Rocky Mountain Care - Maple Dell

Based on observation and interview it was determined that the facility did not label all drugs and biological's used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, medication carts were left unlocked and unattended, insulin pens were open and available for use past the expiration date. In addition, narcotics were repackaged into the narcotic cards. Resident Identifiers: 4, 5, 15, 21, 23, 34, 38, 39 and 48. Findings included: During morning medication pass the following was observed: 1. On 8/27/24 at 7:45 AM, an observation was made of the 300 hallway. Registered Nurse (RN) 2 was observed with a medication cart. RN 2 was observed to walk away from the unlocked medication cart and enter a resident's room. The medication cart was observed to be unlocked, have a drawer open and the computer screen was open to a resident's identifying information. Two residents were observed to be in the dayroom and within viewing distance of the medication cart computer.…

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 employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of nutrition services. Specifically, the facility did not employ a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the Director of Nutrition Services. Findings include: On 8/26/24 at 8:40 AM, an interview was conducted with the DM who stated she had not completed the required certification to work as the dietary manager. The DM stated the RD came to the facility once per week on Thursday, and if she had questions she could call the RD at any time. On 8/28/24 at 12:17 PM, an interview was conducted with the RD who stated the DM was still going through the training plan, and that she had just started in the position 2-3 weeks ago. The RD confirmed that the DM did not have the required certification yet. The RD stated the goal was to provide DM with a list of who offered approved training. The RD stated the DM could call her any time if she had questions or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, the carpets in the facility had multiple stains and the couches were worn and had holes in the cushions. Findings included: On 9/27/22 at 10:15 AM, a walk through of the facility was conducted. The following observations were made; a. Multiple large stains were observed on the carpet between the 300 and 400 hallway. b. Multiple large stains were observed on the carpet in the 300 hallway near the dining room area. c. Multiple large stains were observed on the carpet outside of room [ROOM NUMBER]. d. Multiple large stains were observed on the carpet outside of room [ROOM NUMBER] and 408. e. Multiple large stains were observed on the carpet in the 200 hallway near the dining room. f. Multiple large stains were observed on the carpet in the 100 hallway. g. A couch in the lounge area in between the 300 and 400 hallway had multiple…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 3 out of 34 sampled residents, the facility did not ensure that residents were free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, a Certified Nursing Assistant (CNA) was observed to verbally abuse a resident and two other residents reported the same CNA verbally abused them. In addition, the CNA was able to finish her shift with the residents. Resident identifiers: 16, 36, and 37. Findings included: A facility abuse investigation dated 9/15/22, revealed that resident 16, 36, and 37 alleged abuse from CNA 3. CNA 3 was identified as an agency CNA. The investigation revealed that Registered Nurse (RN) 7 reported that CNA 3 had verbally abused resident 16, 36, and 37. Resident 16 reported that after dinner he was waiting to be changed and when CNA 3 came into change him and pulled off his brief she said eww you smell like a pig and had a disgusted look on her face. Resident 37 was not interviewable…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 3 out of 34 sampled residents, in response to an allegation of abuse, neglect, exploitation, or mistreatment the facility did not ensure that all alleged violations were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involve abuse or resulted in serious bodily injury. Specifically, the State Survey Agency was not notified until five days after an abuse allegation was made. Resident identifiers: 16, 36, and 37. Findings included: A facility abuse investigation dated 9/15/22, revealed that resident 16, 36, and 37 alleged abuse from Certified Nursing Assistant (CNA) 3. CNA 3 was identified as an agency CNA. The investigation revealed that Registered Nurse (RN) 7 reported that CNA 3 had verbally abused resident 16, 36, and 37. Resident 16 reported that after dinner he was waiting to be changed and when CNA 3 came into change him and pulled off his brief she said eww…

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 assess residents using the quarterly review instrument specified by the State and approved by Centers for Medicare and Medicaid Services not less frequently than once every three months. Specifically, for 3 out of 34 sampled residents, quarterly Minimum Data Set (MDS) assessments were not completed every three months. In addition, quarterly MDS assessments were not completed no later than 14 days after the assessment reference date (ARD). Resident identifiers: 3, 4, and 7. Findings included: 1. Resident 3 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, atherosclerotic heart disease, chronic obstructive pulmonary disease, essential hypertension, type 2 diabetes mellitus, and major depressive disorder. Resident 3's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for completion of the quarterly MDS assessment was 8/12/22. The quarterly MDS assessment which was due on 8/12/22, was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that for 3 out of 34 sampled residents, the facility assessments did not accurately reflect the resident's status. Specifically, two resident's Minimum Data Set (MDS) assessments were coded incorrectly by indicating that the two residents were on an anticoagulant when the residents were not, and a resident who was receiving dialysis was not coded as receiving dialysis. Resident identifier: 8, 36, and 44. Findings include: 1. Resident 8 was admitted to the facility on [DATE] with diagnoses which included dementia, hypokalemia, type 2 diabetes mellitus, chronic pain syndrome, essential hypertension, hypothyroidism, and muscle weakness. On 9/27/22, resident 8's medical record was reviewed. Resident 8's most recent MDS assessment from 6/29/22, reported that resident 8 was receiving an anticoagulant. Resident 8's current and recent discharged physician ordered medications were reviewed, and it was revealed that resident 8 was not receiving an anticoagulant. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 6. Resident 155 was admitted to the facility on [DATE] with diagnoses which included unspecified fracture of left femur, hyperkalemia, nonrheumatic aortic stenosis, and acute on chronic combined systolic and diastolic heart failure. On 9/27/22, resident 155's medical record was reviewed. Resident 155's care plan was reviewed, and it revealed that there was no baseline care plan related to falls. On 9/7/22 at 5:19 PM, a Nursing Progress Note revealed, Res [Resident] had fall, called to shower by CNA [Certified Nursing Assistant] res was lying on back. Res said he slipped. Fall was not witnessed. Res denied pain at this time. Assessed, no apparent injury at time. Neuro [neurological] checks started and were wnl [within normal limits] . On 9/11/22 at 3:33 PM, a progress note revealed that resident 155 was here with a L [Left] hip fx [fracture] after a fall. On 9/27/22 at 3:18 PM, an interview with the DON was conducted. The DON stated that if a resident came to the facility with recent falls, the resident should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined, the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, for 7 out of 34 sampled resident, 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 with identified concerns did not have care plans developed and implemented in a timely manner. Resident identifiers: 8, 20, 23, 29, 45, 49, and 53. Findings included: 1. Resident 49 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, hemorrhage of anus and rectum, dementia, history of falling, type 2 diabetes mellitus with hyperglycemia, displaced fracture of second cervical vertebra, major depressive disorder, systolic congestive heart failure, secondary hypertension, and edema. On 9/26/22 at 12:04 PM, an interview was conducted with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident 25 was admitted to the facility on [DATE] with diagnoses which included hypothyroidism, hyperlipidemia, depression, hypertension, borderline personality disorder, pain, and edema. On 9/26/22 at 12:32 PM, an interview was conducted with resident 25. Resident 25 stated she should get a shower today, but did not get one because staff did not show up. Resident 25 stated she got a shower on 9/24/22, but did not have one for two weeks prior to that. Resident 25 stated she took showers by herself because she became very disgusted by herself. Resident 25's medical record was reviewed on 9/29/22. An admission MDS assessment dated [DATE], revealed resident 25 had a Brief Interview of Mental Status (BIMS) score of 11 which revealed mild cognitive impairment. The MDS further revealed resident 25 required one person limited assistance to transfer only and physical assistance with bathing. A care plan with a problem start date of 7/29/22, and created on 7/31/22, revealed [Resident 25] is at risk for altered ADL…

