Pikes Peak Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious disease on three of nine units. Specifically, the facility failed to: -Ensure housekeeping staff wore gloves and performed appropriate hand hygiene while cleaning residents' rooms; -Ensure housekeeping staff wore masks appropriately while the facility was in a flu outbreak; and, -Ensure staff sanitized dining tables and the floor prior to the next meal. Findings include: I. Housekeeping failures A. Facility policy and procedure The Cleaning and Disinfecting Residents' Rooms policy, revised August 2013, was provided by the regional director of clinical services (RDCS) on 1/30/25 at 2:39 p.m. It read in pertinent part, Use heavy-duty gloves and other personal protective equipment (PPE), as indicated, for housekeeping tasks. Gloves, protective eyewear and masks may 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.

Based on observations, record review and interviews, the facility failed to provide a safe, sanitary, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure necessary kitchen equipment was maintained in a safe, sanitary and working condition. Findings include: I. Observations On 1/27/25 at 9:30 a.m. the initial kitchen tour was conducted and the following was observed: -An approximate twelve-inch by twenty-four inch puddle of water was observed coming from underneath the kitchen employee's hand washing sink. -Under the three compartment dishwashing sink, a large silver mixing bowl was observed directly underneath the water pipes. The mixing bowl was collecting the drops of water from a leak in one of the pipes. -Two broken floor tiles by the sink were detached from the floor and floating on top of an accumulation of water. On 1/28/25 at 11:18 a.m. observations of the kitchen revealed there were no changes to the condition of the leak coming from underneath the kitchen employee's hand washing sink, the leak coming 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 record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for three (#1, #9 and #2) of four residents reviewed for abuse out of 10 sample residents. Specifically, the facility failed to report incidents of physical abuse involving Resident #1 to the State Survey Agency (SSA). Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy and procedure, revised September 2022, was provided by the nursing home administrator (NHA) on 9/17/24 at 12:31 p.m. It revealed in pertinent part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of investigations are documented and reported. The administrator or the individual making the allegation immediately…

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, the facility failed to investigate incidents of physical aggression involving one (#1) of four residents reviewied out of 10 sample residents. Specifically, the facility failed to conduct investigations of physical abuse involving Resident #1. Findings include: I. Facility policy and procedure The Resident to Resident Altercations policy and procedure, revised September 2022, was provided by the nursing home administrator (NHA) on 9/17/24 at 12:31 p.m. It revealed in pertinent part, All altercations, including those that may represent resident to resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. II. Incidents of abuse A. Incident of verbal abuse toward Resident #9 on 7/8/24 The 7/8/24 nursing progress note documented, at lunch at approximately 12:20 p.m. in the dining room, Resident #1 was sitting at a table and Resident #9 was sitting at another table. Resident #1, yelled at Resident #9, You are a [expletive] [expletive] that needs to leave. He gets on my nerves making 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 residents received necessary respiratory care and services per physician orders for four (#2, #10, #12 and #13) of four residents reviewed for respiratory care out of 13 sample residents. Specifically, the facility failed to: -Ensure physician's orders for oxygen were obtained for Resident #2 and Resident #10 prior to administering oxygen; -Ensure oxygen saturation levels (SpO2) were being monitored consistently for Resident #2, Resident #10 and Resident #12; -Ensure Resident #12's physician's order for oxygen accurately identified the correct oxygen flow rate; and, -Ensure staff were providing the correct flow rate of oxygen per the physician's order to Resident #13. I. Facility policy The Oxygen Administration policy, revised October 2010, was received by the director of nursing (DON) on 3/14/24 at 12:30 p.m. It read in pertinent part, Verify that there is a physician's order for this procedure. Review the physician's orders or…

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 the resident's responsible party was notified when a change in medication occurred for one (#2) out of three residents reviewed for notification out of 13 sample residents. Specifically the facility failed to: -Ensure the responsible party was notified when a psychotropic medication was ordered and administered for Resident #2. Findings include: I. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included failure to thrive, and anxiety. The 11/15/23 minimum data set (MDS) assessment revealed that the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of 99 out of 15. The resident was dependent on staff for assistance with all activities of daily living (ADLs) B. Record review The October 2023 CPO showed an order for Abilify (an antipsychotic medication) 2 mg (milligrams) to be given at bedtime…

