Sandy Health and Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined for 2 of 28 sample residents, that the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, a resident did not receive treatment to a right foot full thickness laceration and another resident's wounds had no documented measurements. Resident Identifiers: 15 and 26. Findings include: 1. Resident 15 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, difficulty walking, difficulty swallowing, enlarged prostate, and a lack of coordination. Resident 15's medical record was reviewed from 8/14/24 through 8/15/24. On 3/26/24 at 4:28 PM, a facility report incident (FRI) was submitted to the State Survey Agency (SSA). It documented that on 3/26/24 at 1:00 PM, resident 15's right fifth toe had been run over while he was being propelled down the hall in his…

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 interviews, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, black spots were observed in the resident showers. Findings Included: On 8/13/24 at 12:10 PM, an observation was made of the 200-hall resident shower room. Black spots were observed on the lower corner base board left of the shower entrance. On 8/13/24 at 11:50 AM, an interview was conducted with Housekeeping (HK). HK stated the certified nursing assistants (CNAs) were responsible for cleaning the resident shower rooms. HK stated the certified nursing assistants were given the supplies to clean the shower rooms. HK stated they only cleaned resident room and resident common areas. On 8/13/24 at 2:06 PM, an interview was conducted with CNA 1. CNA 1 stated housekeeping cleaned the showers once a week and the cna's were responsible for cleaning up after resident showers. CNA 1 stated they sanitized the shower chairs and housekeeping scrubbed the showers. On 8/13/24 at 2:31 PM, an interview was conducted…

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 1 of 28 sampled residents, in response to allegations of abuse, neglect, exploitation or mistreatment, the facility did not have evidence that the violations were thoroughly investigated. Specifically, an allegation of neglect was not thoroughly investigated to determine if neglect had occurred. Resident identifier: 7. Findings include: 1. Resident 7 was admitted to the facility on [DATE] on hospice services with diagnoses of traumatic subdural hemorrhage without loss of consciousness, subsequent encounter- chronic obstructive pulmonary disease, unspecified- chronic hepatic failure without coma, personal history of transient ischemic attack, major depressive disorder, and generalized anxiety disorder. Exhibit 358 revealed that staff became aware of the incident on 1/26/24 at 2:30 am. The exhibit revealed that resident 7 had a fall and sustained a laceration above R[right] eye. Exhibit 359 revealed that, Staff found [resident 7] on the floor in her…

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 2 of 28 sampled residents the facility did not ensure that the residents were free from significant medication errors. Specifically, a resident was not administered antibiotics as ordered that resulted in a treatment of an autolytic debridement and prophylactic medications were not administered to a resident who had 3rd degree burns to her buttocks and back. Resident identifiers: 15 and 26. Findings include: 1. Resident 15 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, difficulty walking, difficulty swallowing. enlarged prostate, and a lack of coordination. Resident 15's medical record was reviewed from 8/14/2024 through 8/15/2024. On 3/26/24 at 4:28 PM, a facility report incident (FRI) was submitted to the State Survey Agency (SSA). It was documented that on 3/26/24 at 1:00 PM, resident 15's right fifth toe had been run over while he was being propelled down the hall in his wheelchair. The wound nurse assessed…

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 facility shower rooms were dirty; the temperature in a resident's room was repeatedly below 71 degrees Fahrenheit (F); the exit door to the resident smoking area would not open without getting caught on the sidewalk resulting in an injury to a resident; the wheelchairs were in disrepair for two residents; areas of the facility were dirty and in disrepair; and the paint, nightstands and clothing wardrobes in numerous rooms in the 200 and 300 hallways were in disrepair. Resident identifiers: 16, 27, 40, 50, 51, 54 and 88. Findings included: Showers 1. On 7/31/23 at 2:01 PM, an interview was conducted with resident 16. Resident 16 stated that the shower rooms were really dirty and she refused to use the shower in them. Resident 16 stated the shower rooms smelled like mildew. Resident 16 stated It is yucky and stinks really bad.…

