Saint Vincent Healthcare

Based on observation, interview and record review, the facility failed to ensure two (2) of 2 garbage container (dumpster) lids remained closed and were not overflowing with trash in accordance with the facility's policy. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g. rodent's parasitic worms or insects) that could potentially enter the facility and spread diseases to the residents. Findings: During a concurrent observation and interview on 10/16/2024 at 8:32 AM, with Maintenance Supervisor (MS) and Maintenance Assistant (MA), in the facility's parking lot dumpster area, two dumpsters were observed with trash overflowing out of the sides and top of both dumpsters, with the dumpster lids opened due to overflowing trash. MA stated, The trash is overflowing, and the dumpster lids are not closed. Facility may need bigger trashcans. MS stated per facility policy, the dumpster lids should not be open and are to stay closed to make sure rodents, flies and insects [pests] do not go to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP - an infection control practice that involves wearing gloves and gowns during high-contact patient care activities to reduce the spread of multidrug-resistant organisms [MDROs- microorganisms that are resistant to multiple classes of antibiotics and antifungals]) for 11 of 11 sampled residents on EBP (Residents 27, 3, 7, 21, 23, 42, 69, 225, 28, 1, and 24) as indicated in the facility policy, by failing to ensure: 1. Licensed Vocational Nurse 3 (LVN 3) wore indicated personal protective equipment (PPE- protective clothing or equipment designed to protect the body from injury or infection) of a gown while administering medications through Resident 27's gastrostomy tube (GT - a tube that is surgically inserted into the resident's stomach to allow access for food, fluids, and medications) on 10/18/2024. Facility also failed to implement signage posted and PPE cart at the resident's door per policy.…

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 foley catheter (a flexible tube that drains urine from the bladder into a collection bag outside of the body) was covered with a dignity bag (a bag that covers and holds a foley catheter drainage bag to keep it out of sight) for one of 18 residents (Resident 225). This deficient practice had the potential to result in Resident 225 having decreased feelings of self-worth and/or self-esteem. Findings: During a review of Resident 225's admission Record, the admission record indicated resident 225 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (progressive neurological disease characterized by a fixed inexpressive face, tremor at rest, slowing of voluntary movements), muscle wasting (deterioration of muscle tissue) and atrophy (deterioration of a part of the body) and polyneuropathy (damage to multiple nerves outside of the brain and central nervous system). During a review of Resident 225'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 observation, interview, and record review, the facility failed to accommodate the needs of one (1) of three (3) sampled residents (Resident 63) by failing to provide a pad call light (a device for residents who have difficulty using a call light cord). This failure had the potential for Resident 63's needs to not be met, resulting in a lowered quality of care and quality of life. Findings: During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses that included left hand contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), pain in right shoulder, weakness (lack of strength), and major depressive disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 63's Minimum Data Set (MDS- a federally…

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 care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) interventions for one (1) of 18 residents (Resident 3), were applicable and resident-centered. This failure had the potential for Resident 3 to receive inappropriate and/or inadequate services which could harm the resident. Findings: During a review of Resident 3's admission Record, the admission record indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses that included chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure), retention of urine (inability to completely empty the bladder), dementia (a condition characterized by progressive or persistent loss of intellectual functioning) and gross hematuria (a condition where blood is visibly present in the urine).…

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 licensed nursing staff failed to meet professional standards of quality for assessing one (1) of five sampled residents (Resident 72) by failing to ensure Resident 72 was assessed and evaluated by Medical Doctor (MD) before adding a new diagnosis of schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others ) according to accepted standards of clinical practice. This deficient practice had the potential to result in provision of unnecessary care for Resident 72. Findings: During a review of Resident 72's admission Record, the admission record indicated Resident 72 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), major depressive disorder (MDD- a mood disorder that causes a persistent feeling of sadness and loss of interest), and Alzheimer's Disease (a brain disorder that slowly destroys memory and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one (1) of 18 sampled residents (Resident 2) with limitations in mobility was provided assistance while eating as indicated in the care plan and facility policy. This deficient practice had the potential for decline and not to maximize Resident 2's functional ability to perform activities of daily living (ADL), which can affect the resident's physical and mental wellbeing. This failure also had the potential not to meet Resident 2's nutritional needs which could lead to malnutrition (a condition that occurs when a person's body doesn't get the right amount of nutrients it needs to function properly) and hospitalization. Findings: During a review of Resident 2's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included reduced mobility and Parkinson's disease (a progressive disease of the nervous system marked by rhythmic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide the necessary treatment and services for one of one sampled residents (Resident 24) by failing to ensure Resident 24 received treatment for right heel (ankle) stage 3 (full-thickness loss of skin, dead and black tissue may be visible) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) from 10/1/2024 to 10/7/2024 as indicated in Resident 24's wound treatment plan. This deficiency had the potential for Resident 24's right heel stage 3 pressure injury to worsen and had the potential to develop an infection. Findings: During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified protein-calorie malnutrition (inadequate intake of food that leads to changes…

