Orchards Skilled Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and the facility P&P review, the facility failed to ensure the notification of change for one of one resident reviewed for weight loss (Resident 14). This failure resulted in a delay of Resident 14's significant weight loss being communicated to the resident's physician, responsible party, and RD, which had the potential to negatively impact the resident's well-being. Findings: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 dated October 2023 showed If a resident is losing a significant amount of weight, the facility should not wait for the 30- or 180-day timeframe to address the problem. Weight changes of 5% in 1 month, 7.5% in 3 months, or 10% in 6 months should prompt a thorough assessment of the resident's nutritional status. Review the facility's P&P titled Nutrition Management Program revised 5/31/21, showed a weight change is significant per RAI manual definition with a weight loss of 5% and/or 5 lbs.…

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 P&P review, the facility failed to ensure services provided met the professional standards of care for one when LVN 4 failed to properly take a blood pressure for one nonsampled resident (Resident 543). This failure posed the risk for not obtaining accurate blood pressure reading for this resident. Findings: Review of the facility's P&P titled Blood Pressure, Measuring dated 10/2010 showed the purpose of this procedure is to measure the pressure exerted by the circulating volume of blood on the walls of the arteries, veins, and chambers of the heart. The policy further showed to expose the resident's arm by rolling the sleeve up about five inches above the elbow. When locating the pulsation, place the diaphragm of the stethoscope firmly against the skin, and hold the diaphragm in place with hand. On 4/3/24 at 0813 hours, an observation and concurrent interview was conducted with LVN 4. LVN 4 took Resident 543's blood pressure prior to the administration of metoprolol (antihypertensive medication). LVN 4 wrapped the blood pressure cuff on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the timely intervention for one of one resident reviewed for weight loss (Resident 14). This failure had the potential to result in continued nutritional decline and negative outcomes. Findings: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 dated October 2023 showed If a resident is losing a significant amount of weight, the facility should not wait for the 30- or 180-day timeframe to address the problem. Weight changes of 5% in 1 month, 7.5% in 3 months, or 10% in 6 months should prompt a thorough assessment of the resident's nutritional status. Review the facility's P&P titled Nutrition Management Program revised 5/31/21, showed a weight change is significant per RAI manual definition with a weight loss of 5% and/or 5 lbs. in one month. The P&P also showed the following tasks at the time of identification of weight loss: - A referral is made 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, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 26) reviewed for oxygen use was provided with the appropriate respiratory care. The facility failed to ensure Resident 26's oxygen tubing was labeled and not touching the floor. These failures had the potential to affect the respiratory health and well-being of Resident 26. Findings: Review of the facility's P&P titled Oxygen Management revised 5/31/21, showed the oxygen is administered under orders of the attending physician, except in the case of an emergency. The general guidelines concerning oxygen safety during oxygen administration include nasal cannulas, masks and tubing should be changed every seven days, dated, time and initialed. On 4/2/24 at 1023 and 1548 hours, Resident 26 was observed wearing a nasal cannula attached to a portable oxygen tank with a setting of one liter per minute. Part of the oxygen tubing was observed touching the floor. Medical…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs for one of 13 final sampled residents (Resident 13). * The facility failed to ensure Resident 13's oxycodone-acetaminophen (narcotic pain medication) was accurately reconciled. The oxycodone-acetaminophen tablets removed as shown on the Controlled Drug Record was not recorded as administered on the electronic MAR. This failure had the potential for drug diversion. Findings: Review of the facility's P&P titled Controlled Drugs revised 10/2018 showed each dose removed from the supply of controlled drugs shall be signed, dated, and timed out on the proof of count sheet on the line representing that particular dose prior to resident administration. Nurses must sign out, not just initial. Proof of count sheets shall be easily accessible by the medication nurse. Medical record review for Resident 13 was initiated on 4/2/24.…

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 observation, interview, and facility P&P review, the facility failed to ensure the proper disposal and storage of medications as evidenced by: * The facility failed to ensure the medications administered orally were stored separately from the externally used medications in one of two medication carts (Medication Cart A). * The facility failed to ensure the discontinued medications were properly disposed in one of one medication room (Medication Room A). In addition, the facility failed to ensure the medications administered orally were stored separately from the externally used medications in Medicaiton Room A. * The facility failed to ensure safe storage of one Theraworx Muscle Cramp (use to relieve muscle cramps and spasms) foam found at Resident 639's bedside cabinet. These failures had the potential to result in unsafe medication administration, cross-contamination of the medications, and unsafe handling and storage of the residents' medications. Findings: Review of the facility's P&P titled 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.

