Riverside Valley Of Journey

Based on observation, record review, and staff interview, the facility failed to provide physician-ordered adaptive eating equipment to Resident #24. This was a random opportunity for discovery. Resident Identifier: #24. Facility census: 84. Findings included: a) Resident #24 Review of Resident #24's physician's orders showed an order written on 06/26/25 for the resident to have a two (2) handled cup with all meals. On 07/02/25 at 1:05 PM, Resident #24 was observed eating lunch in her room. She did not have a two (2) handled cup. Her beverage was in a cup with no handles. The resident's tray ticket stated she was to have a two (2) handled cup. Registered Nurse (RN) #9 confirmed Resident #24 did not have a two (2) handled cup with her tray. She stated she would obtain one for the resident. No further information was provided through the completion of the survey process.

Based on observation, record review and staff interview, the facility failed to 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. Contact precautions were not followed for a resident with shingles. This was a random opportunity for discovery. Resident Identifier: #46. Facility census: 84. Findings included: a) Resident #46 The facility's policy titled Transmission-based (Isolation) Precautions, with no implementation date or revision date given, stated for Herpes zoster (shingles), airborne precautions would be followed for disseminated disease, contact precautions would be followed for immunocompromised residents, and standard precautions would be followed for localized disease. The policy further stated for contact isolation the following personal protective equipment (PPE) would be utilized: - Gloves would be worn whenever touching the resident's intact skin or surfaces and articles near 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review and staff interview the facility failed to provide a clean comfortable home like environment. These practices were found in more than a limited area of the facility. residents reviewed for environment during the Long-Term Care Survey Process. Sixteen (16) resident rooms had a black substance on the heating/cooling unit. Windowsills and doorjambs were covered in a black substance. The resident's bathroom was not maintained in a sanitray conditin. Room Numbers: #99, #100, #101, #102, #103, #104, #105, #107, #131, #132, #133, #134, #136, #138, #109, #110. Resident identifiers: #43, #75, #32, and #69. Facility census: 80. Facility census: 80. Findings included: a) Resident #32 The initial observation, on 07/30/24 at 1:00 PM, of Resident #32's room revealed a double door that went out into the courtyard. The entire door jamb of the door was covered with buildup of a black substance. The black substance was also found to be around the receptacle and the air conditioning unit.…

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 interview and record review the facility failed to complete a comprehensive assessment for mood and behavior. This was true for six (6) of 25 residents reviewed during the Long-Term Survey Process. Resident identifiers: #44, #47, #34, #71, #4 and #54. Facility Census: 80. Findings Included: a) Resident #44 On 07/31/24 during record review of Resident #44 MDS review of Quarterly Minimum Data Set (MDS) assessment 06/19/24, Section C, cognitive pattern, was not assessed and section D, Mood, was not assessed. During an Interview on 07/31/24 at 1:55 PM the Cooperate Nurse verified the section C and D was not completed for Resident #44s 06/19/24 MDS assessment. b) Resident #47 On 07/31/24 during record review of Resident #47 MDS review of Quarterly Minimum Data Set (MDS) assessment 06/30/24, Section C, cognitive pattern, was not assessed and section D, Mood, was not assessed. During an Interview on 07/31/24 at 1:55 PM the Cooperate Nurse verified the section C and D was not completed for Resident #47s…

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 failed to identify Major Depressive disorder on Preadmission Screening and Resident Review (PASSR). This was found true for two (2) of five(5) residents reviewed during the long term care survey process. Facility Census: 80 Resident identifiers: #22, and #26. Findings included: a) Resident #22 Record review on 07/30/24 for Resident #22 found the PASSR completed on 11/04/16 to have coded diagnosis of Cerebral infarction, Hemiplefie, adjustment disorder with disturbance, and cognitive communication deficit and ataxic gate. further record review found Resident #22 also has Major depressive disorder that was diagnosed on [DATE]. On 7/30/24 at 12:30 PM the Director of Nursing (DON) confirmed the diagnoses of Major Depressive disorder should have been identified on the PASSR. b) Resident #26 Record review for resident #26 and found the PASSR completed on 02/13/24 contained diagnosis of Schizophrenic disorder, and affective bipolar disorder. further record 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.

