Amberwood Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents were permitted to remain in the facility and not transfer or discharge for one (#76) of two residents out of 39 sample residents. Specifically, the facility failed to provide Resident #76 with an appropriate discharge process. Findings include: I. Facility policy and procedure The Facility-Initiated Transfer or Discharge policy and procedure, revised October 2022, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: the transfer or discharge is necessary for the resident's welfare and the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to permit a resident to return to the facility following a facility-initiated transfer to the hospital for one (#76) of two residents reviewed for discharge out of 39 sample residents. Specifically, the facility failed to reassess Resident #76's status at the time the resident sought to return to the facility after a facility-initiated transfer to the hospital, and directed the hospital to discharge the resident to a sister facility instead of allowing the resident to return to the facility. Findings include: I. Facility policy and procedure The Facility-Initiated Transfer or Discharge policy and procedure, revised October 2022, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification 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 incorporate the recommendations from the PASRR (preadmission screening and resident review) Level II determination and evaluation report into the assessment, care planning and transition of care for two (#65 and #43) of three residents reviewed out of 39 sample residents. Specifically, the facility failed to initiate therapy as recommended by the PASRR Level II in a timely manner for Resident #65 and Resident #43. Findings include: I. Facility policy and procedure The Behavioral Health Services policy and procedure, revised February 2019, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part, The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral health services are provided to residents as needed 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 services provided to residents met professional standards of quality for one (#15) of one resident out of 39 sample residents. Specifically, the facility failed to ensure Resident #15's as needed (PRN) pain medications had physician ordered parameters related to the strength of the medications and the severity of the resident's pain level (on a pain scale of 1-10). Findings include: I. Professional Reference According to the Society for Post Acute and Long-term Care (AMDA), Pain Management clinical practice guideline (2021) , retrieved on 10/17/24 from: https://paltmed.org/sites/default/files/2024-02/PainManagement2021CPGFinal.pdf, Levels of pain management identify pain levels by severity. Non-opioid analgesics for mild pain, low potency opioids for moderate pain, high potency opioids for severe pain, and adjunctions combined with any step.Giving PRN analgesics based on guesswork may limit the benefits and increase the risk 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 provide the resident representative with the proper discharge notifications for one (#182) of two residents out of 39 sample residents. Specifically, the facility failed to develop and implement a collaborate discharge plan with Resident #182 Findings include: I. Facility policy and procedure The Facility-Initiated Transfer or Discharge policy and procedure, revised October 2022, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part, A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. II. Resident #182 A. Resident status Resident #182, age [AGE], was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included dementia, type 2 diabetes mellitus,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for one (#24) of four residents reviewed for assistance with ADLs out of 39 sample residents. Specifically, the facility failed to ensure Resident #24's fingernails were trimmed and clean. Findings include: I. Facility policy The Activities of Daily Living (ADL), Supporting policy, revised March 2018, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:30 p.m. It read in pertinent part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Residents will be provided with care, treatment and services to ensure that their ADLs do…

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 were provided services that meet professional standards for one (#51) of one resident out of 39 sample residents. Specifically, the facility failed to ensure Resident #51's leg wraps for lymphedema (a chronic condition that causes swelling due to a buildup of lymph fluid in the body) were ordered in a timely manner. Findings include: I. Resident status Resident #51, age greater than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included lymphedema, heart disease, and obesity. The 9/24/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She was dependent on staff for dressing and personal hygiene. II. Record review A progress note documented by the nurse practitioner (NP), dated 9/17/24 at 11:15 a.m., revealed Resident #51 was referred to the lymphedema clinic 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 proper treatment and assistive devices to maintain vision abilities for one (#18) of one resident out of 39 sample residents. Specifically, the facility failed to arrange optometry services timely for Resident #18. Findings include: I. Resident #18 A. Resident status Resident #18, age [AGE], was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis of one side of the body). The 9/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of nine out of 15. He required partial/moderate assistance for upper body dressing and personal hygiene. He required supervision or touching assistance with oral hygiene. The assessment indicated the resident had adequate vision and had corrective lenses. B. Resident observation and interview On 10/9/24 at 3:41 p.m. Resident #18 said he had asked…

