Ryze West

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent one resident at high risk for pressure ulcer development (R3) from acquiring a new facility acquired pressure ulcer and failed to order and perform a wound treatment to promote healing of R3's right buttock wound initially identified as a partial thickness wound/moisture associated skin damage (MASD). These failures affected one resident (R3) out of three residents reviewed for pressure ulcers. As a result of these failures, R3's right buttock wound progressed to a stage 3 pressure ulcer.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure rehabilitation orders were followed for 1 (R1) out of three residents reviewed rehabilitation services, in a total sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of physical abuse for one (R1) resident out of three residents reviewed for physical abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the low air loss mattress was on the correct setting for the wound care prevention protocol. This failure has the potential to affect 1 (R6) of 3 (R2, R5, R6) residents reviewed for wound care. Findings Include: R6 was readmitted to the facility on [DATE] with diagnosis not limited to Essential (Primary) Hypertension, Type 2 Diabetes Mellitus, Nontraumatic Subdural Hemorrhage, Intervertebral Disc Degeneration, Thoracic Region, Epilepsy, Iron Deficiency Anemia, Disorder of Thyroid, Gastrostomy, Hyperosmolality And Hypernatremia, Vitamin D Deficiency, Muscle Weakness (Generalized), Lack of Coordination, Abnormal Posture, Cognitive Communication Deficit, Protein-Calorie Malnutrition, and Hepatic Encephalopathy. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a system was in place for documentation of medication disposition. This failure resulted in R4s medication being unaccounted for. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility failed to administer ordered topical medication used for lice and scabies exposure; failed to document notification of physician and or nurse practitioner of residents' exposure to lice and scabies; failed to obtain an order for Contact precautions for lice and scabies isolation; failed to perform isolation assessments and infection criteria evaluations for residents exposed to lice and scabies; failed to perform a proper room deep cleaning for residents exposed to lice and scabies; and failed to follow their facility policies for residents with confirmed cases of and exposure to lice and scabies. These failures resulted in R2 experiencing one occurrence of scabies and two occurrences of lice; R4 experiencing one occurrence of head lice; [...]

Inspectors wroteBased on interviews and record review, the facility failed to regularly re-evaluate, refer, and document any referrals to the local contact agencies for discharge planning and assessment for one (R3) of three residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow a resident's food preference by serving oatmeal instead of grits. This failure affected 1 resident (R10) out of 7 residents reviewed for dietary services, in a total sample of 20 residents. Finding Include: R10's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Malignant neoplasm of supraglottis, moderate protein-calorie malnutrition, cerebral infarction, unspecified asthma, vitamin D deficiency. Minimum Data Set Section (MDS) section C (dated 02/13/2025) documents that R10 has a Brief Interview for Mental Status (BIMS) score of 15, indicating that R10's cognition is intact. Care plan (dated 05/28/2024) documents that R10 is at nutritional risk as disease progresses. [...]

Inspectors wroteBased on interview and record reviews the facility failed to follow their policy and coordinate with the appropriate, state-designated authority to refer one resident with a severe mental disorder for a new PASRR level I screen prior to the resident's PASRR level II short-term approval ended. This failure affected one resident (R7) out of four residents reviewed for resident rights, in a total sample of 20 residents. This failure places residents with related conditions at risk to not receive care and services in the most integrated setting appropriate to their needs.

Inspectors wroteBased on records review and interviews, the facility failed to provide person-centered care planning for a resident ' s behavioral concern who refused psychotropic medication for 1 (R1) of 3 residents reviewed for inadequate nursing care. This failure impacted 1 resident (R1) who expressed behavioral concerns and continues to refuse medications that may help with behavioral concerns. Without adequate care planning addressing medication refusal, resident (R1) has the potential to continue to express behavioral concerns.

