Sunrise Health Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility did not ensure staff were qualified to provide CPR (cardiopulmonary resuscitation) and where not aware of licensed staffs' CPR certification status. This was observed with 1(R3) of 1 residents who required CPR in the facility. -R3 was observed non-responsive by facility staff and had prior written wishes to have CPR performed. The facility did not ensure Licensed Practical Nurse (LPN)- G was certified to perform CPR. LPN-G was the first to respond to R3's unresponsive, pulseless change of condition. Findings include: The facility's policy and procedure titled Cardiopulmonary Resuscitation, dated [DATE] documents: . 3. CPR certified staff will be available at all times. 4. Staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration of skills. CPR certification which includes an online knowledge component yet still requires in-person skills demonstrations to obtain…

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 (R1) of 2 residents reviewed received care and treatment in accordance with goals for care, including identifying risk factors and implementing interventions to address the risk factors. The Facility did not recognize or assess the risk factor of R1's knee brace frequently slipping out of place, implement interventions to address the risk factors, and assess the effectiveness of the interventions thus placing Rat increased risk for poor healing. R1's surgical repair of the left patella (kneecap) failed. R1's orthopedic surgeon identified the failure likely occurred due to the fact R1's immobilizer was often not in the correct position. Findings include: The Facility policy, entitled, Use of Assistive Devices, dated 9/19/22, documents, in part . The purpose of this policy is to provide a process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity . Policy…

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 (R5) of 4 residents reviewed for accidents received adequate supervision and assistance devices to prevent future accidents. On 11/20/24, at 1:37 PM, R5 had an unwitnessed fall (UWF) while toileting. R5 was assessed to requires partial/moderate assistance for toilet transferring. R5 was left alone while toileting and had an UWF while attempting to self-transfer. Findings include: The facility's policy titled, Fall Prevention and Management Guidelines dated 11/8/22, last reviewed on 7/18/24, documents: . 4. Suggested standard interventions may include: . g. Complete a fall risk assessment quarterly, post-fall, and as with a significant change of condition. 7. When any resident experiences a fall, the facility will: a. Complete a post-fall assessment and review: 4. Resident and/or witness statements regarding fall f. Obtain witness statements from other staff with possible knowledge or relevant information. R5 is an [AGE] year-old…

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 provide pharmaceutical services to meet the needs of each resident for 1 (R2) of 4 Residents. * R2's order from nephrology on 1/31/25 for Sodium Bicarbonate 1300 mg (milligrams) three times a day was never picked up by the facility. On 3/11/25 Surveyor observed R2's morning medication in a medication cup with pudding & crushed medication on an over bed table. Family Friend (FF)-P informed Surveyor the nurse left the medication and she will give R2 the medication. Findings include: The facility's policy titled, Medication Administration and dated 1/25 under policy documents Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Under procedures documents 5. The person who prepares the dose for administration is the person who administers the dose. R2's diagnoses includes chronic kidney…

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 1(R1) of 5 Resident's reviewed resident representative was notified when a new treatment was ordered. R1's POA (power of attorney) was not notified when a CBC (complete blood count) and urinalysis was ordered for R1 on 4/7/24. Findings include: The Change in Condition of the Resident policy last revised 9/20/22 under Policy documents A facility should immediately inform the resident; consult with the resident's physician' and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Under…

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 quality of care was provided for 1 (R1) of 5 Residents. R1 sustained a fracture of the left forearm after hitting her elbow on the head board of the bed. The Facility did not consistently monitor R1's left arm and did not implement a care plan regarding R1's fracture. R1 was identified with a concern to the right middle toe which was documented as being purple & painful. There was no monitoring of this toe. Findings include: R1's diagnoses includes Alzheimer's disease, depression, anxiety disorder, and dementia. The annual MDS (minimum data set) with an assessment reference date of 2/7/24 has a BIMS (brief interview mental status) score of 7 which indicates severe impairment. The nurses note dated 4/7/24 at 15:36 (3:36 p.m.) documents Resident hurt her elbow on the head board while flailing her arms and hit her left elbow on head board while writer was attempting to straight cath her while staff helped, she c/o (complained of) pain to the area…