Based on observation, U.S. Pharmacopeia, and staff interview, the facility failed to ensure all medical supplies in the medication storage room were stored in accordance with manufacturers recommended standards. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 80 Findings included: a) Inspection of Medication Storage Room East on 07/31/24 at 11:02 AM, accompanied by Registered Nurse (RN) #69. Observation of the medication storage refrigerator log revealed that the PM refrigerator for 07/30/24 had not been recorded. RN # 69 confirmed that the temperature had not been logged. b) Inspection of Medication Storage Room West, on 07/31/24 at 11:14 AM, accompanied by Licensed Practical Nurse (LPN) #40. LPN stated that this medication room was not used for storage of anything other than supplies and IV solutions. The medication room thermometer revealed a temperature of 80 degrees Fahrenheit. LPN #40 confirmed that the temperature of the room was at 80 degrees Fahrenheit. Review of the medication room temperature log revealed that the…

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

Based on record review and staff interview, the facility failed to transmit residents assessments for a discharge. This failed practice was found true for one (1) of two (2) residents reviewed under the Facility Tasks during the Long Term Care Survey and hat the potential to affect a limited number of residents residing in the facility. Facility census:80. Resident Identifier: #45 Findings included: a) Resident #45 On 07/31/24 at approximately 11:20 AM record review of Resident #45's The Minimum Data Set (MDS) { standardized assessment tool that measures health status in nursing home residents} reveaeld on 03/27/24 a discharge MDS was completed, and not transmitted/accepted. During staff interview on 07/31/24 at approximately 1:00 PM the Director of Nursing confirmed the discharge MDS should have been transmitted within 14 days after a facility completes a resident's assessment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review the facility failed to complete a new Preadmission Screening and Resident Review (PASARR) for Resident #20 when the original PASARR had expired. This failed practice was found true for (1) one of (5) five residents reviewed for PASARR during the Long-Term Care Survey Process. Resident identifier: #20. Facility census: 80. Findings included: a) Resident #20 A record review on [DATE] at 2:51 PM, revealed that Resident #20 was admitted to the facility on [DATE] and had a PASARR completed on [DATE]. Further record review showed that Resident #20's PASARR was marked for 3 months or less. During an interview on [DATE] at 3:20 PM, The Director of Nursing (DON) stated, We do know we have a problem with PASARR'S. I just started an audit on them. DON confirmed that the PASARR for Resident #20 had expired.

Based on record review, and staff interview, the facility failed to ensure a Resident had a person-centered comprehensive care plan developed and implemented to meet his / her other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This practice affected one (1) of (24) resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was developed for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident Identifiers: #44. Facility census: 80. Findings included: a) Resident #44 A review of the current Diagnosis List showed the diagnosis of Schizophrenia. A continued review revealed the current care plan did not contain a diagnosis of Schizophrenia or monitoring. On 07/31/24 at 2:06 PM during an Interview with the Director of Nursing (DON), she confirmed the current care plan did not reflect the resident's need.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to revise a care plan for one (1) of 24 residents. Resident #53 regarding the cardiopulmonary (CPR) status. Resident Identifiers: #53. Facility Census: 80. Findings Include: a) Resident #53 On [DATE] at 11:40 AM, a record review was completed for Resident #53. The review found a focus area of I choose to have CPR. An intervention was listed as I prefer to be left alone with my family. On [DATE] at 11:55 AM, the Director of Nursing (DON) was notified. The DON stated, I don't know why this intervention is under this focus area .we will get it corrected.

