Seaview Rehabilitation & Wellness Center, LP

Based on observation, interview, and record review, the facility failed to report an injury of unknown origin potentially resulting from abuse to the Department within two hours. This failure delayed the Department's investigation of the injury and potential abuse. The facility further failed to ensure staff were trained on reporting abuse allegations. This failure placed residents at risk of abuse. During an interview on 5/21/24 at 2:00 PM, the Administrator in Training (AIT) stated injury of unknown origin for Resident 1 was reported on 5/17/24. During an interview on 5/21/24 at 2:35 PM, Unlicensed Staff A stated she entered Resident 1's room on 5/17/24 to assist him with getting dressed. Unlicensed Staff A helped Resident 1 remove his shirt and she observed bruising on his left upper chest and going into his left armpit. The bruising was all shades – purple, blue, yellow, and green. Unlicensed staff A asked Resident 1 what happened. Resident 1 stated it happened last night when a guy came in and roughed me up. Unlicensed Staff A immediately reported the bruising to Licensed Nurse…

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 implement its abuse prevention policy for one of two sampled residents, Resident 1, when staff did not implement Resident 1's care plan for a behavior that put him at high risk for conflict, and staff were not trained on how to respond to his aggression. This resulted in Resident 1 arguing aggressively with a staff member while no staff intervened for approximately 10 to 20 minutes. Findings: During an observation and concurrent interview on 2/7/24 at 11:15 a.m., Resident 1 was sitting in his bed in his room directly across from the nurses' station. A transfer pole (a floor-to-ceiling grab bar used for transferring between the bed and wheelchair) was noted at his bedside. Resident 1 stated that on 1/28/24 he was in bed and needed to go bad, I needed to have a BM (bowel movement). He stated he waited an hour for his aide, and another aide finally came and got him to the bathroom. Resident 1 stated that later when he saw his aide, Unlicensed Staff A, he told her the other aides can't do all your work for you,…

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 report potential abuse timely when a nurse witnessed a certified nursing assistant yell and cuss at a resident, Resident 1, and facility staff did not report the incident, or Resident 1's grievance about the incident, to the Department for three days. This failure resulted in a delayed suspension of a potentially abusive staff member and a delayed investigation into an allegation of abuse of a vulnerable resident. Findings: On 1/31/24, the Department received a report from the facility that indicated, During a meeting on 1/31/24 @ 3:30 pm the ombudsman had reported that they had received a report of potential abuse between this resident and a staff member. Immediately initiated an investigation and staff member suspended immediately. During an observation and concurrent interview on 2/7/24 at 11:15 a.m., Resident 1 was sitting in his bed in his room. Resident 1 stated that on 1/28/24 he waited an hour for his aide to help him with toileting, and another aide finally came and got him to the bathroom. Resident…

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 behavioral management care according to the care plan of one of two sampled residents (Resident 1) when staff argued with Resident 1, who had a known behavior of verbal and physical aggression towards staff, and staff did not remove or redirect Resident 1 from the source of agitation. This failure resulted in Resident 1's behavior escalating and to continue his aggression for 10 to 20 minutes. Findings: During an observation and concurrent interview on 2/7/24 at 11:15 a.m., Resident 1 was sitting in his bed in his room directly across from the nurses' station. Resident 1 stated that on 1/28/24 he was in bed and called for assistance to the bathroom. He stated he waited an hour for his aide, and another aide finally came and got him to the bathroom. Resident 1 stated that later that day he saw his aide, Unlicensed Staff A, and told her the other aides can't do all your work for you, you need to pick it up. Resident 1 stated, She (Unlicensed Staff A) got all mad. I told her to quit being so lazy, she…

