Clark County Rehabilitation & Living Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did notify the resident representative of a change in condition for 1 of 3 residents (R) reviewed (R1).On 08/12/25, the facility was notified of an allegation of abuse regarding R1. R1's legal guardian was not notified of incident or subsequent investigation findings.This is evidenced by:Facility policy titled, Abuse, Neglect, Mistreatment & Misappropriation of Resident Property Policy & Procedure, with no implemented or reviewed date, states in part: G. Reporting and Response: The Administrator or designee will inform the resident or resident's representative of the report of an incident and that in investigation is being conducted. The Administrator or designee, will inform the resident and/or responsible party the results of the investigation.R1 was admitted to the facility on [DATE] with pertinent diagnoses of anxiety disorder, depression, personality disorder with other symptoms and signs involving cognitive functions and awareness, and unspecified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure each resident is free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 3 resident reviewed for restraints (R1).On 08/05/25 and 08/06/25, facility staff used physical restraint to give R1 oral medications.This is evidenced by:Facility policy titled, Restraints, Use of (Physical), with a most recent revised date of 01/09/14, states in part: Policy: The use of any type of physical restraint will be based on evaluation of risk versus benefit of use following a comprehensive assessment and identification of needs and medical symptoms. A physical restraint will be used as a last resort or on a temporary trial following failure of alternative interventions. The choice of physical restrain will be identified as the least restrictive and used only when deemed necessary and appropriate as permitted by regulation. The use of a physical restraint will be an exception. The individual's legal representative…

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 implement policies and procedures for ensuring the reporting of physical abuse in accordance with section 1150B of the Act when an allegation of physical abuse was not reported immediately, but no later than 2 hours to the administrator and local law enforcement in accordance with state law through established procedures for 2 of 3 residents (R) reviewed (R1 and R3).On 08/08/25, the facility was notified by local law enforcement that an allegation was reported of abuse regarding R3. The facility did not investigate or report this allegation to the State Agency (SA).On 08/12/25, the facility was made aware of an allegation of abuse regarding R1. The facility did not report this allegation to the SA.This is evidenced by:Facility policy titled, Abuse, Neglect, Mistreatment & Misappropriation of Resident Property Policy & Procedure, with no implemented or reviewed date, states in part: G. Reporting and Response: It is the policy of this facility that abuse…

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 an allegation of abuse was thoroughly investigated for 1 of 3 (R3) residents reviewed.On 08/08/25, an allegation of abuse was reported to local law enforcement regarding R3. The facility did not investigate this allegation.This is evidenced by:Facility policy titled, Abuse, Neglect, Mistreatment & Misappropriation of Resident Property Policy & Procedure, with no implemented or reviewed date, states in part: E. Investigation: It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriate of property) are promptly and thoroughly investigated. Procedure: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed.R3 was admitted to the facility on [DATE] with pertinent diagnoses of mild cognitive impairment 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 interview and record review, the facility did not ensure prescription medications were administered by qualified staff for 1 of 3 residents (R1) reviewed.R1's medications were administered by a Certified Nursing Assistant (CNA).This is evidenced by:Facility policy titled, Medication Administration & Treatment by Certified Nursing Assistants, with no date, states in part: Policy: This facility will comply with all state and federal guidelines related to medication administration in order to ensure the safety of resident. Nursing assistants may NOT administer any medications or perform any treatments with the following exception as delegated by the nurse: 1. Nursing assistants can apply prescription and nonprescription topical creams and ointments to UNBROKEN skin during daily cares. 2. Nursing assistants can provide oral care with mouthwashes.Facility policy titled, Medication Administration, with no date, states in part: Policy: Medication administration will adhere to all federal and state regulations.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review and policy review, the facility failed to ensure that residents were provided timely updates of concerns voiced at resident council meetings for three residents (Residents (R) 8, R9 and R10) of 13 sampled residents. Failing to update residents of measures taken to address their concerns, demonstrated their lack of knowledge of ensuring resident council was used for what it was intended, an opportunity for residents to voice their concerns and have adequate follow-up. Findings include: Review of the facility policy titled, Resident Voice/Council Policy, modified 06/11/25, revealed, It is the policy of this facility to ensure that all residents have a consistent, respectful; and structured opportunity to share feedback, voice concerns . to improve their quality of life and care within the facility . Responses and updates will be shared with residents during the next meeting. 1.Review of the admission Record under Profile tab, located in the electronic medical record (EMR),…

