Winding Trails Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#3) of three residents out of three sample residents reviewed for discharge planning. Specifically, the facility failed to: -Provide an appropriate discharge process for Resident #3; and, -Notify the family that Resident #3 was transferred to another skilled nursing facility until after the resident had already been transferred. Findings include: I. Facility policy and procedure The Discharge Summary and Plan policy, revised October 2022, was provided via email by the director of nursing (DON) on 10/14/24 at 11:33 a.m. It read in pertinent part, When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge. Policy Interpretation and Implementation The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge 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.

Based on observations, record review and interviews, the facility failed to ensure food items were stored and served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure staff correctly and accurately tested for the correct parts per million (ppm) of the chemical sanitizer used to clean equipment and surfaces where food was prepared. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 3/13/24 from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf, read in pertinent part, Chemical sanitizers that are used to sanitize equipment and utensils shall be provided and available for use during all hours of operation. A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times and be used in accordance with the EPA registered label use instructions. Concentration of the sanitizing solution shall be accurately determined by using a test…

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

Based on observation and interviews, the facility failed to effectively administer its resources to attain the highest practicable wellbeing for each resident. Specifically, the facility failed to: -Implement and maintain safety measures to prevent elopements with significant injury; -Prevent, report and investigate allegations of resident to resident abuse; and, -Provide sufficient leadership to address and/or avoid multiple significant concerns. Findings include I. Quality of care -Cross reference F689 for failure to ensure residents were free from accidents and elopement which caused major injury. -Cross reference F697 for failure to implement an effective pain management program. II. Freedom from abuse -Cross-reference F600 for failure to protect residents from physical abuse. -Cross-reference F609 for failure to report alleged violations. -Cross-reference F610 for failure to investigate alleged violations. III. Nursing services -Cross-reference F760 for failure to ensure residents were free from significant medication errors. IV. Training requirements -Cross-reference F730 for…

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 conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included all resources, education, staff competencies and facility based risk assessments. Findings include: I. Facility policy and procedure -The Facility Assessment policy was requested from the nursing home administrator (NHA) on 3/6/24 at 8:45 a.m. and was not received by the end of the survey on 3/7/24. II. Record review The Facility Assessment, last reviewed by the facility on 3/1/24 (during the survey), was received from the NHA on 3/6/24 at 8:45 a.m. The facility assessment failed to include the following: -Staff competencies that were necessary to provide the level and types of care needed for the resident population or include the staff training program to ensure any training needs were met for all new and existing staff including those presidents with substance…

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 and quality of care. Findings include: I. Cross-reference citations Cross-reference F689: The facility failed to ensure resident safety with accident hazards. The facility failed to ensure residents were assessed accurately and interventions were in place to prevent further elopements after two residents eloped, resulting in one resident sustaining a fracture. The facility's failure to protect residents from accident hazards created an immediate jeopardy (IJ) situation. Additionally, the facility failed to ensure residents were assessed timely for smoking safety and provided smoking assistive devices.…

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 develop, implement and maintain an effective training program for all staff based on the facility assessment and resident population. Specifically, the facility failed to ensure all direct and non-direct care staff received training in dementia care, substance abuse and behavior management. Findings include: I. Facility policy The In-Service Training Policy, revised August 2022, was received from the regional director of clinical services (RDCS) #1 on 3/11/24 at 11:44 a.m. The policy documented in pertinent part, Required training topics include the following: Behavioral health, dementia management. Training requirements are met prior to staff providing services to residents, annually, and as necessary based on the facility assessment. Based on the outcome of the facility assessment, additional training may include substance abuse. II. Record review Staff training records related to behavior management, dementia and substance abuse were requested from RDCS #1 on 3/7/24 at 10:46 a.m. -RDCS #1 said she was unable to find…

