Village Square Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure a written notice and reason for the bed change was given to a roommate (Resident 6), for one of five residents (Resident 3) who required a bed change. This deficient practice had the potential to negatively affect Resident 6's rights and preferences for a new roommate from the bed change. Findings: A review of Resident 3's admission Record indicated Resident 6 was re-admitted to the facility on [DATE] with diagnoses which included a history of diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A record review of Resident 3's minimum data set (MDS - an assessment tool) dated 12/13/24 indicated, a Brief Interview for Mental Status (BIMS - a cognitive assessment to quickly a resident's mental status and identify potential cognitive impairments with a score of 0 -15) score of 14 out of 15 (13-15 indicated intact cognitive function) indicated, Resident 3 had no cognition (pertaining 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 ensure comfortable and home-like environment for four residents (1, 2, 3, 4) when: 1) Televisions (TV) were not functioning properly. 2) Room temperature (temp) levels were warmer (higher) than required. These failures had the potential to affect the resident ' s physical and psychosocial comfort and well-being. Findings: On 9/26/24, an unannounced visit was made to the facility. During an interview with the Director of Nursing (DON) on 9/26/24 at 10:04 A.M., the DON stated that the Director of Maintenance (DM) resigned earlier in the month. On 9/26/24 at 10:54 A.M., an observation was conducted with the Janitorial Supervisor (JS), in the second (2nd) floor nursing station. In the hallway, outside of the service elevator, were three large fans that faced into resident rooms. The JS stated that the fans were placed there to help circulate cool air into resident rooms. On 9/26/24 at 11:11 A.M., an observation was conducted with the JS, in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure nursing assessments and documentation of resident status was accurately completed for one of three residents (Resident 2), during a closed record review (record of a resident that was no longer at the facility). This failure had the potential for miscommunication of care provided to the resident, and resident harm due to incomplete and inaccurate information documented for Resident 2 ' s status and response to medical care. Findings: On 3/11/24 an unannounced visit was made to the facility in response to a complaint. On 3/11/24 at 2:20 P.M., Resident 2 ' s electronic admission Record was reviewed. Resident 2 was admitted to the facility on [DATE] at 4:40 P.M., and discharged from the facility on 2/23/24 at 4:12 P.M. Health problems for Resident 2 included: pneumonia; NSTEMI (a type of heart attack); heart failure (a condition where your heart doesn ' t pump enough blood for your body ' s needs); cachexia (a state of ill health involving great…

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 allow one of two sampled residents (1) to choose their own visitors. As a result, Resident 1 was at risk of decreased social interaction. Findings: Per the facility's Resident Face Sheet, resident 1 was admitted to the facility on [DATE]. Per the facility's Physician Order Report, dated 10/13/23, there was an order for Resident 1 on 8/29/17 for, May visit with her friend .in family room or patio without contact supervision. Per the facility's Resident Progress Notes, on 8/20/23 Resident 1's physician documented, .Her friend (Visitor 1) comes by periodically and she welcomes his visits. There may be some resistance from staff or administration . but unless he is felt to pose some kind of threat (which I don't see), she has a right to have him visit and to hang out with him . On 10/13/23 at 10:15 A.M., an interview was conducted with Resident 1. Resident 1 stated, Visitor 1 was her friend, and she wanted him to continue visiting her. On 10/13/23 at 10:25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility staff interview, and policy and procedure review, the facility failed to ensure the following systems were in place: 1) expired drugs were not available at the facility for administration to any of the facility's residents either in the facility's drug storage rooms, refrigerators, or in the facility's medication carts, 2) that medications and biologicals had been administered timely to all of the facility's residents, as outlined in the facility's policy and procedures, and 3) that all administered medications had been documented immediately after they had been administered to each resident. This deficiency had the potential for residents at the facility to receive expired medications and medications which had not been administered in accordance with their physician's orders. This failure could have resulted in negative outcomes for these residents. Findings include: 1) Inspection of the facility's medication storage room on Station 2, on 7/26/22 at 1:02 P.M., revealed 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 medication pass observation, interview with facility staff, review of the resident's clinical record, and review of the facility's policies and procedures the facility failed to ensure that 1 unsampled resident (82) had not been allowed to self-administer her medication without a physician's order to do so, and without prior approval from the facility's interdisciplinary team prior to doing so. This deficiency had the potential for this resident to administer medications to herself, in an unsafe manner, without an appropriate assessment, and without her physician's approval. Findings: During medication pass observation on 7/28/22 at 8:50 A.M., the State surveyor observed unsampled resident 82 being given her daily medications by LN 1. During the medication pass observation, the LN proceeded to pass the Fluticasone Propionate Nasal Spray, (this medication is indicated for the management of the nasal symptoms of seasonal and perennial allergic and nonallergic rhinitis in adults), bottle to the resident for the resident to self-administer this medication. This medication had…

