Pioneers Memorial Skilled Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure confidential information was kept private for one of five sampled residents (Resident 28 ). As a result, Resident 28's right to privacy and confidentiality was violated. Findings: Resident 28 was re -admitted to the facility on [DATE] with diagnoses which included Acute Prostatitis (painful inflammation of the prostate gland), Local infection of the skin and subcutaneous tissue and Urinary Tract Infection per Facility's admission Record. On 1/7/25 at 7:05 P.M., an observation of nursing station One was conducted. The Vital signs record of Resident 28 was seen on the counter of nursing station one unattended. The vital signs record contains Resident 28's name, room number, blood pressure, pulse, temperature, respiratory rate, bowel movement consistency, and oxygen saturation. On 1/9/25 at 11:45 A.M., an interview with Infection Preventionist/Registered Nurse (IP/RN) was conducted. The IP/RN stated vital signs record are part 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 and record review, the facility failed to provide communication tool for 2 of 18 sampled residents (Resident 13 and Resident 36). As a result, there was a potential for Resident 13 and Resident 36 to not be able to communicate their needs to staff and effect their quality of life. Findings: 1. Resident 13 was admitted to the facility on [DATE] with diagnoses which included dementia (a decline in mental abilities that affects thinking, memory, and behavior), hemiplegia (paralysis of one side of the body), and urinary retention (unable to empty urine in bladder) per Resident 13's admission Record. Observations were conducted on 1/7/25 at 12:30 P.M., and on 1/8/24 at 10:30 A.M., with Resident 13. Resident 13 was observed having difficulty communicating, trying to say incomprehensible words, murmuring words, making sign language, nodding his head up and down or side to side. In addition, Resident 13 was also observed without a communication tool (a book or a board to convey 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 and record review, the facility failed to provide the needed care for one of three residents (Resident 54) when Resident 54's skin discoloration was not assessed and documented for monitoring. This failure had the potential for nursing staff to not identify any deterioration on Resident 54's skin discoloration which could result in delay of treatment. Findings: A review of Resident 54's face sheet indicated, Resident 54 was admitted to the facility on [DATE] with diagnoses that included dementia (forgetfulness), atrial fibrillation (A-Fib -irregular heart rate). A review of Resident 54's physician order dated 1/1/25, indicated, Resident 54 was receiving Apixaban (generic name, anticoagulant - blood thinner) oral tablet. Give 2.5 milligrams (mg - unit of measurement) by mouth two times a day for A-Fib. An initial tour conducted on 1/7/25 at 10:45 A.M., Resident 54 was observed to have a purplish discoloration on his right side of his right elbow. A concurrent interview and record…

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 a gastric tube (GT - tube surgically inserted inserted into the stomach to provide food and medication) was free from a possible complication for one of one resident (Resident 23) when Resident 23's GT had an air bubble (pocket of air trapped)in the line. This failure had the potential to compromise Resident 23's health condition. Finding: A review of Resident 23's face sheet indicated she was admitted to the facility on [DATE] with medical diagnoses of dysphagia (difficulty swallowing), cerebral infarction (blockage in the brain causing weakness), and hemiplegia (weakness in one part of the body). A review of Resident 23's Physician's History and Physical (PHP- physician assessment about a resident's health) dated 4/8/24 indicated, Resident 23 did not have the capacity to understand and make decisions on her own. A concurrent observation and interview were conducted with the Director of Staff Development (DSD) on 1/9/25 at 7:04…

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 replace an oxygen cylinder for one of three residents (Resident 61) in a timely manner. This failure had the potential for Resident 61 to run out of oxygen and affect her wellbeing. Finding: A review of Resident 61's face sheet indicated, Resident 61 was admitted to the facility on [DATE] with diagnoses that included heart failure, respiratory failure with hypoxia (low level of oxygen). A review of Resident 61's physician order dated 7/9/24 indicated, Oxygen at 2 liters per minute via nasal cannula every shift for shortness of breath (SOB). An initial observation and interview was conducted with Resident 61 on 1/7/25 at 11:43 A.M. Resident 61 stated, there was no oxygen coming out of her cannula. Resident 61 further stated she needed continuous oxygen. Resident 61's oxygen tank was observed empty. An interview was conducted with certified nursing assistant (CNA) 6 on 1/7/25 at 11:50 A.M. CNA 6 stated, Resident 61's oxygen tank was empty…