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, record review and interviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent retaliation for abuse reporting. Specifically, the facility failed to: -Post a conspicuous notice of employee rights, including the right of staff to be free from retaliation for reporting abuse; and, -Include protection for employees against retaliation for reporting in its abuse policy. Findings include: I. Professional reference According to the Elder Justice Act notice, undated, retrieved online 3/11/24 from https://lms.healthcareacademy.com/courses/HCA_Annual/ElderJusticeAct1d/EJA_poster.pdf: The Elder Justice Act (the Act) is a federal law passed as part of the Patient Protection and Affordable Care Act. Its aim is to combat abuse, neglect and exploitation of elders by promoting the discovery of crimes against residents of long term care facilities. It does this by requiring that specific individuals report any reasonable suspicion of a crime against anyone who is a resident of, or is receiving care from, a long term care…

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 staff interviews and record review, the facility failed to report alleged violations of potential abuse to the proper authority in accordance with State law for alleged violations involving eight (#4, #17, #6, #7, #3, #18, #14 and #15) of eight residents reviewed for allegations of abuse out of 38 sample residents. Specifically, the facility failed to: -Report an allegation of verbal abuse by Resident #4 to Resident #17 to the nursing home administrator (NHA), director of nursing (DON), local police or the State Agency; -Report an allegation of physical abuse by Resident #6 to Resident #7 and Resident #3; -Report an allegation of physical abuse between Resident #6 and Resident #18; and, -Report an allegation of physical abuse by Resident #14 to Resident #15. Findings include: I. Facility policy and procedure The Abuse and Neglect policy, revised March 2018, was received from the regional director of clinical services (RDCS) #1 on 3/7/24 at 10:55 a.m. The policy documented in pertinent part, Abuse is…

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 incidents of potential abuse were thoroughly investigated for three (#6, #18 and #7) of four residents out of 38 sample residents. Specifically, the facility failed to: -Ensure a known physical abuse incident between Resident #6 and Resident #18 was thoroughly investigated; and, -Ensure reports of physical abuse by Resident #6 to Resident #7 were followed up on and investigated. Findings include: I. Facility policy The Abuse and Neglect policy, revised March 2018, was received from the regional director of clinical services (RDCS) #1 on 3/7/24 at 10:55 a.m. The policy documented in pertinent part, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. The nurse will assess the individual and document related…

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 were kept free from significant medication errors for five (#8, #9, #3, #17 and #21) of five residents reviewed out of 38 sample residents. Specifically, the facility failed to ensure Residents #8, #9, #3, #17 and #21 received all prescribed medications, which resulted in significant medication errors of omission. Findings include: I. Facility policy The Unavailable Medication policy, revised February 2023, was received on 3/6/23 at 10:32 a.m. from the director of nursing (DON). The policy documented in pertinent part, Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable. Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication. Notify physician of inability to obtain medication upon notification or awareness that medication is…

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 nurse aides received 12 hours of training based on annual performance evaluations and facility assessment. Specifically, the facility failed to ensure certified nurse aides (CNAs) #2, #3, #4, #5 and #6 received at least 12 hours of training. Findings include: I. Facility policy and procedure The In-Service Training, All Staff policy, revised August 2022, was provided by the regional director of clinical services (RDCS #1) on 3/11/24 at 11:44 a.m. It read in pertinent part: All staff are required to participate in regular in-service education. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training. Required training topics include the following: -Effective communication with residents and family (direct care staff) -Resident rights and responsibilities, preventing abuse, neglect, exploitation, and misappropriation of resident property…

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 right to refuse treatment for one (#14) of three residents reviewed out of 25 sample residents. Specifically, the facility failed to ensure Resident #14 was not treated and administered medications against his wishes. Findings include: I. Facility policy The Residents Rights policy, revised December 2016, was provided by regional director of clinical services (RDCS) #1 on 5/9/24 at 1:14 p.m. It read in pertinent part, These rights include the right to exercise his or her rights without interference, coercion, discrimination or reprisal from the facility, be informed about his or her rights and responsibilities and be informed of, and participate in his or her care planning and treatment. The Administering Medications policy, revised April 2019, was provided by RDCS #1 on 5/9/24 at 1:14 p.m. It read in pertinent part, If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering…

