Dr Guy Gorman Sr Care Home

Based on interview and record review it was determined the facility failed to ensure a registered nurse worked eight consecutive hours for 1 of 203 days reviewed for staffing. This placed residents at risk for lack of nursing assessments.Findings includeA review of the facility's Licensed Nurses Schedule for week of 5/19/25 showed there were no RN on duty on 5/18/25. Review of Interim Director of Nursing (IDON) Custom Time Card Report for 5/18/25 showed hours worked from 8:30 AM to 1:00 PM (4.5 hours) and then 6:30 PM to 9:15 PM (2.75 hours). The facility census was less than 60.During a concurrent review and interview on 7/24/25 at 10:59 AM IDON confirmed the facility did not have an RN for eight consecutive hours on 5/18/25.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident's drug regimen was free from unnecessary drugs for 1 of 5 sampled resident (R) (R7) reviewed for unnecessary medication use. R7 received anti-hypertensive medications that did not meet physician's ordered blood pressure parameters. This failure placed residents at risk for adverse side effects such as hypotension, dizziness, and falls. Findings includeReview of R7's records documented resident was admitted on [DATE] with diagnoses including congestive heart failure (heart disorder which causes the heart to not pump the blood efficiently), hypertension, dementia, diabetes, and cerebral infarction (stroke, blood supply to part of the brain is blocked, causing parts of the brain to be damaged or die, can cause weakness in one side of the body and swallowing difficulties).Review of R7's care plan documented [Name of R7] has hypertension and takes medicines with goal for resident's blood pressure to be within normal limits.Review of R7's…

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 interview and record review, the facility failed to ensure records were complete and accurate for 1 of 5 sampled residents (R)(R7) reviewed for unnecessary medication use. This placed residents at risk for incomplete clinical records.Findings includeReview of R7's records documented resident was admitted on [DATE] with diagnoses including congestive heart failure (heart disorder which causes the heart to not pump the blood efficiently), hypertension, dementia, diabetes, and cerebral infarction (stroke, blood supply to part of the brain is blocked, causing parts of the brain to be damaged or die, can cause weakness in one side of the body and swallowing difficulties).Review of R7's care plan documented [Name of R7] has hypertension and takes medicines with goal for resident's blood pressure to be within normal limits.Review of R7's physician orders and July 2025 Medication Administration Record documented *Hydralazine 25 mg, give 50 mg by mouth three times a day for hypertension. Hold for SBP (systolic…

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 maintain a Quality Assessment and Assurance (QAA) committee that included the required participants for 2 of 4 quarters reviewed for participation. This failed practice placed residents at risk for quality and infection control deficiencies, adverse events, and diminished quality of life.Findings includeFacility's 2025 Quality Assessment Performance Improvement (QAPI) Committee, undated, documented meetings were at a minimum once every quarter with members listed: Interim Assistant Director of Nursing/Quality Assurance Quality Improvement/Infection Control Nurse (IADON QA QI ICN), Interim Director of Nursing (IDON), Medical Director, Consult Pharmacist, Board of Directors, Supervisors for Housekeeping/dietary, Maintenance, Social Services, Lead Certified Nursing Assistant (CNA), MDS (Minimum Data Set) Coordinator, Activity Supervisor and Nurses, CNAs and all staff are welcome to attend. The facility's list of QAPI/QAA participants met the minimal regulatory requirements that the Medical Director/Designee, Director of…

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

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases when staff did not change gloves during 1 of 2 sampled resident (R) (4) personal care observation when going from dirty tasks to clean tasks. This placed residents at risk for the spread of infection and its associated discomfort and decline in physical condition.Findings includeReview of R4's record indicated the facility admitted the resident on 2/7/23 with diagnoses including heart failure (heart disorder which causes the heart to not pump the blood efficiently), diabetes, and dementia. R4's Minimum Data Set (MDS-assessment tool), dated 4/20/25, documented R4's brief interview for mental status was 2. (BIMS, a scoring system used to determine the resident's cognitive status about attention, orientation, and ability to register and recall information. A BIMS score of 0 to 7 is an indication of severe cognitive impairment), and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure two of five residents (Resident (R) 6 and R56) reviewed for immunizations had been provided with education and the opportunity to decline or receive an updated pneumococcal conjugate vaccine (PCV20 or PCV21). This failure had the potential to affect the residents' ability to decrease the possibility of serious pneumococcal infection and potential hospitalization.Findings include: Review of the facility's policy titled, Pneumococcal Vaccine, revised October 2023, revealed:Policy Statement. All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation.7. Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. 1. Review of R6's admission Record, printed from the electronic medical record (EMR) Profile tab revealed 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 interview and record review the facility failed to offer training on its compliance and ethics program for 5 of 5 sampled staff (Certified Nursing Assistant) (CNA)(3, 21, 26, 6, and 19) reviewed for training. This placed residents at risk for non-compliant and unethical treatment.Findings includeReview of facility all staff list documented CNA3 was hired in March 2014.Review of facility training records for CNA3 lacked documented evidence of compliance and ethics training.Review of facility all staff list documented CNA21 was hired in May 2017.Review of facility training records for CNA21 lacked documented evidence of compliance and ethics training.Review of facility all staff list documented CNA26 was hired in April 2022.Review of facility training records for CNA26 lacked documented evidence of compliance and ethics training.Review of facility all staff list documented CNA6 was hired in January 2008. Review of facility training records for CNA6 lacked documented evidence of compliance and ethics training.Review of facility all staff list documented CNA19 was hired 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 interview and record review the facility failed to demonstrate they had implemented any performance improvement activities for any of their identified concerns. Failure to evaluate problem areas systemically and identify, and test solutions has the potential for resident quality of life to negatively impact all residents. Findings: Review of the facility's 2024 Quality Assurance & Performance Improvement (QAPI) Plan revealed under the heading Scope, The QAPI team will determine which problems will become the focus for a performance improvement project (PIP). Depending on the PIP to be started, the QAPI team will charter a PIP Team who is entrusted with a mission to investigate a problem area and come up with plans for correction and/or improvement to be implemented During an interview on 09/27/24 at 03:30 PM the facility's Quality Assurance and Performance Improvement and Infection Preventionist (ADON/QAPI/IP) and the Director of Nursing (DON) described the QAPI program. ADON/QAPI/IP stated the committee meets quarterly and all departments, the Medical Director, the CEO,…

