Complete Care at Glendale West

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not develop a comprehensive plan of care for residents on antidepressant medication. This was observed with 3 (R40, R6, & R71) of 18 residents reviewed for plans of care. * R40 and R6 were admitted to the facility on antidepressant medication and did not have a plan of care for their depression. * R71 did not have bowel or bladder care that included goals and interventions. Findings include: 1.) R40 was admitted to the facility on [DATE] with diagnoses including Depression and Stroke. The Hospital Discharge summary, dated [DATE], includes Prozac 20 milligram (mg), 3 capsules daily. The facility admission physician orders document Prozac 20 mg, 3 capsules every day for Depression. R40's admission Minimum Data Set (MDS) assessment was completed on 3/4/25. This assessment documents daily use of an antidepressant medication. The Care Area Assessment (CAA) for Psychotropic Drug Use, completed by MDS Registered Nurse (RN) -C on 3/10/25, documents Prozac…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility did not ensure residents with vision impairment received proper treatment and assistive devices including arrangements for an optometrist (eye doctor) visit for 1 (R21) of 1 resident's reviewed for vision. R21 has not been seen by an optometrist since 8/20/21 and R21's last missed vision appointment on 11/18/22 was never rescheduled to evaluate R21's advancing vision issues with an active request and signed consent to receive vision care. Findings include: R21 was admitted on [DATE] which includes a diagnosis of legal blindness and other optic atrophy. R21's comprehensive Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13, indicating R21 has intact cognition. R21 has highly impaired vision with no corrective lenses, glasses or contacts. R21's active Physician Order, dated 10/5/23, documents, May be seen by Optometrist No directions specified for order. R21's Care Plan, date Initiated, 10/06/2023,…

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 adequate supervision and safety to prevent an accident from occurring for 1 of 1 Resident (R65) reviewed for accidents. *R65's physician orders instructed 1:1 (one on one) supervision with all meals. Surveyor had observations during the survey process of R65 not receiving supervision with meals. Findings Include: The facility's Accidents and Supervision policy implemented 11/24 documents: .Policy: The Resident environment will remain as free of accident hazards as is possible. Each Resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s) 2. Evaluating and analyzing(s) and risk(s) 3. Implementing interventions to reduce hazard(s) and risk(s) 4. Monitoring for effectiveness and modifying interventions when necessary Policy Explanation and Compliance Guidelines: 1. Identification of Hazards and Risks 2. Evaluation and Analysis 3. Implementation 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 observation, interview, and record review, the facility did not ensure the medication rate was below 5 percent in 1 (R422) of 3 residents observed receiving medications. The facility medication error rate was 16.67 percent. *R422 had medications that were not administered in the right dose or were omitted from the medications administered. R422 had insulin ordered and the wrong dose was drawn up in the syringe. Findings include: The facility policy and procedure titled Administering Medications dated 12/28/2024 documents: 4. Medications are administered in accordance with prescriber orders, including any required time frame. On 5/20/2025 at 7:56 AM, Surveyor observed Licensed Practical Nurse (LPN)-L obtain R422's blood sugar. The result was 216. At 8:15 AM, Surveyor observed LPN-L prepare R422's morning medications and documented the medications as they were placed into the medication cup: -Allopurinol 100 mg -Aspirin 81 mg -Vitamin D 25 mcg -Docusate 100 mg -Furosemide 40 mg -Midodrine 5 mg -Acetaminophen 1000 mg LPN-L drew up 3 units of 70/30 insulin from the vial and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure the residents were free of significant medication errors for 1 (R122) of 1 resident reviewed for medication transcriptions. R122 had a hospital discharge order for Apixaban, an anticoagulant, 5 mg once in the morning and once at bedtime. The order was transcribed by the facility as Apixaban 5 mg once daily. R122 was a resident of the facility for 34 days and received the wrong dose of Apixaban on those days. Findings include: R122 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure, chronic obstructive pulmonary disease, diabetes, dysphagia requiring a gastrostomy tube for nutrition and medication administration, and atrial fibrillation (a fluttering of the atria in the heart potentially causing blood clots to form and creating an increased risk for a stroke). R122 had an activated Power of Attorney (POA). R122 discharged from the facility on 1/6/2025 and was not a resident at the time of survey. Apixaban, 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, interview, and record review, the facility did not ensure the medical record for 1 (R33) of 18 residents reviewed was complete accurately documented and readily accessible. *During the survey investigation, it was determined R33 was admitted to the facility on [DATE] with multiple pressure injuries that were not comprehensively assessed until 11/25/2024, three days after admission, and treatments were not documented as being completed from 11/22/2024 to 11/25/2024. On 5/28/25, after completion of the survey, the facility submitted hand written documents that were not part of the medical record that indicated details of wound assessments alleged to be completed on 11/22/24. The hand written forms did not include who completed the documentation and were not included as part of the formal medical record until concerns were raised by the surveyor. Findings include: The facility policy and procedure titled Pressure Injury Prevention and Management dated 10/2024 documents: 3. c. Licensed nurses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility 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 for 1 (R45) of 11 residents observed. *R45 was placed in Enhanced Barrier Precautions (EBP) and facility staff did not don a gown on when assisting R45 with cares. Finding Include: The Facilities Policy titled, Enhanced Barrier Precautions revised 11/2024, documents: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug, resistant organisms. Policy explanation and compliance guidelines: . 4. High-contact resident care activities include: . G. Device care or use: central line, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, pick lines, midline catheters. R45 was admitted to the facility on [DATE] 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 Based on observation, interview, and record review, the facility did not ensure that foods were prepared in a way that prevented the risk of foodborne illness for 5 of 10 sampled residents (R2, R5, R7, R8, R10). Interview with residents foud that juices from the chicken served on 11/16/24 was red and touched all other foods on their plates. There was no investgation to determine what may have happened/how the food could have been under cooked, the number of residents who may have been affected, or to determine what steps need to be taken in order to avoid potential food borne illness. Findings include: ~During an interview on 11/26/24 at 8:53 AM, R2 stated on 11/16/24 (weekend) she and other residents in the dining room were served undercooked chicken pieces. R2 stated the blood from the chicken contaminated the noodles, vegetables, and everything else on the plate. R2 was admitted on [DATE]. The Minimum Data Set (MDS) dated [DATE] indicated R2 was cognitively intact with a Brief Interview for Mental Status…

