Broadway Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to complete the Physician Discharge Summary (PDS) form for one of three sampled residents (Resident 61) reviewed for close record. This deficient practice has the potential to result in increased Resident 61's chances of re-injury after discharge home, medication errors (any preventable event that may cause or lead to inappropriate medication use or patient harm while), and improper follow-up care.Findings:During a review of Resident 61's admission Record indicated Resident 61 was admitted to the facility on [DATE], with diagnoses that included displaced intertrochanteric fracture of left femur subsequent encounter for closed fracture with routine healing (The bone near hip joint area, broken hip, has broken into two or more pieces that have shifted out of alignment. occurring on the left side, where the broken bone fragments have shifted, requiring follow-up care), encounter for other orthopedic aftercare (follow-up, post-surgical, or rehabilitative…

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

Based on observation, interview, and record review, the facility failed to ensure the food service area was maintained in a clean and sanitary manner and while providing proper food handling in accordance with the facility's policy and procedure by failing to: 1. Ensure the juice machine did not contain gunk (an unpleasantly sticky or messy substance) inside the juice connector tube. 2. Ensure food container lids were closed. 3. Ensure food trays (meal trays) were in good repair and free from cracks and peels. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the 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 observation on 1/21/2025 at 7:51 AM in the facility kitchen, the juice machine was observed with a box of orange juice connected to the machine. The machine was unclean and observed with dried coffee drippings.…

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 staff failed to protect the confidential personal information for one of 18 sampled residents (Resident 9) by not closing the computer screen after looking up Resident 9's medical information at the Nursing Station when there were other staff, residents, and visitors in the area. This deficient practice had the potential to expose Resident 9's medical records to others and violated the resident's right for privacy and confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the individual's surrogate or representative). Findings: During a review of Resident 9's admission Record, the admission Record indicated the facility initially admitted the resident on 2/27/2024 and readmitted on [DATE] with diagnoses that included but not limited to acute on chronic combined systolic and diastolic congestive heart failure (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate assessment of the Minimum Data Set (MDS, a resident assessment tool) for one (1) of five (5) sampled residents (Resident 35) by failing to include the resident's diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). This deficient practice had the potential for the facility to not develop and implement an individualized care plan, which could negatively affect Resident 35's overall well-being. Findings: During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 35's diagnoses included dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).…

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 revise the care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) for one (1) of 18 sampled residents (Resident 158) in accordance with the facility policy by failing to update Resident 158's care plan on stage 2 pressure ulcer (damage to the skin and underlying soft tissue caused by prolonged pressure) to include Resident 158's non-compliance of interventions. This deficient practice had the potential for Resident 158's pressure ulcer to worsen or develop new pressure injury. Findings: During a review of Resident 158's admission record (front page of the chart that contains a summary of basic information about the resident), indicated Resident 158 was originally admitted to the facility on [DATE]. Resident 158's diagnoses included stage two pressure ulcer of sacral region (localized, pressure-related damage to the skin and/or underlying…