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, staff interviews, and policy review, the facility failed to protect residents from resident-to-resident verbal and physical abuse for three (Residents (R)3, R7, R4) of 13 sampled residents. This failure had the potential to create an environment where other residents had the potential to be abused. Findings include: Review of the undated facility policy titled, Abuse Neglect, Mistreatment & Misappropriation of Resident Property Policy & Procedure, revealed . It is the policy of this facility to prevent abuse by providing residents, families and staff information and education on how and to whom to report concerns, incidents and grievances without the fear of reprisal or retribution 1. According to the admission Record under Profile tab, in the electronic medical record (EMR), R3 admitted on [DATE] with diagnoses that included dementia. R3 discharged from the facility 05/15/25. Review of the quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR, with an assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review, the facility failed to complete a thorough investigation when receiving abuse allegations from residents for two residents (Residents (R)6 and R5) out of 13 sampled residents. Failing to interview other residents to complete a thorough investigation, had the potential to increase a resident's risk of abuse. Findings include: Review of the undated facility policy titled, Abuse Neglect, Mistreatment & Misappropriation of Resident Property Policy & Procedure, revealed, When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident .The investigation will include .Resident statements . According to the admission Record under Profile tab in the electronic medical record (EMR), R5 admitted on [DATE] with diagnoses that included palliative care. Review of the quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 05/07/25 revealed R5 had 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 failed to ensure one out of 13 sample residents (Resident (R)1) was provided with care and services in accordance with the care plan to maintain the highest practicable physical, mental, and psychosocial well-being. R1 expressed the desire to kill herself; a Certified Nursing Assistant (CNA) failed to implement the care plan interventions and did not notify the nurse on duty or the Nurse Care Coordinator (NCC) of R1's suicidal statements. R1 was alone in her room and was not assessed by a nurse to determine what measures might be needed as directed in the care plan. Findings include: Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R1 was admitted to the facility on [DATE]. Review of the Diagnoses tab in the EMR revealed R1 had diagnoses including mild cognitive impairment, legal blindness, abnormality of gait and mobility, osteoarthritis, and anxiety disorder. Review of the quarterly…

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, record review and policy review, the facility failed to ensure two out of two sampled residents at risk for falls and reviewed for alarm use (Resident (R)1 and R4) were not consistently provided with non-alarm interventions prior to the implementation of multiple alarms or following the implementation of alarms, that were implemented to prevent falls/accidents. Five separate alarms were utilized for R1 and four separate alarms were utilized for R4, without a reduction plan in place. A gait belt was not consistently used and the care plan was not followed regarding notifying the nurse if R1 refused the gait belt. This created the potential for residents to experience emotional distress due to the noise level and potential for falls due to being startled by the sound of the alarms. Findings include: Review of the undated Fall Prevention policy and provided by the facility revealed, The [facility name] strives to minimize resident falls and related injuries through a fall management…

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 a resident's right to privacy was maintained when receiving mail for 1 of 3 residents reviewed (R2). R2's mail packages were opened by facility staff without R2's permission. Findings include: The facility policy, titled Distribution of Resident Mail, undated, states: Residents have the right to receive and read mail in private and to receive mail in a timely manner. Resident's will be asked if they would like assistance in opening and /or reading personal mail. Resident's may also receive assistance with personal mail upon request. R2 was admitted on [DATE]. R2's Minimum Data Set (MDS) assessment, dated 9/21/2024, documents R2 is cognitively intact, has clear speech, is able to make self-understood and understands others. On 3/5/2025 at 10:50 AM, Surveyor interviewed Certified Nursing Assistant (CNA) F, who stated mail comes to the nurse's desk and usually activities will deliver the mail to the residents. On 3/5/2025 at 11:07 AM, Surveyor…