Inspectors wroteBased on observations interview and record review the facility failed to keep three residents (R8, R10, R11) safe from a fire incident that occurred on 1/6/25. The facility failed to a.) properly assess and b.) maintain monitoring of R8's motorized wheelchair per the facility preventative maintenance policy in accordance with the manufactures guidelines. This failure resulted in three residents (R8, R10, R11) being involved in a fire and exposed to smoke. This failure has the potential to affect all 221 who reside in the facility. This was identified as an immediate jeopardy situation which began on 01/06/25. On 01/24/25 the administrator was notified of the immediate jeopardy. The abatement plan was sent via e-mail on 1/28/25 and not accepted. The abatement plan was resubmitted on 1/29/25 and 1/30/25 and accepted on 1/31/25. The immediate jeopardy was removed on 02/04/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly assess and implement interventions related to the psychosocial needs of one resident (R8) who was involved in and exposed to fire and smoke surrounding a fire related incident that occurred on 1/6/25 in R8's room. These failures resulted in R8 expressing emotional distress and fear after the incident.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide monthly surveillance and maintain patient care equipment, to ensure that it is in safe operating condition. This failure affected one (R8) out of five residents (R4, R8, R12, R13, R14) reviewed for preventative maintenance.

Inspectors wroteThe facility failed to ensure the resident's call light device was within reach for two residents (R1, R3) out of three residents reviewed for quality of care. This failed practice placed the resident at risk for not being able to call for help, if needed.

Inspectors wroteBased on observation, interviews, and review of records the facility failed to follow policy in giving/providing a shower/bath to 1 (R1) out of 4 residents reviewed for resident shower or bathing schedule. This failure has the potential to affect 1 resident (R1) in maintaining hygiene through bathing at least once a week.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide proper positioning for 1 (R1) resident during dining. This failure has the potential for R1 to be at risk for choking and aspiration during dining experience. Findings Include: R1 has diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Aphasia Following Cerebral Infarction, Essential (Primary) Hypertension, Atrial Fibrillation, Type 2 Diabetes Mellitus, Anxiety Disorder due to Known Physiological Condition and Post-Traumatic Stress Disorder. R1's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 04 indicating severe cognitive impairment. R1's Care Plan document in part: Focus: Bed Mobility: [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to schedule a dental appointment as ordered by a Nurse Practitioner for a dependent resident noted with severe dental decay. This failure has affected one (R5) of nine residents reviewed for nursing care. This failure resulted in R1 experiencing pain and a continuation of dental decay.

Inspectors wroteBased on interview and record review the facility failed to a.) follow their policy and monitor vital signs during a medical emergency and b.) perform needed interventions for a resident who experienced a change in condition for one (R2) resident out of three residents reviewed improper nursing care.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to provide the appropriate treatment to attain the highest practical mental and psychosocial wells-being of one [R125] resident reviewed in a sample of 35. This failure resulted in R125 feeling sad, depressed, tired, and refusing care.

Inspectors wroteBased on observation, interview and record review, facility failed to provide an adequate supply of linens to meet staff and resident needs in the provision of resident care. This failure has the potential to affect all 180 residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure to have sufficient certified nursing assistant (CNA) on weekends to care for residents' needs based on the staffing scheduling, PBJ (Payroll Based Journal) staffing data report and facility assessment. This failure could potentially affect 180 residents residing in the facility as of census 5/21/24.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to a.) ensure food items were labeled and dated with an opened and use by date, b.) discard expired or spoiled food, c.) keep food storage areas clean, d.) sanitize cooking equipment based on manufacturers' directions. These failures have the potential to affect all 176 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 180 residents who reside in the facility.