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 one (#65) of two residents reviewed for accidents out of 39 sample residents received adequate supervision to decrease and/or prevent risk for accident hazards. Specifically, the facility failed to implement a plan of care that adequately addressed the risks posed to Resident #65 and other residents in the facility due to Resident #65's smoking habit and history of self-inflicted injury from fire. Findings include: I. Facility policy and procedure The Smoking policy, dated 6/17/24, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part, Smoking is a privilege. To be an independent smoker, residents must demonstrate that they are safe to smoke by staff assessment and must comply with all smoking rules. II. Resident #65 A. Resident status Resident #65, age less than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included schizophrenia (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 observations and interviews, the facility failed to ensure one (#3) of one resident out of 39 sample residents were free of significant medication errors. Specifically, the facility failed to ensure the insulin pen was primed prior to administration for Resident #3. Findings include: I. Professional reference According to the Tresiba product information, dated July 2022, retrieved on 10/16/24 from https://www.mynovoinsulin.com/insulin-products/tresiba/support-and-resources/videos-and-resources.html, Priming the pen, turn the dose selector to 2 (two) units, hold the pen with the needle pointing up, tap the pen gently to allow any air bubbles to ride to the top, depress and hold the dose button with the needle pointing up. II. Facility policy and procedure The Administering Medications policy and procedure dated, April 2019, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:00 p.m. It revealed in pertinent part, Medications are administered in a safe and timely manner, and 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 and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically the facility failed to: -Ensure the surface disinfectant time was followed for proper disinfection; -Ensure resident rooms were cleaned and disinfected properly; -Ensure staff performed proper hand hygiene; and, -Ensure facility maintained water management program for Legionella. Findings include: I. Failure to clean resident rooms appropriately A. Professional reference According to the Center for Disease Control (CDC), Hand Hygiene Basics retrieved on 5/15/23 from: http://www.cdc.gov/handhygiene/basics.html (2019) read in pertinent part, healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patient including before patient contact; after contact with blood,body fluids, or contaminated surfaces…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interviews the facility failed to ensure one (#39) out of five residents m reviewed was free from a significant medication error of 31 sample residents. Specifically, the facility failed to ensure Resident #39 was administered an accurate dose of cholecalciferol (Vitamin D) medication. Findings include: I. Facility policy The Documentation of Medication Administration policy, revised April 2007, was provided by the facility on 5/19/23 at 9:25 a.m. It read in pertinent part: Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. All medication orders will be supported by appropriate care processes and practices. The physician will identify situations where medications should be tapered, discontinued or changed. II. Resident #39 A. Resident status Resident #39, over the age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the May 2023 computerized physician orders (CPO)…

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 one (#72) of three residents had the right to participate in the development and implementation of his or her person-centered plan of care out of 31 sample residents. Specifically, the facility failed to: -Conduct care plan/conference meetings for Resident #72; and, -Ensure either the resident or the responsible party was involved in the care conferences. Findings include I. Facility policy and procedure The Care Planning Interdisciplinary Team policy, revised March 2022, was received from the nursing home administrator (NHA) on 5/19/23 at 3:40 p.m. It revealed in pertinent part, the interdisciplinary team is responsible for development of resident care plans. The resident, the residents family and/or the residents legal representative/guardian or surrogate were encouraged to participate in the development of and revision to the resident's care plan. Care plan meetings were scheduled at the best time of day for the resident and family when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure the resident's right to receive services in the facility with reasonable accommodation of the resident's needs and preferences for two (#21 and #54) of five residents reviewed out of 31 sample residents. Specifically, the facility failed to: -Follow the physical therapy discharge plan to install a pole in the resident's room for the purpose of assisting the Resident #21 with transferring; and, -Provide a Resident #54 with a call light option that was conducive to her abilities. Findings include: I. Facility policy The Accommodation of Needs, revised March 2021, was provided on 5/19/23 at 3:41 p.m., by the nursing home administrator (NHA). The policy read in pertinent part: The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment are evaluated upon admission and reviewed on an ongoing basis. In order to accommodate the individual needs and preferences,…

