Feather River Care Center

Based on observation, interview, and record review, this facility failed to accommodate the need to communicate with of one (Resident 1) of four sampled residents when the facility failed to provide any means of translation to a Hmong only speaking resident. This failure resulted in Resident 1 not being properly assessed and Resident 1's pain was not treated. Findings: A record review of Resident 1's face sheet indicated an admission date of 4/24/25 for hemiplegia (a condition characterized by paralysis of one side of the body) and hemiparesis (a condition characterized by weakness on one side of the body) following cerebral infarction (tissue death caused by a lack of blood supply to the affected area) affecting right dominant side, and dysphagia (difficulty swallowing). Resident 1 was her own representative. The only language Resident 1 speaks was Hmong. During an interview on 5/9/25 at 11:10 am of Director of Nursing (DON), DON stated that the facility does not have any way of translating for their non-English speaking residents. By a record review of the Minimum Data Set (MDS)…

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

Based on observation, interview, and record review, this facility failed to address and treat the pain of one (Resident 1) of four sampled residents when Resident 1 had an accident in the shower chair, sustained an injury, and complained of pain. This resulted in a complete omission of pain treatment and management and Resident 1 suffering without any pain relief. Findings: A policy titled Pain Management (Undated), indicated that the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan . This policy defines acute pain as pain that is usually sudden onset and time-limited with a duration of less than one month and often is caused by injury . The facility will: 1. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated and evaluate the resident for pain, during ongoing scheduled assessments, and when a significant change in condition occurs. 2. Facility staff will observe for nonverbal indicators…

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, this facility failed to ensure licensed staff the competencies and skill set necessary to provide nursing care for one (Resident 1) of four sampled residents when: Nursing staff did not assess and document when Resident 1 had an accident and sustained an injury. Nursing staff did not complete a change in condition or alert the physician. There was no care plans completed to address the accident and injury Resident 1 had. This resulted in Resident 1 not receiving the treatment and pain relief needed for Resident 1's injury. Findings: A record review of Resident 1's face sheet indicated an admission date of 4/24/25 for hemiplegia (a condition characterized by paralysis of one side of the body) and hemiparesis (a condition characterized by weakness on one side of the body) following cerebral infarction (tissue death caused by a lack of blood supply to the affected area) affecting right dominant side, and dysphagia (difficulty swallowing). Resident 1 was her own…

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 protect one of two sampled residents (Resident 2) from abuse when Resident 2 was pushed out of her wheelchair to the floor by Resident 1. This failure had the potential to cause physical and psychosocial harm to Resident 2. Findings: A review of the undated facility policy titled Abuse, Neglect and Exploitation indicated It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing, and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility policy indicated, III. Prevention of Abuse, Neglect and Exploitation, D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of resident with needs and behaviors which might lead to conflict or neglect. A review of Resident 1's record indicated he was transferred from a skilled nursing facility and admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the accuracy of a Preadmission Screening and Resident Review (PASRR, evaluation for serious mental illness and intellectual disability,) for one of two sampled residents (Resident 1) during an admission from another Skilled Nursing Facility. This failure had the potential for Resident 1 not to receive a plan of care to meet his behavioral and mental health needs. Findings: An undated copy of the facility policy titled, Resident Assessment – Coordination with PASRR Program indicated, This facility coordinates assessments with the readmission screening and resident review (P ASARR) program under Medicaid to ensure that individuals with a mental disorder intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), had a comprehensive care plan that was person-centered to meet his mental health needs. This failure resulted in a resident-to-resident altercation and a transfer to the hospital for suicidal ideation. Findings: A review of the undated facility policy titled Comprehensive Care Plans indicated it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. A review of Resident 1's record indicated he was transferred from a skilled nursing facility and admitted to the new facility on 3/31/25 with diagnoses which included stroke affecting right dominant side and depression unspecified. A review of Resident 1's transfer record included a nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Resident 1 had a behavioral health evaluation and services to meet Resident 1's psychiatric behavioral needs. This failure resulted in a resident-to-resident altercation and a transfer to the hospital for suicidal ideation. Findings: A review of Resident 1's record indicated he was transferred from a skilled nursing facility and admitted to the new facility on 3/31/25 with diagnoses which included stroke affecting right dominant side and depression unspecified. A review of Resident 1's transfer record included a nurse practitioner note dated 3/17/25 at 1:33 pm, indicated he had Bipolar II disorder (cycle of mood swings from high to low) continue sertraline (medication for depression). Social Service Assistant notes indicated Resident 1 had four appointments with psychology on 03/17/25, 3/20/25, 3/24/25, and 3/27/25 before transfer to another skilled nursing facility. A review of Resident 1's PASRR dated 11/4/24 done at the previous SNF admission,…