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 assure that 1 of 4 sampled residents (2) received the necessary services for limited range of motion as designated in the care plan. As a result, Resident 2 had potential to develop further limitations in mobility. Findings: Per the facility's Resident Face Sheet, Resident 2 was admitted on [DATE] to the facility with muscle weakness and lack of coordination. Resident 2's record was reviewed. Per Resident's history and physical, dated 4/7/22, the resident had foot drop. Per Resident 2's physical therapy evaluation, dated 1/2022, the resident required maximum assist with activities of daily living. Per Resident 2's care plan, initiated 10/13/17, the resident was to be observed for changes in range of motion and referred to physical therapy for range of motion services to prevent further contractures. On 7/26/22 at 10:54 A.M. an interview and observation of Resident 2 was conducted. Resident 2 stated he could not lift his feet. Resident 2…

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 wound treatments were provided to 2 of 3 sampled residents (71 and 13) per the standard of practice. 1. For Resident 13, the facility failed to follow wound care orders. 2. For Resident 71, the facility failed to communicate changes to the interdisciplinary team (IDT) or physician, document wound care and wound progression, and implement an IDT to monitor the resident's wound. These failures put Resident 71 and Resident 13 at risk for delayed wound healing and infection. Findings: 1. Resident 13 was admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial skin infection that causes redness, swelling and pain) of right lower limb, cellulitis of left lower limb, fracture of lumbar vertebra. On 7/26/22 at 10 A.M., Resident 13 was observed sitting in his wheel chair. Compression wraps were observed on Resident 13's right and left lower extremities, his right foot was swollen. During an interview on 7/26/22 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that 1 of 21 sampled residents (83) received correct treatment for the pressure ulcer (damage to skin and underlying tissue caused by constant pressure on the area) on the left foot. As a result, Resident 83 had the potential to suffer an infection of the left foot pressure ulcer and increased tissue breakdown. Findings: Per the facility's Resident Face Sheet, Resident 83 was admitted on [DATE] with a diagnosis of hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) of the left side. Resident 83's record was reviewed. Per Resident 83's physician orders for the month of June 2022, the resident received treatment for a pressure ulcer on the left foot. The resident was to have TerraCyte® (topical ointment that contains a powerful antibiotic tetracycline that kills bacteria) applied to the wound area after the wound was cleaned. On 7/28/22 at 8:41…

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 1 of 21 sampled residents (103) on intravenous (IV) antibiotic therapy had their peripherally inserted central catheter (PICC line- to provide access to a large vein for administration of medication for long-term use) monitored per professional standards and facility policy. This failure had the potential to affect Resident 103's care and delay the identification of catheter-related complications or infections. Findings: Resident 103 was admitted to the facility on [DATE] with diagnoses including viral meningitis (an infection of the brain lining) and extradural and subdural abscess (a pocket of pus that develops in different areas in the brain tissue) per the facility's Resident Face Sheet. During an interview with Resident 103 on 7/26/22 at 8:55 A.M., the resident stated he had been at the facility for two weeks. A transparent dressing covering an IV insertion site was observed on Resident 103's left upper arm. There was no date…

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 did not ensure that the actual hours worked for RNs, LVNs and CNAs were posted. This created the potential for residents and visitors to not know the actual nursing hours provided for the resident's care. Findings: On 7/26/22 at 9 A.M., and 7/27/22 at 2 P.M., staffing hours were observed posted in the main hallway on the first floor. The staffing hours were scheduled staffing hours for RNs, LVNs, and CNAs. On 7/28/22 at 3:33 P.M., an interview and record review was conducted with the staffing coordinator (SC). The SC stated that she only posted the nursing schedules not the actual number of staff working on the floor. The SC confirmed that the staff scheduled to work often changed and actual nursing hours worked were not reflected in the posted schedules. The facility did not have a policy that specified actual direct care staffing hours were to be posted daily according to the regulation.

