Wesley Place On Honeysuckle

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, the Long-Term Care Resident Assessment Instrument 3.0 Manual, and the facility policy titled Care Plans, Comprehensive Person-Centered, the facility failed to ensure Resident Identifier (RI) #96's Quarterly Minimum Data Set (MDS) assessment dated [DATE], was accurately coded to reflect Resident Identifier (RI) #96's behavioral symptoms. This deficient practice affected one of 51 sampled residents whose MDS was reviewed. Findings include: RI #96 was admitted on [DATE] and diagnoses that included Dementia, Moderate with Mood Disturbance, Alzheimer's Disease Late Onset. A review of facility policy titled Comprehensive Assessments with a Revised date of 03/2022 documented, Policy Interpretation and Implementation 1. Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual . Section E0200: Behavioral Symptoms of the Long-Term Care Resident Assessment Instrument 3.0 Manual which is also…

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, record review and review of a facility policy titled, Care Plans -Baseline, the facility failed to ensure Resident Identifier (RI) #196's and RI #198's baseline care plans addressed the use of their Continuous Positive Airway Pressure (CPAP) machines. This deficient practice affected RI #196 and RI #198, two of six sampled residents whose baseline care plans were reviewed. Findings include: A review of a facility policy titled, Care Plans-Baseline, with a revised date of 03/2022, revealed the following: . Policy Interpretation and Implementation 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: . b. Physician orders . 4. c. Any services and treatments to be administered by the facility . RI #196 was originally admitted to 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 observations, interviews, record review and review of facility policies titled, Crushing Medications, Administering Medications, and Gastrostomy/Jejunostomy Site Care, the facility failed to ensure: 1) Resident Identifier (RI) #3 had a crush order to crush his/her Clonazepam 1 mg (milligram) tablet, and 2) RI #40's PEG (Percutaneous Gastrostomy) site was cleaned with peroxide as ordered by the physician. These deficient practices affected RI #3, one of six residents observed during the medication pass administration; and RI #40, one of one resident whose PEG site care was observed. Finding include: 1) RI #3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of Epilepsy and Dysphasia. A facility policy titled, Crushing Medications, with a revised date of 04/2018, included the following: Policy Statement Medications shall be crushed only when it is . consistent with physician orders. Policy Interpretation and Implementation . 3. In addition, the following guidelines shall be…

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, record review and review of a facility policy titled, Medication Labeling and Storage, the facility to ensure: 1) Resident Identifier (RI) #395's vial of 70/30 insulin was labeled correctly; and 2) an expired bottle of Enteric Coated (EC) Aspirin (ASA) was not left on the medication cart on the Rehab unit. These deficient practices affected RI #395, and had the potential to affect all resident with orders for EC ASA on the Rehab unit. Findings include: Review of a facility policy titled, Medication Labeling and Storage, with a revised date of 02/2023, revealed the following: . Policy Interpretation and Implementation .6. Medications . are labeled accordingly . Medication Labeling . 2. The medication label includes,at a minimum: . 2. d. expiration date, when applicable; e. resident's name . 5. vials that have been opened or accessed (e.g. [for example] needle punctured) are dated and discharged within 28 days . 1) RI #395 was admitted to the facility on [DATE] with a diagnosis…

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, record review, review of facility policies titled, Handwashing/Hand Hygiene and Gastrostomy/Jejunostomy Site Care, and review of guidelines from CDC's (Center for Medicare and Medicare) Core Infection and Prevention and Control Practices for Safe Healthcare in All Settings, the facility failed to ensure: 1) Certified Nursing Assistant (CNA) #19 removed her mask before exiting a resident on Droplet Precautions's room, Resident Identifier (RI) #53, 2) Licensed Practical Nurse (LPN) #3 changed her gloves and sanitized her hands while performing gastrostomy site care on RI #40; and 3) Registered Nurse (RN) #4 did not use her gloved finger to pack foam into RI #295's wound during wound care. Further RN #4 used her ungloved hands and hand sanitizer to clean RI #295's. These deficient practices affected three of 51 sampled residents. Findings include: Review of undated guidelines for CDC's Core Infection and Prevention and Control Practices for Safe Healthcare in All Settings,…

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 I. Based on observations, interviews and a review of a facility policy titled, Serving & Storage of Food and a document titled, IN-USE UTENSILS, the facility failed to ensure: 1) Cream of wheat in the dry storage room was sealed; 2) Ham in the refrigerator was labeled and; 3) A scoop was not on laying top of the flour in the flour bin. This had the potential to affect 60 of 60 resident who received meals from the kitchen. II. Based on the facility policies titled, Food Received from the Main Kitchen and Food Preparation, the facility further failed to ensure the facility homemakers serving and plating food for meals on the units: 1. completely contained their hair in hair nets; 2. did not use the same gloves to handle food and non food items; 3. did not use hand sanitizer between glove changes while handling food; 4. did not hold an item removed from the refrigerator against her uniform; 5. did not lay a tong on top of the fries, then with the same gloves on handle non food items and then touched the tongs again…

