Haven Health Sky Harbor, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, staff interviews, review of facility documentation and policy, and the State Agency (SA) complaint tracking system, the facility failed to ensure a safe and appropriate transfer of one resident (#1). The deficient practice could result in residents not receiving appropriate care and services during the transition of care. Findings include: Resident #1 was admitted on [DATE] with diagnoses of cerebral palsy, chronic respiratory failure with hypoxia, polyneuropathy, dysphasia, and scabies. The care plan dated April 2, 2024 included that the resident was ventilator dependent related to respiratory failure. Interventions included to assess for signs/symptoms of hypoxia such as altered level of consciousness, irritability, listlessness and cyanosis; chest physio-therapy as ordered; keep head of bed elevated above 30 degrees; maintain spare trach at bedside; maintain ventilator settings as ordered; to monitor oxygen saturation while resident was on mechanical ventilatory support and/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 documentation, staff interviews, and the facility policy and procedures, the facility failed to provide and ongoing program of activities designed to meet the interest and the physical, mental, and psychological well-being of two residents (#48 and #37). The deficient practice could result in a decline in physical and social skills. Findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included blindness in right and left eye, deaf non-speaking, aphasia following cerebral infarction. The care plan dated September 7, 2023 revealed a communication problem related to a hearing deficit and impaired cognition include the goal that the resident will be able to make her basic needs known. Interventions included that the staff will anticipate and meet the needs of the resident, and staff will be conscious of the resident's position when in groups, activities, and the dining room to promote proper communication with others. and discuss with the resident/family concerns 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 clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure pain medications were administered as ordered for one resident (#68). The deficient practice could result in resident receiving unnecessary medication and overmedicated. Findings include: Resident #68 was admitted on [DATE] with diagnoses of acute respiratory failure, critical illness myopathy, and Type II Diabetes. The care plan dated August 14, 2023 revealed that the resident was at risk for pain. Interventions included to anticipate the resident's need for pain relief and respond as soon as possible to any complaint. A physician order dated November 2, 2023 included for Tramadol HCI (narcotic analgesic) oral tablet 50 mg give 25 mg enterally every 12 hours as needed for pain 6-10. The minimum data set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 14 indicating the resident had intact cognition. Review of the medication administration record (MAR)…

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, staff interviews, and the facility policy and procedures, the facility failed to ensure that food items that were unsafe for resident consumption were discarded; and, the facility failed to ensure a clean and sanitary environment was maintained in the kitchen. The facility census was 98. The deficient practice could result in a potential for food borne illness and resident safety. Findings include: An initial tour of the kitchen was conducted with the dietary manager (staff #2809) on April 29, 2024 at 7:20 a.m. There was a 10-pound box of Romaine lettuce in an unsealed plastic bag in the walk-in refrigerator. There was also 10-pound box of snap peas that had white fuzzy growth on the snap peas. The dietary manager stated the bag was approximately one-third full; and, there was approximately two pounds of snap peas remaining in the box. The dietary manager stated that the lettuce leaves were wilted and some of the leaves were brown around the edges; and, the pea pods were no longer good because there was something growing on the pea pods. Further, the dietary…