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 Licensed Nurse followed the physician order and had adequate competency in providing care to: 1. 4 of 18 (Resident 2, Resident 13, Resident 23, and Resident 52) sampled residents with low air loss mattress (mattress that uses air to relieve pressure). 2. 2 of 19 (Resident 2 and Resident 72) sampled residents with wound vacuum (wound vac - a device that uses negative pressure to help wounds heal). This failure had the potential risk to resident's care and well-being. Findings: 1a. Resident 2 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body), diabetes (high blood sugar) and pressure ulcer (wound) per Resident 2's undated admission Record. A review of Residents 2's physician orders indicated the low air loss mattress order: Low air loss mattress .settings are based on weight, may adjust for comfort . A concurrent observation, interview and record review was conducted 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 interview and record review, the facility failed to provide a registered nurse (RN) for at least eight hours a day to 99 residents. This failure had the potential to affect residents care, health, and wellbeing. Findings: Review of the Centers for Medicare and Medicaid Services (CMS - federal agency responsible in implementing standards in the long-term care facilities) Payroll Based Journal (PBJ - system where staffing information are collected on a regular basis) for the quarter 4 2024 (July 1 - September 30) indicated, No RN hours four or more days. A concurrent interview and record review was conducted with the Director of Staff Development (DSD) on 1/9/25 at 12:45 P.M. The DSD reviewed the facility's daily assignment sheets dated, 7/13/24, 7/20/24, 8/10/24, 8/24/24 and 9/15/24. The DSD stated, there was no RN coverage for at least eight hours a day from July to September 2024. The DSD further stated, an RN should have been in the facility to provide RN care when needed. An interview was conducted with the Director of Nursing on 1/10/25 at 10:07 A.M. The DON stated, 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 and record review, the facility failed to ensure administration of medication were implemented per physician orders to 2 of 18 sampled residents. This failure had the potential risk to the residents' well-being and care. Findings: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body), diabetes (high blood sugar) and pressure ulcer (wound) per undated admission Record. A review of Resident 2's physician orders indicated the medication order Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) inject as per sliding scale: if 0[noted possible typo 70}-150=0; 151-200=3; 201-250=5; 251-300=8; 301-350=12; 351-400=15, subcutaneous [under the skin] before meals and at bedtime for diabetes > 400 notify MD [medical doctor] if BS [blood sugar] below 70 and follow hypoglycemic protocol [management/treatment of low blood sugar] A review of facility's meal service times indicated, Breakfast: Rooms at 7:30 A.M. 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, and record review, the facility failed to ensure medication error rate for medication pass did not exceed 5 percent. There were 25 medication opportunities. Four medication errors were identified. The error rate was 16%. This failure had the potential to cause harm to the residents. Findings: 1. Resident 38 was admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar), peripheral vascular disease (PVD - circulatory condition when blood vessels narrow, spasm, or become blocked) and foot ulcer (wound) per undated admission Record. A review of Resident 38's physician orders indicated the following medication orders: 1. Carvedilol oral tablet 3.125 MG (Carvedilol). Give 1 tablet by mouth every 12 hours for HTN. Hold SBP >90 or DBP <60; 2. Ticagrelor Oral Tablet 90 MG (Ticagrelor). Give 1 tablet by mouth two times a day for antiplatelet; 3. Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen). Give 1 tablet by mouth every 6…

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 infection control procedures were maintained in the facility when: 1) A water reservoir tank was observed to be leaking and with greenish black substance. 2) A suprapubic catheter (a tube inserted into the bladder through a cut in the tummy to drain urine from the bladder) bag and dignity bag (a bag used to cover and conceal contents inside), was lying on the floor for one of three residents reviewed for urinary catheter care (Resident 13). These failures had the potential for the spread of infection. Findings : 1) On 1/10/25 at 9:20 A.M., a tour of the facility with the Infection Preventionist (IP) was conducted. A 550-gallon water reservoir tank was observed just outside the kitchen. The water reservoir tank was observed to be with water leaking and with greenish black substance surrounding the opening of the faucet. The opening of the faucet was not covered. On 1/10/25 at 9:25 A.M., an interview with IP was conducted. IP stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record reviews, the facility failed to provide two-person physical assistance with transferring for one of one resident (Resident 1) when Resident 1 was transferred from bed to the Hoyer lift by a staff alone. This failure had the potential to result in harm or even death. Findings: The department received a facility reported incident on 12/16/2024. It was reported that, his (Resident 1) amputee was caught during a weight measuring procedure, skin tear occurred and bleeding. A record review of the facility's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include acquired absence of left leg above the knee , and difficulty walking , not elsewhere classified. A joint observation and interview on 12/17/2024 at 11:40 A.M., with Resident 1 was conducted. Resident 1 had a bandage on his left leg s/p left above the knee amputation. Resident 1 stated the treatment nurse (TXN) last Sunday told him there was bleeding on his left leg.…

