Amaya Springs Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written notice of discharge to one of three sampled discharged residents (8). As a result, Resident 8 was not fully informed regarding his discharge. Findings: Per the facility's admission Record, Resident 8 was admitted to the facility on [DATE] with diagnoses to include osteomyelitis (bone infection). On 9/12/24 a review was conducted of Resident 8's medical record. Per the facility's Progress Note, dated 9/4/24 at 12:42 P.M., Resident 8 was transferred to an acute care hospital for a change in condition and was awake at the time of transfer. There was no documentation on 9/4/24 that Resident 8 was provided with a Notice of Proposed Transfer and Discharge form prior to his transfer. On 9/12/24 at 3:26 P.M., an interview was conducted with Licensed Nurse (LN) 6. LN 6 stated, Resident 8 went to the hospital due to a change in his condition and was awake at the time of discharge. LN 6 further stated, he did not provide any paperwork 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 interview and record review, the facility failed to provide a written notice of the facility's bed hold policy at the time of discharge to one of three sampled discharged residents (8). As a result, Resident 8 was not fully informed of his bed hold rights. Findings: Per the facility's admission Record, Resident 8 was admitted to the facility on [DATE] with diagnoses to include osteomyelitis (bone infection). On 9/12/24 a review was conducted of Resident 8's medical record. Per the facility's Progress Note, dated 9/4/24 at 12:42 P.M., Resident 8 was transferred to an acute care hospital for a change in condition and was awake at the time of transfer. There was no documentation on 9/4/24 or 9/5/24 that Resident 8 was provided with a written notice of the facility's bed hold policy. Per the facility's Bed Hold Agreement, signed by Resident 8 on 1/17/24 (at the time of admission), the portion of the form titled, Notification of Bed Hold Option Upon Transfer/Therapeutic Leave was not completed. The form 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 notify the physician of a resident's low blood sugar readings, and did not monitor fluid intake and output for two of 12 sampled residents (1, 29). As a result, Resident 1 did not receive treatment for low blood sugar, and the facility could not determine if Resident 29 had proper fluid intake and adequate output, which may have lead to the late detection of fluid abnormalities in the body. Findings: 1. Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include diabetes (disease of abnormal blood sugar). A record review was conducted. Per the facility's Orders, there was an order on 11/29/23 to check Resident 1's blood sugar before giving insulin (a medication to lower blood sugar), and to notify the physician if it was less than 70 milligrams (mg)/deciliter (dl). Per the facility's Weights and Vitals Summary, on 8/9/24 at 4:46 P.M., Resident 1's blood sugar reading was 13 mg/dl, and on 8/17/24 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.