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 policy review, the facility failed to identify resident concerns as grievances and failed to provide a written response/resolution after receiving a grievance for 2 of 10 sampled residents (R2 and R3). Findings include: Review of the facility's policy titled, Resident and Family Grievances, dated 01/2024 and provided by the facility revealed, It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal, or fear of discrimination or reprisal . Social Services has been designated as the Grievance Official . Grievance may be voiced in the following forums . a verbal complaint to a staff member or Grievance Official . The staff member receiving the grievance will record the nature and specifics of the grievance . forward the grievance form to the Grievance Official as soon as practicable . In accordance with the resident's right to obtain a written decision regarding his or her grievance, 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, interview, and policy review, the facility failed to serve food that was palatable, at the appropriate temperature, for two of seven residents (Residents (R) 12 and R13) who were asked about food palatability out of 11 sample residents. This failure had the potential to affect resident meal intakes. Findings include: Review of the facility's policy titled, Record of Food Temperatures, dated 10/23 revealed, .It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled .Food temperatures will be verified using a thermometer which is both clean, sanitized and calibrated to ensure accuracy . Review of the Food and Drug Administration (FDA) Food Code, Chapter 3.5 Assessing Holding Time and Temperatures and Date Marking, dated 2022 revealed, .Use of an infrared thermometer for verifying holding temperatures is not consistent with Food Code requirements since verifying only the surface temperature of the food may not alert to problems that exist under the food's surface . Review…

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 staff interviews and record review, the facility failed to monitor the delivery of narcotic medication for one of three residents (Resident (R)1) reviewed for medications in a total sample of nine residents. On 03/04/24, R1 no longer had any Oxycodone at the facility, needed a new prescription from the Physician, and the medication was not available until 03/08/24. This practice has the potential to affect residents' pain management. Findings include: Review of the undated Face Sheet located in R1's electronic medical record (EMR), under the Profile tab, revealed R1 was admitted to the facility on [DATE] with diagnoses including history of a stroke, breast cancer, osteoarthritis, anxiety, and asthma. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/04/24, located in R1's EMR under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Per the MDS, R1 had 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 observation, staff interview, and facility documentation review the facility failed to ensure food was served at palatable temperatures for two of nine sampled residents (Resident (R) 1 and R4) on one ([NAME] unit) of four units. This failure has the potential for decreased meal intake. Findings include: During an interview on 06/05/24 at 9:00 AM, Resident (R)1, who was alert and oriented, stated food was often cold when she received her tray, and the beverages were sometimes not cold enough. R1 stated she complained about the food several months ago and was told to ask the staff to reheat her food. R1 stated the staff would reheat her food when asked but some of the food did not taste good when reheated. R1 stated sometimes the food was still served cold. During an interview on 06/05/24 at 9:15 AM, R4, who was alert and oriented, stated sometimes the food was cold and the staff reheated the food in the microwave when asked. R4 said she did not like the taste of some foods when reheated. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles and included the expiration date when applicable, and medications were stored in safe and secure storage (including proper temperature controls) for 1 medication room and 2 medication carts (Dover and [NAME] Medication carts) reviewed. Insulin's were were not labeled with residents' name and were not dated when opened. Expired stock medications were found in the medication room and medication cart and the refrigerator temperature, which stored medications, was below 36 degrees. Findings include: The Facility Policy and Procedure titled Labeling of Medications and Biological's revised 10/23 documents (in part) . . Policy: All medications and biological's used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration…