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 interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and resident's representative(s) before transfer to the hospital for 4 of 4 sampled residents (R) (R106, R20, R158 and R21) reviewed for hospitalization. These failures did not afford residents and/or their representatives to make informed decisions about transfers and prohibited access to an advocate who could inform resident/representative of their options and rights. This failure had the potential to affect all facility-initiated transfers or discharges. Findings include Review of Nursing Home Transfer or Discharge Notice initiated by [name of facility], undated, documented the form may be used to meet the requirements of notice of transfer or discharge initiated by the nursing home facility and included the location to which resident was being transferred or discharged , reason for transfer/discharge, and provided appeal rights including names of several protection and advocacy agencies…

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 interview and record review, the facility failed to provide a written bed hold notice to the resident or resident's representative(s) before transfer to the hospital for 4 of 4 sampled residents (R) (R106, R20, R158 and R21) reviewed for hospitalization and had an overnight hospital stay. This failure placed resident/representatives at risk for not having a clear understanding of the length of time the bed can be held, the cost associated with the bed hold and/or any other requirements which had the potential for stress/anxiety associated with the potential return to the facility. Findings include Review of Bed Hold Policy, revised 9/2022, documented that it was the policy of the facility to develop an operational policy and procedure to inform residents .before allowing a resident to transfer to the hospital that specifies the duration of the bed-hold policy during which the resident is permitted to return and resume care . The form further stated that bed-hold days for more than allowed are considered…

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 interview and record review, the facility failed to ensure the required Minimum Data Set (MDS-assessment tool) resident assessment data for 6 of 16 sampled residents (R) were accurate as of the Assessment Reference Date (ARD) as evidenced by: 1. R33, R41, R17, R15 medications were inaccurate, 2. R38's wound was inaccurate. 3. R31's restorative care was inaccurate These failure increased the residents' risk for having unmet health care needs. Findings 1. inaccurate medication coding: Review of Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Version 1.19.1, dated October 2024, documented under section N0415 enter yes if an antipsychotic medication (class of medications that treat psychotic symptoms such as hallucinations and delusions) was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Resident 33 Review of Resident 33's (R33) record documented the resident was admitted on [DATE]. R33's Minimum Data Set…