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 written notification of room changes and roommate changes for two (#3 and #1) of three residents reviewed for notifications out of 13 sample residents. Specifically, the facility failed to provide timely written and/or verbal notification of room and/or roommate changes to Resident #3 and Resident #1 and/or their representatives. Findings include: I. Facility policy and procedure The Transfer Room to Room policy, dated December 2016, was provided by the nursing home administrator (NHA) on 11/29/23 at 4:00 p.m. The policy read in pertinent part, The purpose of this procedure guidelines for safely transferring residents from one room to another when such transfer has been approved in accordance with facility policies. Preparation Orient the resident to the transfer in a form and manner that the resident can understand. Provide the resident with the following information: where the room is located, who the resident ' s new roommate…

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 menus were followed to meet the residents' nutritional needs. Specifically, the facility failed to: -Follow the correct portion sizes to ensure adequate nutrition was provided to the residents; and, -Ensure the correct items were served in accordance with the posted menu. I. Facility policy and procedure The Food Service Quality Indicators policy, dated 5/1/23, was provided by the nursing home administrator (NHA) on 8/17/23 at 1:15 p.m. It revealed in pertinent part, Portion sizes of foods served are correct according to the written menu for each diet. Meals are served according to the Diet Guides: recipes are followed, portion sizes are correct, all items are present non-specified items are included and preferences are honored if not contraindicated by diet restriction. II. Follow the correct portion sizes to ensure adequate nutrition was provided to the residents A. Observations and record review During a continuous observation during the dinner meal on 8/15/23 starting at 4:39 p.m. and ended at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen, the north serving kitchen and four out of four nourishment rooms. Specifically, the facility failed to: -Ensure food was labeled and dated and disposed of timely in the walk-in refrigerators, dry storage and reach-in refrigerator in the main kitchen and in four nourishment rooms; -Ensure the main kitchen and four unit nourishment rooms were clean and sanitary; -Ensure garbage was covered and disposed of in the main kitchen; -Ensure appropriate hand hygiene when staff were assisting residents with meals; -Ensure temperatures were taken of refrigerators in the main kitchens and the nourishment rooms; -Have a system in place to monitor the internal temperature of the dishwasher to ensure the functioning of the dishwasher; -Ensure the food delivery order was put away timely and not stored on the ground; and, -Ensure cooked food items were monitored and cooled…

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 develop a facility assessment which included all resources, staff education, staff competencies and facility based risk assessments. Findings include: I. Facility policy and procedure The facility assessment policy, dated October 2018, was provided by the nursing home administrator (NHA) on 9/5/23 at 2:29 p.m. It revealed in pertinent part, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. Once a year, and as needed, a designated team conducts a facility wide-assessment to ensure that the resources are available to meet the specific needs of our residents. The…

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

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 develop and implement effective action plans to address repeat deficiencies and ensure systemic and lasting improvement for quality of care issues. Findings include: I. Facility policy The Quality Assurance Process Improvement Program (QAPI) policy, revised March 2020, was received from the nursing home administrator (NHA) on 11/9/23 at 8:57 a.m. The policy documented in pertinent part, The QAPI program, overseen by the QAPI committee is designed to identify and address quality deficiencies through the analysis of the underlying cause and actions targeted at correcting systems at a comprehensive level. The methodology for analysis and action is guided by a…

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

Based on interviews and record review, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to follow up with residents' concerns regarding meals that were brought up by the food committee. Findings include: I. Facility policy and procedure The Grievance/Concern policy, dated 7/19/23, was provided by the nursing home administrator (NHA) on 8/17/23 at 6:30 p.m. It revealed in pertinent part, The patient/resident has the right to voice grievances to the Center or other agency or entity that hears grievances 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 patients, and other concerns regarding their Center stay. Purpose: to ensure that any patient or patient representative has the right to express a grievance/concern without fear of restraint, interference, coercion, discrimination, or reprisal in any form and to assure prompt receipt 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 interviews the facility failed to ensure that the personal funds accounts were managed adequate for seven (#21, #92, #65, #79, #34, #12 and #97) of seven residents reviewed for personal funds out of 70 sample residents. Specifically the facility failed to: -Ensure Resident #21 was assisted in applying for financial benefits and setting up an account so he could access money; and, -Ensure Resident #92, #65, #79, #34, #12 and #97 were notified and assisted in spending down their bank accounts. Findings include: I. Facility policy and procedure The Resident Funds policy, dated 1/16/23, was provided by the nursing home administrator (NHA) on 8/17/23 at 6:30 p.m. It revealed in pertinent part, Purpose: to ensure that residents have ready and reasonable access to their personal funds and to comply with state and federal regulations and other governmental guidelines which indicated what can and cannot be charged to a resident's fund. During the admission conference, the Admissions Director or designees will inform the resident/representative of the Resident Fund…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide an environment as free of accident hazards as possible and ensure residents received adequate supervision and assistance devices to prevent accidents for eight (#285, #297, #286, #295, #296, #125, #25 and #130) of nine residents reviewed for accident hazards out of 70 sample residents. Specifically, the facility failed to: -Identify elopement/wander risk, implement wander guard and develop a comprehensive wander risk care plan based on knowledge of previous secure placement and elopement evaluations for Resident #285, #297, #286, #295, #296 and #125; and, -Ensure timely interventions were put into place following falls for Resident #25 and #130. Findings include I. Identify elopement/wander risk, implement wander guard and develop a comprehensive wander risk care plan A. Facility policy and procedure The Elopement of Patient policy, revised 10/24/23, was received by the nursing home administrator on 8/17/23 at 6:30 p.m. It read…