Based on clinical record review and facility staff interview the facility failed to ensure that 1 of 21 sampled residents (65), had not been put on Trazodone for a non-FDA approved indication, which resulted in this medication becoming an unnecessary drug for Resident 65, as this medication had been prescribed without an adequate (FDA approved) indication. This deficient practice resulted in this resident receiving Trazodone for a clinical indication, which had not been FDA approved, which could have caused this resident harm. Findings: Review of resident 65's clinical record on 7/28/22 at 12:36 P.M., and concurrent interview with the facility's Interim DON revealed that this resident had been put on Trazodone (DESYREL) [a medication used to treat depression] 50mg every evening on 8/30/21, for sleep. Further review of the physician's order for Trazodone, dated 8/30/21 revealed that this medication had been prescribed to treat this resident's inability to sleep, not depressive disorder for which this medication has been FDA approved. Depression is disease which can occur 24 hours 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 medication room inspection, interview with facility staff, and review of the facility's policies and procedures the facility failed to ensure that the medication refrigerator on Station 2, had been secured and locked, as outlined in the facility's policies and procedures. This deficiency had the potential for medications to be stored in a manner, which created the possibility of controlled drug diversion. Findings: Inspection of the facility's Station 2 medication refrigerator on 7/26/22 at 12:58 P.M., revealed that the padlock on this refrigerator had been left unlocked. The refrigerator's open/unlocked status had been confirmed by the Interim DON, during a concurrent interview, in which this DON indicated that it was the facility's policy that this refrigerator remained locked at all times, because the refrigerator contained controlled substances such as Lorazepam (Ativan), (a schedule IV narcotic). Review of the facility's following policies and procedures confirmed the Interim DON's understanding that this medication refrigerator should have remained locked at all…

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

Based on observation, interview and record review, the facility failed to maintain and clean the appliances, drawers, can opener, ice scoop container, storage shelf and plate warmer in the kitchen. As a result, there was the potential for food borne illness. Findings: On 7/26/22 at 8:35 A.M., during initial tour of the kitchen, the stove was observed to have old sticky grease marks on the door, corners of the stove and sides of the oven. A strand of hair was observed embedded in old sticky grease on the door handle of the oven. Next to the stove was a stainless steel shelf where pots and pans were stored. The shelves had grease stains, dust and a strand of hair was found wrapped around one of the shelves. On 7/26/22 at 8:50 A.M., during an observation of the utensils drawer, dried food crumbs and particles were at the bottom of the drawer. A rusty, hand held can opener was also in the drawer. During an observation and interview on 7/26/22 at 8:55 A.M., with the Director of Dietary Services (DDS) and the Registered Dietician (RD), the RD stated, My expectations are the staff have…

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 fully implement infection control standards of practice when hand hygiene was not performed between glove changes during a wound treatment observation on 1 of 21 sampled residents (71). This failure had the potential for an increase in facility-acquired infection and medical complications for Resident 71. Findings: Resident 71 was admitted to the facility on [DATE] with diagnoses including diabetes (a chronic condition that affects how the body uses sugar) with diabetic neuropathy (nerve damage caused by diabetes), infection of amputation stump, left lower extremity, aftercare following surgical amputation, acquired absence of right leg below the knee, colostomy (surgical opening into the colon from the abdomen), per the facility's Resident Face Sheet. According to a physician order dated 6/28/22, Resident 71 was to have her left leg amputation stump wound cleaned with wet-to-dry dressings twice daily until the wound healed. During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care conferences (a multidisciplanary team meeting with the resident or family to evaluate care plans) were conducted timely for five of nine residents (30, 34, 64, 76 and 88) reviewed. As a result, there was a potential for changes in the resident's care needs to not be evaluated by a group of health care professionals. Findings: 1a. Resident 34 was admitted to the facility on [DATE], per the facility's Resident Face Sheet. On 2/13/19 at 10:10 A.M., an interview was conducted with the MDSN. The MDSN stated resident care conferences were conducted within 7 days of admission, quarterly and when a resident experienced experienced a change in condition. On 2/13/19 at 11:10 A.M., an interview and record review of Resident 34's care conference documentation was conducted with the SSD. The SSD stated, Resident 34 did not have a care conference conducted after 9/14/18. The SSD stated Resident 34's care conference should have been conducted in December…

