Mountain View Health Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not establish an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment. In addition, the facility did not establish an infection prevention and control program system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. Specifically, for 2 out of 30 sampled residents, a nurse dropped a pill on the medication cart, picked up the pill with bare hands, and administered the medication to a resident. In addition, hand hygiene was not performed when the Certified Nursing Assistants (CNA) were passing resident meal trays, medical supplies were stored in a bathroom that was in use by staff, there was no tracking and trending for the IPCP, staff were not using the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP), and the licensed nurse cross contaminated during a wound care dressing…

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, the facility did not ensure that the designated Infection Preventionist (IP) who was responsible for the facility's infection prevention and control program had completed specialized training in infection prevention and control. Specifically, the Director of Nursing (DON) who was the designated IP had not completed the specialized training in infection prevention and control. Findings included: On 7/29/24 at 10:47 AM, an interview was conducted with the DON. The DON stated that she was the designated IP for the facility and she had completed the specialized training for the IP certification. The DON stated she took the training and was supposed to take the test. The DON stated she had until November 2024 to take the test. The DON stated she thought she did the training in May 2024. The DON stated regarding infection control she had been so busy. The DON stated she learned about the enhanced barrier precautions, multidrug resistant organisms, and how she could do charts. The DON stated she was still working on those things to get them in place. The DON stated they…

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, the facility did not ensure that residents have a right to a dignified existence. Specifically, for 3 out of 30 sampled residents, the facility served resident meals on disposable dishware, there were long call lights, there was a resident with socks with holes, and there were observations of staff talking down to residents in the facility. Resident identifiers: 12, 15, and 22. Findings Included: 1. On 7/28/24 at 11:46 AM, an observation was conducted of the lunch meal tray service. The mobile hot buffet was observed in the 300 hallway. Staff were observed preparing the lunch meal for residents eating in their rooms. The lunch meal was served on Styrofoam plates, disposable plastic cups, Styrofoam cups, and disposable cutlery. On 7/30/24 at 12:18 PM, an observation was made of the lunchtime hallway meal tray service. It was noted that residents that chose to eat in their bedroom received their meal on a Styrofoam plate with disposable cutlery. On 8/10/24 at 1:56 PM, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, there were several brown carpet stains found in multiple residents' rooms, there was a television antenna hanging from the ceiling of a resident room, there were damaged blinds in a resident's room, and a resident had dirty wheelchair tires from being pushed through a brown substance found on the floor of the facility. Findings Included: On 7/28/24 at 10:26 AM, an observation was made of resident room [ROOM NUMBER]. There was a large discolored area under the air conditioner near the window. There was a brownish stain on the carpet to the right side of the bed. On 7/28/24 at 12:15 PM, an observation was made of a brown substance on the floor of the bathroom in resident room [ROOM NUMBER] which had been run over by the wheelchair. The brown substance was observed to be on the wheelchair tires. On 7/28/24 at 12:30 PM, an observation was made of the floors throughout the 100 hallway…

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 30 sample residents, the facility did not appropriately document the basis for the transfer or the discharge summary. In addition, appropriate documentation was not completed in order to ensure a safe and effective transition of care. Resident identifiers: 25, 47, and 298. Findings include: 1. Resident 25 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses which included sepsis, acute respiratory failure, type 2 diabetes mellitus, vascular dementia, pneumonia, pressure ulcer of left heal, metabolic encephalopathy, hypertension, and atrial fibrillation. Resident 25's medical record was reviewed from 7/28/24 through 8/14/24. A Health Status Note dated 12/28/23 at 10:33 PM indicated, Res [resident] lungs assessed this shift, resident c/o [complained of] pain with inhalation, lower lobes junky to auscultation, wheezing heard from chest, resident unable to maintain 02 [oxygen] sats [saturation] above 90 w/o…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 6 out of 30 sampled residents, care plans were not created when there was a specified need and therefore were not reflective of the services required for the residents to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Resident identifiers: 7, 17, 24, 26, 32, and 35. Findings included: 1. Resident 32 was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD) with acute exacerbation, fluid overload, hypertension, and hyperglycemia. Resident 32's medical record was reviewed from 7/28/24 through 8/14/24. 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 the interdisciplinary team reviewed and revised the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments. Specifically, or 6 out of 30 sampled residents, care plans were not updated after a change in the resident's condition or in response to implemented interventions. Resident identifiers: 3, 17, 26, 32, 35, and 298. Findings included: 1. Resident 32 was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD) with acute exacerbation, fluid overload, hypertension, and hyperglycemia. On 7/28/24 at 10:14 AM, an interview was conducted with resident 32. Resident 32 stated he had pain in his legs, feet, and arm. Resident 32 stated he was on pain medication, but they were administered late. Resident 32's medical record was reviewed from 7/28/24 through 8/14/24. 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 observation, interview, and record review, the facility did not ensure that a resident who needed respiratory care was provided such care care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 5 out of 30 sampled residents, the facility did not have orders for multiple residents' nasal cannulas, oxygen concentrator humidifier or oxygen concentrator to be changed nor was there any documentation that they were being changed, and a resident with an order for a mustache cannula instead received a standard nasal cannula. Resident identifiers: 7, 17, 24, 26, and 32. Findings Included: 1. Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis without septic shock, pneumonitis due to inhalation of food and vomit, malignant neoplasm of esophagus, acute respiratory failure unspecified whether with hypoxia or hypercapnia, asthma uncomplicated,…

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 5 of ^^ sample residents were seen by the physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. Resident identifiers: 7, 24, 28, 29, and 44. Findings include: 1. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, schizoaffective disorder, paroxysmal atrial fibrillation, obsessive-compulsive disorder, essential hypertension, mild cognitive impairment of uncertain or unknown etiology, adult failure to thrive, and encephalopathy. A review of resident 7's medical record of physician visits revealed that the last facility MD [medical doctor] visit was 2/27/24, indicating that the resident had not been seen by the physician in approximately 5.5 months. 2. Resident 24 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitus, chronic viral Hepatitis C,…