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 diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for three (#64, #52 and #116) of four residents reviewed for dementia care out of 70 sample residents. Specifically, the facility failed to: -Provide a person-centered approach, individualized approach and treatment to Resident #116's dementia care to address her increased confusion prior to moving her to a new room within facility; -Provide a person-centered approach to Resident #64 and Resident #52's dementia care services to address their physically aggressive behavior in order to prevent physical altercations with each other and; -Have consistent, purposeful and meaningful activity programming for one of two secured units. Findings include I. Facility policy and procedures The Dementia policy and procedure, revised 6/1/21, was provided by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 32% or 18 errors out of 56 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 2/13/23, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right…

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 drugs and biologicals were labeled and stored in accordance with accepted professional standards, in five of five medication carts reviewed out of nine medication carts and two of two medication rooms reviewed out of five medication rooms. Specifically, the facility failed to: -Label and date insulin when opened; -Dispose of medications beyond the manufacturer use by date once opened; and, -Ensure medications and vaccines were not stored with resident food. Findings include: I. Manufacturer's recommendations Insulin Glargine (lantus) package insert read in pertinent part: Insulin Glargine pen should be stored at room temperature, below 86°F and must be used within 28 days or be discarded. Insulin Lispro package insert read in pertinent part: Insulin Lispro pen should be stored at room temperature, below 86°F and must be used within 28 days or be discarded. Insulin Levemir Vial package insert read in pertinent part: Insulin Lispro…

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 maintain an infection control program designed to prevent the spread of infection for one of three neighborhoods. Specifically, the facility failed to perform appropriate hand hygiene during medication administration. Findings include: I. Professional standard According to the Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings, last up updated 1/8/21, retrieved from https://www.cdc.gov/handhygiene/providers/index.html on 8/29/23, included the following recommendations: Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task (placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or…

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 the antibiotic stewardship program included antibiotic use protocols addressing documentation of the indication and duration of the antibiotic and a system to monitor antibiotic use for prophylactic antibiotics for five (#52, #74, #43, #45 and #76) of five residents reviewed for antibiotic use out of 70 sample residents. Specifically, the facility failed to evaluate and monitor the use of current prophylactic antibiotic usage for Residents #52, #74, #43, #45 and #76. Findings include: I. Professional reference The Centers for Disease Control and Prevention (2019) The Core Elements of Antibiotic Stewardship for Nursing Homes APPENDIX A: Policy and Practice Actions to Improve Antibiotic Use, retrieved 8/28/23 from: https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-a-508.pdf It read in pertinent parts: Reduce prolonged antibiotic treatment courses for common infections. A large study of antibiotic…

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 self-administration of medications was clinically appropriate for one (#13) of three out of 70 sample residents. Specifically, the facility failed to ensure Resident #13 was assessed for clinical appropriateness of self administration of medication and medications left at the bedside were secured. Findings include: I. Facility policy and procedure The Medication Self-Administration facility policy and procedure, revised on 3/1/22, was provided by the nursing home administrator (NHA) on 8/17/23 at 6:30 p.m. It revealed, in pertinent part, Patients who request to self-administer medications will be evaluated for safe and clinically appropriate capability based on the patient's functionality and health condition. If it is determined that the patient is able to self-administer a physician/advanced practice provider order (APP) is required. Self-administration and medication self-storage must be care planned. When applicable,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure three (#56, #64 and #52) out of 70 sample residents were kept free from abuse. Specifically, the facility failed to: -Ensure Resident #56 was kept free from physical abuse by Resident #188; and, -Ensure resident to resident altercation, which started with yelling, did not result in physical abuse with Resident #64 and Resident #52. Findings include: I. Facility policy and procedure The Abuse Prohibition policy and procedure, reviewed February 2021, was provided by the nursing home administrator (NHA) on 8/17/23 at 6:15 p.m. It read, in pertinent part, (The facility) prohibits abuse, mistreatment, neglect, misappropriation of property, and exploitation of all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. Abuse is defined as the willful infliction of injury, unreasonable confinement,…