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 a care plan (a document providing a way of communication among facility staff) was revised for one of two residents (Resident 1) when Resident 1 ' s care plan did not reflect that he had an inappropriate behavior toward a female resident. This failure had the potential for Resident 1 ' s inappropriate behavior to continue. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a condition that causes memory loss and changes in behavior). An interview was conducted with Certified Nursing Assistant (CNA) 1 on 10/11/24 at 12:12 P.M. CNA 1 stated Resident 1 had been seen placing his hand on female residents ' arm or thigh. CNA 1 stated it seemed like a friendly touch, but others may think it was inappropriate. An interview was conducted with Licensed Nurse (LN) 2 on 10/11/24 at 2:40 P.M. LN 2 stated Resident 1 had a history of sitting next to female…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care and services to maintain the highest quality of life, when haircuts were not provided for one of two resident (Resident 42) reviewed for Activities of Daily Living (ADL-basic daily care such as showers, grooming, dressing, nail care, and personal hygiene). The facility failed to ensure a system was in place to address the haircut needs for all 83 residents in the facility, when haircutting services were not offered or provided by the facility from April 1, 2023 through February 14, 2024 (a 10-month period). As a result, all residents had the potential for diminished dignity and self-esteem. Findings: A review of Resident 42's admission record was conducted. Resident 42 was readmitted to the facility on [DATE], with diagnoses which included dementia (progressive memory loss). On 2/12/24 at 9:36 A.M., an observation was conducted of Resident 42, during initial tour. Resident 42 was sitting in a wheelchair in the physical therapy…

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 an effective Quality Assurance Performance Improvement (QAPI) program, when the committee did not consistently track, address, and follow up on quality issues affecting the residents as follows: 1. The call light system was not functional for several days. Cross reference: Title 22, 72541 2. Infection control practices were not implemented when Covid immunizations were not offered to residents. Cross reference F887 3. A pressure ulcer worsened for a resident. Cross reference F686 4. Haircuts were not offered to residents over an 10-month period. Cross reference F676 5. A resident with diabetes had unidentified hypoglycemia for two days, leading to a 10-day hospitalization. Cross reference F684 6. Gradual Dose Reductions (GDRs) were not routinely performed for residents on antipsychotic medications. Cross reference F758, HSC 1418.8 7. The Medical Director failed to provide oversite regarding GDR's. Cross Reference F841 These failures placed all residents at risk for accidents, infections, worsening physical and…

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

Based on interview and record review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program, when the committee did not consistently track, address, and follow up on quality issues affecting the residents as follows: 1. The call light system was not functional for several days. Cross reference Title 22 72541 2. Infection control practices were not implemented when Covid immunizations were not offered to residents. Cross reference F887 3. A pressure ulcer worsened for a resident. Cross reference F686 4. Haircuts were not offered to residents over an 11-month period. Cross reference F676 5. A resident with diabetes had unidentified hypoglycemia for two days, leading to a 10-day hospitalization. Cross reference F684 6. Gradual Dose Reductions (GDRs) were not routinely performed for residents on antipsychotic medications. Cross reference F758, HSC 1418.8 7. The Medical Director did not provide oversite to the identification of problem-prone QAPI interventions. Cross Reference F841 These failures placed all residents at risk for accidents,…

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 Quality Assurance Performance Improvement (QAPI) committee failed meet at least quarterly, and as needed to develop meaningful activities that identified areas for improvement. This failure had the potential to affect the safety and quality of care provided to residents. Cross reference: Title 22 72541, F887, F686, F676, F684, F758, HSC 1418.8. Findings: On 2/20/24, a record review was conducted. Per a facility documented, updated 11/17/20 and titled QAPI Plan, .The QAPI plan will guide the facility's performance improvement efforts .Framework for QAPI: .The QAA committee will meet a minimum quarterly and as needed . On 2/20/24 at 5:08 P.M., an interview was conducted with the Admin, DON, ADON, and Regional Consultant (RC). Per the Admin, the last QAPI meeting had been on 10/10/23. The Admin stated the QAPI members had identified problems, but had not sat down formally to conduct a proper QA meeting. Per the Admin, .I can't deny more QAPI committee meetings would be helpful . A facility policy, revised 1/1/12 and titled Quality…

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 implement individualized care plans for three of 18 residents sampled (Residents 14, 51, 7). These failures had the potential for the residents to not receive the care and services needed to preserve optimal health status and prevent further decline. Findings: 1) A review of Resident 14's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis which included End Stage Renal Disease (kidney failure) and Dependence on Renal Dialysis (a process to filter the blood of toxins). An interview and observation with Resident 14 was conducted on 2/12/24 at 12:29 P.M. Resident 14 stated he went to dialysis three times a week. A shunt (access site for dialysis) on his right upper arm was observed. A joint interview and record review on 2/14/24 at 4:39 P.M., was conducted with LN 31. LN 31 stated there was no care plan for dialysis. LN 31 stated it was important for a dialysis care plan to have been…

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: 1. Consistently evaluate Fall Risk Assessments and conduct Care Conferences after each resident fall, in order to prevent future falls for two of four residents (Residents 19, 49), reviewed for falls, and 2. Complete continuous quarterly safety smoking evaluations for five of five residents reviewed for smoking (Resident 22, Resident 60, Resident 5, Resident 21, and Resident 26). As a result, there was the potential for additional falls with possible injuries and for residents who smoked to be at risk for smoking-related burn injuries. Findings: 1a. Resident 19 was admitted to the facility on [DATE] with diagnoses to include dementia (the loss of the ability to think, remember and reason, to levels that affect daily life and activities), per the facility admission Record. On 2/12/24 at 11:46 A.M., Resident 19 was observed in his room, in bed. Resident 19's mattress had bolsters on each side, approximately four inches high, four inches…

