Rivertown Health and Rehabilitation Center

Based on interviews, record review, and facility policy review, the facility failed to report two injuries of unknown origin to the state survey agency for one (Resident #1) of three residents reviewed for abuse. Findings included: Review of a facility policy titled, Accidents and Incidents - Investigation and Reporting, revised 07/2017, indicated, .All accidents and incidents involving residents, employees, visitors, vendors, etc. occurring on our premises shall be investigated and reported to the administrator . Review of a facility policy titled, Abuse, Neglect, and Exploitation, with an implementation date of 08/25/2023, indicated under the IV. Identification of Abuse, Neglect and Exploitation section that possible indicators of abuse included but were not limited to: 3. Physical injury of a resident, of unknown source. The policy further indicated under the VII. Reporting/Response section that A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required…

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

Based on interviews, record review, and facility policy review, the facility failed to thoroughly investigate two injuries of unknown origin for one (Resident #1) of three residents reviewed for abuse. Findings included: Review of a facility policy titled, Accidents and Incidents - Investigation and Reporting, revised 07/2017, indicated, .All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator . Review of a facility policy titled, Abuse, Neglect, and Exploitation, with an implementation date of 08/25/2023, indicated under the IV. Identification of Abuse, Neglect and Exploitation section that possible indicators of abuse included but were not limited to: 3. Physical injury of a resident, of unknown source. The policy further indicated, V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Part of the written procedures for…

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 observations, interview, and record review, it was determined the facility failed to develop and implement care plan interventions to address a resident removing their wander monitoring bracelet for one (Resident #2) of three sampled residents reviewed for elopement risk. Findings included: A review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy further indicated, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . A review of Resident #2's admission Record revealed the facility admitted the resident on 03/16/2022 with diagnoses that included Paranoid Schizophrenia, Dementia, Mood Disorder, and Metabolic Encephalopathy (a condition in which the brain function is disturbed either temporarily or permanently due to…

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 reviews, interviews, and facility document review, the facility failed to ensure medical records were readily available and retained for two (Resident #3 and Resident #14) of six residents sampled as closed records. Findings included: During an interview on [DATE] at 9:35 AM, the [NAME] President (VP) of Clinical Operations stated the facility's new owner was on the way to the facility, and she would have him reach out to the previous owners for resident records. During a follow-up interview on [DATE] at 10:10 AM, the VP of Clinical Operations provided a copy of a contract with the facility's electronic health record (EHR) company indicating the current owners would only be able to access records for residents that were on the census as of [DATE]. A review of a Data Copy Authorization for Acquisitions and Transfers of Data between Entities, signed by the facility's previous owner on [DATE], confirmed the previous owner instructed the EHR company to only provide resident records to the current…

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 the 2017 Food Code of the United States (U.S.) Public Health Service and U.S. Food and Drug Administration (FDA); the facility failed to prevent the potential for cross-contamination by: 1.) storing a 50-pound bag of sugar directly on the floor, 2.) running ceiling fans with heavy dust build-up on the blades in the dishwashing area, and 3.) allowing the drain from the dishmachine to extend down into the floor drain. This had the potential to affect 95 of 95 residents receiving meals from the kitchen. Findings Include: 1.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm [centimeters] (6 inches) above the floor. During the initial tour of the kitchen on 01/08/2023 at 11:20 AM, an unopened, 50-pound bag of sugar was observed sitting directly on the floor of the Dry Storage Room. A delivery label…

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 the 2017 Food Code of the United States (U.S.) Public Health Service and U.S. Food and Drug Administration (FDA); the facility failed to ensure the dumpsters were kept closed and there was not discarded equipment and food-related litter around the dumpsters to attract vermin on 01/08/2023 and 01/09/2023. This had the potential to affect 98 of 98 residents residing in the facility. Findings Include: A review of the 2017 Food Code of the U.S. Public Health Service and the FDA revealed the following: . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE . used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and . under the unit. 5-501.113 Covering Receptacles. Receptacles and waste handling units for…