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 provide pharmaceutical services that included the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's to meet the needs of each resident. Specifically, for 4 out of 30 sampled residents, licensed nursing staff were not signing out controlled substances and reconciling at the time of administration. Resident identifiers: 1, 3, 4, and 38. Findings included: 1. Resident 38 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia with agitation, essential hypertension, and neurocognitive disorder with Lewy bodies. Resident 38's medical record was reviewed on 8/12/24. The August 2024 Medication Administration Record (MAR) was reviewed on 8/12/24 at 12:21 PM. Resident 38's ARISE medications had not been administered. (Note: According to the medication pass times provided by the facility the ARISE medications were to be administered between 7:00 AM to 11:00 AM.) The ARISE…

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 did not ensure that residents were free of any significant medication errors. Specifically, for 4 out of 30 sampled residents, one resident had multiple missed doses of two medications, a second resident was not administered pregabalin a time sensitive medication at the scheduled times as ordered by the physician, a third resident received a double dose of their pain and anxiety medications, and a fourth resident received a double dose of warfarin. Resident identifiers: 4, 32, 38, and 298. Findings include: 1. Resident 32 was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD) with acute exacerbation, fluid overload, hypertension, and hyperglycemia. On 7/29/24 at 10:11 AM, an observation and interview were conducted with resident 32. Resident 32 was awake, in bed, and wore a nasal cannula connected to an oxygen concentrator running at 8…

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 did not obtain laboratory (lab) services to meet the needs of the residents. Specifically, for 3 out of 30 sampled residents, residents that had a urinalysis (UA) collected did not have the UA completed in a timely manner. Resident identifiers: 8, 18, and 44. Findings included: 1. Resident 18 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, other stimulant abuse with stimulant-induced psychotic disorder, and unspecified mycosis. On 8/10/24 at 2:17 PM, an observation was made of the physician's phone. There was a text message at 2:03 PM, from Licensed Nurse (LN) 3 to the physician which revealed resident 18 had redness to his groin area and had urgency and burning upon urination. LN 3 text messaged resident 18's urine was positive for leukocytes and nitrates. LN 3 asked the Medical Director (MD) if it was okay to have a UA with Culture and Sensitivity (C&S) completed. On 8/10/24 at 2:52 PM, 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.

Based on interview, observation and record review, the facility did not ensure that the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple areas of immediate jeopardy and harm were identified. In addition, multiple areas of non compliance were cited on the previous survey and again during the current recertification survey. Resident identifiers: 46 and 298. Findings include: 1. Based on interview and record review, the facility did not ensure that 2 of 30 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, ongoing monitoring for changes in condition were not provided after one resident experienced ongoing emesis and abdominal pain, and a second resident had a deep vein thrombosis. The findings for resident 46 were determined to have resulted in immediate jeopardy 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.

Based on interview, observation and record review, the facility did not ensure the the medical director was effective in their role of implementing resident care policies and coordinating medical care in the facility. Specifically, multiple areas of immediate jeopardy and harm were identified. In addition, multiple areas of non compliance were cited on the previous survey and again during the current recertification survey. Resident identifiers: 46 and 298. Findings include: 1. Based on interview and record review, the facility did not ensure that 2 of 30 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, ongoing monitoring for changes in condition were not provided after one resident experienced ongoing emesis and abdominal pain, and a second resident had a deep vein thrombosis. The findings for resident 46 were determined to have resulted in immediate jeopardy for resident 46. Resident identifiers: 46 and 298. [Cross refer to F684] 2. 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 observation, interview, and record review, the facility did not maintain records on each resident that were complete, accurately documented, and readily accessible. Specifically, for 6 out of 30 sampled residents, progress notes, an appointment referral, and Occupational Therapy orders were located in the wrong resident medical records. In addition, resident medical records were unsecured in the Director of Nursing (DON) office. Resident identifiers: 1, 3, 7, 24, 35, and 148. Findings included: 1. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, acute myocardial infarction, acute respiratory failure with hypoxia, age-related cognitive decline, type 2 diabetes mellitus, non-pressure chronic ulcer of foot, rheumatoid arthritis, acquired deformity of lower leg, muscle wasting and atrophy, dysphagia, and difficulty in walking. On 7/29/24, resident 1's paper medical record was reviewed. Progress Notes for resident 3 and…

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

Based on interview, the facility did not have in effect a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs. Specifically, the facility never provided the State Survey Agency (SSA) their hospital transfer agreement. Findings included: On 8/7/24 at 1:03 PM, the hospital transfer agreement was requested from the Administrator. On 8/7/24 at 1:25 PM, an interview was conducted with the Administrator. The Administrator stated that he was having trouble finding the hospital transfer agreement. On 8/12/24 at 9:53 AM, an interview was conducted with the Administrator. The Administrator stated that the hospital transfer agreement that he had was outdated. The Administrator stated that he reached out to the two local hospitals to get the hospital transfer agreement updated. The Administrator stated that one of the hospitals he contacted was by email only. The Administrator stated that he would provide the SSA the hospital transfer agreement when he received it. A hospital transfer agreement was never provided to the SSA.

Based on interview, the facility did not establish an infection prevention and control program (IPCP) that included, at a minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, the facility infection control tracking and trending was not done and the facility had not established an antibiotic stewardship program. Findings included: On 7/31/24 at 7:23 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she could not locate her infection control binder, but would look for the binder and bring it to the State surveyor. The DON stated that she was not currently tracking or trending infections in the facility. The DON stated that she did not have the policy for antibiotic stewardship. The DON stated to prevent infections from being spread, all staff should be hand sanitizing in between contact with residents and then washing their hands after they entered a resident's room. On 8/14/24 at 12:00 PM, it should be noted that the infection control binder was never brought 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 and interview, the facility did not have adequate outside ventilation. Specifically, the facility was found to have numerous odors throughout the survey. Findings included: On 7/28/24 at 10:05 AM, an observation was made of the 100 hall locked unit. There was a strong urine odor near rooms [ROOM NUMBERS]. On 7/28/24 at 10:22 AM, an observation was made of the 300 hall at the facility. There was noted to be a strong urine odor through out the hallway. On 7/28/24 at 10:43 AM, an observation was made of the 200 hall at the facility. there was noted to be a strong urine odor around rooms [ROOM NUMBERS]. On 7/28/24 at 12:18 PM, an observation was made of the 300 hall at the facility. There was noted to be a strong urine odor near the entrance to room [ROOM NUMBER]. On 7/28/24 at 12:28 PM, an observation was made of the 100 hall locked unit. There was a strong urine odor near room [ROOM NUMBER]. On 7/29/24 at 7:36 AM, an observation was made of the 100 hall locked unit. There was a strong urine…