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 interview and facility document review, the facility staff failed to treat six residents (Resident 6, Confidential Resident 30, Confidential Resident 34, Confidential Resident 2, Confidential Resident 3 and Confidential Resident 202.) out to 12 sampled residents with dignity when staff would assist a resident to the bathroom and then leave for an extended period of time, answer a call light and then not return to provide care. These failures resulted in residents feeling like they were worthless or invisible. Findings: During an interview on 1/9/24 at 8:45 a.m., Resident 6 stated that when she pressed her call light for assistance, sometimes her aid would come in and tell her they had three residents they needed to help before her and she would have to wait. Resident 6 stated she thought to herself, I hope they don't forget about me. During an interview on 1/9/24 at 9:36 a.m., with Confidential Resident 202, Confidential Resident 202 indicated some of the staff were disrespectful when providing care. Confidential Resident 202 indicated an occurrence where a 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 observation, interview, and record review, the facility failed to: 1. Replace the roof which had been leaking for at least three years, and 2. Had shower doors which locked and were not easily accessed by staff. These failures resulted in residents living in an environment that was visibly in need of repair and upkeep. Findings: 1. During a phone interview on 1/9/24 at 11:09 a.m., a confidential family member stated she felt the facility looked neglected and could use a good cleaning and paint job. She stated whenever she came here to visit her mom she wanted to bring her gardening gloves and pruning sheers and go to work on the grounds. During an observation on 1/10/24 at 8:25 a.m., while rain was falling on the roof of the facility, the rain gutter and eave midway toward the entrance of the facility looked broken/rotten. Rain water was pouring over the gutter like a waterfall in front of a resident's window as the rain was coming down. Note: a photo was taken of the rotten gutter and eave. During an observation on 1/10/24 at 9:54 a.m., heavy rain was falling on the roof…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident and/or their responsible party with a summary of the resident's Baseline Plan of Care for two of 24 sampled residents (Resident 21 and 102). This failure had the potential to limit communication with the resident and/or their responsible party on how the facility planned to manage the resident's needed services and treatments while at the facility, which could have led to the resident feeling stressed, uneasy and lack of trust with the staff providing care, leading to negatively affecting the resident's physical and psychosocial well-being. Findings: 1. A review of Resident 21's admission Record, indicated Resident 21 was admitted to the facility on [DATE], with a diagnosis including CHF (Congested Heart Failure: long-term condition that happens when your heart cannot pump blood well enough to give your body a normal supply), Non-Stemi Myocardial Infarction (Partial blockage of one of the coronary arteries, causing reduced flow of…

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

Based on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to : 1. Identify failure of staff to follow hand hygiene procedure (Cross Reference F880), 2. Identify failure to provide new residents and families with baseline care plans (Cross Reference F655), 3. Identify the failure of staff to respond to residents' requests for help (Cross Reference F550). These failures prevented the QAPI committee from developing, implementing, and evaluating action plans to correct systematic deficient practices. Finding: During an interview on 1/12/24 at 11:30 a.m. with Administrator and Director of Nursing (DON), Administrator stated the QAPI committee found projects through surveys, complaint investigations, things come up at the meetings, inspections rounds, and floor staff could bring projects. Administrator stated once the committee identified it (a project) we work to fix it. DON stated hand hygiene and baseline care plans were not projects they were currently working on. Administrator stated the committee was not tracking…

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

Based on interview and record review the facility failed to offer COVID-19 ( an infectious disease caused by the SARS-CoV-2 virus and those infection could experience mild to moderate or severe respiratory illness) immunizations (a process by which a person becomes protected against a disease through vaccination.) as appropriate to four (Confidential Resident 30, Confidential Resident 34, Confidential Resident 2 and Confidential Resident 3) out of 12 sampled residents. This failure had the potential for residents to acquire COVID-19 and suffer a more serious illness without the added benefit of having the vaccine in their system. Findings: During a concurrent interview on 1/10/24 at 2:26 p.m. with Confidential Resident 30, Confidential Resident 34, Confidential Resident 2 and Confidential Resident 3 all indicated they had wanted to COVID-19 vaccine but were denied by the facility. Resident 30 indicated the facility had indicated the resident would be vaccinated after training for the nurses had taken place but that was back in October of 2023. Confidential Resident 30 indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of one sampled residents' (Resident 18) Responsible Party (RP) Family Member X was able to participate in care conferences. This failure resulted in Resident 18's RP Family Member X not being involved in the overall plan of care with regard to Resident 18's decline in health. Findings: Review of Resident 18's, admission Record, dated 5/3/19, indicated Resident 18 has been admitted to the facility on [DATE] with a history of unspecified dementia, chronic kidney disease and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing related problems). The admission Record document indicated Resident 18's RP was listed as Family Member X. During an interview on 1/9/24 at 5:26 p.m., with Resident 18's Responsible Person (RP) Family Member X, RP Family Member X, indicated he had wondered when the next care conference was scheduled since he wanted to discuss some issues regarding Resident 18's decline in…