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 did not ensure therapy services were provided in a timely manner for 1 Resident (R2) of 1 Resident reviewed for therapy services. *R2 was re-admitted into the facility on [DATE]. R2 had physician orders dated [DATE] for evaluation and treatment as indicated and R2 was not evaluated and/or screened for speech (ST), physical (PT) therapy, and occupational (OT) therapy. R2's comprehensive care plan indicated R2 was at risk for loss of range of motion due to prior CVA (cerebral vascular accident) and the intervention established on [DATE] was for therapy evaluation and treatment as ordered. Findings Include: Surveyor was provided the facility's Rehabilitation Services Screening Policy and Procedure effective 10/2029 on [DATE] at 1:48 PM and notes the following applicable to R2: Policy . The purpose of the policy is to define the process and timing of Rehabilitation Services Resident screening completion. Procedure 1. Timing: a. Routine Screens* are completed…

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 review of manufacturer's instructions, the facility failed to ensure bed frames and bed rails, if present, were inspected and maintained per the Manufacturer's Instructions for Use (MIFU) to minimize the risks of bed malfunction or resident injury for four of four residents (Resident (R)46, R47, R53, and R55). This failure had the potential to affect all 94 residents in the facility using a bed. Findings include: Review of the facility policy titled Bed Maintenance and Inspections Policy, implemented 06/16/22, showed: Policy: It is the policy of this facility to conduct regular inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify and avoid areas of possible entrapment. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director, or designee, is responsible for keeping records of bed inspections and maintenance. 2. Bed frames, mattresses, and bed rails will be maintained, including 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 record review, the facility did not ensure medications were labeled and stored in accordance with facility policy and procedures for 2 of 4 medication carts reviewed for medication storage and 1 of 3 medications rooms reviewed for medication storage. The facility did not ensure expired medications were properly removed from facility stock. * R84, R40, R13, R85, R7, & R1 had medications stored in medication carts with no dates listed as to when medication had been opened, including ophthalmic and liquid medications. Four ophthalmic medications and one liquid medication were noted by Surveyor with no names or open dates on the first floor medication cart. One expired stock medication was noted on the first floor medication cart. Two ophthalmic medications were noted by Surveyor with no names or open dates on the second floor medication cart. Two expired stock medications were noted on the second floor medication cart. Six expired medications were found in the first floor medication room. Findings include: The facility policy titled Medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility did not ensure that 1 out of 1 residents reviewed ( R141) who went out on therapeutic leave, were able to return to the facility based on following a written policy permitting residents to return after they are finished with a therapeutic leave. Findings include: R141 was originally admitted to the facility on [DATE] and discharged on 2/2/24. R141 is responsible for herself. The admission contract was signed on 8/25/23 by R141. R141 was admitted using Anthem BC/BC levels. On 1/1/24, the primary payor source was changed to Medicaid. Medicaid was the payor source up to 2/2/24. A review of the last quarterly MDS, dated [DATE] indicates that R141 has a BIMS of 15 ( cognitively intact) . Section Q04000- discharge plan- Is active discharge planning already occurring for the resident to return to the community?- No Surveyor conducted a review of R141's Individual Plan of Care. Resident (R141) shows potential for discharge, date initiated 8/24/23. Interventions…

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, interview, and facility policy review, the facility failed to ensure that alternatives to bed rails were attempted prior to the use of bed rails, failed to document reasons for failure of alternatives, and failed to advise residents and/or Resident Representatives (RR) of the risks and/or benefits of rail use with informed consent signed prior to the installation of bed rails for two of four residents (Resident (R) 47 and R53) reviewed for bed rail use. This failure had the potential for the resident, or the RR to be uninformed of the risks associated with bed rail use and could put the residents at risk for injury or entrapment. Findings include: Review of the facility policy titled, Proper Use of Side Rails, reviewed/revised 09/23/22 showed: . Policy Explanation and Compliance Guidelines: 1. In conjunction with review of resident's comprehensive assessment, the Side Rail Assessment will be completed in the electronic medical record. 2. The facility will attempt to use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to ensure a physician ordered pressure ulcer treatment was provided for 1 (R11) of 3 sampled residents reviewed for wound care. Findings include: A review of a facility policy titled Pressure Injuries and Non pressure Injuries dated 07/20/22, revealed, For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. R11 was admitted on [DATE] with diagnoses of multiple sclerosis, type two diabetes, and a stage four pressure ulcer (full-thickness tissue loss with exposed bone, tendon, or muscle) to the sacral region. A review of R11's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/17/23, revealed R11 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to ensure physician ordered catheter care was provided for 1 (R11) of 3 sampled residents reviewed for catheter care. Findings included: A review of a facility policy titled Catheter Care dated 03/15/2023 revealed, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. R11 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis, neuromuscular dysfunction of the bladder, and cystostomy status (a tube placed through the abdominal wall and into the bladder to allow urine to flow from the tube). A review of R11's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/17/2023, revealed R11 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated R11 had an indwelling catheter 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 interviews and record reviews the facility did not ensure staff working as a Hospitality Aide (HA) were not conducting CNA (Certified Nursing Assistant) duties. This has the potential to affect 7 to 10 residents that HA-H worked with on a given shift. The facility allowed HA-H to work throughout the facility as a CNA without the proper certification. Findings include: On 08/30/23, at 08:49 AM, upon entry to the facility, Surveyor requested a facility staff list from NHA (Nursing Home Administrator)-A. On 08/30/23 at 09:58 AM, Surveyor requested the personnel files of three staff listed as CNA's for review. On 08/30/23, at 10:20 AM, Surveyor reviewed the personnel files and did not locate a CNA certification for HA-H. Surveyor noted that the personnel file for HA-H has a CNA job description document signed by HA-H on 10/28/22. The file also contained an offer of employment letter that documented HA-H's position to be a CNA with a hire date of 11/02/22. On 08/30/23, at 10:26 AM, Surveyor spoke to HR (Human Resources) Manager - G and requested a copy of HA-H's CNA…