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 inform the resident representative for 2 of 30 sample residents when there was a significant change in the residents' physical, mental or psychosocial status; or when there was a need to alter treatment significantly. Specifically, two residents had a change in condition, but the facility did not attempt to contact the representative when the change of condition occurred. Resident identifiers: 25 and 46. Findings include: 1. Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, chronic obstructive pyelonephritis, severe sepsis without shock, aspiration pneumonitis, acute kidney failure, supraventricular tachycardia, and bipolar disorder. Resident 46's medical record was reviewed from [DATE] through [DATE]. Progress notes for resident 46 indicated that on [DATE] at 9:24 AM, resident 46 was .having black tarry vomit, constant diarrhea, respirations 40, hunched over more than…

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 all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation was made if the events that cause the allegation involve abuse or result in serious bodily injury. Specifically, for 2 out of 30 sampled residents, an entity report of a physical abuse allegation was not submitted to the State Survey Agency (SSA) until three days after the incident and an entity report of a neglect allegation was not reported to the SSA until 14 days after the incident. Resident Identifiers: 29 and 41. Findings Included: 1. Resident 41 was admitted to the facility on [DATE] with diagnoses including cellulitis of left lower limb, methicillin resistant staphylococcus aureus infection unspecified site, malaise, venous insufficiency, localized edema, morbid severe obesity due to excess calories,…

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, in response to allegations of neglect the facility did not have evidence that all alleged violations were thoroughly investigated. Specifically, for 1 out of 30 sampled residents, a resident that had multiple falls and sustained an acute complete femoral neck fracture with partial displacement did not have the fracture investigated for neglect. Resident identifiers: 298. Findings included: Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, dementia, essential hypertension, acute kidney failure, and anxiety disorder. Resident 298's medical record was reviewed on 8/7/24. A Baseline Care Plan signed by the Director of Nursing (DON) on 3/28/24, documented that resident 298 did not have a history of falls and a Fall Management Care Plan was not implemented. On 3/29/24, a Morse Fall Scale documented that resident 298 was a High Risk for Falling with a score of 50. A resident was considered a High…

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 accurately assess residents. Specifically, for 1 out of 30 sampled residents, range of motion impairment was not documented on the Minimum Data Set (MDS) assessment. Resident identifier: 3. Findings included: Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include, paranoid schizophrenia, chronic obstructive pulmonary disease, chronic viral Hepatitis C, major depressive disorder, suicidal ideations, gastro-esophageal reflux disease, essential hypertension, hypothyroidism, chronic pain, type 2 diabetes mellitus, post traumatic stress disorder, low back pain, and hypo-osmolality and hyponatremia. On 7/29/24 at 8:30 AM, an interview was conducted with resident 3. Resident 3 stated that she could not get out of bed without extensive assistance from facility staff due to a stroke that she had which left her with weakness on the left side of her body. Resident 3 stated that she was unable to walk or use her left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that for 2 of 30 sample residents, a discharge summary was included in the residents' medical records. Resident identifiers: 47 and 248. Findings include: 1. Resident 47 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, edema, hyperlipidemia, major depressive disorder, pain in right hip, spinal stenosis, hypertension, low back pain, history of malignant neoplasm of prostate, and and genetic related intellectual disability. Resident 47's medical record was reviewed on 7/31/24. Resident 47's medical record that the resident discharged from the facility on 5/15/24. No discharge summary or basis for the discharge could be located in resident 47's medical record. On 7/31/24 at 3:25 PM, an interview was conducted with the Director of Nursing. (DON). The DON stated that the Administrator and Social Services Worker worker had a handy [NAME] discharge summary they would provide to the nurse and the nurse would complete…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, for 2 out of 30 sampled residents, recommended treatments of daily prolonged stretching were not followed up on, occupational therapy orders were not implemented, and splints were not being provided. Resident identifiers: 1 and 35. Findings included: 1. Resident 35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included artherosclerotic heart disease, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, gout, memory deficit following cerebral infarction, repeated falls, type 2 diabetes mellitus with diabetic polyneuropathy, cerebral infarction, dysphagia, Charcot's Arthropathy, and acquired absence of other right toe. On 7/28/24 at 1:05 PM, an observation and interview were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that a resident who enters the facility with an indwelling catheter or subsequently received one was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated that catheterization was necessary. Specifically, for 1 out of 30 sampled residents, a resident continued to have an indwelling catheter without having a diagnosis for keeping it in place. Resident identifiers: 298. Findings included: Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, essential hypertension, benign prostatic hyperplasia without lower urinary symptoms, acute kidney failure, weakness, and anxiety disorder. Resident 298's medical record was reviewed on 8/7/24. An admission Minimum Data Set assessment date 4/10/24, documented that resident 298 had a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 to 15 would suggest intact cognition. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of five percent or greater. Observations of 35 medication opportunities on 7/29/2024, revealed two medication errors which resulted in a 5.71% medication error rate. Specifically, for 1 out of 30 sampled residents, a resident was administered a medication after they had consumed their meal and the physician's order documented to administer the medication before meals. In addition, the resident was administered a medication two hours after the time specified on the physician's order. Resident identifier: 4. Findings included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Huntington's disease, psychotic disorder with delusions, mood disorder due to known physiological condition, bipolar II disorder, conversion disorder with seizures or convulsions, migraine, chronic pain, essential hypertension, and 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 observation, interview, and record review, the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date as possible. Specifically, for 1 out of 30 residents, a resident's narcotic medication was being cut in half and then one-half was being placed back in the bubble pack and sealed with tape. Resident identifier: 22. Findings included: Resident 22 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, paranoid schizophrenia, major depressive disorder, type 2 diabetes mellitus without complications, essential hypertension, low back pain, asthma, and cirrhosis of liver. Resident 22's medical record was reviewed on 8/8/24. A physician order with a start date of 6/25/21, documented oxyCODONE HCl [hydrochloride] Tablet 5 mg [milligrams] Give 1 tablet by mouth every 6 hours as needed for Pain related 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 interview and record review, the facility did not obtain laboratory (lab) services only when ordered by a physician; physician assistant; nurse practitioner (NP), or clinical nurse specialist. Specifically, for 2 out of 30 sampled residents, a resident had a urinalysis (UA) collected without a physician's order and a resident had a Complete Blood Count (CBC) blood lab collected without a physician's order. Resident identifiers: 8 and 18. Findings included: 1. Resident 8 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, schizoaffective disorder, chronic kidney disease stage 3, cannabis abuse, essential hypertension, polycystic kidney, type 2 diabetes mellitus without complications, mental disorders, stimulant dependence, and urinary tract infection. Resident 8's medical record was reviewed on 8/11/24. On 8/10/24 at 2:16 PM, a Health Status Note documented Note Text: Resident assisted with her shower before lunch. I obtained a UA sample from resident d/t [due…

