Jacob Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the facility failed to ensure infection control procedures were followed when: 1. Licensed Nurse (LN) 11 did not wear a gown consistently while providing care to Resident 86 who was on enhanced barrier precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with medical devices]), during medication (med) pass. 2. A certified nursing assistant (CNA) failed to properly use personal protective equipment (PPE - equipment such as gown and gloves used to protect staff and residents from potentially infectious diseases) while providing care for one of 24 sampled residents (Resident 94). These failures had the potential for cross contamination and spread of infection. Findings: 1. A review of Resident 86's admission Record indicated Resident 86 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD-irreversible kidney failure). On 1/15/26 at 7:50 A.M., an…

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

Based on interview and record review, the facility failed to follow their policy regarding receipt and storage of controlled medications (drugs regulated by the government for its use, possession, and manufacture). This failure resulted in a medication card containing 60 tablets of Morphine (a controlled medication used for pain) to be missing and unaccounted for. Findings: On 11/1/24, the facility reported to the Department On 10/30/24, Staff reported to the DON that a medication Morphine Sulfate 15 milligrams 60 tablet card was nowhere to be found . On 11/13/24 at 8:45 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated the missing medication was for Resident 1. The ADON stated the medication was noted to be missing on 10/30/24 when the facility attempted to reorder it. The ADON stated the pharmacy informed them it was already delivered on 10/20/24. The ADON stated the Facility Delivery Log was retrieved which indicated the medication was delivered on 10/20/24, and was signed in by a Licensed Nurse (LN 1). The ADON stated upon receipt of controlled…

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 assistance with activities of daily living (ADL - basic and everyday skills that are essential to living independently) were provided to two of three residents (Resident 28 and Resident 30) reviewed for ADL care when: 1. Resident 28 were not provided with incontinence (loss of bladder and/or bowel control) care in a timely manner and, 2. Resident 30 was not provided with nail care. This deficient practice placed Resident 28 and Resident 30 at risk for skin breakdown and decreased quality of life. Findings: 1. According to the admission Record, Resident 28 was admitted on [DATE] with diagnoses which included quadriplegia (inability to use both arms and legs), need for assistance with personal care, and personal history of urinary tract infections. A review of Resident 28's Minimum Data Set (MDS, an assessment tool), dated 10/1/23 indicated, a BIMS (Brief Interview of Mental Status - a tool to assess cognition) score of 3. According…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement non-pharmacological interventions (NPIs - ie. positioning, dark room, ice/heat, massage), as ordered by the physician, prior to the administration of PRN (as needed) pain medications for three of three residents (Residents 22, 99 and 312) reviewed for pain management. This failure had the potential for Residents 22, 99 and 312 not to receive non-prescription pain relief, prior to receiving narcotic pain medications with added side effects. Finding: 1. Resident 22 was admitted to the facility on [DATE], with diagnoses which included chronic pain syndrome (when a person experiences persistent pain that interferes with daily life), per the facility's admission Record. On 9/11/24, Resident 22's clinical records were reviewed: According to the Minimum Data Set (MDS-a clinical assessment tool), Resident 22 had a cognitive score of 15, indicating cognition was intact. The section titled, Health Condition, indicated, Resident 22 received scheduled…

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 and record reviews, the facility failed to provide sufficient staffing to meet care needs, when call lights were not answered timely for three of six confidential residents (CR 1, 2, 3) interviewed for sufficient staffing. This failure had the potential to result in residents' needs not being met, which had the potential to result in physical and psychosocial harm. Findings: On 9/9/24, a review of the offsite survey record indicated, the facility had low weekend staffing on the 3rd quarter of 2024. An interview on 9/9/24 at 8:27 A.M., with CR 2 was conducted. CR 2 stated he had a left heel wound and cannot see well. CR 2 stated he needed assistance in going to the bathroom, transfers, or going to bed. CR 2 stated staff ignored his call light when he needed help. Staff came and turned off the call light. On 9/10/24 at 10:13 A.M., a confidential meeting with the residents was conducted. Two of five residents have identified issues with call light response. 1. CR 2 stated it took a lot of time for call lights to get answered especially on the evening shift (3pm -…

