Alcott Rehabilitation Hospital

Based on observation, interview, and record review, the facility failed to implement and maintain infection control procedures when the facility did not screen family members and visitors for three day on signs and symptoms of Coronavirus (COVID-19, a contagious and infectious disease that is characterized by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) during a COVID-19 outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) in the facility. This deficient practice had the potential to result in the spread of COVID 19 to residents and staff. Findings: During an observation on 10/17/2024 at 11:50 AM, Family Member (FM) 1 was observed entering the facility unmasked. Upon entering the facility, FM 1 was observed entering Resident 15's room. FM 1 did not screen themselves for sign and symptoms of COVID-19. During an interview on 10/17/2024 at 12 PM, FM 1 stated they did not sign in on the visitor…

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 care in a manner that maintained or enhanced a resident's dignity and respect for one of five sampled residents (Resident 51) when Certified Nursing Assistant (CNA) 3 was observed standing over Resident 51 while feeding the resident lunch. This deficient practice had the potential to cause psychosocial harm to the Resident 51 and violated the resident's right to be treated with dignity. Findings: A review of Resident 51's face sheet (admission record), indicated the facility re-admitted the resident on 9/25/2024 with diagnoses including dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that the loss interferes with a person's daily life and activities), lack of coordination (a condition that affects muscle control), muscle weakness (lack of muscle strength), and dysphagia (difficulty swallowing). A review of Resident 51's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/30/2024, indicated the resident had severely impaired…

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 the person-centered care plan for one of three sampled residents (Resident 43), who suffered from depression. Resident 43's care plan did not include the resident's preferred activities. This deficient practice caused an increased risk of Resident 43 having meaningful activity to promote and enhance the resident's quality of life. Findings: A review of the admission Record indicated Resident 43 was admitted to the facility on [DATE], with diagnoses including major depressive disorder (depression [a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living]), dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning), muscle wasting and atrophy (decrease in size and thinning of muscle tissue). A review of the Minimum Data Set (MDS, a federally mandated resident assessment tool) dated…

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 review, update, and/or revise the care plans for two of three sampled residents (Resident 71 and Resident 75). Resident 71 did not have current wound care treatment indicated for the Stage III sacral pressure ulcer and Resident 75's care plan did not include updated interventions for pressure injury prevention. These deficient practices had the potential to affect the provision of necessary care, treatment, and services for Resident 71 and Resident 75. Findings: a. A review of Resident 71's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including dementia (impaired ability to remember, or make decisions that interferes with doing everyday activities) and pressure ulcer of sacral region Stage III. A review of the Physician's Orders dated 9/27/2024, indicated to cleanse the sacro coccyx (tail bone) pressure injury with normal saline (NS-a salt solution), pat dry, apply Santyl (medication that removes dead…

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 one of three sampled residents (Resident 75), who was assessed as a moderate risk to develop pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) was provided with a pillow or heel protectors (pressure relieving devices) to the left and right heels and repositioned every two hours and PRN (as needed), per the resident's care plan. This deficient practice placed Resident 75 at increased risk for developing pressure sores. Findings: A review of Resident 75's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including Type II diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and vascular dementia (a progressive state of decline in mental abilities). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide services for one of two sampled residents (Residents 84) at risk for decline in range of motion (ROM, full movement potential of a joint) and mobility. Resident 84 did not receive Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises and left knee extension splint, per the care plan. This deficient practice had the potential to cause further decline in functional mobility, ROM, and quality of life for Residents 84. Findings: A review of Resident 84's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (condition that causes weakness or an inability to move on one side of the body) following…

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 an environment free from accident hazards to prevent avoidable accidents for one of two sampled residents (Resident 306), who was admitted to the facility with a history of falls and was at continued risk for falls, by failing to: -Accurately assess Resident 306's risk for falls dated 9/10/2024. -Evaluate and analyze fall risk hazards, implement individualized interventions to reduce risk of falling, and monitor for effectiveness of interventions. -Reevaluate and update individualized interventions to prevent recurrent falls after Resident 306 fell on 9/16 and 9/17/2024. -Ensure Resident 306 was not left without staff supervision in the facility patio. As a result, on 9/16/2024 Resident 306 stood up from the wheelchair in front of the nurse's station and fell. On 9/17/2024, Resident 306 was left alone in the wheelchair with a family member and Resident 306 fell again from the wheelchair. These deficient practices placed Resident 306 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one opened vial of Novolin R (a medication used to control blood sugar) was labeled with an open date per the manufacturer's requirements in one of two inspected medication carts (West Medication Cart.) The deficient practices of failing to store or label medications per the manufacturers' requirements increased the risk that residents could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death. Findings: During a concurrent observation on [DATE] at 11:06 AM of [NAME] Medication Cart, with the Licensed Vocational Nurse (LVN 1), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: -One opened vial of Novolin R was found stored at room…

