Pine Bluff Transitional Care

Based on interview, the facility failed to develop and implement a facility assessment. This failed practice had the potential to affect all the residents residing in the facility. The total census was 63. The findings are: On 10/07/2024 the survey team entered the facility. The Administrator provided documents for review, but there was no facility assessment included in the information provided. On 10/11/2024 at 8:43 AM, the Nurse Consultant was informed by this surveyor the facility assessment was needed for review. The nurse consultant returned and stated he had spoken with the Administrator, and she informed him the facility did not have a facility assessment in place. On 10/14/2024 at 4:15 PM, the Administrator was interviewed and asked who was responsible for completing the facility assessment. She stated the Administrator and had no explanation why the facility assessment had not been completed. She informed this surveyor she became the Administrator at the facility on 11/23/2023. She was asked what the purpose of the facility assessment was. The following were some of the…

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

Based on record review, interview, and facility policy review, the facility failed to ensure the antibiotic stewardship program was consistently implemented for 1 (Resident #13) sampled resident who was taking an antibiotic. The findings are: On 10/11/2024 at 5:00 PM, the Nurse Consultant was interviewed and stated he had been at the facility only a few days but managed to catch up 4 months of the infection control tracking logs. He stated he would train the next Infection Preventionist once someone was hired. On 10/14/2024, the Assistant Director of Nursing (ADON) provided the antibiotic stewardship infection mapping and an Order Listing Report for June 2024, July 2024, August 2024 and September 2024. There was no information provided for October 2024. The information was reviewed and did not include a tracking log to indicate what signs/symptoms the resident had, the start date of the symptoms, if the condition required lab tests such as a urine sample/culture, and no criteria to indicate if the antibiotic was necessary. The September Order Listing Report was reviewed and…

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

Based on record review, interview, and facility policy review, the facility failed to ensure an individual was designated as the Infection Preventionist (IP), who had time to monitor and manage the infection prevention and control program. The findings are: On 10/07/2024, the survey team entered the facility. The Administrator provided a document titled Number 21, which was reviewed and indicated the facility did not have an IP. On 10/11/2024, the facility's in-service binder was reviewed and there were no in-services/trainings on any infection control topics from October 2023 to October 14, 2024. On 10/14/2024, the Assistant Director of Nursing was informed the in-service binder did not include any infection control in-services/trainings for the staff. She stated she would investigate the matter. On 10/14/2024 at 4:15 PM, the Administrator was interviewed and stated she had not designated a staff member to fill in as IP until someone was hired. An Infection Preventionist policy, dated as revised on July 2016 and provided by the Administrator on 10/07/2024, was reviewed and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, facility document review, facility policy preview, it was determined the facility failed to ensure residents were provided privacy during care provided for surgically created airway (tracheostomy/trach) care for 1 (Resident #13) of 1 sample mix resident; and to ensure collection bags for resident's indwelling catheters are kept in a privacy bag for 1 (Resident #216) of 1 sample mix residents. The findings are: 1. Review of Resident #13's admission Record revealed the resident was admitted on [DATE] with a diagnoses of tracheostomy complication. Review of Resident #13's Physician Orders, dated 4/19/2024, noted suction tracheostomy (trach) as needed (PRN), every shift, trach care once a day on Thursday, change trach ties one time a day every Thursday, trach care every 24 hours (hrs.) and PRN clean trach site with 1/2 normal saline (NS) and 1/2 Peroxide then rinse with NS and apply dry dressing daily and PRN two times a day related to tracheostomy complications.…

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, interview, facility document review, facility policy review, it was determined that the facility failed to ensure an incident of an injury of unknown source was reported to the Administrator within 2 hours of discovery, which resulted in a delay in initiating an investigation and protective measures, and in reporting to the Office of Long-Term Care (OLTC) and other agencies in accordance with state law for 2 (Resident #50 and #59) of 2 (Residents # 50, and #59) sample mix residents. The findings are: 1. Review of Resident #50's Progress Note revealed, an Incident Note dated 7/13/2024 at 6:11 PM noted the resident was found on floor with cut to forehead, referring to [hospital] for observation. Review of Resident #50's Progress Note revealed an Alert Note dated 7/14/2024 at 5:56 PM that noted [hospital] called regarding resident and stated that x-ray results from 7/13/2024 showed resident with fractured mandible bone and should be placed on soft foods diet and needs to follow up with Ears…

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, interview, facility document review, and facility policy review, it was determined the facility failed to ensure an incident of an injury of unknown origin was immediately and thoroughly investigated, failed to ensure protective measures were consistently implemented and maintained for 2 (Resident #50, and #59) of 2 sample mix resident investigated. The findings are: Review of Resident #50's Progress Notes revealed an Incident Note dated 7/13/2024 at 6:11 PM that noted the resident was found on floor with cut to forehead, referring to [hospital] for observation. Review of Resident #50's Progress Note revealed an Alert Note dated 7/14/2024 at 5:56 PM that revealed [hospital] called regarding resident and stated that x-ray results from 7-13-2024 showed resident with fractured mandible bone and should be placed on soft foods diet and needs to follow up with Ears, Nose, and Throat (ENT.) Review of Resident #50's Order Summary Report revealed an order that indicated, regular diet, mechanical…

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 facility document review and interview, it was determined the facility failed to electronically transmit encoded accurate and complete Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required time frame of 14 days to provide accurate and up-to-date information for quality measures for 2 (Residents #215, #47) of 2 sampled residents whose MDS assessments were reviewed. The findings are: On [DATE] the following reviews were made in Resident #47's health record: a. Discharge return anticipated MDS date [DATE] that was exported but not accepted. b. Entry MDS dated [DATE] that was exported but not accepted. The discharge return not anticipated MDS dated [DATE] in progress. Resident #47 discharged from the facility on [DATE] to the hospital and expired at the hospital on [DATE]. Review of Resident #47's Progress Note dated [DATE] at 11:14 AM showed, the resident was transferred to the hospital Review of Resident #47's Progress Note dated [DATE] at 9:54 AM…