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 head of bed (HOB) was elevated at 30 degrees angle for one (1) of 1 sampled Resident (Resident 28) while receiving gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube (GT) feeding in accordance with the facility's policy. This failure has the potential for Resident 28 to aspirate (feeding could enter the windpipe and lungs) which could lead to lung problem such as pneumonia (an infection/inflammation of the lungs). Findings: During a review of Resident 28's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing). During a review of Resident 28's Care Plan, initiated on 4/9/2024, the Care Plan indicated, to administer tube feeding as ordered and to always elevate the HOB during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide trauma-informed care (an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of traumas) for one (1) of three (3) sampled residents (Resident 35) who was diagnosed with post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) in accordance with the facility's policy. This deficient practice had the potential for Resident 35 to experience re-traumatization, (unintentionally causing harm through practices, policies, and/or activities that are insensitive to the needs of the residents) that could lead to severe psychosocial harm and negatively affecting Resident 23's quality of life. Findings: During a review of Resident 35's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included post…

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 Registry (a placement service that provides staff on a temporary or day-to day basis in a facility) Certified Nursing Assistant 1 (RCNA 1) had the competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) in skill sets necessary before providing care to residents in the facility. RCNA 1 worked in the facility on 10/17/2024. This deficient practice had the potential for residents to not receive appropriate nursing services and had the potential to place residents at risk for injury or harm. Findings: During an interview with the Director of Staff Development (DSD), on 10/18/2024, at 12:30 PM, DSD stated the facility uses a registry when there is not enough staff to work in the facility. The DSD stated RCNA 1 was from a registry and worked during the 7AM to 3PM shift on 10/17/2024. The DSD stated she did not check and did not ask for a copy of RCNA 1's competency skills check and RCNA 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 68) was free from unnecessary use of psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to have a clinical justification for the use of Risperdal (medication used to treat schizophrenia [a serious mental illness that affects a person's ability to think, feel, and behave], bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs], and autism spectrum disorder [ASD - a complex developmental condition that affects how people interact, communicate, and behave]) without a clinical justification for use. This deficient practice had the potential to place Resident 68 at risk for significant adverse (harmful) consequences from the use of unnecessary psychotropic drug, which could result to impairment or decline…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow the resident personal food choices for one of eighteen (18) sampled residents (Resident 68) in accordance with the care plan and facility policy by failing to: 1. Follow Resident 68's food preference for Mexican food on 11/20/2023 and 5/10/2024. 2. Provide Resident 68 requested tacos on 1/25/2024, 1/30/2024 and 2/8/2024. 3. Provide Resident 68 requested beef soup on 1/26/2024. This deficient practice failed to accommodate Resident 68's food preference which had the potential to result in weight loss and affect the resident's psychological, physical, and emotional well-being. Findings: During a review of Resident 68's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), metabolic encephalopathy (ME, occurs when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer the pneumococcal vaccine (a medical injection that protects against the bacteria Streptococcus pneumoniae) for one of five sampled residents (Resident 2) upon readmission on [DATE] as indicated in the facility's policy. This failure placed Resident 2 at a higher risk of acquiring preventable infections such as pneumonia (PNA- an infection in your lungs), bacteremia (infection of the blood), or meningitis (infection of the tissue covering the brain and spinal cord) and increased the risk of transmission to other residents in the facility. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included ventricular tachycardia (a condition in which the lower chambers of the heart [ventricles] beat too fast), Parkinson's Disease (progressive neurological disease characterized by a fixed inexpressive face, tremor at rest, slowing of voluntary…