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 1. Safe water temperatures in resident bathroom sinks were maintained. 2. Adaptive equipment to call staff was provided for a paraplegic resident (88). These failures had the potential to create an unsafe environment for the residents. Findings: 1. On 2/11/19 at 8:24 A.M., an observation was conducted in room [ROOM NUMBER]. The bathroom sink water was measured at 125 degrees Fahrenheit . On 2/11/19 at 8:30 A.M., an observation was conducted in room [ROOM NUMBER]. The bathroom sink water was measured at 128 degrees Fahrenheit. On 2/11/19 at 8:52 A.M., a concurrent observation and interview was conducted in room [ROOM NUMBER]. The bathroom sink water was measured at 136 degrees Fahrenheit. Resident 5 stated, Yes, its very hot. I would burn myself if I didn't know to turn on the cold water with the hot. On 2/11/19 at 9:19 A.M., a concurrent observation and interview was conducted in room [ROOM NUMBER] with Resident 9. The bathroom…

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 did not ensure safe and sanitary conditions were followed regarding food safety and storage, when: 1. The ice machine bin was dirty, and 2. Three air gaps were improperly installed These failures had the potential to cause widespread foodborne illness for the 112 facility residents who consumed food from the Food and Nutrition Services Department. Findings: 1. On 2/11/19 at 8:39 A.M., during the initial kitchen tour, an observation and interview was conducted with the DDS. Three air gaps were not at the correct distance from the drainage sinks and one was propped up by a block of wood. The DDS stated she did not know about air gaps and maintenance was responsible for them. On 2/12/19 at 8:28 A.M., an observation and interview was conducted with the RMD and DDS about the kitchen air gaps. The air gap underneath the coffee machine had a small white pipe that drained directly into the drainage sink and was not at the correct height. The air gap underneath the steamer equipment was propped up by a block of wood and not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and maintain a QAPI plan for when the facility's water distribution system was not maintained in proper working order. Findings: 1. On 2/11/19 at 8:24 A.M., an observation was conducted in room [ROOM NUMBER]. The bathroom sink water was measured at 125 degrees Fahrenheit . On 2/11/19 at 8:30 A.M., an observation was conducted in room [ROOM NUMBER]. The bathroom sink water was measured at 128 degrees Fahrenheit. On 2/11/19 at 8:52 A.M., a concurrent observation and interview was conducted in room [ROOM NUMBER]. The bathroom sink water was measured at 136 degrees Fahrenheit. Resident 5 stated, Yes, its very hot. I would burn myself if I didn't know to turn on the cold water with the hot. On 2/11/19 at 9:19 A.M., a concurrent observation and interview was conducted in room [ROOM NUMBER] with Resident 9. The bathroom sink water was measured at 136 degrees Fahrenheit. Resident 9 stated, The sink water is very hot. On 2/11/19 at 9:56…

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 two of two residents reviewed for dignity, were assisted with feeding in a respectful manner (47, 75). As a result, these failures had the potential to negatively impact Resident 47 and 75's self-esteem. Findings: 1. Resident 47 was admitted to the facility on [DATE], with diagnoses which included altered mental status (general changes in brain function) and muscle weakness, per the facility's Resident Face Sheet. On 2/12/19 at 8:38 A.M., an observation of Resident 47 was conducted. Resident 47 was sitting up in bed while CNA 31 stood beside Resident 47's bed. CNA 31 assisted Resident 47 with his meal while looking down on Resident 47. On 2/12/19 at 8:40 A.M., an interview was conducted with CNA 31. CNA 31 stated she should have sat next to Resident 47 when providing assistance with meals. CNA 31 stated standing and looking down on residents when they ate did not demonstrate respect. On 2/12/19 at 8:55 A.M., an interview with LN 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 record review, the facility failed to verify informed consent was obtained for three of three residents (70, 90, 297) reviewed for the right to be informed when: 1. Resident 70 and 90 did not have verification of consent for the administration of psychotropic medications; and, 2. Resident 297 was not informed prior to the application of a WanderGuard (Trademark) (an alert system device, designed to notify staff when persons at risk attempt to leave a facility). These failures did not provide Resident 70, 90 and 297, the right to be fully informed regarding care and treatment, in order to make health care decisions. Findings: 1a. Resident 70 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (abnormal brain function), per the facility's Resident Face Sheet. On 2/12/19, a review of Resident 70's medical record was conducted. Resident 70's physician's order, dated 1/9/19, indicated .escitalopram oxalate (a medication to treat major…

