Lowry Hills Care And Rehabilitation

Based on observations and interviews, the facility failed to maintain an environment for residents, staff and the public that is safe, functional, sanitary and comfortable for one of two shower rooms at the facility. Specifically, the facility failed to ensure the shower room was sanitary and safe for residents to use. Finding include: I. Facility policy and procedure The Housekeeping Services policy and procedure, revised on 4/12/24, was provided by the director of nursing (DON) on 5/7/24 at 3:17 p.m. It read in pertinent part, It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. II. Observations On 5/7/24 at 2:30 p.m. the shower room between unit 100 and 200 was observed. The following was observed: The shower room had two wooden fabric woven chairs used for residents besides the shower. Both chairs were damp to touch and had visible brown stains on them. The shower curtain divider that hung between both…

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 record review and interviews, the facility failed to ensure five (#1, #4, #5, #6 and #7) of five certified nurse aides (CNA) received the required 12 hours of annual in-service training for continued competence. Specifically, the facility failed to ensure CNA #1, #4, #5, #6 and #7 received 12 hours of training annually. Findings include: I. Facility policy and procedure The Nurse Aide Training Program policy, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/6/24 at 3:13 p.m. It read in pertinent part, The facility maintains an appropriate and effective nurse aide in-service training program for the purpose of ensuring the continuing competence of nurse aides. The staff development coordinator (SDC), with oversight from the director of nursing (DON), shall be responsible for the coordination and/or provision of nurse aide education. Each nurse aide shall be provided at least 12 hours of in-service training annually, based on his/her employment date, not calendar year. II. Training review A review of all five CNAs annual training was reviewed 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 record review and interviews, the facility failed to ensure a Level II preadmission and resident review (PASRR) was completed for one (#33) of three residents out of 34 sample residents reviewed for PASRR to gain and maintain their highest practical medical, emotional, and psychosocial well-being. Specifically, the facility failed to ensure a Level II PASRR was in place for Resident #33. Findings include: I. Facility policy and procedure The Behavioral Health policy, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/6/24 at 3:13 p.m. It read in pertinent part, It is the policy of the facility to ensure all residents receive necessary behavioral health services to assist them in reaching their highest level of mental and psychosocial functioning. II. Resident status Resident #33, age younger than 65, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included mild neurocognitive disorder due to unknown physiological condition with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (#69 and #35) of three residents reviewed out of 34 sample residents. Specifically, the facility failed to ensure Resident #69 and Resident #35, who were dependent on staff for bathing, received their scheduled showers. Findings include: I. Facility policy and procedure The Resident Shower policy, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/9/24 at 10:48 a.m. It read in pertinent part, It is the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues. The Activity of Daily Living policy, revised 4/12/24, was provided by the NHA on 5/6/24 at 3:13 p.m. It read in pertinent part, The facility will, based on the resident's comprehensive assessment and consistent with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (#60 and #58) of six residents out of 34 sample residents reviewed for nutrition status. Specifically, the facility failed to obtain weekly weights per the physician's orders for Resident #60 and Resident #58. Findings include: I. Facility policy and procedure The Weight Monitoring policy, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/7/24 at 4:00 p.m. The policy read in pertinent part, Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended weight loss over a period of time) may indicate a nutritional problem. A weight monitoring schedule will be developed upon admission for all residents: Weights should be recorded at the time obtained. Newly admitted residents and residents with weight loss will have weight…

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 observations, record review and interviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (#46) of five residents reviewed for unnecessary medications out of 34 sampled residents. Specifically the facility failed to ensure: -Acetaminophen (pain medication) administered to Resident #46 did not exceed the recommended 3 grams (gm) in a 24-hour period; and, -As needed (PRN) medication was administered per physician's orders. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.[NAME], St. Louis Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration…

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 observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in one of three medication carts and one of two medication storage rooms. Specifically the facility failed to: -Ensure expired medications and vaccines were disposed of timely; -Ensure insulin pens (medication used for glucose control) were labeled with open dates; and, -Ensure Tubersol (used to test for tuberculosis) vials were labeled with open dates. Findings include: I. Professional references According to the Lantus glargine insulin package insert, retrieved on 4/29/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf, When not in use store in refrigerated temperatures of 36 to 46 degrees fahrenheit (F). When in use, can be kept at room temperature for up to 28 days. According to the Novolog insulin package insert, retrieved on 5/8/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/020986s082lbl.pdf After initial use a vial may be kept at temperatures below 30 degrees…