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 document non-pharmaceutical interventions or gradual dose reductions (GDR) for three of five residents (Resident 3, 42, and 10) reviewed for unnecessary medication review. As a result, Resident's 3, 42 and 10 did not have non-pharmaceutical interventions attempted and Gradual Dose Reductions were not initiated per Federal and State regulations. Findings: 1. Resident 3 was re-admitted to the facility on [DATE], with diagnoses which include dementia (progressive memory loss) and schizoaffective disorder, (a mental disorder that is marked by schizophrenia symptoms such as hallucinations and delusions), per the facility's admission Records. ` On 2/13/24, Resident 3's clinical record was reviewed. According to the quarterly MDS, dated [DATE], a cognitive score of 3 was listed, indicating cognition was severely impaired. According to the physician orders, dated 11/22/23, Memantine (medication for memory loss) 10 milligrams (mg) two time a day…

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 did not ensure Governing Body had an effective oversight and necessary resources for resident care services. Governing Body (the entity responsible for establishing and implementing facility policies) failed to ensure effective oversight and necessary resources to ensure resident care services were met to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. This failure had the potential to affect the quality of care to residents. Cross Reference: F726, F732, F841 and HSC 1418.8, F865, F867, F868, F880, F887, Title 22 72541 Findings: On 2/15/24, a record review of facility documents was conducted. An undated document, titled Governing Body Preparation and Review, indicated: Items to review prior to the Governing Body Meeting for Discussion: .QAPI Plan .B. Review of internal reportable events: pressure ulcers that occurred or worsened, .falls with significant injury .equipment malfunction .Discuss any revisions needed to Facility Assessment .Discuss Performance Improvement Projects…

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 Medical Director (MD 1) did not oversee care area concerns related to psychotropic drug (mind-altering drugs) use and Gradual Dose Reductions (GDR) for 38 out of 83 residents, listed on the facility Matrix currently receiving psychotropic medications. As a result, 38 residents were not having their psychotropic medications evaluated monthly, and their care needs were not addressed in a timely manner such as no psychotropic care conferences and no GDR were attempted for nine months. (Cross reference to F-758 and H&S Code 1418.8) Findings: On 2/20/24 at 7:45 A.M., an interview was conducted with the facility's MD 1. MD 1 stated he was in charge of the management team for all residents receiving psychotropic medication. MD 1 stated the management team was expected to meet monthly, evaluate nonpharmacological interventions, determine the amount of behaviors exhibited, the number of side effects displays, and to determine if the medication was still required or could the dose be reduced. MD 1 stated the Consulting Pharmacist (CP) also…

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: 1. Offer/re-offer/administer COVID-19 vaccinations to five residents (56, 30, 73, 52, 55) sampled for COVID-19 vaccination and 34 residents (64, 55, 81, 85, 193, 2, 22, 84, 40, 19, 15, 76, 79, 1, 26, 83, 39, 56, 11, 5, 33, 23, 67, 80, 17, 51, 78, 82, 44, 31, 36, 190, 240, 192) newly admitted to the facility after 9/14/23. 2. Accurately document COVID-19 vaccination refusals on the facility's vaccination tracking list. 3. Implement their policy and procedure titled COVID-19 Vaccination Program. As a result of this deficient practice, there was the potential for residents, staff, and visitors to be placed at risk for COVID-19 infection. Findings: A review of the facility's document titled All Admissions, dated 2/20/24, indicated there were a total of 36 residents (64, 55, 81, 85, 193, 2, 22, 84, 40, 19, 15, 76, 79, 1, 26, 83, 39, 56, 11, 5, 33, 23, 67, 80, 17, 51, 78, 82, 44, 31, 36, 190, 240, 192, 30, 56) newly admitted after the facility reopened on 9/14/23 (to current date 2/20/24). A review of the facility's document…

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 was unaware of an Advanced Directive (a legal document which lists preferences for life-saving measures) related to a resident wishes for resuscitative efforts (life-saving measures) for one of three residents (Resident 36), reviewed for Advanced Directives. As a result, there was the potential Resident 36's wishes for resuscitative efforts would not be honored. Findings: Resident 36 was admitted to the facility on [DATE], with diagnoses of Parkinson's disease (a progressive neurological disease), per the facility's admission Record. On [DATE], Resident 36's clinical record was reviewed. According to the physician's order dated [DATE], CPR (cardio-pulmonary resuscitation, a life-saving measure) was listed, indicating if Resident 36 were to go into cardiac arrest (when the heart stops beating), the staff were to perform full resuscitation measures. There was no documented evidence a Physician's Order for Life Sustaining Treatment (POLST) was in the clinical…