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 out of 34 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, multiple residents did not receive preventative interventions and/or adequate supervision to prevent future falls. In addition, a resident with a history of wandering did not receive adequate supervision to prevent accidents and the resident did not receive adequate supervision due to being an unsafe smoker. Resident identifiers: 8, 43, 49, 53, and 155. Findings included: 1. Resident 155 was admitted to the facility on [DATE] with diagnoses which included unspecified fracture of left femur, hyperkalemia, nonrheumatic aortic stenosis, and acute on chronic combined systolic and diastolic heart failure. On 9/27/22, resident 155's medical record was reviewed. A progress note dated 9/11/22 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 3. Resident 29 was admitted to the facility on [DATE] with diagnoses which included low back pain, injury to left lower leg, hypothyroidism, edema, chronic pain, and nausea. On 9/26/22 at 12:32 PM, an interview was conducted with resident 29. Resident 29 stated she was unable to stand her pain last night and was groaning. Resident 29 stated there was no nurse on her hallway from 12:00 AM until 6:00 AM. Resident 29 stated she needed Tramadol at 2:00 AM but the nurse told resident 29 it was not her problem because she would not be there and there was not a nurse to administer the medication. Resident 29 stated she had scoliosis that made a hole in her spine and she had no control over her left lower extremities. Resident 29 stated she needed her Tramadol regularly because her pain never quit. Resident 29 stated her Tramadol was not administered at 2:00 AM when she wanted it. Resident 29 stated that her pain was at a 10 and she was crying and sick to her stomach. Resident 29 stated the nurse administered three…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 4 out of 34 sampled residents, a resident's beta blocker medication to treat high blood pressure was not monitored according to the physician ordered parameters. A resident's alpha-adrenergic agonists medication to treat low blood pressure was held without physician's orders. In addition, resident medications were not administered per physician's orders due to nursing staff not completing the task. Resident identifiers: 22, 30, 36, and 49. Findings included: 1. Resident 22 was admitted to the facility on [DATE] with diagnoses which included,…

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 ensure that all drugs and biologicals were stored in locked compartments, and were labeled in accordance with currently acceptable professional principles and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. Specifically, observations were made of medications left on top of the medication cart unattended, the medication cart was observed unlocked and unattended, and medications located in the locked medication fridge were expired and still available for use. Resident identifiers: 9, 12, 29, and 53. Findings included: 1. On [DATE] at 7:38 AM, observations were made of Registered Nurse (RN) 3 during morning medication administration. RN 3 was located at the medication cart on the 400 hallway between room [ROOM NUMBER] and room [ROOM NUMBER]. RN 3 was observed to walk away from the medication cart to the nurse's station to obtain a Kleenex, leaving resident 53's dispensed medications…

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 34 sampled residents, that the facility did not provide or obtain laboratory services to meet the needs of the residents. Specifically, residents had laboratory tests ordered by the provider and the facility did not obtain them. Resident identifiers: 23, 30, 53, and 160. Findings included: 1. Resident 23 was admitted to the facility on [DATE] with diagnoses which included fracture of right femur, congestive heart failure, gastro-esophageal reflux disease, deep vein thrombosis of lower extremity, insomnia, hypothyroidism, alcohol dependence, major depressive disorder, and post-traumatic stress disorder. On 9/27/22 resident 23's medical record was reviewed. Review of resident 23's laboratory (lab) orders revealed the following: a. On 4/25/22, a Complete Blood Count (CBC) and a Comprehensive Metabolic Panel (CMP), were ordered. No documentation could be found of the laboratory reports in resident 23's medical record. b. On 4/28/22, a CBC, a CMP, 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 observations, interview, and record review it was determined, the facility did not provide food prepared by methods that conserve nutritive value, flavor, and appearance; food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, for 9 out of 34 sampled residents, multiple residents complained about the palatability and temperature of the food, and a sample test tray revealed that the food was not palatable. Resident identifiers: 7, 16, 20, 23, 29, 38, 45, 48, and 53. Findings Included: 1. On 9/26/22 at 11:00 AM, an interview was conducted with resident 48. Resident 48 stated that the food was getting better. Resident 48 stated that there was an alternative menu which she ordered from. Resident 48 stated she ordered a hamburger and received a bun, lettuce, cucumber, and no hamburger patty. 2. On 9/26/22 at 11:00 AM, an interview was conducted with resident 38. Resident 38 stated the food was getting better than it used to be but on the weekends the food was not good. Resident 38 stated that this last weekend the cook added white…

