Marysville Post-Acute

Based on observation, interview, and record review the facility failed to have or follow policies and procedures for Quality Assurance and Performance Improvement (QA/PI) nor any formalized QAPI projects as required. This failure demonstrated a lack of quality and performance improvement that could lead to a decrease in Resident quality of life, enjoyment and happiness, causing adverse clinical outcomes. Findings: On 11/16/23 at 10:30 AM during a concurrent interview and record review the Facility Administrator (Admin) was interviewed regarding facility administration functions. The Admin was not able to provide regulation required policies and procedures on Quality Assurance and Performance Improvement (QA/PI). The QA/PI processes assist a facility in recognizing issues potentially affecting residents adversely, guiding the facility in monitoring and improving issues to reduce or prevent adverse outcomes. The Admin stated he did not have a policy for QA/PI processes available. The Admin did not have any documented formalized regulatory required QA/PI projects with planning, review,…

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

Based on observation, interview and record review the facility failed to have records of Quality Assurance and Performance Improvement (QA/PI) meetings to obtain feedback, use data, and take action in conducting structured, systematic investigations and analysis of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The facility failing to have a structured, functional QA/PI process addressing potentially harmful and preventable issues creates the potential for resident harm and adverse clinical outcomes. Findings: During a concurrent record review and interview on 11/16/23 at 9:56 AM, with the Facility Administrator (Admin) when questioned about monthly and quarterly Quality Assurance and Performance Improvement (QA/PI) meetings the Admin stated the facility has, Daily quality meetings with department by department issues the managers select. The Admin was not able to print a report. Observed the form and it appears to be a day by day (not a formal monthly or quarterly) account of departmental quality assessments and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure infection control program was properly maintained or implemented to reduce the spread of infection when: 1. Personal protective equipment (PPE, gloves, gowns, eye protection, and masks) was not consistently and correctly used by staff when providing care for Coronavirus disease (COVID-19: an infectious disease caused by the SARS-CoV-2 virus) positive residents; and 2. Tuberculosis (TB-a bacterial infection that mainly attacks the lung. A tuberculosis screening test checks to see if a person has the bacteria (germs) that cause TB in the body) screen was not done per the facility's policy for one out of six sampled employees. 3. Hospitality Aide (HA) did not perform hand hygiene (wash hands or use hand sanitizer) before or after direct resident contact with five out of five residents (Resident 41, 66, 52, 62, and 15) including contact with self. These failures had the potential to result in the development and transmission 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 follow its Administrating Medications policy and procedure (P&P) for one out of one resident (Resident 53) when Resident 53 was provided a suppository (a meltable medication placed into the rectum) for self-administration. This failure had the potential for incorrect medication administration and could cause Resident 53 negative clinical outcomes. Findings: During a review of the facility's P&P titled, Administrating Medications, revised 12/1/22, indicated, Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. A review of the undated record titled admission Record indicated Resident 53 was admitted to the facility with the diagnosis of morbid (severe) obesity (more than 80 to 100 pounds over the ideal body weight) and chronic obstructive pulmonary disease (a group of lung diseases that made it difficult to breath). The admission Record…

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

Based on observation, interview, and record review, the facility failed to maintain the facility in a safe and operable manner and provide a homelike environment when: 1. A handrail at the end of Hall 3 was not attached securely to the wall, sections of the ceiling had missing and peeling popcorn texture (a sprayed on bumpy texture that was applied to the ceiling) on Hall 3 and near the nurse station. 2. Five of 13 sampled residents (Residents 18, 75, 46, 55, and 27) expressed that their belongings were missing. This failure had the potential to cause resident harm and resulted in residents' inability to access their own belongings and had the potential to foster an environment that was not home-like. Findings: 1. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, revised 10/1/09, indicated Maintenance service shall be provided to all areas of the building, grounds, and equipment. The P&P indicated maintenance personnel were responsible for Maintaining the building in good repair. During a review of the facility's P&P titled, Homelike…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide sufficient staffing that met the needs of the residents when: 1. Two out of 11 residents (Resident 45 and 50) stated they did not receive a shower due to the facility not having enough staff. 2. Eight out of 11 residents stated they experienced long call light wait time due to the facility not having enough staff. This failure had the potential to result in resident inability to attain or maintain their highest practicable level of physical, mental, and psycho-social well-being. Findings: During a review of the facility's policy and procedure (P&P) titled, Staffing, revised 4/1/21, indicated, Our facility provides adequate staffing to meet needed care and services for our resident population. The P&P indicated, Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. 1. During a review if the facility's P&P titled Shower, revised 5/1/18, indicated, The purposes of this…