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 observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure residents who were prescribed mechanical soft diets had food prepared according to their diet orders of mechanical soft as indicated on their meal tray cards. Findings include: I. Facility policy and procedure The Therapeutic Diet Orders policy and procedure, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/6/24 at 3:00 p.m. The policy read in pertinent part, The facility provides all residents with foods in the appropriate form and/or the the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. Mechanically altered diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat and thickened liquids. Dietary…

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 observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on two of six units. Specifically, the facility failed to: -Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high frequency touched areas (call lights, door handles and handrails); -Ensure housekeeping staff were trained appropriately on housekeeping procedures; -Ensure housekeeping staff used the correct surface disinfectant products; and, -Ensure surface disinfectant times were adhered to. Finding include: I. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 5/9/24. It revealed in pertinent part, High-touch…

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 observations and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in one of one facility kitchens. Specifically, the facility failed to: -Ensure the overall kitchen area were free from hanging dust; and -Ensure serving tables are free from chipped paint. Findings include: I. Professional reference According to the Colorado Department of Public Health and Environment (CDPHE)The Colorado Retail Food Establishment Rules and Regulations, 1/1/19, retrieved on 2/5/23 from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Non food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces of equipment shall be cleaned at 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 record review, observation,and interviews the facility failed to provide prompt responses and resolutions to grievances from residents. Specifically, the facility failed to respond to resident grievances regarding missing laundry and implement an acceptable resolution for the resident right to keep and use personal belongings and have the facility protect the resident property from theft and or loss. Findings include: I. Facility policy and procedure A Grievance/Complaint policy and procedure was requested on 1/26/23 and was not received from the facility. II. Record Review A. Resident laundry grievances On 8/24/22 Resident #38 reported that a fleece jacket had gone missing. According to the grievance document it was not found in the residents room or laundry. On 8/28/22 Resident #8 reported that three shirts and one pair of pants had gone missing. According to the grievance document the items were not found in the residents room or laundry. On 10/6/22 Resident #21 reported that four personally owned sheet sets and a blanket had been lost in the laundry. According to 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 and interviews the facility failed to ensure medications and biologics were stored and labeled properly on two of four medications carts and one of two medication storage rooms. Specifically, the facility failed to ensure: -Insulin (medication for diabetes) vials and pen injection devices were stored and labeled appropriately with open dates; -Vials of tubersol (used to test for Tuberculosis) were labeled appropriately with open dates; -Ensure the treatment cart was kept free from expired wound dressing supplies; and, -Medication carts were kept clean and free of loose pills. Findings include: I. Manufacturer recommendations According to the Humalog package insert, retrieved [DATE] from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020563s115lbl.pdf In-use humalog vials, cartridges, pens, and humalog KwikPen should be stored at room temperature, below 86°F (30°C) and must be used within 28 days or be discarded, even if they still contain humalog. Unopened humalog should 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 interviews and record review the facility failed to ensure two residents (#60 and #67) of two residents reviewed out of 39 sample residents, had the right to participate in the development and implementation of his or her person centered plan of care. Specifically the facility failed to conduct consistent care planning meetings and invite Resident #60 and #67 to attend a care plan meeting to discuss and develop a person centered plan of care and services that the facility would provide to them. Findings include I. Facility policy and procedure The Care Planning-Resident Participation policy, undated, received from the chief clinical officer (CCO) on 1/27/23 at 6:29 p.m., revealed in pertinent part, The facility supports the resident's rights to be informed of, and participate in, his or her care planning and treatment. The facility will inform the resident in advance of changes to the plan of care. The plan of care will be discussed at regular scheduled care plan conferences. The facility will discuss…

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 interviews and record review the facility failed to honor resident choices for one (#19) of two reviewed for self-determination, out of 39 sample residents. Specifically, the facility failed to ensure dependent Resident #19, received showers consistently according to the resident's preference. Findings include: I. Facility policy and procedure An undated Resident Shower policy was provided by the nursing home administrator (NHA) on 1/26/23 at 2:08 p.m. It read, in pertinent part It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided showers as per request or as per facility schedules protocols and based on resident safety. II. Resident #19 A. Resident status Resident #19, under age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included bipolar disorder, mild…