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 Preadmission Screening and Resident Review II (PASARR II - a federal requirement to help ensure that individuals with mental disorders were not inappropriately placed in nursing homes for long term care) were conducted for two of five residents (Resident 6 and Resident 99) reviewed for PASARR screening. This failure had the potential for Residents 6 and 99, to be improperly placed and not have received additional qualified services. Findings: 1. Resident 6 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a chronic mental illness that affects how a person thinks, feels, and behaves), per the facility's admission Record. On 9/12/24, Resident 6's clinical records were reviewed: According to the Minimum Data Set (MDS-a clinical assessment tool), dated 8/1/24, Resident 6 had a cognitive score of 12, indicating cognition was intact. According to the PASARR I Screening, dated 6/10/24, Resident 6 was coded, Positive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a resident-centered care plan for one of six residents (Resident 6) when Resident 6's care plan did not include dementia care. This failure had the potential for Resident 6's needs to be unmet. Findings: Resident 6 was admitted to the facility on [DATE], with diagnoses which included major depressive disorder (a mood disorder that causes low interest in things that once brought joy) and anxiety disorder (feelings that results in panic attacks), according to the facility's admission Record. A review of Resident 6's History and Physical (a medical examination that involves a patient interview, physical exam, and documentation of findings), dated 6/15/24, indicated Resident 6 has dementia (loss of cognitive function that affects thinking, remembering, and reasoning) and Resident 6 did not have the capacity to understand and make decisions. A joint interview and record review was conducted with the Director of Nursing (DON) on 9/12/24 at 10:01 A.M.…

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 six residents (Resident 81's) care plan was revised when Resident 81's gastrostomy tube (G-tube, a tube surgically inserted through the belly that brings nutrition directly to the stomach) was discontinued. This failure had the potential for Resident 81's care to be miscommunicated among caregivers. Findings: Resident 81 was admitted to the facility on [DATE], with diagnoses which included traumatic subdural hemorrhage (brain bleed) according to the admission Record. An observation was conducted on 9/9/24 at 11:55 A.M. in the resident dining hall. Resident 81 was observed feeding himself with a family member present. A review of Resident 81's physician's order, dated 8/22/24, indicated Resident 81 had a diet order for soft textured food. A review of Resident 81's care plan indicated, Resident 81 had a G-tube. Resident 81's care plan indicated check tube feeding residuals (the volume of fluid remaining in the stomach during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed for three of eight residents (Resident 5, Resident 6, and Resident 18) when: 1. A resident (Resident 5) was newly diagnosed at the facility with schizophrenia (a chronic mental illness characterized by delusions and hallucinations), without meeting the criteria for schizophrenia as indicated by The Diagnostic and Statistical Manual of Mental Disorders (DSM, a reference manual from the American Psychiatric Association to help define and classify mental disorders). 2. A resident (Resident 6) was newly diagnosed at the facility with schizophrenia without meeting the criteria for schizophrenia as indicated by the DSM. 3. A licensed nurse (LN 32) did not obtain the heart rate of Resident 18 prior to administering two blood pressure medications. This failure had the potential for Resident 5, Resident 6, and Resident 18 to experience unnecessary medication side effects. (Cross Reference…

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 a safe environment was maintained when side rails were not installed for one of one residents (Resident 28) reviewed for side rails. As a result, there was a potential for Resident 28 to sustain injury. Findings: According to the admission Record, Resident 28 was admitted to the facility on [DATE] with diagnoses which included functional quadriplegia (the inability to move due to severe physical disability or frailty) and epilepsy (a disorder which causes seizures). A review of Resident 28's Minimum Data Set (MDS, an assessment tool), dated 10/1/23 indicated, a BIMS (Brief Interview of Mental Status) score of 3. According to the BIMS scoring, a score of 0-7 indicated severe mental impairment. On 09/09/24 at 8:45 A.M. an observation was made in Resident 28's room. Resident 28 was laying in bed with her bed pushed up against the wall. There were no side rails observed on Resident 28's bed. A review of Resident 28's Side Rail…

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 dialysis (treatment to remove waste from the body) access care, including removal of dressing from the dialysis site for one of one sampled residents (Resident 71) reviewed for dialysis. As a result, there was a potential for complications after dialysis. Findings: According to the admission Record, Resident 71 was admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste) and dependence on dialysis. On 9/9/24 at 9:49 A.M., an observation and interview was conducted with Resident 71. Resident 71's dialysis access site was on the left upper arm. There was a pressure dressing taped over the dialysis access site. Resident 71 stated he went to dialysis treatments on Tuesdays, Thursdays, and Saturdays. On 9/9/24 at 10:01 A.M., an interview was conducted with Licensed Nurse (LN) 35. LN 35 stated Resident 71's last dialysis treatment was 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 two of five residents (Resident 5 and Resident 6) were free from unnecessary medications when Resident 5 and Resident 6 were given antipsychotic medications (medication to treat psychosis) without clear indications. This failure had the potential for Resident 5 and Resident 6 to experience unnecessary medication side effects. Cross Reference F658 Findings: 1. Resident 6 was admitted to the facility on [DATE] with diagnoses which included anxiety disorder (a mental condition causing intense feelings of fear and anxiety) and major depressive disorder (a mental illness causing persistent feelings of sadness) according to the admission Record. A review of Resident 6's physician's order, dated 7/9/24, indicated an order for Seroquel (an antipsychotic medication) for schizophrenia as evidenced by unprovoked agitation. An interview was conducted on 9/11/24 at 9:56 A.M. with Licensed Nurse (LN) 3. LN 3 stated Resident 6 was alert, oriented, 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 that it was free of a medication error rate of five percent or greater when two routine medications were not available for one of three sampled residents (Resident 72) observed for medication administration. This failure had the potential to negatively affect Resident 72's health. Findings: According to the admission Record, Resident 72 was admitted to the facility on [DATE] with diagnoses which included nutritional anemia (low red blood cells caused by a lack of either iron, protein, or vitamin B12), and muscle weakness. On 9/11/24 at 9:51 A.M., an observation of a medication pass was conducted with Licensed Nurse (LN) 34. LN 34 was observed preparing, then administering Resident 72's 9 A.M. medications. A review of Resident 72's physician's orders indicated, cyanocobalamin (a vitamin used to prevent and treat low levels of vitamin B12) 5000 micrograms one capsule and Calcium 500 milligrams were due to be given every morning at 9…