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

Based on observation, interview, and record review the facility did not post daily staffing for public viewing as required by regulation. This failure created the potential for staffing issues including, short staffing, staffing and workload misinformation leading to decreased quality of care and adverse clinical outcomes. Findings: During a concurrent Interview and record review on 11/14/23 at 3:42 PM, the Director of Nursing (DON) attempted to locate the daily staffing posting. When the document for 11/14/23 was not available and determined not to exist the DON stated, It is not here. I will check and see if I can find it and left the DON's office. The DON approached the Assistant Director of Nursing (ADON), asked if the ADON was familiar with the form and had a current copy. The ADON did not have knowledge of the form and did not have a copy. Neither the ADON nor DON had the regulation required documents for the last 18 months. At 3:50 PM on 11/14/23 during a concurrent interview and document review the Facility Administrator (Admin) was not familiar with the requirement 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.

Based on observation, interview, and record review, the facility failed to ensure the five rights of medication administration had been followed for one resident (Resident 53) when Licensed Nurse (LN) F did not know the name or dosage of a medication that LN F provided to Resident 53 and LN F did not document the medication had been given. This failure had the potential for incorrect medication administration, duplication for medication administration, and could cause Resident 53 negative clinical outcomes. Findings: During a review of the facility's policy and procedure (P&P) titled, Administrating Medications, revised 12/1/22, indicated, The individual administering the medication must check the label to verify the right medication, right dosage, right time, and right method (route) of administration before giving the medication. The P&P indicated the Individual administering the medication will record in the resident's medical record: the date, time, dose, and sign record. A review of the undated record titled admission Record indicated Resident 53 was admitted to the facility…

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

Based on observation, interview, and record review, the facility did not provide routine showers and/or baths consistent with the residents' needs and choices for 11of 23 (Resident 5, 8, 9, 10, 11, 14, 16, 17, 20, 25, and 26) sampled residents. This failure had the potential to result in depression, poor self-esteem, skin breakdown, infection, and denial of resident rights, all of which could lead to negative clinical outcomes for all residents. Findings: Review of a facility policy titled Bath; Bed Bath, No-Rinse Sponge Bath (undated) indicated baths were to be given to residents to provide cleanliness, comfort, and to prevent body odors. The policy indicated, All residents are given baths unless contraindicated (not advised). The policy indicated bath water should be comfortably warm (between 95- and 110-degrees Fahrenheit) and should be changed intermittently throughout the process when the water becomes too cool or dirty. During review of record titled Resident Council Minutes, dated 7/20/2023 at 1:45 pm, shower was indicated as a concern regarding nursing care. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the supervision required to keep all residents free from potential accidents and hazards when: 1. One of seven residents (Resident 1) eloped unsupervised (left without notice) from the facility without staff being aware he was gone. 2. Wanderguard alarms (prevent wander-prone residents from leaving unattended) were not working at two of four facility exit doors. These failures had the potential to compromise the safety and well-being of all residents from unsupervised wandering/elopement with the potential for accident or harm. Findings: Review of facility policy titled, Safety and Supervision of Residents, revised 10/2022, indicated the facility would strive to make the environment as free from accident hazards as possible based on individual resident need. The policy indicated the facility would monitor the effectiveness of interventions by (a) ensuring that interventions are implemented correctly and consistently, (b) evaluate…

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 residents' linens were being clean and sanitized using infection control standards. This failure resulted in residents' linens not being cleaned and sanitized properly and had the potential to spread disease and infection throughout the facility. Findings: A review of a facility policy titled, Infection Prevention and Control, revised 10/2021, indicated, An infection prevention and control program (ICPC) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During observation on 10/13/2023 at 8:50 am, overheard Director of Nursing (DON) inform Resident 8 an issue with no hot water in the facility was fixed Wednesday (10/11/2023). Resident 8 stated the hot water had been out for like a week. DON again replied that maintenance staff had resolved the issue two days prior. During a review of Plumbing Doctor Invoice #24467745, dated 10/17/2023, the invoice indicated it was an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain essential equipment necessary to ensure resident safety and activities of daily living needs were met when: 1 The Wanderguard Alarm System (prevents wander-prone residents from leaving the facility unattended) did not work for three weeks or more. This failure led to the potential for unsupervised resident elopement (leaving without notice), leading to the potential for harm and preventable accidents/hazards for all residents. 2. One of two facility water heaters did not work for two weeks or more. This failure led to residents not getting baths or showers due to no hot water in the facility with the potential to result in poor self-esteem, depression, denial of resident rights, contribution to skin breakdown, infection, and negative clinical outcomes for all residents. Findings: 1. Review of a facility policy titled, Wandering and Elopements, revised 3/2019, indicated that the facility will identify residents who are at risk 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.

