) psychotropic drugs are limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond the 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Specifically, for 1 of 45 sampled residents, an anti-anxiety drug was not limited to 14 days and the resident's record did not document a rationale for use including a duration for the order. Resident identifier: 112. Findings include: Resident 112 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, bipolar, disorder, hypertension, pain, Wernicke's encephalopathy, and acute respiratory failure. A review of resident 112's medical record was completed on 2/10/20. Resident 112's physician's orders were reviewed. The orders documented that resident 112 was prescribed…

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 and interview, it was determined that the facility did not label all drugs in accordance with professional standards and with the expiration date, and all drugs and biologicals were not stored under proper temperature controls. Specifically, an opened vial of insulin was not labeled with an expiration date and a medication fridge was not registering within the temperature control range for the stored medication. Findings include: 1. On 2/6/20 at 11:27 AM, the medication cart on the 700 hallway was inspected. An open vial of Admelog (Lispro) insulin 100 units/milliliter vial was documented with a date of 2/3/20. The vial did not document if the date was an open date or an expiration date. An immediate interview was conducted with Registered Nurse (RN) 6. RN 6 stated that she would consider the date an expiration date based on the bottle being half empty. RN 6 stated that it was not possible to verify if the date was for open or expiration. RN 6 stated she would discard the medication and obtain a new vial. 2. On 2/6/20 at 11:46 AM, the medication fridge on 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 and interview it was determined, for 1 of 45 sampled residents, that the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. Specifically, facility staff were observed to bare handed touch medication during medication preparation. Resident identifier: 54. Findings include: Resident 54 was admitted to the facility on [DATE] with diagnoses which included adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and Schizophrenia. On 2/6/20 at 10:00 AM, Student Nurse (SN) 1 was observed to prepare and dispense medications for resident 54. SN 1 was not observed to perform hand hygiene prior to dispensing the medication. SN 1 dispensed Lorazepam 1 milligram (mg) tablet into the palm of her hand and then picked it up with three fingers and placed it into a medication cup. SN 1 then dispensed Seroquel 150 mg, 3 tablets into the palm of her hand. One tablet fell…

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.