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 provide a safe, homelike environment when: 1. An exterior resident room door for one of 25 rooms (room A) had peeling paint, and 2. An exterior shower room door frame for one of two shower rooms (Station B), had holes and exposed drywall, along with two protruding nails. As a result, there was the potential for residents to experience diminished self-worth and the possibility of injury from the environment hazards (peeling paint and protruding nails). Findings: 1. On 4/9/24 at 8:24 A.M., an observation was conducted of room A's exterior door leading to the hallway. Room A housed four residents, two of whom were cognitively impaired (Residents 49 and 154) The exterior door had missing and peeling white paint, with an estimated size of 14 inches horizontally and nine inches vertically. On 4/9/24 at 8:56 A.M., an observation and interview was conducted with the Director of Maintenance (DM) of room A's exterior door. The DM stated he received work requests daily from staff, requesting repairs. The DM stated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to capture and transmit accurate MDS (a clinical assessment tool) information to the Centers for Medicare and Medicaid Services (CMS-a Federal agency), for two of five residents (Resident 3 and Resident 36) reviewed for Resident Assessment. This failure had the potential to affect the care and services provided to Resident 3 and Resident 36. Findings: 1. Resident 3 was re-admitted to the facility on [DATE], with diagnoses which include dementia (progressive memory loss) and schizoaffective disorder, (a mental disorder marked by schizophrenia symptoms such as hallucinations and delusions), per the facility's admission Records. On [DATE], Resident 3's clinical record was reviewed. The admission MDS, dated [DATE], Section I, did not identify the diagnosis of, Schizophrenia: (i.e. schizoaffective and schizophreniform disorder). On [DATE] at 9:35 A.M., an interview and record review was conducted with MDSN 2. MDSN 2 stated on admission, the MDSN would 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 interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review Level 2 (PASARR- a Federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was completed after a new diagnoses of schizophrenia was made for one of one resident (Resident 3) reviewed for PASARR. As a result, there was potential for Resident 3 to be improperly placed at the facility where necessary services were not available. Findings: 1. Resident 3 was re-admitted to the facility on [DATE] with diagnoses which included dementia (progressive memory loss) and schizoaffective disorder, (a mental disorder that is marked by schizophrenia symptoms such as hallucinations and delusions), per the facility's admission Records. On 2/13/24, Resident 3's clinical record was reviewed. The admission MDS, dated [DATE], Section I, did not include the diagnoses of Schizophrenia (i.e. schizoaffective and schizophreniform disorder). The original PASARR…

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 and revise individualized care plans for two of 18 residents sampled (Residents 19, 21). These failures had the potential for the residents to not receive the care and services needed to preserve optimal health status and prevent further decline. Findings: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses to include dementia (a loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), per a facility admission Record. On 2/12/24 at 11:46 A.M., Resident 19 was observed in his room, in bed. Resident 19's mattress had bolsters on each side, approximately four inches high, four inches wide, and 36 long. The bolsters were attached to the mattress, and were covered with a fitted sheet. In addition, fall mats were on the floor on either side of the bed. Resident 19 indicated, using gestures, that the bolsters were to prevent him from falling. On 2/12/24 at 11:55 A.M., an…

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 a recommendation for diet changes related to weight loss was followed up for one of three residents reviewed for nutrition (Resident 21). This failure had the potential to affect the health and well-being of Resident 21. Findings: Resident 21 was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss) and protein-calorie malnutrition (a type of undernutrition that occurs when not enough protein and calories were eaten), per the facility admission Record. On 2/12/24 at 12:40 P.M., an observation of Resident 21 was conducted during lunch. Resident 21 had consumed less than half of the foods provided on the tray. Resident 21 was wheeling away from the tray, and indicated he did not want more food by waving his hand at it as he wheeled away. Dining room staff offered Resident 21 a nutritional supplement (NS, a drink which provides protein and calories) but Resident 21 refused. On 2/13/24 at 8:32 A.M., an…

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 date and time enteral tube feedings (a method of delivering nutrition in liquid form into the stomach through a tube), feeding for two of two residents (Resident 49 and Resident 81), reviewed for tube feedings. As a result, there was the potential for Resident 49 and 81 to have complications related to the tube feedings and/or risk for infections. Findings: 1. Resident 49 was admitted to the facility on [DATE], with diagnosis which included hemiplegia (weakness on one side of the body), following cerebral infarction (stroke), affecting the left side and moderate protein-calorie malnutrition, per the facility's admission Record On 2/12/24 at 8:46 A.M., during initial tour, an observation was conducted of Resident 49 in his room. Resident 49 was restless in bed and non-verbal. The head of the bed was elevated at 30 degrees and next to the bed was an enteral pump (a machine that delivers tube feeding formula at a specific rate/per hour 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.