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 inform the conservator (an individual appointed by a court to oversee the mental health care of an individual with a serious mental illness who is unable to make decisions themselves) of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers in advance of a medication change for one of two sampled residents (Resident 1). Resident 1 was receiving Clozapine (medication used to treat severely ill patients with Schizophrenia who have used other medicines that did not work well) for her diagnosed Schizophrenia (a chronic mental health disorder characterized by a disconnection from reality) prior to her admission to the facility and upon admission to the facility on 7/22/2024, and it was placed on hold for an unknown reason from 8/3/2024 until discharge from facility on 10/25/2024, without conservator knowledge. This deficient practice caused a decline in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to update the care plan with a 1:1 monitor (where one staff member is assigned to continuously monitor a single resident for behaviors, needs, etc) for one of four residents (Resident 1) when Resident 1 walked past Resident 2 and hit him in the back of his head. This failure had the potential to result in physical and/or psychosocial harm to other residents. Findings: A record review of facility policy titled Care Plan Revisions Upon Status Change copyright 2024 indicated the care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Facility policy further indicated the Interdisciplinary Team (IDT - a group of facility healthcare professionals who collaborate to provide comprehensive care to residents) will discuss the resident condition and collaborate on intervention options and the care plan will be updated with the new or modified interventions. A record review of Resident 1's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment when: 1a. Certified Nurse Assistant (CNA) I wore the same isolation gown (worn over clothing and used to prevent the spread of infection) while providing care to Resident 24 (who was diagnosed with Clostridium difficile, C-diff, a bacterium that caused diarrhea, was spread from person to person by direct contact, could cause serious illness, hospitalization, or even death) and Resident 23 (who was not diagnosed with C-diff); and 1b. There was no dedicated cleaning equipment for Resident 24's bathroom; and 2. The nurse's station counter was chipped and not able to be disinfected. These failures had the potential to spread infection. Findings: 1a. A review of the facility's undated policy and procedure (P&P) titled, Management of C. Difficile Infection, indicated, the use of isolation gowns would be used as a method to prevent the spread of C-diff. A review of the admission Record, dated 7/9/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' right to privacy were protected for five out of 13 residents sampled for patient rights, (Resident 33, Resident 18, Resident 22, Resident 8, and Resident 5), when Resident 20 entered their room uninvited. This had the potential to make Resident 33, Resident 18, Resident 22, Resident 8, and Resident 5 feel unsafe in their room, and their privacy to be disrespected. Findings: The facility's policy, undated, titled Resident [NAME] of Rights, Sec. 483.10 Resident Rights (e), indicated personal privacy is a right and (1) personal privacy includes accommodations. A review of Resident 33's clinical record indicated Resident 33 was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarct affecting left side (nervous system disorders that cause weakness on one side of the body), frontal lobe and executive function deficit following cerebral infarction (complications after a stroke…

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 foot care and treatment to one out of 13 sampled residents (Resident 201) when Licensed Nursing (LN) did not accurately assess the condition of Resident 201's feet, create a care plan (written plan that described needed care and how care would be provided), and the physician was not notified of the condition of Resident 201's feet. This failure had the potential to negatively impact resident health status and psychosocial well-being. Findings: A review of the facility's undated policies and procedures (P&P) titled, Skin Integrity-Foot Care, indicated, residents would receive proper foot care .to maintain mobility and good foot health. The P&P indicated, The comprehensive assessment will include an assessment of the feet for disorders which may require treatment The P&P indicated, Medical conditions will be managed, and interventions will be implemented in accordance with professional standards of practice to prevent complications…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the safety of one of one sampled resident (Resident 20) when: 1. The shower room door was left unlocked which resulted in Resident 20 wandering into the shower room unsupervised and having a fall. 2. Resident 20 was not on one-to-one supervision every 30 min as described as an intervention in his care plan. 3. Resident 20 was exhibiting wandering behavior, and it was not captured on his Minimum Data Set (MDS, a data driven clinical assessment) assessment. These failures resulted in Resident 20 being unsupervised and falling out of his wheelchair and wandering in other resident rooms which had the potential to cause a decline in Resident 20's physical and social wellbeing. Findings: A review of the facility's policy titled Elopements and Wandering Residents (undated), indicated This facility ensures that residents who exhibit wandering (random or repetitive locomotion [movement] that may be goal-directed or aimless) behavior and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one out of one newly admitted sampled resident (Resident 201) was provided with medical related social services when a referral for a follow up appointment with vascular surgeon (a surgeon that specialized in diseases of the veins and arteries also known as blood vessels) was not done. This had the potential for a decline in health status for a resident that recently suffered a stroke (occurred when something blocked the blood vessel that supplied blood to the brain). Findings: A review of the facility's undated policy and procedure (P&P) titled, Social Services, indicated, The facility, regardless of size, will provide medically related social services to each resident, to assist in attaining or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. The P&P indicated, the social worker would perform an initial assessment of each resident, identify needs, and document them in the medical record. 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 policy review, the facility failed to maintain a clean and orderly environment in the dietary department when there was an unlabeled storage bin and four storage bins with visible dust and adhesive tape residue accumulated on the lids. These failures had the potential to lead to the spread of infections, communicable diseases, and food borne illness to all residents who are served out of this kitchen. Findings: A review of the facility's policy titled Ingredient Bins dated 2018, the policy indicated Ingredient bins must be kept clean and covered to prevent food contamination. Scrub the interior and exterior of the bin with detergent solution. Pay special attention to the corners, lids and casters (wheels). A review of the facility's policy titled Labeling and Dating of Foods dated 2020, the policy indicated All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. During a concurrent observation and interview with the Dietary Manager (DM) on 3/18/25 at 11:17 am, the following were observed in the dry food storage…

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 and interview the facility failed to ensure that all their bedrooms accommodated no more than four residents. This had the potential to result in residents not reaching and maintaining their highest practicable level of well-being. Findings: During the initial tour of the facility on 3/18/25 at 10:30 am, room [ROOM NUMBER] had five beds. The residents had a reasonable amount of privacy. The room had adequate storage space, mobility and the provision of care for 5 residents. During an interview with the Administrator on 3/21/25 at 8:36 am, he stated that he would continue the waiver renewal request.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one out of 13 sampled residents (Resident 4) had access to the resident call system when the call light was not within reach. This failure had the potential to cause a delay in care and could endanger Resident 4's health and safety. Findings: A review of the facility's undated, policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response, indicated, call lights would be placed at the bedside so residents could call for assistance. The P&P indicated, Staff will ensure the call light is within reach of resident and secured, as needed. The P&P indicated, residents would be evaluated for needs and preferences .to determine any special accommodations that may be needed in order for the resident to utilize the call system. A review of Resident 4's admission Record, dated 12/2/23, indicated, admission to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease (a disease that affected the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) was treated with dignity and respect during communication with an employee when asking about lost clothing. This failure caused Resident 3 to feel angry, and had the potential to result in emotional stress, embarrassment, feelings of neglect, and the potential for negative clinical outcomes. Findings: A review of a policy revised 2024, titled, Resident Rights, indicated the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The resident has the right to: Voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished; and the behavior of staff and of other residents; and other concerns regarding their LTC…