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, interview, facility document review, facility policy review, it was determined that the facility failed to ensure physician's orders were followed for 1 (Resident #16) of 1 sample mix resident with a wound and orders for skin evaluations weekly; to accurately assess the quarterly Minimum Data Set (MDS) to reflect to accurate drug class for the medication Risperdal for 1 (Resident #8) or 1 sample mix residents. The findings are: Review of Resident #16's Order Summary Report dated 5/21/2024 noted a stage 3 wound to left big toe: Cleanse with wound cleanser, pat & dry, apply collagen matrix with silver to affected site, cover with dry dressing, complete nursing assessment/ body audit every week on 7 PM-7 AM shift. Review of Resident #16's Quarterly Minimum Data Set (MDS) with an Assessment Reference date of (ARD) of 08/26/2024 noted in Section M0150 the resident did not have an unhealed pressure ulcer/ injury. Section M1030 noted the resident did not have any venous or arterial ulcers. Review of Resident #16's Skin Only Evaluation dated 08/19/2024 revealed left…

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, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure the comprehensive care plan addressed individualized appropriate care and services for 4 (Resident #45, #13, #35, #21) of 4 sample mix residents reviewed for care plan. The findings are: 1. On 10/07/24 at 9:47 AM, the Surveyor observed Resident #45 lying in bed with eyes closed and unshaven with hair on their face. Review of Resident #45's Care Plan dated 5/8/2024 did not note the resident's Activities of Daily Living (ADL) requirements. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/24/2024 revealed the resident is dependent on staff for shower/bath. Review of Resident #45's shower log from 9/27/2024 through 10/12/2024 revealed the resident received a shower/bath on: 9/27/2024 9/28/2024 10/11/2024 10/12/2024 On 10/10/24 at 11:12 AM, the Surveyor observed Resident #45 lying in bed, remaining unshaven, with hair on their face. 2. On 10/08/24 at 11:04 AM, the Surveyor observed Resident #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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure care plans were revised to reflect the most recent care needs for 3 (Residents #13, #16, and #21) sampled residents whose care plans were reviewed. The findings are: 1. On 10/07/2024 at 10:07 AM, Certified Nursing Assistant (CNA) #9 was observed propelling Resident #21 in the hall using a mechanical lift with no other staff member assisting her. CNA #10 was heard telling CNA #9 the resident had to be in a shower chair and was not supposed to be in the lift. CNA #9 propelled the resident to the resident's room in the lift without assistance of another staff member. CNA #10 entered the room with a shower chair and closed the resident's door. Resident #21's Medical Diagnosis health record was reviewed and indicated the resident had diagnoses of a condition of rigidity of the joint (contracture) of the left hip and a decline (atrophy) in the muscle and decrease in size (wasting) of multiple sites, difficulty in making decisions for everyday life…

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, facility document review, facility policy review, the facility failed to ensure female residents had hair removed from their face for 1 (Resident #35) of 1 sample mix resident to promote good hygiene; ensure male residents had been kept clean shaved for 1 (Resident #45) of 1 sample mix residents to promote good grooming; and to ensure that 1 (Resident #32) of 1 sample mix residents received regular scheduled baths and/or showers . The findings are: 1. On 10/7/24 at 12:30 PM, the Surveyor observed Resident #35 sitting in a wheelchair in dining room. The resident observed to have hair on their chin. Review of Resident #35's admission Record with an admission date of 6/8/2022 noted the resident has diagnoses of a paralyzed person with cerebral palsy and high pressure in the eyes (Primary angle glaucoma bilateral.) Review of Resident #35's Care plan, initiated date of 6/3/2024, revealed the resident had an activities of daily living (ADL) self-care performance deficit related to (r/t) confusion. Bathing/ showering: Provide sponge bath when…

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 facility document review, it was determined the facility failed to ensure residents who have physician orders for weekly skin evaluations had their skin evaluated for 4 (Resident #13, #35, #63, #366) of 4 sample mix residents with orders for weekly skin evaluations; and to ensure residents with a contracture had a treatment in place to prevent further decline in accordance with professional standards of practice for 1 (Resident #13) of 1 sample mix residents. The finding are: 1. On 10/8/2024 at 11:03 AM, the surveyor observed a dressing on Resident #13's right lower leg. Resident #13 told the surveyor it was covering an open spot. Review of Resident #13's Order Summary Report dated 5/20/2024 noted weekly nursing assessment and body audit on Wednesdays, right lower leg swelling with small cluster of blisters: cleanse with wound cleanser, pat & dry, paint with betadine, apply abdominal (ABD) pads and wrap with gauze one time a day every Monday, Wednesday, Friday for wound care and every 24 hours as needed for wound care. On 10/9/2024…

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, interview and facility policy review, the facility failed to ensure a mechanical lift was properly used to for 1 (Resident #21) sampled resident reviewed for mechanical lift transfer, and failed to ensure residents were assessed to smoke during the facility designate smoke break times for 1 (Resident #13) of 1 sample mix resident reviewed for smoking. The findings are: 1. Resident #21's Medical Diagnosis health record was reviewed, which indicated the resident had diagnoses of a condition of rigidity of the joint (contracture) of the left hip and a decline (atrophy) in the muscle and decrease in size (wasting) of multiple sites. An annual Minimum Data report, with an Assessment Reference Date of 07/20/2024, was reviewed and indicated Resident #21 had a Brief Interview for Mental Status score 7, which indicated severely cognitively impaired and an impairment in the lower extremity and required substantial/maximal assist with a shower/bath. A care plan, dated as reviewed…

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, interviews, record reviews, and facility policy reviews the facility failed to ensure incontinence care was provided in a clean and sanitary manner to promote cleanliness for 2 (Resident #32 and #33) sampled residents. The findings include: 1. A review of the significant change Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 6/01/2024 revealed Resident #33's Brief Interview of Mental Status (BIMS) score was 14, indicating the resident was cognitively intact. Resident #33 was occasional incontinent of bowel and bladder. a. A plan of care (Revision on: 06/10/2024) revealed Resident #33 had episodes of occasional incontinence related to (r/t) impaired mobility. b. On 10/03/2024 at 9:30 AM, the Surveyor observed Certified Nursing Assistant CNA #14 improperly cleaning Resident #33 genital area by wiping in a back-and-forth motion with one wipe, a practice that can spread germs and cause urinary tract infections. c. On 10/03/2024 at 9:40 AM, the Surveyor asked CNA #14 if they were trained to wipe more than once with one wipe without folding. CNA…

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, facility document review, and facility policy review, it was determined the facility failed to ensure surgically created airway/ tracheostomy care was provided as physician ordered to prevent possible respiratory infections for 1 (Resident #13) of 1 residents with a tracheostomy; to ensure respiratory supplies were properly stored and readily available for 2 (Resident #13, #32) for 2 sample mix residents. The findings are: On 10/08/2024 at 11:07 AM, the Surveyor observed gauze around Resident #13's tracheostomy to be light brown in color with what appears to be dried blood. During an interviewer with Resident #13 the resident confirmed the gauze hasn't been changed and when asked how often they change it she said sometimes. Review of Resident #13's admission Record revealed the resident was admitted on [DATE] with a diagnoses of Tracheostomy complication. Review of Resident #13's Order Summary Report with an order date of 4/19/2024 noted tracheostomy (trach) care…