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, record review, and interviews, the facility failed to ensure one (#55) of three residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition and hygiene, out of 39 sample residents. Specifically, the facility failed to: -Provide timely incontinent care; -Provide timely consistent feeding assistance; and, -Update care plan for Resident #55 to reflect feeding assistance needs. Findings include: I. Facility policy The Incontinence Care policy, undated, was provided by the nursing home administrator (NHA) on 2/26/23 at 2:08 p.m. It read in pertinent part: Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. The Activity of Daily Living (ADLs) policy, undated, was provided by the NHA 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 record review, interview, and observation the facility failed to ensure the residents' environment remained as free from accident hazards as possible, for two (#20 and #42) of six residents reviewed for accident/hazards out of 39 sample residents Specifically, the facility failed to: -Provide effective monitoring and supervision of Resident #20's safety when the resident left the facility without notifying facility staff of an extended absence;. -Provide health assessment and document the assessment (if done) of Resident #20 upon the resident's return from extended and overnight absences for the facility when the resident was out in the community in potential unsafe conditions unsupervised by facility staff; -Provide Resident #20 with appropriate interventions and supervision to prevent the resident from eloping and being missing for hours before staff became aware of the resident's absence; and, -Ensure Resident #42 had a safe and appropriate mattress that was a compatible fit for the bed frame; so 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 record review, observation, and interview the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for one (#20) out of one resident reviewed for a person-centered care plan that supports the resident's behavioral health needs, out of 39 sample residents. Specifically, the facility failed to: -Develop and follow a process to ensure a resident with a substance abuse history was properly monitored for unsafe addicting chemical substances use; -Ensure the facility staff monitored the resident for chemical substance withdrawals and documented concerns when the resident presented with intoxication; and, -Provide a person centered care plan to address Resident #20's mental health needs related to substance use disorder for monitoring and assessment when the resident was actively using an addictive substance, that include and support identified behavioral health care needs. Findings include I.…

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 observations, record review and interviews the facility failed to ensure the medication error rate was less than five percent for two residents (#29 and #45). Specifically, the facility had a medication error rate of 7.41%, which was two errors out of 27 opportunities for error. Findings include I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. 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 observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically the facility failed to: -Perform wound care in a sanitary manner for Resident #237; and, -Sanitize multiple use items after use; when providing wound care for Resident #237. Findings include I. Professional reference According to the Center for disease control (CDC) control and prevention, Hand Hygiene Basics retrieved on 2/2/23 from: http://www.cdc.gov/handhygiene/basics.html (2019), it read in pertinent part, healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patient including before patient contact; after contact with blood,body fluids, or contaminated surfaces (even if gloves worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission…

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

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life, quality of care and infection control. Findings include: I. Facility policy The Quality Assurance and Performance Improvement (QAPI) Program policy, dated July 2016, was received from the nursing home administrator (NHA) on 12/8/21 at 12:44 pm. The policy read in pertinent parts, The Administrator shall delegate the necessary authority for the QAPI Committee to establish, maintain and oversee the QAPI program. The QAPI committee advised the administrator and owner and/or governing body. The committee had the full authority to oversee the implementation of the QAPI program, including, but not limited…

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 observations and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in one out of six units. Specifically, the facility failed to: -Ensure appropriate personal protective equipment (PPE) was worn prior to entering an isolation room; and, -Hand hygiene performed when gloves were removed during wound care. Findings include: I. Facility policy and procedure The Infection Control Guidelines for All Nursing Procedure policy, revised August 2012, was provided by the interim nursing home administrator (INHA) on 10/11/21 at 10:00 a.m. It read in pertinent part, standard precaution will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard precaution applies to blood, body fluids, secretions and excretions regardless of whether…

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 resident and staff interviews and record review, the facility failed to ensure three (#231, #31, #49) out of five residents of 37 sample residents, were provided the opportunity to participate in the development and implementation of his or her person-centered plan of care. Specifically, the facility failed to invite residents to their care plan meetings which occurred quarterly, annually and upon a resident's change of condition for Resident #231, #31, and #49. Findings include: I. Facility policy and procedure The Care Planning and Interdisciplinary Care Plan Meeting policy, written 2001 and revised September 2013, was provided by the interim nursing home administrator (INHA) on 10/14/21 at 12:55 p.m. The policy revealed in pertinent part: Our facility's Care Planning/ Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. -The resident, resident's family and/ or the resident's legal representative/ guardian or surrogate are encouraged…