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 3) needs were accommodated when a second bedside table was removed from her room that stored art supplies used daily. This failure resulted in Resident 3 becoming frustrated, angry, and violated the right to accommodate specific resident needs. Findings: A review of a policy revised 2024, titled, Resident Rights, indicated the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The resident has a right to be treated with respect and dignity, including: The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. A review of 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 ensure a care plan for one of three sampled residents (Resident 3) was revised and updated to reflect current individual needs for pain management. This failure resulted in the resident ' s individual care needs to go unrecognized, and the potential for a further decline in resident ' s physical, mental, and psychological status. Findings: During a review of a policy revised 8/2024, titled, Care Plan Revisions Upon Status Change, indicated the purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. The care plan will be updated with the new or modified interventions. Staff involved in the care of the resident will report resident response to new or modified interventions. During a review of a policy revised 8/2024, titled, Pain Management,…

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 complete daily hair care for one of three sampled residents, (Resident 3). This failure had the potential to result in Resident 3 feeling depressed with poor self-esteem, frustrated, and negatively impact their ability to attain or maintain their highest practicable level of well-being. Findings: A review of the facility ' s policy revised 8/2024, titled, Hygiene, Grooming, and Activities of daily Living (ADLs), indicated care and services will be provided for the following Adls: bathing, dressing, grooming, oral care, transfers, ambulation, toileting, and eating. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. A review of the facility ' s policy titled, Promoting/Maintaining Resident Dignity, revised 2/2023, indicated, It is the practice of this facility to protect and promote resident rights and treat each resident…

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

Based on observation, interview, and record review, the facility failed to protect resident rights for 6 out of 6 residents (Resident 1, 2, 3, 4, 5and 6) when nursing staff failed to safeguard the resident ' s dignity and respect when they ignored call lights, calls for assistance, and failed to administer pain medications in a timely manner for Resident 2. These failures resulted in residents feeling angry, sad, scared, and with an increase in anxiety and pain. Findings A review of a policy and procedure titled, Resident Rights, copyrighted in 2024, states that a resident has the right to a dignified existence and self-determination. The resident has a right to be treated with respect and dignity, and a right to a safe, comfortable homelike environment, including support for daily living. A review of a policy and procedure titled, Pain Management, copyrighted in 2023, states that the facility must ensure that pain management is provided to resident ' s who require such services. The facility will utilize a systematic approach for recognition, assessment, treatment, and monitoring…

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, record review and observation, the facility did not meet this requirement when three of eight sampled residents (Residents 1, 4, and 5) stated their soiled briefs were not changed in a timely manner, including one resident (Resident 1) being left wet for approximately 12 hours until the next day's shift reported for duty. This had the potential to result in negative health outcomes (infection, illness), skin breakdown, and residents' loss of dignity. Findings: Review of the facility's policy titled Activities of Daily Living dated 2023 indicated: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; 2. Transfer (moving between two places) and ambulation (walking); 3. Toileting. Review of the facility's record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to meet this regulation when two of eight sampled residents (Residents 1 and 2) reported to the facility that Licensed Vocational Nurse (LVN A) spoke to them in a disrespectful manner; that LVN A threatened to withhold medication from Resident Two; residents indicated they were fearful of him. This had the potential to result in psychosocial (mental) harm, pain, and adverse medical outcomes. Findings: A review of the facility's Employee Handbook (undated), provided by the facility's administrator on 6/28/24, indicated policy as follows: We are a service business and all of us must remember that while the resident is not always right, the resident is never wrong, and, Our residents have the right to be free from verbal, sexual, physical and mental abuse, corporal [physical] punishment, neglect, and involuntary seclusion; and, Residents are to be treated courteously and always given proper attention. Never regard a resident's question or…

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

Based on interview, observation, and record review, this requirement was not met when a staff member closed the room door for one of eight sampled residents (Resident 3), and silenced the resident's call light. This resulted in the potential for psychological harm and adverse outcomes and was contrary to the facility's stated policy. Findings:Resident 3 was admitted to the facility 4/29/24 for respiratory failure, a worsening brain disease, anxiety, need for assistance with personal care, and difficulty communicating. The resident had a history of calling out loudly from her room and a history of being fearful of confinement following trauma from a local wildfire disaster. A review of Resident 3's Basic Interview for Mental Status (BIMS) indicated that her score was 2, Severe cognitive impairment. A review of the facility's Employee Handbook policy (undated), provided by the facility's administrator on 6/28/24, indicated policy as follows: We are a service business and all of us must remember that while the resident is not always right, the resident is never wrong, and, Our…

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 2) was treated with dignity and respect while eating meals. This deficient practice had the potential to negatively affect Resident 2's psychosocial well-being and did cause Resident 2 to become frustrated. Findings: The facility ' s policy dated 2/2023, titled, Promoting/Maintaining Resident Dignity, indicated it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident ' s quality of life by recognizing each resident ' s individuality. This facility ' s policy also indicated all staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights and respond to requests for assistance in a timely manner. During a review of Resident 2 ' s medical record, the admission…