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 and facility policy review the facility failed to ensure the facility had full-time Director of Nursing (DON) coverage. The findings include: On 10/08/2024 at 3:35 PM, the Surveyor was provided a calendar for the months of July, August, September, and October. The Surveyor noted there was not a DON employed, nor an interim filling in for role of DON, at the facility from August 10, 2024-August 18, 2024. On 10/14/2024 at 1:00 PM, the Surveyor was provided check stubs of the Director of Nursing's which did not reflect fulltime hours consistently during a two-week timeframe. On 10/14/2024 at 4:40 PM, the Administrator stated sometimes we had DON coverage sometimes we did not. A policy titled Staffing noted the facility provided sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with the facility assessment.

Based on observations, interviews, and facility policy review, the facility failed to ensure daily staffing was posted visible for resident and visitor with all the required components. The findings include: On 10/10/2024 at 9:00 AM, the Surveyor noted there was no posting of the daily staffing and resident census visible for visitors and residents to see. The Surveyor noted on previous sign in sheet there was no tally of actual hours worked per shift for direct care staff. On 10/10/2024 at 2:00 PM, Licensed Practical Nurse #7 the facility's Staff Coordinator stated she did not know it was required to have a visible posting which included the facility name, date, census, nursing staff responsible for director care, and a tally of actual hours worked per shift. On 10/14/2024 at 04:40 PM, the Administrator stated there was not a daily posting for staffing which included all the required components. A policy titled Posting Direct Care Daily Staffing Numbers noted the facility would post daily for each shift the number of nursing personnel responsible for providing direct care 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 review, and interview, the facility failed to accurately account for a controlled medication after administration for 1 (Resident #50) resident who was reviewed for pharmaceutical services and failed to ensure pharmaceuticals available for the residents during medication administration were dispensed with the accurate dosage for 1 (Resident #63) sampled resident reviewed for medication dosages. The findings are: Resident #50's Order Summary Report was reviewed and indicated the resident had a diagnosis of a disorder associated with mood swings from depressive lows to manic highs (bipolar). Clonazepam 0.5 milligram (mg) was ordered 08/31/2024 to give 1 tablet by mouth every 8 hours as needed for anxiety. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/15/2024 was reviewed and indicated Resident #50 had a Staff Assessment for Mental Status (SAMS) score of 2, which indicated moderately cognitively impaired and was taking antipsychotic medications. Review of a care…

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, the facility failed to ensure a pharmacist recommendations for psychotropic medications were addressed for 3 (Residents #8, #50 and #57) sampled residents reviewed for medication regimen review recommendations. The findings are: 1. Resident #50's Order Summary Report was reviewed and indicated the resident had a diagnosis of a disorder associated with mood swings from depressive lows to manic highs (bipolar). Trazodone (psychotropic medication) 50 milligrams (mg) take one tablet by mouth at bedtime was ordered on 01/30/2024. The order summary report indicated the resident should be observed closely for side effects of antipsychotic medications including disorientation and increased agitation. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/15/2024 was reviewed and indicated Resident #50 had a Staff Assessment for Mental Status (SAMS) score of 2, which indicated moderately cognitively impaired, and the resident was taking antipsychotic medications. A Care Plan, dated as last reviewed 06/19/2024, was reviewed and…

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

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5 percent (%) during the medication administration observation of 4 (Residents #31, #36, #37 and #54) of 4 sampled residents who received medications from 1 Registered Nurse (RN) and 1 Licensed Practical Nurse (LPN). 29 opportunities of medication administration were observed and 7 of the 29 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 24.14%. The findings are: 1. On 10/10/2024 at 8:08 AM, RN #6 entered Resident #36's room to administer medication she had prepared. She obtained the resident's blood pressure and heart rate and indicated the heart rate was 58 and she was going to hold the resident's Coreg (Carvedilol) 25 milligram (mg) tablet. She administered Albuterol Sulfate 90 micrograms (mcg) inhaler, 2 puffs, to the resident. Resident #36's Order Summary Report was reviewed and indicated the resident had diagnoses of an irregular heartbeat (atrial fibrillation) and a lung condition which…

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

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served in accordance with the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. The findings are: 1. The week 3-day lunch menu for 2024 to 2025 specified for the residents on regular diets, and mechanical soft diets to receive 3 ounces of ham and 1/2 cup of white beans and for the residents on pureed diets to receive a #8 scoop (1/2 cup) of pureed ham and a #8 (1/2 cup) of pureed white beans. 2. On 10/7/24 at 8:57 AM, Dietary [NAME] (DC) #1 used a 4-ounce spoon to place 7 servings of black-eyed peas from a container dated 10/04/2024 into a blender and pureed. When asked during an interview if black eyed peas were on the menu, DC #1 stated we are having lima beans for lunch, and using leftover black-eyed peas for the pureed. 2. On 10/07/24 at 11:09 AM, ten small pieces of ham weighed 3 ounces, which is the amount each resident should have received. DC #1 used tongs to place 30 small pieces of ham into a blender, resulting in 3 servings,…