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, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food items were not labeled and dated, trash was found on the floor, food splatter on the cooking equipment, and food items were left open to the air. Findings included: 1. On 9/26/22 at 10:10 AM, an initial tour of the kitchen was conducted. The following observations were made: a. A fry sauce cup and four butter packets were on the floor in the walk-in refrigerator. b. Whipped topping with no date was in the refrigerator and the label stated unopened thawed shelf life: 2 weeks. c. A white substance was on the wall by the door of the refrigerator. d. Styrofoam cups and caps to the soda machine were on the floor around the soda machine. e. Food splatter was on the front of the steamer. f. The griddle and the drawers under the griddle had food splatter. g. A cup was on the floor between the steamer and the griddle. h. The front of the stove/oven had flood splatter. i. There was dust 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, it was determined, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance with F584, F655, F656 and F880 which were cited within the facility's 2019 and 2021 recertification survey. The facility was also found to be in non-compliance with F755, F757, F759, and F812 which were cited within the facility's 2018, 2019, and 2021 recertification survey. In addition, the facility was found to be in non-compliance and cited at a harm level with F690, F697, F725, and F745. Findings included: An annual recertification survey was completed on 2/27/18. The following deficiencies included, but not limited to, F755, F757, F759, and F812. An annual recertification survey was completed on 4/4/19. The following deficiencies included, but not limited to, F584, F655, F656, F755, F757, F759, F812, and F880. An annual recertification survey was completed on 7/21/21. The following…

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 infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, observations were made during a meal service and assisted dining without hand hygiene being performed. Additionally, observations were made of bare handed contact during medication dispensing and administration. Resident identifiers: 3, 6, 12, 23, and 53. Findings included: 1. On 9/26/22, the following observations were made during the lunch meal service by Certified Nurse Assistant (CNA) 2: a. At 12:01 PM, CNA 2 delivered the meal tray to resident 6. CNA 2 did not perform hand hygiene prior to or after delivery of the food tray. b. At 12:01 PM, CNA 2 delivered resident 3's tray to the dining room table. Resident 3 was not seated at the table. CNA 2 placed a straw in the cup of milk touching the tip of the straw…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined, the facility did not ensure the resident's medical record included documentation that indicates, at a minimum, the following: that the resident or resident representative was provided education regarding the benefits and potential risks associated with Coronavirus Disease-2019 (COVID-19) vaccine; each dose of COVID-19 vaccine administered to the resident; or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Specifically, for 4 out of 34 sampled residents, the facility did not provide the resident or resident representative with education of the benefits and potential risks associated with the COVID-19 vaccination. In addition, the resident's medical record did not include documentation regarding the residents' COVID-19 vaccination refusal or acceptance. Resident identifiers: 10, 13, 45, and 49. Findings included: 1. Resident 13 was admitted to the facility on [DATE] with diagnoses which included, but not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 1 out of 34 sampled residents, that the facility did not ensure that the resident could exercise their rights without interference, coercion, discrimination, or reprisal from the facility. Specifically, a resident was denied access to their cigarettes and had their quantity of cigarettes limited when the resident asked for more. Resident identifier: 8. Findings included: Resident 8 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance, hypokalemia, type 2 diabetes mellitus, chronic pain syndrome, hypertension, hypothyroidism, urinary tract infection, muscle weakness, abnormalities of gait and mobility, and hyperlipidemia. On 6/16/22, resident 8's admission Minimum Data Set assessment documented a Brief Interview of Mental Status of 8/15, which indicated moderately cognitively impaired. The assessment did not address the short-term and long-term memory. The assessment documented that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined, the facility did not ensure that the resident's right to self-administer medications was evaluated and determined to be safe. Specifically, for 2 out of 34 sampled residents, resident's had medications stored in their rooms without an evaluation to determine if the resident's were safe to self-administer medications. Resident identifiers: 25 and 48. Findings included: 1. Resident 25 was admitted to the facility on [DATE] with diagnoses which included hypothyroidism, hyperlipidemia, depression, hypertension, borderline personality disorder, gastroesophageal reflux disease, pain, and edema. On 9/26/22 at 12:32 PM, an observation was made of resident 25. Resident 25 had an inhaler in a box on her over bed table. Resident 25 was interviewed. Resident 25 stated she needed the inhaler off and on. Resident 25 stated she had the inhaler in her purse and brought it out so she had it when she needed it. Resident 25 stated she could not rely on staff 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, it was determined, the facility did not ensure the resident's right to request, refuse, and/or discontinue treatment, and to formulate an advance directive. Specifically, for 1 out of 34 sampled resident, a resident did not have an advance directive accessible to the nursing staff. Resident identifier: 48. Findings included: Resident 48 was admitted to the facility on [DATE] with diagnoses which included Alcoholic hepatitis without ascites, metabolic encephalopathy, respiratory failure, hypokalemia, severe protein-calorie malnutrition, and anxiety disorder. Resident 48's medical record was reviewed on 9/26/22. There was no advance directive located in resident 48's medical record. On 9/28/22 at 9:44 AM, an interview was conducted with resident 48. Resident 48 stated that she had a Do Not Resuscitate (DNR) that she provided the facility when she was admitted . On 9/28/22 at 9:58 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated for a resident's code…