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

Based on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify concerns related to unnecessary use of antipsychotic (drug used to treat clinical psychiatric symptoms or mental disorders) medication due to lack of indications. This failure had the potential for deficiencies to remain uncorrected and could result in residents being exposed to unnecessary medication side effects. (Cross reference F758) Findings: An interview was conducted on 9/12/24 at 4:17 P.M. with the Administrator (ADM), the Director of Nursing (DON), and Administrator in Training (AIT) regarding the facility's QAPI committee and their plans. The DON stated the psychotropic committee met to perform gradual dose reductions (GDR, a process of lowering the dose of psychotropic medications) and complete a Medication Review Regimen (MRR, a process to review any issues with ordered medications) for all residents on psychotropic medications. The information gathered from the psychotropic committee was then brought to QAPI. The DON acknowledged there…

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, the use of gowns, gloves, and face mask during resident care to prevent the transmission of bacteria) for one of four residents (Resident 211) reviewed for infection control. This failure had the potential to spread infectious organisms to Resident 211 and others. Findings: According to the admission Record, Resident 211 was admitted on [DATE] with diagnoses which included chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys). On 9/9/24 at 9:01 A.M., an observation was conducted inside Resident 211's room. Licensed Nurse (LN) 32 was observed wearing full Personal Protective Equipment (PPE, gown gloves and a mask) while providing care to Resident 211. There was no sign posted outside the room indicating the need to wear PPE. In addition, there was no PPE available outside the room. On 9/9/24 at 9:10 A.M., an interview was conducted with LN 32.…

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 residents (Resident 1) was provided care/treatment to prevent the worsening of pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence as a result of prolonged pressure) when: 1. Certified nursing assistant (CNA) 1 removed Resident 1 ' s pressure ulcer dressings and the resident did not have his wounds covered while in bed. 2. Infection control was not maintained during pressure ulcer care when Resident 1 ' s open wounds were not re-cleansed after touching the resident ' s used bedding. 3. Resident 1 ' s pressure ulcer treatment orders were not followed. 4. Resident 1 ' s pressure ulcer treatment administration record (TAR) for November and December 2023 had blank entries and wound treatment could not be verified as having been done. As a result of these deficient practices, there was the potential for Resident 1 ' s pressure ulcers to worsen and/or become infected.…

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 licensed nurse (LN) 1 had the necessary competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) to perform pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence as a result of prolonged pressure) treatments for one of three residents (Resident 1). As a result of this deficient practice, there was the potential for Resident 1 ' s wound to deteriorate and/or become infected. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include quadriplegia (paralysis affecting all four limbs). A review of Resident 1 ' s wound provider assessment and treatment titled SNF Wound Care dated 1/18/24, indicated the resident had a pressure ulcer on the left buttock that extended into…

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 dress one sampled resident in a dignified manner during a meal (31). This failure had the potential for Resident 31 to feel humiliated and isolated during meal time. Findings: Resident 31 was admitted to the facility on [DATE] with diagnoses to include diabetes (blood sugar imbalance), heart failure, and Alzheimer's disease per the facility's Resident Face Sheet. During lunch observation on 6/8/21 at 11:55 A.M. in the Moss station, there were 10 residents sitting on their wheelchairs waiting for lunch including Resident 89. Resident 89 was observed leaning forward wearing a hospital gown with the gown untied and the back was exposed. On 6/8/21 at 12:09 P.M., an interview was conducted with CNA 10. CNA 10 stated when getting residents up for meals, residents should be washed, cleaned and dressed appropriately. On 6/8/21 at 12:11 P.M., a joint interview was conducted with CNA 11 and the DON. CNA 11 acknowledged he put a hospital gown 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 resident's medical information was secured and protected for one sampled resident (32). As a result, Resident 32's medical information was exposed to unauthorized people. Findings: Resident 32 was admitted to the facility on [DATE] with diagnoses to include subdural hemorrhage (bleeding in the brain) and quadriplegia (paralysis of the whole body) per the facility's Resident Face Sheet. An observation was conducted in the sub-acute area on 6/10/21 at 11:20 A.M. A medication cart parked next to room [ROOM NUMBER] had a form on top that indicated Sub acute vitals which contained nine resident names including Resident 32's. The form indicated the residents' tube feeding names, amount of water flush, resident's blood pressure, temperature, oxygen saturation, blood sugar and respiration values. On the same day, the following observations were done: At 11:32 A.M., two staff and a resident passed by the medication cart. At 11:33 A.M., one…