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 physician orders for wound care were obtained upon admission to the facility for one of three residents, (Resident 2) sampled for new admission. This failure had the potential for a negative clinical outcome, re-hospitalization, and Resident 2 did have specific needs that were not identified in a timely manner. Findings: The facility ' s policy dated 2/2023, titled, admission Orders, indicated the orders should allow facility staff to provide essential care to the resident consistent with the resident ' s mental and physical status on admission. This facility ' s policy also indicated the admission orders should provide information to maintain or improve the resident ' s functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. The facility ' s policy dated 2/2023, titled, Walking Rounds Shift Report, indicated it is the policy of this facility to use walking round shift…

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, record review, and the facility ' s policy, the facility failed to develop a baseline care plan within 48 hours for one of three residents (Resident 2). This failure had the potential to not meet the individual needs of the resident and cause a negative clinical outcome. Findings: A review of the facility ' s policy dated 2/2023, titled, Baseline Care Plan, indicated the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This policy also indicated the baseline care plan will be developed within 48 hours of a resident ' s admission. The baseline care plan policy will include the minimum healthcare information necessary to properly care for a resident. During a review of Resident 2 ' medical record, the admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included specified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the temperatures were at comfortable levels for six of 21 sampled Resident Rooms (room [ROOM NUMBER],5, 6, 7, 8, and 9). These failures resulted in Resident 1 to be uncomfortable, feeling hot and sweaty. Findings: During a review of the facility's policy titled, Safe and Homelike Environment , undated, indicated: 1. In accordance with residents' right, the facility will provide a safe, clean, comfortable, and homelike environment. 2. The facility will maintain comfortable and safe temperature levels - The facility should strive to keep the temperature in common resident areas between 71- and 81-degrees Fahrenheit (F). During a review of Resident 1's clinical record, indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses which included acute myocardial infraction (commonly known as a heart attack, usually occurs when a blood clot blocks blood flow to the heart. Without blood, tissue loses oxygen and dies),…

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 room temperatures were at a comfortable level for six of 21 resident rooms sampled. This failure had the potential for 11 of 44 residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) to be susceptibility to loss of body heat, risk of hyperthermia and the actual feelings of being hot, sweaty, having difficulty breathing and not wanting to stay in their room. Findings A review of the facility's, undated, policy titled Resident Rights revealed, The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. A review of the facility's, undated, policy titled Safe and Homelike Environment revealed, 7. The facility will maintain comfortable and safe temperature levels. a. The facility should strive to keep the temperature in common resident areas between 71- and 81-degrees Fahrenheit (F). During an interview on 6/6/24 at 10:47 am,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the right to personal privacy for one of one resident (Resident 1), when medical treatment was provided to Resident 1 without privacy being provided by staff. This failure had the potential to cause distress for Resident 1 and threaten her health and well-being. Findings: A review of the facility's, undated, policy titled Resident Rights revealed Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. a. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. A review of Resident 1's undated admission Record , indicated Resident 1 was admitted on [DATE], with diagnoses including lung disease, diabetes (high sugar in the blood), heart disease, blindness, 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 and interview the facility failed to ensure the communication call light system was working for two of three residents (Resident 1 and 2), sampled for working call lights, when Resident 1 and Resident 2's call light would not stay on after the button was depressed. This failure had the potential for Resident 1 and 2 to be at risk for accidents and their care needs not to be met. Findings A review of the facility's, undated, policy titled Call lights: Accessibility and timely Response indicated The purpose for this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. A review of Resident 1's undated admission Record , indicated Resident 1 was admitted on [DATE], with diagnoses including lung disease, diabetes (high sugar in the blood), heart disease, blindness, 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 that resident assessments accurately reflected the resident's current status for one of five sampled residents (Resident 1) when his admission Minimum Data Set (MDS, a standardized resident assessment) dated 3/3/2024, inaccurately assessed that Resident 1 was admitted with an indwelling catheter (a catheter that is maintained within the bladder for the purpose of continuous drainage of urine into a drainage bag). This failure had the potential for the resident to not receive treatments and care that met their individual needs. Findings: During a review of the facility ' s policy titled, Conducting an Accurate Resident Assessment, no revised date provided, indicated: 1. Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident ' s status, needs, strengths, and area of decline. The assessment will be documented in the medical record. 2. The appropriate, qualified health professional will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop individualized and comprehensive care plans that identified the needs for one of five sampled residents who was exhibiting a behavior issue by constantly removing all his clothes (Resident 1). These failures had the potential for Resident 1 not to receive the necessary care and services to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings: During a review of the facility ' s policy titled, Comprehensive Care Plans, no revised date provided, indicated: 1. It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, and mental and psychosocial needs that are identified in the resident ' s comprehensive assessment. 2. The care planning process will include an assessment of the resident ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the appropriate care and services were provided to one of five sampled residents (Resident 1) who was exhibiting the sign and symptoms of urinary tract infection (UTI, bacteria in urinary system) when Urinalysis (UA, a urine specimen that determines if there is a bacterial infection in the urine)) was not done in a timely manner as ordered. This failure had the potential for delaying Resident 1 ' s treatment and to develop urosepsis (systemic body infection) and other related clinical complications. Findings: During a review of Resident 1 ' s clinical record, indicated that he was initially admitted to the facility on [DATE] with diagnoses which included arthritis (painful inflammation and stiffness of the joints), end stage renal disease (a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), dependence on renal dialysis (the process of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the laundry practices were implemented, and handled and processed in a safe and sanitary manner when numerous bags of soiled laundry were observed to be overflowing the laundry room and stored inside a broken dryer. This failure had the potential to spread disease and infection throughout the facility. Findings: During a review of the facility ' s policy titled, Policies and Practices – Infection Control, revised 10-2018, indicated: 1. This facility ' s infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections. 2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infections in the facility; b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public . During 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 record reviews, interviews, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed in a timely manner for 3 (Residents #8, #6, and #19) of 5 residents reviewed for resident assessments. Findings included: A review of a facility policy titled Assessment Frequency/Timeliness, with a copyright date of 2023, revealed, The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI Manual. The policy specified, 5. The annual assessment will be completed not less than once every 12 months. It will be completed within 366 days after the ARD [Assessment Reference Date] of the most recent OBRA [Omnibus Budget Reconciliation Act] comprehensive resident assessment and within 92 days of the ARD of the previous quarterly or significant correction of a quarterly assessment (SCQA). A review of the CMS Long-Term…