Based on investigation, record review and interview, the facility failed to develop a discharge summary which included a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of all pre and post discharge medications, and develop a post-discharge plan of care, including discharge instructions. Resident identifier #85. Facility Census: 80. Findings included: a) Resident #85 Record review, on 07/31/24 at 09:27 AM, revealed no discharge summary, post discharge plan of care, or discharge instructions for Resident #85. Further document review revealed a nursing note on 5/1/2024 at 10:31 by RN #69, which stated: Resident discharged from facility at this time via public bus. All personal belongings taken with resident upon discharge. Discharge instructions reviewed with resident, and she verbalized understanding. Resident refused to have medication called in to her pharmacy for refill, she states I'm not going to take it. Interview with Registered Nurse (RN) #69 on 07/31/24 at 11:57 AM, revealed Resident #85 refused RN's offer to call 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 record review and staff interview, the facility failed to maintain an accurate and complete record for transfers to an acute care facility for Resident #15. This is true for two (2) of three (3) residents reviewed under the care area of hospitalizations. Resident identifier: #15. Facility Census: 80. Findings include: a) Resident #15 A record review was completed on 08/01/24 at 9:45 AM. The review found the resident had been transferred to an acute care facility on 06/12/24. However, the date listed on the transfer form was dated 04/14/24. On 08/01/24 at 10:25 AM, the corporate nurse and the Director of Nursing were notified. The Corporate nurse stated, I will check and see why the date is incorrect. A record review was completed on 08/01/24 at 9:45 AM. The review found the resident had been transferred to an acute care facility on 07/09/24. However, the date listed on the transfer form was dated 06/12/24. On 08/01/24 at 10:25 AM, the corporate nurse and the Director of Nursing were notified. The Corporate nurse stated, I will check and see why the date is incorrect.

Based on observation, record review and staff interview, the facility failed to maintain an appropriate infection control program during meal service for Resident #15. This was a random opportunity for discovery. Facility Census: 80. Findings included: a) Resident #15 On 07/30/24 at 1:13 PM, the resident was observed receiving a lunch tray from Nurse Aide (NA) #30. The resident asked for assistance with setting up the tray. NA #30 was observed touching the hamburger buns with bare hands. NA #30 was asked, Do you normally wear gloves when assisting residents with their meals? NA #30 stated, I sanitize my hands between trays. On 07/30/24 at 1:40 PM, the Director of Nursing (DON) was notified of the observation. The DON stated, I'll take care of this right away.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to incorporate an effective pest control program. One (1) room had gnats. Facility census: 80. a) room [ROOM NUMBER] A On 07/29/24 12:13 PM during the initial tour there were gnats all over the over bed table including his drinks and pudding. On 07/29/24 at 12:15 PM during an interview Nurse Aide #3 verified the gnats and stated that they do have an issue with gnats in this room. She stated that she would get someone to clean the room.

Based on observation and staff interview the facility failed to notify residents of a menu change. This was a random opportunity of discovery. This failed practice has the potential to affect all residents, as all residents residing in the facility currently receive a diet. Facility census: 84. Findings included: a) On 11/21/23 at 11:50 AM observation of the noon meal tray pass, revealed that residents had green beans, but the dietary meal tickets stated they received roasted Brussel sprouts. Review of the posted menu on the 100 Hall also revealed the residents would receive Brussels sprouts with an alternate of broccoli. On 11/21/23 at 11:55 AM Dietary Service Director #98 confirmed the residents should have received roasted Brussels sprouts as stated on their dietary ticket. She stated the residents were not notified of the change and she is unaware of why the change of vegetable occurred. No further information was obtained during the long-term survey process.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items that were opened. The facility also failed to complete dishwasher temperature logs. This failed practice had the potential to affect all residents, as all residents residing in the facility at this time receive an oral diet. Facility Census: 84 Findings included: a) Kitchen Tour On the initial tour of the kitchen on 11/21/23 at 10:15 AM, the following food was found in the walk-in refrigerator with no label to determine the date they were opened or the expiration date. --Angel Food Cake --[NAME] beans --Gravy --Whipped topping --Cooked breaded fish --Chicken stock base --Minced garlic On 11/21/23 at 11:00 AM the Food Services Director #98 confirmed the above items should have been labeled and dated once they were opened. No further information was obtained during the long-term survey process. b) Dishwasher Temperature Log…

