Guardian Rehabilitation Hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to follow professional standards of practice by failing to manage, assess and monitor resident and implement the facility policy and procedure (P&P) titled, Licensed Nurses - Assessments and Notes, for one of four sampled residents (Resident 1), when resident was admitted with a medical device called a Leaf Sensor (uses a wearable sensor and display monitor for turn status and alert that provides point-of-care turn reminders and measures turn quality).This deficient practice placed Resident 1 at risk of developing skin-related risks such as skin irritation or damage, allergic reactions, skin tears, bruising and infection.Cross Reference F656During a review of the admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), metabolic encephalopathy (a chemical imbalance in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had diagnosis of dementia (condition of a person losing the ability to think, remember and reason) and history of fall, received care and services to prevent fall by failing to: 1. Implement Resident 1's Dementia Care Plan and At Risk for Fall Care Plan to ensure: Licensed Vocational Nurse (LVN) 1 and Certified Nurse Assistant (CNA) 1 explained procedure, remind not to have position change, remind for safety, reassure resident safety, and avoid environmental hazard (using multiple ramps) to Resident 1 before transporting Resident 1 in a wheelchair. 2. Identify and develop an appropriate care plan to addressed how to safely transport Resident 1 using wheelchair when resident have episodes of forgetfulness, confusion and poor safety awareness to maximize resident safety. 3. Ensure Resident 1 who had dementia, episodes of confusion, forgetfulness, poor safety awareness was safe when…

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 two of seven sampled residents (Residents 49 and 54) received appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) and mobility by failing to: -For Resident 49, put on a left knee splint correctly during the 1/28/25 Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment session as ordered by a physician. -For Resident 49, provide an appropriate RNA order for wearing both knee splints for no more than three hours as determined by physical therapy. -For Resident 54, provide resident with active range of motion (AROM, movement at a given joint when the person moves voluntarily) exercises to both upper extremities and both lower extremities during the 1/28/25 RNA treatment session as ordered by a physician. These deficient practices had the potential for injury and worsening of contractures (a stiffening /…

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 annual competencies were completed for six of six sampled Restorative Nursing Aides, who perform RNA program tasks including putting on and taking off splints and braces. This deficient practice had the potential to result in injury, worsening contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion), and skin breakdown for residents who require splints and braces for physical therapy. CROSS REFERENCE TO F688 Findings: A review of Restorative Nursing Aide (RNA) 2's RNA Competency Evaluation dated 8/23/24 indicated there was no skills performance check on how to put on and take off splints and braces. A review of RNA 1's RNA Competency Evaluation dated 11/18/24 indicated there was no skills performance check on how to put on and take off splints and braces. A review of RNA 3's RNA Competency Evaluation dated 11/29/24 indicated there was no skills performance check on how to put on and take off splints and braces. Further review of RNA 4, 5 and 6's competency…

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 maintain six of six electrical rehabilitation therapy (given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) equipment for resident use. This deficient practice had the potential for injury to residents using the therapy equipment during therapy treatment. Findings: A review of the upper and lower extremity bicycle - Therapy Equipment (TE) 1 and TE 2's User Manual (UM) revised 12/8/2020, indicated a Certificate of Conformance Inspection, consisting of an electrical safety check, was recommended to be performed at least biannually (every two years). Users should follow and complete the following recommendations on an ongoing basis: routinely check for power cord fraying or any other damages to the power cord. Check to ensure that the cycle ergometer was operating smoothly. Always check that the power cord, cardia pickup and display control cables were properly routed and were not in danger or being snagged/pulled by the lower or upper cycle…

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 interventions to prevent accident risks and hazards for one of five sampled residents (Resident 77. Resident 77 was not provided supervision and assistance with transfers. This deficient practice resulted in Resident 77 sustaining a fall on 1/27/2025, which had the potential for the resident to develop an injury. Findings: A review of Resident 77's admission Record indicated the facility admitted the resident on 1/9/2025 with diagnoses including hemiplegia (severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of the body), difficulty in walking, lack of coordination (a condition that affects the body's ability to control and execute smooth, precise movements), cerebral infarction (stroke, injury to part of the brain that can affect the use of the body and the ability to speak and walk), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your…

