White River Healthcare

Through observation, interviews, and policy review, the facility failed to ensure that equipment was in a clean, safe, useable condition and food was stored in a safe and sanitary manner. The findings are: During an observation on 11/19/2024 at 6:20AM, 20 small bowls were placed in a pan on the steam table serving side up without a covering. During an observation on 11/19/2024 at 6:32AM, Refrigerator #2 ' s left, and right door seals held a brownish color with dark brown and black spots along the inside seals. During an observation on 11/19/2024 at 6:33AM, Refrigerator #3 ' s left, and right door seals held a brownish color with dark brown and black spots along the inside seals. The seal contained a purplish discoloration of the seal. During an interview on 11/19/2024 at 6:34AM, the Dietary Manager stated the purplish discoloration was from chemicals used to clean the seals of the brownish color with the dark brown and black spots. Cleaning was unable to remove the unknown substance. The seals look dirty, like there is mold on the seals. The concern is cross contamination from 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.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure proper hand hygiene was performed between residents, failed to ensure cleaning of personal equipment (fan) to prevent contamination and failed to ensure Enhanced Barrier Precautions (EBP) were followed for a tube fed resident (Resident #7) of 1 resident reviewed for infection prevention and control. Findings include: A review of a facility policy titled, Handwashing/Hand Hygiene, revised in August 2019, indicated the primary purpose of hand hygiene was to prevent the spread of infections and that all personnel will follow the hand hygiene procedures to help prevent the spread of infections to others. A review of a facility policy titled Policies and Practices-Infection Control, revised in October, 2018, indicated the objectives for infection control policies were to maintain a safe, sanitary and comfortable environment; prevent, detect and investigate and control infections; implementing isolation precautions when necessary;…

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 record interview, it was determined that the facility failed to notify the resident/representative or Power of Attorney (POA) in writing of the resident's transfer/discharge to the hospital as required for Resident #5 of 1 resident reviewed for the process of notification at time of transfer/discharge. Findings include: A review of a facility policy titled, Transfer or Discharge Notice, revised in December 2016, made no indication of notifying the resident/representative or POA. The policy indicated that a written notice would be sent in the event of an impending transfer or discharge within 30 days. A review of Resident #5 ' s admission Record, indicated the facility admitted Resident #5 with diagnoses that included congestive heart failure, atrial fibrillation, stage 3 chronic kidney disease and a personal history of urinary tract infections. Review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/06/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated Resident #5 had…

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 interview, it was determined that the facility failed to notify resident representatives or Power of Attorney (POA) in writing of the bed hold policy upon a resident's transfer to the hospital and/or discharge as required for 1 (Resident #5) of 1 resident reviewed for bed hold notification. Findings include: A review of a facility policy titled, Transfer or Discharge Notice, revised in December 2016 made no indication of notifying the resident/representative or POA. The policy indicated that a written notice would be sent in the event of an impending transfer or discharge within 30 days. A review of Resident #5 ' sadmission Record, indicated the facility admitted Resident #5 with diagnoses that included congestive heart failure, atrial fibrillation, stage 3 chronic kidney disease, and a personal history of urinary tract infections. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/06/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated Resident #5 had severe cognitive…

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.

Through observation, record review, and interview, the facility failed to ensure one of one resident sampled (Resident #31) environment remained free of accident hazards as was possible. The findings are: Record review of quarterly Minimum Data Set with an Assessment Reference Date of 09/10/2024, revealed for Section C, Cognitive Patterns, Resident #31 showed a Brief Interview for Mental Status of 15. Record review of Resident # 31 ' s admission Record showed two Power of Attorneys for Care Conference. Record review of a Care Plan dated 9/10/2024, did not have documentation to support Resident # 31 to self-administer medicine. During an observation on 11/18/2024 at 11:05AM, in Resident # 31 ' s room a bottle of nasal spray was on rolling bedside table, while cough drops and wound cleanser were on the dresser. During an interview on 11/18/2024 at 11:09AM, LPN #1 confirmed wound cleanser should not be in Resident # 31 ' s room. LPN #1 stated she did not know where the nose spray or cough drops came from and should not be in Resident # 31 ' s room either. During an interview 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.