Based on observation, interview, and record review, the facility failed to ensure that opened dressings in the refrigerator were labeled with an open date and that the freezer's foods were stored per the facility's policy and procedure. These failures placed residents at risk of acquiring foodborne illness and may have caused the texture of the food in the freezer to become less palatable. Findings: On 9/10/24 at 7:42 A.M., an initial tour of the kitchen was conducted with the Dietary Manager (DM). It was observed in the reach-in refrigerator that two large jars of dressings were opened, and there was no date. In addition, inside the reach-in freezer, there was a large sealable bag full of air, containing chicken thighs that had icicles built up on the meat. There was also an opened clear bag of diced chicken which was manually tied to close the item. On 9/10/24 at 8:07 A.M., an interview was conducted with the DM. The DM stated that opened items should be labeled and dated. Items in the freezer should have been stored appropriately. Per the facility's policy and procedure, 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 ensure infection control practices were followed when: (1) The nebulizer (a small machine that turns liquid medicine into a mist that gets inhaled into the lungs), mask, and cup (contains liquid medicine for the nebulizer) were not cleaned and bagged after each use, per the facility's policy, and (2) The water waste management program was not implemented. These deficient practices placed residents at risk for infections. Findings: 1. Resident 29 was re-admitted to the facility on [DATE] with diagnoses which included Respiratory Failure (breathing problem), per the admission Record. On 9/11/24 at 10:09 A.M., Resident 29's nebulizer machine was observed on top of the dresser with a long clear tubing attached to the machine. The clear tubing was hung on the privacy curtain and down tuck inside the drawer. Inside the drawer were opaque-colored nebulizer cup and masks attached to the tubing. On 9/11/24 at 10:12 A.M., Resident 29 stated 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 ensure the Infection Control Preventionist (ICP) completed the specialized infection and prevention training. This failure could result in the ICP not being knowledgeable or qualified to perform the duties to prevent the spread of infection. Findings: On 9/13/24 at 9:37 A.M., an interview and record review was conducted with the Infection Preventionist Nurse (IPN). The IPN stated she was helping with the infection control prevention program, and the designated IPN quit, leaving her to do the job. IPN further stated she did not have the chance to do the required specialized training. On 9/13/24 at 11:38 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the designated ICP should have had the required training. Per the facility's policy and procedure, dated 2/19/21, titled Infection Preventionist, .[The Infection Preventionist] Have education, training, expertise or certification in specialized infection control and prevention practices .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to fully prepare three of four sampled residents, (1, 2, 4) for discharge in accordance with the facility discharge policy. Findings: A review of the facility policy entitled Discharge and Transfer of Residents revised February 2018 indicated, .When a resident is admitted to the Facility, Facility Staff will initiate a discharge plan. The resident/ resident representative will be provided with a Notice of Proposed Transfer and Discharge 30 days prior to discharge or as soon as practicable. When the resident is near a planned discharge, the Interdisciplinary Team (IDT) will complete a Discharge Summary/ Post Discharge Plan of Care. Nursing Staff will complete a Discharge Summary/ Post Discharge Plan of Care for each resident, which will include a recapitulation of the resident ' s stay and final summary of the resident ' s status . 1. Resident 1 was admitted to the facility on [DATE] with diagnoses that included bilateral lower extremity lymphedema (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 supervised and assisted ambulation to one of one sampled Residents, (1), at high risk for falls. This failure resulted in Resident 1 experiencing an unwitnessed fall that resulted in a broken bone in her left ankle. Findings: Resident 1 ' s admission Record indicated admission to the facility on 5/5/22, and included diagnoses of paranoid schizophrenia (a pattern of thoughts, feelings and behaviors that include suspicion of others), generalized muscle weakness, essential hypertension (high blood pressure often requiring medication that can have side effects increasing risk for falls) and cognitive communication deficit (difficulty with thinking and communication). A review of the Minimum Data Set (MDS) section GG dated 11/11/23 indicated Resident 1 required supervision or touching assistance (assistance from one person) for toileting hygiene, lower body dressing, chair and bed to chair transfer, walking 10 feet or more. The MDS…

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 provide resident safety for 1 resident (Resident 1) when Resident 1 eloped (leaving the facility unsafely or unescorted) from the facility ' s exit door which was equipped with an audible alarm. As a result, Resident 1 had a successful elopement and there was the potential risk for the elopement of other residents. Findings: On 11/22/23 the Department of Public Health received a facility report of an elopement for Resident 1 on 11/22/23 at 4:30 A.M. During a review of Resident 1 ' s facility record on 11/22/23 at 7:05 A.M., the record indicated .around 4;30[sic] am resident up on wheelchair and verbally responsive, no c/o[sic] and any discomfort.at[sic] 5Am[sic] went to resident room and unable to find resident on her room checked the whole building. But resident nowhere to found and call 911 and informed resident is missing and gave description of resident . During a review of Resident 1 ' s facility record on 11/23/23 at 7:41 A.M., the record indicated, .Spoke to Sheriff .Deputy will give the facility a call…