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

Based on observation, interview and record review the facility failed to safeguard one of one sample residents when Resident 18 had lost his glasses and the facility did not know nor replace his glasses. This failure resulted in Resident 18 wearing non- prescription glasses until his eyes were re-examined and potentially injuring himself by running into obstacles not in focus. Findings: During an observation an interview and observation on 1/8/24 at 1:19 p.m., with Resident 18, he indicated he was not aware how long he had resided at the facility. Resident 18 indicated during the interview that his memory was not so good anymore. Resident 18 was observed wearing glasses with a clear lens so as not to be confused with sunglasses on his face. During a telephone interview on 1/9/24 at 5:26 p.m., Resident 18's Responsible Party (RP) indicated Resident 18 had an eye appointment and received new prescription glasses, but the glasses were lost approximately a year and half ago. Resident 18's Responsible Party indicated he had contacted the facility and had been waiting for the facility to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interview and record review the facility failed to keep one of one sampled resident (Resident 38), safe from verbal abuse. This failure resulted in Resident 38 suffering verbal abuse from a staff member. Findings: During a review of a facility-reported event to the Department, dated 12/26/23 , between Resident 38 and Unlicensed Staff E, it indicated Unlicensed Staff E was speaking disrespectfully to Resident 38 as described, stop and eat your lunch, you are a grown ass man. Unlicensed Staff E was indicated to then slam the desert on Resident 38's lunch tray causing it to fall on the ground. Unlicensed Staff E was indicated to state, now I have to go an get you another one. During a review of Resident 38's, admission Record, dated 9/26/23, indicated Resident 38 was admitted to the facility on [DATE], with a history of end stage liver disease , hepatic encephalopathy, chronic diastolic heart failure and chronic hepatic failure for which he was place on end of life care. Multiple attempts were made to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed for have an individualized care plan for two of 24 sampled residents (Resident 21 and 23) when: 1. Resident 21 was not care planned for being on Eliquis (Apixaban: blood thinner medicine that reduces blood clotting). 2. Resident 23 was not care planned for Hospice [A type of care and philosophy of care that focuses on the palliation (easing the severity of a pain or a disease without removing the cause) of a chronically ill, terminally ill, or seriously ill patient's pain and symptoms, and attending to their emotional and spiritual needs]. The lack of care plans had the potential for direct care staff not to monitor, treat, and reassess and/or prevent: 1. Resident 21 for blood thinner side effects, which include higher risk of bleeding, bruise more easily, may take longer than usual for any bleeding to stop, and may have a higher risk of bleeding if resident takes blood thinners in combination with other medicines that increase ones risk of bleeding,…

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. Verify the identity of a resident prior to medication administration; and 2. Carry out a physician order for a referral to an out-of-town physical therapy clinic (Resident 19). These failures had the potential to result in a medication error or delay treatment for Resident 19's back pain. Findings: 1. During an medication pass observation and concurrent interview on 1/10/24 at 5p.m., Licensed Staff D entered a resident's room with a cup of medications. Licensed Staff D greeted the resident and the resident took her medications with water. Licensed Staff D returned to the medication cart to document the medications. When queried, Licensed Staff D stated she identified the resident by greeting her with her name and the resident answered. Licensed Staff D stated the facility did not have arm bands for the residents, so she did not have any other way to verify their identity. During an interview on 1/11/24 at 3:22 p.m., Director of…