Through investigation and record review the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. The findings are: During an investigation on 11/19/2024 at 7:43AM, the Dietary Manager confirmed classes have not been started for dietary certification. During an investigation on 11/21/2024 at 9:02AM, the Administrator confirmed the Dietary Manager took position on 12/31/2022. Facility was working on Dietary Manager to be enrolled in a program, paperwork had not been finished. Review of an email dated 08/8/2024 at 7:00AM, from Dietary Consultant provided a list of online programs to the Dietary Manager and the Administrator.

Through record review, interviews and policy of arbitration agreement the facility failed to ensure that four of four residents sampled for arbitration agreements (Resident #7, #13,#16 and #22) or representative were clearly informed that arbitration is to be a neutral site that both parties agree to The findings are: Review of arbitration agreements signed by Resident #7, Resident #13, Resident #16, and Resident #22 with the current arbitration agreement in use, failed to provide the resident or the resident's representative notice of the fact that both parties must agree to a neutral place. During an interview on 11/20/24 at 1:30PM, the Social Director confirmed there was not anything about a neutral meeting place stated in the contracts. During an interview on 11/20/24 at 1:47PM, the Administrator stated the facility may have left something out.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Activities of Daily Living were maintained to prevent the potential for injury, infection, and to promote personal hygiene and sense of wellbeing for 3 sampled residents (Resident #15, #22, and #25). This failed practice had the potential to affect 6 case mix residents from halls 100 and 200 dependent for ADL/Nail Care based on a list provided by the Director of Nursing (DON) on 11/8/23 at 11:45 AM. The findings are: 1. Resident #15 had diagnoses of flaccid hemiplegia affecting left nondominant side, cerebral infarction due to embolism of left middle cerebral artery, dysphagia following cerebral infarction, and other specified diabetes mellitus with diabetic neuropathy, unspecified. A Minimum Data Set (MDS) with an assessment review date of 8/24/23 documented a Staff Assessment for Mental Status (SAMS) for, Cognitive skills for daily decision making Severely Impaired requiring extensive assistance with 2- person physical support 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure that standard and transmission-based precautions of sanitizing, handwashing, and or donning gloves between residents during morning medication pass were followed to prevent the possible spread of infections. This failed practice had the potential to affect 26 residents administered medications during morning medication pass based on a list provided by the Director of Nursing on 11/9/23 at 915 AM. The findings are: 1. On 11/08/23 at 8:05 AM, the Surveyor observed Licensed Practical Nurse (LPN) #1 standing at the medication cart in hall 200. The LPN #1 had prepared by mouth and liquid medications that were sitting on top of medication cart. The Surveyor accompanied LPN #1 into room [ROOM NUMBER] and observed medication administration of medications and leave the room without washing hands or sanitizing. 2. On 11/08/23 at 8:11 AM, LPN #1 prepared medications in hallway 100 at the medication cart for the resident in room [ROOM NUMBER]-A without…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a Surety Bond was current and up to date, to assure the security of all personal funds in the resident trust funds to prevent financial loss. The failed practice had the potential to affect the 40 residents who had a trust fund account managed by the facility according to a list provided by the Business Office Manager [BOM] on [DATE] at 10:10 am. The finding are: 1. On [DATE] at 10:10 am, a review of Trust - Current Account Balance dated [DATE] showed an ending balance of $18,101.16. 2. A Surety Bond provided by [Company Name] provided by the BOM on [DATE] at 10:10 am. The document had an original effective date of [DATE] and was issued by [Company Name] as Surety, in the amount for $35,000. The bond documented .In witness whereof, the said [SURETY COMPANY] has caused these presents to be execute by .with the corporate seal affixed this 19th day of [DATE]. The Rider attached documented .This rider became effective on the 19th day of July, 2019 .…