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

Based on interview, record review, and review of facility Quality Assurance and Performance Improvement Process (QAPI) meeting attendance records, the facility failed to ensure the QAPI committee was composed of the required committee members. Specifically, the facility failed to provide evidence that the Infection Preventionist (IP) participated as a required QAPI committee member. This deficient practice had the potential to affect all 98 residents residing in the facility. Findings Include: Review of the facility's QAPI Meeting sign-in sheets dated 05/2022, 6/2022, 7/2022, 8/2022, 9/2022, 11/2022, and 12/2022 revealed an IP had not signed as present during the meetings. In an interview on 01/11/2023 at 4:17 PM, Employee Identifier (EI #1), Administrator, stated the facility's Infection Preventionist left in April 2022. EI #1 stated EI #8, Registered Nurse (RN)/ Regional Infection Control has been the facility's interim IP. EI #1 said, the members of the QAPI committee were herself, the DON, the medical director, the social worker, the MDS Coordinator, Dietary, and the Business…

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 observations, interviews, review of the Maintenance Supervisor's Job Description and review of a facility document titled, Quality of Life - Homelike Environment, the facility failed to ensure Room Locators (RL) #1-9, were not found in need of repair. This affected nine RLs out of 78 RLs observed. Findings Include: An undated and unsigned facility Job Description for the Maintenance Supervisor documented: . SUMMARY Responsible and accountable for maintaining physical plant and essential mechanical, electrical, and resident care equipment in safe operating condition. ESSENTIAL DUTIES AND RESPONSIBILITIES . Maintenance and beautification of facility and grounds. Review of a facility policy with a revised date of May 2017, titled Quality of Life - Homelike Environment revealed: Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment . On 01/08/2023 at 11:44 AM, RL #3 was observed with paint scraped from the wall. On 01/09/2023 at 8:29 AM, RL #2 was observed with paint scraped from the wall behind the bed. On 01/09/2023 at 12:08 PM, RL…

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, interviews, record review, and review of Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #88's Minimum Data Set (MDS) assessments dated 12/21/2021, 05/31/2022, and 06/25/2022 were accurately coded to reflect RI #88 as a current tobacco user. This deficient practice had the potential to affect RI #88, one of 24 sampled residents for whom MDS assessments were reviewed. Findings Include: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, revealed: . SECTION J: HEALTH CONDITIONS . J1300: Current Tobacco Use . RI #88 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #88's comprehensive care plans included a care plan, initiated 12/24/2021, identifying RI #88 as a smoker. On 01/10/2023 at 7:48 AM, the surveyor reviewed RI #88's comprehensive MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of Resident Identifier (RI) #24's and #14's medical record including the PASRR (Pre-admission Screening and Resident Review) Screening & Results, and the facility policy titled, admission Criteria (used as their guidance for the pre-admission screening process), the facility failed to ensure a valid Level 1 PASRR was completed for RI #24 and RI #14. This had the potential to affect RI #24 and #14, two of ten residents whose Pre-admission Screening and Resident Reviews (PASRR) were reviewed for completion. Findings Include: The facility policy titled, admission Criteria with a revision date of December 2016, revealed, Policy Statement Our facility will admit only those residents whose medical and nursing care needs can be met. 1. The objectives of our admission criteria policy are to: a. provide uniform criteria for admitting residents to the facility; b. admit residents who can be cared for adequately by the facility; . 6. Residents will be admitted to this facility if their nursing…