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 provide services in accordance with currently accepted professional principles. Specifically, the facility failed to ensure medications were not dispensed and stored in medication cups in the top drawer of the medication cart. Findings include : A. Professional references Nursing rights of medication administration last updated on 9/5/22, was retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560654/ on 8/31/23 at 8:50 a.m. It read in pertinent part: ' Right time '-administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. A guiding principle of this ' right ' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability or other chemical mechanisms. I. Facility policy and procedure The Medication Storage policy 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 record review, observations, and interviews the facility failed to ensure one resident (#63) reviewed for activities of daily living (ADLs) received the necessary care and services to maintain their abilities in ADLs out of 70 sample residents. Specifically, the facility failed to provide language communication tools in order for Resident #63 to effectively communicate her needs, requests, opinions and participate in social conversation. Findings include: I. Resident status Resident #63, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the resident's diagnoses included pneumonia, unspecified organism and acute respiratory failure with hypoxia (low oxygen). The 7/3/23 minimum data set (MDS) assessment revealed the resident was severely impaired with a brief interview for mental status score of zero out of 15. She required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing and toilet use. II. Observation The staff…

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 facile to ensure activities designed to support residents physical, mental and psychosocial well-being were provided for two (#21 and #335) of 10 residents reviewed for activities out of 70 sample residents. Specifically, the facility failed to ensure Resident #21 and #335 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 Components policy, dated 7/1/14, was provided by the nursing home administrator (NHA) on 8/17/23 at 5:09 p.m. It revealed in pertinent part, The Recreation Department will create a program environment that supports resident/patient well being. Purpose: to provide experiences for each resident/patient which address the domains of wellbeing: identity, growth, autonomy, security, connectedness, meaning, and joy. The Program design policy, dated 7/1/14, was provided by the NHA on 8/17/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries from occurring for two (#1 and #335) of two residents out of 70 sample residents. Specifically, the facility failed to: -Ensure timely identification of a stage 2 pressure injury, notify the physician, receive a treatment order and update the comprehensive care plan for Resident #335; -Ensure treatment orders were in place from a licensed medical provider before a treatment was applied for Resident #335; and, -Ensure timely identification of Stage 1 deep tissue injury (DTI) for Resident #1. 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 8/24/23 from http://www.npiap.org/resources/educationaland-clinical-resources/npuap-pressure-injury-stages. read in pertinent part: A pressure injury is localized…

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 (#62) of four residents reviewed were provided with services or treatments to prevent the reduction in range of motion out of 70 sample residents. Specifically, the facility failed to ensure Resident #62 was provided with preventative measures for his contracture. Findings include: I. Resident status Resident #62, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebrovascular disease (stroke) affecting unspecified side and major depressive disorder. The 6/6/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. He required supervision from one person for bed mobility, dressing, toileting and personal hygiene. He had an upper extremity impairment on one side and he had five days 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 record review and interviews, the facility failed to have scheduled physician visits for two residents (#297 and #295) out of five newly admitted residents reviewed for physician visits out of 65 sample residents. Specifically, the facility failed to ensure the physician evaluated Resident #297 and Resident #295 timely upon admission. Findings include: I. Facility policy and procedure The Physician Visits policy, dated April 2013, was provided by the nursing home administrator (NHA) on 9/5/23 at 2:29 p.m. It revealed in pertinent part, The Attending Physician will visit residents in a timely fashion, consistent with applicable state and federal requirements and depending on the individual ' s medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. II. Resident #297 A. Resident status Resident #297, under age [AGE], was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included mood disorder 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 provide each resident with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the allergens and preferences of each resident for two (#118 and #14) of two residents out of 70 sample residents. Specifically, the facility failed to: -Ensure Resident #118's allergen to gluten was not served to her; and, -Ensure Resident #14 requests, preferences, and options for a vegetarian diet were served to her. I. Facility policy and procedure The Selective Menus policy, dated 5/1/23, was provided by the nursing home administrator (NHA) on 8/17/23 at 1:15 p.m. It revealed in pertinent part, Personal Choice Menus are distributed to the residents based on the facility plan. Personal Choice Menu selections are reviewed for appropriateness for the resident's diet. Inappropriate selections that are high risk and unsafe may include: allergy to food or ingredient, selected food…