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 develop and or implement a comprehensive care plan for two of 16 sampled residents (R31 and R16). * R31: The Physical Therapist (PT) was not included in the care planning process, and their input and recommendations for knee brace related to knee buckling, and trapeze for mobility were not incorporated into the care plan. Staff were unaware of PT recommendations for transfer and mobility care, and did not implement transfer care as care planned and recommended by PT. The care plan did not include if R31 had refused to use any of the PT's recommendations. Additionally, the [NAME] used by the Certified Nursing Assistants (CNA) for awareness of the care plan did not include the use of a sit to stand lift and was outdated. The Treatment Record, used by the nurses for awareness of the care plan, did not include the transfer interventions as planned on the care plan. * R16: The facility identified significant weight loss on 12/29/23 and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy, the facility failed to ensure that wound care was provided in accordance with the comprehensive care plan and professional standards of practice for one of two residents reviewed (Resident (R) 17). The deficient practice increased the risk for pain, infection and rehospitalization. Findings include: R17 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia (dementia without a specific diagnosis; a condition which causes a person to lose the ability to think, remember, and reason to the point that it interferes with their daily life, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety) and type 2 diabetes mellitus without complications (a chronic disease that causes a person's blood glucose levels to rise too high). The admission MDS assessment dated [DATE] revealed the resident scored 10 on the BIMS assessment, indicating moderately impaired cognition. Review of Section M of the assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure sufficient staffing to meet resident care needs on 7 of 16 days when resident (R) R106 fell and there were less than three required Certified Nursing Assistant on duty, as outlined in the Facility Assessment. This placed resident at risk for delayed or unmet care needs and lack of supervision to prevent falls and resident to resident altercations. Findings include Review of Resident 106's (R106) record documented the resident was admitted on [DATE] with diagnosis including dementia, diabetes, frequent falls, orthostatic hypotension (sudden drop in blood pressure when you stand up from a sitting or lying position) and stroke. R106's Minimum Data Set (MDS-assessment tool), dated 1/30/24, documented resident's brief interview for mental status was 12 of 15, indicating moderate cognitive impairment and required supervision or touch assistance when transferring from chair to bed or walking 50 feet while using a walker. Resident was transferred to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure 2 of 6 sampled staff reviewed for competencies had documented competencies as evidenced by charge nurse did not complete any trainings in past two years, including fall prevention and Certified Nursing Assistant (CNA) working the floor had an expired CPR certificate. These failures placed residents at risk for unmet and unsafe care needs. Findings include Review of Facility Assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) received from facility on [DATE], dated [DATE], documented the following was required for CNAs, RNs (Registered Nurses), and LPNs (Licensed Practical Nurses), Cardiopulmonary Resuscitation (CPR) Basic Life Support (BLS) upon hire and every two years when CPR expired and training on resident fall prevention protocols and fall management policy upon hire, annually, and as needed. Charge nurse Review of staffing schedule from [DATE] 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 interviews, review of records, and policy, the facility failed to ensure one of two residents reviewed for dental concerns (Resident (R) 38) received routine dental care. The deficient practice resulted in delayed dental services. Findings include: R38 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease (a progressive brain disorder that causes nerve cells in the brain to die or become damaged, leading to movement problems, stiffness and other symptoms ) with dyskinesia (involuntary movement disorder that involves involuntary movements, such as tics, tremors, or shakes) with fluctuations (may range from mild to severe) and low back pain, unspecified. Review of the Nursing admission Screening/History dated 11/20/24 at 12:45 PM included an assessment of the resident's mouth. Per the documentation, the resident had dental caries (decay/cavities) and broken teeth. The notes indicated the resident had, Several remaining natural teeth to upper and lower gums. Poor…

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

Based on observations, interviews, and review of policy, the facility failed to ensure food was stored in accordance with appropriate guidelines. Specifically, 1. A box of frozen blueberries was not left in the freezer open and undated, 2. A scoop was not left in the powdered sugar bin, 3. Expired baking soda was not left on the pantry shelf available for resident use, 4. Refrigerator temperatures/temperature logs were maintained for facility refrigerators, and 5. Staff did not keep personal food items in the resident's refrigerator. The facility census was 53. The deficient practice could increase the risk for foodborne illness. Findings include: On 09/24/24 at 8:05 AM an observation of the kitchen was conducted with the Dietary Manager (DM). During a review of the walk-in freezer, a box of frozen blueberries with a received date of 08/23/24 was noted. The box had been ripped open and the interior plastic bag had been opened but not resealed. The DM stated that dietary staff were supposed to tie the bag up after opening. She instructed a Dietary Assistant to throw the blueberries…

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 that staff completed mandatory QAPI (Quality Assurance and Performance Improvement) training as part of its QAPI program. The deficient practice placed residents at risk for receiving care from staff who did not understand the goals and various elements of the program, including their role in communicating concerns, problems, or opportunities for the facility's improvement to the facility's QAA (Quality Assessment and Assurance) Committee. Findings include: During an extended survey, conducted 10/09/24 through 10/11/24 a review of staff education records was conducted. Review of the evidence provided via electronic training records revealed approximately 48 out of 54 direct care staff had not completed QAPI training for 2024. On 10/09/24 at 2:45 PM an email was received from the Assistant Director of Nursing (ADON). She stated that the QAPI training module had a due date until 12/31/24 and the module was open as well, meaning that staff could complete before the due date. At 3:16 PM on 10/09/24 another email from…

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 five of five currently employed sampled Certified Nursing Assistants (CNAs) or Licensed Nursing Assistants (LNA) (CNA16, LNA2, CNA13, CNA9, CNA8) completed the required 12 hours of annual in-service education based on their hire dates. The facility also failed to ensure CNA16 received annual abuse and dementia training and LNA2 received annual infection control training. These failed practices had the potential to negatively affect the competency of the NAs, placed residents at risk for receiving care from unskilled staff and increased risk for abuse, neglect, unmet care needs and diminished quality of life. Findings include Review of CNA16's personnel file and training records documented hire date of 6/22/21 and 0.5 hours of annual training was completed and did not include abuse and dementia. Review of LNA2's personnel file and training records documented hire date of 6/2/23 and 8.47 hours of annual training was completed and did not include infection control. Review of CNA13's personnel file and training records…