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

Based on interview and record review the facility failed to provide an annual review for one (Unlicensed Staff F) out of one sampled unlicensed staff. This failure had the potential for unlicensed staff working in the facility to be either incompetent or inappropriately working with residents. During a concurrent interview and record review on 1/12/24 at 10:22 a.m. with Director of Staff Development (DSD), DSD indicated that Unlicensed Staff F was initially hired at the facility on 3/16/16. DSD was unable to locate the annual review document for 2022 or 2023. DSD indicated Unlicensed Staff F had been terminated as of 10/24/23 but could not locate the paperwork to indicate cause for termination. DSD was reviewing piles and piles of loose papers in folders and unable to locate the annual review documents or cause for termination. DSD was able to locate in-service training through labeled binders but nothing further. Review of the facility's policy and procedure titled, Staff Competency Assessment, dated 3/17/22, indicated, Competency assessments will be performed upon hired during the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 24 sampled residents (Resident 21) was being monitored closely while on Eliquis (Apixaban: blood thinner (anticoagulant) medicine that reduces blood clotting). Not monitoring for the risks for blood thinner side effects, which include higher risk of bleeding, bruise more easily, may take longer than usual for any bleeding to stop, and may have a higher risk of bleeding if resident takes blood thinners in combination with other medicines that increase ones risk of bleeding, unexpected pain, swelling or joint pain, headaches or weak or dizzy, serious fall or hit on the head could impact one's physical wellbeing, lead to harm and even death. Findings: A review of Resident 21's admission Record, indicated Resident 21 was admitted to the facility on [DATE], with a diagnosis including CHF (Congested Heart Failure: long-term condition that happens when your heart cannot pump blood well enough to give your body a normal supply), Non-Stemi…

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 that its staff performed hand hygiene when entering and exiting residents' bedrooms and between doffing and donning of gloves when providing resident care as indicated in the facility's policy and procedure on hand hygiene. This failure had the potential to lead to the spread on infection among other residents. During an observation on 01/09/24 at 08:35 a.m., Unlicensed Staff (Staff B) entered a resident's shared room without performing hand hygiene. Staff B picked up a meal tray and brought it to the cart in the hallway. No hand hygiene was observed being performed by Staff B. During an observation on 01/09/24 at 08:38 a.m. Staff B returned to pick up another meal tray and did not perform hand hygiene prior to entering the resident's room. Staff B proceeded to bring to the meal tray to the cart in the hallway at the nurse's station. Staff B did not perform hand hygiene and went on to perform another task. During an observation on 01/09/24 at 10:06 a.m. in the [NAME] Hallway, Licensed Staff A (Staff A)…

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

Based on interview and record review, the facility failed to provide sufficient nursing staff to deliver nursing care to residents when 11 of 31 days in the month of July 2023 only one licensed nurse worked the evening shift. This failure had the potential to cause delayed response to call for assistance making residents feel unattended and irritated, or cause falls and other accidents. Findings: During an interview on 8/16/23, at 2:47 p.m., Resident 1 stated it had irritated him to wait for assistance while sitting/lying in soiled underpants/linen. Once at 2 to 3 in the morning he soiled his underpants/sheets and had to wait for 7 a.m. to be cleaned by the morning shift Certified Nursing Assistants (CNAs). He had told the Administrator about the long waiting time, but things are still the same. During an interview on 9/25/23, at 1:57 p.m., Certified Nursing Assistant A (CNA-A) stated they were given more patient assignment and it is possible to have residents wait long if they are short staff because they have more things to do - take care of more residents, leave one resident 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 ensure five of five sampled residents (Resident 36, Resident 28, Resident 35, Resident 10, and Resident 17) were informed, and had access to the binder containing survey findings from the last State survey. This failure had the potential to result in lack of information regarding facility deficiencies and inability to receive information from agencies acting as client advocates, which could have resulted in residents not having the opportunity to contact these agencies. Findings: During a resident council meeting on 5/03/22, Resident 36, Resident 28, Resident 35, Resident 10, and Resident 17 were asked if the results of the most recent survey were available to read. All five residents stated they did not know where to find them, including Resident 36, the Resident Council President. During an interview on 5/03/22 at 4:14 p.m., the Activities Director confirmed he had not discussed with the residents where to find the results of the most recent survey. The Activities Director was asked to show the Surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan consistent with residents' rights, when: 1. Two (2) of thirteen (13) sampled residents (Resident 146 and Resident 24) with high pain levels, did not have comprehensive person-centered care plans for pain management, and the ones they had did not mention non-pharmacological (Interventions not consisting of medications) interventions in helping the residents with pain control. This had the potential to result in lack of information to facility staff on techniques and interventions to control the residents' pain to tolerable levels, which could have caused harm and suffering to the residents. 2. One (1) of thirteen (13) sampled residents (Resident 35), who spent most of the time in his room, did not have a comprehensive person-centered care plan for activities. This had the potential to result in lack of information to facility staff on the residents' activities of choice, which could have…