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 document review, record review, observations, interviews, and facility policy review, the facility failed to prevent potential accidents by failing to: 1. ensure hot water temperatures were maintained at safe temperatures between 105 - 115 degrees Fahrenheit (F) in 1 (700 Hall; secured memory care unit) of 8 halls in the facility. 2. complete a smoking assessment for one (Resident #260) of one newly admitted residents who smoked tobacco products and required such an assessment prior to smoking. Findings included: 1. A review of a document titled, Direct Supply TELS, printed 06/10/2022, revealed, Water temps [temperatures]: test and log the hot water temperatures .Ensure patient room water temperatures are between 105 [degrees] and 115 [degrees] Fahrenheit. On 06/07/2022 at 9:39 AM, the hot water in the sink of room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] felt hot to the touch. The rooms were located on the secured memory unit. The temperature of the water in room [ROOM NUMBER] was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I screening was completed within thirty days of admission for one (Resident #89) of one residents reviewed for PASARR. Findings included: A review of the facility policy, revised 01/15/2021, titled, Preadmission Screening for Mental Disorder and/or Intellectual Disability Patients, revealed, Purpose: To ensure that all individuals are screened for a MD [Mental Disorder] and/or ID [Intellectual Disability] prior to admission. A review of the Centers for Medicare and Medicaid (CMS) COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, updated 05/24/2021, revealed, Waive Pre-admission Screening and Annual Resident Review (PASARR). CMS is waiving 42 CFR 483.20 (k), allowing nursing homes to admit new residents who have not received Level 1 or Level 2 Preadmission Screening. Level 1 assessments may be performed post-admission. On or before the 30th day of admission, new…

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 2. A review of Resident #32's admission Record revealed the facility admitted the resident on 02/28/2020 with diagnoses which included chronic obstructive pulmonary disease (COPD) and vascular dementia without behavioral disturbance. A review of Resident #32's annual Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. A review of Resident #32's care plan, dated 03/21/2021, revealed the resident exhibited or was at risk for respiratory complications related to COPD, with goals that the resident would have no sign/symptoms of respiratory distress during this treatment period. The interventions included to monitor and report oxygen (O2) saturation levels via pulse oximetry as ordered and prn (pro re nata; as needed) and administer O2 as ordered via nasal cannula. Further review of Resident #32's care plan revealed no interventions addressing the resident changing oxygen settings. A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and review of the facility policy, the facility failed to provide appropriate treatment and care for 1 of 2 residents (Resident #96) with alterations in skin integrity. Specifically, Resident #96 had a rough patch of skin with open cracks in the skin that had not been identified by the facility. Findings included: A review of the facility policy titled, Skin Integrity Management, with a revision date of 06/01/2021, revealed, The implementation of an individual patient's [resident] skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implement revisions to the plan of care as needed .3. Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. 3.3 Perform wound observations and measurements and complete Skin Integrity Report (Forms on Demand (FOD) #GHC-692R) upon initial identification…

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, interviews, and policy review, the facility failed to ensure an indwelling urinary catheter was utilized with adequate justification for one (Resident #103) of three residents sampled with indwelling urinary catheters. Findings included: A review of the facility's policy and procedure, titled NSG209 Catheter: Urinary - Justification for Use, last revised on 03/01/2022, revealed: Patients who enter the Center without an indwelling catheter will not be catheterized unless the patient's clinical condition demonstrates that catheterization was necessary. Indwelling catheter criteria: Contamination of Stage III or IV wound with urine which has impeded healing despite appropriate personal care for the incontinence. Purpose .To ensure there is a valid medical justification for use of an indwelling catheter and that the catheter is discontinued as soon as clinically warranted. A review of Resident #103's admission Record revealed the facility admitted the resident on 02/10/2022 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, interviews, policy review, and record review, it was determined the facility failed to maintain an infection control program to help prevent the transmission of communicable diseases for two (Resident #154 and Resident #159) of 32 sampled residents. Observations revealed staff did not wear appropriate personal protective equipment (PPE) when entering the rooms of Resident #154 and Resident #159 and there was not appropriate signage posted on the residents' doors about infection prevention precautions. Findings included: Review of the policy titled, Infection Control Policies and Procedures, dated 06/07/2021, revealed, In addition to Standard Precautions, Contact and Airborne Precautions will be implemented for patients suspected or confirmed to have Covid19 based on the Centers for Disease Prevention and Control (CDC) guidance. For the purposes of this policy, Airborne Precautions is defined as wearing an N95/approved KN95 respirator upon entry into the patient's room, in addition 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.