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 follow their abuse policy when Resident 1 claimed an allegation of sexual abuse. This failure had the potential for Resident 1 to not receive the appropriate follow up care. Findings: Resident 1 was admitted to the facility on [DATE], per the undated admission Record. A record review was conducted on 7/27/23. Per a Minimum Data Set (an assessment tool) Basic interview for Mental Status (BIMS) score, dated 7/1/23, Resident 1 had mildly impaired cognition. Per an Alert Note, dated 7/26/23 at 11:42 A.M., Licensed Nurse (LN) 1 documented Resident 1 had reported being sexually assaulted the previous night. LN 1 documented she conducted an assessment and found no evidence of bruising, abrasions, or discoloration on Resident 1's skin. Per a Progress Note, dated 7/26/23 at 11:50 A.M., the Administrator (Admin) documented she had received a report that Resident 1 had been sexually assaulted by another resident. The Admin and LN 1 documented an interview with…

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

Based on interview and record review, the facility failed to properly prevent COVID-19 (a respiratory infection) when three sampled residents (10, 13, 24) and six unsampled residents (161, 17, 31, 37, 42, 49) were not offered vaccines when they were due. Findings: On 2/16/22 at 2:40 P.M., an interview with resident 13's Responsible Party (RP 13) was conducted. RP 13 stated, My mom was in the Covid unit last week. She just moved to a regular room this week. RP 13 further stated, I was wondering why they didn't offer her the COVID-19 booster vaccine. On 2/17/22 at 9 A.M., a document titled, Respiratory Illness Case Log for Residents and Staff dated, 2/4/2022 was reviewed with the Infection Control Preventionist (ICP). The ICP stated, The resident's Covid tests and vaccinations have been recorded on the line list. Review of the list indicated: Resident 161 received 1st Covid vaccine on 2/3/21 the 2nd on 2/24/21, and the booster dose on 2/1/22. Resident 161's Covid-19 PCR test result was Positive on 2/1/22. Resident 10 received 1st Covid vaccine on 1/7/21, the 2nd on 2/4/21, and 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 did not deliver mail to four of four Confidential Residents (CR 1, CR2, CR3, CR4) on Saturdays. This deficient practice did not ensure the resident's right to receive and send mail was met. Findings: On 02/16/22 at 10 A.M., the resident council meeting took place in the conference room. CR 2 stated, We haven't been getting mail on Saturdays for several months now. I would like to get my mail on Saturdays. CR 3 stated, I have never received mail on Saturdays. I would like to get mail on Saturday or Sunday. CR 1 stated, No, I've never gotten my mail on Saturday or Sunday. CR 4 stated, I would like to get mail on Saturday or Sunday. CR 1, 2, 3 and 4 all stated they did not get mail delivered to them on Saturdays. On 02/16/22 at 4:51 P.M., an interview was conducted with the MRD (Medical Records Director) and ICP (Infection Control Preventionist). The MRD stated, The Activities department was responsible for passing out mail. The ICP stated, If mail came in on Saturday, it should have been delivered to the residents 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 give a complete and accurate Notice of Medicare Non-Coverage (NOMNOC) for one of three sampled residents (100) reviewed for beneficiary notification. As a result, Resident 100 did not receive adequate information to make an appeal. Findings: Resident 100 was admitted to the facility on [DATE] with diagnoses which included asthma (breathing problem) and hypertension (high blood pressure), and congestive heart failure (congestion in the heart) per the facility's admission Record and physician's history and physical. On 2/17/22, a record review was conducted of Resident 100. Resident 100 was discharged to an independent living facility on 9/4/21. The facility's form titled Notice of Medicare Provider Non-Coverage form contained blank lines under the sections, Date, Time, Spoke to, at:, Relationship to Patient, Signature, and Title. In addition, the facility's typewritten telephone number on the form was missing a digit making it impossible…