Inspectors wroteBased on observations and interviews, and record review the facility failed to repair a hole in the ceiling and replace the missing/stained ceiling tiles in the first-floor dining room and failed to maintain the walls in the residents' rooms in good repair for 3 (R114,R86, R58) residents in a sample of 35. Findings Included: During the facility tour of the first-floor dining room on 05/21/24 at 09:16 AM a missing ceiling tile was observed at the west end of the dining room and 4 ceiling tiles with brown stains. The ceiling that was observed above the missing tile was peeling. There was a large yellow garbage can positioned near the area of the missing tile with what appeared to have water in it. On 05/21/24 at 11:25 AM R112 was observed sitting in the first-floor dining room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to (a) ensure that smoking materials including cigarette and lighter were given to designated staff; (b) complete smoking assessment / evaluation in a timely manner; (c) develop comprehensive care plan and follow plan of care for smoking. These failures could potentially affect 4 (R28, R84, R92, and R132) residents reviewed for smoking in a total sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) ensure narcotic medications were administered in accordance with physician orders, b.) ensure the narcotic count was correct at the change of shift and c.) document ordered narcotic medications when given for 2 (R76, R118) of 2 residents reviewed in 2 of 3 medication carts. Findings Include: On 05/21/24 at 09:59 AM the third-floor medication cart 2 was reviewed with V5 (Licensed Practical Nurse). R76 Physicians order document in part: Morphine Sulfate Oral Solution 20 MG (Milligram)/5ML (Milliliter) 0.25 ml sublingually every 8 hours for pain -Start Date- 04/17/24. During the narcotic reconciliation review R76 Individual Controlled Substance Record document: Date received 04/19/24. Quantity received 30 ML (Milliliter) with 43 doses given. First dose dispensed 04/19/24 at 06:00 AM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow professional standards of practice and facility policy to prevent and control infection in the provision of patient care. This failure has the potential to affect all 180 residents in the facility. Findings On 05/21/24 at 9:13 AM V33 (CNA) was observed leaving room R121's room which had a sign for enhanced barrier precautions (EBP) on the door. V33 took the breakfast tray out of room , placed the tray in the return cart, did not perform hand hygiene and then entered room [ROOM NUMBER] which also had a sign for EBP on the door. V33 took the breakfast tray out of R162's room, placed it in the return cart, did not perform hand hygiene and began to push the cart down the hall. V33 was asked about the EBP signage. V33 stated It means that we gown up before doing care. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to follow their policy and procedure (a) to determine and assess a resident if self-administration of medications is appropriate; (b) to obtain a physician's order for medication self-administration; and (c) to implement a person-centered care plan addressing self-administration of medications for 1 (R124) out of 1 resident reviewed for self-administration of medications in the final sample of 35 residents. Findings Include: On 5/21/24 at 12:17 PM R124 was in R124's room. Surveyor noted wound dressings on top of R124's drawer. R124 stated that R124 has colon cancer and uses the dressings for R124's wound on R124's buttock. R124 opened R124's drawer and showed Surveyor the solution R124 uses for R124's wound. R124 stated that the wound care nurse gave the solution for R124 to use. [...]

Inspectors wroteBased on observation, interview, record review facility failed to follow facility policy in reporting an abuse and neglect allegation by one resident (R23) out of a total of 35 residents in the sample. Findings On 05/21/24 at 9:18 AM, R23 approached surveyor and asked Are you with the state? R23 stated They are stealing my money and stuff. R23 stated that she told the administrator. V13 (LPN) approached surveyor and R23 and stated It hasn't reached us yet. Surveyor repeated to V13 R23's statement that They are stealing my money and stuff. R23 stated They also neglect me a lot. They bully people. (V13 did not report the allegation to V1 Administrator) On 05/22/24 at 10:40 AM, V1 (Administrator) was interviewed about the facilities abuse allegation and reporting process. V1 stated that when a resident alleges abuse, V1 is the first person notified. [...]

Inspectors wroteBased on interview and record review, the facility failed to refer one resident (R3) to the appropriate state designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation out of 5 residents reviewed for PASARR in a total sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to (a) provide the necessary care and services to ensure that one (R92) resident was assisted or supervised with personal hygiene / shaving and (b) follow facility policy and standards of professional practice in providing care and communication in one resident's (R179) primary language. These failures affected two (R92 and R179) residents reviewed for activities of daily living (ADL) in a sample of 35.