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 staff interviews, the facility did not ensure Certified Nursing Assistant (CNA) received a performance review every 12 months for three of five CNAs reviewed. (CNA H, CNA I, CNA J). The facility failed to have a system in place to ensure that performance reviews were being done for any of the facility CNAs. This had the potential to affect all 147 residents residing in the facility. This is evidenced by: On 08/15/24, a random sample of CNAs employed by the facility was selected for review for the completion of annual performance reviews. The facility provided the following information: CNA H has been employed at the facility since 06/14/22. An annual performance review could not be located. CNA I has been employed at the facility since 07/13/17. An annual performance review could not be located. CNA J has been employed at the facility since 08/15/22. An annual performance review could not be located. On 08/15/24 at 4:23 PM, Surveyor asked Human Resources Manager (HR) G for their policy on performance reviews. On 08/15/24 at 4:28 PM, HR G 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 interview and record review, the facility did not report an incident of potential misconduct to the state agency immediately upon learning of the incident and did not submit the 5-day investigation within 5 days as required. The facility practice had the potential to affect 1 of 2 residents (R) reviewed for abuse (R78). This is evidenced by: The facility policy entitled Abuse, neglect, mistreatment & misappropriation of resident property policy and procedure, indicates the definition of abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. According to Appendix PP of the State Operation manual Willful is defined at §483.5 in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. R78 was admitted to the facility on [DATE], and has diagnoses that include unspecified dementia, unspecified, severity, with agitation.…

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 interview, the facility did not ensure 2 residents (R), R56 and R127, of 7 sampled residents reviewed for hospitalizations received the proper notice of transfer, reason for transfer and location of transfer. R56 was transferred to the hospital on [DATE]. R56 was own decision maker and was not provided a written notice of the transfer. R127 was transferred to the hospital on [DATE]. R127 was not provided with written notice of the transfer. Findings: Example 1 R56 was admitted to the facility on [DATE] with a Brief Interview of Mental Status of 15; the resident was cognitively intact. On 03/10/24, R56's medical record indicated that R56 had a fever of 101.5 degrees. R56 had not slept since 03/08/24, and R56 could feel an 'infection brewing inside.' R56 was requesting transfer to the hospital. On 08/15/24 at 1:19 PM, Surveyor requested hospitalization notification of transfer provided to the resident. On 08/15/24 at 1:55 PM, Surveyor interviewed Director of Nursing (DON) B…

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, observation and interview, the facility did not implement the comprehensive, person-centered care plan for 1 of 29 sampled residents (R) (R12), reviewed with comprehensive, person-centered care plans. Findings: The facility's policy titled, Care Plans, dated 5/31/23 states in part, Staff is expected to follow the individual baseline plan of care at all times for each resident. R12 was admitted on [DATE] with diagnoses of Huntington's disease (a fatal genetic disorder that causes the progressive breakdown of nerve cells in the brain) and pneumonitis (a general term that refers to swelling and irritation, also called inflammation, of lung tissue) due to inhalation of food and vomit. R12's care plan reads, This resident has a history of inadequate oral intake related to Huntington's disease a need for enteral nutrition. The resident needs the HOB (head of bed) elevated 45 degrees during and thirty minutes after tube feed. On 08/14/24 at 8:47 AM, Surveyor observed tube feeding administered by…

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 ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 6 residents (R) R34 and R100. Findings include: The facility's policy titled, Care Plans, dated 5/31/23 states in part, Staff is expected to follow the individual baseline plan of care at all times for each resident. R34 was admitted to facility on 11/02/22 and has diagnoses that include dementia and seizure disorder. R34's Significant Change Minimum Data Set (MDS) assessment, dated 07/12/24, indicated short term and long-term memory problems and requires substantial/maximal assistance for transfers with one-person physical assist. R34's Fall Risk Assessment completed by facility on 05/27/24 indicates high risk score of 23. R34's care plans indicate R34 is at risk for falls related to confusion, gait/balance problems, psychoactive drug use, unaware of safety needs, vision problems, wandering/pacing, lower extremity edema, calloused feet, 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 failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Facility staff were walking trays with uncovered food past other residents' rooms. This has the opportunity to effect 3 of 3 residents (R117, R296, R295). Findings: The facility policy titled, Dining - Meal Service that was not dated states, 4. Nursing Staff will notify the food and nutrition serviced staff serving their unit of those who wish to receive meals in their rooms. When residents receive meals in their room, all food must be covered that travels through the unit. On 08/13/24 at 12:50 PM, Surveyor observed room trays being passed by Certified Nursing Assistant (CNA) M and CNA N. CNA M walked a food tray down R117's unit hallway to R117's room. The tray had uncovered cake and drinks. CNA N walked a tray down the unit's hallway with uncovered cake and drinks to R295. CNA M walked a tray with uncovered cake and drinks to R296. R296 was eating in their own room located on this unit. All drinks 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 record review and staff interview, the facility did not ensure vaccinations were reviewed, offered, or administered for 1 of 5 sampled residents (R) for immunizations. R23. Findings: The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults 65 years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those who have received PCV13 and 1 dose of PPSV23, the CDC recommends you give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine. For adults 65 years or older who have received PCV13, give 1 dose of PCV20 or PPSV23 at least 1 year after PCV13. Regardless of vaccine used, their vaccines are then complete. R23 was admitted on [DATE] with a Brief…