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 2.) RI #7 was admitted to the facility on [DATE] and readmitted [DATE] and had diagnoses that included Vascular Dementia and Dysphagia. Review of RI #7's physician orders revealed an order dated 10/24/2022 for a regular diet, puree texture, thin consistency, one time per day at lunch. RI #7 also had an order dated 01/08/2023 for enteral feeding every shift for nutrition with Isosource 1.5 at 50 cc/hr (cubic centimeters/hour) via Kangaroo Pump. Review of RI #7's care plan revealed a care plan with an initiation date of 10/24/2022 for being fed by tube, but there was not a plan of care for RI #7 receiving a regular diet, puree texture, thin consistency, one time per day at lunch. On 01/10/2023 at 12:39 PM, RI #7 was observed being assisted with a pureed texture lunch tray. In an interview on 01/11/2023 at 9:35 AM, EI #7, MDS Coordinator, stated RI #7 received nutrient intake by PEG (Percutaneous Endoscopic Gastrostomy) tube feeding and a PO (per os/by mouth) diet. EI #7 stated the concern with the care plan not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of a facility policy titled, Enteral Feedings - Safety Precautions, the facility failed to ensure the Enteral Nutrition provided to Resident Identifier (RI) #3 and RI #71 were labeled appropriately on 01/08/2023. This had the potential to affect RI #3 and RI #71, two of six residents who received Enteral Nutrition. Findings Include: A facility policy titled, Enteral Feedings - Safety Precautions with a revision date of November 2018, documented, . Purpose To ensure the safe administration of enteral nutrition. Preparation 1. All personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. 2. The facility will remain current in and follow accepted best practices in enteral nutrition. General Guidelines . Preventing errors in administration 1. Check the enteral nutrition label against the order before administration. Check the following information: a. Resident name,…

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, resident record reviews, interviews, and review of a facility policy titled Administering Medications, the facility failed to ensure Resident Identifier (RI) #54 and RI #48 received 9:00 AM scheduled medication within the time frame of one hour before or one hour after the scheduled time on 01/08/2023. This had the potential to affect two of the six residents observed for medication pass. Findings Include: A review of a facility policy titled, Administering Medications with a revised date of December 2013 revealed, Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within (1) one hour of their prescribed time, . Review of an undated facility document titled Medication Pass Observation-Skills Test revealed, OBSERVATION . Medication is administered at correct time (1…

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, interviews and review of a facility policy Perineal Care, the facility failed to ensure a Certified Nursing Assistant (CNA) changed her gloves and performed hand hygiene before applying a clean brief during incontinent care for Resident Identifier (RI) #17. This was observed on 01/10/2023 and had the potential to affect RI #17, one of two residents observed for incontinent care. Findings Include: A review of a facility policy titled Perineal Care with a revised date of February 2018 revealed, Purpose The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Steps in the Procedure . 7. Put on gloves . b. Wash perineal area . (5) discard soiled gloves, wash hands and re-glove. e. wash the rectal area . g. Discard soiled gloves, wash hands and re-glove. h. Apply clean brief. RI #17 was admitted to the facility on [DATE] and had diagnoses of Hemiplegia and Hemiparesis following…

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 observations and interviews, the facility failed to ensure that each bed having ceiling suspended curtains, extended around the bed to provide total visual privacy, in combination with adjacent walls and curtains, in Room Locators (RL) #1, #3, and #7. This affected three of 39 semi-private rooms at the facility. Findings Include: On 01/11/2023 beginning at 10:48 AM, the following observations were made with Employee Identifier (EI) #4, Maintenance Director from a sister facility: - RL #1's privacy curtain was observed by the surveyor and appeared too short for the track for Bed A. EI #4 was asked to check the privacy curtain. EI #4 pulled the privacy curtain and said the privacy curtain was about two and a half feet too short. - RL #3's privacy curtain was observed by the surveyor and appeared too short for the track for Bed A. EI #4 was asked to check the length of the curtains for both A and B beds. EI#4 pulled the privacy curtain and said it was over a foot short for A bed and about three feet too short for B bed. - RL #7's privacy curtain was observed by the surveyor…

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

Based on record review, interviews, review of a facility policy titled Comprehensive Assessments and the Care Delivery Process, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, the facility failed to ensure Comprehensive Minimal Data Sets (MDS) assessments for Resident Identifiers (RI) #9, 14, 15, 49, 109, 112, and 257 were completed timely. This affected seven of seven Comprehensive MDS assessments reviewed for completion. Findings Included: A review of a facility policy titled Comprehensive Assessments and the Care Delivery Process, with a revised date of December 2016 revealed: . Assessment and information . (2) Complete the Minimum Data Set within 14 days after admission, . and annually. A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1, with a date of October 2019 revealed: . Chapter Two: Assessments for the RAI . RAI . required Assessment Summary . admission (Comprehensive) . MDS…