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 promptly notify the ordering physician, physician assistant, nurse practitioner (NP), or clinical nurse specialist of results that fell outside of clinical reference ranges. Specifically, for 1 out of 30 sampled residents, the Medical Director (MD) was not notified timely when the x-ray results documented that the resident had an acute complete femoral neck fracture with partial displacement. Resident identifier: 298. Findings included: Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, dementia, essential hypertension, acute kidney failure, and anxiety disorder. Resident 298's medical record was reviewed on 8/7/24. On 5/20/24 at 11:00 PM, an encounter documented Date of Service: 05/21/2024 Visit Type: Acute Transition of Care: No transition occurred. Progress Note . Chief Complaint / Nature of Presenting Problem: Right hip pain History Of Present Illness: [Resident 298] is…

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 file in the resident's clinical record the signed and dated reports of radiological and other diagnostic services. Specifically, for 1 out of 30 sampled residents, a resident's ultrasound and x-ray reports were not filed in the medical record. Resident identifier: 298 Findings included: Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, dementia, essential hypertension, acute kidney failure, and anxiety disorder. Resident 298's medical record was reviewed on 8/7/24. A. On 6/20/24 at 11:08 AM, a health status note documented, [Name redacted] came in to do an US [ultrasound] to residents RLE [right lower extremity]. RESULTS: Thrombus in common femoral. Femoral vein pros and dist, popliteal and posterior tibial veins with minimal flow. Veins non compressible. IMPRESSION: RLE DVT [deep vein thrombosis] MD [Medical Doctor] notified immediately. A review of the medical record…

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

Based on observation and interview, the facility did not dispose of garbage and refuse properly. Specifically, the facility was found to have stored uncovered, used aluminum soda cans outdoors directly outside of the kitchen. Findings included: On 7/30/24 at 11:49 AM, an observation was made of the facility kitchen. There was a large black plastic garbage bag stored outdoors directly outside the entrance to the kitchen. The garbage bag was torn open and empty aluminum soda cans were spilling out of the bag and onto the concrete ground. On 7/30/24 at 1:52 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that she was aware of the empty soda cans being stored outside the kitchen. The DM stated that a resident of the facility was collecting the cans to be recycled. The DM stated that the bags of soda cans had been torn open by a recent windstorm.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not arrange services with an outside agency. Specifically, for 2 out of 30 sampled residents, residents had physician's orders to follow up with a specialist and the facility staff had not made the appointments. Resident identifiers: 25 and 35. Findings included: 1. Resident 35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included artherosclerotic heart disease, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, gout, memory deficit following cerebral infarction, repeated falls, type 2 diabetes mellitus with diabetic polyneuropathy, cerebral infarction, dysphagia, Charcot's Arthropathy, and acquired absence of other right toe. Resident 35's medical record was reviewed from 7/28/24 through 8/14/24. A Minimum Data Sheet assessment Section GG Functional Abilities and Goals dated 6/13/24, indicated, Functional Limitation in Range of Motion to the Lower extremity (hip, knee, ankle,…

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 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 pneumococcal immunization; and that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindications or refusal. Specifically, for 2 out of 30 sampled residents, residents were not provided education regarding the benefits and potential side effects of the pneumococcal immunization. In addition, the medical record did not include the administration or refusal of the pneumococcal immunization. Resident identifiers: 7 and 24. Findings included: 1. Resident 7 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia with other behavioral disturbance, schizoaffective disorder bipolar type, paroxysmal atrial fibrillation,…

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 10 of 33 sampled residents, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community were not provided. Specifically, residents in the memory care unit did not receive activities in the unit and activities were not provided during the day. Resident identifiers: 5, 7, 9, 13, 26, 31, 32, 35, 36, and 37. Findings include: The facility activity calendar was reviewed for October 2022. The calendar revealed the following activities: a. On 10/11/22: 5:15 PM Travel Bug, 5:45 PM Reminiscing, and 6:15 PM Sensory b. On 10/12/22: 10:00 AM Relief Society, 5:15 PM Banking, 5:45 PM, Current…

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 record review and interview, the facility did not have an activities program that was directed by a qualified professional who is a qualified therapeutic recreation specialist. Specifically, the facility did not employ a Certified Therapeutic Recreation Specialist. Findings include: The facility Administrator (ADM) was asked to provide the most recent notes from the Certified Therapeutic Recreation Specialist (CTRS). Review of the notes revealed that the CTRS provided feedback to the facility in October and November 2021. There were no notes for December 2021. The notes also revealed that the CTRS provided feedback to the facility from January 2022 through April 2022, but not in May 2022. The CTRS also provided feedback in June and July of 2022. On 10/25/22 at 1:35 PM, an interview was conducted with the ADM. The ADM confirmed that the last time the CTRS provided feedback to the facility was in July of 2022 because the Therapeutic Recreation Specialist (TRT) had been sick. On 10/26/22 at 3:30 PM, a phone interview was conducted with the TRT. When asked about her work…

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 record review, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there was, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Specifically, the facility did not accurately assess the residents' needs. Findings include: The Facility Assessment (FA) was requested from the facility Administrator (ADM) on 10/11/22. The FA provided by the ADM was reviewed. 1. The FA did not address the care required by the resident population with regard to the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. Areas of the FA entitled Common diagnoses, Major RUG-IV Categories, Assistance with Activities of Daily Living, and…