Based on observation, interview, and record review, the facility failed to provide consistent administrative oversight to ensure the residents received the care and services to meet their needs when: 1. Pain management and Hospice services were not coordinated and monitored to meet the needs of residents. Refer to F 697, F 726 and F 849. 2. Pharmacy services related to administration, labeling, and storage did not meet standards. Refer to F 755, F 759, F 880 3. Resident council complaints were unresolved. Refer to F 565 4. Ensure safe smoking practices in the facility. Refer to F 689 Findings: A review of the facility's job description, titled Administrator, revised on 3/1/2014, indicated: a. The Administrator (ADMIN) assumes full-time administrative authority, responsibility and accountability for the operations and for the financial viability of the nursing facility. Manages facility employees in the provision of care and services rendered in accordance with professional standards, and in compliance with county, state and federal laws and regulations, as applicable. Collaborates…

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 full visual privacy to one out of two sampled residents (Resident 67) when a privacy curtain had been missing for one month. This failure had the potential to cause a decline in Resident 67's mental health and cause psychosocial harm. Findings: A review of the records indicated Resident 67 was admitted to the facility 1/29/21 with the diagnoses of generalized anxiety disorder (extreme worrying that interferes with daily activities), cognitive communication impairment (inability to interact meaningfully with others), and bipolar disorder, current episode mixed, moderate (mood disorder that can cause rapid speech, racing thoughts, and agitation). Resident 67 was her own responsible party and could make her own medical decisions. During a concurrent interview and observation on 8/9/22, at 9:24 am, Resident 67 was sitting in a wheelchair in the hallway, had rapid speech, an elevated tone (variations in speech), and was waving arms in the air. Resident 67 stated being upset because the privacy curtain in…

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

Based on interview and record review, the facility failed to address and resolve Resident Council identified issues and concerns for the past four months This failure resulted in pain management needs not to be met, call lights remained being unanswered for an extended amount of time, nutritional needs not to be met and residents felt their grievances were not listened to. Findings: The facility used a form titled Resident Council Minutes that kept attendance of the participants in resident council and tracked their grievances. This form also discussed old business, and new business, including resolutions the facility department related to any issues were responsible for addressing the concerns. Review of Resident Council Minutes, dated 06/23/2022, had a section titled Old Business - Any new business identified at the last council meeting must be addressed here - either as resolved or unresolved. Five out of six items in this list are marked as resolved, with one unresolved. The unresolved items are as follows - Food comes out cold sometimes. However, PM janitor could use more…

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 that two of eighteen smoking residents (Resident 74 and 49) smoked safely in the designated supervised area, securing smoking supplies, and use of safety equipment. This resulted in unsupervised smoking, hazards including cigarettes not properly being disposed of, lack of safety equipment, and had a potential to put all residents at risk for fire hazard and injuries. Findings: 1. A review of the facility's policy titled, Smoking Policy - Residents, revised in April 2012, it is listed under Policy Interpretation and Implementation, that smoking is only permitted in designated resident smoking areas, which are located outside of the building. It also states that all residents will have a smoking agreement signed upon admission and quarterly - which includes a statement saying that residents who had smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow physician orders when the pain management needs for one of four sampled Hospice (supportive care to terminally ill residents that focuses on their comfort, quality of life, and being pain free) residents when; Resident 281 received a lower than the ordered dose of morphine (a strong pain medication) on 12 of 20 occasions. This failure had the potential for Resident 281 to have uncontrolled moderate or severe pain. Findings: 1. A review of Resident 281's admission record, indicated he was admitted to the facility on [DATE] with diagnoses which included prostate (a small gland in men) cancer, brain cancer, spine cancer and palliative care (specialized medical care for people living with a serious illness, such as cancer or heart failure). Resident 281 expired on [DATE]. A review of Resident 281's Minimum Data Set (MDS, a standardized resident assessment), dated [DATE], indicated Resident 281's Brief Interview for Mental Status (BIMS,…

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 9. During a concurrent observation and interview on 8/8/22 at 11:30 am, Resident 74 stated pain medications are late and looked in his journal and gave examples. On 8/1/22 at 9:30 am, CNA showed up at 10 am, then another correct CNA comes at 10:19 am, then he called another CNA at 10:40 am then by 11:50 am, he received his pain medication. On 8/5/22, Resident 74 called CNA at 10:40 am due to reporting pain level was a 7/10 (severe) and by 11:50 am he received his pain medication. Resident 74 stated his pain level right now was a 7/10. Resident 74 stated it makes him feel not happy, frustrated and causes anxiety. Resident 74 stated his pain level after receiving medication is usually a level of 4-5 and was tolerable at that level. Resident 74 stated I'm not the waiting type and stand in the hallway. Resident 74 stated The Hospice nurse was aware. Resident 74 stated Timeliness could be improved; they should hire more people. 10. During an interview on 8/9/22 2:53 pm, CNA Y stated she works with Resident 57 often…

