The Center At Cordera

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 17 of 44 resident rooms in four hallways. Specifically, the facility failed to ensure walls, and ventilation fans were cleaned and properly maintained. Findings include: I. Initial observations Observations of the resident living environment was conducted on 4/24/23 at 3:30 p.m. revealed: room [ROOM NUMBER]: The exhaust fan in the resident's restroom had a large accumulation of dust which was affecting the functionality of the fan. room [ROOM NUMBER]: The wall next to the resident's restroom had peeling and chipped sheetrock approximately four feet high by two inches wide. The exhaust fan in the resident's restroom had a large accumulation of dust which was affecting the functionality of the fan. room [ROOM NUMBER]: The wall next to the resident's restroom had chipped and peeling sheetrock approximately four two feet high by two inches wide. The exhaust fan 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 observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring for one (#9) of two residents reviewed out of 28 sample residents. Specifically, the facility failed to ensure Resident #9's bilateral heels were offloaded while in bed. Findings include: I. Professional reference The National Pressure Injury Advisory Panel (NPUAP), Prevention and Treatment of Pressure Ulcers accessed on 4/27/23 from https://npiap.com/ read, steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. II. Facility policy and procedure The Pressure Ulcer policy, revised 2/8/21, was provided by the nursing home administrator (NHA) on 4/25/23 at 12:25 p.m. It read in pertinent part: The (name) will provide the necessary requirements to ensure that a patient…

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 implement interventions to reduce hazards and risks for falls for two (#198 and #197) residents out of five residents reviewed for falls out of 28 sample residents. Specifically, the facility failed to ensure Resident #197 and #198 were provided the interventions available to prevent repeated falls and staff were aware of person-centered interventions. Findings include: I. Facility policy and procedure The Fall Prevention Program policy, revised August 2022, was provided by the nursing home administrator (NHA) on 4/24/23 at 4:06 p.m. It read in pertinent part, Any patient deemed to be high risk will have the following interventions implemented or at least considered: -Low bed (or lower our standard bed to its lowest position) -Bedside floor pads on both sides of bed. For post falls: -Determine what interventions need to be implemented to prevent further falls. Intervention will be reviewed by Interdisciplinary Team for appropriate…

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 maintain communication with the hospice provider, including how the communication would be documented between the facility and the provider for two (#198 and #104) of two residents reviewed for hospice care services out of five residents reviewed for hospicare care out of 28 sample residents. Specifically, the facility failed to: -Demonstrate documentation of a collaboration of care between the facility and the hospice provider for Resident #198; and, -Ensure medication orders from the hospice provider were received and administered for Resident #104. Findings include: I. Resident #198 A. Resident status Resident #198, age [AGE], was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease and major depressive disorder. The 4/17/23 minimum data set (MDS) assessment revealed a brief interview of mental status (BIMS) was not conducted with the 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 observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection, including COVID-19. Specifically, the facility failed to: -Ensure staff and visitors wore the appropriate personal protective equipment (PPE) and performed appropriate hand hygiene when entering transmission-based precaution (TBP) rooms; -Ensure residents were offered hand hygiene before meals; -Ensure staff performed handwashing; -Ensure equipment was disinfected between residents; and, -Ensure housekeeping used chemicals correctly. Findings include: I. Facility policy and procedures A. The Infection Prevention, Control, and Immunizations policy, last revised 2/8/21, was provided by the nursing home administrator via email on 1/17/22 at 3:37 p.m. It read in pertinent part, Staff will use standard precautions (hand hygiene and appropriate PPE equipment). Staff will follow…

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 that professional standards of practice were followed for three (#13, #40 and #204) of three out of 29 sample residents. Specifically the facility failed to: -Notify the provider of missed medications, late medications or unavailable medications for Resident #40 and #204 (cross-reference F755 pharmacy services); and, -Obtain a crush medication order from the physician prior to administering medications to Resident #13; Findings include: I. Facility policy The Medication Administration policy, revised on 2/8/21, provided by the nursing home administrator (NHA) on 1/19/21 read in pertinent part; It is the policy of this facility that medications are to be administered as prescribed by the attending physician. Procedures: -Medications must be administered in accordance with the written orders of the attending physician. -All current drugs and dosage schedules must be recorded on the patient's medication administration record (MAR as…