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 ensure 1 of 16 sampled residents (R) (R27) was treated with respect and dignity and received care in an environment that promoted maintenance or enhancement of his or her quality of life. R27 was fed by staff standing over him. This failed practice had the potential to negatively affect the resident's self-esteem. Findings include Review of Resident 27's (R27) record documented resident was admitted on [DATE] with diagnoses including cerebral infarction with hemiplegia (blocks blood supply to part of the brain or when a blood vessel in the brain bursts and part of brain becomes damaged or dies resulting in weakness or loss of strength on one side of the body), diabetes, benign prostatic hyperplasia (enlarged prostate that can block flow of urine out of the bladder) with lower urinary tract symptoms. During an observation on 9/24/24 at about 3:55 PM Certified Nursing Assistant (CNA)13 stood while placed several spoonfuls of apple sauce into…

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 interview and record review the facility failed to ensure background check for criminal history was completed prior to caring for vulnerable adults for 1 of 9 sampled staff (Licensed Practical Nurse (LPN)6) reviewed for background check. This failure placed residents at risk for receiving care from unqualified staff and at risk of abuse and neglect. Findings include Review of staffing schedule from [DATE] to [DATE] showed Licensed Practical Nurse (LPN)6 worked on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. Review of facility policy Abuse-Investigation and Reporting, revised [DATE], documented .[name of facility] shall not employ individuals with criminal background. Background check shall be completed with and/or State of Arizona Public Safety Fingerprinting Department of fingerprinting clearance before employment . Review of LPN6's personnel file documented hire date of…

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

Based on interview and record review, the facility failed to ensure allegations of abuse was reported to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for 1 of 7 sampled residents (R) (R27) reviewed for abuse allegations. This failure placed the resident at risk for potential unidentified abuse and lack of protection from abuse. Findings include Review of facility policy Abuse-Investigation and Reporting, revised 4/18/24, outlined that abuse included physical abuse such as hitting/slapping grabbing . Under the Reporting/Response section the protocol for alleged instances of abuse documented if reportable bodily injury, CN (Charge Nurse) shall report RI (risk incident) to CMS within 2 hours and if no bodily injury, CN shall report to CMS within 24 hours. Review of R27's progress notes dated 3/18/24 at 10:35 PM documented R27 was hit in the face by [R106]. R27 was noted to have minimal amount of redness to the right side of his face. Review of facility's alleged abuse investigation, dated 3/18/24 documented that Licensed Nurse Aide (LNA)2 observed…

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 interview and record review, the facility failed to transmit required Minimum Data Set (MDS-assessment tool) resident assessment data to the Centers for Medicare & Medicaid Services (federal agency that provides health coverage) within the required timeframe for 2 of 2 sampled residents (R) (R10 and R30) reviewed for timeliness in transmitting discharge Minimum Data Set (MDS-an assessment tool). This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings include Review of Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Version 1.19.1, dated October 2024, documented discharge (non-comprehensive) MDS must be completed no later than 14 days after the Assessment Reference Date (ARD) (A2300), and it must be submitted/transmitted within 14 days of the MDS completion date (Z0500+14 days) to the database as required. Resident 10 Review of Resident 10's (R10) record documented the resident was admitted on [DATE] and discharged on 5/17/24. Review…

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 update or correct the Preadmission Screening and Resident Review (PASARR) and notify the state mental health authority for 1 of 1 sampled resident (R) (R29) reviewed for Pre-admission Screening and Resident Review (PASRR) that had a mental health condition or an inaccuracy with current level I form. This failure placed the resident at risk for unmet mental health services necessary to obtain the resident's highest level of functioning and psychosocial well-being. Findings include Review of R29's PASRR Level I, dated 6/30/21, showed No was circled for both Mental Retardation (MR) evaluation criteria and Mental Illness (MI) evaluation criteria. Under MI evaluation criteria, No was circled that resident did not have a primary diagnosis of serious mental illness (SMI) defined in DSM IV at: major depression, psychotic disorder, mood disorder, schizophrenia, delusional disorder (i.e., paranoid) and level of impairment limiting life activities…

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 interview, record review, and policy the facility failed to update/revise the comprehensive care plan for one of two residents (R)17 reviewed for pressure ulcers (PU). The deficient practice had the potential to negatively impact the provision of care and services for R17. Findings include: R17 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia (dementia without a specific diagnosis; a condition which causes a person to lose the ability to think, remember, and reason to the point that it interferes with their daily life, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.) Review of the Weekly Wound Measurements dated 06/02/24 at 7:44 AM revealed for a wound to the resident's right lower leg (front) described as, 1 centimeter (cm) by 1.5 cm, with 0.5 cm by 0.5 cm of yellow eschar tissue, surrounded by 4 cm of yellowish eschar. 2 smaller yellow eschars above this area 1.5 cm and 0.5 cm by 0.8 cm. Areas not draining. Another…