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 pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. The findings are: 1. On 10/07/24 at 8:57 AM, Dietary [NAME] (DC) #1 used a 4-ounce spoon to place 7 servings of black-eyed peas from a container dated 10/04/2024 into a blender and pureed. When asked during an interview if black eyed peas were on the menu, DC #1 stated we are having lima beans for lunch, and using leftover black-eyed peas for the pureed. DC #1 poured the pureed black-eyed peas into a pan, covered it with foil and placed it in the oven. The consistency of the pureed black-eyed peas was mushy and not formed. 2. On 10/7/24 at 10:56 AM, DC #1 used a 4 ounce ladle spoon to place 9 servings of turnip greens into a blender, and pureed. At 11:01 AM, DC #1 poured the pureed turnip greens into a pan and placed it in pan of hot water on the stove. The consistency of the pureed turnip green was watery and not formed. 3. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review, the facility failed to ensure enhance barrier precautions were consistently implemented during care for 1 (Resident #31) sampled resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube; failed to ensure a water management program included the necessary components; failed to ensure laundry was transported in a manner to decrease the potential for contamination; failed to ensure the required personal protective equipment (PPE) was used during a resident care activity for 2 (Residents #33 and #35) sampled residents: Resident #33, during incontinent care and Resident #35, during care of and opening in the neck leading to the wind pipe (Tracheostomy); failed to perform appropriate hand hygiene during a resident care activity for 2 (Residents #33 and #35) sampled residents and failed to maintain a technique of remaining free of germs (aseptic) during a resident care activity for 1 (Resident #35) sampled resident reviewed 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 record review, interview, and facility policy review, the facility failed to ensure a pneumococcal vaccine was provided for 1 (Resident #59) of 5 (Resident's #13, #16, #31, #33, and #59) sampled residents and failed to provide documentation of education provided to a resident after an influenza vaccination was declined for 1 (Resident #33) of 5 (Resident's 13, #16, #31, #33, and #59) sample residents reviewed for immunizations. The findings are: Resident #59's admission Record was reviewed and indicated the Resident's original admission date was 06/22/2023. The admission record indicated the resident had no know drug allergies and diagnoses of difficulty in the ability to think which interferes with daily living (dementia) and a disease affecting the body's blood sugar level (type 2 diabetes mellitus). Resident #59's electronic health record was reviewed and there was no indication if the resident consented to or declined the pneumococcal vaccine. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/17/2024 was reviewed and indicated Resident #59…

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 reviews, and facility policy review, the facility failed to ensure 1 (Resident #265) sampled resident was safe to self-administer medications. The findings include: A plan of care for Resident #265 (Revision on: 09/11/2024) revealed Resident #265 had impaired cognitive function/dementia or impaired thought processes related to history of suicidal ideation. Interventions included to administer medications as ordered, monitor, and document for side effects and effectiveness. On 10/07/24 at 11:14 AM, the Surveyor observed over the counter medications in Resident #265's bathroom. On 10/07/24 at 12:47 PM, the Surveyor observed over the counter medications in Resident #265's bathroom. On 10/08/24 at 9:03 AM, the Surveyor observed over the counter medications in Resident #265's bathroom. On 10/08/24 at 9:30 AM, the Nurse Consultant stated there were no residents on 400 hall (the hall on which Resident #265 resided) who self-administered medications. The Nurse Consultant stated Resident #265 did not have an order for the medications to be kept in…

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 and facility policy review, the facility failed to ensure residents received mail on Saturdays. The findings include: On 10/10/24 at 11:31 AM, during a meeting with the resident council members, the surveyor was informed mail is not delivered on Saturdays. On 10/10/24 at 11:35 AM, the Activity Director stated she delivers mail Monday through Friday, which are the days she works. On 10/14/24 at 4:40 PM, during an interview the Administration stated nobody delivers mail Saturdays. A policy titled Resident Rights noted residents in the facility have the right to send and receive mail promptly.

Based on record review and interview, the facility failed to notify the Ombudsman of a resident's transfer to the hospital for 1 (Resident #57) sampled resident reviewed for hospitalization. The findings are: On 10/09/2024 at 2:23 PM, Resident #57's Progress Notes were reviewed and indicated on 08/26/2024 at 2:14 AM, the resident was being sent to a local hospital due to a decrease level of consciousness (LOC) and resident's relative was notified. On 09/05/24 at 18:25 (6:25 PM) an admission summary note indicated the resident was received back from [local hospital]. Resident #57's Order Summary Report was reviewed and indicated the resident had a diagnosis of a type of disorder affecting a person's movements, ability to communicate, think, feel, and behave clearly (catatonic schizophrenia). Resident #57's admission Minimum Data Set, with an Assessment Reference Date of 08/21/2024, was reviewed and indicated the resident had a staff assessment for mental status score of 3, which indicated the resident was severely cognitively impaired and received antipsychotic medications since…

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, it was determined the facility failed to complete timely quarterly assessments for 1 (Resident #215) of 1 sampled resident reviewed for resident assessments. Findings include: A review of the Minimum Data Set's (MDS) for Resident #215 shows an entry MDS was completed on 03/28/24, as the only one completed for resident. Resident #215 is lacking an admission MDS and a Quarterly MDS. A review of an undated facility policy titled, MDS Error Correction did not address the timeliness of MDS's being completed. On 10/10/24 at 4:32 PM, the Administrator (AD) was asked when was the last time the facility had an MDS Coordinator. The AD indicated they had a Registered Nurse (RN) start July 8 and resign July 25. The AD then indicated another RN started on August 27th and worked 3 days and quit. The AD indicated they have a sister facility in Oklahoma and the Licensed Practical Nurse (LPN) MDS Coordinator has been helping complete the MDS's for the facility. The AD indicated they just contracted with an RN that would be doing the…

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

Based on record review, interview, facility document review, and facility policy review, it was determined that the facility failed to ensure physician's orders were followed for 1 (Resident #16) of 1 sample mix resident with a wound and orders for skin evaluations weekly. The findings are: Review of Resident #16's Order Summary Report dated 5/21/2024 noted a stage 3 wound to left big toe: Cleanse with wound cleanser, pat & dry, apply collagen matrix with silver to affected site, cover with dry dressing, complete nursing assessment/ body audit every week on 7 PM-7 AM shift. Review of Resident #16's Quarterly Minimum Data Set (MDS) with an Assessment Reference date of (ARD) of 08/26/2024 noted in Section M0150 that the resident did not have an unhealed pressure ulcer/ injury. Section M1030 noted the resident did not have any venous or arterial ulcers. Review of Resident #16's Skin Only Evaluation dated 08/19/2024 revealed left great toe wound length 0.4 centimeters (cm), width 0.4 cm, 0.1 cm. Skin Only Evaluation dated 10/12/2024 revealed left great toe wound length 1.5 cm, width 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.