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

Based on interview and record review, the facility did not ensure that residents were afforded the right to organize and participate in resident groups in the facility. Specifically, no resident council had been formed and held since June of 2022. Findings include: On 10/12/22, the facility Administrator (ADM) was asked to provide the resident council minutes for the previous six months. The ADM provided the resident council minutes the same day they were requested, however the last resident council notes were from June 2022. On 10/11/22 at 8:22 AM, Ombudsman (OM) 2 sent an email to the surveyors stating that she was concerned about the lack of resident council meetings at the facilty. OM 2 stated that she had brought this to the Administrator's (ADM) attention multiple times. On 10/18/22 at 1:48 PM, an interview was conducted with the ADM. The ADM confirmed that the resident council had not been conducted since June 2022. On 10/12/22 at 10:17 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated she did not know if there was a resident council and…

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

Based on interview and record review, the facility did not act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the residents deposited with the facility. In addition, the facility did not deposit resident funds into an interest bearing account. Resident identifiers: 2, 10, 28, and 30. Findings include: On 10/11/22 at 10:23 AM, an interview was conducted with resident 2. Resident 2 stated that the facility was not providing him with the $45 he was entitled to every month, because they say I owe them $20,000. On 10/18/22 at 11:55 AM, the Administrator (ADM) was asked to provide the transactions from resident 2's personal funds account with the facility. The ADM did not provide these transactions until 10/27/22 at 9:16 AM. Review of resident 2's personal funds account transactions from 1/1/22 to current, indicated that no transactions had been listed since 7/6/22. In addition, the account did not list any interest paid to the resident, and no evidence that his funds had been deposited into an interest bearing account. The…

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

Based on interview and record review, the facility did not establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. In addition, the facility did not ensure that the individual financial record was available to the residents and surveyors upon request. Resident identifiers: 2, 10, 28, and 30. Findings include: On 10/11/22 at 10:23 AM, an interview was conducted with resident 2. Resident 2 stated that the facility was not providing him with the $45 he was entitled to every month, because they say I owe them $20,000. On 10/18/22 at 11:55 AM, the Administrator (ADM) was asked to provide the transactions from resident 2's personal funds account with the facility. The ADM did not provide these transactions until 10/27/22 at 9:16 AM. Review of resident 2's personal funds account transactions from 1/1/22 to current, indicated that no transactions had been listed since 7/6/22. In addition, the account did not list any…

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, observation and record review, the facility did not consult with 1 of 33 sample resident's physician when there was a change in the resident's status. Specifically, a resident had an ongoing rash that the physician was not notified about. Resident identifier: 32. Findings include: Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia, chronic obstructive pyelonephritis, severe sepsis, aspiration pneumonitus, supraventricular tachycardia, acute kidney failure, bipolar disorder, epilepsy, thyrotoxicosis and osteoarthritis. Resident 32's medical records were reviewed between 10/11/22 and 10/31/22. Resident 32's nurses notes included the following entries: a. On 8/19/22, . scrotum is red and excoriated with new order for Zinc oxide 40% to be applied TID (three times a day). b. On 9/14/22, Nystatin Powder Apply to neck [and] L (left) armpit topically two times a day for rash use until resolved. c. On 9/18/22, . Resident has a rash 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.

Based on observation and interview it was determined that the facility did not provide each resident the right to have secured and confidential personal and medical records. Specifically, resident charts were on a rolling cart that was placed in front of the memory care unit open door. Findings include: On 10/23/22 at 12:04 AM, an observation was made of Registered Nurse (RN) 5. RN 5 was observed to open the locked door to the memory care unit. RN 5 moved a cart with residents medical records from the memory care unit in front of the open door. On 10/17/22 at 11:13 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated when she was the only CNA for the facility, the staff opened the door to the memory care unit and placed the medical record cart in front of the open door. CNA 1 stated staff were able to see what was going on in the memory care hallway with the door open. CNA 1 stated she glanced down the memory care unit hallway and then obtained vital signs from residents outside of the locked unit. CNA 1 stated the nurse sometimes watched 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 11. Resident 31 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, hyperlipidemia, dementia with behavioral and major depressive disorder. On 10/12/22 at 10:37 AM, an interview was conducted with resident 31's family member. The family member stated resident 31 had dentures but the dentures were lost during the COVID-19 lock down when family could not visit. The family member stated resident 31 would wear dentures if she had them. On 10/11/22 at 7:50 AM, an observation was made of resident 31 in the memory care dining room. Resident 31 was observed to not have teeth or dentures. Resident 31's medical record was reviewed. An annual Minimum Data Set (MDS) dated [DATE] revealed resident 31 had no broken or loosely fitting full or partial denture. Resident 31 had natural teeth or tooth fragments. A care plan dated 8/25/16 revealed The resident has oral/dental health problems r/t (related to) Poor oral hygiene. The goal developed was The resident will comply with mouth care at…

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 8 of 33 sampled residents, that the facility did not implement their written policies and procedures to prevent abuse and investigate any allegations. Specifically, allegations of sexual, physical abuse and a bruise of unknown origin were not reported and investigated according to facility policy and procedures. Resident identifiers: 9, 13, 14, 5, 26, 36, 31 and 39. Findings include: 1. Resident 31 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified dementia with behavioral disturbance, and depression. Resident 31's medical record was reviewed. An annual Minimum Data Set (MDS) dated [DATE] revealed resident 31 did not have a Brief Interview for Mental Status (BIMS) because she rarely/never understood. The MDS further revealed resident 31 had short and long term memory problems. The MDS revealed her cognitive skills for daily decision making were severely impaired. The MDS revealed resident 31…