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 ensure that one of two residents review for pressure ulcers received care consistent with professional standards when Resident 35's (R35) wound care assessments were not completed weekly, and care planned intervention of a multi-podus boot (an orthopedic device) was not implemented. This had the potential for R35's pressure ulcers to worsen. Findings: Observed R35 on 09/24/24 at 09:18 AM sitting in a wheelchair in the common area of Household 1. R35 was propelling herself slowly by using her feet over to the surveyor. R35 responded to the surveyor's questions indicating she could not remember what she had for breakfast that day. R35 was well groomed and wore slippers. R35's wheelchair did not have footrests attached. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility admitted R35 on 10/18/23 without any pressure ulcers. The facility assessed R35 to be at risk for pressure ulcers and utilized…

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 ensure 1 of 1 sampled resident (R) (R24) reviewed for urinary catheter received treatment and services to prevent urinary tract infections when staff failed to ensure urinary drainage bag spigot/spout did not touch the inside of the urinal to prevent contamination and failed to develop individualized and specific clinical indications for changing the urinary and bag instead of changing at routine fixed intervals. These failures placed the resident at increased risk for urinary tract infections and its associated complications. Findings include Review of facility policy Indwelling Catheter Care, reviewed 1/2024, documented The urinary tract is the most common site of Healthcare-Associated Infections (HAI), accounting for approximately 40% of hospital infections. The intent of this policy .will assist in the prevention of Catheter-Associated Urinary Tract Infections (CAUTI) .6. Urine in drainage bags should be emptied at lease (least, sp)…

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 interview, record review, and policy, the facility failed to ensure that 1 out of 6 residents (R) reviewed for timeliness of physician's visits (R207), was seen by a physician at least once every 30 days for the first 30 days after admission. This deficient practice had the potential to affect resident care and services. Findings include: Review of the facility policy titled, Physician Services and Visits, revised 01/2024, included it was the policy of the facility, as stated in Federal regulations that govern this certified nursing facility that the resident will be seen at least every thirty (30) days for the first ninety (90) days and at least every sixty (60) days thereafter. A physician's visit is considered timely if it occurs no later than ten (10) days after the visit is required. At the option of the Physician, the required visits in Nursing facilities, after the initial visit, may alternate between personal visit by the Physician and visits by the Physician Assistant (PA), Nurse Practitioner…

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 interview and record review the facility failed to ensure Resident 158 (R158) did not receive duplicate anticoagulant therapy unnecessarily when they failed to ensure the physician intended R158 to be treated with two different anticoagulants. This placed R158 at higher risk of bleeding side effects. Findings: Review of R158's most recent Quarterly MDS assessment dated [DATE] revealed the facility admitted R158 on 05/24/24, diagnoses included hypertension, cerebral infarction (stroke), COVID-19, atrial fibrillation, and gastroesophageal reflux disease. Section M (Medications) indicated R158 took anticoagulant therapy. Review of active physician order dated 5/28/2024 read, Apixaban Oral Tablet 2.5 MG (Apixaban) Give 2.5 mg by mouth two times a day for reducing the risk for stroke and blood clots. related to unspecified atrial fibrillation (an abnormal heart rhythm that predisposes a person to blood clots). Apixaban is an oral anticoagulant. Progress note dated 09/12/24 08:51 revealed R158 was not feeling…

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's assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) was not conducted with input from the required individuals stated in the regulation. This failure placed residents at risk for unmet care needs if their assessed population's needs and resources were not comprehensively identified and addressed. Findings include Review of Facility Assessment (FA) received from facility on 9/23/24, dated 9/19/24, documented several individuals were involved in completing assessment. The following required individuals were not listed: representative from governing body, medical director, resident, representatives, direct care staff and representatives of the direct care staff. The FA showed date assessment reviewed with QAA/QAPI (Quality Assessment and Assurance/ Quality Assurance and Performance Improvement) committee was blank and no date was entered. During an interview on 9/26/24 at 2:32 PM Quality Assurance and Performance Improvement and Infection…

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 establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases when gloves were not changed between residents during 1 of 3 staff (Licensed Practical Nurse 2) medication pass observations. This failure increased the resident risk for infections and its associated discomfort and decline in physical condition. Findings include During an observation on 9/26/24 at 7:22 AM Licensed Practical Nurse (LPN)2 was observed passing medications to residents in the dining room. LPN2 wore gloves and passed four medications to Resident (R )34. Wearing the same gloves, LPN2 prepared, poured and passed seven medications to R27. LPN2 returned to medication cart and wearing the same gloves, prepared and poured three medications for R39. LPN2 approached R39 who was eating his breakfast and touched resident's hand and then repositioned knife that was previously held by resident. LPN2 then placed spoonful of medications…

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 interview and record review the facility failed to ensure infection control practices were implemented to protect vulnerable residents during a COVID-19 (Coronavirus, an infectious disease caused by the SARS-CoV-2 virus) outbreak. The facility failed to notify the local Navajo Nation Health Department, potentially limiting assistance from outside resources, and failed to directly protect residents when they did not ensure symptomatic and/or COVID-19 positive staff did not work in the facility. This deficient practice and system wide failure may have contributed to the extent of the outbreak where thirty-one (31) residents developed COVID-19 infections while residing in the facility, five (5) of which required hospitalization for their symptoms. 1. The facility did not report the COVID-19 outbreak to the Arizona Department of Health and/or the Navajo Nation Health Department. 2. The facility failed to protect residents when they failed to ensure symptomatic and/or COVID positive staff did [NAME] work.…