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 interview, the facility did not ensure food was stored and prepared safely, for 71 of 75 Residents who eat food prepared by the kitchen. *The low temp dish machine did not properly sanitize dishes. *Food held in the food warmer on [NAME] Hall did not have a holding temperate taken prior to service of the meal. Staff plating the food did not wear a hair restraint. *Unit refrigerators located in the activity room and [NAME] Hall did not have a temperature log and were not having temperatures taken on a regular basis. Open food was not dated in the refrigerator on [NAME] Hall. Findings: The facility policy, entitled Dishwasher Temperature, dated 10/2023, states: It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. #1. All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. #4. For low temperature dishwashers (chemical sanitization):…

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 care and treatment in accordance with professional standards of practice related to assessment and monitoring a resident with a possible change of condition for 1 Resident (R422) of 12 Residents reviewed for change of condition. *R422 had abnormal vital signs recorded and a blood pressure medication held related to the vital signs. The nurse on duty did not update the physician regarding R422's abnormal vital signs and there was no documented follow up regarding the change in condition. Findings include: R422 was admitted to the facility on [DATE] and had diagnoses including quadriplegia and type 2 diabetes. R422's Minimum Data Set assessment, dated [DATE], documented R422 had a BIMs (Brief Interview for Mental Status) of 14, indicating R422 was cognitively intact and R422 had hypertension. Surveyor reviewed R422's Electronic Medical Record (EMR) and noted the following physician order: Metoprolol 50mg (milligrams), give one tablet by mouth two…

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 1 (R13) of 6 residents received adequate supervision to prevent accidents for residents at risk with swallowing guidelines. * R13 was assessed to have a pureed nectar thick diet due to swallowing concerns and was observed taking another resident's dessert. This dessert was not part of R13's approved consistency for diet and swallowing guidelines. Findings include: Surveyor reviewed the facility's Policy and Procedure, Meal Supervision and Assistance dated 10/2022 and last reviewed on 2/2023, noting the following as applicable: 1. The resident will be prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This includes: a. Identifying hazard(s) and risk(s) b. Evaluating and analyzing hazard(s) and risk(s) c. Implementing interventions to reduce hazard(s) and risk(s) 4. Monitoring…

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 failed to ensure food was served at a palatable temperatures for 3 of 8 residents. Residents on the Oakland Unit complained that breakfast foods were often cold which was confirmed during a test tray evaluation. Findings include: On 11/27/23 and 11/28/23, during confidential interviews with residents who resided on the Oakland unit, the residents were asked if the food was appetizing and served at a palatable temperature. Three residents, who wished to remain anonymous, stated breakfast foods were often cold when they received their breakfast trays in their rooms. On 11/28/23 the breakfast meal service was observed from the kitchenette off the main dining room from 8:14 AM to 9:26 AM. DA F (Dietary Aide) was observed placing the food items on plates, covering the plate with a plastic cover, and placing the plate in a food cart that was open in the front. There was no door on the food cart. On 11/28/23 at 9:01 AM, DA F started plating food for the meal trays on the Oakland unit. At 9:11 AM, after the last resident tray was plated, 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 the facility did not ensure residents received services with reasonable accomodation of resident needs and preferences for 1 of 18 (R62) residents observed on survey. R62 waited an extended period of time for her call light to be answered. When staff answered R62's call light R62 requested to lay down in bed and staff declined to do so. Findings include: R62 admitted to the facility on [DATE] and has diagnoses that include Cerebral Infarction, Hemiplegia and Hemiparesis, Diabetes Mellitus type 2, Lymphoid Leukemia, Major Depressive Disorder, Anxiety Disorder, Adult Failure to Thrive and Osteoarthritis. Facility Policy and Procedure titled Answering the Call Light updated 3/8/22 documents (in part) . .The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Steps in the Procedure 1. When answering from the call light station, turn off the signal light. 2. Identify yourself and politely respond to the resident by his/her name. a. If the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R5) of 1 residents received the appropriate intervention for low blood glucose. On 7/4/22, R5's medical record documents R5 was experiencing a hypoglycemic episode. The nurses note indicate R5's glucose level was 50 and R5 was very diaphoretic, unable to focus or answer and was moaning. The nurses note indicate 911 was called but other interventions to address R5's hypoglycemia were not attempted. Findings include: The facility policy on Management of hypoglycemia dated 12/10/21 indicate: . 1. Classification of hypoglycemia: a. Level 1 hypoglycemia: blood glucose < (less than) 70 mg/dL (milligrams per decilitre) but > (greater than) 54 mg/dL; b. Level 2 hypoglycemia: blood glucose is <54 mg/dL; and c. Level 3 hypoglycemia: altered mental and/or physical status requiring assistance for treatment of hypoglycemia. 3. For Level 2 hypoglycemia (<54mg/dL); a. Administer glucagon (intranasal, intramuscular, or as provided) b. Notify provider; c. Remain…