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 good grooming and personal hygiene for four (#10, #298, #13, and #40) of six residents reviewed out of 29 sample residents. Specifically, the facility failed to: -Ensure Residents #10, #298, and #40 received their scheduled showers; -Ensure Residents #40 and #13 received timely meal assistance; and, -Ensure Residents #40 received catheter care according to the care plan to assist with the prevention of infections (cross-reference F880, infection control). Findings include: I. Resident #10 A. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO) diagnoses included multiple fractures, and abnormality of gait and mobility. The 12/15/21 minimum data set (MDS) revealed the resident had moderately impaired cognitive status with a brief interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide an ongoing program to support residents in their choice of activities designed to meet the interests of the resident and support the physical, mental, and psychosocial well-being of each resident for three (#13, #16, and #10) of four out of 29 sample residents. Specifically, the facility failed to offer and provide activities to Residents #13, #16, and #10. Findings include: 1. Resident #13 A. Resident status Resident #13, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the December 2021 clinical physician orders (CPO), diagnoses included traumatic subdural hemorrhage with loss of consciousness of unspecified duration, abnormalities of gait and mobility, generalized muscle weakness, dysphagia, cognitive communication deficit, aphasia, disorientation, diabetes mellitus. The December 2021 minimum data set (MDS) assessment documented the resident had moderate cognitive impairment with a brief interview 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 observations, interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support. Findings include: I. Professional reference According to the National Certification Council of Activity Professionals (NCCAP) at www.nccap.org accessed 2/1/22, an activity director must meet specific qualifications in education, certification and/or experience. The qualifications read in part: The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who is: Licensed or registered, if applicable, by the State in which practicing; .Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body .Has 2 years of experience in a social or recreational program within the last 5 years, one of which was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to administer oxygen in a manner consistent with professional standards of practice for three (#13, #16 and #296) out of three sample residents out of 29 sample residents. Specifically, the facility failed to: -Clarify titration orders for Residents #13, #16, and #296; and, -Ensure the oxygen tubing was dated when when changed for Residents #13, #16 and #296. Findings include: I. Facility policy On 1/19/22, the nursing home administrator (NHA) provided a copy of the oxygen policy dated 12/20/18. The policy read in pertinent parts, a patient receiving oxygen therapy, the patient's record must reflect ongoing evaluation of the patient's respiratory status, response to oxygen therapy and include, at a minimum, the attending practitioner's orders and indication for use. In addition, the record should include the type of oxygen delivery system; when to administer and/or when to discontinue; equipment settings for the prescribed flow rates;…