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 nursing staff utilized professional standards when providing resident care when: 1) Licensed Staff did not place a pressure-relieving mattress on the bed of one resident (Resident 94) when she had restricted mobility due to pain. This failure caused potential for Resident 94 to experience skin breakdown and potentially develop pressure ulcers (bed sores), that could lead to increased pain and poor quality of life (Pressure Ulcers are areas of localized damage to the skin and underlying tissue resulting from prolonged pressure on the skin); 2) One Licensed nurse (Licensed Nurse D ) crushed an Enteric-coated tablet (designed to resist dissolving and being absorbed in the stomach. Reduce gastric irritation associated with uncoated tablets) for Resident 26 without a physician's order. This failure could potentially alter the absorption or stability of the medication compromising Resident 26's health and well-being; and 3) One Licensed nurse (Licensed Nurse D) did not ensure a large chewable tablet 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 provide activities of daily living (ADLs-A term used in healthcare to refer to people's daily self-care activities) to dependent (Residents that depended on staff for ADLs) residents when: 1. Eight (8) of thirteen (13) sampled residents (Resident 35, Resident 39, Resident 36, Resident 24, Resident 6, Resident 26, Resident 17 & Resident 10), and nine (9) of thirty-five (35) unsampled residents (Resident 4, Resident 30, Resident 37, Resident 25, Resident 20, Resident 21, Resident 16, Resident 19 & Resident 28), did not receive their scheduled showers or baths for weeks, with some not having received any baths or showers in over one month, and; 2. Two (2) of (13) sampled residents (Resident 17 & Resident 36), did not receive incontinence care (Cleaning of the skin and changing soiled disposable briefs on a resident with an incontinent episode) promptly, causing them to remain in soiled briefs for hours. These failures had the potential to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure the Activities Program met the needs of all the residents in the facility when no residents were observed, or confirmed participating in activities throughout the Recertification Survey from 5/02/22 through 5/09/22. This failure had the potential to result in boredom, depression, and anxiety for the residents of the facility. Findings: Record review indicated Resident 35 was admitted to the facility on [DATE] with medical diagnoses including Congestive Heart Failure (A chronic progressive condition that affects the pumping power of the heart muscle), and Respiratory Failure (A condition in which the lungs have a hard time loading the blood with oxygen or removing carbon dioxide), according to the facility Face Sheet (Facility demographic). Resident 35's MDS (Minimum Data Set-An assessment tool) dated 3/24/22 indicated his BIMS (Brief interview of mental status-a cognition assessment) score was 13, which indicated his cognition 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.

Based on interview and record review, the facility did not ensure 23 residents, out of a census of 48, (Resident 36, Unsampled Resident 25, Resident 29, Resident 7, Resident 194, Resident 4, Resident 10, Resident 15, Resident 9, Resident 26, Resident 20, Resident 19, Resident 4, Resident 3, Resident 33, Resident 196, Resident 201, Resident 40, Resident 2, Resident 147, and Resident 28) had in-person, onsite physician visits when Physician P only provided telemedicine consults/visits. (Telemedicine allows health care professionals to evaluate, diagnose and treat patients at a distance using telecommunications technology - computers, video, phone, messaging). This failure prevented Physician P from physically assessing 23 residents and potentially prevented him from providing an in-depth evaluation of the each resident's condition and total program of care. Findings: During a telephone interview on 05/06/22 at 9 a.m., Physician P was asked about Resident 94's admission and pain control while at the facility. Physician P stated he provided telemedicine services and Resident 94 had 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 interview, and record review, the facility did not have sufficient staff to meet the residents' needs when: 1. Call lights were not answered promptly, and; 2. There were insufficient staff to provide residents with their Activities of Daily Living (ADLs-A term used in healthcare to refer to people's daily self-care activities) when sixteen (16) of forty-eight (48) residents were found to not be receiving their scheduled showers/baths. These findings had the potential to result in inability for the residents to obtain assistance when they needed it, inability for staff to respond to medical emergencies, and lack of health services provided to the facility residents. Findings: 1. During Resident Council Meeting on 5/03/22 at 11:04 a.m., Resident 14 stated it took at least half an hour for staff to respond to call lights. Record review of Resident 14 MDS (Minimum Data Set-An assessment tool) dated 2/12/22, indicated his BIMS (Brief Interview of Mental Status-A cognition assessment) score was 14, which…