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 3. A review of Resident 74's record indicated he was admitted to the facility on [DATE], with diagnoses which included heart failure, lung disease, and palliative hospice (end of life) care. Resident 74 was able to make his own health care decisions. A review of physician order dated 4/13/22, Morphine Sulfate Continuous release (MS Contin- a strong, long-acting narcotic pain medication) 15 milligrams (mg) every 12 hours for chronic pain. Morphine concentrate (liquid) 100 mg/5 milliliter (ml), administer 0.25 ml every 2 hours for mild pain (1-3 on pain scale), 0.5 ml orally every 2 hours for moderate pain (pain scale 4-6) and 1 ml every 2 hours for severe pain (pain scale number 7-10). A review of the MAR History dated 4/1-4/30/22, indicated Morphine Concentrate 0.5 ml for moderate pain levels 4-6 was administered 16 opportunities when Resident 74 reported severe pain levels at 7-8 out of ten. On 4/19/22 late administration was documented for the as needed dose. On 4/28/22 at 1:06 am, the post pain assessment 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.

Based on observation, interview, and record review the facility failed to ensure: 1. Accurate accountability and disposition of the medications awaiting final disposition (means destroying the unused medications to render it ineffective and prevent abuse or diversion) in the facility with a census of 76, 2. The facility's Consultant Pharmacist (CP) documented medication refrigerator temperatures were checked and logged for three out of three months (April, May, and June) when the facility temperature logs had missing data. 3. Routine medications (medications given daily) were not available for use for three out of four residents. These failed practices could contribute to unsafe medication use and prevention of drug diversion in the facility which could lead to negative outcomes. Findings: 1. During a concurrent interview, observation and review on 8/9/22, 2:30 pm, of the facility's medication destruction binder, accompanied by the Director of Nurses (DON), narcotic sheets (documentation with name of narcotic, resident name, instructions for use, and the total number of individual…

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 had a 17.24 % (percent) medication error rate, when five medication errors out of 29 opportunities were observed during medication pass for two out of three residents (Resident 16 and Resident 19). These failures resulted in four medications not given and one medication administered at an incorrect dose, which did not follow physician orders. This had the potential for residents to have a decrease of therapeutic medication effects (symptoms the medication is treating), a decline in health status, and negative psychosocial outcomes. Findings: During a concurrent observation and interview on 8/10/22, at 8:14 am, Licensed Nurse (LN) F was orientating LN H on medication cart #3 (a locked cart on wheels, resident medications were stored in). LN H was not able to locate the blister pack (medication storage device) for Keppra (seizure medication). LN H stated, this is not the first time we were out of Keppra. LN H stated, if a surveyor was not watching the…

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

Based on observations, interviews, and record reviews, the facility failed to provide safe storage and labeling of medications and medical supplies when: 1a. the refrigerator and room temperatures were not consistently monitored in one out of one medication storage rooms. 1b. an unlabeled medication with wet, deteriorated packaging located in medication refrigerator was available for use. 2a. expired medication stored in one out of four medication carts (a locked cabinet on wheels where resident medication is stored). 2b. one out of four medication carts where medication was stored contained loose debris and was dirty. 2c. Expired and unlabeled medication were stored in one out of one treatment cart. These failures had the potential for unsafe medication use, and the use of medical supplies which would no longer be effective, which could lead to negative clinical outcomes. Findings: 1a. During a concurrent observation and interview on 8/9/22, at 10:29 am, Director of Nurses (DON) and Licensed Nurse H (LN) confirmed medication refrigerator temperature logs were missing temperature…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure the food service met resident needs as evidenced by unresolved food complaints surrounding the form, taste and temperature of the food that was served. These failures had the potential to result in decreased resident meal intakes, negatively impact their nutritional health status and quality of life. Findings: 1. A review of Resident 44's record indicated diagnoses that include transient cerebral ischemic attack (a stroke - damage to the brain from interruption in its blood supply), difficulty walking, respiratory failure with hypoxia. Resident 44 had a Brief Interview for Mental Status (BIMS) score (a number value between 00-15 with 13-15 cognitively intact, 08-12 moderately impaired, and 00-07 severe impairment) score of 15 on 6/9/22 and Part G of the facility's Minimum Data Set (MDS) (provides a comprehensive assessment of the resident's functional capabilities. Section G is specific to Functional Status) on 6/20/22 indicated Resident 44 needed…