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 sampled resident (Resident 230) receiving oxygen therapy had properly labeled nasal cannula (tubing that provides additional oxygen through the nose), pre-filled humidifier (a medical device that adds water vapor to oxygen to help prevent dry air from irritating the sinuses and lungs), and a physician's order to administer the oxygen therapy. This deficient practice caused an increased risk in Resident 230 having skin breakdown and exacerbation of symptoms. Findings: A review of Resident 230's admission record indicated the resident was admitted to the facility on [DATE] with a diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), cerebral infarction (a medical condition where blood flow to the brain is interrupted, causing brain tissue to die), and nicotine dependence. A review of Resident 230's Minimum Data Set (MDS - a resident assessment tool), dated 1/31/25,…

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 maintain complete and accurate documentation for one of six sampled residents (Resident 49), when Resident 49's tolerance of both knee splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) were not documented with the accurate time. This deficient practice had the potential for inaccurate medical documentation and reporting of RNA treatments, which can minimize the facility's ability to recognize a change of condition and reassess Resident 49's tolerance for knee splints. Findings: A review of Resident 49's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis (a life-threatening blood infection) with septic shock (life-threatening drop in blood pressure), muscle wasting and atrophy (gradual decline), generalized osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Residents 1's) comprehensive assessment accurately reflected the residents' history of fall and functional limitation in range of motion [ROM, full movement potential of a joint (where two bones meet)]. This deficient practice had the potential to result in a negative effect to Resident 1's plan of care that can lead to an injury or fall. Findings: a. A review of the Orthopaedic Surgery H&P notes from the General Acute Care Hospital (GACH) dated 7/15/24 indicated Resident 1 presented with right hip pain on 7/14 after an unwitnessed ground level fall at home. The clinical impression indicated a right hip fracture. A review of Resident 1 ' s admission Record indicated the facility originally admitted the resident on 7/21/24 with diagnoses including repeated falls and displaced comminuted fracture (bone breaks into three or more pieces) of shaft of right femur and was readmitted on [DATE] with diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a history of falls, received supervision per the Interdisciplinary Team (IDT) plan to provide a sitter from 3 PM to 7 AM. Resident 1 was observed in the room without a staff member present. This deficient practice caused an increased risk of another fall with injury for Resident 1. Findings: a. A review of the Orthopaedic Surgery H&P notes from General Acute Care Hospital (GACH) dated 7/15/24 indicated Resident 1 presented with right hip pain on 7/14/24 after an unwitnessed ground level fall at home. The clinical impression indicated a right hip fracture. A review of Resident 1 ' s admission Record indicated the facility originally admitted the resident on 7/21/24 with diagnoses including repeated falls and displaced comminuted fracture (bone breaks into three or more pieces) of shaft of right femur and was readmitted on [DATE] with diagnoses including periprosthetic fracture…

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 for one of four sampled residents (Resident 1) who had a change in condition (CIC- is a sudden significant deviation from a patient's baseline in physical, cognitive mental ability to make decisions), manifested by chest congestion (abnormal or excessive accumulation of a body fluid), and productive cough, was assessed without a delay in treatment by failing to: 1. Ensure Licensed Vocational Nurse 3 (LVN 3) immediately checked Resident 1's vital signs (blood pressure [BP], heart rate [HR], respirations [RR], oxygen saturation [O2 Sat - amount of oxygen in the blood] and temperature [Temp]) when Certified Nursing Assistant 2 (CNA 2) informed LVN 3 that Resident 1 had a change in condition on 6/14/2024 at around 7:30 AM. 2. Ensure LVN 3 immediately informed a Registered Nurse 1 (RN) on duty when Resident 1 had a CIC and Resident 1's chest was congested and had a productive cough (a cough that produces mucus) on 6/14/2024 at around 7:30 AM. 3.…