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

Based on observation, interviews, and record review, the facility failed to have a policy that addressed how to store and reheat resident's left-over food brought into the facility from outside kitchens / restaurants to ensure safe and sanitary food storage, handling, and consumption. This deficient practice had the potential to cause food borne illness in residents in the facility who were served the food brought by family or visitors. Findings: During an interview on 10/16/2024 at 2:45 PM, Registered Nurse (RN 1) stated resident families were encouraged to bring enough food for one meal and take the leftovers home or discard the leftovers. RN 1 stated the facility did not encourage the storage of resident food brought from outside. RN 1 stated facility policy did not allow storing perishable food (food that needs refrigeration) for residents. During an interview on 10/16/2024 at 3 PM, RN 2 stated there was no refrigerator for residents to keep food brought from the outside. RN 2 stated there was a refrigerator in the Director of Nursing's (DON) office that could be used for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report a resident-to-resident altercation to the state survey agency (SSA) within 2 hours for two of three sampled residents (Resident 1 and Resident 2). This deficiency resulted in a delay of an onsite inspection by the Department of Public Health and had a potential for ongoing resident-to-resident altercations leading to resident harm. Findings: A review of Resident 1's admission Record indicated the facility originally admitted the resident on 7/20/2021 with diagnoses including ischemic heart disease (heart damage caused by poor blood flow to your heart), Type II diabetes (a long term condition I which the body has trouble controlling blood sugar and using it for energy, leading to high sugar levels in the blood), chronic kidney disease (a condition in which the kidneys are damages and cannot filter blood as well as they should), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dementia (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, interviews, and record review, facility failed to ensure one of one sampled residents (Resident 1) received adequate supervision and assistance to prevent a fall by failing to ensure bed siderails were up before leaving the resident's bedside. This deficient practice led Resident 1 falling from her bed on 11/23/2023 resulting in a laceration which required stitches. Findings: On 11/23/2023 9:50AM an unannounced visit was made to the facility to investigate an allegation that Resident 1 had sustained an injury of unknown origin. A review of Resident 1 ' s admission record indicated facility admitted the [AGE] year old female on 09/30/2023 with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness of one side of the body) following cerebral infarction (a condition caused by disrupted blood supply and restricted oxygen supply to part of the brain) affecting the right dominant side, urinary tract infection (UTI), Alzheimer ' s disease (a brain…

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 facility's policy and procedure (P&P) for Personal Protective Equipment are implemented by failing to: a. Ensure the Certified Nursing Assistant 1 and Certified Nursing Assistant 2 (CNA 2) wear the full personal protective equipment (PPE-a barrier precaution which includes the use of gloves, gown, mask, face shield, when anticipating coming in contact with blood, body fluids or other communicable toxins or agents) while providing care to four out of 10 sampled residents (Resident 5, 6, 7, 8's) room who are on transmission based precaution. b. Ensure the Certified Nursing Assistant 3 (CNA 3) wear a fit-tested NIOSH approved N95 or higher-level respiratory protection (mask that protect used by filtering out contaminants in the air) in the facility. These deficient practices had the potential to transmit infectious diseases and increase the risk of infection to the residents, staffs and visitors. Findings: 1a. A review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy and procedures (P&P) of incident reporting for unusual occurrence for one of seven sampled residents (Resident 1) by failing to report an unusual occurrence to the State Survey Agency and send a written report within 24 hours of Resident 1's death. This deficient practice resulted in a delay of an onsite inspection by the Department of Public Health and had potential to place other residents during an COVID-19 (an infectious disease that can cause respiratory illness in humans) outbreak. Findings: A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), peripheral vascular disease (PVD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and chronic obstructive pulmonary disease…