Inspectors wroteBased on observations, interview and record review, facility failed to identify and address an alteration in skin integrity for one resident (R147) out of 35 residents in the sample. This failure resulted in unaddressed skin lesions and resident discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow care plan to ensure pressure redistribution mattress or low air loss mattress was provided as ordered and complete an assessment or tool used to identify resident at risk for pressure ulcer in a timely manner. These failures affected 1 (R90) resident reviewed for pressure ulcer in a sample of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to provide physician ordered oral nutritional supplements and other nutrition interventions. These failures potentially affected 2 residents (R18, R21) of 7 residents reviewed for nutrition in a total sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide total volume of prescribed gastrostomy tube feeding as prescribed by physician. These failures could potentially affect 2 (R59, R67) of 2 residents reviewed for nutrition and tube feeding in a sample of 35.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow residents' care plans to ensure physician orders were followed and administer the correct oxygen flow rate for 2 (R39, R148) out of 2 residents reviewed for respiratory care in the final sample of 35. Findings Include: 1) On 5/21/24 at 10:56 AM, R39 was lying in bed alert and able to verbalize needs. R39 was noted using oxygen (O2) via nasal cannula with the flow rate set to 1.5 liters per minute (LPM). When asked R39 if R39 changes the dial on R39's oxygen, R39 answered, The nurse sets that up. I don't touch it. R39 stated that R39 uses oxygen for R39's diagnoses of Asthma and Chronic Obstructive Pulmonary Disease (COPD). On 5/22/24 at 9:53 AM, R39 was resting in bed alert and awake. R39's was using oxygen via nasal cannula with the flow rate set to 1 LPM. R39 denied changing the flow rate. [...]

Inspectors wroteBased on interview and record review the facility [A] failed to ensure the physician documented in one [R125] resident's clinical record their assessment, current condition, and medical problems for each visit, [B] failed to ensure the physician sign and date psychotropic narcotic medication. These failures resulted in R125 not receiving a prescribed psychotropic medication for nine days. Findings Include: R125's clinical indicates in part, he is a twenty-eight-year-old admitted on [DATE], with the medical diagnosis of attention-deficit hyperactivity disorder, depression, paraplegia, neuromuscular dysfunction of bladder, essential (primary) hypertension. R125's physician order dated 5/15/24- Dextroamphetamine Sulfate Oral Tablet 5 MG (Adderall) [Controlled Drug], give 1 tablet by mouth in the morning and afternoon for ADHD. R125's Progress Notes: Documented in part. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their policy to (a) obtain an informed consent for psychotropic medication use; (b) ensure PRN (as needed) psychotropic medication will have a duration of no longer than 14days; (c) attempt Gradual Dose Reduction (GDR) for psychotropic medication use; (d) complete AIMS (Abnormal Involuntary Movement Scale) test in a timely manner. These failures could potentially affect 3 (R3, R130, R132) residents reviewed for Unnecessary Psychotic medication use in a sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident is free of significant medication errosr to 1 (R134) of 8 residents reviewed for medication administration resulting in administering 4 units of Humalog Insulin one hour before meal instead of with meal. This deficient practice has the potential to place R134 in Hypoglycemia distress. Findings Include: R134's electronic Medication Administration Record (eMAR) as at 5/2024 documents in part: Humalog Solution 100 Unit/ML. Inject as per sliding scale (251-300 = 4 units) subcutaneously with meals. R134's Minimum Data Set (MDS) dated [DATE] shows R134 is cognitively intact. On 5/21/24 at 11:43 AM, surveyor observed V39 (Licensed Practical Nurse/LPN) administering 4 Units of Humalog Insulin subcutaneously at Left Lower Quadrant (LLQ) to R134 before meal was served on the unit. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) ensure medications were labeled when opened, b.) ensure expired medications were removed from the medication cart/medication room and c.) ensure medications for discharged residents were removed from the medication cart in 2 of 3 medication carts and 1 of 2 medication rooms reviewed for medication storage and labeling. Findings Include: On 05/12/24 at 10:28 AM the fourth-floor medication cart 1 was reviewed with V6 (Licensed Practical Nurse). Expired medications were observed in the top drawer of the medication cart including; [...]