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 resident (R1) of 1 resident's reviewed was provided with information from their baseline/comprehensive care plan after admission including a copy of the plan or a summary of the plan. During the survey, R1 indicated they have asked multiple times for information regarding their care, particularly information regarding their medications. This information would be included in a baseline/comprehensive plan of care or summary established within 48 hours after admission. This information was not provided to R1. Findings include: Surveyor reviewed the facility's Baseline Care Plan policy and procedure dated 9/22/22 and notes the following: .Policy: The facility will develop and implement a baseline care plan for each Resident that includes the instructions needed to provided effective and person-centered care of the Resident that meet professional standards of quality care. Policy Explanation and Compliance Guidelines: 1. The baseline care plan will: a.…

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

Based on record review and interview, the facility did not ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The facility did not call the local police department to report resident to resident abuse concerns for incidents involving 5 (R85, R20, R11, R4 and R26) of 6 residents reviewed for abuse in facility self-reports. * R11 was involved in a resident to resident altercation with R20 that was not reported to the local police department. * R11 was involved in a resident to resident altercation with R26 that was not reported to the local police department. * R85 was involved in a resident to resident altercation with R4 that was not reported to the local police department. Findings include: Surveyor reviewed facility's Abuse Neglect and Exploitation policy with a revision date of 7/15/2022. Documented under Reporting Response was: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other…

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 medications requiring refrigeration were stored at the appropriate temperature for 2 of 2 medication room refrigerators reviewed. This has the potential to affect 6 of 6 (R12, R10, R60, R42, R27, and R104) observed to have medications stored in medication room refrigerators. *Observation of the first-floor medication room was observed to not have a temperature log to document the temperatures of the medication room refrigerator storing medications. *Observation of the second-floor medication room refrigerator temperature log documented the facility was not monitoring the medication room refrigerator temperature daily to ensure proper storage of medications that require refrigeration. Monitoring was not completed for 7 days in the month of January. Findings Include: The facility policy, entitled Storage of Medications, with a revision date of 1/2021, states (in part) .: .Procedure .Medications requiring refrigeration .are kept in a refrigerator with a thermometer to allow temperature monitoring .A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not fully investigate 2 of 3 reportable incidents reviewed for resident to resident abuse. * R11 was involved in a resident to resident altercation with R26 on 11/4/22 that was not fully investigated including putting interventions in place to prevent further resident to resident abuse. * On 12/12/22, R11 was again involved in a resident to resident altercation with R20. The incident was not fully investigated including documentation and putting interventions in place to prevent further resident to resident abuse. Findings include: Surveyor reviewed the facility's Abuse Neglect and Exploitation policy with a revision date of 7/15/2022. Documented was: V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying 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 observation, record review and interview the facility did not ensure timely assessment and removal of a gastrostomy tube (g-tube) for 1 (R67) of 1 resident reviewed. Findings include: R67 was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia following cerebral infarction, and muscle wasting and atrophy. R67's Quarterly MDS (Minimum Data Set) dated 12/6/22 documents a BIMS (Brief Interview for Mental Status) score of 14, indicating that R67 is cognitively intact. R67's admission MDS, dated [DATE], Section K (Nutrition), documents no checked box next to feeding tube. On 1/10/23, at 12:24 PM, Surveyor was interviewing R67. Surveyor observed tubing coming out from the front of R67's pants. R67 informed Surveyor that it was a g-tube. R67 stated, I think the tube needs to be flushed every day, but it's the long-forgotten g-tube and no one remembers I have it. R67 further stated that he believes it…