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

Based on observation, interview, and record review the Facility did not ensure 1 (R28) of 6 Residents reviewed for accidents had their care plan interventions implemented. R28's call light was observed on the floor, behind the bed's head board and not in R28's reach according to R28's fall care plan. Findings include: R28's diagnoses includes spinal stenosis, quadriplegia, schizoaffective disorder, hypertension and diabetes mellitus. The at risk for falls care plan initiated 2/21/22 & revised on 6/14/22 includes the following interventions: * Recommendation is to offer/provide resident alternative entertainment when offloading position does not allow her to see television. Initiated 6/13/22. * Anticipate my needs, and potential fall times. Initiated 2/21/22. * Assess for pain. Initiated 2/21/22. * Call light or personal items available and in easy reach or provide reacher. Initiated 3/10/22. * Keep environment well lit and free of clutter. Initiated 3/10/22. * Low bed, fall matt. Initiated 6/13/22. * Make sure my call light/personal belongings are in reach. Initiated 2/21/22. *…

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 interview, the facility did not ensure residents that were fed by enteral means or received medication through an enteral tube received appropriate treatment for 3 (R19, R63, and R66) of 4 residents reviewed with feeding tubes. *R19 received medication through the gastrostomy tube and tube placement verification was not done prior to administering the medication. *R63 and R66 had tube feeding supplies not always dated, were dated with a previous date; supplies were not changed daily as ordered. Findings include: The facility policy and procedure entitled Procedure: Administering Medications through an Enteral Tube dated 1/11/2022 states: 6. Verify placement of feeding tube: a. If you suspect improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse of Physician. The facility policy and procedure entitled Confirming Placement of Feeding Tubes dated 12/14/2021 states: To Confirm Placement of an Existing Feeding Tube at Bedside: 1. The exit…

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 each Resident's drug regimen was free from unnecessary drugs for 1 (R23) of 5 Residents reviewed. * R23's pulse was not taken two times a day prior to administering Metoprolol Tartrate Tablet 100 MG (milligrams) per physician orders. Findings include: The Administering Medications policy updated 12/28/2021 under policy interpretation and implementation includes documentation of: 22. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; b. the dosage; c. the route of administration; d. the injection site (if applicable); e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug. h. Any additional monitoring needed (blood pressure, pulse). R23's diagnosis includes hypertension. The physician orders dated 5/15/20 documents Metoprolol Tartrate Tablet 100 mg…

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 2 (R18 and R63) of 5 residents receiving psychotropic drugs received the appropriate for duration of an antianxiety and an antipsychotic medication had indications for use. * R18 was prescribed Seroquel (antipsychotic) without indications of use and without monitoring the specific behaviors for the medications. * R63 was prescribed Lorazepam PRN (as needed) without a duration of use for the medication. Findings include: 1. R18 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, seizure disorder, down syndrome and chronic respiratory failure. The admission MDS (Minimum Data Set) dated 8/21/22 indicate R18 has cognitive impairment and has exhibited no behavioral symptoms including no behaviors regarding being physically or verbally aggressive towards others or self. The medical record indicates R18 was prescribed Seroquel 0.5mg every afternoon and Seroquel 1.0 mg every evening, upon admission. The pharmacy…

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

Based on observation, interview and record review, the Facility did not establish and maintain an infection control program designed to help prevent the development and transmission of disease and infection for 2 (R28 & R57) of 7 Residents. * CNA (Certified Nursing Assistant)-R was not wearing appropriate PPE (personal protective equipment) when changing R28's colostomy bag. R28 is on enhanced barrier precautions. R28 was observed not to have appropriate hand hygiene during cares. * CNA-R was not wearing appropriate PPE during continence cares for R57 who is on enhanced barrier precautions. R57 was observed not to have appropriate hand hygiene during cares. Findings include: The Enhanced Barrier Precautions Policy and Procedure last revised 7/22/2022 under purpose documents Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. The implementation of Enhanced Barrier Precautions (EBP) will reduce transmission of resistant organisms by employing targeted gown…

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.