Based on observation, interview, and record review, the facility failed to identify a resident's source of pain for one of one residents reviewed for pain management (Resident 7). This failure had the potential for Resident 7 to experience unrelieved pain. (Cross Reference F656) Findings: A review of Resident 7's admission Record indicated Resident 7 was admitted to facility on 4/1/23 with diagnoses that included a history of dementia (memory loss) and a left humerus (upper arm bone) fracture. A record review of Resident 7's Minimum Data Set (MDS- an assessment tool) dated 12/26/23, indicated Resident 7's cognitive skills to make daily decisions was moderately impaired. On 2/15/24 at 10:48 A.M., an observation of Resident 7 was conducted. Resident 7 could be heard yelling from the hallway several rooms away. Resident 7 was in bed, lying down. Resident 7 continued yelling, and waving her hands. On 2/15/24 at 10:48 A.M., a concurrent observation and interview was conducted with CNA 22 in Resident 7's room. CNA 22 stated Resident 7 yelled when she wanted something, such as being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the physician (MD 2) supervised and managed the care of one of three residents reviewed for nutrition (Resident 21). This failure had the potential for Resident 21 to experience additional weight loss and other medical complications affecting his overall well-being. Cross reference: F692, F657 Findings: Resident 21 was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), protein-calorie malnutrition (a type of undernutrition that occurs when not enough protein and calories were eaten), and diabetes (a condition that affects how the body turns food into energy), per the facility admission Record. On 2/12/24 at 12:40 P.M., an observation of Resident 21 was conducted during lunch. Resident 21 had consumed less than half of the foods provided on the tray. Resident 21 was wheeling away from the tray, and indicated he did not want more food by waving his hand at it as he wheeled away. Dining room staff…

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

Based on interview and record review, the facility failed to ensure staff were competent in managing residents with diabetes (abnormal blood sugar levels) for one of three residents reviewed for closed record review (Resident 51). This failure had the potential to negatively affect Resident 51's health. Findings: A review of Resident 51's admission Record indicated Resident 51 was admitted in the facility on 1/10/24 with a diagnosis that included diabetes. An interview was conducted on 2/14/24 at 8:27 A.M., with LN 1. LN 1 stated Resident 51 was sent to the hospital on 1/31/24 due to a low blood sugar of 43 milligrams per deciliter (mg/dl, where a normal range is approximately 70 - 110). LN 1 stated, it was very important to check residents' blood sugars to prevent episodes of high or low blood sugars. LN 1 stated the physician should be notified for any blood sugar results that were outside of the normal range. LN 1 stated she had been employed by the facility for one year. On 2/14/24 at 4:25 P.M., an interview and record review of the Medication Administration Record (MAR) with LN…

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

Based on observation, interview, and record review, the facility failed to ensure the nurse staffing data was posted and readily accessible to the residents and public, and to accurately document the total number and actual hours worked by the nursing staff. As a result, staff and the public were unaware of the daily facility staffing. Findings: On 2/12/24 at 10:37 A.M., during an initial tour of the facility, the posted staffing data reflected a date of 2/7/24 (five days prior). Staffing data is required to be posted daily for public view. On 2/14/24 at 3:26 P.M., during an interview with the DSD, the DSD stated the staff posting was missed and had not been posted from 2/8/24 through 2/12/24. The DSD stated she was responsible for the staff posting, but she had been off work for the past five days. The DSD stated in her absence, she expected the staffing to be posted by team leaders. The DSD stated it was important the staff data be posted to let the residents and visitors know they had sufficient nursing staff available. On 2/14/24 at 3:35 P.M., during an interview with the DON,…

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 label and store medications properly when: 1. A medication was left unsecured and unmonitored at a nurses station, 2. A medication was stored improperly within a medication cart, and 3. An Automated Drug Dispensing System (ADDS) was not being monitored for temperature controls. These failure had the potential for accidental ingestion of an unprescribed medication, and for medications to be at risk for degradation. Findings: 1. On 2/12/24 at 12:48 P.M., an observation and interview was conducted at the east wing nursing station with LN 23. An unattended and unlabeled medication cup with two Tylenol (a medication used for pain management) pills was left at the edge of the nursing station table within wheelchair height. LN 23 acknowledged that that unattended medication was meant for a co-worker who was complaining of a headache. LN 23 stated that medications should not have been left unattended due to the safety concerns for facility residents, staff and visitors to easily reach medications while unattended 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 observation, interview, and record review, the facility failed to follow food preferences during meal service for one of two residents, (Resident 73) reviewed for choices. As a result, Resident 73 felt ignored and disrespected. Findings: Resident 73 was admitted to the facility on [DATE] with diagnoses which include malignant neoplasm (cancer) of head, neck and face, per the facility's admission Record. On 2/12/24 at 11:52 A.M., an observation was conducted of Resident 73 in the dining room. Resident 73 was sitting with others at a table, drinking coffee, and waiting for lunch to arrive. On 2/12/24 at 12:07 P.M., the lunch trays arrived in the dining room and were delivered individually by staff. On 2/12/24 at 12:28 P.M., an observation and interview were conducted with Resident 73 while in the dining room. Resident 73's meal ticket was viewed, which read Dislikes: milk (milk substitutes okay to provide). On Resident 73's lunch tray was a full, untouched glass of milk. Resident 73 stated they served her…