Inspectors wroteBased on interview and record review, facility failed to protect a resident from physical abuse. This failure affected one resident (R12) of seven residents reviewed for abuse. This failure resulted in R11 and R12 having an altercation. R11 put R12 into a headlock and scratched R12's face. Findings Include: Facility's Investigation Report (dated 02/29/2024) states: R11 noted with agitation while walking with staff member and he began flailing his arms, in the process of flailing his arms resident scratched R12, while he was sitting in the dining area. R12 was immediately removed from common area and placed with social services with de-escalation techniques initiated. MD made aware with orders received to send resident out to [community] hospital for psychiatric evaluation, orders noted and evaluated. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin to the regional office. This failure affects one of three residents (R9) reviewed for injury of unknown origin in a total sample of 19.

Inspectors wroteBased on interview and record review the facility failed to keep a resident (R6) free from physical abuse.

Inspectors wroteBased on observation, interview and record review, facility failed to ensure wound care orders and wound care interventions are in place in order to be followed for 2 (R1 and R5) out of three residents reviewed for pressure ulcer prevention.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for four of four residents (R3, R7, R5, R6) reviewed for ADL care.

Inspectors wroteBased on observations and interviews, the facility failed to provide sufficient staffing to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for four of four residents (R3, R7, R5, R6) reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall interventions for one of three residents (R1) reviewed for falls.

Inspectors wroteBased on observation, interviews and record reviews the facility (A) failed to ensure the safety of residents by not monitoring and preventing a resident [R125] with a document history of drug usage and drug overdose from obtaining and using an illegal drug. This failure resulted in R125 overdosing on heroin, requiring transfer and treatment to local hospital for treatment. (B) failed to follow smoking safety policy by not ensuring smoking materials are kept by facility or designated staff members for 4 (R82, R113, R118 and R413) residents and ensure that residents who smoke will be evaluated quarterly and annually for 2 (R113, R118) residents. These failures can potentially affect 4 (R82, R113, R118, R413) of 5 residents reviewed for smoking in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve food as planned on the cycle menu, and failed to ensure standardized recipes were followed during food preparation. This has the potential to affect all 157 residents receiving food prepared in the facility's kitchen. Findings Include: On 08/15/23 at 10:42 AM, V6 (Cook) stated for lunch residents on regular diet consistencies would be receiving fried chicken, white rice, and salad. The residents on mechanical soft diets would be receiving ground chicken, white rice and green beans. The residents on pureed diets would be receiving pureed chicken, pureed rice and pureed green beans. V6 stated they are in the 4th week of the cycle menu and pointed to the menu posted on the bulletin board near the food preparation area. Surveyor observed four weeks of cycle menus posted on the bulletin board. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a.) kitchen staff wearing hair net and beard coverings b.) food items were properly labeled, dated, and stored, c.) to discard moldy food, d.) properly rotate food by first in, first out practice, e.) store scoops in separate area from bulk food container. This failure has the potential to affect all 157 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the dumpsters was covered to prevent the harborage and feeding of pests. This failure has the potential to affect all 161 residents who reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that MDS (Minimum Data Set) assessments were transmitted within 14 days of the final completion date to thCenters for Medicare and Medicaid Services (CMS) system. This failure can potentially affect 11 (R4, R16, R17, R31, R51, R62, R72, R92, R93, R109, R112) of 11 residents reviewed for resident assessment in a sample of 32.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure incontinence care was provided in a timely manner for a resident (R13) who is dependent in toileting, and to ensure nail care was provided to 3 (R69, R3, R42) of 4 residents who are dependent with personal hygiene reviewed for activities of daily living (ADL) in a total sample of 32. Findings Include: 1. On 8/15/23 at 11:26 AM, R69 was still lying in bed alert wearing a hospital gown, alert and able to verbalize needs. R69's fingernails were noted approximately 2.0 centimeters (cm) long with black substance under R69's fingernails. R69 does not remember the last time R69's fingernails were cut and cleaned. [...]