Based on observation, record review and interview, the facility failed to ensure a Percutaneous Endoscopic Gastrostomy (PEG) tube was properly checked for placement before fluids and medications were administered, and failed to ensure the enteral feeding rate was set per the physician's orders for 1 (Resident #31) sampled resident reviewed for enteral feeding. The findings are: On 10/07/2024 at 10:36 AM, Resident #31 was lying in bed on the right side with a wedge pillow behind the back and the head of bed (hob) was elevated. [Brand name] enteral feeding was hanging, and the feeding pump rate was set at 95 milliliters/hour (ml/hr) and flush set at 50 ml every (q)1 hr. The feeding bottle was labeled with the resident's name, room number, date and the rate indicated 95 ml/hr. There was not a time to indicate when the bottle was hung or the nurse initials who initiated the feeding. Resident #31's Order Summary Report was reviewed and indicated the resident had a diagnosis of difficulty swallowing (dysphagia) and an encounter for attention to a surgical opening in the abdominal wall 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 record reviews, interviews, and facility policy review, the facility failed to ensure Monthly Medication Regimens (MMR) were completed at least monthly for 1 (Resident #8) sampled resident. The findings include: A review of the quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 8/25/2024 revealed on the Brief Interview of Mental Status (BIMS) Resident #8 scored 11, indicating moderate cognitive impairment. Resident #8 was taking high risk medications used to treat depression, anxiety, and fluid retention. A plan of care for Resident #8 (Revision on: 05/28/2024) revealed Resident #8 used antidepressant medication related to depression. On 10/14/24 at 4:40 PM, during an interview the Administrator stated the facility could not provide any documentation to prove MMRs were completed. A policy titled Medication Regimen Reviews noted the Consultant Pharmacy shall review the medication regimen of each resident at least monthly.

Based on observations, interviews, record review, and the facility failed to ensure care and services were provided to prevent pressure ulcer development for 2 (Residents #10 and #11) of 3 sampled residents reviewed for pressure ulcers and/or skin concerns. Specifically, the facility failed to monitor the resident's skin by not following physician orders for dressing changes. The findings are: On 07/02/2024 at 10:54 AM, the Surveyor asked for a wound care policy, or guideline. The Administrator informed the surveyor the facility did not have a policy for Wound care or a Guideline. 1. Review of Resident #10's Medication Administration Record noted the resident had diagnoses of unspecified dementia, pressure ulcer of back, buttock, and hip, stage 4, type 2 diabetes, acquired absence of left below the knee amputation, encounter for aftercare following surgery on skin and subcutaneous tissue, and unspecified open wound right leg. a. Review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/09/2024 documented Resident #10 scored 0 (0-7 indicates severely…

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 a Director of Nursing (DON) was employed full-time. The findings are: On 07/01/2024 at 9:15 AM, the Administrator provided a list of the key personnel. The list did not have a DON named. On 07/01/2024 at 12:30 PM, the Administrator indicated the facility has not had a DON since March 20, 2024. The Administrator indicated the facility doesn't have a policy for DON coverage. On 07/01/2024 at 2:30 PM, the Administrator indicated the facility should have a fulltime DON.

Based on observations, interviews, document review, and policy review, the facility failed to maintain an effective pest control program throughout the entire facility and in one of one kitchen as evidenced by the presence of flies in the kitchen, dining room, resident rooms, as well as hallways. The findings are: On 07/01/2024 at 2:42 PM, during review of the policy titled, Pest Control, the policy noted, Policy Interpretation and Implementation. 1. The facility maintains an on-going pet control program to ensure that the building is kept free of insects and rodents. On 06/30/2024 at 9:32 AM, while the surveyor was rounding, the surveyor observed flies on the 200, 400, and 500 hallways, and common areas where residents sit, and in the resident rooms. On 06/30/2024 at 12:05 PM, the surveyor observed flies sitting on the resident's food, mashed potatoes and gravy, while they were attempting to eat. Residents and staff were waving them off the food for the entire meal. On 06/30/2024 at 12:21 PM, the surveyor went back into the kitchen and observed flies in the kitchen area where staff…

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 and record review the facility failed to ensure a discharge summary was completed on 1(Resident #3) of 4 (Resident #3, Resident #4, Resident #5, and Resident 8) discharged sampled residents. The findings are: A review of Resident #3's Medical Diagnosis List indicated the resident had a diagnosis of type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene. A review of Resident #3's Discharge Minimum Data Set (MDS) with an Assessment Reference Date of 04/01/2024 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score or 15, which indicated the resident was cognitively intact. The resident required maximum assistance with activities of daily living (ADL's). The discharge MDS indicated Resident #3 was discharged on 04/01/2024. On 07/01/2024 at 2:20 PM, Resident #3's medical records were reviewed. There was not a discharge summary in the medical records. On 07/02/2024 at 8:45 AM, during an interview, Registered Nurse (RN) #9 indicated the nurses are responsible for completing the discharge summary when a resident discharges. 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 observations, interviews, and record reviews, it was determined that the facility failed to ensure food was served in a timely manner for 1 (Resident #5) of 2 (Residents #5 and #6) sampled residents observed in the dining room. The findings are: A review of an Order Summery Report indicated Resident #5 had a diagnosis of unspecified protein-calorie malnutrition. The Quarterly Minimum Data Set with an Assessment Reference Date of 03/01/2024 revealed Resident #5's cognitive skills for daily decision making were severely impaired per a Staff Assessment for Mental Status. On 05/22/2024 at 12:00 PM, Resident #5 was sitting at the feed assist table. Resident #5 hadn't received the resident's meal tray, and most of the residents in the dining room had finished their meal. During an interview on 05/22/2024 at 12:19 PM, the Dietary Manager was asked, Can you tell me why [Resident #5] hasn't been served a lunch tray? She stated, I don't know how [Resident #5] got missed. During an interview on 05/22/2024 at 12:19 PM, the Assistant Director of Nursing (ADON) was asked, Can you tell me…

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 record review, the facility failed to keep smoking materials secured and provide adequate supervision during all smoke breaks to prevent potential injury for one (Resident #1) of one sampled resident reviewed for smoking. The findings include: The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2024, revealed Resident #1 had a Brief Interview for Mental Status [BIMS] score of 14 which indicated the resident was cognitively intact and had diagnoses of Dementia and Chronic obstructive pulmonary disease [COPD]. During an observation on 04/02/2024 at 9:57 AM, Resident #1 was lying in bed on his/her side with back to the door, the over bed table was parallel to the right side of the bed, and a blue package of cigarettes and a white disposable lighter was sitting on top of table. During an observation on 04/03/2024 at 11:03 AM, Resident #1's bedside table drawer was open and two blue packages of cigarettes were in the drawer. A review of Resident #1's April Physicians Orders did not address residents smoking. A…

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, the facility failed to ensure residents who had Medicaid coverage with Trust Funds managed by the facility were able to have funds available on the weekends and after hours. The failed practice had the potential to affect 52 residents. The findings are: 1. On 11/27/23 at 11:06 AM, Resident #14 was interviewed by the surveyor. The surveyor asked are you able to get your money after hours or on the weekends? The resident said, no there isn't anyone here on the weekends to give it to us. 2. On 11/29/23 at 2:48 PM, the surveyor interviewed the Business of Manager (BOM), and asked, do you leave money for the residents to have access to on the evenings or weekends when you are not available? The BOM stated, absolutely not . 3. On 12/01/23 at 2:05 PM, the surveyor asked the Administrator for a policy addressing a resident ' s personal funds. The Administrator stated, We do not have a Personal Fund Policy.