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 send a copy of resident 30-day discharge notices or hospitalizations to the Long-Term Care Ombudsman. Findings include: On 10/11/22 at 8:22 AM, Ombudsman (OM) 2 sent an email to the surveyors stating that there has been no monthly transfer logs sent to the state ombudsman notifying of resident transfers since May 2022. OM 2 stated that she had brought this to the Administrator's (ADM) attention multiple times. On 10/25/22 at 1:35 PM, an interview was conducted with the facility ADM. The ADM was asked if she was completing the monthly transfer logs for the state ombudsman. The ADM stated I did not know we were supposed to do that. I guess I missed a memo or something. The ADM confirmed however, that OM 2 had talked to her about filling out the logs prior.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 10 of 33 sample resident, the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, residents that had care areas trigger on the Minimum Data Set (MDS) Care Area Assessment (CAA) Summary did not have care plans developed and implemented in a timely manner. In addition, residents care plans were not updated regarding specific needs. Resident identifiers: 5, 12, 13, 14, 24, 26, 32, 35, 36 and 37. Findings include: 1. Resident 35 was admitted to the facility on [DATE] with diagnoses which included Schizophrenia, cognitive communication deficit, and non-pressure chronic ulcer. On 10/11/22 at 7:59 AM, resident 35 was observed in the dining room. Resident 35 was observed to wear blue plaid pajama pants. Resident 35 was observed with greasy hair and beard. On 10/20/22 at 12:05 PM, resident 35 was observed in blue plaid pajama pants. Resident 35's hair and beard were observed to be…

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, for 5 of 33 sampled residents, the facility did not ensure that services provided met professional standards of quality. Specifically, a nurse did not sign out narcotics when they were administered, one resident who had not been administered their narcotic was recorded as having received the narcotic, and expired Tuberculin solution was used when determining if residents had tuberculosis. Resident identifiers: 8, 10, 11, 29 and 30. Findings include: On 10/11/22 at 4:10 AM, an observation was made of Registered Nurse (RN) 1. RN 1 was observed to have greasy hair that was knotted in the back. RN 1 was also observed to have restless movements of her hands. At 4:58 AM, RN 1 was observed to perform the narcotic reconciliation with RN 3. RN 1 stated that she forgot to sign out narcotics that she had administered overnight. RN 1 was observed to sign out narcotics for residents 8, 10, 11, 29, and three unsampled residents. RN 1 stated that she did not administer any narcotics to resident 10, but one narcotic was missing…

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 7 of 33 sampled residents, based on the resident comprehensive assessments that each resident was not given appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. Specifically, residents were not bathed, residents were not provided personal hygiene, residents were not provided assistance with eating, and a resident was not changed for 44 minutes after having a bowel movement. Resident identifiers: 10, 12, 13, 14, 31, 35 and 37. Findings include: 1. Resident 12 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, dementia, anxiety disorder, and severe protein-calorie malnutrition. On 10/11/22 at 7:35 AM, an observation was made of resident 12 in the dining room. Resident 12 was observed to have greasy and stringy chin length hair. Resident 12 was observed with a gray cardigan with stains on the front of it. On 10/24/22 at 5:22 PM, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 5 of 33 sampled residents, that the facility did not ensure a resident environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistive devices to prevent accidents. Specifically, a resident with a history of elopements, eloped from the facility. In addition, resident's experienced repeated falls with no interventions. Another resident experienced a fall during a transfer. Resident identifiers: 24, 36, 30, 31 and 96. Findings include: 1. Resident 26 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, diabetes mellitus, and hypertension. Resident 26's medical record was reviewed. Resident 26's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. The MDS further revealed resident 26 walked in corridor, walked in room, locomotion on the unit and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that for 5 of 33 sample residents, the facility did not provide routine and emergency drugs and biologicals to its residents. The facility did not provide pharmaceutical services to meet the needs of each resident, and did not obtain the services of a licensed pharmacist who consults on all aspects of the provision of pharmacy services in the facility. 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. Specifically, multiple narcotic medications were not documented at the time they were administered. In addition, narcotic medications were not signed as administered in the Medication Administration Record and on the Controlled Drug Record. In addition, a third party did not reconciled narcotic medications monthly. Resident identifiers: 8, 10, 11, 14 and 29. Findings include: 1. On 10/11/22 at 4:58 AM, Registered Nurse (RN) 1 was observed performing…

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 4 of 33 sampled residents, that the facility did not file, in the resident's clinical record, laboratory results that were dated and contained the name and address of the testing laboratory. Specifically, residents did not have laboratory results available to the nursing staff and results were not filed in the medical record. Resident identifiers: 2, 28, 36, and 94. Findings include: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included a cerebral infarction, convulsions and seizures, paranoid schizophrenia, substance use, chronic peptic ulcer, respiratory failure with hypoxia, kidney failure, coagulation deficit, Wernicke's encephalopathy, hypomagnesemia, and hemiplegia. On 10/13/22 at approximately 9:30 AM, resident 2 was observed to have a seizure. Licensed Practical Nurse (LPN) 1 stated that resident 2 had increased seizure activity when his magnesium was low. On 10/24/22 at approximately 2:00 PM, a pile of papers…

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 5 of 33 sampled residents, that the facility did not provide food prepared in a form designed to meet individual needs. Specifically, residents on mechanically altered diets were provided grapes and lettuce. Resident identifiers: 9, 22, 31, 37 and 39. Findings include: 1. Resident 31 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia with behavioral disturbance, and major depressive disorder. On 10/11/22 at 7:45 AM, an observation was made of the breakfast meal. Resident 31 was served ground meat, pancake, hot cereal and grapes. On 10/20/22 at 11:49 AM, an observation was made of the lunch meal. Resident 31 was observed to be served shredded lettuce. Resident 31's medical record was reviewed. A diet order dated 9/22/21 revealed regular with minced texture. Resident 31's meal ticket revealed a minced diet texture. 2. Resident 39 was admitted to the facility on [DATE] and readmitted on [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.

Based on observation and interview it was determined the facility did not store, prepare and distribute food in accordance with professional standards for food service safety. Specifically, frozen Mighty Shakes were observed to be thawing at room temperature. Findings include: On 10/27/22 at 2:30 PM, an observation was made of the facility medication room. There were 25 Mighty Shakes on a tray, on the counter, in the medication room. An immediate interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she had received the Mighty Shakes that morning and had administered a few with the lunch medication pass. The ADON stated the Mighty Shakes were frozen for the morning medication pass. The ADON stated that residents cannot drink the Mighty Shakes when they're frozen, so they were not administered in the morning. The ADON stated that she was thawing the Mighty Shakes on the counter, but they needed to be refrigerated during the thawing process. According to the United States Department of Agriculture, there are three safe ways to thaw food: 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.