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 infection control practices were established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the possible development and transmission of Coronavirus (COVID-19) on two of two units out of four units. Specifically, the facility failed to: -Ensure staff had access to and wore PPE in COVID-19 positive resident rooms; -Provide education to staff on use of PPE and disinfection of multi use equipment; and, -Test and document results of staff who had been potentially exposed to COVID-19. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC), revised 5/8/23, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During Coronavirus Disease 2019, retrieved 11/19/23 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html Ensure everyone is aware of recommended IPC (infection prevention and control) practices in the facility. Post visual alerts like signs…

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 received the necessary services to maintain mobility for two (#1 and #2) of three residents out of six sample residents. Specifically, the facility failed to ensure Resident #1 and Resident #2, who required assistance with bathing, were showered or bathed per the resident's preference. Findings include: I. Facility policy and procedure The Shower Bath policy, revised February 2018, was received from the nursing home administrator (NHA) on 11/20/23 at 10:16 a.m. The policy documented in pertinent part, Documentation, The date and time the shower/tub bath was performed. The name and title of the individual(s) who assisted the resident with the shower or bath. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. How the resident tolerated the shower or bath. If the resident refused the shower or bath,…

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 residents and or their representatives were provided prompt efforts by the facility to resolve grievances for one (#1) of one resident out of six sample residents. Specifically, the facility failed to address, resolve, document and follow up on grievances expressed by Resident #1 regarding missing and late meals, missed showers, being left alone in the shower, wound dressing changes and lack of bed linen changes. Findings include: I. Facility policy and procedure The Grievances policy, revised December 2009, was received on 11/16/23 at 3:32 p.m. from the NHA. -The policy addressed staff grievances, but did not address resident grievances. II. Resident #1 A. Resident status Resident #1, age [AGE], admitted on [DATE]. According to the November 2023 computerized physician orders (CPO) diagnoses included, congestive heart failure (CHF), fistula (abnormal connection of tissue due to surgery or injury) of the abdomen and large intestine…

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 two (#3 and #1) of three residents reviewed for accidents out of six sample residents remained as free from accident hazards as possible. Specifically, the facility failed to ensure: -Resident #3 received immediate interventions including increased supervision during a change of condition to prevent falls; -Resident #3 was assessed for injury, including neurological checks, after witnessed falls with head injury and unwitnessed falls; and, -Resident #1 had a resident centered care plan to prevent falls. I. Facility policy and procedure The Fall Risk policy, revised March 2018, was received from the nursing home administrator (NHA) on 11/20/23 at 10:16 a.m. The policy documented in pertinent part, The nursing staff, attending physician, and consultant pharmacist will review medications or medication combinations that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or hypotension. The staff will look…

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 resident rights, quality of life, quality of care and infection control. Findings include: I. Facility policy The Quality Assurance and Performance Improvement (QAPI) Plan, revised June 2023, was received from the nursing home administrator (NHA) on 6/12/23. The plan read in pertinent parts, All staff and stake holders are involved in QAPI to improve the quality of life and quality of care that our patients and residents experience. The Center's approach to QAPI culture and processes is standardized by implementing the following key elements: data driven and comprehensive, addressing all aspects of care, quality of…

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

Based on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to: -Include the email address of the State Survey agency so a resident may file a care complaint; and, -Post the information in a manner accessible and understandable to all residents. Findings include: I. Resident group interview The group interview was conducted on 6/14/23 at 10:00 a.m. with four residents (#36, #19, #41 and #6) identified by assessment and facility as interviewable. All four residents said they did not know where the facility posted information in regard to pertinent State Agencies' contact information and was not reviewed in the resident council meeting. Resident #19 said she was provided a website address for complaints by the facility ombudsman, but did not have a phone number or email address. Resident #6 said he had not been informed of his right to or provided information on how to formally complain to State Agencies about the care he was receiving.…

