Adara Living

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure that a consent and a safety bed rail evaluation was in place for one (#151) of five residents with bed rails out of 53 residents. Specifically, the facility failed to: -Ensure a signed consent was obtained from Resident #151 or the resident's representative prior to the initiation of side rails; -Ensure a physical therapy or occupational therapy (PT/OT) safety evaluation was conducted for Resident #151 prior to the use of half bed rails on a new bed; -Ensure the least restrictive alternatives were tried and documented prior to the use of half rails; and, -Ensure a physician's order was obtained for Resident #151 prior to the use of bed rails. Findings include: I. Professional reference According to the U. S. Food and Drug Administration (FDA) (2023), Recommendations for Health Care Providers Using Adult Portable Bed Rails, retrieved on 1/22/25 from…

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 in one of five dining rooms. Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to the resident's diet orders of mechanical soft as indicated on their meal tray cards. Findings include: I. Facility policy and procedure The Therapeutic Diet Orders policy, undated, was provided by the nursing home administrator (NHA) on 1/16/25 at 4:55 p.m. It read in pertinent part, The facility provides all residents with foods in the appropriate form and/or 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. A 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…

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 maintain accurately documented medical records for one (#114) of four residents out of 53 sample residents. Specifically, the facility failed to ensure Resident #114's wound orders and treatment records were accurate. Findings include: I. Facility policy and procedure The Documentation of Medical Record policy, undated, was provided by the nursing home administrator (NHA) on 1/16/25 at 4:30 p.m. It read in pertinent part, Licensed staff and interdisciplinary team members shall document all assessments, observations and services provided in the resident's medical record in accordance with state law and facility policy. Documentation may be performed manually or as per the facility's specific electronic medical record software program. Principles of documentation include but are not limited to: Documentation shall be factual, objective and resident centered; documentation shall be accurate, relevant and complete, containing sufficient details about 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 provide sufficient nursing staff to ensure the residents received the care and services they required per their comprehensive plans of care, to achieve and maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to consistently provide adequate nursing staff given the acuity and diagnoses of the facility's population, resident census, and the residents' daily need for care and services. Cross-reference citations: -F677 for the failure to provide timely incontinence care and reposition to residents; -F686 for the failure to provide repositioning for residents with pressure injuries; -F689 for the failure to ensure two staff were utilized when transferring residents with mechanical lifts; and, -F692 for the failure to provide timely eating assistance and consistently provide fluids to residents between meals. Findings include: I. Resident census and conditions 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.

Based on observations and interviews, the facility failed to prepare and serve food in a sanitary manner. Specifically, the facility failed to have a system in place to monitor the internal temperature of the dishwasher to ensure the functioning of the dishwasher. Findings include: I. Professional reference According to the Food and Drug Administration Food Code (2022) accessed on 8/16/23 from https://www.fda.gov/media/164194/download?attachment read in pertinent part, Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 160°F (Fahrenheit). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices 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 and interviews, the facility failed to ensure residents had safe, clean, comfortable and homelike environments in multiple areas of the facility. Specifically, the facility failed to ensure resident rooms and facility hallways. Findings include: I. Initial observations The following was observed during the initial walkthrough of entering the facility on [DATE] at 9:00 a.m. until [DATE] at 4:00 p.m. The third floor memory care was observed to have bugs (deceased ) in multiple ceiling light fixtures throughout the unit. room [ROOM NUMBER] and #17: The window blinds were observed to be broken, bent and missing. room [ROOM NUMBER]: The electrical outlet on wall behind head of bed was observed to be dislodged from wall and unusable. room [ROOM NUMBER]: Multiple holes and tears, ranging from approximately one inch to four inches were observed in the screen to the window. room [ROOM NUMBER]: Two vertical holes, approximately three inches in length and half an inch wide were observed in the wall…