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 31 was admitted to the facility on [DATE] with diagnoses that included COVID-19, viral pneumonia, chronic kidney disease stage 4, dementia, depression and acute respiratory failure. Resident 31's medical record was reviewed from 7/30/23 through 8/16/23. On 7/31/23 at 11:30 AM, an interview was conducted with resident 31's wife. Resident 31's wife stated that since resident 31 was admitted , 4 pair of pants, 7 pairs of socks, and multiple shorts and shirts had gone missing. Resident 31's wife stated that the resident's name had been put inside his clothing to prevent it from being lost. Resident 31's wife stated that she had informed multiple CNAs, but the CNAs looked but can't find the missing items. Resident 31's wife stated she had not been offered to fill out a grievance form for the missing items. An inventory list for resident 31 could not be located in the electronic medical record. On 8/16/23 at 9:44 AM, an interview was conducted with the RA. The RA confirmed that an inventory list for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 9 out of 68 sampled residents, that the facility did not ensure all alleged violations of abuse, neglect, exploitation or mistreatment were reported immediately, but no later than 2 hours after the allegation was made. Specifically, allegations of verbal and physical abuse were not reported to the State Survey Agency (SSA) within the 2 hour timeframe. Resident identifiers: 4, 12, 22, 29, 38, 51, 54, 78 and 157. Findings Include: 1. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included seizures, dementia in other diseases, type 2 diabetes mellitus, persistent atrial fibrillation, gastroesophageal reflux disease and depression. The exhibit 358 revealed that staff became aware of an incident on 7/14/23 at 1:50 PM. The exhibit revealed that resident 12 Alleged she was sexually assaulted when she first admitted to [name of facility] by 2 males. Resident 12's medical record was reviewed 7/30/23 through…

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 b. Resident 38 was admitted to the facility on [DATE] with diagnoses which included other specified arthritis multiple sites, bipolar disorder, anxiety disorder, borderline personality disorder, unspecified dementia, post-traumatic stress disorder, polyneuropathy, and presence of right artificial hip joint. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 38 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. Resident 38's medical record was reviewed 7/30/23 through 8/16/23. On 7/31/23 at 11:53 AM an interview was conducted with resident 38. Resident 38 stated when she is out smoking, she has issues with another resident 54. Resident 38 stated she goes out during supervised smoking times, but she still feels bullied by resident 54. On 8/10/23 at 9:39 AM a follow-up interview with resident 38 was conducted. Resident 38 stated there was an incident in June, it scared her, she felt hurt, and this keeps going on. Resident 38 stated resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident 21 was admitted to the facility on [DATE] with diagnoses which included myocardial infarction, failure to thrive, depression, left ventricular failure, asthma, vascular dementia, and obstructive sleep apnea. Resident 21's medical record was reviewed on 7/30/23 - 8/16/23. On 7/30/23 at 12:03 PM, an interview was conducted with resident 21. Resident 21 stated she didn't feel like her CPAP machine was working correctly. Resident 21 stated she had asked for filters so she cold change them out but she hadn't gotten any from the facility. Resident 21 stated they don't clean her CPAP machine or tubing and she stated she just hasn't had the time to do it. On 7/30/23 at 12:05 PM, an observation was made of no date or time on the CPAP machine or tubing. A Resident Inventory List dated 2/23/23 documented under the section titled Dentures/Hearing Aides/Walker/Cane/Glasses/O2 Tank that resident 21 had CPAP with bag. An Admit Nurse Progress note dated 2/24/23 documented, Pt (patient) oriented to room and . pt was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined, for 3 of 68 sampled residents the facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless circumstances of the individual's clinical condition demonstrated that such diminution was unavoidable. Specifically, three residents did not receive assistance with showers. Resident identifiers: 12, 40 and 45. Findings include: 1. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included seizures, dementia, type 2 diabetes mellitus, persistent atrial fibrillation, anemia, melena and depression. On 7/31/23 at 3:14 PM, an interview was conducted with resident 12. Resident 12 stated she was showered not often enough. Resident 12 stated it had been over a week since her last shower. Resident 12 stated she would like more showers because when she was at home she showered everyday. Resident 12 stated if she refused a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for 3 of 68 sampled residents, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, dependent residents reported not receiving their twice weekly showers. Resident identifiers: 24, 81 and 87. Findings include: 1. Resident 24 was admitted to the facility on [DATE] with diagnoses that included incomplete paraplegia, pressure ulcer to sacral area, pressure ulcer to right hip, pressure ulcer to right ankle, morbid obesity, reduced mobility, and colostomy. On 7/31/23 at 2:58 PM, an interview was conducted with resident 24. Resident 24 stated he had been at the facility for just over a month and had only received 1 bed bath. Resident 24 stated that the wound nurse had told staff that bathing was important for his wound care. Resident 24 stated he wanted to have a bed bath at least 2 times per week. Resident 24's medical…