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 three (#9, #33 and #44) of six residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition and hygiene out of 36 sample residents. Specifically, the facility failed to: -Ensure Resident #9 was provided consistent bed baths according to the plan of care; -Ensure Resident #33 was provided timely meal assistance, consistent nail care and frequent toothbrushing; and, -Provide eating assistance for Resident #44, who required extensive assistance with eating. Findings include: I. Facility policy and procedure The Activity of Daily Living (ADLs) policy, revised May 2023, was provided by the nursing home administrator (NHA) on 6/15/23 at 10:38 a.m. It read in pertinent part, Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure that the resident's environment was free from accident hazards for four (#15, #28, #29, #39 and #47) of six out of 36 sample residents. Specifically, the facility failed to: -Conduct a post fall investigation after Resident #29 had fallen and consistently implement fall measures; -Resident #15 and #39 had effective fall interventions in place; -Resident #28 fall interventions in place and the care plan was updated with appropriate post fall interventions; and, -Resident #47 fall interventions were consistently implemented. Findings include: I. Facility policy and procedure The Falls Management policy and procedure, reviewed 6/15/22, was provided by the nursing home administrator (NHA) on 6/14/23 at 11:21 a.m. It revealed in pertinent part, All patients will be assessed for risk of falls upon admission, with reassessments routinely (quarterly, post-fall) performed to determine ongoing need for fall prevention precautions. In the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to manage pain in a manner consistent with professional standards of practice for three (#2, #303 and #24) of three residents reviewed for pain out of 36 sample residents. Specifically, the facility failed to complete a thorough pain assessment for Resident #2, #24 and #303 which included, recognizing the onset, presence of and characteristics of pain. Findings include: I. Facility policy and procedure The Pain Management policy, dated 10/24/22, received from the nursing home administrator on 5/14/23 read in pertinent part, Patients will be evaluated as part of the nursing process for the presence of pain upon admission/readmission, quarterly, with change in condition or change in pain status, and as required by state regulations. Assess and identify the presence of pain and need for pain management. Assessment components include, but we are not limited to: -Pain locations -Pain level, -Pain onset -Pain descriptions, -Factors that worsen…

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 implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for two residents (#2 and #49) out of 36 sample residents. Specifically, the facility failed to: -Ensure resident refrigerator temperatures were monitored for refrigerated food storage; and, -Provide the resident and/or resident representative with information on their right to store food and the process for doing so. I. Facility policy The Refrigerators: Patient In-Room policy, dated 9/1/22, was provided by the NHA on 6/15/23 at 1:00 p.m. It read in pertinent part, Food supplied by the patient/responsible party that required refrigeration must be labeled with the date the food was placed in the refrigerator. Food considered unsafe for consumption or beyond the expiration date will be discarded by staff upon notification to the patient or patient representative. The patient and/or patient representative will be provided with the In Room…

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 staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections in one out of three units. Specifically, the facility failed to ensure that toiletry items were marked in the shared bathroom. Findings include: I. Observations An observation of residents' shared bathrooms was completed on 6/13/23 at 11:15 a.m. There were about eight shared resident bathrooms with personal hygiene items such as toothbrushes, toothpaste, hair comb, razors, urinal containers and deodorant were not marked. A second observation of the residents' shared bathrooms and central bathroom was completed on 6/14/23 at 3:20 p.m. Toothbrushes and deodorant at the central bathroom were not labeled. The call light string of the call light device had brown stains around the string. Towels in shared bathrooms were not marked and some rooms did not have any towels at all. II. Residents interview Resident #28 was interviewed on 6/15/23…

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 staff interviews, the facility failed to ensure resident bathrooms ventilation fans were functioning on three of four resident bathrooms. Specifically, the facility failed to ensure vents were properly working in residents bathrooms. Findings include: I. Observations An observation of the residents' environment was completed on 6/13/23 at 3:20 p.m. There were exhaust fans installed in the ceiling of each resident's bathrooms.The exhaust fans in the bathroom of room [ROOM NUMBER], 107 and 304 did not generate air movement with the switch turned on. As a measure of checking the function of each fan, a small square of single ply toilet paper was placed against the vent. The exhaust fans were unable to hold the toilet tissue in place which indicated the fans were not functioning at that moment. II. Staff Interview An environmental walk through was conducted with the maintenance director (MTD) on 6/14/23 at 3:20 p.m. The MTD checked the ventilation systems in each of the above bathrooms and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to promote and maintain resident's dignity for one (#302) of three residents reviewed for meal assistance out of 36 sample residents. Specifically, the facility failed to ensure Resident #302 was offered his breakfast and lunch in a timely manner. Findings include: I. Resident status Resident #302, over the age [AGE], was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnosis included muscle weakness, chronic obstructive pulmonary disease (COPD), type 2 diabetes and chronic pain syndrome. According to the 5/25/23 minimum data set (MDS) assessment, the resident had moderate impaired cognitive function with a brief interview for mental status (BIMS) score of ten out of 15. He required extensive assistance with two person physical assistance with bed mobility, transfers and one person physical assistance with dressing. He required supervision with set up assistance for eating. The resident had no…