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 care in a manner that promote or enhanced resident's dignity and respect for one of two sampled resident (Resident 1) by failing to ensure facility staff gave some time to Resident 1 when Resident 1 had an episode of resisting care with combativeness during activities of daily living (ADL-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). This deficient practice had the potential to cause psychosocial harm to the Resident 1 and can violate resident's right to be treated with dignity. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis (MS- a disabling disease of the brain and spinal cord [ central nervous system]), right hand contracture (permanent tightening of the muscles that causes joints to shorten and become very stiff) and dementia (loss of cognitive functioning-thinking, remembering, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to ensure physician (MD) notification and change of condition (COC/SBAR [situation, background, appearance and review/notify- structured tool for healthcare provider that provides communication between members. Also, being used as documentation for any changes of condition]) documentation was done for one of one sampled resident (Resident 1). Resident 1 had multiple, scattered skin discolorations on upper extremities (arm/leg) and had an episode of resisting care with combativeness during activities of daily living (ADL-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). These deficient practices had the potential to result in possible delayed provision of necessary care and services specific for Resident 1. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis (MS- a disabling disease of the brain and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure documentation of grievances was completed for one of three sampled residents (Resident 1). This deficient practice violated Resident 1 ' s family right to have their grievance addressed. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), difficulty in walking and abnormal posture. A review of Resident 1 ' s Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 4/5/2024, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was severely impaired and requiring moderate assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use). A review of facility ' s Grievances from 4/1/2024 to 4/24/2024, indicated no…

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 document a medication intolerance for cephalexin (medication to treat infection) medication in the medication allergy profile between 3/12/2024 and 4/15/2024 for one of three sampled residents (Resident 1). Resident 1 received the first dose on 3/12/2024, causing Resident 1 to have an episode of nausea and vomiting. Facility staff failed to document intolerance of cephalexin medication use for Resident 1 ' s medication allergy profile. This deficient practice caused Resident 1 to receive another dose on 4/15/2024, causing Resident 1 to experience another episode of nausea and vomiting related to the use of cephalexin. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), difficulty in walking and abnormal posture. A review of Resident 1 ' s Minimum Data Set (MDS - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of four sampled residents (Resident 1) by failing to develop a comprehensive care plan for physician ' s order of, May go out on pass with two responsible parties for four (4) hours at all times. This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Findings: A review of admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) due to thrombosis (blood clot in the deep vein), abnormalities of gait and mobility, and dysphagia (difficulty swallowing food or liquid). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 1/11/2024, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide reasonable accommodations for resident needs and preferences for one of one sampled resident (Resident 1) by failing to assist resident to the restroom timely and change her wet and soiled incontinent brief. This deficient practice had the potential to affect Resident 1 ' s wellbeing, level of satisfaction with life and feeling of self-worth and self-esteem due to lack of or delay in receiving sufficient services to maintain personal hygiene. Findings: A review of admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), difficulty in walking and muscle wasting and atrophy (characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 1/5/2024, indicated Resident 1 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy regarding reporting of residents ' allegation of sexual abuse and to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of six sampled residents (Resident 2). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further sexual abuse for Resident 2. Findings: A. A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including type 2 diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) with hypoxia (low levels of oxygen in the body causing confusion, bluish skin, and changes 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 implement its abuse prevention policy by failing to report an allegation of abuse within 2 hours or in accordance with state or federal law for one of six sampled residents, Resident 2. This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further sexual abuse for Resident 2. Cross Reference F609 Findings: A. A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including type 2 diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) with hypoxia (low levels of oxygen in the body causing confusion, bluish skin, and changes in breathing and heart rate), chronic…