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, job description review and document review, the facility failed to ensure a Registered Nurse (RN) was placed in the position of Director of Nursing (DON) services. This deficient practice had the potential to affect the care and nursing services provided to all 50 residents. Findings include: Review of the DON's job description provided by the facility, dated on 06/2011, revealed a Job Summary that read, Oversee the nursing department, ensuring the residents receive first quality care in all areas of care . Job Requirements: State registered RN License. During an interview on 09/12/23 at 9:37 AM, the DON was asked for her nursing qualifications. The DON stated, I am not an RN but a Licensed Practical Nurse (LPN). They are supposed to be writing a letter for a waiver. Review of the Licensed Verification Report dated 09/12/23 revealed the DON's license indicating she was an LPN. Review of a Transition Plan for IDON [Interim Director of Nursing] dated 06/27/23 revealed, . I recommend [DON by name] to be delegated as the IDON. The delegation will be effective Friday,…

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

Based on observations, interview, and policy review, the facility failed to ensure food was served and stored in a manner to prevent the potential spread of food borne illness to all 23 residents on the Men's unit and to all residents who were served bread for two meals observed during the survey. Dietary staff failed to adhere to proper glove use when handling ready to eat food. The refrigerator on the Men's Unit was too warm and the temperatures were not adequately monitored. Findings include: Review of the Handwashing and Glove Use policy dated 04/15/20 and provided by the facility revealed, Guidelines for handwashing and glove use to promote safe and sanitary conditions throughout the Food and Nutrition Services Department must be followed . Handwashing is a priority for infection control . When gloves are used, handwashing must occur per above procedure prior to putting on gloves and whenever gloves are changed. Gloves must be changed as often as hands need to be washed, see above. Gloves may be used for one task only. It is important to remember that gloves can often give 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to to establish a process in which the infection control policies and procedures were updated at least annually. In addition, the facility failed to provide indwelling urinary catheter care in a manner to prevent infection for one (Resident (R) 29) of two sampled residents reviewed for indwelling urinary catheters. The deficient practice has the potential to affect all residents in the facility. Findings include: 1. During the survey, the Infection Control Preventionist/DON was asked for the updated facility's infection control policy and procedures several times. The ICP/DON was unable to provide the survey team a copy of the overall facility's infection control policy and procedures. During an interview on 09/14/23 at 2:26 PM, the ICP/DON stated, I don't think it's been updated, and I am not aware. 2. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised 03/29/22, revealed This facility considers hand…

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 interview, record review, and review of the facility's policy, the facility failed to implement an antibiotic stewardship program that promoted safe usage of antibiotics and collect outcome data for one (Resident (R) 99) of one sampled resident reviewed for antibiotic stewardship. In addition, the facility failed to review their antibiotic stewardship policy and procedure annually. This failure placed all residents at risk for antibiotic resistance and poor outcomes. Findings include: Review of the facility's policy titled, Antibiotic Stewardship, dated December 2016 revealed, .Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program . Review of the Transfer and Discharge form provided by the Director of Nursing (DON), revealed, R99 was admitted to the facility on [DATE] with diagnoses that included a stroke with one sided paralysis, diabetes, and heart disease. Review of the admission Minimum Data Set (MDS) located in the MDS tab…

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 develop a Compliance and Ethics Program. Findings: During the survey non-compliance at F610, investigate alleged abuse violation revealed the facility did not consistently follow their own policies. A review of the Facility Assessment revealed a lack of information regarding a Compliance and Ethics Program. During an interview on 09/15/23 at 8:51 AM the Director of Nursing was asked if the facility had a Compliance and Ethics Program. She stated, No, we do not have one. She further stated she was not aware of the requirement. During an interview on 09/15/23 at 9:00 AM the Chief Executive Officer, the appointed Administrator for the facility, was asked if there was a Compliance and Ethics Programs. He stated Staff 80 in HR provides copies of all the policies for staff to follow. When asked to clarify if they had appointed a Compliance Officer, written standards, and/or policies and procedures, for a Compliance and Ethics Program he stated No.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, the facility failed to report misappropriation of personal property, injuries of unknown source, and allegations of abuse to their administrator and/or the Centers for Medicare & Medicaid Services (CMS) immediately, but not later than two hours for four of 11 sampled residents reviewed for abuse/neglect and injuries of unknown injuries (Resident (R)17, R22, R99 and R45). Failing to report timely has the potential to delay facility actions to protect residents from further potential abuse while the allegation is investigated. Findings include: Review of the facility's policy titled, Abuse and Investigation and Reporting, revised 06/15/23, revealed, . has developed the Elder Abuse Policy. to prohibit abuse, neglect, involuntary seclusion, corporal punishment, and misappropriation of property. 7 Components of Abuse Prevention. 4. Identification: The facility will identify events such as bruising of residents, occurrences, patterns, and trends…