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 staff interviews, the facility failed to provide services for two (#8 and #29) out of 36 sample residents according to professional standards of practice Specifically, the failed to: -Ensure Resident #8's vital signs, specifically the resident's blood pressure, was monitored prior to the administration of a blood pressure medication; and, -Notify the physician when Resident #29's blood sugars were out of parameters and follow physician's orders for insulin. Findings include: I. Resident #29 A. Professional reference According to Khashayar, F., [NAME], J. (2022) Beta Blockers. Stat Pears. National Library of Medicine, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK532906 on 6/24/23. Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may…

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 one (#27) of five out of 36 sample residents with a pressure ulcer had preventative measures and received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to: -Have consistent skin assessments documented in Resident #27's electronic medical record; and, -When Resident #27 developed a stage 2 pressure ulcer to his right ankle, interventions for his feet and ankles were not implemented until nine days after the wound developed. Findings include: I. Professional reference The Joint Commision (March 2022). Quick Safety 25: Preventing pressure injuries. The European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) (2019). The International Guideline (Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline).…

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 staff interviews the facility failed to ensure one (#50) of reviewed for hydration out of 36 sample residents was provided sufficient fluids to maintain hydration health. Specifically, the facility failed to provide and offer fluids to Resident #50, who had a history of dementia and was dependent resident, outside of mealtimes. Findings include: I. Professional reference [NAME], C., [NAME], A., Holyday, M., [NAME], K. (2021, October 13). Interventions to Improve Hydration in Older Adults: A Systematic Review and Meta-Analysis. Nutrition. National Library of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8537864/ retrieved on 6/27/23. Dehydration is the most common fluid and electrolyte complication amongst the elderly. It is highly prevalent in hospitalized and institutionalized settings. Nursing homes have also identified inadequate fluid intake amongst 50-90% of residents. Dehydration increases risk of morbidity and mortality. This is because lower hydration…

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 that residents were free of unnecessary psychotropic medications for two (#33 and #50) of five residents reviewed for psychotropic medications out of 36 sample residents. Specifically, the facility failed to: -Ensure that Resident #50 had behavior monitoring for target behaviors in place while on an antipsychotic and failing to conduct a gradual dose reduction (GDR); and, -Ensure that Resident #33 had behavior monitoring for target behaviors and followed through on recommendation for GDR for a psychotropic medication. Findings include: I. Facility policy and procedure The facility was unable to provide a Psychotropic Medication or Behavioral Monitoring policy when requested on 6/15/23. II. Professional reference [NAME]. S. L., Cations, M, et al. (12/11/18). Approaches to Deprescribing Psychotropic Medications for Changed Behaviors in Long Term Care Resident Living with Dementia. Drugs & Aging.…

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 establish a communication process that included how the communication would be documented between the facility and the provider for one (#24) of two residents reviewed for hospicare care out of 36 sample residents. Specifically, the facility failed to establish a communication process according to the hospice agreement that included documentation of care and services provided by hospice filed and maintained for Resident #24. Findings include: I. Facility and hospice agreement The Nursing Facility Agreement with Resident #24's hospice agency, dated 3/9/22, read in pertinent part, Medical Chart: Facility and hospice will prepare and maintain complete medical records for hospice patients receiving facility services in accordance with this agreement and will include all treatments, progress notes, authorizations, physician orders and other pertinent information. Documentation of care and services provided by hospice will be filed 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 record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to address and include in the facility assessment an evaluation of the restorative nursing program. Findings include: I. Record review Facility assessment was provided by the assisting nursing home administrator (ANHA) on 14/19/22 at 4:05 p.m. Facility assessment contained a blank skills and techniques evaluation for nursing assistants that included a section of restorative services. The evaluation was meant to be completed and evaluated by the nurse upon hiring a new nursing assistant. The facility assessment did not include the description of the restorative nursing services that were offered in the facility. It did not include who was in charge of the restorative program, how the program was evaluated for its effectiveness and what residents were receiving services. Cross-reference F688-Failed 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.