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

Based on interviews, record review, review of a facility policy titled MDS (Minimum Data Set) Completion and Submission Timeframes, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, the facility failed to ensure Resident Identifier (RI) # 1, 3, 5, 6, 7, 8, 16,17, 18, 20, 21, 24, 25, 26, 40, 45, 46, and 47's Quarterly MDS assessments were completed. This affected 18 of 18 residents who were reviewed for timely completion of Quarterly MDS assessments. Findings Include: A review of facility policy titled MDS Completion and Submission Timeframes with a revised date of July 2017 revealed: Policy Statement Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument (RAI) Manual. A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment…

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

Based on observations, interviews, and review of a facility policy titled POT AND PAN WASHING, the facility failed to ensure cookwares were not sanitized improperly when a dietary aid submerged cookware in the sanitizing solution for less than one minute and then placed the cookware on a rack to air dry. This had the potential to affect 61 of 61 resident who received meals from the kitchen on 9/23/21. Findings Include: A review of an undated facility policy titled POT AND PAN WASHING revealed: . POLICY: Proper pot and pan washing procedure reduce the possibility of food contamination. The following procedures will be used: PROCEDURE: . 4. Pots and pans are sanitized in the third sink using warm water and bleach or sanitizer to provide no less than 50 PPM (parts per million) chlorine in solution for one minute. A review of the product label for the Oasis 146 Multi-Quat Sanitizer revealed: . DIRECTIONS FOR USE: . TO SANITIZE FOOD CONTACT SURFACES . Use Oasis 146 Multi-Quat Sanitizer to sanitize . food utensils, dishes . Expose all surfaces to the sanitizing solution for a period of…

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

Based on record review, interviews, a review of a facility policy titled MDS (Minimum Data Set) Completion and Submission Timeframes, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, the facility failed to ensure timely submissions of MDS assessments for Resident Identifiers (RI) #1, 6, 7, 8, 16, and 45. This affected six of nine residents who's completed MDS assessments were reviewed for timely submission. Findings Included: A review of a facility policy titled MDS Completion and Submission Timeframes with a revised date of July 2017 revealed: Policy Statement Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument (RAI) Manual. A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, review of facility policies titled Comprehensive Assessments and the Care Delivery Process and Care Plans, Comprehensive Person-Centered, the facility failed to ensure Resident Identifier (RI) #257 had Comprehensive care plans developed and implemented within 21 days of admission. This affected one of one resident who was reviewed for timely development and implementation of comprehensive care plans. Finding Include: A review of a facility policy titled Care Plans, Comprehensive Person-Centered with a revised date of December 2016 revealed: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 12. The comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment (MDS). A review of another facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review and review of a facility policy titled Wound Care, the facility failed to provide evidence wound care was provided to Resident Identifier (RI) #109's right buttocks daily as ordered by the physician. This deficient practice affected RI #109; one of three residents sampled for Pressure Ulcers. Findings Include: Review of a facility policy titled Wound Care, with a revised date of 10/2010, revealed the following: Purpose The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physician's order for this procedure. Documentation The following information should be recorded in the resident's medical record: . 4. The name and title of the individual performing the wound care. RI #109 was admitted to the facility on [DATE] and discharged from the facility on 9/14/21, with a diagnosis of Generalized Muscle Weakness. RI #109's admission Minimum Data Set assessment, with an Assessment Reference Date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of a document received from the facility titled Food Preferences, the facility failed to ensure Resident Identifier (RI) #257's dietary preferences were honored when he/she received a ham sandwich in his/her Dialysis sack lunch on 9/22/21 after the resident had pork listed as a dislike on his/her dietary preferences. This affect one of one resident whose dietary preferences were reviewed. Findings Include: An undated document received from the facility from Health Technologies, Inc. Guideline & Procedure Manual, 2016 Edition titled Food Preferences revealed: Guideline: Dining Services Department will gather information upon admission to the facility regarding resident food preferences. Procedure: 1. Following admission to the facility, and periodically as necessary, the Dining Services Manager . will interview the resident to determine foods preferred . A form such as Food Preferences Form may be used to document this information and filed in 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.