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, resident interview and staff interview, the facility failed to follow Physicians orders for medication and treatment orders. This was true for five (5) of eight (8) medication administration Resident records reviewed. In addition, one (1) resident was not served the portions of food as ordered by the physician. Resident Identifiers: #17, #40, #66, #75, #79 and #1. Facility Census: #84. Findings Included: a) On 11/21/23 at 11:43 AM, Resident #17 stated she doesn't always get her medications on time. On 11/21/23 at 1:10 PM record review of Medication Administration Audit Review Reports for eight (8) residents found the following medications/treatments administered late according to the standard practice of care to administer medications/treatments one hour prior or one hour after the scheduled time. 1) Resident #17 11/09/23 Cleanse abrasion to left buttock with in house wound cleanser (IHWC), pat dry, apply zinc to area twice a day (BID) and after every incontinence episode. Scheduled time: 11/09/23 at 9:00 AM Administration Time: 11/09/23 at 12:18 PM. Two (2)…

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

Based on observation, resident interview and staff interview, the facility failed to provide a safe, clean, and homelike environment for Resident #25 and #29. These were random opportunities of discovery. Resident identifiers: #25 and #29. Facility Census: 84. Findings Included: a) Resident #25 On 11/21/23 at 10:57 AM, an initial interview was conducted with Resident #25. Resident #25 stated, there is something on my curtain .I've told them, but they don't do anything about it .I've only been here one (1) week. An observation of a dry brown substance the length of the privacy curtain and approximately six (6) inches in width was made. On 11/21/23 at 11:24 AM, Scheduler #51 confirmed there was a dry brown substance on the privacy curtain. Scheduler #51 stated, I will put a work order in. On 11/21/23 at 11:30 AM, the Administrator was notified. The Administrator stated, we are getting this taken care of now. b) Resident #29 On 11/21/23 at 11:10 AM, an initial interview was conducted with Resident #29. Resident #29 stated, They don't hardly clean my room .maybe three (3) times a week…

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 staff interview the facility failed to provide a therapeutic diet as ordered by the physician for a resident with diagnosis of adult failure to thrive. This was a random opportunity for discovery. Resident identifier: #1. Facility census: 84 Findings included: a) Resident #1 On 11/21/23 at 11:50 AM, during observation of the lunch meal pass revealed Resident #1's lunch plate appeared to be smaller portions than the amount listed on his meal ticket. The meal ticket stated Encrusted Pork Loin - - 6 ounces, Roasted Brussels sprouts, 1 cup, AuGratin potatoes 0 1 cup, dinner roll/bread 2 each, margarine - 2 each, Snickerdoodle cookie - 2 each, tea of choice -12 ounces. Upon review of his current orders, it was discovered that the resident was ordered Regular texture, thin liquids consistency, no salt packet, double portions for a diagnosis of failure to thrive. On 11/21/23 at 11:55 AM the Dietary Manager and Administrator confirmed the resident did not have double portions on his noon meal tray. No further information was obtained during the long term survey…

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.

a) Resident #12 During an interview and observation on 02/06/23 at 2:49 PM, Resident #12 states that he don't / can't get out of bed. He stated that no activities are provided for him. Resident #12 does have a television available. A review of the current care plan with the initiated date of 01/13/23 showed activities care plan: Focus: --Prefers to be called ---- and is dependent for emotional, intellectual, physical, and social needs. Resident #12 has an Activities of Daily Living (ADL) self-care performance deficit related to limited mobility, generalized weakness, Atherosclerotic Heart Disease (ASHD), history of falls,Pulmonary Embolism ( PE), Congestive Heart Failure (CHF), and Epilepsy. Goal: --Resident #12 will attend or participate in activities of choice one or two times weekly by next review date. --Resident #12 will maintain involvement in cognitive stimulation, social activities as desired through review date. This showed it was not updated to reflect the resident's current status. Interventions: --All staff to converse with Resident while providing care, he enjoys…