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 quality for administering oxygen was met for one (1) of one sampled resident (Resident 9) by failing to ensure Resident 9 was administered oxygen by a licensed nurse and not by a certified nurse assistant. This deficient practice had the potential to result in provision of unnecessary/incorrect care for Resident 9, which could result to harm. Findings: During a review of Resident 9's admission Record, the admission Record indicated the facility initially admitted the resident on 2/27/2024 and readmitted on [DATE] with diagnoses that included but not limited to acute on chronic combined systolic and diastolic congestive heart failure (a sudden worsening of a pre-existing chronic condition where the heart struggles to both pump blood effectively and fill properly due to stiffness, leading to fluid build-up and congestion in the body), acute respiratory failure with hypoxia (a condition where the lungs are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of 18 sampled residents (Resident 9) was provided a communication device with the language that the Resident 9 preferred. This deficient practice prevented Resident 9 from communicating with the staff and had a potential to delay receiving appropriate care/treatment Resident 9 needed. Findings: During a review of Resident 9's admission Record, the admission Record indicated the facility initially admitted the resident on 2/27/2024 and readmitted on [DATE] with diagnoses that included but not limited to acute on chronic combined systolic and diastolic congestive heart failure (a sudden worsening of a pre-existing chronic condition where the heart struggles to both pump blood effectively and fill properly due to stiffness, leading to fluid build-up and congestion in the body), acute respiratory failure with hypoxia (a condition where the lungs are unable to absorb enough oxygen into the blood), acute pulmonary edema (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide grooming services for one (1) of 18 sampled residents (Resident 23) who was dependent with activities of daily living (ADLs- are activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), in accordance with the facility's policy. This deficient practice resulted in Resident 23 having long and jagged (having rough, sharp points protruding) fingernails, potentially leading to skin injury, infection, and scarring. Findings: During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was initially admitted to the facility on [DATE] and re admitted on [DATE] with diagnosis which included lack of coordination, sepsis (a serious condition in which the body responds improperly to an infection), and dysphagia (swallowing difficulties). During a review of Resident 23's Annual History and Physical (H&P) 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 provide the necessary respiratory care services for one of one sampled resident (Resident 9) by failing to ensure oxygen ( a colorless, odorless gas necessary for most living organisms to breathe and function properly) was administered according to the physician's orders. This deficient practice placed Resident 19 at risk for experiencing complications such as respiratory distress (a condition that occurs when the body needs more oxygen, resulting in difficulty breathing, rapid breathing, and low blood oxygen level) that can lead to serious illness and/or death. Findings: During a review of Resident 9's admission Record, the admission Record indicated the facility initially admitted the resident on 2/27/2024 and readmitted on [DATE] with diagnoses that included but not limited to acute on chronic combined systolic and diastolic congestive heart failure (a sudden worsening of a pre-existing chronic condition where the heart struggles 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 accurately measure the salt content of food served for one of three sampled residents (Resident 17) who was on renal diet (a specialized dietary plan designed for individuals with kidney disease, and it aims to protect and improve the kidney function by limiting certain nutrients such as salt). This failure placed Resident 17 at risk for receiving more than the required amount of sodium (salt) which can lead to serious illness/ disease. Findings: During a review of Resident 17's admission record indicated, the reisdent was originally admitted at the facility on 5/21/2023 and was re-admitted on [DATE]. with diagnoses that includes end stage renal disease (ESRD, is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), and dependent on renal dialysis (a procedure to remove waste products and excess fluid…

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 its infection control policy for one (1) of 18 sampled residents (Resident 158) by failing to ensure enhanced barrier precaution (EBP, an infection control practice that involves wearing isolation gowns and gloves during high-contact activities with residents with wounds in nursing homes) was implemented to Resident 158 who has a wound. This deficient practice had the potential to result in Resident 158 developing an infection and spread of infection among staff and residents. Findings: During a review of Resident 158's admission record (front page of the chart that contains a summary of basic information about the resident), indicated Resident 158 was originally admitted to the facility on [DATE]. Resident 158's diagnoses included stage two (2) pressure ulcer of sacral region (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), urinary tract infection (UTI- an infection 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 interview, and record review the facility failed to: 1. Administer medications timely to one (1) of four (4) residents (Resident 158) observed for medication administration. This deficient practice had the potential for Resident 158's health and well-being to be negatively impacted. 2. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Antibiotic or Controlled Drug (also known as Controlled Medication [CM] or Controlled Substance [CS, medications which have a potential for abuse and may also lead to physical or psychological dependence]) accountability logs for November 2023, December 2023, and January 2024. This deficient practice resulted in not following the facility's Controlled Medication Disposal Policy and Procedure (P&P) on the control and accountability of CS's awaiting final disposition (process of returning and/or destroying unused medications). This deficient practice also increased 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 that its medication error rate was less than five (5)percent (%). Two (2) medication errors out of 37 total opportunities contributed to an overall medication error rate of 5.41% affecting 2 of four (4) residents observed for medication administration (Resident 44 and 110.) The medication errors were as follows: 1. Resident 44 did not receive a dose of calcium with vitamin D3 (a combination medication used as a dietary supplement to provide support to bones) as indicated on the Physician's order. 2. Resident 110 was to be administered potassium chloride (a medication used to prevent low amounts of potassium in the blood) against Resident 110's physician orders. These failures had the potential to result in Resident 44 and 110 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 44's and 110's health and well-being to be…

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: 1. Remove and discard one expired insulin (medication used to regulate blood sugar levels) Humulin R (short-acting insulin) vial for Resident 17, and one expired inhalation solution for Resident 48, in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart South Station 4.) 2. Label one inhalation treatment with an open date for Resident 36, in accordance with facility requirements in one of two inspected medication carts (Medication Cart South Station 4.) 3. Store one insulin Humulin R vial for Resident 209 and one insulin Lantus (long-acting insulin) Solostar pen (type of insulin injection devise) for Resident 259, in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart South Station 4.) These practices increased the risk for Residents 17, 36, 48, 209, and 259 to have received medication that had become ineffective or toxic due to improper…