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 out of 34 sampled residents, that the resident did not have the right to voice grievances to the facility or other agencies or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. In addition, the facility did not maintain evidence demonstrating the results of all grievances for a period of no less than three years from the issuance of the grievance decision. Specifically, there were no grievances for a period of time during transition of staff into the Resident Advocate position. In addition, residents reported grievances that were not followed up. Resident identifiers: 16 and 29. Findings included: The grievance log was reviewed. There was a grievance dated 5/2/22, regarding call lights. There were two grievances dated 9/12/22, regarding call lights not being answered and meal cards not being followed. There were no grievances between 5/3/22 through 9/12/22. The Administrator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, the facility did not ensure that a transfer or discharge was documented in the resident's medical record and that appropriate information was communicated to the receiving health care institution or provider. Specifically, for 2 out of 34 sampled residents, residents that were transferred to the hospital did not have a transfer assessment or a reason for the transfer documented in the medical record. In addition, no documentation was found in the resident's medical record to indicate the receiving provider was provided contact information of the practitioner responsible for the resident's care, resident representative contact information, advance directive information, all special instructions for care, a discharge summary, and any other documentation necessary for a safe and effective transition of care. Resident identifiers: 44 and 45. Findings included: 1. Resident 44 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choice. Specifically, for 1 out of 34 sampled residents, a resident was admitted with two different admission orders, a chest x-ray revealed congestive heart failure with edema and no interventions were provided, a cardiologist had different medication orders, and laboratory services were not provided according to physician's orders. Resident identifier: 160. Findings included: Resident 160 was admitted to the facility on [DATE] and discharged on 4/5/22 with diagnoses which included hypertension, diabetes mellitus, and atrial fibrillation. On 9/27/22 at 9:21 AM, a phone interview was conducted with resident 160's family member. Resident 160's family member stated resident 160's medications were all messed up when she was admitted . Resident 160's family member stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, for 1 out of 34 sampled residents, a resident who was receiving dialysis services did not have a physician's order for dialysis services or monitoring of the fistula. The resident did not receive ongoing assessments and oversight before and after dialysis treatments. In addition, ongoing communication and collaboration with the dialysis facility regarding the residents dialysis care and services was not completed by facility staff. Resident identifier: 44. Findings included: Resident 44 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, acute kidney failure, diabetes mellitus type 2, anxiety disorder, essential hypertension, and urinary tract infection. 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 it was determined that the facility did not ensure that the medication error rates was not 5 percent or greater. Observations were made of 28 medication opportunities, on 9/28/22, revealed two medication errors which resulted in a 7.14 percent medication error rate. Specifically, an enteric coated Aspirin (ASA) was administered instead of a chewable and Omeprazole was substituted for Pantoprazole. Resident identifier: 53. Findings included: Resident 53 was admitted to the facility on [DATE] with diagnoses which included surgical aftercare of the digestive system, edema, type 2 diabetes mellitus, morbid obesity, obstructive sleep apnea, anxiety disorder, major depressive disorder, insomnia, hypertension, benign prostatic hyperplasia, and chronic kidney disease. Review of resident 53's physician's orders revealed the following: a. ASA tablet 81 milligrams (mg), chewable by mouth one time a day. b. Pantoprazole tablet 40 mg by mouth one time a day. On 9/28/22 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 interview and record review it was determined, for 2 of 34 sampled residents, the facility must obtain laboratory services only when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist. In addition, the facility must promptly notify the ordering physician of laboratory results that fall outside of clinical reference ranges. Specifically, a resident's laboratory (lab) tests were obtained without a provider order. In addition, a resident's urinalysis (UA) results were not obtained from the lab and reported to the ordering physician. Resident identifiers: 29 and 30. Findings included: 1. Resident 30 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, abscess of perineum, muscular dystrophy, hypertension, type 2 diabetes mellitus, anxiety disorder, gastro-esophageal reflux disease, major depressive disorder, and cellulitis of the buttocks. On 9/28/22, resident 30's medical record was reviewed. On 9/20/22, a Complete Blood Count…

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 out of 34 sampled residents, the facility did not establish an infection prevention and control program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, a resident was receiving a prophylactic antibiotic without a diagnosis to treat. Resident identifier: 53. Findings included: Resident 53 was admitted to the facility on [DATE] with diagnoses which included surgical aftercare of the digestive system, edema, type 2 diabetes mellitus, morbid obesity, obstructive sleep apnea, anxiety disorder, major depressive disorder, insomnia, hypertension, benign prostatic hyperplasia, and chronic kidney disease. On 10/3/22, resident 53's medical record was reviewed. Review of resident 53's physician's orders revealed an order for Macrobid capsule 100 milligrams by mouth at bedtime. The order was initiated on 8/1/22. No documentation could be found for the rationale for the use of the prophylactic antibiotic Macrobid. 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 interview and record review, it was determined, the facility did not ensure that each resident's medical record included documentation that indicated that the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations; and that the resident either received the influenza and pneumococcal immunizations or did not receive the influenza and pneumococcal immunizations due to medical contraindications or refusal. Specifically, for 1 out of 34 sampled residents, a resident's pneumococcal vaccine was not documented as administered after the resident's responsible party consented to the pneumococcal vaccine. Resident identifier: 10. Findings included: Resident 10 was admitted to the facility 6/8/22 with diagnoses which include, but not limited to, cerebral infarction, gastrointestinal hemorrhage, delirium die to known physiological condition, essential hypertension, and chronic diastolic congestive heart failure. Resident 10's medical record was reviewed on 10/3/22. A Consent 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.