Based on interviews and record review, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to provide resolutions to food concerns voiced by residents in the food committee, resident council and reported directly to a staff member. I. Facility policy and procedure The Patient Protection policy, revised October 2021, was provided by the assistant nursing home administrator (ANHA) on 4/18/22 at 2:30 p.m. It revealed in pertinent part, The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment, which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their long-term care (LTC) facility stay. The facility must make information on how to file a grievance or complaint available to the resident. The facility must…

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 revise and review comprehensive care plans for four (#51, #23, #68, and #22) of 18 residents out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #51's care plan was reviewed and revised to reflect the resident's range of motion needs; -Ensure Resident #23 care plan was integrated with hospice services; and, -Ensure Resident #68 and Resident #22 were invited and participated in their plan of care conference and care plan updated accordingly. Cross0reference F688 for range of motion Findings include: I. Professional reference According to [NAME], P., & [NAME], A., & Stockert, P., & Hall, A. (2017) Fundamentals of Nursing (9th ed.), pp. 248-249, which read in pertinent part, A nursing care plan includes nursing diagnoses, goals, and/or expected outcomes, specific nursing interventions, and a section for evaluations so any nurse is able to quickly identify a patient's clinical needs and situation. Nurses…

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 activities designed to support residents physical, mental and psychosocial well-being were provided for three (#44, #74 and #282) of four residents reviewed for activities out of 33 sample residents. Specifically, the facility failed to ensure Resident #44, #74, and #282 were provided activities and developed a comprehensive care plan which addressed each resident's socialization and activity needs. Findings include: I. Facility policy and procedure The Program Types policy and procedure, dated July 2019, was provided by the activities director (AD) on 4/19/22 at 2:43 p.m. It revealed in pertinent part, Group programs involve a number of people in physical, mental and social interactions. By providing group programs, the center maximizes resources, encourages cohesiveness and promotes socialization. A one-to-one program is provided for patients unable or unwilling to participate in large group settings, meeting some or all 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 record review and staff interviews, the facility failed to ensure six (#6, #25, #27, #44, #59 and #282) residents reviewed of 10 residents received treatment and care in accordance with professional standards of practice out of 33 sample residents. Specifically, the facility failed to assess Resident #6 for change of condition. Resident developed severe edema on his left lower leg and was sent to the emergency room for evaluation. In addition, Resident #6's skin assessments were not consistently and accurately documented to reflect the development of several wounds on his legs that led to infection and cellulitis. Resident #25-Failure to perform treatments as ordered by the physician, failure to notify the physician of newly developed skin concerns; Resident #27-Failure to ensure medications were administered according to physician orders and notify the physician was a medication was not administered; Resident #44-Failure to regularly monitor the resident's skin; Resident #59-Failure to perform…

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 a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for four (#22, #40, #51 and #59) of five residents reviewed for activities of daily living of 33 sample residents. Specifically, the facility failed to: -Provide restorative care services to Resident #40 on a regular basis, and consistently apply wrist splint as recommended by an occupational therapist (OT), -Provide range of motion (ROM) exercises for Resident #22, and, -Ensure Resident #51 and #59 received range of motion services for impaired mobility. In addition, the facility failed to assign a licensed nurse responsible for the audit and maintenance of the restorative nursing program, and failed to provide education to certified nurses aides (CNAs) who were assigned to provide the restorative care. Findings include: I. Facility policy and procedure The Restorative Nursing Guideline policy and procedure,…