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 resident (Resident 2) was free from significant medication error by failing to properly administer Resident 2's medications by the Licensed Vocational Nursing 1 (LVN 1) who prepared the medications and administered medications in the scheduled timeframe per physician's order. These deficient practices resulted in the Resident 2 missed the medication as scheduled and placed Resident 2 at risk of inadequate pain relief and experienced health complications from her medication therapy. Findings: A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) with hypoxia (low levels of oxygen in 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 allow and readmit one of three sampled resident (Resident 1) to return to the facility following therapeutic leave at General Acute Care Hospital 1 (GACH 1) on 1/15/2024 according to the facility's policy and procedure (P&P) titled Bed hold and Notice. As a result, Resident 1 experienced sadness as Resident 1 was sent to another facility after hospitalization and was not allowed to be readmitted to her original facility where she had resided. Findings: A review of Resident 1 ' s admission Record indicated resident was originally admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder or urethra), unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning), and depression (a mood disorder that causes…

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 post daily actual hours worked by licensed and unlicensed staff providing direct care to the residents for 1/1/2023 to 2/10/2024. As a result, residents and visitors did not know the accurate number of hours of staff working. Findings: On 2/11/2024 at 11:56 AM, a review of copies of the Projected Daily Care Staffing form for the months of January and February 2024 indicated there were no actual hours worked by direct care staff posted. During a concurrent interview, the Director of Staff Development (DSD) stated she was responsible for posting the daily staffing report and that she only posted the projected staffing hours. The DSD stated she had never posted the actual hours worked by direct care staff because she did not know that she needed to and that it was not part of her training. The DSD stated, Staffing was posted in order for residents and their families or visitors to see that we are meeting our staffing hours. During an interview on 2/11/2024 at 5:16 PM, the Administrator (ADM) stated the current…

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 properly store and dispose of seven used Fentanyl (a medication classified as a narcotic which is a drug that produces pain relief, narcosis [state of stupor or deep sleep], and possible addiction [physical dependence on the drug]) patches (a medicated adhesive patch that is placed on the skin to deliver a specific dose of medication through the skin) per the facility's policy. This deficient practice had the potential to result in the untimely disposal of narcotic waste. Findings: During an observation on 2/11/2024 at 10:50 AM, Medication Cart 1 was observed with Licensed Vocational Nurse (LVN) 7. In Medication Cart 1, seven used Fentanyl patches were observed, each patch was stored in a small plastic bag. Two patches were dated 1/20/2024, one patch was undated, and the remaining four patches were dated 1/17, 1/26/2024, 2/3, and 2/11/2024. During a concurrent interview, LVN 7 stated the Fentanyl patches were supposed to be given to the Director of Nurses (DON) for storage, the DON was then supposed to dispose…

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 reasonable accommodations for one of three sampled residents (Resident 25), by failing to ensure the resident's call light was answered timely. This deficient practice had the potential to result in Resident 25 not having their needs met resulting in possibly injury. Findings: A review of Resident 25's admission Record indicated the facility admitted the resident on 5/2/2023 and re-admitted the resident on 12/9/2023 with diagnoses including neuromuscular dysfunction of the bladder (a lack of bladder control due to a brain, spinal cord or nerve problem), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), and Urinary Tract Infection (UTI, infection in the urinary system). A review of Resident 25's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 12/16/2023, indicated the resident was cognitively (ability to think, understand, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a current copy of the resident's advance directive (a written instruction, recognized under State law, relating to the provision of health care when the individual was unable to make decisions for themselves) was in the resident's medical chart for one of seven sampled residents (Resident 26). This deficient practice had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment. Findings: A review of Resident 26's admission Record indicated the facility originally admitted the resident on 6/30/2022, and readmitted on [DATE], with diagnoses including acute (sudden) and chronic (lasting a long time) respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body, essential hypertension (high blood pressure), and lack of coordination. A review of Resident 26's Advance Directive Acknowledgement Form dated 7/20/2022, indicated the resident had executed an…

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

Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADL) for one of six sampled residents (Resident 69). For Resident 69, who was unable to feed herself, staff did not provide assistance to feed the resident during lunch while the lunch tray sat untouched in front of Resident 69. This deficient practice had the potential for the resident to experience poor oral intake, loss of dignity and risk for weight loss. Findings: A review of Resident 69's admission Record indicated the facility admitted the resident on 10/21/2023 with diagnose including cachexia (a condition that leads to extreme weight loss and muscle wastage), and adult failure to thrive (syndrome of weight loss, decreased appetite, and poor nutrition). A review of the Physician's Order dated 10/22/2023, indicated Resident 69 was to receive a 1:1 feeder (the action of a person feeding another person who cannot otherwise feed themselves). A review of the Physician's History and Physical (H&P) dated 10/23/2023, indicated Resident 69 could make needs…