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 store, date, and protect food under sanitary conditions in one of two freezers (mobile kitchen freezer), reviewed for kitchen sanitation. This improper food safety practice had the potential to cause foodborne illness and/or food contamination. Findings: On 2/12/24 at 8:19 A.M., during initial kitchen tour with the DSS, an observation was conducted in the mobile kitchen freezer. On the left side of the freezer, on a middle shelve was a clear plastic bag of approximately 10 dinner rolls. The plastic bag was knotted, and contained no date or label of when the bag was opened. On the same shelve was a partially opened bag of parmesan cheese. An expiration date could not be seen on the commercial bag of cheese. On 2/12/24 at 8:20 A.M., an interview was conducted with the DSS. The DSS stated the dinner rolls and parmesan were not sealed and dated and they should have been. The DSS stated the foods could have caused foodborne illness if served to residents. On 2/13/24 at 9:52 A.M., an interview was conducted with the…

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

Based on observation, interview, and record review, the facility failed to ensure one Staff 21 adhered to proper glove use and hand hygiene (acceptable methods for cleaning hands such as handwashing or using hand sanitizer) while bringing soiled linens into the facility laundry. This deficient practice had the potential to spread harmful microorganisms around the facility which could lead to residents developing infections. Findings: On 2/15/24 at 3:12 P.M., an observation was conducted in the hallway near the laundry room. Staff 21 was observed entering the facility's back entrance wearing a personal protection gown and gloves. Staff 21 was pushing a barrel containing soiled linens into the building. Staff 21 stopped at the back entrance and applied hand sanitizer to her gloved hands. Staff 21 then continued to push the linen barrel into the building and into the laundry room. On 2/15/24 at 3:15 P.M., an interview was conducted with Staff 21. The housekeeping supervisor (HS) was also present. Staff 21 stated she should not have used hand sanitizer on her gloves. On 2/15/24 at 3:24…

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 staff followed their policy and procedure on receiving and returning personal belongings for three of three sampled residents (Resident 1, 2 and 3). As a result, there was a potential the residents' belongings were not returned to the family after discharge from the facility. Findings: 1) Resident 1 was admitted to the facility on [DATE] per the facility ' s admission Record. A review of records was conducted. The document titled Resident Inventory dated 8/1/22, indicated Resident 1 had personal belongings listed on admission. There were no signatures or dates from the resident/representative and the staff certifying the belongings were received by the facility on admission and received by the resident/representative upon Resident 1 ' s transfer to the hospital or discharge from the facility. On 7/18/23 at 1:25 P.M., an interview with the Medical Records (MR) staff was conducted. The MR stated there was no documentation in Resident 1 ' 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 a fall risk care plan was developed and implemented for one of three sampled residents (Resident 1) with a high risk for falls. As a result, Resident 1 had an unwitnessed fall at the facility. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of falling per the facility ' s admission Record. On 7/6/23, a review of Resident 1 ' s records was conducted. A Fall Risk Evaluation dated 8/1/22 indicated Resident 1 had a score of 20, indicating she was at risk for falls due to level of consciousness (intermittent confusion), history of 1-2 falls in the past 3 months, ambulation/elimination status (chair bound and requires assist with elimination), and multiple medications and diagnoses. A progress note dated 8/4/22 and authored by the previous Assistant Director of Nursing (ADON), indicated Resident 1 was transferred to the hospital after an unwitnessed fall at the facility. There was no documentation 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, and record review, the facility failed to ensure staff followed infection control practices and appropriate transmission-based precautions when: 1. An ice scoop was found laying on top of the ice in the ice chest in one of two nursing stations (Station A). 2. A resident (Resident 55) was observed crossing into and out of a red zone area (a designated Isolation area). 3. Two of eight urinary catheter drainage bags were in contact with the floor. ( Resident 26 and 61). 4. A staff member did not don (to put on) PPE (personal protective equipment) when entering one of one transmission based isolation room. 5. A licensed nurse (LN) did not perform hand hygiene or change gloves during medication administration. These failures had the potential to increase the risk of infection to residents and staff within the facility due to cross - contamination. Findings: 1. On 12/12/22 at 10 A.M., an observation of an ice chest was conducted. The ice chest located on station A when inspected had an…

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 have a call light assessable to activate for one of one resident (Resident 39) reviewed for accommodation of needs. As a result, there was the potential for Resident 39 to not have her needs met. Findings: Resident 39 was re-admitted to the facility on [DATE], with diagnoses which included quadriplegia (paralysis resulting in the inability to move from the neck down), per the facility's admission Record. On 12/12/22 at 10:04 A.M., 11:27 A.M., and 3:24 P.M., an observation was conducted of Resident 39 as she laid in bed. Resident 39 was able to move her head only and the call light pad (a flat push pad that a resident uses to notify staff when assistance is needed, by using the side off her head or chin to activate a light), was positioned above the resident's head out of visual and physical range. On 12/13/22 at 8:30 A.M., 11:39 A.M., and 1:04 P.M., an observation was conducted of Resident 39 as she laid in bed. The call light push pad…