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 record review, interview, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 1 (Resident #1) of 1 sampled resident reviewed for Preadmission Screening and Resident Review (PASRR) requirements, 2 (Resident #8 and Resident #11) of 2 sampled residents reviewed for pressure ulcers, and 1 (Resident #40) of 1 sampled resident reviewed for hospitalization. Findings included: A review of a facility policy titled, Conducting an Accurate Resident Assessment, with a copyright date of 2023, revealed, The purpose of this policy is to assure [sic] that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. The policy further indicated, 3. The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional…

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, record review, interviews, and facility policy review, the facility failed to provide care and services to prevent potential worsening of pressure ulcers for 2 (Resident #8 and Resident #11) of 2 sampled residents reviewed for pressure ulcers. Specifically, the facility failed to consistently implement and provide wound treatments as ordered by the Wound Specialist and failed to follow the Wound Specialist's recommendations for Resident #8 and Resident #11. Findings included: A review of a facility policy titled, Wound Care, revised in October 2010, revealed, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physician's order for this procedure. 1. A review of an admission Record revealed the facility admitted Resident #8 on 10/21/2016 and readmitted the resident on 12/09/2018. According to the admission Record, the resident had a medical history that included diagnoses of type two diabetes mellitus with diabetic neuropathy, protein-calorie malnutrition, and atherosclerotic…

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, record reviews, interviews, and facility document and policy review, the facility failed to ensure 2 (Licensed Vocational Nurse (LVN) #2 and LVN #3) of 2 LVNs observed administering insulin pens were trained on the proper use of insulin pens and their skillsets were evaluated to ensure they could competently administer insulin pens in accordance with the manufacturer's guidelines. This failure affected 2 (Resident #32 and Resident #8) of 2 residents observed receiving insulin by way of an insulin pen injection and had the potential to affect all 10 of 10 residents with orders for insulin pens. Findings included: A review of a facility policy titled Staffing, Sufficient and Competent Nursing, revised in August 2022, revealed, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. The policy revealed, 6. Staffing numbers and the skill requirements of direct care staff are…

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 record review, interview, and facility policy review, the facility failed to follow physician orders to obtain laboratory testing for 3 (Residents #8, #13, and #23) of 3 residents reviewed for laboratory services. Findings included: A review of a facility policy titled Laboratory Services and Reporting, dated February 2023, revealed, The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The policy revealed, The facility must provide or obtain laboratory services to meet the needs of its residents. The policy revealed, All laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the resident's clinical record. 1. A review of Resident #8's admission Record revealed the facility originally admitted Resident #8 on 10/21/2016 and most recently admitted the resident on 12/09/2018. The admission Record revealed the resident had diagnoses that included diabetes mellitus with diabetic neuropathy,…

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 interviews, record review, and facility document and policy review, the facility failed to ensure 2 (Resident #144 and Resident #143) of 2 sampled residents reviewed for dignity were treated with dignity and respect. Specifically, staff searched Resident #144's personal belongings without consent, and a staff member responded to Resident #143 by using profanity during a conversation with the resident. Findings included: A review of a facility policy titled Resident Rights, revised in February 2021, revealed, Employees shall treat all residents with kindness, respect, and dignity. 1. During the entrance conference on 01/02/2024 at 9:16 AM, the Administrator reported the facility was a non-smoking facility. A review of Resident #144's admission Record revealed the facility admitted the resident on 11/29/2023. A review of Resident #144's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/06/2023, revealed Resident #144 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. A 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 interview, record review, and facility document and policy review, the facility failed to report an allegation of abuse for 1 (Resident #144) of 2 sampled residents reviewed for abuse allegations. Findings included: A review of a facility policy titled Abuse, Neglect and Exploitation, with a copyright date of 2023, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy further specified, 2. The Administrator is the Abuse Prevention Coordinator (or designee) in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. The section of the policy titled VI. Reporting/Response revealed, 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g.…

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 record review, interview, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete quarterly Minimum Data Set (MDS) assessments in a timely manner for 2 (Resident #3 and Resident #13) of 5 residents reviewed for resident assessments. Findings included: A review of a facility policy titled, Assessment Frequency/Timeliness, with a copyright date of 2023, revealed, The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI Manual. The policy specified, 4. A quarterly review assessment will be completed no less than once every 3 months. It must be completed within 92 days of the ARD [Assessment Reference Date] of the most recent OBRA [Omnibus Budget Reconciliation Act] assessment. A review of the CMS Long-Term Care Facility RAI 3.0 User's Manual, Version 1.18.11, dated October 2023, under Chapter 2: Assessments for the RAI revealed Quarterly…

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 record review and interview, the facility failed to follow-up on Level II Preadmission Screening and Resident Review (PASRR) recommendations for 1 (Resident #1) of 1 sampled resident reviewed for PASRR requirements. Findings included: A review of an admission Record revealed the facility admitted Resident #1 on 09/14/2023 with diagnoses that included unspecified psychosis and dementia with psychotic disturbance. A review of Resident #1's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 09/15/2023, revealed the result was positive for suspected mental illness. The Level I PASRR indicated the resident had a diagnosis of unspecified psychosis and received psychotropic medication. The letter attached to the Level I PASRR, dated 09/15/2023, indicated that a Level II Mental Health Evaluation was required. A review of Resident #1's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 09/20/2023, revealed specialized services were recommended to address the resident's mental health needs. These recommendations…