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 observations, and interviews, the facility failed to honor preferences of five (#64, #77, #10, #73 and #49) of six residents reviewed for choices out of 38 sample residents. Specifically, the facility failed to: -Ensure breakfast choices were honored for Resident #64, #77, #10, #73 and #49. Findings include: 1. Resident interviews Resident #64 was interviewed on 11/30/21 at 11:40 a.m. Resident #64 said she did not get a choice of what she wanted to eat for breakfast. She said she did get her choice of lunch and dinner but not breakfast. She said she would have liked to choose her own breakfast. Resident #77 was interviewed on 11/30/21 at 2:00 p.m. Resident #77 said her lunch missed her onions and she had to ask four different people for them. She said she never get to choose her breakfast, she just got what they brought her. She said she did want to choose her breakfast. Resident #10 was interviewed on 11/30/21 at 2:15 p.m. Resident #10 said she never was able to choose her breakfast, she only got to choose lunch and dinner. She said she wanted to speak to administration…

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 interviews and record review, the facility failed to resolve resident grievances for two (#1, #31) and six (#39, #45, #31, #49, #40, #231) resident council members out of 37 sample residents. Specifically, the facility failed to: -Respond to residents regarding their grievances expressed in resident council meeting; and, -Reply to Resident #1 and #31 grievances after the grievance was submitted. Findings include: I. Facility policy The Grievances Complaints Filing policy, 2001 and revised April 2017, was provided by the interim nursing home administrator (INHA) on 10/14/21 at 12:55 p.m. The policy documented in part: -Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. -The Administrator and staff will make prompt effort to resolve grievances to the satisfaction of the resident and/or representative. -The resident, or person filing the grievance and/or complaint on behalf of 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 observations and interviews, the facility failed to provide a safe, clean, comfortable and homelike environment for four (#51, #58, #64 and #77) out of 37 sample residents, and in two of two shower rooms. Specifically, the facility failed to: -Ensure rooms and bathrooms were clean for Residents #51, #58, #64 and #77; -Ensure towels and washcloths were available in the residents' rooms; and -Ensure the shower room fans and faucet heads were not broken and shower stalls were useable. Findings include: I. Facility policy The Resident Rooms and Environment policy was provided by the regional nurse consultant (RNC) on 10/14/21 at 1:00 p.m. It read in pertinent part, The facility provides residents with a safe, clean, comfortable, and homelike environment. Facility staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. II. Resident rooms and linens A. Resident #51 Resident #51, age [AGE], 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 observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADLs) to ensure the highest practicable quality of life and care, for five (#51, #58, #63, #64 and #77) of six residents reviewed out of 37 sample residents. Specifically, the facility failed to: -Provide regular showers to Residents #51, #58, #63, #64 and #77 who needed assistance with ADLs; and -Provide nail care for Residents #51 and #58. Residents said during interviews that they requested baths and nail care and did not receive the assistance they needed. Residents #51, #58 and #63 said they could smell themselves it had been so long since they bathed. Resident #64 said she did not want to put on clean clothes because she felt dirty. Resident #77 said she wore a cap because she did not want anyone to see her stringy, greasy hair. Cross-reference F725, sufficient nursing staff Findings include: I. Facility policy The Bath/Shower/Tub policy, revised February 2018, was provided by 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 observations, interviews and record review, the facility failed to ensure one (#74) of two residents reviewed out of 37 sample residents received an ongoing person-centered program of activities designed to meet the needs and interests, and promote physical, mental and psychosocial well-being. Specifically, the facility failed to provide ongoing activities for one resident and failed to turn on the television or play music in his room which he could not do on his own. Findings include: I. Facility policy The Activity Programs policy, dated 2001 and updated November 2010 was provided by the interim nursing home administrator (INHA) on 10/14/21 at 12:55 p.m. It revealed in pertinent part: Activity programs designed to meet the needs of each resident are available on a daily basis. 1. Our activity programs are designed to encourage maximum individual participation and are geared to the individuals needs. 3. Our activity programs consist of individual and small and large group activities that are designed…

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 and interviews, the facility failed to investigate accident hazards thoroughly and timely to rule out abuse, and failed to prevent further injury affecting one (#56) of five residents reviewed out of 37 sample residents. Specifically, the facility failed to timely and thoroughly investigate an injury involving the Hoyer (mechanical) lift for Resident #56 on 8/10/21. Findings include: I. Facility Policy The Accidents and Incidents Investigating policy, revised July 2017, provided by the interim nursing home administrator (INHA) on 10/14/21 at 12:50 p.m., read in pertinent part: All accidents or incidents involving residents, employees, visitors, vendors, etc., occuring on our premises shall be investigated and reported to the administrator. The nurse supervisor, charge or department director shall promptly initiate and document the investigation of the accident or incident. II. Resident #56 status Resident #56, age [AGE], was admitted on [DATE]. According to the October 2021 computerized…