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 give one of three sampled residents (900) the Advanced Beneficiary Notice (ABN/CMS 10055) (a form which gave the choice to continue services under private pay if Medicare did not provide payment), including the appeal contact information, and the Notice of Medicare Non-Coverage Notice (NOMNC Form CMS 10123). As a result, Resident 900 did not have the choice to appeal the decision, or have knowledge of the costs to continue treatment in the facility. Findings: On 2/12/2019, a review of the Beneficiary notices for non-coverage was conducted. On 2/12/19, Resident 900's medical record was reviewed. Resident 900 received Medicare Part A services from 11/1/18 to 11/15/18. Resident 900 remained in the facility after termination of services until 11/16/18. On 2/13/19 at 7:17 A.M., a joint interview and record review was conducted with the SSD. The SSD stated the facility's procedure was to provide the ABN notification three days prior to Resident 900 discharge date and the NOMNC two days prior to Resident 900 discharge date . 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 interview and record review, the facility failed to provide a bed hold notice to a resident transferred to a hospital for one of three closed records (94) reviewed. This failure had the potential for Resident 94 to not be aware of his right to return to the facility. Findings: On 2/14/19, a record review of Resident 94's closed medical record was conducted. A LN documented in the nursing notes Resident 94 was discharged from the facility to a hospital, on 2/5/19. The facility's Confirmation of Transfer and Bed Hold Provision was not signed by Resident 94 or his RP when transferred to the hospital. On 2/14/19 at 9:55 A.M., an interview and record review of Resident 94's medical record was conducted with the MRD. The MRD stated The Confirmation of Transfer and Bed Hold Provision section of the Bedhold Informed Consent document, had not been signed by Resident 94 or his RP when transferred. The MRD stated the Bedhold Informed Consent should have been signed. The MRD stated the importance of the Resident or RP signing the document was to ensure they were aware the bed would 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 interview and record review, the facility failed to ensure a baseline care plan was initiated for three of six residents, reviewed for admission care plans. (76, 88, 30). This failure had the potential for Residents 76, 88 and 30 to not receive appropriate care. Findings: 1. Resident 76 was admitted to the facility on [DATE] with diagnoses which included encephalopathy (a disease that affects the function or structure of your brain) per the facility's Resident Face Sheet. On 2/13/19 at 1 P.M., a joint interview and record review was conducted with the MDSN. The MDSN stated no baseline care plan could be found in Resident 76's medical record. The MDSN stated it was important to initiate a care plan, so interventions could be shared with the care team. 2. Resident 88 was admitted to the facility on [DATE], with diagnoses which included quadriplegia (paralysis of all four limbs) and multiple sclerosis (a chronic disease that attacks the central nervous system) per the facility's Resident Face Sheet. 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 develop care plans for two of five residents (297, 34) reviewed for care plan development. As a result, there was a potential for residents to not receive the care required or ordered by their physicians. Findings: 1. Resident 297 was admitted to the facility on [DATE] with the diagnoses of edema (an excessive amount of fluid in cells or tissues), per the facility's Resident Face Sheet. On 2/11/19 at 8:01 A.M., an observation of Resident 297 was conducted. Resident 297 was sitting in his bedside chair. Resident 297's lower legs and feet were swollen. On 2/11/19, a record review of Resident 297's Physician Order Report was conducted. An order was noted for furosemide (a medication used to reduce extra fluid in the body) tablet; 20 mg; oral Special Instructions; edema (swelling caused by excess fluid) Once A Day; . There was also an order noted to elevate all extremities. Resident 297's care plans were reviewed and a care plan for edema…

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 transcribe admission wound treatment orders, therefore wound treatments were not performed for one of 1 residents (297) reviewed for nursing care issues. As a result, Resident 297 did not receive the care and treatment required to meet his physical needs. Resident 297 was admitted to the facility on [DATE], with the diagnoses of osteomyelitis of right foot (a serious infection of the bone) with right third toe amputation (removal), per the physician's History and Physical. On 2/11/19 at 8:01 AM, an observation and interview with Resident 297 was conducted. Resident 297 was sitting in a bedside chair. There was a tan colored wound dressing covering Resident 297's right toes. Resident 297 stated he had been admitted to the facility on [DATE], he had his third right toe amputated at the hospital due to an infection. Resident 297 stated the dressing on his toes had been placed in the hospital. Resident 297 stated no one had changed his…