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 5. Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included mild cognitive impairment, unspecified dementia, bipolar disorder, type 2 diabetes mellitus with diabetic polyneuropathy, schizophrenia, depression, anxiety, and hypertensive chronic kidney disease. Resident 6's medical record was reviewed 7/30/23 through 8/16/23. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 6 had a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. On 6/10/23 at 1:04 PM a Progress Nurses Note for resident 6 revealed that CNA reported to nurse that patient was on the floor in her bathroom .No visible injuries .X-ray ordered .Neuro checks started . A review of the Neurological Flow Sheet dated 6/10/23 for resident 6 releaved the following: a. Intial at 12:00 PM vital signs (V/S) completed. b. 15 min check at 12:15 PM V/S blank. c. 15 min check at 12:30 PM V/S blank. d. 15 min check at 12:45 PM V/S blank. e.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 3 of 68 sampled residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice. Specifically, a resident did not receive a Continuous Positive Airway Pressure (CPAP) machine or care as ordered, and facility staff were not cleaning the resident's CPAP machines, mask and tubing. Resident identifiers: 18, 21 and 47. Findings include: 1. Resident 18 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hemiplegia, conversion disorder with seizures, Todd's paralysis, morbid obesity, anxiety disorder, post traumatic stress disorder, and seizures. On 7/31/23 at 11:02 AM, an interview was conducted with resident 18. Resident 18 stated that during a recent hospitalization, he had been put on a CPAP machine. Resident 18 stated since returning to the facility, he had not received a CPAP machine or heard anything…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that medication error rates were not 5 percent or greater. Observations of 50 medication opportunities, on [DATE], revealed 7 medication errors which resulted in a 14.00% medication error rate. Specifically, a resident's blood pressure medication was administered out of the ordered parameters, a resident was not administered an antibiotic, a resident was administered the wrong dose of Vitamin D, a resident was administered a medication at the wrong time and one resident was administered an expired medication. Resident identifiers: 12, 19, 27 and 91. Findings included: 1. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, depression, insomnia, hyperlipidemia, type II diabetes, hypertension and cardiac murmur. On [DATE] at 7:58 AM, an observation was made of Registered Nurse (RN) 3 during morning medication administration on the south 300 hallway. RN 3 was observed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview 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, insulin pens were expired, open and available for use, not labeled with an expiration date or resident identifier information, a narcotic box in a medication room was not locked, cream for peri area care was kept in an unsecured cupboard at the nurses station. Findings included: 1. On [DATE] at 8:10 AM, an observation was made of the 300 hallway medication cart with Registered Nurse (RN) 3, the following medications were located inside: a. A pre-filled pen of Lantus (Insulin Glagine) 100 units/ml (milliliter) was opened and available for use, the pen had only a last name written on it in black marker. No open date or expiration date could be seen. On [DATE] at 8:10 AM, an interview was conducted with RN 3. RN 3 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 observation, interview and record review, for 4 of 68 sampled residents, the facility did not have menus that met the the nutritional needs of resident in accordance with established national guidelines. In addition, the menus were not followed. Specifically, watermelon was substituted for sausage for a breakfast, macaroni and cheese was substituted for chicken parmesan, cooked spinach was served verses broccoli. Resident identifiers: 58, 62, 65, and 92. Findings include: 1. On 7/31/23 at 11:50 AM, an interview was conducted with resident 92. When asked about the quality of food at the facility, the resident stated that there was no seasoning on the food and that its all bland. Resident 92 stated that the food was gray and horrible to look at. Resident 92 stated that the amount of food provided was minimal. Resident 92 stated that a typical breakfast consisted of one piece of toast, one strip of bacon and a small amount of eggs. Resident 92 stated that this is not enough food. When asked if the resident…

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

Based on observation, interview and record review it was determined, for 21 of 68 sampled residents, that the facility did not ensure each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, resident complained of the food quality, the test tray was not palatable and there were complaints in residents council. Resident identifiers: 4, 8, 12, 16, 18, 20, 28, 38, 40, 49, 51, 54, 58, 62, 65, 66, 85, 86, 92 and 148. Findings include: 1. On 7/31/23 at 3:08 PM, an interview was conducted with resident 12. Resident 12 stated lunch and dinner seemed like the same food. Resident 12 stated her plate consisted of four round balls of food. Resident 12 stated she did not have teeth and had to gum the food. Resident 12 stated the food did not look good. Resident 12 stated she would eat more food if the food was more palatable, like maybe soft sandwiches. Resident 12 stated she had told the staff that picked up her tray up, that she would like different food. Resident 12 stated that her tray ticket with her diet order on it had…