Based on record review and interview, the facility failed to ensure residents who receive Medicaid benefits and/or their responsible parties were notified when the amount in their resident Trust Fund account was within $200 of the maximum Medicaid limit for 12 Residents sampled. The findings are: 1. On 11/29/23 at 2:48 PM, The Surveyor asked for October Trust account balances. Business Office Manager (BOM) provided the month of November account balances. 2. On 12/01/23 at 11:25 AM, the Surveyor asked the BOM manager to provide the documentation regarding the Medicaid notification letters for Resident #2, who had a balance of $2,183.69, Resident #5, who had a balance of $1891.67, Resident #11 with balance of $2,070.19. Resident #13 with balance of $ 1,850.59, Resident #18 with Balance of $2,376.59, Resident #19 with Balance of $2,040.17, Resident #128 with balance of $4,658.45, Resident # 129 with balance of $1,964.10, Resident # 130 with balance of $2,248.42, resident # 136 with balance of $2,129.28, Resident #175 with balance of $4,657.62, Resident #228 with balance of $4,616.09.…

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 and record review, the facility failed to ensure a Registered Nurse (RN) worked at least 8 consecutive hours a day, 7 days a week, each week. The failed practice has the potential to affect 69 residents in the facility. The findings are: 2. On 11/28/23, the Surveyor reviewed the staffing documentation provided by the Business Office Manager (BOM), and noted the following information: a. On 11/16/23, 11/17/23, and 11/18/23 there was no Registered Nurse (RN) that worked as the Director of Nurses (DON). b. On 11/19/23 and 11/20/23 both RNs. worked on the floor. There was no RN who worked as the DON. c. On 11/22/23 and 11/23/23 The RN worked the floor both days. d. On 11/24/23 and 11/25/23, 11/26/23 There was no RN working. e. On 11/27 and 11/28/23 the RN worked the floor. f. On 11/29/23, the RN worked as the DON from 12:59-21:30. 2. On 11/28/23 at 2:01 PM, the Surveyor asked the Administrator, since there is no DON and the Assistant Director of Nurses is on vacation, who is working as the RN in charge? The Administrator stated, I have RNs here Named {RN #1}. We are…

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 ensure completion and follow up on the pharmacy medication regimen review [MRR] recommendations for four (Resident #17, #18, #20, and #185) of four (Resident #17, #18, #20, #185) sampled residents. The findings are: On 12/1/2023 at 9:30 AM The facility was only able to locate the Monthly Regimen Reviews for Resident #17 for the following months, August 2023, and November 2023. According to Registered Nurse #1 the following months were not to be found November 2022, December 2022, January 2023, February 2023, March 2023, April 2023, May 2023, June 2023, July 2023, September 2023, and October 2023. Resident #18 had a diagnosis of dementia with behavior disturbance, depression, and post-traumatic stress disorder [PTSD]. Minimum data set [MDS] with an assessment reference date [ARD] of 06/20/2023 documented no potential indicators of psychosis, no behavior symptoms observed, no rejection of care and no wandering observed. Resident #18's Physician's Orders for 11/01/2023 to 11/30/2023 documented, .Cymbalta 60 mg 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.

Based on observation and interview, the facility failed to ensure food item stored in the refrigerator and freezer were covered, sealed, and dated; leftover foods were used in a manner to maintain food quality; expired dairy products was promptly removed / discarded on or before the expiration or use by date to prevent the growth of bacteria; kitchen ceiling tiles were free of peeling, floors, dish washer and kitchen walls, and baseboards were free of chipped debris, dirt, grease, grime, rust, stains, and spills, ice scoop holder and ice machine were maintained in clean and sanitary condition and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, and hot food items were maintained at above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 60 residents who received meals from the kitchen. The findings are: 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.

Based on interview and policy review, the facility failed to develop and implement a Quality Assurance Performance Improvement (QAPI), plan that includes identification of problems, implementation of corrective actions, documentation, review, analyze and tracking of the data. The findings include: Interview on 12/1/2023 at 2:17 PM the facility Administrator stated, I have nothing as far as no QAPI Plan or QAA meeting notes. On 12/1/2023 at 2:39 PM review of the facility policy QAPI Committee, (July 2016), documented, .The administrator shall delegate the necessary authority for the QAPI Committee to establish, maintain and oversee the QAPI program .The committee will meet monthly at an appointed time .The committee shall maintain minutes of all regular and special meetings that include at least the following information: .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure that staff wore Personal Protective Equipment (PPE) in the transmission-based precaution rooms for 2 residents (#184, #226); the facility failed to have proper signage on isolation room [ROOM NUMBER] and failed to clean the glucometers according to the manufactures guidelines on hall 200 which had the ability to effect (11) residents who reside on the hall. The findings are: 1. On 11/27/2023 at 11:10 AM Certified Nursing Assistant (CNA) #6 walk into R (#226) room without donning PPE. 2. On 11/27/23 at 11:15 AM, observed CNA (#6) go into R #226 room without donning PPE. 3. On 11/28/23 at 8:02 AM, observed CNA (#4), go into R (#184), room to deliver breakfast tray without donning PPE. 4. On 11/28/23 at 08:43 AM, observed Housekeeper going into R (#184) room without donning PPE. 5. On 11/29/23 at 12:22 PM, observed CNA (#5) go into R (#184) room to deliver lunch tray without donning PPE. 6. On 11/28/23 at 8:05 AM surveyor asked CNA (4), are you aware…

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 and record review the facility failed to screen, educate, and offer Covid-19 immunization and to maintain documentation for facility staff and residents. This failed practice had the potential to affect all residents who reside in the facility and all staff employed by this facility. On 11/29/2023 at 3:30 PM RN #1 stated they did not have documentation for Covid 19 immunizations given to any of the residents. On 11/29/23 03:47 PM when asked about Covid 19 education and vaccine for staff, the Administrator stated, We have not been doing this, we were unaware this was still a requirement since the pandemic is over. When asked for a Covid 19 vaccine policy RN#1 stated she was unable to find it.