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 make prompt efforts to resolve a grievance for one (#60) of six residents reviewed for grievances out of 31 sample residents. Specifically, the facility failed to act on a report of a missing passport, driver's license/ID, and social security card for Resident #60. Findings include: I. Facility policy The Grievances/Complaints, Recording and Investigating policy, revised April, 2017, was provided by the social services director (SSD) on 5/18/23 at 3:00 p.m. It read in pertinent part: Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended within ____(number not filled in on policy) working days of the filing of the grievance or complaint. II. Resident #60 Resident #60, age [AGE], was admitted on [DATE]. According to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to develop a comprehensive care plan that included measurable objectives needed to provide effective and person centered care for two ( #29 and #21) out of 31 sample residents. Specifically, the facility failed to: -Ensure Resident #29's bed height preference was on the comprehensive care plan; and, -Revise Resident #21's care plan to include intravenous (IV) administration of antibiotics after hospitalization. Findings include: I. Facility policy and procedure The Comprehensive Care Plan policy, revised March 2022, was provided by the nursing home administrator (NHA) on 5/19/23 at 3:41 p.m. It read in pertinent part, A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT), with input from the resident, and his/her family…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure one (#61) of two residents reviewed for communication out of 31 sample residents were provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to ensure Resident #61 had access to a whiteboard for his communication needs. Findings include: I. Facility policy and procedures The Activity of Daily Living (ADLs), Supporting policy and procedure, revised March 2018, was by the nursing home administrator (NHA) on 5/19/23 at 3:42 p.m. It read in pertinent part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Residents will be provided with care, treatment and services to ensure 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 staff interviews, the facility failed to provide appropriate care and services to maintain the activities of daily living for two (#2 and 71) of five residents who required extensive assistance out of 31 sample residents. Specifically, the facility failed to: -Ensure Resident #2 and Resident #71 received consistent showers according to their preference and plan of care; and, -Ensure Resident #71 received regular nail care according to her preference and plan of care. Findings include: I. Facility policy The Shower/Bath policy, revised February 2018, was provided on 5/19/23 (a day after the survey exit). The policy read in part: The purposes of this procedure are to promote cleanliness, provide comfort to the resident, and observe the condition of the resident's skin. Document the date and time the shower/tub bath was performed and document reasons for refusal and the interventions taken. The Fingernails/Toenails care policy, revised February 2018, was provided by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to ensure one (#40) out of 31 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to investigate, determine origin and monitor a bruise to Resident #40's wrist. Findings include: I. Resident status Resident #40, age [AGE], was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnoses included atherosclerotic heart disease (plaque buildup in the arteries supplying blood to heart), reduced mobility and dementia. The 3/3/23 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. She required extensive assistance of two staff members with transfers; and, extensive assistance of one staff member for bed mobility, dressing, toilet use and personal hygiene. II. Observation 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 three (#83, #187 and #24) of six out of 31 sample residents who required respiratory care were provided such care and services consistent with professional standards of practice. Specifically, the facility failed to: -Ensure a physician's order was obtained for Resident #83 and Resident #187 for use of supplemental oxygen; and, -Ensure Resident #24's supplemental oxygen was on correct order liter flow per physician's order Findings include I. Facility policy and procedure The Oxygen administration policy, revised October 2010, received from the nursing home administrator on 5/19/23 at 3:40 p.m. revealed in pertinent part, the purpose of this procedure is to provide guidelines for safe oxygen administration. Verify there is a physician order. Documentation in medical record includes: rate of oxygen flow, route, frequency, and duration. II. Resident #83 A. Resident status Resident #83, age [AGE], was admitted on [DATE]. According to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure assessment, inspection and maintenance of a bed cane (fixed bed rail assistive device) was completed for one (#51) resident of three residents reviewed using bed cane for positioning out of 31 sample residents. Specifically, for Resident #51, the facility failed to: -Assess the resident for risk of entrapment prior to installing or using a bed cane/bed rail; -Obtain consent from resident; and, -Check bed rail/bed cane regularly for ongoing maintenance. Findings include: I. Professional reference The U.S. Food and Drug Administration (FDA) Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, last updated 2/27/23 and retrieved on 5/23/23 from https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health-care-providers-using-adult-portable-bed-rails included bed rail safety guidelines, read in pertinent part: -Any decision regarding bed rail use 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.

Based on observations, record review, and interviews, the facility failed to ensure proper storage of medications for one of two medication storage rooms and one of three medication storage carts. Specifically, the facility failed to: -Discard prepared medications on the medication cart that had not been administered to residents; -Maintain medication storage room in a clean and orderly manner; and, -Discard medication that had expired. Findings include: I. Facility policy and procedure The Storage of Medications, revised November, 2020, was provided by the nursing home administrator (NHA) on 5/18/23. The policy heading included, the facility stores all drugs and biologicals in a safe, secure and orderly manner. The policy, in part, contained the following information: -Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they were received. -Nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Discontinued, outdated or deteriorated drugs or biologicals are…