Based on observation, interview, facility personnel file, and facility document review, the facility failed to ensure the Food and Nutrition Services Director who was responsible to oversee the main kitchen which produced food for the skilled nursing facility was competent in managing the day-to-day functions of the food services department. The failure to employ staff with the skills and abilities to effectively implement departmental processes in accordance with standards of practice, may jeopardize the health and well-being of the 40 residents who received food prepared in the kitchen. Findings: Review of the facility's Resident Assessment Report (CMS-802) dated 4/2/24, showed 40 of 40 residents residing in the facility received food prepared in the kitchen. Review of the facility's personnel file for the Food and Nutrition Services Director (FNSD) included the facility's document titled Food and Nutrition Services Director, Job Description signed and dated by the Food and Nutrition Services Director on 6/23/23, showed the Food and Nutrition Services Director was primarily…

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 resident menu was followed when the puree procedure for meat and vegetables was not followed. This failure posed the risk for an inconsistent product and to not meet the nutritional needs of the five residents who received puree diets. Findings: Review of the facility's recipe: Pureed Vegetables (undated) showed Number of Servings: five. Ingredients: Seasoned Vegetables two and ½ cup, Cooked and Drained (Reserve liquid). Food Thickener: one and ½ (half) teaspoon. The Directions were as follows: 1. Remove portions required from regular prepared recipe; drain and reserve cooking liquid. Place in food processor or blender and process until smooth. 2. If necessary, add a small amount of reserved cooking liquid or hot water. 3. If needed, gradually add thickener and process until smooth in consistency. Note: volume of liquid required may vary slightly, depending on the texture of the product. Note: Amount of thickener will vary slightly. Start with one and ½ teaspoon and add more gradually…

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 facility P&P review, the facility failed to honor the food preference for one of two sampled residents (Resident 17) reviewed. This failure had the potential for inadequate nutrition. Findings: Review of the facility's P&P titled Initial Resident Visitation/Nutritional Screening dated 9/2/21, showed obtain food preferences, allergies or intolerance and note on Dietary interview/pre-screen (FORM 101) or other designated form and tray card. The interview form is filed in the medical record, preferably. Medical record review for Resident 17 was initiated on 4/2/24. Resident 17 was admitted to the facility on [DATE], and readmitted on [DATE]. On 4/2/24 at 0845 hours, a concurrent observation and interview was conducted with Resident 17. Resident 17 almost finished her breakfast and had one glass of cranberry juice on her breakfast tray. Resident 17 stated she did not like the cranberry juice and had mentioned this to the staff, but she still was provided with cranberry juice. 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.