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, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open. The facility also failed to keep kitchen equipment clean and sanitized. The facility also failed to complete the dishwasher and refrigerator temperature log. This failed practice had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen. Facility Census: 80 Findings Included: A review of a facility policy titled Food Storage: Cold Foods with a revision ate on 04/18 read as following. Procedures 4. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. 5. All foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. a) Food Labeling During the initial tour of the kitchen on 02/06/23 at 11:05 AM, the Food Service Director (FSD) was not present upon entering 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 . d) Resident #20 During an observation during the initial interview on [DATE] at 12:50 PM Nurse Aide (NA) #68 delivered Resident # 20 lunch meal tray. The resident stated he did not want it, NA #68 stated its meatloaf. Do you not even want to try it? NA #68 offered him an alternative to the lunch meal Resident # 20 stated, No I will be fine. NA #68 took the tray and left the cup of coffee and a glass of juice. During a review on [DATE] at 9:00 AM Resident #20's medical record revealed a documentation under the nutrition task of the amount eaten on [DATE] at 12:17 PM - 76-100 % consumed. During an interview on [DATE] at 9:47 AM NA #68, stated Resident # 20 did refuse his lunch meal yesterday, Not sure what I documented for his percentage consumed I would have to look. This surveyor revealed the documentation of 76-100 % eaten. NA #68 stated I probably confused him with another Resident. During an interview on [DATE] at 11:08 AM DON stated the documentation on [DATE] at 12:17 PM was the lunch meal percentage 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 failed to ensure five (5) of five (5) residents reviewed were informed about the benefits and risks of pneumococcal vaccines and had the opportunity to receive pneumococcal vaccines unless medically contraindicated, refused, or already immunized. This deficient practice had the potential to affect more than a limited number of residents at the facility. Resident identifiers: #2, #61, #33, #65, #12. Facility census: 80. Findings included: a) Policy Review The facility's policy titled 'Vaccination of Residents' with implementation date 2001 and revision date March 2022 stated all residents would be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, would be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident had already been vaccinated. Assessments of pneumococcal vaccination status would be conducted within five (5) working days of the resident's…

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

Based on resident interview, medical record review, and staff interview, the facility failed to ensure the resident could make choices that were important to him. Resident #61's preferred to have his prosthetic leg kept in his room, but it was kept in the physical therapy department. This deficient practice had the potential to affect one (1) of seven (7) residents reviewed for the care area of choices. Resident identifier: #61. Facility census: 80. Findings included: a) Resident #61 During an interview on 02/06/23 at 11:23 AM, Resident #61 stated he wanted to be able to keep his prosthetic leg in his room. The resident stated his prosthetic leg was locked up in the physical therapy department. The resident stated he had a blister on the end of his limb stump and the therapists wanted to limit the time he was able to wear his prosthetic leg because they were concerned the blister would get worse. The resident stated that even if he decided not to wear his prosthetic leg, he wanted to be able to keep it in his room because other residents were permitted to keep their prosthetic legs…

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 interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for one (1) of 29 residents reviewed in the long-term care survey process. Resident identifier: #6. Facility census: 80. Findings included: a) Resident #6 Review of Resident #6's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 12/22/22 showed the resident had taken an antibiotic seven (7) days during the look back period. Review of Resident #6's physician's orders showed no orders for antibiotics during the look back period for the MDS assessment. During an interview on 02/08/23 at 2:44 PM, the Director of Nursing confirmed Resident #6's MDS with ARD 12/22/22 was incorrect in stating the resident had taken an antibiotic during the look back period. No further information was provided through the completion of the survey. .

Based on record review and staff interview, the facility failed to revise a care plan under the care area of hospice and end-of-life care. This was true for one (1) of 29 residents reviewed for care planning. Resident Identifier: #325. Census: 80. Findings Included: a) Resident #325 On 02/06/23 at 2:10 PM, a record review was completed for Resident #325. The care plan interventions dated 08/19/22 listed hospice referral indicated and notify MD (medical doctor) and/or Hospice for potential changes or needs for treatment changes. (Typed as written.) The record review found no active physician's order indicating the resident was currently under hospice services. The facility matrix was also reviewed and hospice services were not indicated. An interview with Social Services (SS) #84 on 02/07/23 at 11:54 AM took place. SS #84 confirmed the resident was not under the care of hospice services. SS #84 stated the resident is not on hospice services, maybe in the community before she came here, and the care plan did need the information regarding the hospice services removed. No further…