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, record review, interview, and facility policy review, the facility failed to ensure the use of bed rails was reflected on the comprehensive care plan for 1 (Resident #29) of 2 sampled residents reviewed for the use of bed rails. Findings included: A review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy specified, 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes, b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. The policy further…

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 record review, interview, and facility policy review, the facility failed to ensure staff followed physician orders for 1 (Resident #23) of 5 residents reviewed for medication use. Findings included: A review of a facility policy titled, Administering Medications, revised in April 2019, revealed Medications are administered in a safe and timely manner, and as prescribed. The policy revealed, Medications are administered in accordance with prescriber orders, including any required time frame. A review of Resident #23's admission Record revealed the facility admitted the resident on 11/02/2023 with diagnoses that included hypertension (high blood pressure). The admission Record revealed the resident discharged from the facility on 12/01/2023. A review of Resident #23's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/08/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS revealed the resident had an active diagnosis of hypertension. A review of Resident…

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

Based on interviews, record review, and facility policy review, the facility failed to complete pre- and post-dialysis assessments before and after each dialysis appointment for 1 (Resident #26) of 1 sampled resident reviewed for dialysis care. Findings included: A review of a facility policy titled, Dialysis, with a copyright date of 2023, revealed, The facility will assure [sic] that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: *Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices: [sic] and *Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. A review of Resident #26's admission Record revealed the facility admitted the resident on 05/19/2023 and readmitted the resident on 10/30/2023 with diagnoses…

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, record reviews, interviews, and facility policy review, the facility failed to ensure bed rail assessments reflecting the need for bed rails were conducted and informed consents were obtained prior to the use of bed rails for 2 (Resident #29 and Resident #11) of 2 sampled residents reviewed for the use of bed rails. Findings included: A review of a facility policy titled Bed Safety and Bed Rails, revised in August 2022, revealed, The use of bed rails is prohibited unless the criteria for use of bed rails have been met. The policy specified, 8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails; b. The resident's risks from the use of bed rails and how these will be mitigated; c. The alternatives that were attempted but failed to meet the resident's needs; and d. The alternatives that were…

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, record reviews, interviews, facility policy review, and review of manufacturer's guidelines, the facility failed to ensure a medication error rate of less than 5 percent (%). The facility had 3 medication errors out of 28 opportunities, resulting in a medication error rate of 10.71 %, affecting 3 (Residents #32, #8, and #22) of 10 residents observed during medication administration. Specifically, licensed nursing staff did not prime an insulin pen (safety test) in accordance with the manufacturer's guidelines prior to administering insulin to Resident #32 and Resident #8, and staff administered the wrong inhaler and dosage to Resident #22. In addition, when staff administered two puffs of the wrong inhaler to Resident #22, the nurse did not wait one minute between puffs as directed by the manufacturer's guidelines. Findings included: 1. A review of the Instruction Leaflet for Lantus SoloStar (insulin glargine injection), revised in November 2018, revealed, Step 3. Perform a Safety test. Always perform the safety test before each injection. Performing 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 record review, interview, and facility policy review, the facility failed to ensure nursing staff documented the administration of medication for 1 (Resident #5) of 5 residents sampled for medication review and failed to document the completion of wound care for 1 (Resident #8) of 2 residents reviewed for wound management. Findings included: 1. A review of a facility policy titled, Administering Medications, revised in April 2019, revealed Medications are administered in a safe and timely manner, and as prescribed. The policy revealed Medications are administered in accordance with prescriber orders, including any required time frame. A review of Resident #5's admission Record revealed the facility originally admitted Resident #5 on 11/30/2017 and readmitted the resident on 12/05/2023. The admission Record revealed diagnoses that included type two diabetes mellitus with hyperglycemia (high blood sugar). A review of Resident #5's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/13/2023, revealed Resident #5 had a Brief Interview for Mental…

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 interviews, record review, and facility policy review, the facility failed to ensure that 1 (Resident #1) of 5 residents reviewed for vaccination status was offered the influenza vaccine. Findings included: A review of a facility policy titled Influenza Vaccination, copyright 2022, revealed, It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza. The policy specified, 2. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or refuses to receive the vaccine. 3. Additionally, influenza vaccinations will be offered to residents upon availability of the seasonal vaccine until influenza is no longer circulating in the facility's geographic area, and 9. The resident's medical record will include documentation that the resident and/or the resident's…

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

Based on interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident #23) of 5 residents reviewed for vaccination status was offered the Coronavirus-2019 (COVID-19) vaccine. Findings included: Review of a facility policy titled, Novel Coronavirus Prevention and Response, dated 09/01/2022, revealed, All residents who are not up to date with all recommended COVID-19 vaccine doses and are new admission and readmissions should be placed in quarantine, even if they have a negative test upon admission; COVID-19 vaccination should also be offered. During the entrance conference on 01/02/2024 at 9:16 AM, the Administrator reported the facility's former Infection Preventionist (IP) ended their employment the previous Friday on 12/29/2023 unexpectedly, noting she would put someone in that position later in the day. At 11:39 AM, the Administrator said the Corporate IP would be filling in as the facility's interim IP. A review of Resident #23's admission Record revealed the facility admitted the resident on 11/02/2023 with diagnoses that included aftercare…

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 meet this requirement when quarterly care conferences were not held for one of three sampled residents (Resident 1). This resulted in the facility's failure to ensure that the comprehensive care plan was ireviewed and revised by an interdisciplinary team who had knowledge of the resident's needs, and that each resident and resident representative was involved in developing the care plan and making decisions about his or her care. Findings: Review of the facility's policy titled, Care Planning--Resident Participation, dated 2023, indicated: The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initally, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best itme of day for the resident/resident's representative. The facility will obtain a signature from the resident and/or…