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 clinical record review, staff interviews, review of facility documentation, and policy, the facility failed to ensure that the electronic health record for resident #48 was complete and accurately documented. The sample size was 20. The deficient practice could result in incomplete and/or inaccurate clinical records. Findings include: Resident #48 was admitted on [DATE] with diagnoses including aphasia, dysphagia, major depressive disorder-recurrent, schizophrenia, generalized anxiety disorder, deaf, and blindness-right eye. A review of the quarterly MDS (minimum data set) dated November 23, 2024 revealed a BIMS (brief interview of mental status) score of 99, suggesting severe cognitive impairment. A review of the plan of care (POC) response history, denoting the caregiver task of eating, for resident #48 on May 1, 2024 revealed that the resident had refused breakfast; however, the facility video revealed that staff #5901, had provided the meal tray and assisted with breakfast. The breakfast entry 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 staff interviews, and review of facility documentation and policies, the facility failed to ensure that the QAA (quality assessment and assurance) committee developed and implemented action plans on identified problem related to PRN (as needed) pain medication administration. Findings include: In an interview conducted on May 2, 2024 at 3:34 p.m., with the Director of Nursing (DON/staff #4558) and the [NAME] President of Clinical Operations (Staff #2908). Staff #4558 stated that pain medications prescribed on an as needed basis (PRN) need a pain scale and it is her expectation that nurses assess the pain level prior to administration and document the pain level. She also stated that there is a risk of over or under medicating a resident if the pain medication is administered outside to the pain scale. Staff #2908 stated that they have identified the administration of pain medication as a problem in the last couple of months, and it is being addressed through quality assurance and performance improvement (QAPI). An interview was conducted on May 6, 2024 at 11:24 a.m., 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 Based on review of the clinical record, staff interviews, facility documentation, policy and procedure, the facility failed to ensure that one resident's (#48) communication deficit was appropriately care planned and implemented. The deficient practice could result in a plan of care that did not meet the resident's needs. Findings include: Resident # 48 was admitted on [DATE] with diagnoses which included blindness, deafness, dysphasia, anxiety disorder, aphasia, schizophrenia, and major depressive disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had highly impaired hearing and unclear speech. The MDS noted that the resident was rarely/never understood and rarely/never understands. Furthermore, the MDS indicated that the resident had severely impaired vision. The MDS assessment also noted that the resident was dependent for cares. Further review of the annual MDS dated [DATE] indicated that the resident's diagnoses included aphasia, Cerebrovascular Accident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, family and staff interviews, and facility policy and procedure, the facility failed to provide care and services related to communication for one resident (#48) assessed with communication/language deficit. The deficient practice could result in residents not maintaining their communication abilities. Findings include: Resident # 48 was admitted on [DATE] with diagnoses which included blindness, deafness, dysphasia, anxiety disorder, aphasia, schizophrenia, and major depressive disorder. A neurology note dated May 19, 2023 indicated that resident #48 is bed ridden and needs tactile sign language to communicate. The note revealed that the resident has a complex medical history. She was born deaf, and had been high functioning for many years. However, she developed [NAME] syndrome and retinal detachment and lost her vision in her 30's. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had highly impaired hearing and unclear…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure assistance with meals was provided to one resident (#48). The sample size was 20. The deficient practice could result in resident not receiving adequate nutrition. Findings include: Resident #48 was admitted on [DATE] with diagnoses of aphasia, dysphagia, major depressive disorder-recurrent, schizophrenia, generalized anxiety disorder, deaf, and blindness-right eye. The minimum data set (MDS) dated [DATE] included a staff assessment for mental status score of 3 indicating the resident had a severe cognitive impairment. The care plan dated September 7, 2023 included that the resident had communication problem related to hearing deficit and impaired cognition. Interventions included anticipating and meet resident needs; and to communicate regarding resident's capabilities and needs. The care plan further revealed that the resident was at risk for functional self-care deficits, required…

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

Based on record review, staff interviews, and the facility policy and procedures, the facility failed to provide documentation of nursing and non-nursing staff working hours. The deficient practice could result in a lack of sufficient staffing and impact the residents' treatment and care. Findings included: Review of the daily staff posting dated July 30, 2023 revealed that one registered nurse (RN), four licensed practical nurses (LPNs), and eight certified nursing assistants (CNAs) were scheduled to work a 12-hour shift on the day shift. Review of the nursing and non-nursing schedule dated July 30, 2023 revealed that one RN, four LPNs, eight CNAs were scheduled to work 12 hours on the day shift, However, none of the staff signed in to indicate that they were present for the shift. Review of the daily staff posting dated July 30, 2023 revealed that three LPNs, and five CNAs were scheduled to work 12 hours on the night shift, and one CNA was scheduled to work eight hours during the night shift. Review of the nursing and non-nursing schedule dated July 30, 2023 revealed that three…