Based on interview and record review, it was determined, the facility did not ensure that all staff including contracted staff were fully vaccinated for Coronavirus Disease-2019 (COVID-19), except for those staff who had been granted exemptions to the vaccination. Specifically, for 2 out of 8 sampled staff members (SM), who were not temporarily delayed, had not completed the vaccination series for a multi-dose COVID-19 vaccine. Staff identifiers: SM 1 and SM 2. Findings included: 1. The COVID-19 Staff Vaccination Status for Providers was reviewed. The following were documented: a. SM 1 had received one dose of the Pfizer COVID-19 vaccine on 1/11/22. b. SM 2 had received one dose of the Pfizer COVID-19 vaccine on 2/4/21. [Note: Staff members were not fully vaccinated and did have a pending or granted exemption or a temporary delay per the Centers for Disease Control and Prevention.] On 10/3/22 at 10:47 AM, an interview was conducted with SM 1. SM 1 stated that she had received the first dose of a COVID-19 vaccine on 1/11/22. SM 1 stated that she had not received the second dose of 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, it was determined that the facility did not employ a clinically qualified full-time dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not employ a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. Findings include: On 7/12/21 at 9:08 AM, an interview was conducted with the facility Dietary Manager (DM). The DM stated that she was not a Certified Dietary Manager (CDM). The DM stated she had been taking the courses to become a CDM for 2 years. The DM stated her qualifications included experience working in the kitchen at another facility and being a mom. On 7/13/21 at 3:45 PM, an interview was conducted with the facility DM. The DM stated the facility Registered Dietitian (RD) approved the menus and helped with meal planning. The DM stated that the RD spends a lot of time at the facility, and comes in when she needs to. The DM stated the RD came in…

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

Based on interview, the facility did not designate one or more individual as the infection preventionist who was responsible for the facility's Infection Control Policy. Specifically, the facility did not have an infection preventionist for approximately 5 months. Findings include: On 7/14/21 at 10:45 AM, an interview was conducted with the current Infection Preventionist (IP). The IP stated that he had started working as the IP the previous week. The IP stated that he had completed the Centers for Disease Control (CDC) IP training, and had received additional training from the Director of Nursing (DON). On 7/14/21 at 11:52 AM, an interview was conducted with the DON. The DON stated that the previous IP was terminated on 2/4/21. The DON stated that the facility had not had an IP from 2/4/21 until the first week of July 2021 when the new IP started working. The DON stated she was not certified as an IP. The DON stated that she was acting as the IP between February and July, but had not completed more than 3 courses with the CDC.

Based on interview and observation, the facility did not treat 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, residents were referred to as feeders, and residents reported having to wait for extended periods of time for their call lights to be answered. Findings include: 1. On 7/15/21 at 8:15 AM, Certified Nursing Assistant (CNA) 4 was observed to be at the 300/400 hall nurses station, speaking with other staff members. CNA 4 stated that staff needed to help the feeders with their meals. There were three residents in the 300 hall dining room, and within earshot of CNA 4. 2. On 7/12/21 at 12:11 PM, CNA 3 was interviewed regarding a resident's eating habits. CNA 3 stated, He's a feeder. This was spoken in the main dining hall, in the presence of other nearby residents seating themselves for lunch. 3. On 7/14/21 at 4:34 PM CNA 2 was interviewed regarding resident's eating habits. CNA 2 stated, I know 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 ensure that residents had the right to make choices about aspects of his or her life in the facility that were significant to the resident; nor did the facility ensure that residents had the right to choose activities consistent with his or her interests. Specifically, residents were not allowed to leave the facility. Resident identifiers: 8, 12, and 18. Findings include: 1. On 7/12/21 at 9:50 AM, an interview was conducted with resident 12. When asked if resident 12 had any concerns about his care at the facility, resident 12 stated that he was upset about not being able to leave the facility when he wanted. When asked to clarify, resident 12 stated that if residents wanted to go outside, they were only allowed to go out the back door and then out to the fenced area. Resident 12 stated that if residents wanted to sit outside in the front area of the building, they were not allowed to do so without staff supervision. Resident 12 stated that residents were not allowed to leave the building to spend time with family or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation, the facility did not allow residents to receive visitors of their choosing at the time of their choosing. Specifically, the facility did not allow residents to leave the building and did not allow immediate family to visit residents in their rooms. Residents and families were made to schedule appointments during the week to visit each other in a facility meeting room. Resident identifiers: 12, 18, 26, 86, 136, and 192. Findings include: 1. On 7/12/21 at 11:05 AM, an interview was conducted with resident 86. Resident 86 stated that he could only have visitors during the day on weekdays during certain hours. Resident 86 stated that visitors were not allowed on weekends. Resident 86 stated that my best friend of 30 years has only been able to see me twice because of the visitation rules, and its been hard. Resident 86 stated that visitors were only allowed to stay for 30 minutes. 2. On 7/12/21 at 12:15 PM, an interview was conducted with resident 26. Resident 26 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.

Based on interview and observation, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, dead and living insects were observed in 3 residents' rooms, a resident complained of poor housekeeping, couches were observed to be soiled, tablecloths were observed to be sticky, and areas of the facility had odors of feces and urine. Resident identifiers: 188, 191, 192, and 193. Findings include: 1. On 7/13/21 at 10:39 AM an interview was conducted with resident 192. Resident 192 stated, I've been killing earwigs all over in here. I've killed them crawling out of my sheets, I've killed them in the bathroom, I've seen them on the wall, and there's always one at the bathroom sink, almost every morning! Resident 192 was asked if he had alerted facility staff and he stated, Oh sure, I let them know, but what good would it do? They are more scared than I am of bugs. I've always killed them first by the time they come around to check it out. 2. On 7/12/21 at approximately 3:30 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not send a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman for 3 of 32 residents. Specifically, three residents were transferred to the hospital for overnight stays and the Ombudsman was not notified. Resident identifiers: 7, 23, and 136. Findings include: 1. Resident 7 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, type 2 diabetes, and anxiety disorder. On 4/27/21 at 10:25 AM, resident 7 was sent to the local hospital due to abdominal pain and possible blood in vomit. The resident returned to the facility the next day. 2. Resident 23 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, type 2 diabetes, and dementia. On 7/8/21 at 3:45 PM, resident 23 was sent to the local hospital due to low blood sugar and unresponsiveness. The resident returned to the facility the next day. 3. Resident 136 was admitted to the facility 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, the facility did not conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 5 of 32 sample residents. Resident identifiers: 85, 86, 135, 136, and 189. Findings include: 1. Resident 86 was admitted on [DATE] with diagnoses that included cerebral palsy, cellulitis of lower left and right lower limb, severe protein calorie malnutrition, lymphedema, anemia, electrolyte and fluid disorder, lack of coordination, and weakness. Resident 86's medical record was reviewed on 7/12/21. Review of resident 86's Minimum Data Set (MDS) Assessments in the facility electronic medical record revealed that a a 5 day MDS dated [DATE], and an admission MDS dated [DATE] were in progress and were not yet complete. Review of the State Survey Agency (SSA) program revealed that there was not a 5 day MDS or admission MDS completed for resident 86. 2. Resident 85 was admitted to the facility on [DATE] with diagnoses…