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 seven (#19, #69, #90, #92, #25, #98 and #75) residents were provided prompt efforts by the facility to follow up on grievances out of 71 sample residents. Specifically, the facility failed to ensure grievances were followed up timely with a resolution in regards to missing property. Findings include: I. Facility policy and procedure The Complaints and Grievances policy, revised 2/8/19, was provided by the nursing home administrator (NHA) on 7/26/23 at 11:03 p.m. It read in pertinent part This facility encourages and requests that staff, residents, families, visitors, express their concerns, complaints and grievances. The facility will review, investigate and respond to all such concerns. A resident, his or her representative, family member, visitor or advocate may file a verbal or written grievance or complaint concerning treatment, abuse, neglect, harassment, medical care, behavior of other residents or staff members, theft 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to consistently provide activities of daily living (ADL) support for three (#27, #98 and #106) of six dependent residents reviewed for ADL care out of 71 sample residents. Specifically, the facility failed to: -Provide repositioning adjustments for Resident #27 and Resident #98 who were unable to reposition themselves; and, -Provide timely incontinence care for Resident #27 and Resident #106. Cross-reference F725: Lack of sufficient staffing to meet residents' needs for care and services Findings include: I. Facility policy and procedures A turning and repositioning document not dated or titled as a policy was provided by the nursing home administrator (NHA) on 7/26/23 at 11:05 p.m. It read in pertinent part, Evaluate bed mobility and develop a turning schedule based on identified risk. Individualized positioning regime and repositioning schedule must be documented and displayed. If the patient is able to make large body movements easily…

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 (#78, #89 and #127) of five out of 71 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to: -Ensure Resident #78 did not receive another resident's medications; -Ensure Resident #89 was transferred with a mechanical lift according to professional standards of practice; and, -Ensure cleaning chemicals were not left in Resident #127's room unsecured. Findings include: I. Resident #78 A. Resident status Resident #78, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included hypertension and depression. The 6/19/23 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 was independent with all activities of daily living. B. Resident interview and observations Resident #78 was interviewed on 7/19/23 at 3:34 p.m. She said the…

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

Based on record review and interview the facility failed to ensure certified nurse aides (CNAs) received 12 hours of training per year for seven (CNA #20, CNA #21, CNA #22, CNA #23, CNA #7, CNA #24, and CNA #25) out of 49 CNAs. Specifically, the facility failed to provide 12 hour training for CNA #20, CNA #21, CNA #22, CNA #23, CNA #7, CNA #24 and CNA #25. Findings include: I. Record review The facility was unable to provide documentation CNA #20 (hire date of 1/11/19) , CNA #21 (hire date of 8/22/22), CNA #22 (hire date of 6/6/17), CNA #23 (hire date of 8/1/19), CNA #7 (hire date of 1/21/22), CNA #24 (hire date of 9/15/2020) and CNA #25 (hire date of 9/29/22) had completed 12 hours of training during the survey process. II. Staff interview The infection preventionist (IP) interviewed on 8/8/23 at 2:10 p.m. He said the system they use for tracking training records was through a computer based program. He said he had his own tracking spreadsheet for education. He said he did not have a list of mandatory training for the CNAs to complete. He said he would look at the list of classes…

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 three out of four medication refrigerators stored narcotic, non-narcotic medications and biologicals in accordance with accepted professional standards. Specifically, the facility failed to ensure controlled medications were in a locked storage area that was permanently secured to the refrigerator. Findings include: I. Facility policy and procedure The Medication Storage policy was requested from the director of nursing (DON) on 7/25/23 but was not provided. II. Observations 7/25/23 -At 10:34 a.m. the third floor medication room medication refrigerator was observed with licensed practical nurse (LPN) #4. The refrigerator was not locked and it contained a locked box to hold controlled medications needing refrigeration that could be picked up and removed from the refrigerator. The narcotic locked box was not permanently affixed to the refrigerator. The nurse confirmed the controlled substance locked box inside of the refrigerator contained Lorazepam. -At 10:50 a.m. the second floor medication room medication…

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 provide food that accommodated resident preferences for four (#13, #78, #79 and #86) of four residents out of 71 sample residents. Specifically the facility failed to offer food choices according to resident preferences for Residents #13, #78, #79 and #86. Findings include: I. Observations and record review On 7/25/23 the noon kitchen line was observed continuously from 12:00 p.m. to 1:00 p.m. The trays were prepared using a resident list, which had the resident's preferences (likes and dislikes) and what the resident wanted to eat for their meal. At approximately 12:30 p.m. Resident #13 was served half of a serving of carrots. -Tray card for Resident #13 indicated that the resident disliked carrots. At approximately 12:30 p.m. Resident #78 was served a full serving of carrots. -Tray card for Resident #78 indicated that the resident disliked carrots. At approximately 12:30 p.m. Resident #79 was served gravy. -Tray card for Resident #79 indicated that the resident disliked gravy. At approximately 12:30 p.m.…