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

Based on observation, interview and record review the facility failed to develop and implement a comprehensive care plan to address the need for oxygen for 1 (Resident #20) sampled resident. The findings are: Resident #20 had a diagnosis [dx] of congestive heart failure. On admission MDS with Assessment Reference Date [ARD] 8/22/23. a. Review of the resident's care plan on 11/07/23 at 3:13 pm did not address the potential need for oxygen as identified in the physician's order dated 10/31/23. b. Review of the physician order dated 10/31/23 showed resident #20 to have oxygen at 2 liters as needed to maintain oxygen saturation above 90%. b. On 11/08/23 at 10:45 AM, the surveyor Interviewed Licensed Practical Nurse (LPN #1). Surveyor asked what the order was for resident's oxygen. LPN#1 answered, The resident physician order is for 2 liters per minute. c. During interview on 11/09/23 at 1:59 PM, the MDS Coordinator reported that they are responsible for completing the MDS and the care plans for the residents in LTC. MDS Coordinator was asked what the possible complications are of 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, interview and record review the facility failed to ensure that physicians orders were followed for oxygen flow rates for 2 sampled residents (Resident #20 and #22) receiving oxygen therapy. This failed practice had the potential to affect 3 sampled residents on halls 100 and 200 based on a list of residents with orders for oxygen therapy provided by the Director of Nursing (DON) on 11/8/23 at 11:45 AM. The Findings are: 1. Resident #20 had diagnoses of chronic combined systolic (congestive) and diastolic (congestive) heart failure. A Minimum Data Set (MDS) dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 9 (8-12 moderate cognitive impairment) requiring extensive assistance with toileting with 1-person physical assist, and minimum assistance for bed mobility and transfers with 1-person physical assist and support. a. A Care Plan initiated 8/22/23 documented no oxygen/respiratory status goals or interventions. b. A Physician's order dated 10/31/23 documented, PRN…

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

Based on observation and interview the facility failed to ensure dishware is stored in a clean location, not exposed to dust, dietary equipment is cleaned and maintained in good working condition, and nutritional supplements are dated with a use by date in the nourishment refrigerator to minimize the potential for food borne illness for residents who receive meals from the kitchen. The failed practice had the potential to affect 49 residents who receive meals from the kitchen and nourishment room refrigerator as documented on a list provided by the Director of Nursing (DON) on 8/11/22. The findings are: a. On 08/08/22 at 10:48 AM, there were fuzzy translucent particles on the wall behind a rack with disposable foam cups, and clean plastic coffee mugs stored on it. b. On 08/08/22 at 10:50 AM, the hood vents above the stoves were covered with gritty, brownish buildup. The Surveyor asked the Dietary Manager to turn on the hood lights. She said, They don't work. The sticker posted on the hood reflected the last professional cleaning was completed April 2021. The Surveyor asked 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 observation, record review and interview, the facility failed to ensure a bruise of unknown origin was investigated, reported to the Office of Long-Term Care and other state agencies in accordance with state law for 1 of 1 (Resident #6) who had bruising observed on 08/08/22 during survey initial rounds. This finding had the potential to affect all 50 Residents that reside at the facility based on the list provided by the DON (Director of Nursing) on 08/08/22. The findings are: 1. Resident #6 had diagnoses of Unspecified Dementia, Muscle Wasting and Atrophy. A Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/04/22 documented the resident scored 3 (Severely impaired) on a Staff Assessment for Mental Status (SAMS) and required extensive assistance of one to two staff for bed mobility, dressing, toileting, personal hygiene, transfers, locomotion, eating and total dependence for bathing. a. On 08/08/22 at 11:41 AM, Resident #6 was lying in bed with blanket up to chest,…

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.