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 registered nurses (RNs) were able to demonstrate competencies 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 ensure nursing staff had completed competencies prior to providing skilled services as ordered by the physician for three out of three nurses reviewed for competencies. Findings include: I. Facility acuity On 1/17/22 the facility had seven residents with a catheter, three residents who were receiving intravenous therapies, one resident with an ostomy, and three residents receiving nutrition and medications through tube feedings to include a nasogastric tube and percutaneous endoscopic gastrostomy (PEG) tubes. II. Competency records The facility did not have any competency records for registered nurses (RN) #3, #4, and #5. III. Interviews Registered nurse (RN) #7 was interviewed on 1/19/22 at 1:45 p.m. She said she had not had competencies completed. The nursing home…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY III. Resident #32 A. Resident status Resident #32, age [AGE], was admitted on [DATE]. According to the December 2021 CPO, diagnoses included stable burst fracture of T11-T12 vertebra, Covid-19, generalized muscle weakness, abnormalities of gait and mobility, and anxiety disorder. The December 2021 minimum data set (MDS) assessment documented the resident had severe cognitive impairment and a brief interview for mental status (BIMS) was not conducted. The MDS coded the resident required limited assistance of one person with transfers, mobility, and supervision of one person for personal hygiene and eating. B. Record review The January 2022 CPO showed a physician's order for Lidocaine patch 4% to be applied to the resident's left hip topically every morning for postoperative pain. The order start date was 12/28/21. The December 2021 and the January 2022 MAR were reviewed and found the Lidocaine patch was not available and was not administered. The medication administration record (MAR) read as follows: On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure as needed (PRN) orders for psychotropic drugs were evaluated by a physician within 14 days for use and duration for four (#13, #37, #40 and #152) of five residents reviewed for unnecessary medication use out of 29 sample residents. Specifically, the facility failed to: -Re-evaluate the use of a PRN psychotropic medication by a physician within 14 days for Residents #13, #37 and #40; -Have a duration for the PRN psychotropic medication for Resident #13, #37 and #40; -Follow several pharmacy recommendations to discontinue a PRN psychotropic medication; and, -Track hours of sleep for the use of a hypnotic for Resident #152. Finding include: I. Facility policy and procedures The Medication Administration policy, revised on 2/8/21, provided by the nursing home administrator (NHA) on 1/19/21 read in pertinent part: It is the policy of the facility that medications are to be administered as prescribed by the attending 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 record review and interviews, the facility failed to ensure that the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#37) of one resident reviewed for hospice services out of 29 sample residents. Specifically, the facility: -Failed to have a member of the interdisciplinary team (IDT) team who collaborated with hospice to provide coordinated care for a resident; -Failed to orientate hospice aides to the facility including the policies and procedures; and, -Failed to develop a care plan that included frequency of visits for a resident receiving hospice services. I. Facility policy The Hospice Program policy, provided by the nursing home administrator (NHA) on 1/19/22 at 11:10 a.m. included; The facility and hospice, with input from the patient and family, will establish a coordinated plan of care, which reflects and supports the hospice philosophy. -The plan of care will include directives for managing pain 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 maintain dignity during personal care in a manner consistent with professional standards of practice for one (#13) out of one out of 29 sample residents. Specifically, the facility failed to ensure privacy during personal care for Resident #13. Findings include: I. Facility policy On 1/19/22 the nursing home administrator (NHA) provided an undated copy of the facilities notice of privacy practices that states the facility is committed to keep health information as confidential as required by law and it will not be shared with others without written permission except as needed for treatment, payment, and health care operations. II. Personal privacy 1. Resident #13. A. Resident status Resident #13, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the December 2021 computerized physician orders (CPO), diagnoses included traumatic subdural hemorrhage with loss of consciousness of unspecified duration, abnormalities of gait 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 record review and interviews, the facility failed to implement an effective discharge planning process that focused on the resident's discharge goals, to ensure the discharge needs were identified, resulted in the development of a discharge plan, and involved the interdisciplinary team in the ongoing process, for one (#302) of three residents reviewed out of 29 sample residents. Specifically, the facility failed to ensure there was discharge planning for Resident #302 to include: -Regarding further communication with the resident about her goals, treatment needs, preferences for discharge and/or the change from her previously stated goal to discharge home; and, -Development of a comprehensive discharge plan by the interdisciplinary team (IDT). Findings include: I. Resident status Resident #302, age [AGE], was admitted on [DATE] and discharged on 11/24/21. According to the November 2021 computerized physician orders (CPO), diagnoses included hypertension, obstructive uropathy and hyperlipidemia. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide the necessary assistance with activities of daily living (ADL) for one (#13) out of two residents reviewed for communication needs out of 29 sample residents. Specifically, the facility failed to develop an effective person-centered individualized communication plan and failed to train the staff on family identified communication tools for Resident #13. Findings include: I. Facility policy On 1/19/22, the nursing home administrator (NHA) provided a copy of the ADL services policy dated 12/3/20. The policy read that the resident shall receive assistance with ADLs every shift as appropriate. If the resident requires assistance with meal services, a staff member will be assigned to the resident to provide the services needed. If the resident is not able to verbally tell staff what their needs are, the staff will anticipate their needs and also ask power of attorney (POA)/Family what resident's daily routine was at home and attempt…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#10) of one reviewed out of 29 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan. Specifically, the facility failed to: -Ensure physician's orders were followed in regards to the administration of Acetaminophen; and, -Ensure the resident's blood pressure was monitored when outside of his baseline. Findings include: I. Acetaminophen administered in excess of 3 milligrams (mg) A. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO) diagnoses included multiple fractures, and abnormality of gait and mobility and epilepsy. The 12/15/21 minimum data set (MDS) revealed the resident had moderately impaired cognitive status with a brief interview for mental status score of 11 out of 15. The resident was coded as requiring limited assistance for activities of daily living 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 ensure supervision and assistive devices to prevent accidents for two (#298 and #299) of four residents reviewed for falls out of 29 sample residents. Specifically, the facility failed to ensure: -Resident #298 was assessed properly for falls, and interventions were put into place to prevent falls; and -Effective interventions to prevent falls for Resident #299 were assessed, provided and followed. Findings include: I. Facility policy and procedure The Fall Prevention Policy revised on 2/9/21 was received on 1/19/22 at 10:11 a.m., by the nursing home administrator read in pertinent parts, Any patient deemed to be high risk by nursing and/or therapy staff will have the following interventions implemented immediately or at least considered: though physical and occupational therapy evaluation, low bed, bedside floor pads on both sides of bed, routine toileting throughout shift, increase time spent in common area in ine of sight of nursing…