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, for 7 of 68 sampled residents, the facility failed to provide a suitable, nourishing alternate meals and snacks for residents wanting to eat at non-traditional times, or outside of scheduled meal service times. Specifically, evening snacks were either not offered, were not nourishing, and were not consistent with the resident's plan of care. In addition, there were 2 snacks available for residents throughout the day. Resident identifiers: 4, 16, 18, 20, 38, 40, and 51. Findings include: 1. On 7/31/23 at 10:51 AM, an interview was conducted with resident 18. Resident 18 stated most of the time the facility was out of snacks, or staff did not want to go down to ask for a snack. Resident 18 stated that staff told residents that after 7:00 PM, the kitchen was locked up. 2. On 7/30/23 at 12:43 PM,an interview was conducted with resident 4. Resident 4 stated she was the last to receive a meal tray because she was at the end of the hall and last on the list. Resident 4 stated most times she did not get what was on the menu or even the alternate.…

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 68 sample resident that the facility did not maintain medical records on each resident that were accurately documented. Specifically, a residents sleep study and respiratory therapy notes from a hospitalization were not in their medical records. A resident did not have documentation of an emergency department observation notes in the medical records. A resident had another resident's Advance Beneficiary Notice in their medical records. Resident identifiers: 18, 62, 65 and 162. Findings include: 1. Resident 62 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic post-traumatic stress disorder, anxiety disorder, insomnia and depression. Resident 62's medical record was reviewed from 7/31/23 through 8/16/23. Resident 62's progress notes revealed: a. On 5/16/23 at 11:01 AM, a nursing order for a medication increase for hydroxyzine from 25mg(milligrams) to 50mg documented, Pt [patient] c/o [complained of]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, clean linens were stored in the soiled laundry area. Clean linens were not transported in garbage bags through the facility. Staff members were observed to touch the resident's medications with bare hands during medication administration. Also, medications were dropped on the medication cart and then administered to a resident. Resident identifiers: 6 and 19. Findings include: Linens: On 8/10/23 at 12:41 PM, an observation was made of the dirty side of the laundry room which had a combined total of at least 15 Hoyer slings and gait belts that hung on the wall between two cleaning carts. [Note: One of the cleaning carts still had murky looking water inside of the mop bucket with a mop.] On 8/10/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility did not have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two. Specifically, there were odors throughout the facility. Findings include: The following observations were made: 1. On 7/30/23 at 3:39 PM, there was a urine odor that was observed in the hallway between rooms 300 to 306. At 3:51 PM, there was a urine odor that was observed in the hallway between rooms 300 to 306. 2. On 7/30/23 at 3:40 PM, there was a bowel movement odor in the hallway outside room [ROOM NUMBER] to 317. 3. On 7/31/23 at 10:46 AM, there was a strong urine odor in the hallway outside rooms 301 to 305. 4. On 8/1/23 at 2:21 PM, there was a strong bowel movement odor in the hallway outside room [ROOM NUMBER]. 5. On 8/2/23 at 2:27 PM, there was a strong urine odor outside of room [ROOM NUMBER]. 6. On 8/7/23 at 10:25 AM, there was a urine odor in the hallway outside room [ROOM NUMBER] through 307. There was a bowel…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that each resident is treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, staff members did not knock prior to entering a resident room, and multiple residents reported that the Dietary Manager did not treat them with respect. Resident identifiers: 38 and 149. Findings include: 1. Resident 149 was admitted to the facility on [DATE] with diagnoses that included cellulitis of the lower limb, acute respiratory failure with hypoxia, diabetes mellitus, and sepsis. On 7/31/23 at 10:44 AM, an interview was initiated with resident 149. At 10:58 AM, during the interview, Certified Nursing Assistant (CNA) 5 entered the resident's room without knocking. As she entered, CNA 5 stated to the resident, I'm going to come back and weigh you. Oh. CNA 5 made eye contact with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review it was determined, for 2 of 68 sample residents, the facility did not ensure the residents' right to retain and use personal possessions. Specifically, residents' clothing was lost. Resident identifiers: 31 and 94. Findings include: 1. Resident 94 was admitted to the facility on [DATE] with diagnosis which included weakness, anxiety and depression. On 8/1/23 at 2:46 PM, an interview was conducted with Resident 94. Resident 94 stated that she was missing the clothing she came to the facility with. Resident 94 stated that she gave her clothing to staff to be washed. Resident 94 stated that her clothing was placed in a sack and taken down to be cleaned, but she has not received those items back. Resident 94 stated that since facility staff could not locate her clothing she was placed in a hospital gown. She stated that she did not want to wear a hospital gown and wanted to wear her own clothing. Resident 94 stated that she was missing a gray coca cola shirt, a black…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 1 of 68 sampled residents, that the facility did not provide each resident with reasonable accommodation of resident needs and preferences. Specifically, a resident was not provided return transportation to the facility on two separate occasions when requested by the resident, after going on a leave of absence. Resident identifier: 9. Findings include: Resident 9 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included achondroplasia, altered mental status, hypokalemia, chronic pain, pressure ulcer, difficulty walking, muscle weakness, lack of coordination, spinal stenosis, bipolar disorder, major depressive disorder, anxiety and dependence on a wheelchair. Resident 9's medical record was reviewed on 7/30/23 - 8/16/23. A Nurse progress note dated 5/1/23 documented the following, Pt (patient) called facility to state she was stuck up in [local city] after visiting a friend, staff…