Based on observation, interview, and facility P&P review, the facility failed to ensure the P&P for the resident's food brought by the visitors was followed. * The facility failed to ensure the safe food handling guidelines were communicated to the resident's family/visitors who brought the resident food from the outside. This failure had the potential to cause foodborne illness to the residents who received food brought by the visitors. Findings: Review of the facility's P&P titled Food from Outside Sources dated 2020 showed if the food is brought in by the visitors, friends, family members or other guests, the community should help them understand safe food handling practices as summarized in Safe Food Handling Guide for Visitors and Staff (DOC 403). On 4/2/24 at 1506 hours, an interview was conducted with LVN 1. LVN 1 stated she normally educated the resident's family members/visitors regarding the resident's diet only and not on safe food handling. LVN 3 further stated she did not know any document they ave for the family members/visitors regarding for safe food handling. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the complete and accurate medical records for three of six residents reviewed for advanced directives (Residents 14, 26, and 35). * Residents 14, 26, and 35's POLST were incomplete. This failure had the potential for the resident's advanced directive status not being communicated to the health care staff in the event of an emergency for these residents. Findings: 1. Medical record review for Resident 14 was initiated on 4/2/24. Resident 14 was readmitted to the facility on [DATE]. Review of Resident 14's Internal Medicine History and Physical examination dated 3/27/24, showed Resident 14 did not have capacity (to understand and make decisions). Review of Resident 14's POLST form dated 3/25/24, showed the POLST was a legally valid physician's order, and to send the form with the resident whenever they are transferred or discharged . Resident 14's POLST also showed Section D - Information and Signatures was incomplete when asked to select if 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 observation, interview, facility document review, and facility P&P review, the facility failed to establish and maintain the infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. * The facility failed to ensure the water management program was established and implemented to include the implementation of measures to prevent the growth of Legionella and other opportunistic pathogens; and a way to monitor the measures they had in place * The facility failed to ensure the staff changed gloves after touching the bedside table and prior to administering eye drop medications for Resident 543 * CNA 4 failed to perform hand hygiene after touching the floor mat with bare hands in Room A These failures had the potential to increase the risk for the spread of infection. Findings: Review of the facility's P&P titled legionella monitoring dated 5/2020 showed infection control committee supports the administrator, Director of nursing and Plant Operation Director 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, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the proper labeling and dating of the foods in the kitchen was utilized once the food item was opened. * The facility failed to ensure the proper labeling and dating of the foods in refrigerator was in placed for the residents' food brought in by visitors. In addition, the facility failed to ensure the food items were discarded after 72 hours. * The facility failed to ensure a proper sanitary condition of the ice machine. * The facility failed to ensure hair restraints were correctly worn by the dietary staff working in the kitchen. * The facility failed to ensure the meat thawing in the refrigerator was labeled with the use-by date, and the date when the meat was pulled from the freezer. * The facility failed to ensure the bins containing the adaptive utensils (specialized forks, spoons and other specially designed cutlery with built-up handles to help people 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and equipment instruction manual, the facility failed to maintain essential equipment in safe operating condition. * The facility failed to ensure the ice machine was cleaned and sanitized according to the manufacturer's specification. The facility used a sanitizing spray to clean and sanitize the ice machine, instead of the Hoshizaki Scale Away solution to clean and sodium hypochlorite solution (chlorine bleach) solution to sanitize the ice machine as per the ice machine instruction manual. This failure had the potential for the equipment to not function in the way it was intended, which could cause food borne illnesses for the residents. Findings: According to the CMS 672, Resident Census and Conditions of Residents completed by the Administrator and dated 7/31/23, 32 of 33 residents in the facility were served food prepared in the kitchen. According to USDA Food Code 2022, Section 4-501.11, Good Repair and Proper Adjustment, showed the proper…

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, medical record review, and facility P&P review, the facility failed obtain and maintain the copy of advance directives (legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions), and failed to provide the information regarding the rights to formulate the advance directives for three of 12 final sampled residents (Residents 1, 31, and 192). * The facility failed to review the copy of advance directives provided by Resident 31 and resident's representative, and ensure it was complete to show the resident's wishes and instructions for healthcare. * The facility documented in Resident 192's POLST the resident had a legally recognized decisionmaker, however, the facility failed to ensure the copy of the resident's advance directive for healthcare was obtained and maintained in the resident's medical record. * The facility failed to provide Resident 1 with the written information regarding the advance directive and ensure…