Based on observation and interview it was determined that the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Specifically, resident's medical records were used to block an open door from the memory care unit, preventing egress. Findings include: On 10/23/22 at 12:04 AM, an observation was made of Registered Nurse (RN) 5. RN 5 was observed to open the locked door to the memory care unit. RN 5 moved a cart with residents medical records from the memory care unit in front of the open door. On 10/17/22 at 11:13 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated when she was the only CNA for the facility, the staff opened the door to the memory care unit and placed the medical record cart in front of the open door. CNA 1 stated staff were able to see what was going on in the memory care hallway with the door open. CNA 1 stated she glanced down…

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 4 of 33 sampled residents, that the facility did not maintain medical records on each resident that were complete, accurately documented, readily accessible and systematically organized. Additionally, the facility must safeguard medical record information against loss. Specifically, narcotic medications were not reconciled monthly, nursing staff did not sign out narcotic medications, and nursing staff did not document behaviors according to physician's orders. Resident identifiers: 4, 8, 9, and 10. Findings include: 1. Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diabetes, neuropathy, asthma, spinal stenosis, hypertension, anxiety disorder, and dysthymic disorder. On 10/31/22, resident 8's medical record review was completed. On 10/25/22, a nursing note revealed that resident 8 was taking antibiotics and was very shaky, some weakness and confusion . and had a fever. Resident 8 was transported 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 interview, observation, and record review, it was determined that the facility did not document the corrective actions taken by the facility after it identified incidents under the facility's infection prevention and control program (IPCP), or establish and maintain an IPCP designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, a nurse did not sanitize the glucometer between residents, antibiotics for wounds did not have a corresponding culture, tuberculosis testing was not completed, TB testing was completed with expired tuberculin and staff were observed without a mask. Resident identifiers: 4, 10, 8, 11, 14, 15, 20, 29, 24, 31 and 39. Findings include: 1. On [DATE] at 4:35 AM, Registered Nurse (RN) 1 was observed obtaining blood glucose readings. RN 1 was observed to not clean the glucometer between residents. Readings were obtained from the following residents: a. resident 39 b. 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.

Based on interview and record review, the facility did not designate one or more individuals as the infection preventionist who are responsible for the facility's infection control program. Findings include: On 10/17/22 at 12:33 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that he talked to the Director of Nursing (DON) who would log infections, but there was no infection preventionist in the building. On 10/18/22, the DON was asked for the IP certificate. On 10/18/22 at 1:48 PM, an email was provided by the Administrator. The Administrator wrote I do not think that [DON name] finished her certification. On 10/21/22 at 11:44 AM, the Director of Nursing (DON) was interviewed. The DON stated that she did not have time to do all the responsibilities of the DON because when she was working, she was the nurse on shift (the floor nurse). The DON stated that she had a second nursing job outside the facility, and did not have specific days when she was able to work as the DON at the facility. The DON stated that she found a few minutes during her shift…

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 failed to test facility staff who were not fully vaccinated based on the current parameters. Specifically, there was no documentation that COVID-19 testing was completed and the results of the testing were available. Findings include: In September, 2022, staff who were not fully vaccinated were required to complete COVID-19 testing twice weekly. A list of eleven staff members who were not fully vaccinated was provided. The following testing forms were observed: a. Speech Therapist (ST) 1 tested on [DATE], 9/7/22, 9/15/22, 9/19/22, and 9/29/22 b. [NAME] 2 worked on Fridays, Saturdays, Sundays and Mondays. [NAME] 2 tested on [DATE] and 9/30/22. c. [NAME] 3 worked on Tuesdays, Thursdays, Fridays and Saturdays, and tested on [DATE] and 9/22/22. d. [NAME] 4 worked on Sundays, Tuesdays, Wednesdays and Thursdays. [NAME] 4 tested on [DATE], 9/9/22, 9/14/22, and 9/18/22. e. Registered Nurse (RN) 6 tested on [DATE]. f. RN 7 worked part time and did…

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 have adequate ventilation by means of windows, or mechanical ventilation, or a combination of the two. Specifically, there were observations of urine and bowel movement odor throughout the facilty throughout the survey. Findings include: 1. On 10/11/22 at 4:22 AM, an observation was made in the memory care unit. There was a strong urine odor in the hallway. At 5:52 AM, the strong urine odor continued to linger in the hallway. 2. On 10/11/22 at 4:25 AM, an observation was made in the 200 hall. There were strong urine and bowel movement odors in the hallway outside rooms [ROOM NUMBERS]. 3. On 10/11/22 at 4:51 AM, an observation was made of the 200 hall. There was a strong bowel movement and urine odor. A follow-up observation was conducted, and the strong bowel movement and urine odor was lingering at 7:21 AM. 4. On 10/11/22 at 4:54 AM, a strong urine smell was observed in the 300 hall. 5. On 10/12/22 at 9:53 AM, an observation was made in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility did not maintain an effective pest control program so that the facility was free of pests and rodents. Specifically, a resident had a swollen eye from a bug bite, another resident collected pests in a small cup, and residents were observed with flies around them. Resident identifiers: 9, 14 and 39. Findings include: 1. On 10/11/22 at 7:00 AM, an observation was made of resident 39. Resident 39 was observed to have a swollen right eye. CNA 2 stated it was reported to her by another CNA that resident 39 had a bug bite on her eye. 2. On 10/11/22 at 6:23 AM, an interview was conducted with resident 9. Resident 9 stated he was being bitten by bugs and had scabs on his head and arms from the bites. Resident 9 showed a small cup with black spots in it. Resident 9 stated they were in his bed. On 10/20/22 at 12:15 PM, an interview was conducted with resident 9. Resident 9 stated he was waiting for his skin test results. Resident 9 stated he had bug bites…

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, the facility did not treat 4 of 33 sample residents with respect and dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, staff were observed to yell down the hallway during the early morning hours, staff were observed to converse in a language that was not known to a resident, a staff member was observed to speak with a resident in the locked area of the facility through the locked doors instead of face to face, residents were served on Styrofoam plates, and a resident was seated by staff facing the doors of the locked unit. Resident identifiers: 9, 25, 35 and 37. Findings include: 1. On 10/11/22 at 4:50 AM, while many of the residents were sleeping, Registered Nurse (RN) 1 was observed to be in the 300 hall, approximately one quarter of the way down the hall. RN 1 started yelling from this location down to the 100 hall, saying…