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

Based on interview and record review, the facility: 1. Failed to designate a Director of Nursing (DON) after DON left the faciity on 9/27/2023. 2. Failed to staff a Registered Nurse (RN) for a minimum of 8 hours on the following days: September 2, 3, 4, 28, 29, 30 and October 4, 5, 6, 10, 11, 15, 22, 23, 24, and 28 of 2023. These failures resulted in decreased supervision of nursing staff to ensure the delivery of quality of care of all residents. Findings: During a review of the facility's DON Job Description, copyright 2023, the indicated the DON will: - Participate in daily or weekly management team meetings to discuss resident changes in status, complaints, or concerns (e.g., frequent falls, mood changes). - Ensure delivery of compassionate quality care and nursing supervision as evidenced by adequate staff coverage on the units and maintaining optimal resident function. - Oversee nursing schedules to ensure resident needs are met. - Perform rounds to observe residents and ensure nursing needs are being met. - Communicate directly with residents, medical and nursing staff,…

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

Based on interview and record review, the facility failed to implement their abuse policy to ensure the health and safety of Resident 1 when facility staff did not identify, report, protect and investigate allegations of abuse. This resulted in Resident 1 having pain, emotional distress and had the potential to put all residents at risk for abuse. Refer to F 697. Findings:A review of a facility policy titled Abuse, Neglect and Exploitation, dated July 2022, indicated it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services by resident, staff or family report of abuse. Ensuring the health and safety of each resident with regard to visitors such as family members or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a non-verbal resident (Resident 1) had a plan of care for pain that met her needs when her pain was not monitored, reassessed, and physician was not notified of changes. This failure resulted in Resident 1 experiencing increased pain levels and had the potential to negatively affect the resident's physical and psychosocial (emotional and social) well-being and decrease mobility, function, and quality of life. Refer to F607. Findings:During a review of facility policy Pain Management, dated 2023, the policy indicated: - The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. - The facility will observe for nonverbal indicators which may indicate the presence of pain to include: loss of function or inability to perform activities of daily living (ADLs), (e.g., rubbing 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 that food was stored, prepared and distributed in accordance with professional food safety standards when: 1. The kitchen was not sanitary. 2. Staff were not wearing aprons. 3. Fixed equipment (equipment that cannot be cleaned in the dish washer or in the three-compartment sink) was not washed and rinsed prior to sanitizing. 4. Food was not stored, labeled, dated or discarded appropriately. 5. Nutrition supplements stored on medication carts and distributed by nursing during medication administration were not monitored for safe temperatures, stored or discarded within food safety guidelines. 6. The ice machine was not sanitary. 7. An air gap was not present in the cook's food preparation sink. These practices have the potential to result in foodborne illness for residents consuming food from the facility food services. Findings: 1. The kitchen was not sanitary. A review of the facility policy titled Sanitation dated 2001 shows All kitchens, kitchen areas and dining areas shall be kept clean . All…

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 a system was in place to help residents, their families and other visitors understand safe food handling practices for food brought in from outside sources. This failure has the potential to increase the risk of foodborne illness for residents receiving food brought in by their families or others. Findings: A review of the undated facility policy titled Food: Safe Handling for Foods from Visitors directs staff how to handle food safely after it is brought in, but there is no indication safe food handling education is provided to residents or their family members regarding food they bring to the resident. During an interview at the nurses' station on 07/14/21 at 04:50 PM, Licensed Nurse A (LN-A) stated she wasn't sure if any education regarding safe food handling was provided to residents or family on admission. She suggested the social services staff (SOC) would know about it. During an interview in the social services office on 07/14/21 at 04:52 PM, the SOC stated she didn't know if that information or education was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and document reviews, the facility failed to provide a safe and sanitary environment for residents and staff when: 1. Oxygen tanks were stored in an unlocked closet, without separation of empty and full tanks. 2. Hand washing and resident care supplies were stored under the sink in the Clean Utility Room. 3. Expired Foley insertion kits (used for insertion of a urinary catheter into the bladder) stored in the Clean Utility Room cupboard were available for use. 4. Laundry dryer area had lint buildup on the wall, around the ceiling vent, on top of the dryer and around the hinges of the door jam. 5. Two plastic bags of clean linen were being stored on the floor in a Clean Linen closet. 6. Floors, walls, ceiling and cabinets in the Food and Nutrition Services kitchen were not maintained in good repair when wholes, cracks and missing pieces of surfaces were observed. These failures had the potential for resident and staff safety to be jeopardized, to create an environment for germs…

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 This regulation was not met when a total of three of 25 medication pass opportunities included errors in administration technique. This resulted in an error rate of 12 percent, and medication doses not being delivered per manufacturer specifications and professional standards, with the potential of continued illness. Findings: 1. On 7/13/2021 at 8:10 AM, Licensed Nurse (LNB) was observed administering Dulera inhaler 200 micrograms to Resident 25. The nurse did not shake inhaler prior to administering to resident. Additionally, medication was administered after resident had already taken a deep breath and was holding her breath. Resident exhaled medication held in her mouth and then took a deep breath afterwards. No instruction was given to Resident 25 by LNB regarding the proper technique. 2. On 7/13/2021 at 12:10 PM, LNB was observed administering a Combivent/Respimax inhaled medication to Resident 4. The nurse did not shake the medication. In a concurrent interview, LNB stated, As a general nursing practice…