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 monitor and record the intake and output for one of five sampled residents (Resident 26), who was dependent on staff for fluid intake and at risk of dehydration, per the care plan and physician's order. This deficient practice had the potential to cause Resident 26 to suffer dehydration or fluid overload. Findings: A review of Resident 26's admission Record indicated the facility re-admitted the resident on 1/25/2024 with diagnoses including protein-calorie malnutrition (inadequate intake of food as a source of protein, calories, and other essential nutrients) occurring in the absence of significant inflammation, injury, or another condition , unstageable pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin where the extent of the injury is unknown) and dysphagia (difficulty swallowing). A review of Resident 26's care plan developed 1/25/2024, indicated the resident was at risk for dehydration related 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 provide services that promote the prevention of pressure ulcer injury (injury to the skin caused by pressure) for one of three sampled residents (Resident 69). For Resident 69, who was a high risk for pressure ulcer injury, the low air loss mattress (LALM-mattress designed to treat and prevent pressure ulcers) was not monitored to ensure turned on, properly functioning, and maintained proper weight settings for the mattress. These deficient practices had the potential for worsening of pressure ulcer and harm to Resident 69. Findings: A review of Resident 69's admission Record indicated the facility admitted the resident on 10/21/2023, with diagnose including Stage IV pressure ulcer (very deep and reaches into the muscle and bone causing extensive damage), on the sacral region (a large, triangular bone at the base of the spine). A review of the Physician's Orders dated 10/22/2023, indicated to apply a LALM for wound management and to monitor the LALM every shift. A review of the Physician's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedure titled,Fall Risk and Prevention of Injuries, for one of three sampled residents (Resident 51). For Resident 51, who was a high fall risk and found on the floor, there was no post fall risk assessment completed. This deficient practice placed Resident 51 at increased risk for recurrent falls and injuries. Findings: A review of Resident 51's admission Record (Face Sheet) indicated the facility admitted the resident on 1/24/2024, with diagnoses including repeated falls, and difficulty in walking. A review of Resident 51's Fall Risk assessment dated [DATE], indicated Resident 1 had 1-2 falls in the past three months, was chair bound, legally blind, and was not able to stand on both feet. The fall risk assessment indicated Resident 1 had a total score of 16 and a score of 10 or greater indicated the resident should be considered at high risk for potential falls. A review of Resident 51's nursing Progress Notes dated 1/28/2024…

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 the care and services necessary to prevent urinary tract infections (UTI, infection in the urinary system) for one of three sampled residents (Resident 25) by failing to maintain the resident's urinary catheter bag below the level of the bladder. This deficient practice placed Resident 25 at risk for urine backflow through the catheter tubing and back into the resident's bladder and kidneys, placing the resident at risk for a UTI, sepsis (infection throughout the blood), and possible death. Findings: A review of Resident 25's admission Record indicated the facility originally admitted the resident on 5/2/2023 and re-admitted the resident on 12/9/2023 with diagnoses including neuromuscular dysfunction of the bladder (a lack of bladder control due to a brain, spinal cord or nerve problem), acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), and UTI. 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.