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 review of a facility policy Quality of Life - Dignity the facility failed to ensure Resident Identifier (RI) #11 received the supper meal on 8/27/18 and was fed the same time the roommate was fed. This was observed on 8/27/18 and affected one of two residents observed for meals. Findings Include: A review of a facility policy Quality of Life -Dignity with a revised date of August 2009 revealed: Policy Statement Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. RI #11 was admitted to the facility 1/22/15 with a diagnosis of Dementia. A review of a Quarterly Minimal Data Set with an Assessment Reference Date of 5/31/18 revealed RI #11 was totally dependant for eating. On 8/27/18 at 5:01 PM the surveyor observed the supper meal served to the roommate who required to be fed. On 8/27/18 at 5:40 PM the surveyor observed staff take a tray in to RI #11's room and begin to feed the resident. On 8/28/18 at 4:05 PM, an interview was conducted with Employee Identifier (EI) #13,…

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 review of a facility policy titled, Housekeeping, Cleaning & Laundry, the facility failed to ensure: 1) Resident Identifier(RI) #85's room was clean and free of crumbs, the carpet was not wet and the bathroom was clean and 2) the 600 Hall was free of a urine odor. This was observed on four days of the survey and affected RI #85 and the 600 Hall. Findings Include: A review of a facility policy Housekeeping, Cleaning & Laundry, no date, revealed .II. P.M. Homemaker Duty List The P.M. Homemaker will accomplish daily the following day shift cleaning duties.Clean resident rooms. 1) RI #85 was admitted to the facility 2/17/17 with a diagnosis of Urinary Tract Infection. On 8/28/18 at 10:13 AM, during a brief family interview there was concerns voiced about RI #85's room and dirty bathroom. The surveyor observed crumbs on the carpet next to the bed and near the chair. The carpet was also noted wet and stained and the bathroom had trash on the floor. The isolation trash bin was noted full with the lid not completely closed due to trash above the rim. On…

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

Based on observation, interview, record review and review of a facility policy titled, Perineal Care of Incontinent Residents, the facility failed to ensure a Certified Nursing Assistant (CNA) performing incontinent care for RI # 85 did not 1. change gloves without washing her hands before applying clean gloves, and 2. did not remove a soiled pad then with same dirty gloves place a clean bed pad. This was observed on 8/29/18 and affected one of two residents observed for incontinent care. Findings Include: A review of a facility policy titled, Perineal Care of Incontinent Residents, no date, revealed .Procedure: .5. Wash your hands .11. Put on clean gloves.15 a.wash . b. rinse .20.put soiled linens in a bag. 21. Remove gloves and discard. PUT ON NEW GLOVES .22. Apply clean undergarments, diaper or underpad. RI #85 was admitted to the facility 2/17/17 with a diagnosis of Urinary Tract Infection. A review of a facility lab report revealed: .8/17/18 .Bacteriology .Source : .Urine .Final Report .Confirmed Extended Spectrum Beta-Lactamase (ESBL) organism . On 8/29/18 at 9:17 AM, Employee…

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 review of a facility policy Security of Medication Cart, the facility failed to ensure a licensed staff did not leave the medication cart unlocked as she walked away from it. This was observed on 8/27/18 and affected one of six nurses observed for medication pass. Findings Include: A review of a facility policy titled, Security of Medication Cart, with a revised date of April 2007 revealed, Policy Statement The medication cart shall be secured during medication passes. Policy Interpretation and Implementation .4. Medication carts must be securely locked at all times when out of the nurse's view. On 8/27/18 at 4:00 PM, the surveyor observed Employee Identifier (EI) #2, Licensed Practical Nurse passing medication. EI #2 was in the medication cart then left the cart and went to a resident's room. EI #2 did not lock the medication cart. Once EI #2 got to the the resident's room she realized she had forgot something and returned to the medication cart. She then realized she had not locked it before leaving it. On 8/27/18 at 4:40 PM an interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of a facility policy titled, Perineal Care of Incontinent Residents, the facility failed to ensure a Certified Nursing Assistant(CNA) did not place a soiled brief on the floor and did not touch a clean brief and clean clothing with the same soiled gloves she had on during the provision of incontinent care for Resident Identifier (RI) #10. This was observed on 8/28/18 and affected one of two residents observed for incontinent care. Findings Include: A review of a facility policy Perineal Care of Incontinent Residents revealed: .Procedure: .11. Put on clean gloves. 20.put soiled linens in a plastic bag. 21. Remove gloves and discard. PUT ON NEW GLOVES before continuing with care. 22. Apply clean undergarments, diaper or underpad. RI #10 was admitted to the facility on [DATE] with a diagnosis of Vascular Dementia. On 8/28/18 at 11:10 AM, Employee Identifier (EI) #5, CNA was observed performing incontinent care for RI #10. EI #5 put on clean gloves and carried out 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.