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 interview, the facility failed to ensure certified nurse aides (CNA) are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to evaluate the competencies of certified nurse aides on restorative tasks such as brace/splint application, active and passive range of motion. Finding include: I. Facility assessment The facility assessment identified the facility accepted residents with contractures, and identified the facility could provide support and care for individuals with limited range of motion. II. Record review Records of five random CNAs working in the facility were reviewed. Out of five CNAs, three CNAs had no records of restorative skills checklist. Out of 30 plus CNAs that signed residents medical records indicating that range of motion was provided to residents with contractures, only six have completed the Skills and Techniques evaluation upon hire. The other CNAs had no records…

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 five (#27, #81, #25, #59, and #37) out of five residents reviewed out of 33 sample residents were free from unnecessary medications as possible. Specifically, the facility failed to: -Identify and monitor targeted behaviors for psychotropic medications for Resident #27; and, -Ensure consents were obtained and contained black box warnings for the usage of psychotropic medications for Resident #27, #81, #25, #59, and #37. Findings include: I. Facility policy and procedure The Behavior Management policy and procedure, dated March 2022, was provided by the assistant nursing home administrator (ANHA) on 4/18/22 and 3:00 p.m. It revealed in pertinent part, The individualized comprehensive care plan addresses the behavior management program, the goal for behavior management, individualized interventions to address the patient's specific risk factors and the plan for the reduction of risk related to behaviors. Patients, families/responsible parties are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and interviews, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, in three out of five medication carts. Specifically, the facility failed to: -Label insulin vials and pens with an open date and store them according to manufacturer's recommendation; -Label inhalers and eye drops with an open date; and, -Remove expired medication from the medication cart. Findings include: I. Manufacturer's recommendations Advair HFA package insert read in pertinent part: Discard after 12 months, or when the dose counter displays 0. Humalog (Insulin Lispro) package insert for Humalog (Insulin Lispro) (2019) read in pertinent part Unopened Humalog should be stored in a refrigerator (36° to 46°F), but not in the freezer. Do not use Humalog if it has been frozen. In-use Humalog vials, cartridges, pens, and Humalog KwikPen should be stored at room temperature, below 86°F and must be used within 28 days or 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 observations and interviews, the facility failed to ensure one (#37) out of 33 sample residents had the right to a dignified existence. Specifically, the facility failed to ensure Resident #37 was treated with dignity and respect by answering her call light timely and speaking to her in a respectful manner. Findings include: I. Resident #37 status Resident #37, age [AGE], was admitted on [DATE]. According to the April 2022 computerized physician orders (CPO), the diagnoses included major depressive disorder. The 2/8/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required extensive assistance of one person with bed mobility and personal hygiene and extensive assistance of two people with toileting and transfers. A. Observations and resident interview On 4/10/22 at 11:32 p.m. Resident #37's call light was activated. -At 11:40 p.m. Resident #37 was observed walking with her front wheel walker from 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 and interviews the facility failed to ensure residents had the right to formulate advance directives by not keeping advance directives updated and current for two (#27 and #44) of two residents reviewed for advance directives out of 33 sample residents. Specifically, the facility failed to ensure the medical orders for scope and treatment (MOST) forms matched Resident #27 and Resident #44's physician orders. Findings include: I. Facility policy and procedure The Social Services Guidelines policy and procedure, revised [DATE], was provided by the assistant nursing home administrator (ANHA) on [DATE] at 3:00 p.m. It revealed in pertinent part, Advance care planning is defined as-A process used to identify and update the resident's preferences regarding care and treatment at a future time, including a situation in which the resident subsequently lacks capacity to do so. This is a comprehensive definition that includes decisions established by advance directives and decisions established…

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, observations and interviews, the facility failed to ensure services provided to three (#24, #32 and #13) of 33 sample residents met professional standards of practice. Specifically, the facility failed to ensure an assessment was completed and documented by a registered nurse (RN) following a fall sustained by Resident #24, Resident #32 and Resident #13. Findings include: I. Resident #24 A. Resident status Resident #24, age [AGE], was admitted on [DATE]. According to the April 2022 computerized physician orders (CPOs), the diagnoses included dementia with behavioral disturbance, adult failure to thrive, macular degeneration, muscle weakness, obsessive compulsive behavior, and history of falling. The 1/27/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of five out of 15. She required extensive assistance of one person with bed mobility, toileting and personal hygiene. She required limited assistance…