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 observations, record review and interviews, the facility failed to ensure two (#42 and #72) of two residents reviewed out of 37 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to: -Notify the physician when Lasix (a diuretic) and potassium (supplement) medications were refused or missed for Resident #42, and -Notify the physician when Buspar (an antianxiety medication) and Labetalol (an antihypertensive medication) were left at Resident #72's bedside without a self-administration assessment and were administered late. Findings include: I. Facility policy The Medication Administration General Guidelines Policy, dated 2007, provided by the interim nursing home administrator (INHA) on 10/14/21 at 10:50 a.m., read in pertinent part: When two consecutive doses of a vital medication are withheld or refused, the physician is notified. Medications must be administered 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 III. Resident #1 A. Resident status Resident #1, under age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnoses included Guillain-Barre Syndrome (the body's immune system attacks the nerves), paraplegia, quadriplegia, type 2 diabetes mellitus, sleep apnea, morbid obesity, and glaucoma. The 7/11/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. The resident required total dependence with bathing. The resident was independent with eating. The resident did not walk in his room or corridors. The resident had upper and lower extremity impairment on both sides of his body. Resident #1 had received no restorative services for the previous seven day look-back period. B. Resident interview Resident #1 was interviewed 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 record review and interviews, the facility failed to ensure one resident (#52) of one out of 37 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to: -Have a complete dialysis communication form between the facility and dialysis center for continuity of care for Resident #52; and, -Obtain a physician order to check for bruit (swishing sound) and thrill (vibration/pulse) to Resident #52 dialysis site for possible complications. Findings include: I. Facility policy The Dialysis Care policy, revised June 2020, was provided by the regional nurse consultant (RNC) on 10/14/21 at 3:00 p.m. It read in pertinent part,the facility will be responsible for care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment, and providing for all non dialysis needs of the resident including during the time period when the resident is receiving dialysis. Inspect shunt sites for color,…

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 and interview, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of two (#68 and #182) out of 37 sample residents. Specifically, the facility failed to: -Ensure physician-ordered Apokyn Solution medication (for Parkinson's/tremors) was available for Resident #68; and -Ensure Buprenorphine Hydrochloride (analgesic) medication was available for Resident #182. Cross-reference F760, significant medication errors. Findings include: I. Facility policy The Provider Pharmacy Requirements policy dated 2007, provided by the interim nursing home administrator (NHAI) on 10/14/21 at 10:50 a.m., read in pertinent part: Regular and reliable pharmaceutical service are available to provide residents with prescription and non-prescription medications, services, and related equipment and supplies. Assisting the nursing care center, as necessary, in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or less on one of two units. Specifically, the medication administration observation error rate was 8.11%, or three errors out of 37 opportunities for error for Resident #42. Ocean spray, advair disk and fluticasone medications were not administered during medication observation times. Findings include: I.Facility policy The Administering Medication policy, revised December 2021, provided by the nursing home administrator interim (NHAI) on 10/14/21 at 10:50 a.m., read in pertinent part: Medication shall be administered in a safe and timely manner, and as prescribed. For residents not in their room or otherwise unavailable to receive medication on the pass, the medical administration record (MAR) may be ' flagged. ' After completing the medication pass, the nurse will return to the missed resident to administer the medication. II.Resident #42 Resident #42, age [AGE], 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 observations, interviews and record review, the facility failed to provide special eating equipment and utensils for eating meals for one (#68) of one resident reviewed out of 37 sample residents. Specifically, the facility failed to provide physician ordered adaptive devices, a plate guard and weighted silverware, for Resident #68. The resident, after calling for assistance and not receiving it, had to eat his spaghetti with his hands. Cross-reference F550, dignity/respect. Finding include: I. Facility policy The Adaptive Equipment - Feeding Device policy, revised December 2020, was provided by the minimum data set (MDS) coordinator on 10/14/21 at 4:56 p.m. It revealed in pertinent part: Adaptive feeding equipment is used by residents who need to improve their ability to feed themselves and in order to enable residents with physically disabling conditions to improve their eating functions. -Upon request, verbal or written, from the nutrition or nursing departments, an occupational therapist, when…

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.