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 allow 1 of 68 sample residents and/or resident representatives to obtain a copy of medical records upon request and 2 days advance notice to the facility. Resident identifier: 156. Findings include: Resident 156 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, Alzheimer's disease, dementia, and major depressive disorder. Resident 156's medical record was reviewed from 7/30/23 through 8/16/23. Resident 156's progress notes also included the following entries: a. 1/10/23 at 6:32 PM a late entry was made for an effective date of 1/9/23 at 6:32 PM: . unwitnessed fall [at 12:30 AM), resident was found outside on the southeast side of the building on the ground in the snow. Root Cause Analysis: ambulating outside of the facility without assistance . sent to the hospital for hypothermia and evaluation . b. 1/13/23 Late Entry Resident had elopement/unwitnessed fall on 1/8/2023 at 0000 (12:00 AM) resident was reported…

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, for 1 of 68 sampled residents, that the facility did not ensure that the residents were free from physical restraints imposed for purposes of convenience, and not required to treat the residents' medical symptoms. Specifically, a resident's left leg was tied to the wheelchair footrest with a cloth strip and the resident was not assessed regularly and evaluated for the continued need of the restraint. Resident identifier: 13. Findings include: Resident 13 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia to left side, traumatic brain injury, dementia, morbid obesity, dysphagia, and age related osteoporosis. Resident 13's medical record was reviewed on 7/30/23 - 8/16/23. On 7/30/23 at 11:00 AM, an observation was made of resident 13. Resident 13 was observed to be sitting in a wheelchair with a piece of felt cloth tied around her left leg and the wheelchair foot rest. The piece of cloth was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined for 2 of 68 sampled residents, that the facility did not accurately assess residents. Specifically, weightloss was not documented on the Minimum Data Set (MDS) assessments, and the nature of a resident's discharge conflicted with the resident's medical record. Resident identifiers: 87 and 96. Findings include: 1. Resident 87 was admitted to the facility on [DATE] with diagnoses which included dysphagia, dementia, cognitive communication deficit and muscle weakness. Resident 87's medical record was reviewed from 7/30/23 through 8/16/23. On 5/15/23 an admission MDS assessment preformed revealed resident 87's weight (in pounds) 108. On 8/7/23 a quarterly MDS assessment revealed, resident 87's weight (in pounds) 96. In the section regarding weight loss, Loss of 5% or more in the last month or loss of 10% in the last 6 months it was documented as No or unknown. A care plan dated 5/4/23 revealed, Resident is at risk for nutritional and hydration status r/t…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that for 2 of 68 sample residents the resident had a discharge summary that includes, but is not limited to: 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; a final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative; reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter); or 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 environment. Resident identifier: 157 and 158. Findings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide routine and emergency drugs and biologicals to 1 of 68 sample residents. Specifically, multiple medications were not available for a resident the day the resident admitted . Resident identifier: 149. Findings include: Resident 149 was admitted to the facility on [DATE] with diagnoses that included cellulitis of the lower limb, acute respiratory failure with hypoxia, diabetes mellitus, and sepsis. On 7/31/23 at 10:44 AM, an interview was initiated with resident 149. Resident 149 stated that he did not receive his medications the first day he was at the facility. Resident 149's medical record was reviewed from 7/30/23 through 8/16/23. Resident 149's physician orders dated 7/22/23 included the following medications to be administered: a. Carvedilol 3.125 milligrams (mg) twice daily. b. Glimepiride 4 mg twice daily. Resident 149's July 2023 Medication Administration Record (MAR) was reviewed, and revealed that on 7/22/23, resident 149 did not receive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 68 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicated that the dose should be reduced or discontinued. Specifically, a resident's blood pressure (B/P) medication was administered outside of physicians ordered parameters. Resident identifier: 12. Findings included: Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included seizures, dementia, type II diabetes, atrial fibrillation, anemia and hypertension. Resident 12's medical record was reviewed on 7/30/23 through 8/16/23. Review of resident 12's physician orders revealed the following: a. Felodipine ER Oral Tablet (ER) Extended Release 24 Hour 5 MG (milligrams).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined for 1 of 68 sampled residents, that the facility did not ensure that a resident who used psychotropic drugs was not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, there was no behavior monitoring when a resident was administered psychotropic medications. Resident identifier: 62 Findings include: Resident 62 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic post-traumatic stress disorder (PTSD), anxiety disorder, insomnia and depression. Resident 62's medical record was reviewed from 7/30/23 through 8/16/23. A review of the Pre-admission Screening Resident Review level 2 dated 4/12/23, documented under section 7: mental illness/substance use disorder diagnostic summary impression that resident 62 had major depressive disorder, anxiety disorder, post traumatic stress disorder, and personality disorder. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 68 sampled residents, the facility did not obtain laboratory services to meet the needs of the residents. Specifically, resident 6 had physician's orders to obtain a basic metabolic panel (BMP) for medical monitoring purposes and the labs were not completed as ordered. Resident identifier: 6. Findings include: Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, bipolar disorder, type 2 diabetes mellitus with diabetic polyneuropathy, schizophrenia, depression, anxiety, and hypertensive chronic kidney disease. Resident 6's medical record was reviewed 7/30/23 through 8/16/23. A review of laboratory results for resident 6 revealed that that resident 6 had a Comprehensive Metabolic Panel (CMP) collected on 7/21/23. On the laboratory results sheet, there was a handwritten note: 2L (liters) IV (intravenous) fluids given. -Repeat BMP (Basic Metabolic Panel) on 7/24/23 -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 68 sampled residents, that the facility did not provide or obtain laboratory services only when ordered by a physician. Specifically, laboratory services were provided for resident 6 without physician's orders. Resident identifier: 6. Findings include: Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, unspecified dementia, bipolar disorder, type 2 diabetes mellitus with diabetic polyneuropathy, schizophrenia, depression, anxiety, and hypertensive chronic kidney disease. Resident 6's medical record was reviewed 7/30/23 through 8/16/23. A review of laboratory results for resident 6 revealed a Comprehensive Metabolic Panel (CMP) was collected on 6/29/23 at 6:55 AM. A review of physician's orders revealed no laboratory order for CMP to be drawn on 6/29/23. On 8/16/23 at 2:05 PM, an interview with Assistant Director of Nursing (ADON) 2 was conducted. ADON 2 stated she oversaw the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined for 1 out of 68 sampled residents that the facility did not file in the resident's clinical record laboratory (lab) reports. Specifically, resident 6 had multiple laboratory results that were not located in the medical record. Resident identifier: 6. Findings include: Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, bipolar disorder, type 2 diabetes mellitus with diabetic polyneuropathy, schizophrenia, depression, anxiety, and hypertensive chronic kidney disease. Resident 6's medical record was reviewed 7/30/23 through 8/16/23. Review of resident 6's laboratory orders included the following: a. On 4/13/23, a physician's order was entered into resident 6's electronic medical record to draw a hemoglobin A1c (HbA1c) and Basic Metabolic Panel (BMP). b. On 6/13/23, a physician's order was entered into resident 6's electronic medical record to draw a Comprehensive Metabolic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 1 of 68 sampled residents, that the facility did not provide or obtain outside resources for routine and emergency dental services to meet the needs of the residents. Specifically, a resident was not provided dental services for dentures. Resident identifier: 20. Findings include: Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included multiple sclerosis, disorder of central nervous system, peripheral vascular disease, chronic pain, psychosis, and muscle weakness. On 7/31/23 at 11:43 AM, an interview was conducted with resident 20. Resident 20 stated he was waiting to get dentures. Resident 20 stated he was missing teeth and then had all of his teeth removed. Resident 20 stated he had asked the dentist about dentures when he had his teeth removed. Resident 20 stated no one had followed up with him to get dentures. Resident 20 stated he had a hard time with the pronunciation of words.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility did not provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Specifically, observations were made of trays delivered later than posted meal times. Findings included: On 10/12/21 at 8:52 AM, a posting of meal times was observed on the 200 hall near the nurses station. The sign documented, Meal time posting: Breakfast 100 Timpanogos: 7:00 300 [NAME]: 7:10 200 Olympus: 7:20 Assisted Dining: 7:30 Lunch 100 Timpanogos: 11:30 300 [NAME]: 11:40 200 Olympus: 11:50 Assisted Dining: 12:00 Dinner 100 Timpanogos: 5:00 300 [NAME]: 5:10 200 Olympus: 5:20 Assisted Dining: 5:40 On 10/12/21 a lunch service was observed. The following observations were made: a. On 10/12/21 at 11:50 AM, the lunch meal trays arrived to the 100 hall for delivery to the residents' rooms. At 12:06 PM, the final tray was delivered to a resident on the 100 hall. [Note: Per meal times posted for lunch…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined, that the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections, including properly preventing and/or containing Coronavirus disease 2019 (COVID-19). Specifically, observations were made of eye protection not worn by staff, vendors or visitors, facial masks were not worn over the mouth and nose by staff, and N95 masks were not worn by third party vendors during an outbreak. Staff were observed to not perform hand hygiene while assisting residents with eating and between residents, during the passing of meal trays to residents, and during dressing changes. Shared vital signs equipment was not sanitized between resident usage and the glucometer was not cleaned according to manufacturer instructions between resident use. Resident identifiers: 62 and 288. Findings included: 1. Resident 62 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. In addition, the facility did not exercise reasonable care for the protection of the resident's property from loss or theft. Specifically, for 3 out of 49 sampled residents, there was debris on the floor of resident rooms, in the resident hallways and common areas, and the resident hallways and common areas were not vacuumed. Additionally, a resident who was missing a personal item did not have the missing item located or replaced. Resident identifiers: 13, 17, and 22. Findings included: 1. Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, left ankle osteomyelitis, peripheral vascular disease, left lower limb cellulitis, type 2 diabetes mellitus with foot ulcer, chronic obstructive pulmonary disease, repeated falls, muscle weakness, left shoulder rotator…