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, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs for one of five unnecessary medication final sampled residents (Resident 3). * The facility failed to develop the comprehensive person-centered care plan to address the use of PICC (peripherally inserted central catheter - intravenous access used for a prolonged period of time) line for Resident 3. This failure had the potential risk of not providing appropriate, consistent, and individualized care to the resident. Findings: Review of the facility's P&P titled Nursing Services - Care Plan dated 3/24/20, showed the facility shall implement each resident's care plan according to the resident's needs, physician orders, resident preferences and facility protocols as indicated. The care plans updated upon significant change in status, quarterly and annually. On 7/31/23 at 1415 hours, Resident 3 was observed sitting on his bed awake.…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of 12 final sampled residents (Resident 10) attained and maintained their highest practicable well-being. * The facility failed to coordinate the care of Resident 10 with the contracted hospice. There was no physician's order to indicate the frequency of licensed staff and CHHA visits. The hospice forms such as the hospice certification, comprehensive plan of care, assessment, and the calendars for the months of June, July, and August 2023 were not in the hospice binder or Resident 10's medical records. This failure had the potential for Resident 10 to not receive the appropriate care and treatment. Findings: Review of the facility's P&P titled Hospice/Palliative/End of Life Care Guidelines revised 5/7/21 showed to coordinate care plans for residents receiving hospice services will include the most recent hospice plan of care 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 2. Review of the facility's P&P titled Proper Use of Assist Rail Guidelines revised 7/6/21, showed the following: -The use of assist rails will be determined by the IDT, physician, and resident's ability to use the assist rail to improve function or as requested; - An assessment will be made by the IDT to determine the resident's symptoms, risk of entrapment and reason for using assist rails. When used for mobility or transfer, an assessment will include a review of the resident's bed mobility, ability to change positions, transfer to and from bed or chair, and to stand and toilet, risk of entrapment from the use of assist rails, and the bed's dimensions are appropriate for the resident's size and weight; - Less restrictive interventions that will be incorporated in care planning include: providing restorative care to enhance abilities to stand safely and to walk, placing the bed lower to the floor and surrounding the bed with a soft mat, providing staff monitoring at night with periodic assistance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of 12 final sampled residents (Residents 10, 392, and 541) were free from the unnecessary psychotropic medications (any drug that affects brain activity). * The facility failed to ensure Resident 10's episodes of behaviors for the use of quetiapine (antipsychotic medication use to treat symptoms of schizophrenia or bipolar disorder (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and escitalopram (antidepression medication) were completed, accurate, summarized, and made available to the prescriber on a monthly basis to serve as reference for gradual dose reduction. * The facility failed to ensure Resident 392's episodes of behaviors for the use of risperidone (antipsychotic medication use to treat symptoms of schizophrenia or bipolar disorder (a mental illness that causes disturbed or unusual thinking, loss of interest 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 facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the opened tuberculin purified protein derivative (PPD) vial was labeled with opened date. This failure had the potential to negatively impact the residents' well-being. * The facility failed to ensure the discontinued medications for one of the 12 final sampled residents (Resident 10) was removed from the medication cart. This failure had the potential for medications to be accidentally administered and/or diverted. * Multiple prescription medications were left unattended inside Medication Room A with an unaccompanied unlicensed staff. This failure had the potential for unauthorized access and drug diversions in the facility. * The facility failed to ensure the medication carts were properly locked and secured. Medication Cart 1 was left unlocked and unattended. This had the potential for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to maintain the accurate medical record for one of the 12 final sampled residents (Resident 341). * Resident 341's I/O documented in the MAR was inconsistent with the I/O documented in the Intake/Output Record (Shift) form. This failure had the potential for Resident's 341 care needs not being met as his I/O information was inaccurate in the medical record. Findings: Medical record review for Resident 341 was initiated on 8/2/23. Resident 341 was admitted to the facility on [DATE]. Review of the Order Summary Report for 7/28 to 8/31/23 showed the following orders: - Fluid Restriction 2000 ml - Total Dietary 1200 ml: breakfast = 720 ml, lunch = 240 ml, and dinner = 240 ml - Total Nursing 800 ml: morning shift = 340 ml, afternoon shift = 340 ml, and night shift = 120 ml. - Monitor I/O for 30 days every shift. Review of Resident's 341's I/O on the MARs for July and August 2023 showed the I/O documentation in the MARs was not consistent with the I/O…

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, medical record review, and facility document review, the facility failed to ensure residents' entrapment assessments were accurate, complete, and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for all seven residents with side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. 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.