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 safeguard and accurately identify a resident's medical record for one of 12 sampled residents (156). This failure had the potential for residents' private medical information to be visible to unauthorized persons. Findings: Resident 156 was admitted to the facility on [DATE] with diagnoses which included Covid-19 (an infectious virus (corona virus) affecting respiratory system) per the physician's history and physical note. On 2/16/22 at 7:58 A.M., an observation was conducted of the facility's hallway. Next to a zippered plastic divider was an isolation cart. On top of the cart were two facility documents titled Activities of Daily Living (ADL) and one titled Bowel and Bladder Tracking form. The forms indicated a resident's name and room number, and their abilities to function with daily activities and bowel and bladder regimen. There was no staff present near the cart were documents were located. Resident 156 medical information 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 observation, interview and record review, the facility failed to develop and implement a baseline care plan for three of 12 residents (160, 102, 153). This deficient practice did not ensure provision of effective and person-centered care for these residents. Findings: A. Per the admission Record, Resident 0 was admitted to the facility on [DATE] with diagnoses which included Urinary Tract Infection (an infection in any part of your urinary system ) and Schizoaffective Disorder, Bipolar type (a mental illness that can affect your thoughts, mood and behavior). On 2/16/22 at 9:30 A.M., Resident 160 was observed walking out of her room using a walker. As Resident 160 walked down the hall, Resident 160's pants were observed to have brown stains and brown substance on her ankle and in her shoe. Certified Nurse Assistant (CNA) 1 stated, She had a bowel movement, she has a brief on. On 2/18/22 at 10:45 AM, a joint interview and record review for Resident 160's clinical record was conducted with Licensed Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for three of 12 sampled residents (160, 102, 153). Failure to develop a comprehensive care plan had the potential for residents to not receive accurate medical needs and appropriate treatment goals. Findings: A. Per the admission Record, Resident 160 was admitted on [DATE] with diagnoses which included, Urinary Tract Infection (problem with urination) and Schizoaffective Disorder (mental problem), Bipolar type. On 2/16/22 at 9:30 A.M., Resident 160 was observed walking out of her room using a walker. As Resident 160 walked down the hall, Resident 160's pants were observed to have brown stains and brown substance on her ankle and in her shoe. Certified Nurse Assistant (CNA) 1 stated, She had a bowel movement, she has a brief on. On 2/18/22 at 10:45 A.M., a joint interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated, When a new admission comes in, the Resident admission Assessment…

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 an accurate and complete physician discharge summary on three of three sampled residents reviewed for closed records (52, 53, 54). Failure to keep a physician discharge summary had the potential for residents to not receive a safe transition between care settings. Findings: Resident's 52, 53, and 54's clinical record was reviewed on [DATE]. Resident 52 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive respiratory disease (a lung disease) per the facility's admission Record. Resident 52 expired at the facility on [DATE]. Resident 53 was admitted to the facility on [DATE] with diagnoses which included kidney (body organ that produces urine) failure per the facility's admission Record. Resident 53 was discharged from the facility on [DATE]. Resident 54 was admitted to the facility on [DATE] with diagnoses which included diabetes (abnormal blood sugar in the body) per the facility's admission Record. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to safeguard a gated fence that led to the parking lot. As a result, Resident 152 eloped from the facility. Findings: Resident 152 was admitted to the facility on [DATE] with diagnoses which included dementia (memory loss) per the facility's admission Record. An observation was conducted of the facility's smoking patio on 2/16/22. The patio had a gate and had an opened padlock. The gate was partially open which led to a small trail going to the facility's back parking lot. The gated fence had a laminated sign which indicated, This door must remain locked at all times. On 2/16/22 at 10:02 A.M., a joint interview was conducted with the MA (Maintenance Assistant) and HSK (Housekeeper). The MA and the HSK both stated the gate should always be locked so residents could not leave without being noticed. The MA acknowledged the gate's padlock was unlocked and did not know how long it had been open. On 2/16/22 at 10:06 A.M., an interview 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 observation, interview, and record review, the facility failed to ensure an oxygen nasal cannula (device used to deliver oxygen to a person) was changed on one of one sampled resident (154) reviewed for oxygen use. Failure to change an oxygen cannula had the potential for residents to be placed at risk for infection. Findings: Resident 154 was admitted to the facility on [DATE] with diagnoses which included oxygen dependent user and COPD (Chronic Obstructive Pulmonary Disease - lung problem) per the facility's admission Record and physician's history and physical. During the tour of the facility on 2/15/22, Resident 154 was observed laying on her bed wearing an oxygen nasal cannula. The nasal cannula did not have a date when it was placed. Resident 154 was interviewed on 2/15/22 at 9:04 A.M. Resident 154 stated she could not remember when was the last time the nasal cannula was changed. Resident 154 stated they changed the nasal cannula, every month. On 2/15/22 at 9:15 A.M., a concurrent interviews 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.