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 documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that a registered nurse (RN) worked at least 8 consecutive hours per day. Findings included: Review of the daily staff posting dated December 31, 2023 did not reveal that a RN was scheduled to work on the day or night shift. Review of the nursing schedule dated December 31, 2023 did not reveal that a RN was scheduled to work the day or night shift. Review of the punch cards dated December 31, 2023 did not reveal that a RN worked during the day or night shift. The PBJ Staffing Data Report for the fourth quarter, October 1 through December 31, 2023 revealed that the facility had four or more days within the quarter with no RN hours. An interview was conducted on May 2, 2024 at 3:48 p.m. with the Staffing Coordinator (staff #7750), who stated that one RN is needed to work in the facility at least one 12-hour shift daily. An interview was conducted on May 2, 2024 at approximately 4:45 p.m. with Human Resources (staff # 9814), who stated that she starting inputting the staffing…

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 clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure dental needs were met for one sampled resident (#14). The deficient practice could result in residents not receiving care and services for oral/dental conditions. Findings include: Resident # 14 was initially admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, chronic obstructive pulmonary disease, aphagia, dysphagia, and general anxiety disorder. A physician order dated July 31, 2023 directed that resident may be seen by podiatrist, dentist, eye doctor, wound care consultant, psychiatrist, and audiologist of choice as needed. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident has obvious or like cavity or broken natural teeth. A care plan regarding oral/dental health revised on December 5, 2023 indicated that the resident had potential for oral/dental health problems. Interventions included to coordinate for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and policy review the facility failed to ensure a resident's (#48) food was served warm and palatable. The sample size was 20. The deficient practice has the potential for residents to refuse meals and or potentially impact the resident's nutritional intake as well as weight. Findings include: Resident #48 was admitted on [DATE] with diagnoses of aphasia, dysphagia, major depressive disorder-recurrent, schizophrenia, generalized anxiety disorder, deaf, and blindness-right eye. The minimum data set (MDS) dated [DATE] included a staff assessment for mental status score of 3 indicating the resident had a severe cognitive impairment. The care plan dated September 7, 2023 revealed that the resident was at risk for functional self-care deficits, required assistance with meals, had a nutritional or potential nutritional problem requiring one on one assistance with dining. A review of facility's video recordings for the 2100 nurses' station was conducted on May 2, 2024 at 3:09 P.M. 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 Based on documentation, staff interviews, and facility policies the facility failed to ensure that staff were trained in communication skills needed to communicate with one resident (#48). The deficient practice could result in staff not understanding the medical and care needs of the residents. Findings include: Resident # 48 was admitted on [DATE] with diagnoses which included blindness, deafness, dysphasia, anxiety disorder, aphasia, schizophrenia, and major depressive disorder. A neurology note dated May 19, 2023 indicated that resident #48 is bed ridden and needs tactile sign language to communicate. The note revealed that the resident has a complex medical history. She was born deaf, and had been high functioning for many years. However, she developed [NAME] syndrome and retinal detachment and lost her vision in her 30's. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had highly impaired hearing and unclear speech. The MDS noted that the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and policy review, the facility failed to ensure that medications were administered as ordered by the physician for one resident (#400). The deficient practice could result in residents not receiving prescribed doses of medications. Findings include: Resident #400 was admitted on [DATE] with diagnoses of cerebral infarction, myalgia, hyperlipidemia, polyneuropathy, and gastro-esophageal reflux disease. A care plan initiated on April 1, 2024 revealed the resident had a history of stroke. Interventions included to give medications as ordered by the physician. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident had intact cognition. The physician order dated March 28, 2024 revealed the following orders: - Atorvastatin (anticholesterol) calcium oral tablet, give 40 mg (milligram) by mouth one time a day for hyperlipidemia; and, - Gabapentin (anticonvulsant) oral capsule,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, facility documents, and resident records, the facility failed to ensure there was adequate oxygen for 6 residents. The sample size was 6. This deficiency could result in significant harm to the residents. Findings include: On 01/0120/24 at 900 PM respiratory therapy told security that the main oxygen supply was low. Security then told the Maintenance Director, (Staff #13), who directed them to switch oxygen supply to reserve tanks of oxygen. On 01/02/2024 at 4:00 AM, the respiratory staff noticed the reserve was low and switched oxygen supply from in wall to e-tanks (small 3-foot aluminum tanks with up to 3,000 psi-pounds per square inch- of compressed oxygen). At 5:40 AM, the Respiratory Therapy Director, (Staff #72) was notified of an emergent oxygen situation. At 6:10 AM, the Director of Nursing (DON/Staff #8), arrived on site and was then informed of the concerns with facility oxygen supply. The decision was made to start sending residents to hospitals due to emergent…