Inspectors wroteBased on observation, interview, and record review, the facility: 1. Failed to ensure emergency tracheostomy care equipment was readily accessible for 2 (R70, R82) of 2 residents reviewed for tracheostomy care. 2. Failed to ensure that oxygen liter flow ordered by physician is followed for 3 (R33, R104, R413) residents. 3. Failed to place oxygen in use sign outside the room for 3 (R33, R104, R413) residents. 4. Failed to ensure oxygen cannula tubing is place in bag when not in use for 1 resident (R155). 5. Failed to ensure that oxygen cylinder / tank was in a cylinder stand for 2 (R104 and R413) residents. These failures have the potential to affect 6 (R33, R70, R82, R104, R155, R413) of 6 residents reviewed for respiratory care in the sample of 32.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to properly date opened multi-dose inhaler, nasal spray, and multi-dose insulin pens and vial for 4 residents (R42, R150, R413, R86), and to properly store medications according to the manufacturers' guidelines for 2 residents (R2, R11) from three of three medication carts inspected for medication storage and labeling. Findings Include: On 8/15/23 at 12:26 PM, inspected 4th floor's medication cart 2 with V18 (Licensed Practical Nurse). The following were noted: -R11's opened Lorazepam liquid oral concentrate stored inside the narcotic locked box. Label shows to STORE IN REFRIGERATOR. -R42's opened Novolog insulin vial without the date opened written on the label. At 12:32 PM, inspected 2nd floor's medication cart 2 with V17 (Registered Nurse). The following were noted: [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to a.) administer the pneumococcal vaccination to 1 (R131) resident with a signed consent and b.) the facility failed to assess the residents for eligibility and ensure residents were offered the pneumococcal vaccination for 3 (R70, R82, R90) of 4 (R215) residents reviewed for immunization in a sample of 32. Findings Include: R70 has diagnosis not limited to Encounter for Attention to Tracheostomy, Chronic Respiratory Failure with Hypoxia, Dysphagia, Pressure Ulcer of Sacral Region, Stage 4, Chronic Obstructive Pulmonary Disease, Anoxic Brain Damage and Gastrostomy. R70: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was self-administering medications, had a self-administration of medications evaluation, a physician's order, and a care plan completed for 1 (R102) of 1 resident reviewed for self-administration of medications in a total sample of 32. Findings Include: On 8/15/23 at 10:01 AM, a medication administration observation conducted with V4 (Licensed Practical Nurse). At approximately 10:12 AM, V4 administered some of R102's morning medications except for R102's nasal spray and eye drops. V4 stated that R102 self-administers the nasal spray and R102 keeps it at bedside. At 10:37 AM, interviewed R102 and stated that R102 keeps the nasal spray in R102's room. R102 stated, I gave it to myself this morning. At 11:18 AM, Surveyor observed V4 enter R102's room with R102's eye drops. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow policy for comprehensive care plan to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's needs and problems. This failure can potentially affect 3 (R113, R138, R413) of 3 residents reviewed for comprehensive care plan in the sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an air mattress used for pressure reduction was on the correct setting for 1 (R37) of 2 (R70) residents reviewed for pressure ulcers in a sample of 32. Findings Include: R37 was admitted to the facility on [DATE] with diagnosis not limited to Muscle Weakness, Elevated [NAME] Blood Cell Count, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Protein-Calorie Malnutrition, Acquired Deformity of hand, Left Hand, Sepsis, Paroxysmal Atrial Fibrillation, Chronic Embolism and Thrombosis, Pressure Ulcer of Unspecified Site, Disorder of Muscle, Disorder of Bone Density and Structure, Reduced Mobility, Abnormalities of Gait and Mobility and Lack of Coordination. R37 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 14 indicating intact cognitive response. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pain was thoroughly assessed and adequately treated for in a timely manner for 1 (R102) of 1 reviewed for pain management in a total sample of 32. Findings Include: During the medication administration observation with V4 (Licensed Practical Nurse) on 8/15/23 at 10:02 AM, R102 requested pain medication from V4. V4 did not assess the type, location, and rate of R102's pain. At 10:12 AM, V4 administered some of R102's morning medications except the pain medication R102 requested. V4 stated that the pain medication ordered for R102 was not available in the medication cart. At 10:37 AM, interviewed R102 and stated that V4 has not given R102 the pain medication R102 requested. R102 stated that R102's pain is at 8 out of 10. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure for Psychotropic Medication Program and ensure that a gradual dose reduction (GDR) was attempted for a resident receiving antipsychotic medication. This failure has the potential to affect 1 (R42) of 5 residents reviewed for psychotropic medications in a total sample of 32. Findings Include: On 8/17/23 at 9:28 AM, reviewed R42's Medication Administration Record (MAR) for August 2023 and revealed R42 was receiving antipsychotic medication SEROquel Oral Tablet (Quetiapine Fumarate) Give 12.5 mg by mouth in the morning related to ADJUSTMENT DISORDER WITH ANXIETY (F43.22) AND Give 12.5 mg by mouth in the evening related to ADJUSTMENT DISORDER WITH ANXIETY (F43.22). [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy of dating opened boxes of food, and canned goods, in the refrigerator, freezer, and pantry. This had the potential to affect all 171 resident who reside at the facility.