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 2. A review of Resident 36's admission Record, indicated Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of COPD, morbid obesity (abnormal or excessive fat accumulation), and diabetes mellitus type 2 (high blood sugar). A review of Resident 36's Quarterly Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/9/2023, indicated the resident had an active diagnosis of COPD with acute exacerbation. A review of Resident 36's COPD care plan, dated 7/4/2023, indicated the care plan was not revised according to the re-evaluation date on the care plan. A review of Resident 36's care plan on 11/2/2023 at 10:03 AM, indicated Resident 36's quarterly COPD care plan's re-evaluation date listed as 10/2023. During a concurrent interview and record review on 11/2/2023 at 10:10 AM with Director of Nursing (DON), the DON stated the COPD care plan for Resident 36 was not and should have been revised during the quarterly interdisciplinary team (IDT) meeting 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 ensure four (3) of five (5) Residents (Resident 3, 5, and 45) were hydrated as indicated on the facility policy. a. Resident 3 was not provided a water pitcher b. Resident 5 was not provided a water pitcher c. Resident 45 was not given 200 milliliters ([ml] unit of measurement) of water, as ordered, after administration of Glucerna (a nutritional supplement meal replacement designed for residents with diabetes [a condition whereby the body is not able to regulate blood levels of sugar]) via gastrostomy tube (G-tube, surgical procedure wherein a tube is inserted through the abdomen wall and into the stomach used for nutrition and medication administration) on 10/31/23. This deficient practice had the potential to place the residents at risk for dehydration (harmful reduction in the amount of water or fluids in the body). Findings: a. A review of Resident 3's admission Record indicated Resident 3 was initially admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure they do not have a medication error rate of five percent (%) or greater as evidenced by the identification of eleven (11) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturers specifications (not recommendations) regarding the preparation and administration of the medication or biological; accepted professional standards and principles which apply to professionals providing services) out of 25 opportunities (observed administered medications) for error and yielded a facility medication error rate of 44 percent for five out of 23 sampled residents (Residents 9, 16, 41, 45, and 48) observed during medication administration (med pass). Licensed Vocational Nurse (LVN 1) failed to administer: 1. Metoprolol (a medication that lowers your blood pressure and heart rate) twice daily for Resident 9 as indicated in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors by failing to administer 10 medications on 10/31/2023 according to the physician's order for five (5) of 11 residents observed for medication administration (Residents 9, 16, 41, 45, and 48). 1. Late administration of Metoprolol Tartrate (a medication used to treat high blood pressure) 50 milligrams (mg-a unit of measure for mass) for Resident 9. 2. Late administration of Metformin (a medication used to treat high blood sugar levels caused by type 2 diabetes) 850 mg for Resident 48. 3. Late administration of Carvedilol (a medication that slows down the heart rate making it easier for the heart to pump blood around the body) 25 mg and Metformin 1000 mg for Resident 16. 4. Late administration of Carvedilol 3.125 mg for Resident 41. 5. Late administration of Citalopram (a medication used to treat depression) 10 mg, Amlodipine (a medication used to treat high blood pressure) 10 mg,…

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

Based on observation, interview, and record review, the facility failed to store and dispose medication for one of one medication storage room in accordance with the facility's policy and procedure. There were four (4) medications observed stored in the medication storage room with past the expiration date. In addition, there were 4 bottles of medications/ supplements that were stored in the Director of Nursing's (DON) office. These deficient practices had the potential to cause inaccurate test results when expired blood sugar strips are used, medication error (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturers specifications [not recommendations] regarding the preparation and administration of the medication or biological; accepted professional standards and principles which apply to professionals providing services), and for residents to be exposed to adverse side effects ( unwanted undesirable effects that are possibly related to a drug) of using expired supplies such as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the diet menu instructions when serving lunch for two of four sampled residents. (Residents 45 and 61). This had the potential for the residents not to receive the required amount of nutrition as indicated on the therapeutic diet (a meal plan that controls the intake of certain foods or nutrients in the treatment or management of certain diseases, illnesses, or medical conditions) menu, which could lead to weight loss or gain. Findings: a. A review of Resident 45's admission Record indicated Resident 45 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of dysphagia (difficulty swallowing), Gastro-Esophageal Reflux Disease (GERD - a digestive disease in which stomach acid or contents irritates the food pipe lining), and Type 2 Diabetes Mellitus (a disorder in which the body does not produce enough or respond normally to insulin [a hormone released from the pancreas that controls the amount of…