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's Orders for Life Sustaining Treatment (POLST - a document that indicates what emergency treatment a resident wants the facility to provide if the resident's heart or lungs stop working) were accurate and/or complete for three of ten sampled residents (Resident 11, Resident 255, and Resident 256) as evidenced by observations of blank POLSTs signed by a physician in Resident 11's, Resident 255's and Resident 256's active chart. This deficient practice had the potential to result in Resident 11, Resident 255, and Resident 256 receiving medical treatment that would not honor the resident's wishes and decisions regarding end-of-life care. Findings: a. A review of Resident 11's admission Record indicated the facility originally admitted the resident on [DATE] and re-admitted the resident on [DATE] with diagnoses including aftercare following joint replacement surgery (a surgical procedure in which parts of a damaged joint…

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 food in a sanitary manner to prevent the growth of microorganisms that could cause food borne illness as evidenced by: -Failing to label and date an opened bottle of white distilled vinegar and a half sandwich in two out of four refrigerators. -Failing to dispose of an open bag of tater tots and a can of granulated mushroom bullion which had past their use by date. These deficient practices had the potential to place residents in the facility at risk for food borne illness and/or contamination. Findings: During an initial kitchen tour on 10/30/2023 at 7:47 AM, the following were observed: -An opened bottle of white distilled vinegar with a received date of 10/23/2023. The opened bottle of white distilled vinegar was observed half empty without an open or use by date. -Half a sandwich wrapped in plastic wrap without a label or date. -An open bag of tater tots with an open date of 9/12/2023 and a use by date of 10/17/2023. -A can of granulated mushroom bullion with a receive date of 2/16/2023, an open…

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 privacy and dignity by leaving a resident uncovered without pants, with briefs (adult diaper) showing, and without use of privacy curtain for one of one sampled resident (Resident 306). This deficient practice had the potential for Resident 306 to experience loss of privacy and dignity. Findings: A review of Resident 306's admission record indicated the facility admitted the resident on 10/13/2023 with unspecified dementia (decline in mental ability severe enough to interfere with daily functioning/life), Parkinsonism (degenerative disorder affecting the motor system with symptoms that included shaking, rigidity, slowness of movement and difficulty with walking and gait), and diabetes mellitus Type II (a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 306's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 10/10/2023 indicated the resident was moderately cognitively impaired (decisions poor; cues/supervision…

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 report serious bodily injury to the state survey agency (SSA) within 24 hours for two of three sampled residents (Resident 18 and Resident 87). The facility failed to report: -Resident 18, an [AGE] year-old confused female, who sustained a left clavicle fracture (broken bone) after a fall on 8/22/2023. -Resident 87, an [AGE] year-old confused female who on 8/19/2023, had left wrist swelling and was then transferred to a general acute care hospital (GACH) and diagnosed with a wrist fracture (broken bone). Five days after the wrist fracture, on 8/24/2023, Resident 87 fell in her room and was unable to relate how she fell. These deficient practices resulted in a delay of onsite inspection from the SSA and caused an increased risk of injuries or potential abuse to Resident 18 and Resident 87. Findings: a. A review of Resident 18's admission record indicated the facility originally admitted Resident 18 on 11/29/2018 and readmitted her on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to conduct a comprehensive admission assessment for elopement risk (leaving the facility without staff knowledge, presenting an imminent threat to the resident's health and safety) for one of one sampled resident (Resident 19). This deficient practice caused an increased risk of Resident 19's elopement and care plan goals. Findings: A review of the admission Record indicated the facility admitted Resident 19 on 1/25/2023 and readmitted on [DATE] with diagnoses including vascular dementia (decline in mental ability severe enough to interfere with daily functioning/life), chronic kidney disease Stage IV (CKD - longstanding disease of the kidneys' failure to filter waste from the blood and excrete into the urine), and congestive heart failure (CHF - heart muscle is weakened and cannot pump enough blood to meet the body's needs for blood and oxygen). A review of a Physician's Order for Resident 19 dated 6/28/2023, indicated Ambien (sedative [induce sleep or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise a care plan for at risk for falls for one of three sampled residents (Resident 87), who sustained a fall on 8/24/2023 and was unable to explain how the fall occurred. This deficient practice had the potential to place Resident 87 at risk for recurrent falls. Findings: A review of Resident 87's admission record indicated the facility admitted the resident on 8/4/2023 and readmitted her on 8/20/2023 with diagnoses including encephalopathy (disease of the brain manifested by an altered mental state sometimes accompanied by physical changes), muscle weakness, and diabetes mellitus (high blood sugar). A review of Resident 87's Care Plan initiated 8/5/2023, indicated the resident was a fall risk due to unsteady gait, delirium, and encephalopathy. The care plan goal was to provide preventive intervention to minimize injury potential. -What were the interventions? A review of Resident 87's Cognitive Loss Care Plan, initiated 8/5/2023,…