Inspectors wroteBased on observation, interview and record review, facility failed to follow their call light policy to ensure call lights are placed within reach for 5 (R331, R15, R88, R108, R160) residents reviewed for call lights in a final sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy's on Physician's Orders and Weighing of residents, for 4 residents (R28, R43, R134 and R122) reviewed for quality of care. Findings Include: On 6/22/22 at 10:20 AM during record review of R28, R43, R134 and R122. Residents noted with physicians orders for bi-weekly weights to be done on Tuesday and Friday. Record review showed from the date order was placed on 2/16/22, for R28, R43, R134, R122, recordings to the electronic medical record inconsistent to said order, noted multiple weights not recorded. R28 was admitted to facility on 8/14/20; with a diagnosis, not limited to, Congestive Heart Failure (CHF). One weight recorded on 6/3/22, up to date of survey entrance of 6/21/22. One weight recorded on 5/5/22, no other weights recorded for May. R43 was admitted to facility on 3/15/21; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to a.) ensure medications were not pre-poured during one medication pass, b.) ensure expired medications were removed from the medication cart c.) ensure items other than medications were not stored in the medication refrigerator and d.) ensure the temperature was monitored in one of 2 medication refrigerators during the Medication Labeling and Storage and the Medication Administration observation. Findings Include: R55 has diagnosis not limited to Type 2 Diabetes Mellitus, Dementia and Mild Protein-Calorie Malnutrition. Order Summary Report dated 06/22/22 document in part: Lantus Solution 100 UNIT/ML (Milliliter) inject 6 units at bedtime. Medication Administration Record dated 06/01/22 - 06/30/22 document in part: R55 received Lantus Solution 100 UNIT/ML (Milliliter) inject 6 units 5 times from 06/16/22 - 06/21/22. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper infection control practices were performed to prevent cross contamination when using blood glucose testing supplies. This deficient practice has the potential to affect 8 residents (R3, R50, R55, R61, R75, R79, R127, R162) receiving blood glucose monitoring on the 4th floor. The facility also failed to follow policy related to urinary catheter care by placing a urinary catheter bag directly on the floor for 1 (R177) of 4 residents with history of urinary tract infection (UTI) in a sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy on immunization protocol and failed to provide documentation on the educational component on why the influenza and the pneumococcal vaccines are important for the elderly or immunocompromised residents for 6 residents (R37, R40, R57, R83, R332 and R433) reviewed for vaccines in the sample of 24 residents.