Based on interview and record review, the facility failed to ensure regulated in-services were provided. The findings are: 1. On 11/2/23 at 4:00 PM, the Surveyor requested In-service trainings for Abuse/Neglect/Exploitation, Resident Rights, Dementia Care, Infection Control, Communication, Behavioral Health, and Special resident needs such as Pain, Trach care, Medication side effects, Hospice, and Changes in Condition. The Administrator provided a form documenting after an exhausting search of the facility there were No Inservices to be located. 2. There was no Director of Nurses (DON)/Acting DON employed. The Assistant Director of Nursing was on vacation. 3. The Administrator was asked if she knew which in-services are required yearly. The Administrator stated, The Administrator was asked to explain the purpose behind In-service training. The Administrator stated, To educate your staff on Policies and Procedures, rules and regulations, changes of conditions, and any communication needed. 4. The Administrator was asked for a policy on in-servicing/educating on 12/01/23 at 03:00 PM…

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 record review the facility failed to provide appropriate/comfortable water temperatures in two (Hall 400 and Hall 600) of four (Hall 200, Hall 400, Hall 500, and Hall 600) bathing areas. The failed practice had the potential to affect 67 residents who have the potential to be bathed/showered on Hall 400 or 600. The findings are: On 11/27/23 3:15 PM the surveyor checked the water temperature in the shower room on 400 halls, the warmest it registered on the thermometer after 5 minutes was 91 degrees Fahrenheit. At 03:20 PM the water temperature in the whirlpool on the 500-hall registered 103 degrees Fahrenheit and at 03:25 PM the water temperature in the whirlpool room on 200 hall registered at 102 degrees Fahrenheit. The temperature of the water in the 400-hall shower room was checked again on 11/30/2023 at 1:30 PM and registered 91.2 degrees Fahrenheit. On 11/30/2023 at 1:20 the Maintenance Director was asked, What is an appropriate temperature range for bath water for 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 residents were assessed for smoking, that oxygen was maintained securely in a safe manner and hazardous chemicals were secured in a locked container. The findings are: On 11/27/23 at 11:29 AM observed Resident #178 drop a used (unlit) cigarette from her lap. On 11/30/23 02:11 PM, the Surveyor asked resident # 178 if she smoked. Resident #178 stated, Yes, all my life. Resident #178 was asked if the facility kept her cigarettes and lighter. Resident #178 stated, No I keep them on me or in my pillow. On 11/30/23 at 12:00 PM during smoking schedule resident #178 pulled out a lighter and a cigarette and lit the cigarette. On 11/30/23 at 12:22, the Activities Director (AD) was asked who oversees the residents during smoke times. The AD stated, I do. The AD was asked if she was aware of resident #178 having smoking paraphernalia on her person. The AD was asked if residents were allowed to keep their cigarettes and lighters. The AD stated,…

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

Based on observation record review, and Interview, the facility failed to ensure Psychotropic medications had an appropriate diagnosis for 1 of 1 sampled Resident (#20 and #185). The findings are: a. Resident #20 was prescribed Trazodone 50 mg 1 po @bedtime Psychophysiological Insomnia, Depakote 125 mg (milligrams) 1 po (by mouth), (without diagnosis) Depakote 500 mg 1 po (without diagnosis), Seroquel 25 mg 1 po (without diagnosis.) and on resident #185 who was prescribed on Trazadone 100 mg 1 po, Divalproex 125 mg, escitalopram 10 mg for anxiety, olanzapine 5 mg all without a diagnosis. a. On 11/30/23 at 9:23 AM, the Surveyor asked Registered Nurse (RN) #1 for diagnoses for these medications on resident # 20 and #185. RN #1 stated, I'll have to look for the diagnoses. b. On 11/30/23 at 12:56 PM, the Administrator provided a written statement that documented, After chart audit and EHR (Electronic Health Records) and admission documentation there was not a physician's order for Psychotropics for resident # 20 [named]or Resident # 185. [named]. d. On 12/01/23 at 2:25 PM, the…

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

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. These failed practices had the potential to affect 6 residents who received mechanical soft diets and 8 residents who received pureed diets and residents who received fortified foods from the kitchen according to a list provided by the Assistant Dietary Supervisor (DS). The findings are: The cycle Day 9 lunch menu for 2023 specified for the residents on meglazedcal soft diets to receive a-6 scoop (2/3) cup of ground maple glaze fish with 2 ounces of gravy, residents on pureed diets were to receive a #8-scoop (1/2) cup of pureed maple glazed fish and a #16 -scoop (1/4) cup of pureed lemon cheesecake bar. On 11/27/23 at 11:53 AM, Dietary Employee (DE) #1 used 4 ounces (oz) spoon to place 6 servings of diced chicken into a blender, added 5 slices of cream chicken soup and pureed. At 11:56 AM, he poured the pureed chicken into a pan and placed it on the steam…

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 pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 3 of 3 meals observed. This failed practice had the potential to affect 8 residents. The findings are. 1. On 11/27/23 at 11:17 AM, the following observations were made during the lunch meal preparation: a. Dietary Employee (DE) #1 used a 4 ounces spoon to place 10 servings of broccoli into a blender and pureed. At 11:20 AM, he poured the pureed broccoli into a pan. He covered the pan with foil and placed it on the steam table. The consistency of the pureed broccoli was runny and not formed. b. On 11/27/23 at 11:35 AM, DE #1 used a #8 scoop to place 8 servings of garden rice blend into a blender, added cream of chicken soup and pureed. At 11:42 AM, he poured the pureed rice into a pan and placed it on the steam table. The consistency of the pureed rice was lumpy, sticky and not smooth. There were pieces of black food particles visible in the mixture. c. 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, record review and interview, the facility failed to ensure resident received physician ordered Fortified foods for 1 (Resident #21) sampled resident who were to receive fortified foods. This failed practice had the potential to affect 22 residents, who required fortified foods with all meals, as identified by a list provided by the Certified Supervisor on 11/28/2023 at 10:01 AM. The findings are: a. Resident #21's Physician's Order dated 03/28/2023 documented, .fortified foods TID [three times a day] with meals . b. On 11/27/2023 at 12:30 PM, Resident #21 was not given fortified foods. c. On 11/28/23 at 12:30 PM, the surveyor asked Dietary Employee #3 what was prepared for the residents on fortified foods. He stated, I forgot to do it. I gave regular oatmeal to every resident.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide influenza and/or pneumococcal immunizations as required or appropriate for residents. This failed practice had the potential to affect all 70 residents who reside in the facility. The findings are: On 11/29/2023 at 3:30 PM RN #1 stated, they did not have documentation for any influenza or pneumococcal education, or immunizations given. They were unable to document the flu vaccines given due to the lot number and expiration dates being discarded. The Facility Influenza Vaccine policy documented, All residents .who have no medical contraindication to the vaccine will be offered the influenza vaccine annually .Between [DATE]st and March 31st each year Prior to vaccination the resident (or resident legal representative) will be provided with information and education regarding the benefits and potential side effects .Provision of such education shall be documented in the residents medical record . the date of vaccination, lot number, expiration…