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 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. Specifically, the facility failed to ensure: -Housekeeping staff engaged in appropriate infection control practices when cleaning a resident room; -Residents were provided with proper hand hygiene prior to meals; -Proper hand hygiene was conducted during medication pass; and, -Shared equipment was consistently sanitized between resident uses. Findings include: I. Facility policy and procedure A. The Infection Control policy and procedure manual, revised August 2015, was received by the administrator in training (AIT) on 7/26/23. It read in pertinent parts: This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance 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 7/24/23 at 10:36 p.m. with five residents (#10, #68, #91 #104 and #105) identified by assessment and the facility as interviewable. All five residents said they did not know they could file a complaint with the State Agency and they did not know where the facility posted information in regard to pertinent State Agencies' contact information and it was not reviewed in the resident council meeting. III. Staff interviews and observation On 7/19/23 at 10:46 a.m. observation of the mandatory posting for the State Agency was made on the third floor across from the unit manager's office. An eight inch by 11 inch paper…

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 keep two residents (#108 and #133) free from resident to resident physical abuse of two residents reviewed out of 71 sample residents. Specifically, the facility failed to ensure there was an effective plan to monitor, or provide increased oversight and effective interventions to protect, Residents #108 and #133 from Resident #409's behavior. Resident #409 physically abused two residents on 7/9/23. Findings include: I. Facility policy and procedure The Abuse, Neglect, & Exploitation Prevention policy and procedure, revised 12/17/18, documented in pertinent part: It is the policy of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to, facilities staff, other residents, consultants or volunteers, staff or other agencies serving…

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 provide written information regarding the facility's bed-hold policy to a resident's representative for one (#409) resident reviewed for discharge out of 71 sample residents. Specifically, the the facility failed to provide Resident #409's representative with a written notice of the bed hold policy when he was transferred to the hospital. Findings include: I. Resident status Resident #409, age [AGE], was admitted on [DATE] and discharged to hospital on 7/9/23. According to the July 2023 computerized physician orders (CPO), the diagnoses included dementia with other behavioral disturbances. The 7/7/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of four out of 15. He required extensive assistance for transfers, dressing, toilet use and personal hygiene. II. Record review The 7/9/23 nursing progress note revealed Resident #409 was sent to the emergency room to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to allow a resident to return to the facility after going to the hospital for one (#409) of one resident reviewed for discharge out of 71 sample residents. Specifically, the facility failed to assess Resident #409 when he went to the hospital to be stabilized to return to the facility. Findings include: I. Facility policy and procedure The Involuntary Discharge policy and procedure, revised 2/14/19, was provided by the administrator in training (AIT) on 7/26/23. It read in pertinent part, To assure residents will be transferred or discharged only for the resident's welfare, the resident's needs cannot be met in the facility, the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility, the health and safety of individuals in the facility are endangered or for non-payment. If the resident is being transferred due to the resident being a danger to self or others, there must be documentation to show…

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 interviews, the facility failed to ensure two of three residents (#41 and #136) reviewed for activities of daily living (ADLs) received the necessary care and services to maintain their abilities in ADLs out of 71 sample residents. Specifically, the facility failed to provide language communication tools in order for Resident #41 and #136 to effectively communicate their needs, requests, and opinions, as well as to participate in social conversation. Findings include: I. Resident #41 A. Resident status Resident #41, over the age of 65, was admitted on [DATE]. According to the July 2023 Computerized Physician Orders (CPO), the resident's diagnoses included unspecified dementia, of unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The June 2023 minimum data set (MDS) assessment revealed the resident with severe cognitive impairment with a brief interview for mental status score of four out of 15. She required…