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 -Resident #44 was admitted to the facility on [DATE] with diagnoses that included intracranial injury with loss of consciousness, personal history of traumatic brain injury, restlessness and agitation, and anxiety disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) was not assessed, but the assessment indicated the resident was severely impaired for daily decision making. The order summary included an order dated October 10, 2022 for lorazepam (an antianxiety medication) 1 milligram (mg) tablet via Gastrostomy tube (G-tube) every 6 hours as needed for anxiety. This order did not include a stop date. Review of the Medication Administration Record (MAR) for October, November, and December 2022 revealed that the lorazapam was administered on two occasions on October 18 and one occasion on October 30 as well as on November 2, 6, and 30. Review of the clinical record revealed no evidence that the physician had reevaluated the need 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.

Based on facility documentation, interviews, policy, and Centers for Disease Control (CDC) guidance, the facility failed to ensure the Infection Preventionist (IP) had completed infection control training. The deficient practice could lead to unqualified staff acting as the IP and improper infection prevention practices within the facility. Findings include: During an interview with the administrator (staff #41) on December 12, 2022 at 1:04 p.m., he stated that the facility was currently experiencing a COVID-19 outbreak due to staff testing positive. He said that the facility does have a staff member assigned to be the IP and that this person is Licensed Practical Nurse (LPN/staff #67). An interview was conducted with the IP (LPN/staff #67) on December 14, 2022 at 1:08 p.m. He stated the facility was utilizing him as the IP and had done so since October 10, 2022. He stated that he does not have infection control training, but he was totally responsible for infection control and prevention in the facility. During an interview with the administrator (staff #41) on December 15, 2022 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, interviews, and policy, the facility failed to ensure one resident's (#255) dignity was maintained by failing to ensure the resident's catheter bag was covered. The deficient practice could result in residents not being treated with respect and dignity. Findings include: Resident #255 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, aphasia, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of a nursing note dated December 1, 2022 revealed the resident was admitted to the facility with an indwelling catheter. An observation was conducted on December 12, 2022 at 1:45 p.m. The resident was observed with the indwelling urinary catheter full of urine. The drainage bag was on a mattress on the floor and it did not have a privacy bag. The tubing and the drainage bag was visible from the door to the resident's room. Review of the resident's care plan, initiated 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 observations, clinical record review, interviews, policy and manufacturer guidelines, the facility failed to ensure medication orders met one resident's needs (#255) according to professional standards of care and the facility failed to ensure glucometers were disinfected properly. The deficient practice could result in unmet resident needs and improperly disinfected glucometers. Findings include: Regarding medication orders: -Resident #255 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, aphasia, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of the physician order summary dated December 14, 2022 included the following orders: -Nothing by mouth -Augmentin tablet 875-125 mg - give 1 tablet by mouth two times a day for pneumonia/leukocytosis for 7 days -Doxycycline tablet 100 mg - give 1 tablet by mouth two times a day for pneumonia/leukocytosis for 10 days Review of the Medication…