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

Based on observation, interview, and record review, the facility failed to label foods in the kitchen with item names, open date, and expiration date and discard expired food as indicated on the facility policy. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation in the kitchen and interview with [NAME] 1 on 10/30/2023 at 8:26 AM, [NAME] 1 stated all food items were supposed to be labeled with item name and dated with the open and used by date. In Freezer 1 were the following: a. Ham dated 10/22/2023. The date did not indicate if it was received on this date or needed to be used by this date. b. A piece of turkey was dated 9/7/2023. The date did not indicate if it was received on this date or needed to be used by this date. c. An unidentified meat dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to promote dignity and respect for one of 23 sampled residents (Resident 24). The facility staff was observed standing above Resident 24's eye level while assisting the resident during mealtime. This deficient practice had the potential to affect Resident 24's self-esteem and self-worth and violates Resident 24's right to be treated with dignity. Findings: A review of Resident 24's admission Record indicated Resident 24 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and dementia (a brain disorder that results in memory loss, poor judgment, and confusion). A review of Resident 24's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/1/2023, indicated Resident 24 had moderately impaired cognition…

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 call light device (a device used by a resident to signal his or her need for assistance) was within reach for one of 23 sampled residents (Resident 69) who had a history of cerebrovascular accident (CVA, stroke- loss of blood flow to a part of the brain) and left sided weakness. This deficient practice had the potential to negatively impact the psychosocial well-being of Resident 23 and result in delayed provision of care and services. Findings: A review of Resident 69's admission Record indicated Resident 69 was admitted on [DATE] with diagnoses that included occlusion and stenosis of right carotid artery (condition that happens when the large artery on either side of the neck becomes blocked), dementia (a brain disorder that results in memory loss, poor judgment, and confusion), and essential hypertension (high blood pressure). A review of Resident 69's Care Plan titled, Falls Care Plan, dated 9/15/2023, indicated Resident 69…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide quarterly statement of funds per policy and procedure for one of one sampled resident (Resident 3). This deficient practice had the potential to result in Resident 3 being worried about how much money was in his account and potential for misappropriation of funds. Findings: A review of Resident 3's admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right elbow and right hand. A review of Resident 3's Minimum Data…

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' medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or resident representatives for two (2) of nine (9) sampled residents (Resident 23 and 30). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. Findings: 1. A review of Resident 23's admission Record indicated Resident 23 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of dementia (progressive brain disorder that slowly destroys memory and thinking skills), schizophrenia (a chronic 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 notify the State Long Term Care Ombudsman (public advocate) of the resident's transfer from the facility to the General Acute Care Hospital (GACH) for one (1) of 1 sampled resident (Resident 30). This deficient practice had the potential to result in the State Long Term Care Ombudsman not being aware of the resident's transfer and condition and inappropriate resident discharge or transfer. Findings: A review of Resident 30's admission Record indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of dementia (progressive brain disorder that slowly destroys memory and thinking skills), paranoid schizophrenia (characterized by predominately positive symptoms of schizophrenia including delusions and hallucinations), and bipolar disorder (mental disorder characterized by episodes of mania and depression). A review of Resident 30's Minimum Data Set (MDS - a standardized assessment and care planning…

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 an individualized baseline care plan with 48 hours of admission to meet the immediate needs that included interventions for safety and preferences for one of 23 sampled residents (Resident 69) who had left-sided hemiplegia (paralysis of one side of the body). This deficient practice had the potential to negatively affect the well-being and the delivery of necessary care and services for Resident 69. Findings: A review of Resident 69's admission Record indicated Resident 69 was admitted to the facility on [DATE] with diagnoses that included occlusion and stenosis of the right carotid artery (condition that happens when the large artery on either side of the neck becomes blocked), dementia (a brain disorder that results in memory loss, poor judgment, and confusion), and essential hypertension (high blood pressure). A review of Resident 69's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 09/19/2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive and resident-centered care plan for two of 23 sampled residents (Residents 45 and 69) as indicated on the facility policy and procedure. 1. Resident 45's Care Plan did not indicate complete interventions to prevent falls. 2. Resident 69 did not have a care plan for left-sided hemiplegia (paralysis of one side of the body. These deficient practices had the potential for Resident 45 and Resident 69 to not be appropriately cared for by facility staff in providing resident-centered care and services. Findings: 1. A review of Resident 45's admission Record indicated Resident 45 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included pneumonia (an infection that affects one or both lungs), unspecified dementia (a brain disorder that results in memory loss, poor judgment, and confusion), and schizophrenia (a mental disorder that affects the way a person thinks, acts,…