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 interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Physician's orders for fingerstick blood glucose levels were not followed for one (1) of three (3) residents reviewed for the care area of insulin. Resident identifier: #61. Facility census: 80. Findings included: a) Resident #61 Review of Resident #61's physician's orders showed an order for fingerstick blood glucose checks four (4) times a day with insulin coverage. The order stated the fingerstick was to be repeated in one (1) hour if the result was over 400. Review of Resident #61's Medication Administration Records (MARs) for January 2023 and February 2023 showed the resident's fingerstick blood glucose level was over 400 on the following dates and times: - On 01/01/23 at 8:30 PM, the result was 401. - On 01/19/23 at 6:00 AM, the result was 404. - On 01/19/23 at 11:30 AM, the result was 499. - On 01/20/23 at 6:00 AM, the result was 433. - On 02/01/23 at 8:30 PM, the result was 438. For each of these fingerstick…

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, resident and staff interview the facility failed to provide respiratory care by not providing their Bi-Pap as ordered. This was true for two (2) of two (2) residents reviewed for the Respiratory Oxygen care area. Resident Identifiers: #33 and #70. Facility Census: 80. Findings Included: a) Resident #33 On 02/06/23 at 2:46 PM Resident #33 states she is to have a Bi-Pap but she doesn't know where it is. The Bi-Pap was not in her room. This was confirmed with Registered Nurse (RN) #24 on 02/06/23 at 2:47 PM. During an interview on 02/07/23 at 10:05 AM, RN Unit Manager #61 stated due to COVID needs, the Resident was moved from room [ROOM NUMBER] to her current room, #132 on 01/17/23 and is moving back to 129 today. Upon investigation the BiPap was located in the overnight drawer in her old room [ROOM NUMBER]. According the the January and February 2023 Treatment Administration Record (TAR), staff has been documenting that they are placing the BiPap every night since 01/18/23…

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

Based on observation, record review, and staff interview, the facility failed to provide medication administration in accordance with professional standards of practice. Resident #35. Facility Census: 80. Findings Included: a) Resident # 35 On 02/07/23 at 9:16 AM, a medicine cup with multiple pills with no label was found in the medicine cart. There was no way to identify pills which were opened and poured in the medicine cup. Licensed Practical Nurse (LPN) #91 stated I tried to give them to the resident but she said she was sick and couldn't take them right now. LPN #91 stated I can get rid of them and pull some more for the resident. On 02/07/23 at 9:20 AM, Unit Manager (UM) #61 was notified and confirmed the pills were poured into the medicine cup without any type of label. UM #61 stated I'll dispose of them. On 02/07/23 at 9:55 AM, the Director of Nursing (DON) #54 was notified and stated we tell them if the resident won't take them to try again in a little bit. They are in their section with their name on it. On 02/07/23 at 1:00 PM, the Medication Administration Policy was…

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

Based on record review and staff interview, the facility failed to clarify two (2) of five (5) residents reviewed for the care area of immunizations wishes to receive COVID-19 vaccinations. Resident identifiers: #12, #65. Facility census: 80. Findings included: a) Resident #12 Information provided by the facility's Infection Preventionist showed Resident #12 had not received COVID-19 vaccination. Review of Resident #12's admission records showed the resident had signed a document titled COVID Risk Acknowledgement and Education Signature Page on 10/26/22. The document had the following areas: - I have been partially or fully vaccinated against COVID-19. - I have not been fully vaccinated against COVID-19 and I would like a COVID-19 vaccine made available at no cost to me. - I have not been fully vaccinated against COVID-19 and I am not interested in a COVID-19 vaccine at this time. None of these areas had been checked to indicate the resident's eligibility and interest in receiving COVID-19 vaccination. During an interview on 02/07/23 at 1:27 PM, the Infection Preventionist confirmed…

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.