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 clinical record review, interviews, and facility policy, the facility failed to provide timely continence care for one resident (#2). The deficient practice could affect residents' self-esteem and cause skin breakdown. Findings include: Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure, Chronic Obstruction Pulmonary Disease (COPD), and unspecified dementia. Review of the resident's care plan revealed the following focus areas: -November 4, 2021 - Resident has potential for skin impairment related to impaired mobility and incontinence. Interventions for this plan included to apply barrier cream to buttocks after each incontinence episodes and/or with a.m. and p.m. care as ordered, and to identify and document potential causative factors and eliminate/resolve them when possible. -December 16, 2021 - Resident had an Activities of Daily Living (ADL) performance deficit related to activity intolerance, fatigue, impaired balance,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, interviews, and policy, the facility failed to provide respiratory care and treatment as ordered by the physician for one resident (#255). The deficient practice could result in unmet respiratory needs. Findings include: Resident #255 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, pneumonitis due to inhalation of food and vomit, and cerebral infarction. Review of modification of admission MDS (Minimum Data Set) dated December 7, 2022 revealed BIMS was not conducted due to resident was rarely/never understood. The assessment included special treatment of oxygen therapy. Review of physician orders dated December 2, 2022 revealed an order for oxygen via nasal cannula with humidification. The order included the ability to titrate oxygen to keep oxygen saturation greater than 90 percent every shift. Review of Treatment Administration Record (TAR) for December 12, 13 and 14, 2022 revealed the order for oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, clinical record reviews, review of medlineplus.gov, and policy, the facility failed to ensure the medication error rate was not 5% or greater by failing to administer a medication as ordered for one of five sampled residents (#51) and by crushing a medication tablet that was not supposed to be crushed for one resident (#47). The medication error rate was 8%. The deficient practice could result in additional medication errors. Findings include: -Resident #51 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and hypertension. Review of the physician order summary dated December 15, 2022 included an order to give an aspirin, enteric-coated tablet, delayed release, 81 milligrams (mg) by mouth one time a day. During an observation of medication administration on December 14, 2022 at 09:00 a.m. by Licensed Practical Nurse (LPN, #154), the nurse dispensed…

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 personnel file reviews, staff interviews, and policy, the facility failed to provide evidence that 3 of 10 sampled staff (#182, #176, and #45) were provided resident rights training. The deficient practice could result in residents not being afforded their rights. Findings include: -Review of the personnel file for staff #182, a Certified Occupational Therapy Assistant (COTA), revealed a hire date of October 1, 2019. Further review of the personnel file revealed no evidence that staff #182 had received training on resident rights. -Review of the personnel file for staff #176, a Physical Therapist (PT), revealed a hire date of April 7, 2021. Further review of the personnel file revealed no evidence that staff #176 had received training on resident rights. -Review of the personnel file for staff #45, a Respiratory Therapist (RT), revealed a hire date of April 30, 2020. Further review of the personnel file revealed no evidence that staff #45 had received training on resident rights. During an interview conducted on December 14, 2022 at 12:08 p.m. with human resources (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 personnel file reviews, interviews, and policy, the facility failed to provide evidence that 3 of 10 sampled staff (#182, #176, and #45) were provided training on abuse, neglect, exploitation, misappropriation of resident property, and dementia management. The deficient practice could result in staff not being educated to protect residents from abuse and to provide the appropriate services to residents with dementia. Findings include: -Review of the personnel file for staff #182, a Certified Occupational Therapy Assistant (COTA), revealed a hire date of October 1, 2019. Further review of the personnel file revealed no evidence that staff #182 had received training on abuse, neglect, exploitation, misappropriation of resident property, and dementia management. -Review of the personnel file for staff #176, a Physical Therapist (PT), revealed a hire date of April 7, 2021. Further review of the personnel file revealed no evidence that staff #176 had received training on abuse, neglect, exploitation, misappropriation of resident property, and dementia management. -Review 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 personnel file reviews, staff interviews, and policy, the facility failed to provide evidence that 3 of 10 sampled staff (#182, #176, and #45) were provided training on infection control. The deficient practice could result in the spread of infection. Findings include: -Review of the personnel file for staff #182, a Certified Occupational Therapy Assistant (COTA), revealed a hire date of October 1, 2019. Further review of the personnel file revealed no evidence that staff #182 had received training on infection control. -Review of the personnel file for staff #176, a Physical Therapist (PT), revealed a hire date of April 7, 2021. Further review of the personnel file revealed no evidence that staff #176 had received training on infection control. -Review of the personnel file for staff #45, a Respiratory Therapist (PT), revealed a hire date of April 30, 2020. Further review of the personnel file revealed no evidence that staff #45 had received training on infection control. During an interview conducted on December 14, 2022 at 12:08 p.m. with human resources (staff #132), he…

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.