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

Based on observation, record review and staff interview, the facility did not ensure pressure injury prevention measures were implemented per plan of care. This was observed with 2 (R12 and R47) of 2 residents reviewed with risk for pressure injury. * On 1/10/23 and 1/11/23, R12 and R47 were observed with their heels directly on an air mattress and not off-loaded as per their care plan. Findings include: The facility's policy and procedure for Pressure Injuries and Non Pressure Injuries, dated 7/20/22, was reviewed by Surveyor. The policy indicates the facility will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries. A pressure injury refers to localized damage to the skin or underlying sift tissue usually over a bony prominence or related to a medical device or other device. 1. On 01/10/23 at 9:35 AM Surveyor observed R12 laying in bed with their heels against the air mattress and not off-loaded. R12 does not move themselves in bed. On…

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

Based on observation, record review and interview, the facility did ensure that 1 (R23) of 1 resident reviewed for Oxygen (O2) use were provided such care consistent with professional standards of practice. * R23 was observed with O2 administered at 1.5 liters (L) per minute via nasal cannula (NC) during survey. The NC and tubing was also observed dirty and the humidifier bottle was empty. Surveyor noted one observation of the NC tubing not connected to the concentrator. Upon review of the medical record for R23, there was no orders for O2 and no care plan for O2. Findings include: Surveyor reviewed facility's Oxygen Concentrator policy with a date of 06/23/2022. Documented was: Policy: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. Definition: An oxygen concentrator is a medical device that extracts oxygen from room air by filtering out or separating the nitrogen from the oxygen. The oxygen passes through a filter system and is then stored within the device for delivery based on the flow meter setting. Policy Explanation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not provide dementia care to 1 (R11) of 1 resident reviewed for dementia with behaviors with a diagnosis of dementia. The facility did not provide and R11 did not receive the appropriate dementia treatment and service to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. * R11 was admitted to the facility on [DATE] with dementia with behaviors. Shortly after admission, R11 started having behaviors included wandering into residents' rooms, taking other resident's things, hitting, screaming, yelling and swearing. The resident was not seen by psych services to assist with behaviors and pharmacological interventions. The resident did not have a behavioral care plan in place to assist staff with non-pharmacological interventions to prevent behaviors. A care plan was put in place on 11/3/22. On 11/4/22 R11 had a resident to resident altercation. The care plan was updated but dementia behavior interventions were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide medically-related social services for 3 (R11, R20, and R26) of 3 residents reviewed for social services assessments and follow-up to attain or maintain the highest practicable physical, mental and psychosocial well-being. R11 was admitted to the facility on [DATE] with dementia with behaviors. R11 had a psychosocial assessment completed on 9/11/22 that documented no behaviors or concerns with behaviors. Shortly after admission, R11 started having behaviors included wandering into residents' rooms, taking other resident's things, hitting, screaming, yelling and swearing. There were no psychosocial reassessments for R11 to reflect the behaviors. Social Services stated they were unaware of these behaviors. Social Services also did not involve psych services for R11 until Surveyor brought it to the attention of the facility. On 11/4/22, R11 was involved in a resident to resident altercation with R26. There were no follow up assessments 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 2 (R48 and R82) of 2 residents reviewed for narcotic medications, had accurate records of the controlled substance record and MAR (medication administration record). * R48 had a physician order for Oxycodone 5mg every 4 hours PRN (as needed). Surveyor reviewed the December 2022 controlled substance record and the MAR. The controlled substance record indicate when and how much medication was dispensed. The MAR indicates when and how much medication was administered. R48's December controlled substance record and MAR do not equal. * R82 had a physician order for Oxycodone 5mg every 6 hours PRN. Surveyor reviewed the December controlled substance record and the MAR. The controlled substance record indicate when and how much medication was dispensed. The MAR indicates when and how much medication was administered. R82's December controlled substance record and MAR do not equal. Findings include: During medication administration pass task,…

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 act timely or did not act on recommendations by the pharmacist for 1 (R21) of 5 residents reviewed for unnecessary medications. * R21 had pharmacist recommendation in September, October and November 2022 that were not followed up on by the facility or the Physician. Findings include: Surveyor reviewed the facility's Medication Monitoring: Medication Regimen Review and Reporting policy with a date of 09/18. Documented was: POLICY Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the IDT (Interdisciplinary Team), including 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.