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

Based on observations, interviews and record reviews, the facility failed to ensure medication error rate was below 5% when one (1) of three (3) Licensed Nurses (Licensed Nurse D) did not follow the manufacturer's recommendations and doctor's order regarding administration of medication for five residents (Residents 6, 9, 15, 26 and 31) which resulted in seven (7) medication administration errors out of 33 administration opportunities (21% error rate). This failure had the potential to compromise the absorption of the medication and the risk of compromising the resident's health and well-being for not getting the required dose of medication according to the doctor's order and according to the manufacturer's recommendation. Findings: #1 During a medication pass observation with Licensed Nurse D on 5/04/22 at 8:21 a.m. Licensed Nurse D administered medications to Resident 31 that included one chewable tablet of Calcium Carbonate (TUMS - treat symptoms caused by too much stomach acid) 500 mg (milligram - weight equal to one thousandth of a gram). Resident 31 was not instructed to chew…

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 sanitary conditions in the kitchen when: 1) One dietary staff member (Staff L) did not wear an N95 respirator (face mask designed to achieve a very close facial fit and very efficient filtration of airborne particles) per policy; dietary staff did not wear face coverings (masks) per policy; and dietary staff did not wash their hands after touching and repositioning their face masks/respirators, and 2) The facility did not monitor documented mold inside the ice machine and on fans utilized within the kitchen. These failures caused potential for transmission of disease-causing microorganisms, including Covid-19 and mold, to vulnerable residents with multiple health issues, staff, and visitors. Findings: 1) During an observation and concurrent interview on 5/02/22 at 2:50 p.m., Dietary Staff L (who was not vaccinated against Covid-19) was washing dishes; he was not wearing a face covering (mask or N95) while washing the dishes. When asked about his lack of face covering, Staff L stated he had a mask 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 identify quality deficiencies, and develop and implement plans to resolve them in their QAPI (Quality Assurance and Performance Improvement-a data driven and proactive approach to quality improvement to ensure services are meeting quality standards and assuring care reaches a certain level) program, when: 1. The facility did not have a QAPI project focused on sixteen (16) of forty-eight (48) residents not getting their regular showers and baths for weeks. This had the potential to result in continuous lack of ADL (Activities of daily living-a term use to describe self-help skills) services, which could have caused skin breakdown and infections, discomfort and loss of dignity to the residents involved. 2. The facility did not have a QAPI project focused on infection control, and the lack of an antibiotic steward program that identified, tracked, and ensured antibiotics were used properly, and only when needed. This had the potential to result in inappropriate use of antibiotics, increased microbial resistance and poor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement measures to reduce the risk of disease and infection transmission when: 1. Two of three Licensed Nurses (Licensed Nurse D and Licensed F) did not perform proper hand hygiene before and after medication administration to residents. This failure had the potential to result in a spread of infections and/or transmission of diseases to the residents. 2. Two of 11 sampled residents (Resident 35 and Resident 194) received oxygen therapy via nasal cannula and the cannula tubing was not changed and dated per facility policy. This failure could result in bacteria build up which could potentially lead to respiratory infections. 3. One dietary staff member (Staff L) did not wear an N95 respirator (face mask designed to achieve a very close facial fit and very efficient filtration of airborne particles) per policy; dietary staff did not wear face coverings (masks) per policy; and dietary staff did not wash their hands after touching 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 develop and implement an antibiotic stewardship program (A coordinated program that promotes the appropriate use of antibiotics) that included antibiotic use protocols and a system to monitor antibiotic use. This failure had the potential to result in unnecessary and inappropriate use of antibiotics, and the development of antibiotic resistant organisms, which could have caused superinfections (Infection occurring after or on top of an earlier infection, especially following treatment with broad-spectrum antibiotics) and poor clinical outcomes to the residents of the facility. Findings: During a concurrent observation and interview on 5/04/22 at 9:41 a.m., the Infection Preventionist was asked to provide evidence of the facility's antibiotic stewardship program. The Infection Preventionist provided four handouts. The handouts provided indicated two residents (Resident 28 and Resident 36) had been on antibiotics in 2022, but the information was limited. The first handout was about Resident 28. This document titled,…