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 functioning television remote control for one of 23 sampled residents (Resident 64) to support her choice of activity based on the comprehensive assessment. This deficient practice resulted in Resident 64 not able to watch television from 10/27/2023 to10/30/2023, which is a part of her preferred activity and had the potential to affect Resident 64's sense of self-worth and psychosocial well-being and meaningfulness. Findings: A review of Resident 64's admission Record indicated Resident 64 was admitted on [DATE] with diagnoses that included schizoaffective disorder (a mental illness that can affect the thought, mood, and behavior), osteoarthritis (a disease in which the tissues in the joint breakdown over time), and muscle weakness. A review of Resident 64's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 02/15/2023, indicated Resident 64 had moderately impaired cognition (thought process and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer/injury (painful wound caused as a result of pressure or friction) by failing to ensure that the low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure sores designed to circulate a constant flow of air for the management of pressure sores) was on the correct settings for one of one sampled resident (Resident 3) in accordance with the facility's policy. This deficient practice had the potential to place the Resident 3 at risk for skin integrity complications and pressure injury. Findings: A review of Resident 3's admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of open wound of scrotum (the external sac of skin that encloses the testes [male reproductive gland that produces sperm]) and testes, Parkinson's disease (progressive disease 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a safe environment for one (1) of six (6) sampled residents (Resident 57), a fall risk resident, when Resident 57's bed was observed not in the lowest position. Resident 57 did not have a fall risk signage inside the room per facility policies and procedures. This deficient practice had the potential for Resident 57 to sustain an injury in an event of a fall. Findings: A review of Resident 57's admission Record indicated, the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of muscle weakness, dementia (a loss of thinking, remembering, and reasoning skills), and schizophrenia (a mental disorder involving a disconnection from reality). A review of Resident 57's Fall Risk Assessment, dated 10/8/2023, indicated a score of 14. A total score above 10 on the Fall Risk Assessment indicated high risk for falls. A review of Resident 57's Falls Care Plan, dated 10/8/2023, indicated Resident 57 was at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident with a gastrostomy tube (GT, a tube that is passed through the abdominal wall to the stomach used to provide nutrition) received tube feeding as indicated on the physician's order for one (1) of five (5) sampled residents (Resident 23). This deficient practice had the potential to result in Resident 23 to not receive the volume of tube feeding formula ordered, which can lead to weight loss, malnutrition (lack of sufficient nutrients in the body), and death. Findings: A review of Resident 23's admission Record indicated Resident 23 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of failure to thrive (state of decline that may include weight loss, decreased appetite, poor nutrition, and inactivity), dementia (progressive brain disorder that slowly destroys memory and thinking skills), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a coordination of care between facility and hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) staff for one of one sampled resident (Resident 54) in accordance with the facility's hospice policy and hospice agreement by failing to ensure: a. a hospice comprehensive assessment to include a documented evidence of hospice staff notes visits on 10/25/2023, and 10/28/2023. b. hospice care plan was revised This deficient practice had the potential for Resident 54 not to receive the hospice care and services necessary to promote comfort and quality of life. Findings: A review of Resident 54's admission Record indicated Resident 54 was admitted to the facility on [DATE]. Resident 54's diagnoses included diabetes mellitus (high blood sugar), dysphagia (difficulty swallowing), and senile degeneration of bran (mental decline). A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control measures for three (3) of three (3) sampled residents (Residents 16, 41 and 45), when: 1. Cleaning of the manual blood pressure monitor (an instrument for measuring blood pressure), was not done prior to use for Resident 16. 2. Cleaning of the blood pressure cuff (attached to the manual blood pressure monitor) was not done between each use for Residents 41 and 45. 3. Purified water was not used to flush the gastrostomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach), per policy, for Resident 45. These deficient practices had the potential to spread infection through pathogens (organisms or agents that can produce disease) to Residents 16, 41, and 45 by using an unclean blood pressure cuff, and using unfiltered water in Resident 45's g-tube. Findings: 1. A review of Resident 16's admission Record indicated, Resident 16 was admitted to the facility 4/7/2023 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.