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 convey 1 of 33 sample residents funds to his estate within 30 days of the resident's death. Resident identifier: 92. Findings include: Resident 92 was admitted to the facility on [DATE] with diagnoses that included dementia and schizophrenia. Resident 92's medical record indicated that resident 92 passed away at the facility on 7/12/21. On 10/18/22 at 11:55 AM and 10/25/22, the Administrator (ADM) was asked to provide the transactions from resident 92's personal funds account with the facility. The ADM did not provide these transactions until 10/27/22 at 9:16 AM. Review of resident 92's personal funds account transactions indicated that although the resident passed away on 7/12/21, his personal funds were not conveyed to resident 92's estate until 4/27/22, nearly nine months later. On 10/27/22 at 10:00 AM, an interview was conducted with the facility ADM. The ADM stated that there was no good reason that resident 92's estate did not receive 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 1 of 33 sampled residents, that the facility did not allow a resident's representative to access personal and medical records within 24 hours of the request. Specifically, a resident family member, a hospice representative, and the county ombudsman all requested medical records for a resident, however the records were not provided at all, or not provided within 24 hours. Resident identifier: 93. Findings include: Resident 93 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, and dementia. The resident was discharged from the facility on 6/22/22. On 6/10/22, a quarterly Minimum Data Set indicated that resident 93 had a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. On 10/18/22 at 10:55 AM, an interview was conducted with resident 93's family member (FM). The FM stated that she was the resident's power of attorney, because resident 93 had severe dementia. The FM stated 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 record review and interview, the facility did not include provisions to inform and provide written information to 1 of 33 sampled residents concerning the right to accept or refuse medical or surgical treatment and, at the residents' option formulate an advance directive. Resident identifiers: 35. Findings include: Resident 35 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, cognitive communication deficit, muscle weakness and non-pressure chronic ulcer. Resident 35's medical record was reviewed. There was no advanced directive or Physicians Order of Life Sustaining Treatment (POLST) form completed and signed by the physician located in resident 35's medical record. On 10/26/22 at 5:46 PM, an interview was conducted with the Social Service Worker (SSW). The SSW stated she was at the facility Monday through Friday from 5:30 PM until 9:30 PM. The SSW stated she socialized with the residents in the dining room while they had coffee and dinner. The SSW stated she did…

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 33 sampled residents, that the Minimum Data Set (MDS) assessment did not accurately reflect the resident's status. Specifically, residents dental status, dietary orders, and discharge plans were not assessed accurately. Resident identifiers: 31 and 34. Findings include: 1. Resident 31 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, hyperlipidemia, dementia with behavioral and major depressive disorder. On 10/12/22 at 10:37 AM, an interview was conducted with resident 31's family member. The family member stated resident 31 had dentures but were lost during the COVID-19 lock down when family could not visit. The family member stated resident 31 would wear dentures if she had them. On 10/11/22 at 7:50 AM, an observation was made of resident 31 in the memory care dining room. Resident 31 was observed to not have teeth or dentures. Resident 31's medical record was reviewed. a. An annual MDS 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 did not develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 2 of 33 sampled residents. In addition, the facility did not involve the resident or the interdisciplinary team in the development of a discharge plan. Resident identifiers: 20 and 34. Findings include: 1. Resident 20 was admitted to the facility on [DATE] with diagnoses that included sepsis, osteomyelitis, hypertension, metabolic encephalopathy, diabetes mellitus, lymphedema, and atherosclerotic heart disease. On 10/11/22 at 8:00 AM, an interview was conducted with resident 20. Resident 20 stated that he wanted to go back to the assisted living facility (ALF) that he was previously living at prior to being hospitalized , but that no one was helping him with the process. 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, for 2 of 33 sampled residents, that the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used without adequate monitoring. Specifically, residents blood pressure medications were administered when their blood pressure was outside the physician ordered parameters. Resident identifiers: 13 and 14. Findings include: 1. Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cellulitis and abscess of mouth, osteoarthritis in left hip, chronic pain, metabolic encephalopathy, Wernicke's encephalopathy, dementia and psychosis. Resident 14's medical record was reviewed. A physician's order dated 3/3/18 revealed Propranolol HCL the instructions were give 20 milligrams (mg) by mouth two times daily for prophylaxis of esophageal varices hold for heart rate less than 60. Another physician's order dated 3/30/18 revealed Blood pressure parameters -…

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 that the facility did not ensure safe and secure storage of drugs and biological's in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, tuberculin solution was expired, and narcotics were missing. Resident identifiers: 8, 10, 11 and 29 Findings include: 1. On [DATE] at 4:58 AM, Registered Nurse (RN) 1 was observed performing the narcotic reconciliation with RN 3. RN 1 stated that she forgot to sign out narcotics that she had administered overnight. RN 1 was observed to sign out narcotics for residents 8, 10, 11, 29, and three unsampled residents. RN 1 stated that she did not administer any narcotics to resident 10, but one narcotic was missing from resident 10's narcotic medications. RN 1 was observed to sign out the narcotic as having been administered to resident 10. [Note: The missing medication was not located. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not obtain laboratory services only when ordered by a physician for 1 of 33 sample residents. Specifically a resident had laboratory services completed without a physician's order. Resident identifier: 94. Findings include: Resident 94 was admitted to the facility on [DATE] with diagnoses that included chronic atrial fibrillation, aortic regurgitation and stenosis, pulmonary hypertension, hypertension, and type 2 diabetes mellitus with both diabetic nephropathy and peripheral angiopathy. Resident 94 was discharged from the facility on 9/6/22. Resident 94's medical record was reviewed from 10/11/22 through 10/31/22. A lab results sheet for resident 94 revealed that on 6/28/22, resident 94 had a Prothrombin Time/International Normalized Ratio (PT/INR) drawn. A physician's order for this lab to be drawn could not be located. On 10/24/22 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). When asked about the process for labs, the DON…

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.