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

Based on observations, staff interviews, and record review, the facility failed to ensure food was served and stored under sanitary conditions during meal services. Specifically, the facility failed to: -Offer, assist or encourage resident to perform hand hygiene prior to eating meals and after eating meals and handling and throwing away trash from the meal, in one of one dining rooms and two of three units; and, -Clean refrigerator used to store resident snacks and outside foods; date and label sandwiches for resident consumption and discard expired food items, in two of two unit refrigerators used for resident food. Findings include: I. Resident hand hygiene A. Facility policy The Assistance with Meals policy, revised July 2017, was provided by the corporate nurse consultation (CNC) on 2/15/22 at 3:01 p.m., read in pertinent part: The nursing staff will prepare residents for eating. -The policy did not provide a policy or procedure on resident hand hygiene prior to or after meals. B. Observations Lunch service was observed in the main dining room on 2/9/22 from 11:15 a.m. to 12:45…

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 resident interviews, staff interviews, and the tasting of the test tray, the facility failed to consistently serve food that was palatable and at the proper temperature. Specifically, the facility failed to ensure resident food was palatable in taste, texture, appearance, and temperature. Findings include: I. Facility policy and procedure The Food Wholesomeness policy and procedure, developed 1/12/16, was provided by the corporate nurse consultant (CNC) on 2/14/22 at 5:15 p.m. It read, in pertinent part, Food temperatures are taken for serving at every meal and at the point when a resident is served a meal on a regular basis. Hot foods are cooked to above 165 degrees or per USDA (United State Department of Agriculture) Food Code and held at least 140 degrees until service. II. Resident group interview The resident group interview was conducted on 2/14/22 at 10:35 a.m. The residents in attendance were Resident #16, #46, #13, #33, and #54. All residents were identified by facility and assessment as interviewable. Resident #33 said meals were served in styrofoam containers.…

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 notify, make immediate notification to the resident representative when the resident had a significant change in condition requiring a need to alter treatment; initiate a resident transfer or discharge from the facility; or when the resident was involved in an accident with an injury or portent for an injury for two (#62 and #116) of three residents out of 30 sample residents. Specifically, the facility failed to immediately inform the resident representative(s): -For Resident #62 when the resident was transferred to the hospital for assessment and treatment of a medical illness; and, -For Resident #116 after a fall which could have resulted in an injury with the potential for a need for physician intervention. (Cross-Referenced to F689 failure to prevent a resident fall). Findings include: I. Facility policy The Physician Notification policy, revised [DATE], was received from the director of nursing (DON) on [DATE] at 1:10 p.m. It read in pertinent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure two (#42 and #117) of five residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, hygiene, dressing and grooming, out of 30 sample residents. Specifically, the facility failed to: -Provide timely incontinent care and repositioning for Resident #42 and #117, who required staff assistance for bed mobility and incontinence care; and, -Provide Resident #42 positioning and set-up assistance for eating meals. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) Support policy, revised May 2018, provided by the corporate nurse consultant (CNC) on 2/15/22 at 3:01 p.m., read in pertinent part: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently…

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 (#15) of three residents with limited mobility reviewed for range of motion (ROM) received appropriate services, equipment, and assistance to maintain maximal mobility and services to prevent further decrease in ROM, out of 30 sample residents reviewed. Specifically, the facility failed to ensure Resident #15 received consistent restorative services for daily splinting assistance and passive range of motion (ROM) six day a week as written in the resident comprehensive care plan based on therapy services recommendations; to address limitations related to self-care deficits due to decreased mobility and limited ROM. Findings include: I. Facility policy The Restorative Nursing Services policy, revised July 2017, was provided by the corporate nurse consultant (CNC) on 2/15/22 at 3:17 p.m., read in pertinent part: Restorative goals and objectives are individualized, resident-centered, and are outlined in the resident ' s plan 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 observations, interviews, and record review, the facility failed to ensure appropriate care and services were provided for incontinence care for one (#24) of three residents reviewed out of 30 sample residents. Specifically, the facility failed to ensure Resident #24 had physician orders and a corresponding person centered care plan related to the nephrostomy bags. Findings include: I. Facility policy and procedure: The Nephrostomy Tube, revised October 2010, was provided by the corporate nurse consultant (CNC) on 2/15/22 at 12:03 p.m. It read, in pertinent part, Verify that there is a physician's order for this procedure. Review the resident's care plan to assess for any special needs of the resident. Empty the drainage bag once per shift and as needed. Change dressings every 1-3 days, or as ordered. II. Resident #24 A. Resident #24 status Resident #24, under age [AGE], was readmitted on [DATE]. According to the February 2022 computerized physician orders (CPO), diagnosis included sepsis, urinary tract…

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.