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one of four sampled residents (Resident 132) by failing to ensure the resident had a date on the nasal cannula (a device used to deliver supplemental oxygen) tubing and humidifier bottle (a medical device used to increase humidity or moisture and decrease dryness of supplemental oxygen during therapy) for prompt weekly changing. This deficient practice had the potential to cause complications associated with oxygen therapy, including infections and/or respiratory distress. Findings: A review of Resident 132's admission Record indicated the facility admitted the resident on 2/2/2024 with diagnoses including acute respiratory failure (a condition when the lungs can not release enough oxygen into your blood), acute pulmonary edema (an abnormal buildup of fluid in the lungs), and pleural effusion (an unusual amount of fluid around the lung). A review of the Physician's Order dated 2/2/2024, indicated Resident 132 was to receive oxygen at 2 liters per minute (LPM)…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 15) who received dialysis (process of removing waste products and excess fluid from the body) treatment received care in accordance with standards of practice, by failing to: -Review the Dialysis Unit Progress and Post Dialysis Checklist following Resident 15 returning from dialysis treatment. -Contact the dialysis center to provide the missing documentation. These deficient practices had the potential to place Resident 15 at risk for a delay in detecting complications related to dialysis including, infections, hypotension and bleeding. Findings: A review of Resident 15's admission record indicated the facility admitted the resident on 10/17/2022 with diagnoses including end stage renal disease (ESRD - loss of kidney function in which the kidneys no long work to meet the body's needs) and dependence on renal dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) and diabetes (high blood sugar). 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 observation, interview, and record review the facility failed to: -Ensure all opened food items stored in one of one walk-in freezers were labeled with the name of the food item, open date, and expiration date. -Ensure one metal container of minced garlic was properly sealed in one of one walk-in refrigerator. These deficient practices had the potential to cause food-borne illnesses. Findings: During initial kitchen tour on 2/9/2024 at 4:41 PM, an opened package of hamburger buns and frozen dinner rolls were observed stored in the freezer without a date. During a concurrent interview, the facility's Assistant Dietary Supervisor (ADS) stated the hamburger buns and dinner rolls were not dated and they should have been. The ADS stated staff label and date all opened items to prevent foodborne illnesses. There was also one metal container of prepared minced garlic observed, dated as opened on 2/7/2024 and with an expiration date of 2/10/2024, uncovered. During a concurrent interview, the ADS stated all prepared food should be completely covered and sealed to prevent…

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

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with physician's orders to maintain the highest practicable physical, mental, and psychosocial well-being by failing to ensure: -Licensed staff followed Resident 1's Nurse Practitioner's (NP- a nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor) order to inform NP that an In and Out catheter (a catheter that is inserted and left in only long enough to empty the bladder and then is removed) was placed and kept inside for Resident 1. -A person-centered care plan was initiated for indwelling urinary catheter (a tube inserted inside the bladder which drains urine from bladder into a bag outside the body) after the insertion and catheter monitoring was conducted. These deficient practices had the potential to negatively affect the delivery of care and services necessary for Resident 1. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident 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 implement its' abuse prevention policy and procedures (P &P) for one of three sampled residents, (Resident 1), when Resident 1's son reported to the Administrator that his mom told him that a male nurse touched her inappropriately in her private area on 05/13/2022. This deficeint practice resulted in the delay of an onsite inspection by the State Survey Agency (SSA), to rule out abuse placing Resident 1 and others residents at risk for further abuse and to ensure the safety of all residents. Findings: A unannounced visit was conducted at the facility on 10/31/20023, regarding an alleged abuse incident. A review of Resident 1's admission Record indicated Resident 1, was originally admitted to the facility on [DATE], with diagnoses including closed fracture repair of the lower end of the femur (fracture of the leg) difficulty walking, lack of coordination and generalized muscle weakness. A review of Resident 1's Minimum Data Set (MDS-a standardized…

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

Based on interview, and record review, the facility failed to maintain an effective infection prevention and control program (A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases) to include monitoring and tracking all communicable diseases including Coronavirus (COVID-19, a virus that spreads from person to person causing respiratory illness). This deficient practice had the potential to expose residents and staff to communicable disease and infections including Coronavirus. Findings: A review of Resident 1's admission record indicated the facility admitted the resident on 7/6/2023 with fracture (broken bone) of the lumbar vertebra (five bones in the lower spine), Type II diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and Coronavirus (COVID-19, a virus that spreads from person to person causing respiratory illness). A review of the Physician's Order dated 7/6/2023 indicated COVID-19 swab via anterior nares (external portion of the nose) testing. A review of Resident 1's…

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