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 an effective pest control program was maintained to keep the facility free of pests. This failed practice had the potential to affect 69 residents according to the list provided by the Dietary Supervisor on 11/28/2023. The findings are: 1. On 11/27/2023 at 11:00 AM Resident #184 stated, I sleep with the light on so roaches dont crawl in my bed. 2. 11/27/23 01:08 PM A roach was crawling inside the top door of the refrigerator in the nourishment room behind the nurse's station facing 300 Hall. The surveyor pointed it out to the Dietary Supervisor who pushed it out of the refrigerator and killed it. 3. On11/28/23 at 12:38 PM A roach was crawling on the counter where microwave and the food blender were located. The surveyor showed it to the Dietary Supervisor pushed it down and killed it. 4. On 11/28/23 at 12:39 PM Another roach was crawling Do we know it was crawling, maybe it was walking on the floor in the kitchen. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure activities were regularly provided, resident activity participation was regularly evaluated and documented, and plans for activities were revised to meet residents' individual interests and needs to promote quality of life for 1 (Residents #2) of 14 residents who required 1:1 activities. The findings are: On 11/27/23 at 11:30 AM Resident #2 was in bed, no TV, or other activity related item in room. On 11/27/23 at 05:14 PM Resident #2 was lying in bed window shades were closed and there was no TV or activity in room. On 11/28/23 at 08:15 AM Resident #2 was lying in bed with no TV or other activities observed. On 11/29/23 at 04:08 PM, Resident #2 was lying in bed and did not get any activities in the room. Resident #2 does not have a TV in her room. Resident #2's Activity Comprehensive assessment dated [DATE] documented the resident listens to music. A review of Resident #2 Care Plan showed a care plan for psychosocial well-being,…

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 ensure oxygen tubing, nasal cannulas, and humidified water were properly changed, dated, and bagged in a closed container to prevent infections for 1 resident (#239) who received oxygen, and the facility failed to ensure nebulizer mask was contained and bagged properly. The findings are: On 11/27/2023 at 11:53 AM, surveyor observed R #239 was receiving oxygen therapy via nasal cannula with the humidified water dated 11/18/23. On 11/28/2023 at 9:47 AM, surveyor observed R #239 was receiving nebulizer treatment with tubing dated 11/14/23. On 11/28/2023 9:47 AM, surveyor observed a nebulizer mask not bagged or contained lying on the bed for R #239. On 11/28/23 at 9:54 AM Surveyor asked Licensed Practical Nurse (LPN) #1, Who is responsible for taking care of the resident's oxygen? She stated, The nurses are responsible for the oxygen. When are the oxygen tubing, humidified water and nebulizers changed? LPN #1 stated, on Sunday nights. Should the nebulizer be bagged. LPN #1 replied, Yes, it should. On 12/01/23 at…

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, the facility failed to ensure a policy was developed regarding use and storage of foods that were brought to residents by family and other visitors, to ensure safe and sanitary storage, handling, and consumption for the residents who resided in 1 of 1 facility. This failed practice had the potential to affect 11 residents who had food brought in by family. The findings are: 1. On 11/28/2023 at 1:00 PM, the Administrator was asked to provide the facility's policy regarding use and storage of foods that were brought to residents by family and other visitors. The administrator stated they have no policy. 2. On 11/28/2023 at 10:01 AM, a list provided by the Certified Nursing Assistant/Receptionist #2 documented there were 11 residents currently residing in the facility who had food brought in by family members. 3. On 11/27/23 1:08 PM, an opened bottle of sweet tea was on a shelf in the refrigerator in the nourishment room behind the nurse's station facing 300 Hall. There was no name to whom it belongs to, no opened or received date on the bottle.

Based on observation, interview and record review, the facility failed to update resident assessments for three (R#1, #2 and #3) of three (R#1, #2 and #3) sampled residents. The findings are: 1. On 11/08/2023 at 12:00 PM the surveyor was unable to locate the Minimum Data Set [MDS] in the paper medical record for Residents #1, #2 and #3. 2. On 11/08/2023 at 12:05 PM the DON was asked, where would the MDS be found on R#1, #2 and #3, the DON, stated, I will check on that for you, I believe the MDS coordinator has them in her office. 3. On 11/08/2023 at 1:00 PM, the MDS coordinator was asked to provide a copy of Resident #1, #2 and #3's MDS. The MDS coordinator replied, Do you want the most recent? The surveyor replied, Yes, please. At 4:30 PM they still had not provided a copy of the MDS. 4. On 11/09/2023 at 9:30 AM the MDS coordinator provided a Quarterly MDS, which was the most current, for Resident #1 with an assessment reference date [ARD] of 04/12/2023, and a Quarterly MDS, most current, with an ARD of 04/19/2023 for Resident #2. 5. On 11/09/2023 at 9:59 AM when the surveyor asked…

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 an individual care plan for three (Resident #1, #2 and #3) of three (Resident #1, #2 and #3) sampled residents. The findings are: 1. On 11/08/2023 at 12:03 PM, the surveyor was unable to locate the residents care plan in the paper medical record for Residents #1, #2 and #3. 2. On 11/08/2023 at 12:05 PM the DON was asked, where would the MDS be found on R#1, #2 and #3, the DON, stated I will check on that for you, I believe the MDS coordinator has them in her office. 3. On 11/08/2023 at 1:00 PM, the MDS coordinator was asked to provide a copy of Resident #1, #2, and #3's MDS. The MDS coordinator replied, Do you want the most recent? The surveyor replied, Yes, please. At 4:30 PM they still had not provided a copy of the MDS 4. On 11/09/2023 at 9:59 AM, when the surveyor asked about the care plan for Resident #3, the MDS coordinator stated she was unable to find it. 5. On 11/09/2023 at 11:29 AM, CNA (Certified Nursing Assistant) #1 was asked, how do you know how to properly care for 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.