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 enter the facility without an indwelling catheter was not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary, consistent with professional standards of practice for one (#147) of three residents reviewed for catheters out of 29 sample residents. Specifically, the facility: -Failed to obtain an order for a catheter for Resident #147; -Failed to notify the medical power of attorney (MPOA) of the catheter placement for Resident #147; -Failed to care plan the use of a catheter for Resident#147; and, -Failed to have ongoing monitoring of a catheter for Resident #147. Findings include: I. Facility policy The Foley Catheter policy, revised 2/8/21, provided by the nursing home administrator (NHA) on 1/19/22 at 5:01 p.m. included, When possible, all Foley catheters should be removed prior to admission unless an appropriate diagnosis exists. If a patient requires an indwelling…

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 manage pain in a manner consistent with professional standards of practice for one (#201) of three residents reviewed out of 29 sample residents. Specifically, the facility failed to administer pain medications in a timely manner for Resident #201. Findings include: I. Facility policy and procedure The analgesia policy and procedure revised on 2/1/2018 provided by the nursing home administrator (NHA) on 1/19/22 read in pertinent part: Pain is a medical problem that we face on a daily basis in the facility. Frequently residents arrive from the hospital with acute pain secondary to being transformed and transported. The facility protocol should help with alleviating any delays in our attempts to control the pain. Upon admission, all residents will be evaluated for pain. Pain level will also be evaluated every shift. Once a resident expresses the perception of pain or makes a request for pain medication, resident will be provided with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide dementia care in a manner consistent with professional standards of practice for one (#32) out of one resident out of 29 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #32. Finding include: I. Facility policy The Dementia Care policy, dated 2/10/2020, states the purpose of dementia care in this facility is to provide a quality of life with respect, dignity, and caring in a friendly, clean, and non-abusive atmosphere. This facility is committed to serving the needs of all elders including elders with dementia-related behaviors. The policy goes on to state that dementia is a disease process referring to progressive decline in cognitive function, intellectual functions including thinking, memory, and reasoning affecting everyday life. The facility promotes person-centered care considering the elder's needs, not just medical or physical needs. 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 accuracy of records for one resident (#47) out of 29 sample residents. Specifically, the facility failed to document the events that occurred surrounding the death of Resident #47. Findings include: I. Facility policy The Facility Records policy, revised on [DATE], was provided by the nursing home administrator (NHA) read in pertinent part: A completed health record shall be maintained on every patient from the time of admission through the time of discharge. All health records shall contain the following procedures. Nursing records dated and signed by nursing personnel, which include the patient evaluation of special procedures performed, notes of observations, and the time and circumstances of death if applicable. II. Record review Review of Resident #47's medical orders of scope of treatment (MOST) form revealed he wanted full treatment to include cardiopulmonary resuscitation (CPR). He signed the form on [DATE]. The nurse note dated [DATE]…

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.