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 5 of 32 sample residents, the facility did not develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality care within 48 hours of a resident's admission. Specifically, several residents had unfinished baseline care plans that were not completed until weeks after admission, and others had not yet been completed. Resident identifiers: 29, 36, 86, 187, and 189. Findings include: 1. Resident 189 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included pyogenic arthritis, opioid abuse, chronic pain, chronic respiratory failure, atherosclerotic heart disease, major depressive disorder and muscle weakness. On 7/12/21 at 4:14 PM, resident 189 was interviewed. Resident 189 had concerns about the timing of his pain medication and stated he had had no communication about his care.…

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

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: On 7/15/21, Therapeutic Recreation Technician (TRT) 1 provided the consultant notes from the facility Certified Therapeutic Recreation Specialist (CTRS). The consultant notes indicated that the CTRS had not provided oversight since November 2020. On 7/15/21 at 1:50 PM, an interview was conducted with TRT 1. TRT 1 stated that the CTRS had not provided oversight since December 2020. On 7/15/21 at 11:30 AM, an interview was conducted with the Administrator (ADM). The ADM confirmed that the CTRS had not provided oversight since November 2020. The ADM stated he was not aware that the CTRS was not currently providing oversight.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population. Specifically, residents voiced concern with the level of staffing at the facility, and the wait times for call lights to be answered. In addition, staff were observed to not respond timely to a resident who subsequently fell out of bed. Also, review of the facility's call light logs revealed patterns of extended wait times. Resident identifiers: 12, 18, 26, 29, 135, 136, 185, 189, 191, and 192. Findings include: 1. On 7/12/21 at 1:22 PM, resident 185 stated that sometimes it takes a while to answer call lights. 2. On 7/12/21 at 2:23 PM,…

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 have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, two residents were transferred onto the scale by staff inappropriately, one of whom experienced a fall. In addition, a staff member's certification had expired, a resident had an unwitnessed fall but was not appropriately assessed, and a pain pill was given to an unlicensed staff member to administer to a resident. Resident identifiers: 29, 86, 135, and 187. Findings include: 1. Resident 86 was admitted on [DATE] with diagnoses that included cerebral palsy, cellulitis of lower…

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 have the nurse staffing information posted. The facility must post the following information on a daily basis: Facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses, Licensed practical nurses, Certified Nurse aides, and resident census. The facility must post the nurse staffing data on a daily basis at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Additionally, the information must be displayed in a prominent place readily accessible to residents and visitors. Findings include: On 7/12/21, an initial tour was conducted of the facility. The nurse staff posting could not be located. On 7/13/21, a tour was conducted of the facility. The nurse staff posting could not be located. On 7/13/21, at 12:10 PM, an interview was conducted with Receptionist 1. When asked where the nurse staff posting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to provide pharmaceutical services to meet the needs of 4 of 32 sample residents. Specifically, the 4 residents were not given scheduled medication due to it not being available. Resident identifiers: 4, 10, 29, and 136. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, hypertension, and atrial fibrillation. Resident 4's medical record and physician orders were reviewed on 7/12/21. A physician order indicated that resident 4 was to be administered Midodrine HCl Tablet 5 milligrams (mg) once daily for low blood pressure, severe dizziness and fainting. Resident 4's July 2021 Medication Administration Record (MAR) was reviewed. Review of the MAR revealed that resident 4 was not administered Midodrine on 7/8/21, 7/9/21, 7/10/21, or 7/14/21. Resident 4's nursing progress notes were reviewed and revealed the following: a. On 7/8/21, the Midodrine was not administered due 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 it was determined that for 3 of 32 sample residents, the facility did not ensure that the monthly drug regimen recommendations by a licensed pharmacist were implemented in a timely manner. Resident identifiers: 16, 20, and 29. Findings include: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses that included combined systolic and diastolic heart failure, atrial fibrillation, diabetes mellitus, iron deficiency anemia, hyperlipidemia, cardiomyopathy, heart failure, major depressive disorder, long QT syndrome, chronic fatigue, and thyrotoxicosis. Resident 29's medical record was reviewed on 7/12/21 and again on 7/19/21. The Pharmacist Consultant Therapeutic Recommendation (PCTR) for resident 29 dated 7/3/21 was reviewed. The PCTR indicated that the pharmacist stated resident 29 is receiving Novolog 70/30 Mix insulin four times a day on a sliding scale. Sliding scale is not very effective when using a mixed or long-acting insulin. His blood sugars are…