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 that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. Specifically, for 4 out of 49 sampled residents, following witnessed and unwitnessed falls and a documented significant weight loss the facility did not maintain and update the comprehensive care plan of a resident to include the services that were to be furnished. In addition, two residents were not provide showers per the developed and initiated comprehensive care plan and a resident that was hospitalized for aspiration pneumonia did not have a comprehensive care plan developed and implemented. Resident identifiers: 22, 32, 54, and 289. Findings included: 1. Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but not limited to fracture of unspecified part of neck…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility did not ensure that residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene. Specifically, for 6 out of 49 sampled residents, residents were not provided assistance with showers. Resident identifiers: 17, 22, 29, 32, 51, and 288. Findings included: 1. Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, left ankle osteomyelitis, peripheral vascular disease, left lower limb cellulitis, type 2 diabetes mellitus with foot ulcer, chronic obstructive pulmonary disease, repeated falls, muscle weakness, left shoulder rotator cuff tear, and presence of urogenital implants. On 10/12/21 at 10:20 AM, an interview was conducted with resident 17. Resident 17 stated he would like to shower at least twice weekly but the facility only allowed him to shower on Mondays. Resident 17 stated if there was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility did not label all drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, multiple vials of insulin were open and available for use without an expiration date and without resident identifier information and multiple bottle/packages of medication were expired and available for use. Findings included: 1. On [DATE] at 9:02 AM, an observation was made of the 100 hallway medication cart with Licensed Practical Nurse (LPN) 6. The following medications were located inside: a. Two multiple-dose vials of Admelog (insulin lispro) 100 units/milliliter (ml) were opened and not labeled with an open date on either vial. b. A pre-filled pen of Semglee (insulin glargine) injection 100 units/ml was opened and not labeled with an open date on the pen. c. A multiple-dose vial of Lantus 100 units/ml, marked as…

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

Based on observation, interview, and record review, it was determined the facility did not have menus which must be followed. Specifically, during tray line service, dietary staff provided incorrect meals and serving sizes for physician prescribed therapeutic diets. Findings included: On 10/13/21 at 11:21 AM, Dietary [NAME] 1 was observed to review the menu Therapeutic Spreadsheets to determine scoop sizes for lunch service and gathering serving scoops according to spreadsheet for different diet types. On 10/13/21 at 11:26 AM, Dietary [NAME] 1 was observed to plate a meal with the tray ticket that read Consistent Carbohydrate (CCHO) Diet. Dietary [NAME] 1 reported residents who received a CCHO diet were being provided the same lunch as residents on a regular diet. Dietary [NAME] 1 reported there were no differences between the serving sizes. [Note: The lunch meal's Therapeutic Spreadsheets indicated residents' who received regular diets were to be provided a #8 sized scoop of rice (1/2 cup) and residents' who received a CCHO diet were to be provided a #16 sized scoop of rice (1/4…

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, cross contamination through hand hygiene and use of a sanitation rag were observed during tray line, and the resident communal refrigerator located between the 200 and 300 resident hallways was found to include unlabelled, undated items with some items remaining within the fridge past the facility policy length of 3 days. Findings included: 1. On 10/13/21 at 11:29 AM, the facility's lunch tray line was observed. At this time, food had been placed and uncovered in the steamer table for tray line service. While wearing gloves, Dietary Aide 1 was then observed to take a rag from the sanitation bucket located under the sink and wipe the service area directly in front of the opened food serving trays. At this time it was observed for the corner of the sanitation rag to enter the serving dish with Spanish rice. Dietary Aide 1 then placed the rag back into the sanitation bucket and without…