Inspectors wroteBased on observation, interview and record review, facility failed to follow their policy to maintain a resident's dignity by placing a Foley catheter drainage bag in a drainage cover for 1 (R83) resident out of 3 residents reviewed for Foley catheter care in a sample of 24. The facility also failed to provide privacy during an insulin injection for 1 (R125) of 7 (R63, R78, R91, R121, R163, R171) residents reviewed during medication administration.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was self-administering medication had a physician's order, self-administration of medications assessment and a care plan completed. This failure has the potential to affect 1 resident (R91) for taking medication without supervision. Findings Include: R91 was readmitted to the facility 05/26/21 with diagnosis not limited to Unspecified Dementia, Mild Cognitive Impairment, Unspecified Glaucoma, Altered Mental Status and Post Traumatic Stress Disorder. Order Summary Report dated 06/23/22 document in part: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide tube feedings as ordered for 1 (R108) of 2 (R41) residents reviewed for tube feeding. R108 has diagnosis not limited to Encounter for Attention to Gastrostomy, Cognitive Communication Deficit, Dysphagia, Cerebral Infarction and Gastritis. On 06/21/22 10:55 AM R108 was observed in bed in a semi-Fowler_position with the Enteral feeding infusing at 65 ml/hr (Milliliter/hour) per pump amount delivered 29 ml. On 06/21/22 at 11:42 AM V5 (Licensed Practical Nurse) entered R108 room with the surveyor. V5 stated R108 enteral feeding infuses at 65 ml/hr from 06:00 AM - 12:00 midnight. R108 enteral feeding pump was observed to be turned off. V5 stated I had to hang another bottle at 10:00 AM. I don't know who turned it off. It may have been a Certified Nurse Assistant. R108 Physician Orders document in part: [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to develop a person-centered dementia care plan for 1 (R103) out of 1 resident reviewed for dementia care in a sample of 34 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all medications were administered without an error rate of 5% or more. for 3 of 7 residents (R121,R163, R125) During Medication administration on 06/22/22 the surveyor observed 3 nurses administer medication to 7 residents. There were 25 opportunities for error and 5 errors were observed. This deficient practice resulted in a medication administration error rate of 20%. Findings Include: 1. R121 has diagnosis not limited to Essential (Primary) Hypertension, Vitamin D Deficiency, Heart Failure, Dementia, Syncope and Collapse. Order Summary Report dated 06/22/22 document in part: Aspirin Tablet Chewable 81 MG by mouth in the morning and Cholecalciferol Tablet Give 2000 unit by mouth in the Morning. On 06/22/22 at 08:49 AM V15 (Registered Nurse) was observed preparing R121 medications. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was free from a significant medication error related to insulin administration for 1 (R125) of 7 residents reviewed for medication administration. Findings Include: R125 has Diagnosis not limited to Chronic Kidney Disease, Cerebral Infarction, Type 2 Diabetes Mellitus, Cognitive Communication Deficit and Major Depressive Disorder. Order Summary Report dated 06/22/22 document in part: Novolog Flex Pen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 15 unit subcutaneously with meals and Novolog Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 201 - 250 = 3; 251 - 300 = 5; 301 - 350 = 8; 351 - 400 = 10 Greater than 400 mg/dL. Give highest dose and call MD., subcutaneously with Meals. Medication Administration Record dated 06/01/22 - 06/30/22 document in part: [...]