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 interviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. Specifically, 3 of 32 residents were given medication outside of ordered parameters. Resident identifiers: 3, 135, and 136. Findings include: 1. Resident 3 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, diabetic neuropathy, end edema. Resident 3's medical record and physician orders were reviewed on 7/12/21. A physician order indicated that resident 3 was to be administered Insulin Lispro Solution 100 UNIT/Milliliters (ML) before meals and at bedtime for elevated blood glucose. The order contained the following the following caveat: Call MD (Medical Director) for BG (blood glucose) [greater than] 450 for additional orders. Resident 3's May, June, and July 2021 Medication Administration Record (MAR) and nursing progress notes were reviewed and revealed the following: a. On 5/24/21, BG was 475, max dose was given, will check in one hour. b. 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, interview, and record review, it was determined the facility failed to ensure that it's medication error rates are not 5 percent or greater for 3 of 32 sample residents. Specifically, 2 residents did not have scheduled medication available, and 1 resident was given the incorrect dose of insulin. This resulted in a 12 percent medication error rate. Resident identifiers: 4, 19, and 34. Findings include: 1. On 7/14/21 at 7:45 AM, Registered Nurse (RN) 3 was observed during the morning medication pass. When RN 3 was withdrawing medication for resident 19, it was discovered that resident 19's scheduled Clopidogrel was not available in the Pyxis dispensing unit. [Note: Clopidogrel is a blood thinner that can prevent stroke, heart attack, and other heart problems.] RN 3 was immediately interviewed. She stated, When we have a missing med we'll call the pharmacy and let the doctor know. At 3:44 PM, RN 3 was interviewed regarding the missing AM medication for resident 19. RN 3 stated, The doc didn't reply but he usually won't if it's something he's ok with. 2. On 7/14/21…

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 32 sample residents were free of significant medication errors. Specifically, residents were not administered medications due to the medications being unavailable, were administered the incorrect dose, and/or were administered medications outside of physician prescribed parameters. Resident identifiers: 4, 19, 29, 34, and 136. Findings include: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses that included combined systolic and diastolic heart failure, atrial fibrillation, diabetes mellitus, iron deficiency anemia, hyperlipidemia, cardiomyopathy, heart failure, major depressive disorder, long QT syndrome, chronic fatigue, and thyrotoxicosis. Resident 29's medical record was reviewed on 7/12/21. Resident 29's physician orders were reviewed. The physician orders indicated that resident 29 was to be administered Mexiletine 150 mg twice daily for a diagnosis of atrial fibrillation. Resident 29's July 2021 MAR 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 observation, interview and record review it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards of food service safety. Specifically, food in the freezer was not dated and open to air, food items in the dry storage room were not sealed and open to air, staff members entered the kitchen during tray line without hair nets, and food was plated for a resident's lunch tray without checking the temperature. Findings include: 1. On 7/12/21 at 9:08 AM, an initial observation of the kitchen was conducted. The following observations were made: a. The steam table was dirty with food particles and spills. b. A bag of [NAME] Krispies cereal in the dry storage room was open to air. c. Panko bags in the dry storage room were open to air. d. A bag of grits in the dry storage room was open to air. e. A box of sugar cookies in the freezer was open to air. f. A bag of frozen vegetables in the freezer was open to air. g. A box of frozen rolls in the freezer was open to air. h. A box of Salisbury steak patties 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, record review and interview the facility was not administered in a manner that enabled 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, the facility was found to be in non-compliance with F880, which was cited at an Immediate Jeopardy, scope and severity of L. In addition, several deficiencies were cited during the 2019 recertification survey, and again during the 2021 survey. Resident identifiers: 85, 86, 185, 186 and 187. Findings include: 1. Based on observation, interview, and record review it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically,with regard to residents who were on Transmission Based Precautions (TBP), staff were observed to not fully don gowns, wear soiled gowns throughout the facility, not wear appropriate eye protection, not clean face shields after exiting the room, not store face shields…

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 32 sample residents that the facility did not maintain medical records on each resident that were complete and accurately documented. Specifically, a newly admitted resident's COVID testing results were not included in the medical record. Additionally, facility staff failed to keep resident medical records confidential and out of public view, and a resident's hospital records were not in the electronic health record. Resident identifiers: 86 and 193. Findings include: 1. Resident 193 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, chronic atrial fibrillation, hypotension, essential hypertension, anemia, elevated white blood cell count, and major depressive disorder. On 7/13/21, a review of resident 193's medical records was conducted. No vaccination information regarding COVID-19 was found in resident 193's medical chart. In addition, no COVID-19 testing results were found in resident 193's…

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

Based on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance with F880, which was cited at an Immediate Jeopardy, scope and severity of L. In addition, several deficiencies were cited during the 2019 recertification survey, and again during the 2021 survey. Resident identifiers: 85, 86, 185, 186 and 187. Findings include: 1. Based on observation, interview, and record review it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically,with regard to residents who were on Transmission Based Precautions (TBP), staff were observed to not fully don gowns, wear soiled gowns throughout the facility, not wear appropriate eye protection, not clean face shields after exiting the room, not store face shields appropriately, not clean vital signs equipment…

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 inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. Specifically, the facility experienced two positive staff members/residents, and did not inform residents, their representatives, and families of the outbreaks. Findings include: On 7/14/21 at 10:45 AM, an interview was conducted with the facility Infection Preventionist (IP). The IP stated that he had started working as the IP the previous week. The IP stated that he had completed the Centers for Disease Control (CDC) IP training, and had received additional training from the Director of Nursing (DON). The IP was asked about the facility policy regarding notification of families when a resident or staff member tested positive for COVID-19. The IP stated that if a staff member or resident tested positive for COVID-19,…