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 maintain medical records on each resident that were complete, accurate, and readily accessible. Specifically, for 2 out of 49 sampled residents, a residents hospital records were not in the individual medical record and a residents hospice plan of care, nurse assessments or Certified Nursing Assistant (CNA) visit notes were not in the individual medical record. Resident identifiers: 38 and 187. Findings included: 1. Resident 187 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to disorders of the digestive system, acute cholecystitis, elevated white blood cell count, schizophrenia, generalized muscle pain, difficulty walking, anxiety disorder, hypothyroidism, and hypothyroidism. Resident 187's medical record was reviewed on 10/18/21. Resident 187's progress notes were reviewed. The progress notes indicated that on 6/26/21 at 2:43 AM, pts (patients) overall face is now swollen. lip…

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 include provisions to inform and provide written information concerning the right to accept or refuse medical or surgical treatment, and at the residents' option formulate an advance directive. Specifically, for 1 out of 49 sampled residents, the facility did not accurately document the resident's life-saving preferences. Resident identifier: 76. Findings included: Resident 76 was admitted to the facility on [DATE] with medical diagnoses that included, but were not limited to, ventricular premature depolarization, hyperlipidemia, adult failure to thrive, bradycardia, coronary angioplasty, dependence on supplemental oxygen, benign prostatic hyperplasia, atherosclerotic heart disease, atrioventricular block, chronic obstructive pulmonary disease, acute kidney failure, type 2 diabetes mellitus, low back pain, muscle weakness, and difficulty walking. Resident 76's medical record was reviewed on [DATE]. The Physician Orders for Life…

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 1 out of 49 sampled residents, no documentation was found in the resident's medical record to indicate the basis for the transfer or that 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 identifier: 288. Findings included: Resident 288 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of cellulitis of right lower limb, sepsis, type 2 diabetes mellitus, morbid obesity, peptic ulcer, chronic pain,…

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 the resident received proper treatment and assistive devices to maintain vision abilities. Specifically, for 1 out of 49 sampled residents, a resident received a new prescription for eye glasses and the new glasses were not ordered as the resident believed they had been. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] with diagnoses which consisted of acute pulmonary edema, atrial fibrillation, sleep apnea, shortness of breath, morbid obesity, type 2 diabetes mellitus, heart failure, hypertension, and anxiety disorder. On 10/12/21 at 3:02 PM, an interview was conducted with resident 15. Resident 15 stated that he had an eye exam at the facility and ordered new glasses approximately one month ago. Resident 15 stated that he had asked about when the glasses would be ready, but had not heard back from any of the staff. Resident 15 stated he could not see without the new…

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 a resident received care, consistent with professional standards of practice, to prevent pressure ulcers (PU) and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, for 1 out of 49 sampled residents, a resident developed an unstageable pressure ulcer on the second metatarsal-head pad of the plantar surface and interventions were not implemented specific to the prevention of its development. Resident identifier: 288. Findings included: Resident 288 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of cellulitis of right lower limb, sepsis, type 2 diabetes mellitus, morbid obesity, peptic ulcer, chronic pain, hypertension, sleep apnea, neuromuscular dysfunction of bladder, and anxiety disorder. On 10/12/21 at 9:59 AM, an interview was conducted with resident 288. Resident 288 was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, for 1 out of 49 sampled residents, a resident who had experienced a significant weight loss did not have interventions put in place to prevent further significant weight loss. Resident identifier: 54. Findings included: Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but not limited to fracture of unspecified part of neck of right femur, type 2 diabetes mellitus (T2DM), chronic kidney disease stage 4, gastroparesis, repeated falls, essential hypertension, muscle weakness, lack of coordination, difficulty in walking, acquired absence of other left toe(s), pain in left foot, acquired absence of other right toe(s), pain in right foot, anemia, hypokalemia, other disorders of plasma-protein metabolism,…

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 each resident received drinks, including water and other liquids, consistent with resident needs and preferences and sufficient to maintain resident hydration. Specifically, for 1 out of 49 sampled residents, a resident with a physician's order for nectar thick liquids was provided with thin liquids from care staff and was provided thin liquids on a meal tray. Resident Identifier: 33. Findings included: Resident 33 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, dysphagia following cerebral infarction, chronic respiratory failure, dysarthria following cerebral infarction, history of pulmonary embolism, history of methicillin resistant staphylococcus aureus infection, dependence on supplemental oxygen, protein-calorie malnutrition, muscle weakness, atrial fibrillation, hyperlipidemia,…

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.