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 three (#24, #46 and #44) of four residents reviewed out of 33 sample residents for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to ensure three female residents (Residents #24, #46 and #44) received grooming services to remove long facial hair from their chin. Findings include: I. Facility policy and procedure The Activities of Daily Living policy and procedure, revised October 2019, was provided by the nursing home administrator (NHA) on 4/14/22 at 2:00 p.m. It revealed in pertinent part, Morning care should be individualized to each patient's preferred morning hygiene habits and routine. Apply deodorant and/or make-up, comb hair, and shave as applicable and as needed. II. Resident #24 A. Resident status Resident #24, age [AGE], was admitted on [DATE]. According to the April 2022 computerized physician…

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 necessary care and services for residents who were unable to carry out activities of daily living for two (#40 and #51) of six residents reviewed for activities of daily living of 33 sample residents. Specifically, the facility failed to: -Provide showers and personal care such as washing face and brushing teeth for Residents #40; and, -Offer and encourage oral care for Resident #51, who required assistance with personal hygiene. Findings include: I. Facility policy and procedure The A.M. Care policy was provided by the nursing home administrator on 4/14/22 at 2:00 p.m., read in pertinent part, Assist with face and hand washing and oral hygiene. The H.S. (hour of sleep) Care P.M. read in pertinent part, Assist with mouth care. II. Resident 40 A. Resident status Resident #40, age [AGE], was admitted to the facility 2/9/21. According to the April 2022 computerized physician orders (CPO), diagnoses included contracture of the left…

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 assist one (#20) of two residents out of 33 sample residents with obtaining vision services. Specifically, the facility failed to ensure Resident #20 received her prescribed eye glasses timely. Findings include: I. Resident #20 A. Resident status Resident #20, age [AGE], was admitted on [DATE]. According to the April 2022 computerized physician orders diagnoses included chronic pain, anxiety disorder, personality disorder and heart failure. The 1/21/22 minimum data assessment (MDS) assessment showed the resident did not have any cognitive impairment with a brief interview for mental status score of 15 out of 15. The MDS showed the resident required limited assistance for activities of daily living. The resident had adequate vision and did not wear corrective lenses. B. Resident interview Resident #20 was interviewed on 4/6/22 at 4:44 p.m. The resident said that she had an eye exam, however she has not received her glasses. She said that…

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 one (#13) of three residents received adequate supervision to prevent accidents out of 33 sample residents. Specifically, the facility failed to conduct a root cause analysis and implement person-centered interventions after Resident #13, who had five falls in four months. Findings include: I. Facility policy and procedure The Falls Practice guide, dated December 2011, was provided by the regional nurse manager (RNM) on 4/13/22 at 12:15 p.m. It revealed in pertinent part, Events considered to be a fall include when a patient: unintentionally comes to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force; loses balance and would have fallen, if not for staff intervention; and is found on the floor, unless there is evidence suggesting otherwise. Fall reduction and injury prevention strategies that can be implemented upon admission may include, but are not limited to the following:…

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 assist a resident to obtain routine or emergency dental services, as needed, for one (#51) of two out of 33 sample residents. Specifically, the facility failed to provide dental services for Resident #51. Findings include: I. Resident #51 A. Resident status Resident #51, age [AGE], was admitted on [DATE]. According to the April 2022 computerized physician order (CPO) diagnoses included cerebral vascular accident (CVA), and hemiplegia and hemiparesis following cerebral infarction affecting the right non- dominant side. The 2/22/22 minimum data set (MDS) assessment coded the resident with a brief interview for mental status of 15 out of 15. The resident required extensive assistance with activities of daily living. The resident had his own teeth both upper and lower. B. Resident interview The resident was interviewed on 4/7/22 at 10:32 a.m. The resident said he needed to be seen by a dentist. He said he had a tooth on his lower jaw…

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.