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 an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (#69) of two residents out of 71 sample residents. Specifically, the facility failed to offer and provide activity programs for Resident #69 to meet her activity needs. Findings include: I. Facility policy and procedure The Federal Resident Right and Facility Responsibilities document, not dated, was provided by the nursing home administrator (NHA) on 7/26/23 at 11:00 p.m. It read in pertinent part: The resident has a right to choose activities, schedules (including sleeping and waking times), health care and provider of health care services consistent with his or her interests, assessments, plan of care and other applicable provisions of this part. II. Resident status…

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, observation and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#7) out of 71 sample residents. Specifically, the facility failed to ensure Resident #7, who was diagnosed with diabetes, had her fingernails cut by a licensed nurse. Resident #7 sustained a laceration on her finger when the certified nurse aide (CNA) cut her nails. Findings include: I. Resident #7 status Resident #7, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included type two diabetes mellitus and Parkinson's disease. The 5/15/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of two people with bed mobility, transfers, toileting and extensive assistance of one person with dressing and personal hygiene. A. Resident interview Resident #7 was interviewed…

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 provide the necessary treatment and services to prevent pressure injuries from occurring for two (#23 and #85) of two residents in a sample of 71 residents. Specifically, the facility failed to implement or plan interventions to reduce pressure injury risk factors for Resident #23 and #85, both of whom had been identified at high risk for pressure injuries. Cross-reference F725: Lack of sufficient staffing to meet residents' needs for care and services Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel (NPIAP) Pressure Injury Stages, the National Pressure Injury Advisory Panel - NPIAP web. (2/4/18) accessed 8/2/23 from http://www.npiap.org/resources/educationaland-clinical-resources/npuap-pressure-injury-stages. read in pertinent part: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination 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 two (#130 and #92) of three out of 71 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Specifically, the facility failed to: -Ensure Resident #130 received assistance to meet her nutrition and hydration needs; and, -Ensure Resident #92 received sufficient hydration. Findings include: I. Facility policy and procedure A. The Hydration policy and procedure, revised January 2020, was provided by the director of nursing (DON) on 7/25/23 at 6:30 p.m. It read in pertinent part, Purpose: to identify residents at risk for dehydration. To evaluate the fluid requirement of each resident. To identify risk factors which lead to dehydration and develop an appropriate preventative care plan. To provide sufficient fluid intake to maintain proper hydration and health. B. The Facility Nutrition Program policy and procedure, revised April 2007, 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 ensure one (#108) resident who required respiratory care received the care consistent with professional standards of practice out of 71 sample residents. Specifically, the facility failed to ensure a portable oxygen concentrator was in working condition for Resident #108. Findings include: I. Resident status Resident #108, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included dementia, chronic obstructive pulmonary disease (COPD), emphysema (lung disease that causes breathlessness) and anxiety. The 6/16/23 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 from one staff member for dressing, toilet use and personal hygiene. She required oxygen therapy. II. Observations and interviews On 7/24/23 at 12:34 p.m. certified nurse aide (CNA)…

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 develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (#143) resident reviewed for antibiotic stewardship out of 71 sample residents. Specifically, the facility failed to thoroughly assess and document clinical signs and symptoms of an infection to ensure the criteria of the infection was met prior to the administration of an antibiotic for Residents #143. Findings include: I. Professional reference The Centers for Disease Control and Prevention (2019) The Core Elements of Antibiotic Stewardship for Nursing Homes APPENDIX B: Measures of Antibiotic Prescribing, Use and Outcomes, retrieved 7/27/23 https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-a-508.pdf. It read in pertinent part, Incomplete assessment and documentation of a resident's clinical status, physical exam or laboratory findings at the time a resident 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 observations, interview, record review, and policy review, the facility failed to ensure over-the-counter medications were secured for 1 (Resident #115) of 8 sampled residents who resided on the third floor. Findings included: A review of the facility policy titled, Bedside Storage of Medications Self Administration of Drugs, revised 03/14/2018, revealed, Purpose: To provide a safe environment for self-administration of drugs .Procedure: .2. Assess the resident's ability to self-administer medications if the resident so chooses by completing the Self-Administration Pretest .5. Storage of the medications should de only in lockable drawers, cabinets or boxes to prevent access by other residents. A review of the admission Record revealed Resident #115 was admitted to the facility with a diagnosis of vascular dementia with behavioral disturbance. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident scored a 10 on the Brief Interview for Mental Status (BIMS), which indicated…

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.