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 failed to ensure residents received care and treatment based on professional standards of practice for 1 of 3 residents (R4) reviewed who are at risk for the development of pressure injuries. R4 was noted on 6/01/24 with a new stage 2 pressure injury to her coccyx. R4 pressure injury was noted as healed on 7/09/24. R4's repositioning schedule is not consistent with current standards of practice to prevent redevelopment of pressure injury. This is evidenced by: Surveyor requested and received the facility policy titled Nursing-Pressure Injury Policy and Treatment Procedures dated as most recently revised on 8/01/23. The Policy in part read: Policy: To prevent the development of avoidable pressure injuries .the facility provides care and services which: ~Promote the prevention of pressure Injury development. ~Promote the healing of pressure injuries that are present . ~Prevent the development of additional pressure injuries. Preventative strategies may include: ~Keeping the skin clean and dry. ~Turning/repositioning schedules .…

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 failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an allegation of sexual abuse, was not reported immediately but not later than 2 hours after the allegation is made, to the administrator of the facility and to other officials (including to the State Survey Agency and law enforcement where state law provides for jurisdiction in long-term care facilities) in accordance with state law for 1 of 1 abuse allegatoins reviewed for resident (R) 1. Findings include: The facility policy, entitled Abuse, Neglect, Mistreatment & Misappropriation of Resident Property Policy & Procedure, reads in part, It is the policy of the facility that reports of abuse are promptly and thoroughly investigated. R1 was admitted to the facility on [DATE], and has diagnoses that include congestive heart failure, anxiety disorder, major depressive disorder, type 2 diabetes…

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

Based on observation and interview, the facility did not ensure controlled drugs were stored in separately locked, permanently affixed compartments. Observation of a controlled medication stored in the unlocked refrigerator located in the medication room. The facility's controlled substances shift count log was missing documentation of shift counts to accurately detect missing doses of the controlled substances. Findings include: The facility policy, entitled Pharmacy Medication Management, dated 12/14/20, states: .Schedule II controlled substances will be kept in the separate locked storage drawer of the medication cart .Reconciliation will be done each shift as follows: a shift count shall be required between two nurses to verify the accuracy of count for all controlled substances. A controlled substances shift count log will be utilized to document shift count . On 11/13/23 at 12:15PM, Surveyor observed medication pass with Registered Nurse (RN) D on 2 West. RN D went into the locked medication room where an unlocked medication refrigerator was located. Surveyor asked RN D what…

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 consult with the resident's physician when a stage 2 pressure injury developed for 1 of 8 residents reviewed (R26). R26's physician was not notified when development of a stage 2 pressure injury was identified. This is evidenced by: The facility policy, entitled, Pressure Injury Policy & Treatment Procedures, states in part Consult MD by telephone within 24 hours if a new injury is discovered that is a stage 2 or greater or there is deep tissue injury of heels or other areas to obtain treatment orders. R26 was admitted to the facility on [DATE] and has diagnoses that include orthopedic aftercare following surgical amputation, right leg below the knee amputation, diabetes mellitus type 2, cancer, heart disease, peripheral vascular disease, and complications of amputation stump. R26's Minimum Data Set (MDS) assessment, dated 06/10/23, indicates that R26 has a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). R26 is own responsible…

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 ensure that residents receive treatment and care in accordance with professional standards of practice based on a comprehensive assessment for 1 of 8 residents (R) (R78) reviewed for a toe lesion. The facility did not complete a thorough assessment, notify the physician, address the care plan, and initiate treatment and interventions for R78 with a toe lesion. This is evidenced by: R78 was admitted to the facility on [DATE] with diagnoses that include, in part, type 2 diabetes, chronic kidney disease, stroke with left sided paralysis, gout, long term anticoagulant, history of blood clots in lungs and legs, congestive heart failure and edema. On 07/24/23 at 10:29 a.m., Surveyor was informed by Registered Nurse (RN) G that R78 has a pressure ulcer on the left great toe. Surveyor observed the bottom of the left great toe and there was an irregular shaped bright red intact area that was approximately 1.5cm long and had the appearance of a…

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