Based on observation, interview, and record review, the facility failed to have a system for receiving, reviewing and recording irregularities identified by the pharmacist during the MRR Medication Regimen Review). This deficient practice did not ensure the irregularities identified by the pharmacist was acted upon. Findings: On 2/18/22 at 10:30 A.M., a concurrent review of the MRR and interview with the Director of Nursing (DON) was conducted. The MRR binder contained the Pharmacist's report for December 2021. The binder did not have the MRR for January 2022. The DON stated, I just started reviewing the MRR from December 2021 and I haven't gotten to the January 2022 MRR yet. On 2/18/22 at 10:45 A.M., the December 2021 MRR was reviewed. The MRR indicated, Executive Summary of Consultant Pharmacist's medication Regimen Review .Data compiled on: 12/13/2021 for outcomes entered between 12/10/2021 and 12/13/2021 . These visits, 40 recommendations were forwarded to the following disciplines . 32 written to Nursing. On 2/18/22 at 10:51 A.M., an interview was conducted with the Pharmacy…

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. A medication cart was locked and, 2. A medication with an unknown expiration date was disposed of. Failure to lock a medication cart had the potential for drug diversion, and failure to dispose a medication with an unknown expiration date had the potential for all residents to receive an ineffective and expired medication. Findings: 1. A tour of the facility's red zone (Covid-19 zone- an area where people with infectious respiratory disease are placed) unit was conducted on [DATE]. Upon entrance to the red zone, there was a medication cart that was unlocked and unattended. On the first drawer of the medication cart were medication bubble packs with resident names. On [DATE] at 4:02 P.M., an interview was conducted with Licensed Nurse (LN) 15. LN 15 stated she should have locked the medication cart for safety reasons because they had ambulatory residents. 2. On [DATE] at 4:22 P.M., a joint observation of the treatment cart 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.

Based on observation, interview and record review, the facility did not maintain proper infection control practices based on current standards when a staff opened and walked through a barrier that separated a Covid-19 red zone (an area where people with infectious respiratory disease are placed) and a green zone (an area where there was no infection). This failure had the potential to spread infection throughout the facility affecting residents' quality of life and care. Findings: During the initial tour of the facility on 2/15/22, a staff was observed unzipping a taped plastic barrier from the Covid-19 red zone area. The staff proceeded to walk in the hallway of the green zone area carrying a ladder and a clear bag with an unknown material inside. On 2/15/22 at 3:35 P.M., an interview was conducted with Certified Nurse Assistant (CNA) 17. CNA 17 stated staff who came from the red zone should not unzip the barrier to go out in the green zone because they came from an infectious unit. On 2/15/22 at 3:39 P.M., an interview was conducted with the facility's Regional Consultants (RC1,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the corridor had firmly secured handrails on each side. This deficient practice had the potential for harm to all residents. Findings: On 2/15/22 at 9:30 A.M., a loose hand rail next to the physical therapist's room was observed. On 2/16/22 at 11 A.M., Resident was observed in the hall near the kitchen. Resident 18 was observed using the handrail to propel along the hall while in his wheelchair. On 2/17/22 at 8:15 A.M., the Physical Therapy Assistant (PTA) was interviewed. The PTA stated, the hand rails are sometimes used by the residents to assist in standing. On 2/17/22 at 11:15 A.M., an interview was conducted with the Maintenance Assistant (MA). The MA acknowledged the loose rails They need to be fixed. On 2/17/22 8:25 A.M., an observation and interview was conducted with the Director of Nursing (DON) and Administrator (ADM). The observations were discussed with the ADM and DON: The hand rail near room [ROOM NUMBER] 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.