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 This regulation was not met when a total of three of 25 medication pass opportunities included errors in administration technique. This resulted in medication doses not being delivered per manufacturer specifications and professional standards, with the potential of continued illness due to ongoing errors in technique over time. Findings: 1. On 7/13/2021 at 8:10 AM, Licensed Nurse (LNB) was observed administering Dulera inhaler 200 micrograms to Resident 25. The nurse did not shake inhaler prior to administering to resident. Additionally, medication was administered after resident had already taken a deep breath and was holding her breath while the inhaler was put in her mouth. Resident blew out medication held in her mouth and then took a deep breath afterwards. No instruction was given to Resident 25 by LNB regarding the proper technique. 2. On 7/13/2021 at 12:10 PM, LNB was observed administering a Combivent/Respimax inhaled medication to Resident 4. The nurse did not shake the medication. In a concurrent…

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 facility document review, the facility failed to ensure the qualifications, competencies, and skill sets of the Registered Dietitian (RD) and the Dietary Services Supervisor (DSS) were in place to carry out the functions of the food and nutrition service when: 1. There was inadequate oversight and collaboration provided by the RD for the DSS to ensure essential food service and food safety systems were in place. 2. The roles and practices of the RD and the DSS were incongruent with job descriptions, the RD contract, and professional scope of practice in the completion of essential tasks such as oversight of the kitchen, and care planning in the provision of resident care. These actions have the potential to result in foodborne illness, compromised nutritional status, ineffective resident care interventions, and decreased quality of life for the 32 residents living in the facility. Findings: During intermittent review of facility dietetic services from 7/12-7/15/21 between the hours of 08:00 AM and 05:00 PM multiple issues surrounding lapses 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 observation and interview, the facility did not provide a comfortable and homelike environment for four residents (Residents 4, 14, 15, and 16) when the bathroom they shared was in disrepair. This failure had the potential to negatively affect the residents' well-being. Findings: A review of Resident 4's clinical record showed admission to the facility on 4/19/2021 with diagnoses that included cerebrovascular accident (stroke) and depression. A review of Resident 14's clinical record showed admission to the facility on 5/8/2005 with diagnoses that included dementia (a mental disorder) and schizophrenia (disorganized thought and perception). A review of Resident 15's clinical record showed admission to the facility on 7/10/2018 with diagnoses that included Parkinson's disease (a chronic disease of the central nervous system that affected movement, thought and mood) and anxiety. A review of Resident 16's clinical record showed admission to the facility on 1/4/2019 with diagnoses that included 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, this requirement was not met when two of 25 sampled residents' (Resident 11 and 21) nursing care plans were not revised by the interdisciplinary team after each assessment. This resulted in care plans that did not comprehensively reflect successful and unsuccessful interventions and led to repeated falls and the potential for serious injury. Findings: A review of the facility's policy titled, Care Plans - Comprehensive dated 2001 indicated as follows: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Additionally, the policy indicated, 8. Assessments of residents are ongoing and care plans are revised and information about the resident and the resident's condition changes, and, 10. The resident has the right to refuse to participate in the development of his/her care plan and medical or nursing treatments. When such…

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, this requirement was not met when three of 25 sampled residents' nursing care plans were not reviewed and revised following each assessment. This resulted in care plans that did not indicate the date and time of new interventions, or the date and time of discontinued, unsuccessful interventions, and did not tie them to any particular assessment dates. This had the potential for repeated falls and serious injury. Findings: A review of the facility's policy titled, Care Plans - Comprehensive dated 2001 MedPass indicated as follows: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Additionally, the policy indicated, 8. Assessments of residents are ongoing and care plans are revised and information about the resident and the resident's condition changes, and, 10. The resident has the right to refuse to participate 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, observation, this requirement was not met when there were medications available for use that were labeled past the manufacturer's expiration date. These failures could result in the accidental administration of expired medications or biologicals to residents with questionable potency or sterility. Findings: In an observation of the medication refrigerator at Nursing Station 1 on 7/12/21 at 13:14 PM a box labeled Afluria Quadrivalent influenza vaccine (serial number 0033332320011, lot 60781V03), indicated an expiration date of 6/30/2021. In a concurrent interview, MDS (Minimum Data Set Coordinator) confirmed that the drug label indicated the medication was expired, and stated, it should have been to be taken out. In an observation of the medication refrigerator at Nursing Station 1 on 7/12/21 at 13:21 AM, a bottle of Sterile Diluent indicated that it was dispensed on 6/30/20 and expired 6/30/21. In a concurrent interview, [NAME], LVN stated that the bottle was supposed to be kept with…

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

Based on observation, interview and record review the facility failed to have an effective system in place to monitor and ensure resident meal tray accuracy and that food preferences were honored. This has the potential to result in residents receiving foods and textures non-compliant to their diet orders, food allergens, and foods identified as resident preference dislikes on their meal tray. Findings: During an observation on 07/12/21 12:12 PM the AM Diet Aide (AM DA) pre-loaded drinks and silverware on to resident lunch trays. The AM Cook-A looked at the tray ticket, dished the hot food and placed it on the tray. During an observation of lunch meal service and concurrent interview on 07/12/21 at 12:22 PM, the meal tray ticket for Resident 25 listed Dislikes: No tomato sauce, No punch. The AM DA put punch on Resident 25's tray. He identified the red fluid in the cup as punch. The AM Cook-A dished gravy over meatloaf topped with red sauce and put it on Resident 25's tray. There was no double check system in the kitchen to ensure the meal tray was accurate or that resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the therapeutic diet for one resident was prescribed by the attending physician. This failure has the potential to result in residents receiving food that is not in an appropriate form or with appropriate nutrient content to support the resident's safety, treatment, care plan, goals and preferences. Findings: A review of the facility policy titled Medication and Treatment Orders dated 2001 showed Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners shall be allowed to write orders in the medical record. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, and date and the time of the order. Verbal orders must be signed by the prescriber at his or her next visit. Nursing staff will use a diet change notification form to inform the Food Services staff when diet orders change. A review of 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.