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 ensure all ceiling vents were clean for one of twenty-four sampled residents, and one unsampled resident (resident 223, room [ROOM NUMBER]). As a result, there was an increased risk of poor air quality. Findings: On 6/8/21 at 10:40 A.M., an observation and interview was conducted with Resident 223. Resident 223 stated, the ceiling vent was dirty, and he could see dirt and dust falling out of it. Clumps of dust were observed throughout the ceiling vent of Resident 223's room. On 6/8/21 at 11:05 A.M., an interview was conducted with Resident 44. Resident 44 stated, the air quality at the facility was bad, and he woke up in the morning with dust particles on him which came out of the vent. On 6/9/21 at 1:39 P.M., an observation was conducted of room [ROOM NUMBER]. The ceiling vent was covered with clumps of dust. On 6/11/21 at 2:40 P.M., an interview was conducted with the administrator. The administrator stated, the vents should not be full of dust because…

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 did not provide requested grooming services to one of twenty-four sampled residents (44). As a result, Resident 44 had unwanted facial hair. Findings: Per the facility's Resident Face Sheet, Resident 44 was admitted to the facility on [DATE] with diagnoses to include hemiplegia following a cerebral infarction (one side of body is paralyzed due to a stroke). Per the facility's MDS (Minimum Data Set), dated 4/18/21, Resident 44 required extensive assistance with shaving. On 6/8/21 at 11:05 A.M., an observation and interview was conducted with Resident 44. Resident 44 had unshaved hair on his neck. Resident 44 stated, he asked the staff to shave him each time they bathed him, but the staff often told him they didn't have time, and that they would shave him the next day, or the next time they bathed him. Resident 44 further stated, he did not want his neck to have hair, but the staff usually did not follow through when they said they would shave him…

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 review of facility documentation, the Quality Assurance and Performance Improvement (QAPI) committee failed to identify the current Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccination. In addition, the facility failed to take the necessary corrective action to ensure that pneumonia vaccinations were offered, discussed, and provided in accordance with the current CDC standards. This failure had the potential to affect all 124 residents who currently live in the facility (refer to F883). Findings: On 6/9/21 at 1:33 P.M., an interview was conducted with the ICP. The ICP stated the facility did not offer both pneumonia vaccines and the facility only gave, The 23 (PPSV23). On 6/10/21 at 9:15 A.M., an interview was conducted with LN 14. LN 14 stated the facility only gave one kind of Pneumoccoccal vaccine which was the PPSV23. On 6/10/21 at 11:13 A.M., an interview was conducted with the QA nurse. The QA nurse stated she was not sure if there was another pneumococcal vaccine that the facility was giving. On 6/10/21 at 1:52…

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 did not ensure two staff wore the appropriate PPE when entering the room of one of one sampled residents on transmission based precautions. In addition, the facility failed to ensure staff in the kitchen donned (put on) gloves appropriately, to prepare food. (dietary aide 1- DA 1) These failures had the potential to spread infection to other residents, and to cause foodborne illness among the facility residents. Findings: 1. On 6/9/21 at 1:15 P.M., an observation was conducted of the facility's Person Under Investigation (PUI) unit. A male staff was observed entering room [ROOM NUMBER] with a sign on the door that indicated yellow zone. The staff picked up a gown outside the room, went inside carrying the gown on his hand then closed the door. The staff was interrupted and opened the door still carrying the isolation gown in his hand. During interview, the male staff stated he would put the gown inside the room after sanitizing his hands because…

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, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer 5 of 5 residents reviewed for flu/pneumonia vaccinations (Resident (R) 1, R2, R3, R4, R5) and/or their representatives, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to offer residents the opportunity to be vaccinated with PCV13 (pneumococcal vaccine- vaccine to prevent some cases of pneumonia, a respiratory disease) in accordance with CDC guidelines. Residents and/or their representatives were unable to share in clinical decision making with the medical provider as they were not given information or offered PCV 13. This failure to offer a recommended pneumococcal vaccination had the potential to place all 124 residents of the facility at risk for pneumonia. Findings: Review of the Centers for Disease Control and Prevention (CDC) website titled, Pneumococcal Vaccine…

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.