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 appoint a qualified individual for the Infection Preventionist role, when: 1. The Infection Preventionist did not have the qualifications and training to implement an antibiotic stewardship program to promote and monitor appropriate antibiotic use. This failure had the potential to result in the development of antibiotic resistant organisms, which could have caused superinfections (Infection occurring after or on top of an earlier infection, especially following treatment with broad-spectrum antibiotics) and poor clinical outcomes to the residents of the facility. 2. The Infection Preventionist was not educated on the state requirements for checking visitors' vaccination status. This failure had the potential to result in spread of COVID-19, a potentially deadly virus, to the residents and staff at the facility. 3. The Infection Preventionist was unaware of simple infection control tasks such as how often tubing changes needed to be performed on residents using supplemental oxygen. This had the potential to result in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide 1 of 5 sampled residents (Resident 35) and his family, the opportunity to participate in care planning when no care conference meetings (A meeting between healthcare professionals, the resident, and family members to decide the resident's needs, discuss the medical team's goals, and discuss the family's ideas for meeting those needs) were held inviting him and his family to help develop his plan of care. This failure had the potential to result in inability for the Resident 35 and his family to advocate for his needs and receive information regarding his care. Findings: Record review indicated Resident 35 was admitted to the facility on [DATE] with medical diagnoses including Congestive Heart Failure (A chronic progressive condition that affects the pumping power of the heart muscle), and Respiratory Failure (A condition in which the lungs have a hard time loading the blood with oxygen or removing carbon dioxide), according to the facility Face…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC - Completed by the facility to notify the resident of his or her right to an expedited review of skilled services provided (Nursing and Rehab services (Physical Therapy, Occupational and Speech therapy)) to one (1 ) of three (3) sampled residents (Resident 34) who received Medicare Part A (Federal Health Insurance) benefits. This failure resulted in Resident 34 not given the choice to appeal the facility's decision to discontinue her treatment. During a clinical record review for Resident 34, the Face Sheet (A one-page summary of important information about a resident) indicated Resident 34 was admitted to the facility on [DATE] under Medicare Part A Skilled Services with diagnosis including Fractures and other multiple traumas. During a clinical record review for Resident 34, the Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths,…

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 room of 1 of 5 sampled residents (Resident 17), was kept safe, and in good repair, when a hole, the size of a US (United States) quarter, was observed in the bathroom door facing the room, containing wooden splinters with sharp edges. This room and bathroom were shared with Resident 33, who had vision impairments. This failure had the potential to result in residents accidentally placing a finger inside the hole, causing serious cuts and scrapes. Findings: Record review indicated Resident 17 was admitted to the facility on [DATE] with medical diagnoses including Diabetes Mellitus (A condition in which blood sugars are abnormally high) with Circulatory Complications (A condition that affects how the heart or blood vessels pump blood), and Memory Deficit (Unusual forgetfulness), according to the Facility Face Sheet (Facility demographic). During a concurrent observation and interview on 05/02/22 at 3:43 p.m., a hole about 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 interview and record review, the facility failed to complete a comprehensive assessment for one (1) of thirteen (13) sampled residents (Resident 39) when a Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) was not completed within 14 days of Resident 39's admission to hospice care. This failure resulted to an inaccurate representation of Resident 39's current clinical status and had the potential to cause inadequate care based on a delinquent comprehensive assessment and care planning. (Reference F686) Findings: During a clinical record review for Resident 39, the Physician's Order dated 4/6/22 indicated Resident 39 was admitted to hospice services for the diagnosis of Alzheimer's Disease (type of dementia that causes problems with memory, thinking and behavior). During a clinical record review for Resident 39 and concurrent interview on 5/05/22 at 10:15 a.m. with Licensed Nurse G regarding Resident 39's assessments, Licensed Nurse G stated she was responsible in making sure MDS…