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 interview, record review, and review of the facility's policy, the facility failed to investigate an injury of unknown origin for one resident (Resident (R) 1) of four residents reviewed for injury of unknown origin. In addition, the facility failed to implement their abuse policy and take steps to protect residents from the potential of further abuse by removing the alleged perpetrator from resident care, pending investigation for four residents (R3, R16, R17 and R45) of 11 residents reviewed for abuse. This failure had the potential to contribute to further abuse or psychosocial harm for residents. Findings include: Review of the facility's policy titled Abuse Policy revised 12/02/21 revealed, Policy.facility practices (b) to prohibit abuse, neglect, involuntary seclusion, corporal punishment, and misappropriation of property. 7. Components of Abuse Prevention. 5. Investigation: The facility will investigate different types of incidents and identify the staff member responsible for investigation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident and/or the resident representative was provided with written transfer notices upon emergent transfer to the hospital for four out of five residents reviewed for hospitalization (Resident (R)15, R6, R298, and R36) out of a total sample of 17 residents. This had the potential for Residents and/or their representative to be unaware of their rights. Findings include: 1. Review of R15's undated Transfer/Discharge Report provided by the facility revealed R15 was admitted to the facility on [DATE]. Review of R15's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/29/23 in the electronic medical record (EMR) under the MDS tab revealed the facility assessed R15 to have a brief interview for mental status (BIMS) score of three out of 15 which indicated the resident was severely cognitively impaired. Review of R15's hospital Discharge Summary dated 06/16/23 in the EMR under the Misc tab revealed EMS [emergency medical…

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 interview, record review and policy review, the facility failed to ensure four out of five sampled residents reviewed for hospitalization out of a total sample of 17 residents (Resident (R) 15, R6, R298, and R36) were provided with bed hold notices upon emergent transfer to the hospital. Findings include: Review of the facility's Bed Hold Policy dated 09/2022 revealed, Upon admission and at the time a resident is allowed to transfer for hospitalization or for therapeutic leave, Social Service Coordinator shall provide the resident and a family member or legal representative with information concerning Dr Guy [NAME] Sr Care Home's bed-hold policy . When emergency transfers are necessary, the facility will provide the resident or representative with information concerning the facility's bed-hold policy within 24 hours of said transfer . 1. Review of R15's undated Transfer/Discharge Report provided by the facility revealed R15 was admitted to the facility on [DATE]. Review of R15's annual Minimum Data Set…

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, record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for five out of 17 sampled residents (Resident (R) 24, R19, R3, R42, and R43), creating the potential for a lack of appropriate care and services. Findings include: Review of the facility's policy titled, Comprehensive Assessment and Care Planning dated 03/29/22 and provided by the facility revealed, Initially and periodically, NNHI (Navajoland Nursing Homes Inc) will conduct a comprehensive, accurate, standardized reproductive assessment of each resident's functional capacity. This assessment will provide the facility with the information necessary to develop a care plan and to provide the appropriate care and service for each resident. 1. Review of R24's undated Transfer/Discharge Report provided by the facility revealed R24 was readmitted to the facility on [DATE] with diagnoses including dementia, type two diabetes mellitus, and age-related physical debility. Review of R24's…

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

Based on interview, record review and policy review, the facility failed to ensure three of three Certified Nursing Aide (CNA)35, CNA67, and CNA96) completed the required training annually. Findings include: Review of the facility's undated policy titled Staff Development and Training from the personnel policy manual presented by the facility, revealed, 1. Employees are mandated to participate in job related training to enhance job performance, development and strengthen skills, and to keep current on specific developments and trends. 1. Review of User Learning document, provided by the facility revealed for Certified Nursing Assistant (CNA) 35 no evidence of completion of the required in-services for abuse, neglect, and exploitation; resident rights; dementia; infection control (IC); compliance; and Quality Assurance (QA). Further review revealed that Abuse, Neglect, and Exploitation training was due on 06/30/23, Protecting Resident Rights in Nursing Facilities self-paced was due 06/30/23, About Infection Control and Prevention was due 03/31/23, Communication and People with…