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 that resident preferences were honored and offered substitutes of similar nutritive value for 10 of 10 sampled residents (Residents 21, 33, 39, 44, 49, 50, 56, 66, 67, and 76) and four out of eight confidential resident interviews. This failure not to provide food in accordance with resident preferences may result in decreased meal satisfaction and overall caloric intake. Findings: 1. Resident 39's record was reviewed. Resident 39 was admitted to the facility on [DATE], with a diagnosis that included, Parkinson's disease (uncontrollable tremors, stiffness, and difficulty with balance and coordination), and history of falling. The most recent Minimum Data Set (MDS, a standardized resident assessment) dated 6/9/22, indicated that Resident 39 was cognitively intact. During an interview on 8/8/22, at 11:10 a.m., with Resident 39, Resident 39 stated, The food here is terrible and cold most of the time. They serve the same bland stuff every day, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement Hospice agreements and Hospice program ((a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) policy and procedures, and collaborate in the development of a coordinated plan of care, to ensure the physical, psychosocial, spiritual, and emotional needs were meet for four of four sample residents (Resident 57, 58, 74 and 281) when: 1.a. Resident 281 was given wrong dosage, wrong pain medication for the wrong pain level. This resulted in agitation and four falls. 1.b. Resident 281 wasn't provided with Oxygen concentrator on 4/15/22, 4/22/22 and 4/23/22 per physician ordered and hospice plan of care. This could potentially cause respiratory distress for Resident 281. 2. Resident 58 wasn't given his pain medication per physician order when he asked for it. Resident 58 was upset and had to suffer a longer pain. 3. Resident 74 was given incorrect dose of medication 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.

Based on interview and record review, the facility failed to ensure care and services met accepted standards of quality when the Quality Assurance and Performance Improvement (QAPI) did not identify and correct quality deficiencies when: 1. Pain management and Hospice services were not coordinated and monitored to meet the needs of residents. Refer to F 697, F 726 and F 849. 2. Pharmacy services related to administration, labeling, and storage did not meet standards. Refer to F 755, F 759, F 880 3. Resident council complaints were unresolved. Refer to F 565 4. Ensure safe smoking practices in the facility. Refer to F 689 This failure resulted in substandard quality of care and had the potential to put all residents at risk for safety and decreased quality of care and life. Findings: A Review of the facility's policy, titled 2022 Quality Assurance and Performance Improvement (QAPI) Plan, updated on 7/28/2022, showed: - Guiding: a. The organization uses quality assurance and performance improvement to make decisions and guide their day-to-day operations. b. The outcome of QAPI 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.

Based on interview and record review, the facility's Quality Assessment and Assurance (QAA) committee failed to develop and implement plans of action to correct identified facility issues related to: 1. Pain management and Hospice services were not coordinated and monitored to meet the needs of residents. Refer to F 697, F 726 and F 849. 2. Pharmacy services related to administration, labeling, and storage did not meet standards. Refer to F 755, F 759, F 880 3. Resident council complaints were unresolved. Refer to F 565 4. Ensure safe smoking practices in the facility. Refer to F 689 Findings: A Review of the facility's policy, titled 2022 Quality Assurance and Performance Improvement (QAPI) Plan, updated on 7/28/2022, showed: a. QAPI Plan: The QAPI plan guides the facility's performance improvement efforts. b. The QAPI team will review the sources of information to determine if gaps or patterns exist in the systems of care that could result in quality problems; or if there are opportunities to make improvements. The facility's governing body is ultimately responsible for overseeing…

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 safe infection control practices to prevent spread of infection when: 1. The blood pressure (BP) cuff was not effectively sanitized in-between resident care use on two out of two sampled residents (Resident 16 and Resident 19). 2. Licensed Nurse H (LN) touched medications with bare hands on two out of two sampled residents (Resident 16 and Resident 19). 3. a. Oxygen tubing was found on floor, outdated, and or undated for one out of two residents (Resident 43). b. Oxygen tubing was undated for one out two residents (Resident 38). c. Oxygen tubing was unlabeled for one out of one resident (Resident 77) while using a portable oxygen tank. 4. Staff failed to wear the required Personal Protective Equipment (PPE, face shield or goggles, gloves, gown) in the facility's yellow zone (area used to quarantine new admissions who require isolation) These failed practices may pose health and infection risk to facility's residents potentially…

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.