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 oxygen was administered and monitored per the physician's order for 3 of three residents (75, 82, 63) reviewed for oxygen administration. These failures had the potential to affect the residents health and well-being. Findings: 1a. Resident 75 was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (a weakening of the heart that leads to fluid buildup in the lungs), per the facility's Resident Face Sheet. On 2/11/19 at 9:16 A.M., Resident 75 was observed in his room. Resident 75 was sitting up in bed, watching television. Resident 75 had a nasal cannula (clear tubing used to deliver oxygen) resting in his nostrils. An oxygen condenser (a machine used to deliver oxygen) was on the floor to the right of Resident 75's bed. The machine flow dial indicated Resident 75 had continuously received 3 litres of oxygen per minute, via the nasal cannula. On 2/11/19 a review of Resident 75's medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of one resident (62) reviewed for dialysis (the process of removing toxins and excess fluid from the blood through a machine), care did not meet professional standards. As a result, the resident was at risk of developing undetected complications related to dialysis treatment. Resident 62 was admitted to the facility on [DATE], with diagnoses that included end stage renal disease (chronic irreversible kidney failure) and dependence on renal dialysis (a treatment to remove waste material from the kidneys) per the facility's Resident Face Sheet. Per Resident 62's physician order dated 2/12/19, After return from dialysis on M- (Monday) - W (Wednesday)-F (Friday) monitor AV shunt for bruit (auscultation of shunt for swooshing sound), thrill (lightly palpate for vibration of shunt), infection and pain . Resident 62's Dialysis Communication records were reviewed. No bruit and thrill assessment entries were documented on 1/16/19,…

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, two of four facility medication carts reviewed were found to have medications not stored in accordance with standard professional practices, when: 1. An opened insulin vial was not dated, and; 2. A pain cream was not labeled with the resident's name. This failure caused the potential for insulin to be expired, and the potential for pain cream to be administered to the wrong resident. Findings: On [DATE] at 10:48 A.M., a concurrent observation and interview of a third floor medication cart attended by LN 1. The cart was observed to contain Inmotion Pain Creme, a topical (to be rubbed onto the skin) pain reliever. LN 1 stated the creme was not generic, but was prescribed for Resident 67. The pain creme was observed to not have any resident's name marked on it. LN 1 confirmed it should have been marked with Resident 67's name and acknowledged the pain medication could have been inadvertently used on a different resident. On [DATE] at 11:27 A.M., a concurrent…

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

Based on food and nutrition services observations, staff interviews, and record reviews, the facility failed to ensure food and nutrition services department staff appropriately carried out tasks in a safe and sanitary manner. This repeated failure to ensure effective safe and sanitary practices may place residents at nutritional risk, and in turn, further compromise the health status of 112 residents. Findings: On 2/11/19 at 10:49 A.M., an observation and interview was conducted with CK 1. CK 1 was preparing salads and tuna sandwiches. While preparing the sandwiches, CK 1 picked up a paper off the floor then proceeded to cut iceberg lettuce and slice tomatoes for the salad. CK 1 then touched the garbage can lid with same hand that was contaminated from touching the floor. CK 1 proceeded to slice the tomatoes for the salad. CK 1 then stated he did not know he should have washed his hands before beginning the cutting process. CK 1 walked over to the hand wash sink, rinsed his hands without soap for 2-4 seconds, dried his hands with a paper towel, then put gloves on and continued…

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 follow its policy related to food for residents brought in from outside the facility and did not ensure safe and sanitary practices. This repeated failure had the potential to result in widespread foodborne illness for 112 residents in the facility. Findings: On 2/11/19 at 3:17 P.M., an observation and interview was conducted with LN 41. LN 41 stated resident food was labeled with room numbers, dated, and kept for 72 hours. Reheated resident food was prepared in the staff lounge on 1st floor. LN 41 stated she did not know what the proper food reheating temperature was and had not received training. On 2/11/19 at 3:25 P.M., an observation and interview was conducted with LN 42. LN 42 stated resident food is labeled with name and date. LN 42 further stated resident food was reheated in the microwave, inside the employee lounge for 1-2 minutes, or depending on how the residents say they want their food reheated. LN 42 stated housekeeping checked the refrigerators for expired food items during their weekly…

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 an infection prevention and control program when: 1. During a dining observation in the main dining room, the AD was observed assisting residents without performing hand hygiene (cleaning of the hands) in between each resident contact. 2. During a dining observation in the main dining room, the AD was observed moving between four of 11 resident's, providing assistance without performing personal hand hygiene. 3. Resident 30's urinary catheter drainage bag was lying on the floor one of 2 residents reviewed for catheter care. As a result, there was a potential for cross contamination and the spread of infection. Findings: 1. On 2/11/19 at 12:15 P.M., The AD was observed before meal service. The AD assisted residents with hand hygiene, using an individual warm cloth for each of eleven residents, without performing personal hand hygiene in between each resident contact. On 2/11/19 at 12:45 P.M., an interview was conducted with the AD.…

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.