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 Review of the facility demographic sheet revealed R7 was admitted on [DATE]; diagnoses included diabetes. A current physician order read, Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 30 unit subcutaneously at bedtime for Lowering Blood Sugar . During an observation of medication administration with Licensed Nurse (LN) 15 on 09/13/23 at 7:35 PM, LN15 prepared 30 units of Insulin Glargine at the medication cart in the hallway outside of R7's room. R7 was wheeling their wheelchair toward their room. Observed LN15 raise R7's shirt exposing their abdomen and inject the insulin while in the hallway outside of R7's room. Following the injection LN15 was asked if she usually gave injections in the hallway. She stated, I didn't realize I did that. She confirmed injections should be given in privacy. Based on observation, interview, and record review, the facility failed to ensure that two residents (Resident (R) 348, R7) of eight residents observed during Medication Administration were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to ensure one resident (Resident (R) 17) of 17 sampled residents were free misappropriation of property by staff. This deficient practice had the potential to allow staff to take advantage of residents for personal gain. Findings include: Review of the facility's policy titled Abuse Policy revised 12/02/21 revealed, Policy.facility practices (b) to prohibit abuse .and misappropriation of property.3. Residents shall not be subject to abuse by any individual which includes: Facility staff. Family members.Definitions. 6. Personal Property Misappropriation. Appropriate wrongly as by theft or embezzlement. Appropriate to set apart of or assign to particular purpose. Review of R17's undated admission Record, located in the Electronic Medical Record (EMR), under the Profile tab, revealed the resident was admitted to the facility on [DATE]. Review of R17's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy, the facility failed to identify and complete a significant change in status Minimum Data Set (MDS) assessment for two (Residents (R) 3 and R36) in a total sample of 17. The facility failed to assess R3 for increased behaviors and declining cognition, and R36 for a significant decline in their physical condition which impacted their ability to perform activities of daily living (ADLs). This had the potential for care and services needed for R3 and R36 to reach their highest practical well-being not to be identified, assessed, planned, and provided. Findings included. According to the State Operations Manual (SOM) 483.20 (b)(2)(ii), effective 11/28/17, a Significant Change Assessment is performed, Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a Significant Change means a major decline or…

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, review of the Resident Assessment Instrument (RAI) manual and policy review, the facility failed to ensure that two residents (Resident (R) 2, and R4), out of 17 sampled residents', and one unsampled resident's (R46) Minimum Data Set (MDS) assessments were transmitted in a timely manner. Findings include: Review of the facility's policy titled, Electronic Transmission of the MDS, revised November 2019, revealed All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records are completed and electronically encoded into our facility's MDS information system and transmitted to Center for Medicare and Medicaid Services (CMS) Internet Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in accordance with current Omnibus Budget Reconciliation Act (OBRA) regulations governing the transmission of MDS data. Policy Interpretation and Implementation .1. All staff members…

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 interview, record review, and policy review, the facility failed to ensure one of two sampled residents recently admitted to the facility (Resident (R) 98), out of a sample of 17 residents, was provided with the written summary of the baseline care plan following admission. R98 stated she did not know what the services and treatments for her care entailed. Findings include: Review of the facility's policy titled, Comprehensive Assessment and Care Planning dated 03/09/22 and provided by the facility revealed, An admission care plan will be created on the date of admission by initiating an Interim Care Plan . Within three (3) days of admission, each discipline will review and edit or add a new problem to provide all essential services. The policy did not address the provision of a summary of the Interim Care Plan to the resident or responsible party. Review of R98's undated Transfer/Discharge report provided by the facility revealed R98 was admitted to the facility on [DATE] with diagnoses including…

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 develop a care plan for the problem of dehydration for one of one resident (R )15 in the sample of 17. Specifically, the resident was admitted to the hospital on two occassions for diagnosis of dehydration. Findings include: Review of R15's undated Transfer/Discharge Report provided by the facility revealed R15 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease stage 2, dysphagia (swallowing disorder), hypo-osmolality and hyponatremia (retention of water with low sodium level). Review of R15's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/29/23 in the electronic medical record (EMR) under the MDS tab revealed the facility assessed R15 to have a brief interview for mental status (BIMS) score of three out of 15 which indicated the resident was severely cognitively impaired. Continued review of the MDS revealed R15 was required extensive assistance with eating. R15 was 55 inches tall 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, interview, record review, and policy review, the facility failed to ensure one out of four residents reviewed for nutrition (Resident (R)15), out of a total sample of 17 residents, received sufficient fluids to ensure adequate hydration. R15, who was on a physician ordered fluid restriction, was hospitalized twice, and noted to be dehydrated in June and July 2023. Failures included a lack of reassessment following hospitalization with dehydration, not monitoring fluid intake records, and not putting together a plan to ensure adequate hydration status. Findings include: Review of the facility's policy titled, Hydration Protocol dated 07/26/18 and provided by the facility revealed, Residents should be provided sufficient fluid intake to maintain hydration and health . For elderly, recommend not giving less than 1500 ml per day unless this conflicts with the physician's orders . In the Nutrition Risk Review process, identify residents with a diagnosis of dehydration or at risk of dehydration…

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 interview and record review the facility failed to ensure an as needed (PRN) antipsychotic medication order was limited and prescribed for only 15 days for R43, one of five residents reviewed for unnecessary medications. Findings: Review of the facility demographic sheet revealed R43 was admitted on [DATE]; diagnoses included dementia with behavioral disturbance. Review of Current Orders in the Electronic Medical Record (EMR) included, Quetiapine Fumarate [an antipsychotic medication] Oral Tablet 25 MG (Quetiapine Fumarate) Give 25 mg by mouth as needed for treat certain mental/mood disorder related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE (F03.918). The order was date 5/11/2023. Review of the Consultant Pharmacist's recommendation dated 06/30/23 read, We recommend: Discontinue unused PRN Seroquel [generic med is Quetiapine Fumarate] (not used in last 2 months). Note: Patient is high fall risk. In the Follow-Through column it read, note written to physician 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.