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 Physicians Orders for Life Sustaining Treatment (POLST-a form which indicated a resident's code status) forms and the code status (the level of medical interventions a person wishes to have if their heart or breathing stops) order was available to the staff for two of three residents reviewed for Advanced Directives (Residents 42 and 46). This failure had the potential for Resident 42 and Resident 46 to receive incorrect care in the event of a medical emergency. Findings: 1. Resident 42 was readmitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD, chronic kidney disease), per the facility's admission Record. On 12/12/22, a review of Resident 42's record was conducted. There was no POLST in Resident 42's paper chart or in the electronic record. There was no code status in the physician's order upon Resident 42's admission. On 12/12/22 at 3:03 P.M., a joint review of Resident 42's record and an interview…

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 develop person-centered comprehensive care plans for two of six residents (Resident 22 and Resident 39), reviewed for care plans. As a result, there was a potential for inconsistent care and for the needs of Resident 22 and 39's to not be met. 1. Resident 22 was admitted to the facility on [DATE] with diagnoses which included left hemiplegia (left sided weakness) following a cerebral infarction (stroke), per the facility's admission Record. On 12/15/22, Resident 22's clinical record was reviewed. According to the physician's order, dated 12/9/22, the resident was admitted to hospice (end of life, comfort care). There was no documented evidence a hospice care plan had been developed. On 12/15/22 at 9:26 A.M., an interview was conducted with LN 17. LN 17 stated when a resident was admitted to hospice, the LN should immediately develop a care plan for the hospice care. LN 17 stated care plans acted as a means of communication among staff and guided the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to consistently provide catheter (a tube inserted into the bladder) care for one of four residents (44) reviewed for catheter. This failure had the potential to increase the risk of urinary infection for Resident 44. Findings: Resident 44 was admitted to the facility on [DATE], with diagnoses which included obstructive uropathy (condition in which the flow of urine is blocked), per the facility's admission Record. A review of Resident 44's History and Physical dated 7/2/22, indicated the attending physician documented Resident 44 did not have the capacity to understand and make decisions. A review of Resident 44's physician order was conducted. There was no catheter care order for Resident 44. A review of Resident 44's laboratory results, dated 12/9/22, indicated Resident 44 had more than 100,000 organisms (possible infection) in his urine. On 12/12/22 at 9:47 A.M., an observation and interview of Resident 44 was conducted. Resident 44 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, interview, and record review, the facility failed to follow a physician's order related to oxygen use for one of one resident (12) reviewed for respiratory care. This failure had the potential for Resident 12 to develop oxygen toxicity (an adverse effect). Findings: Resident 12 was admitted to the facility on [DATE], with diagnoses which included respiratory failure and was dependent on supplemental oxygen (O2), per the facility's Record of Admission. A review of Resident 12's history and physical dated 10/30/22 indicated the physician documented Resident 12 had a fluctuating capacity to understand and make decisions. A review of Resident 12's MDS (an assessment tool) Special Treatment, Procedures, and Programs, dated 10/31/22, indicated Resident 12 was on oxygen therapy. A review of Resident 12's physician's order dated 10/18/22, indicated, Oxygen at 2 L/min (liters per minute) via NC (nasal cannula, a device used to deliver supplemental oxygen) . On 12/12/22 at 8:35 A.M., an observation…

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 dialysis (the process of cleaning the blood through a machine) access site was properly cared for timely for one of one resident investigated for dialysis (37). The deficient practice had a potential for Resident 37's dialysis access to clot. Findings: Resident 37 was readmitted to the facility on [DATE], with diagnoses that included End Stage Renal Disease (kidney failure), per the facility's admission Record. A review of Resident 37's history and physical dated 9/15/22, indicated Resident 37 had the capacity to understand and make decisions. On 12/12/22 at 11:20 A.M., an observation of Resident 37 was conducted. Resident 37 wheeled himself into his room with left upper arm pressure dressings over his dialysis access site. On 12/12/22 at 3:10 P.M., an observation and interview of Resident 37 was conducted. Resident 37 was sitting up in bed, watching a movie. Resident 37 stated he returned from dialysis. Resident 37 stated his…

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 did not ensure proper food storage's were met when expired food were found in the refrigerator. This failure has the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illnesses to residents in the facility. Findings: On 12/12/22 at 8:45 A.M., a concurrent observation and interview with the CDM of the kitchen refrigerator was conducted. The top shelf of the refrigerator had a five (5) pound bag of grated parmesan cheese with an opened date of 11/28/22 and a use by date of 5/27/22. The CDM validated the above findings. The CDM stated the refrigerator should not have expired food in it to prevent potential cross contamination and foodborne illnesses being passed to the residents. 12/12/22 at 2:33 P.M., an interview with the RD was conducted. The RD stated, the refrigerator should not have any expired food in it. The RD stated, it is the expectation for the staff to follow the guidelines for expired foods, and should have discarded any expired foods from the refrigerator…

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.