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 record reviews, the facility failed to provide services to prevent the worsening of a pressure ulcer for one (1) of thirteen (13) sampled residents (Resident 39) when the facility did not provide low air loss mattress and followed their policy and procedure. This failure contributed to the increased size of the wound since admission. Findings: During a clinical record review for Resident 39, the Face Sheet (A one-page summary of important information about a resident) indicated Resident 39 was admitted to the facility on [DATE] with diagnosis including Alzheimer's Disease (type of dementia that causes problems with memory, thinking and behavior), Diabetes Mellitus (a condition that occurs when the body can't use glucose (a type of sugar) normally), Adult Failure to Thrive (a decline seen in older adults), Protein Calorie Malnutrition (inadequate intake of food )as a source of protein, calories, and other essential nutrients)) and a Stage Three Pressure Ulcer of sacral region…

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 safety of one(1) of two (2) sampled residents (Resident 29) , when he attempted to light a cigarette while wearing a nasal cannula (A small, flexible plastic tube worn around the head that directs oxygen from a source to a person's nostrils), that administered oxygen. This resulted in burns to Resident 29's face, lip, cheek and nose, melted the nasal cannula and had the potential for substantial harm and possibly death. Findings: During an interview on 1/13/12 at 9:15 a.m., the Director of Nursing (DON) stated she interviewed Licensed Nurse V after the incident, and she stated on 1/09/21 at around 7:00 a.m., Licensed Nurse V stated she was in Resident 29's room and smelled cigarette smoke. The DON stated Licensed Nurse V stated she asked Resident 29 about the smell and he stated he just wanted to smoke a cigarette. The DON stated Licensed Nurse V stated she observed discoloration on Resident 29's face and his facial hair looked…

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 its own Policy and Procedure when one of two sampled residents (Resident 146) with a indwelling suprapubic catheter (Hollow, flexible tubes inserted into the bladder through a small cut in the abdomen to drain urine into a bag) draining dark red urine, did not have his urine output monitored. This failure had the potential to result inability to identify blockage of the urinary catheter, which could have caused serious bladder conditions, and urinary tract infections. Findings: Record review indicated Resident 146 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Head and Neck of Left Femur (Thigh bone) and Benign Prostatic Hyperplasia (Prostate gland enlargement), according to the facility Face Sheet (Facility Demographic). During an observation on 5/03/22 at 10:48 a.m., Resident 146 was observed in bed, in a hospital gown. A urinary catheter was observed hanging from the left side of the bed. 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 the consulting Pharmacist's (Consultant CC) review of Resident 7's medications identified and addressed irregularities with her physician's order for Insulin Lispro (rapid-acting insulin; medication to treat high blood sugar in diabetics; onset of action is within 15 minutes). This failure resulted in nursing staff administering Insulin Lispro at 9 p.m. and 3 a.m., which potentially contributed to Resident 7 experiencing hypoglycemia (low blood sugar). Findings: During an observation and interview on 5/05/22 at 10:41 a.m., Resident 7 was in her room and stated she took Insulin and her blood sugars had improved. Review of Resident 7's MAR (medication administration report; nurses document medication administration here) indicated her physician ordered her to receive, Insulin Lispro . subcutaneously (injection under the skin into the soft tissue) five times a day related to Type 2 diabetes . The MAR indicated the Insulin Lispro was timed to be given at 3 a.m., 7:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m.…

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.

The facility failed to ensure a large chewable tablet was administered safely to one (1) of eight (8) sampled residents (Resident 31) when Licensed Nurse D did not instruct Resident 31 to chew a chewable tablet before medication administration. This failure resulted to a choking experience for Resident 31 that caused him to feel distressed. (Reference F759) Findings: During a medication pass observation with Licensed Nurse D on 5/04/22 at 8:21 a.m. Licensed Nurse D administered medications to Resident 31 that included one chewable tablet of Calcium Carbonate (TUMS - treat symptoms caused by too much stomach acid) 500 mg (milligram - weight equal to one thousandth of a gram). Licensed Nurse D did not instruct Resident 31 to chew the medication before handing the medication cup. Resident 31 took all his medications all at once and started gasping for air, tried to clear his throat by coughing, and tapping his chest. Licensed Nurse D watched Resident 31 and kept asking if he was okay. Resident 31 had difficulty talking at that time while he took several sips of water. After clearing…

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.