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 a resident was provided a communication device with the language that the resident was able to understand for one of one sampled resident (Resident 98). This deficient practice prevented Resident 98 from communicating with the staff and had a potential to delay receiving appropriate care/treatment the resident needed. Findings: A review of Resident 98's admission Record indicated the facility admitted Resident 98 on 8/30/2023, with diagnoses including unspecified dementia (decline in mental ability severe enough to interfere with daily functioning/life), generalized muscle weakness (lack of physical or muscle strength and the feeling that extra effort is required to move your arms, legs, or other muscles), and hypertension (HTN - elevated blood pressure). A review of Resident 98's Minimum Data Set (MDS - standardized assessment and care planning tool) dated 9/2/2023, indicated the resident was cognitively mildly impaired (some difficulty in new situations only). The MDS indicated Resident 98's…

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

Based on observation, interview and record review, the facility failed to ensure the actual direct care staffing hours were posted daily in the facility for the month of October. As a result, the actual hours worked by the staff was not readily accessible to residents, family or visitors. Findings: During an observation on 11/1/2023 at 1:07 PM, posted in the lobby of the facility, the Nurse Staff Projection Form, dated 10/31/2023, indicated for the three shifts (Day shift, evening shift and night shift), there were a total of 402 hours for seven Registered Nurses (RN), five Licensed Vocational Nurses (LVNs), 33 Certified Nursing Assistants (CNAs), three Restorative Nurse Assistants (RNA), one Treatment Nurse, two Minimum Data Set Coordinators and one admission staff. The Nurse Staff Projection Form indicated the average daily census was 109. The projected Nursing Hours Per Patient Day (NHPPD) was 3.688 hours. The projected CNA NHPPD was 2.477. It also indicated 0.00 for Actual NHPPD and 0.00 for Actual CNA NHPPD. There was also a column for Actual hours worked for all listed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 50) who received Remeron (an antidepressant) had a gradual dose reduction (GDR - the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) attempted. This deficient practice had the potential to result in the continued use of unnecessary medications causing adverse consequences. Findings: A review of Resident 50's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dementia (a decline in mental ability severe enough to interfere with daily life) without behavioral disturbance and dysphagia (difficulty swallowing). A review of the Physician's Order for Resident 50 dated 11/17/2022, indicated to administer Remeron 15 mg by mouth at bedtime for poor oral intake. A review of the Consultant Pharmacist's Medication Regimen Review, dated 7/3/2023, indicated…

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 safe provision of pharmaceutical services by failing to remove an expired morphine sulfate solution (opioid analgesic [a class of medication], indicated for the relief of moderate to severe pain) medication, from the Middle East medication cart 2, for one of one sampled resident (Resident 17). This deficient practice had the potential to cause medication errors by possibly administering an expired medication. Findings: A review of Resident 17's admission Record indicated the facility admitted Resident 17 to the facility on 8/5/2022 with medical diagnosis that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), chronic kidney disease stage 1 (CKD - longstanding disease of the kidneys' failure to filter waste from the blood and excrete into the urine), hemiplegia (one sided paralysis) and hemiparesis (inability to move one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain…

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 follow infection control practices as evidenced by: -Failing to label and date intravenous (IV - a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein) tubing for Resident 6. -Failing to ensure Resident 81 had a date on the nasal cannula (device used to deliver supplemental oxygen placed directly on a resident' s nostrils) to ensure prompt weekly changing of the nasal cannula. These deficient practices had the potential to result in complications of intravenous and oxygen therapy, including the spread of diseases and infection. Findings: a. A review of Resident 6's admission record indicated the facility admitted the resident on 9/26/2023 with diagnoses that included sepsis (the body's extreme reaction to an infection that can lead to organ failure, tissue damage, and death), hydronephrosis (a condition where one or both kidneys become stretched and swollen as the result of a build-up of urine inside them), polyneuropathy (damage of the body's peripheral nerves),…

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.