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 for 1 of 32 sample residents the facility interdisciplinary care team (IDT) did not determine a resident to be safe for self-administration of medication before the resident exercised the right to do so. Specifically, an unlicensed staff member was provided medication by a licensed nursing staff to administer to a resident, and the resident did not have a self-administration evaluation. Resident identifier: 187. Findings include: Resident 187 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis, spondylolisthesis, type 2 diabetes, hypertension, encephalopathy, history of falling, non-Hodgkin's lymphoma, hypokalemia and cirrhosis of the liver. On 7/15/21 at 8:18 AM an observation was made of resident 187 wheeling himself to the nurse cart. Resident 187 was observed to ask Registered Nurse (RN) 4 for his medications because he was going to an appointment. RN 4 was observed to administer resident 187's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that the facility did not develop and implement a comprehensive person-centered care plan for 1 of 32 sample residents, consistent with the resident right that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a fall care plan was not developed as required. Resident identifier: 29. Findings include: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses that included combined systolic and diastolic heart failure, atrial fibrillation, diabetes mellitus, iron deficiency anemia, hyperlipidemia, cardiomyopathy, heart failure, major depressive disorder, long QT syndrome, chronic fatigue, and thyrotoxicosis. Resident 29's medical record was reviewed on 7/12/21 and again on 7/19/21. An admission Minimum Data Set (MDS) assessment dated [DATE] for resident 29 was reviewed. The MDS indicated on the Care Area Assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility did not complete a discharge summary for 1 of 32 sample residents. When the facility anticipates a discharge, a resident must have a discharge summary that includes, but is not limited to, the following: (a) A recapitulation of the resident's stay that includes but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results. (b) A final summary of the resident's status at the time of discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative. (c) Reconciliation of all pre-discharge medications with the resident's post discharge medications (both prescribed and over-the-counter). (d) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility did not ensure that 2 of 32 sample residents who were unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, one resident did not receive a shower after asking for one several times, and one resident did not receive the feeding assistance she needed at meal time. Resident identifiers: 136 and 193. Findings include: 1. Resident 193 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, chronic atrial fibrillation, hypotension, essential hypertension, anemia, elevated white blood cell count, and major depressive disorder. On 7/12/21 at 3:45 PM, resident 193 was interviewed. Resident 193 was observed to be wearing a hospital gown. Resident 193 stated she had not had a shower since her admission. Resident 193 stated she had asked for a shower but that the staff keep putting it off. During 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 2. Resident 29 was admitted to the facility on [DATE] with diagnoses that included combined systolic and diastolic heart failure, atrial fibrillation, diabetes mellitus, iron deficiency anemia, hyperlipidemia, cardiomyopathy, heart failure, major depressive disorder, long QT syndrome, chronic fatigue, and thyrotoxicosis. Resident 29's medical record was reviewed on 7/12/21 and again on 7/19/21. On 7/14/21 at approximately 1:00 PM, an observation was made of resident 29. Resident 29 was being wheeled by the Van Driver (VD) onto the wheelchair scale. The front wheels of the wheelchair were observed to catch on the lip of the scale, causing the resident to jerk forward. Resident 29's feet were observed to drag under the frame of the wheelchair as the resident was being wheeled onto the scale. The VD was observed to reach down and reposition the resident's feet. On 7/15/21 at approximately 9:30 AM, an interview with the VD was conducted. When asked if the VD had received training on transfers and wheelchair safety,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observation, and record review, it was determined the facility failed to offer sufficient fluid intake to maintain proper hydration and health to 2 of 32 sample residents. Specifically, two residents who were at risk for dehydration were not consistently provided fresh drinking water. Resident identifiers: 136 and 193. Findings include: 1. Resident 136 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, cognitive communication deficit, and major depressive disorder. Resident 136's medical record was reviewed on 7/12/21. The record revealed a Dehydration Risk assessment was 35 days overdue. The record also contained a nurses' note dated 7/8/21 described resident 136 having a recent visit to the hospital. The note stated, Pt (patient) returned from hospital at 1530 (3:30 PM). Pt was found to have a UTI (Urinary Tract Infection) and was given IV (intravenous) antibiotics. On 7/12/21 at 3:12 PM, resident 136 was observed lying in bed with an untouched meal…

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, record review and observation, the facility did not ensure that a staff member was currently registered to work as a Certified Nursing Assistant. Findings include: On [DATE], the Director of Nursing (DON) was asked to provide a copy of Certified Nursing Assistant (CNA) 1's current certification. The DON provided a copy of a card that indicated that CNA 1's certification had expired on [DATE]. On [DATE], the Utah Nurse Aide Registry (UNAR) was checked to verify the current certification of CNA 1. The UNAR indicated that CNA 1's certification expired on [DATE]. On [DATE], CNA 1 was observed to be assisting residents with the lunch meal in the 400 hall dining room. Review of the CNA schedule for the facility revealed that from [DATE] through [DATE], CNA 1 was scheduled to work 9 times. On [DATE] at 5:45 PM, an interview was conducted with the DON. The DON stated that she was unaware that CNA 1's certification had expired until she was asked to provide a copy of the certification. The DON stated…

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 provide or obtain laboratory services to meet the needs of 1 of 32 sample residents. Resident identifier: 29. Findings include: Resident 29 was admitted to the facility on [DATE] with diagnoses that included combined systolic and diastolic heart failure, atrial fibrillation, diabetes mellitus, iron deficiency anemia, hyperlipidemia, cardiomyopathy, heart failure, major depressive disorder, long QT syndrome, chronic fatigue, and thyrotoxicosis. Resident 29's medical record was reviewed on 7/12/21 and again on 7/19/21. Resident 29's physician orders were reviewed. The physician orders indicated that resident 29 was to have a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP) and B-type Natriuretic (BNP) drawn every day shift every Wed (Wednesday), Thu (Thursday), Fri (Friday) for Cardiac monitoring. Resident 29's June and July 2021 CBC, CMP and BNP laboratory results and nursing progress notes were reviewed and revealed the following: a. 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, the facility did not develop policies and procedures to ensure that 1 of 32 sample residents was educated about and offered the COVID-19 vaccine. Resident identifier: 86. Findings include: Resident 86 was admitted on [DATE] with diagnoses that included cerebral palsy, cellulitis of lower left and right lower limb, severe protein calorie malnutrition, lymphedema, anemia, electrolyte and fluid disorder, lack of coordination, and weakness. On 7/12/21 at 11:05 AM, an interview was conducted with resident 86. Resident 86 stated that he had not been vaccinated for COVID-19. Resident 86 stated that when he was admitted to the facility no one talked to me about the vaccine or offered it. Resident 86 stated that he asked staff about receiving the vaccine but they just told me they don't do that here. I would like to know how to get one. On 7/21/21 at 10:30 AM, a second interview was conducted with resident 86 regarding a separate issue. Resident 86 redirected the surveyor's questions…

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.