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 prevent food contamination and the spread of foodborne illness as indicated on the facility policy when: 1. Used bottles of juice and water were found on top of the bucket that contains the dishwasher's cleaning solution. 2. A broiler and a fan that are used to airdry clean dishes were found to have dust. The broiler and fan were not on the cleaning schedule log. These deficient practices had the potential to increase the risk of food contamination and the spread of foodborne illness to the residents. Findings: 1. During an observation and concurrent interview on 1/16/24 at 8:25 AM, of the kitchen's dishwashing station, with Food and Nutrition Services Aide (DA), the following were observed on top of the bucket that contains the cleaning solution for the dishwasher: a. a used bottle with red liquid b. a used bottle with clear liquid c. an empty soda can DA stated the bottles and soda can should not be on top of the bucket that contains the cleaning solution for the dishwasher because of the risk 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 and interview, the facility failed to ensure infection control procedures were maintained for two (2) of 2 sampled residents (Residents 158 and 19) for infection control care area, as indicated in the facility policy by failing to ensure: 1. reusable medication bubble packs (medication packaging system that contains individual doses of medication per bubble) and multi-use medication bottles were disinfected (cleaning with a solution that destroys organisms) during medication administration for Resident 158. This deficient practice increased the risk for Resident 158 and all Residents utilizing medications from Medication Cart 1 to be exposed to infective pathogens (a bacteria, virus or other organism that can cause disease) that were transferred from Resident 158's room to Medication Cart 1 to subsequent residents, resulting in possible active infections (organisms causing disease that is rapidly reproducing.) 2. Certified Nurse Assistant 2 (CNA 2) perform handwashing after touching the toilet seat and proceeding to Resident 19 to fix the resident's nasal…

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 safe, clean, comfortable sanitary and home like environment for four of five sample residents (Resident 24, 19, 38 and 3) for environment care area by failing to ensure: 1. Resident 24's gastrostomy tube (G-tube, tube inserted through the belly that brings nutrition directly to the stomach) pump was clean free of dry milk brownish in color. 2. The toilet seat cover screw in Room A's bathroom was not sticking out. 3. The side drawers in Room C did not have peeled off and missing vinyl panels leaving an exposed brown wood with sharp edges. 4. The toilet seat in Room B's bathroom was free of dry brown fecal matter and used toilet paper on the floor. 5. The hallway was free from clutter such as the shower chair with dirty bucket with dry brownish black stuff on it. These deficient practices caused an unsanitary environment and had a potential for residents to be placed at risk for injury. Findings: 1. A review of Resident 24's…

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

Based on observation, interview, and record review, the facility failed to ensure the call light device (one of the major communication technologies that link nursing home staff to the needs of residents) was within reach (an arm's length) for one (1) of 18 sampled residents (Resident 208). This had the potential to result in a delay in care for Resident 208 not to receive the necessary care and services which can lead to illness or serious injury. Findings: A review of Resident 208's admission record indicated the facility admitted Resident 208 on 1/3/24 with diagnosis which include history of falling, anxiety (persistent and excessive worry that interferes with daily activities) and aphasia (language disorder that affects a person's ability to communicate). During a review of Resident 208's care plan date initiated 1/03/24 indicated Focus: Actual incident of fall related to poor safety awareness and increase agitation. Goal: will be free from falls. Intervention: Call light within reach. A review of Resident 208's Minimum Data Set (MDS, standardized care and screening tool), 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 interview and record review, the facility failed to develop and implement a comprehensive resident centered care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) to address resident's central venous catheter (a type of access used for hemodialysis [a procedure removing metabolic waste products or toxic substances from the bloodstream]) for one (1) of 18 sampled resident (Resident 160). This deficient practice had the potential to not be able to provide the specific interventions such as monitoring Resident 160's access site for bleeding and infection, which could result in harm. Findings: A review of Resident 160's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 160's diagnoses included end stage renal disease (kidneys suddenly become unable to filter waste products from your blood that can develop rapidly over a few hours or a…

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

Based on observation, interview, and record review, facility failed to meet professional standards to ensure a neurological assessment ( a group of questions and tests to check for disorders of the nervous system [sends messages back and forth between the brain and the body]) was completed for two (2) of 18 sampled residents (Resident 38 and Resident 52) who had a fall, in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to result in a delay of care and services, which could negatively affect Residents 38 and 52's overall wellbeing. Findings: A review of Resident 38's admission Record indicated the facility admitted Resident 38 on 12/1/24. Resident 38's diagnoses included were history of falling, anxiety (persistent and excessive worry that interferes with daily activities), and muscle weakness. A review of Resident 38's Minimum Data Set (MDS, standardized care and screening tool), dated 12/11/23, indicated Resident 38 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. 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, and record review, the facility failed to ensure the safety for one of two sampled residents (Resident 38) for accident care area, by not monitoring and supervising the resident. This deficient practice resulted to Resident 38's fall (move downward, typically rapidly and freely without control, from a higher to a lower level) on 12/27/23 and 1/17/24. Findings: A review of Resident 38's admission Record indicated the facility admitted Resident 38 on 12/1/20. Resident 38's diagnoses included were history of falling, anxiety (persistent and excessive worry that interferes with daily activities) and muscle weakness. A review of Resident 38's Minimum Data Set (MDS, standardized care and screening tool), dated 12/11/23, indicated Resident 38 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 38 was dependent (helper does all the effort to complete the activity or, the assistance of 2 or more helper required for the resident to complete the activity) on oral hygiene,…

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 remove an intravenous (IV, within the vein) catheter saline lock (a thin plastic tube that is threaded into a vein, flushed with saline, and then capped off for later use) that was inserted for more than 96 hours for one (1) of 18 sampled residents (Resident 258), as indicated on the facility policy. This failure had the potential to put Resident 258 at risk for developing an infection. Findings: During a review of Resident 258's admission Record, it indicated the resident was admitted to the facility on [DATE] with admitting diagnoses of fracture (broken bone) of the left humerus (bone in the arm), hypertension (high blood pressure even at rest), acute sinusitis (infection and inflammation of the sinus), and history of falling. During a review of Resident 258's History and Physical, dated 1/14/24, it indicated the resident has the capacity to understand and make decisions. During a review of Resident 258's hospital report titled, Hospital Record 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 one of one sampled resident (Resident 160) for dialysis (a process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane) care area, who was receiving hemodialysis (process of removing waste products and excess fluid from the body) treatment was provided dialysis care and services in accordance with the facility policy. This deficient practice had the potential for Resident 160 to suffer from complications such as bleeding or infection from the central venous catheter (a catheter [thin tube] that is placed under the skin in a vein, allowing long-term access to the vein. Findings: A review of Resident 160's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included end stage renal disease (kidneys suddenly become unable to filter waste products from your blood that can…

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 there was a Registered Nurse (RN) on duty for at least eight (8) consecutive hours on 10/1/23, 11/12/23 and 12/10/23 to ensure all the residents' clinical needs were met either directly by the RN or indirectly by the Licensed Vocational Nurses (LVNs) or Certified Nurse Assistants (CNAs) for whom the RN was responsible for overseeing resident care. This deficient practice had the potential for delay in care and services and have the potential for harm to residents. Findings: A review of Payroll Based Journal (PBJ, a system for facilities to submit staffing information) Staffing Report, dated 1/10/24, indicated there were RN hours triggered (requires follow-up during the survey) on 10/1/23 to 12/31/23. During a concurrent review of the Facility's Report of Hours Worked Summary for the month of October 2023 to December 2023, and interview with Administrator (ADMIN) and Business Office Assistant (BOA) on 01/19/24 at 9 AM, BOA verified that on 10/1/23, 11/12/23 and 12/10/23, the requirement to have an RN for 8 hours was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to maintain accurate medical records for one (Resident 49) of 18 residents when Resident 49's three vaccination (vaccines, medication given to provide protection from certain diseases) declination forms were not completed. This failure had the potential to put Resident 49 at risk for missing future opportunities to be vaccinated. Findings: During a review of Resident 49's admission Record indicated the resident was admitted to the facility on [DATE] with admitting diagnoses of myocardial infarction (heart attack), hypertension (abnormally high blood pressure, even at rest), and history of falling. During a concurrent interview and record review of Resident 49's medical record on 1/18/24 at 11:25 AM with Registered Nurse 1 (RN 1), RN 1 stated Resident 49 declined the Pneumococcal (inflammation of the lungs due to an infection), Respiratory Syncytial Virus (RSV, infection of the lungs and respiratory tract caused by a virus), and COVID-19 (infectious…

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.