Brookshire Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#113) of three residents reviewed for assistance with activities of daily living (ADL) out of 30 sample residents received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to ensure Resident #113 received assistance with showers in accordance with her physician orders. Findings include: I. Facility policy and procedure The Supporting Activities of Daily Living (ADL) policy, revised March 2018, was provided by the nursing home administrator (NHA) on 1/14/25 at 1:57 p.m. The policy revealed residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL). Residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. If residents with cognitive…

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 complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for two of five certified nurse aides (CNA) reviewed. Specifically, the facility did not complete a performance review for CNA #3 and CNA #4. Findings include: I. Record review CNA #3 was hired on 2/1/23. A request for a performance review was made on 1/14/25. -The facility was unable to provide documentation indicating a performance review for CNA #3 was completed in the past 12 months. CNA #4 was hired on 12/22/23. A request for a performance review was made on 1/14/25. -The facility was unable to provide documentation indicating a performance review for CNA #4 was completed in the past 12 months. II. Staff interviews Regional director of clinical services (RDCS) #2 was interviewed on 1/16/25 at 10:52 a.m. RDCS #2 said an annual performance review and in-service education were not completed for CNA #2 and CNA #4. RDCS #2 said she was not sure why the training had…

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 assist residents in obtaining routine or emergency dental services, as needed for one (#14) of two residents reviewed for dental services out of 30 sample residents. Specifically, the facility failed to ensure dental services were offered to Resident #14. Findings include: I. Facility policy and procedure The Dental Services policy, undated, was provided by the nursing home administrator (NHA) on 1/16/25 at 4:44 p.m. It read in pertinent part, It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. The dental needs of each resident are identified through the physical assessment and MDS (minimum data set) assessment processes, and are addressed in each resident's plan of care. Oral/dental status shall be documented according to assessment findings. Oral care and denture care shall be provided in accordance with identified needs and as specified in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that the medical record was complete and accurate in keeping with accepted standards of practice for one (#63) of four residents reviewed for medical record accuracy out of 30 sample residents. Specifically, the facility failed to document Resident #63's toileting in an accurate and easy to understand manner. Findings include: I. Facility policy and procedure The Charting and Documentation policy, revised December 2022, was provided by regional director of clinical sciences (RDCS) #2 on 1/16/25 at 3:02 p.m. The policy revealed the services provided to the resident progress toward the care plan goals. Any notable changes in the resident's medical, physical, functional, or psychosocial condition observed by staff should be documented in the resident's medical record. The medical record was a format that facilitated communication between the interdisciplinary team. Documentation in the medical record might be entered electronically, manually 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 and interviews the facility failed to maintain a clean, comfortable and homelike environment for the residents on two of the two resident hallways and the secured unit. Specifically, the facility failed to ensure residents' rooms, bathrooms and shower rooms were odor free and received necessary repairs. Findings include: I. Facility policy and procedure The Homelike Environment policy, revised February 2021, was provided by the nursing home administrator (NHA) on 1/28/24 at 11:45 a.m. It revealed in pertinent part, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: -clean, sanitary and orderly environment; -inviting colors and décor; and -pleasant, neutral scents. The facility and management minimizes, to the…

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

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications for the medication storage room and one of two medication storage carts. Specifically, the facility failed to: -Discard medication on the medication cart that had been discontinued; and, -Discard medications that have expired. Findings include: I. Facility policy and procedure The Storage of Medications policy, revised November, 2020, was provided by the nursing home administrator (NHA) on 1/28/24 at 11:45 a.m. The policy heading included, the facility stores all drugs and biologicals in a safe, secure and orderly manner. Discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. II. Observations On 1/24/24 at 10:58 a.m. the medication storage cart was reviewed with licensed practical nurse (LPN) #1. The LPN picked up Tiotropium Bromide/Olodaterol (Stiolto) inhaler for Resident #19 which contained a label showing an opened date of 10/12/23. The LPN placed the inhaler back in the compartment of the medication cart. 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.

Based on record review and interviews the facility failed to have a system for identifying deviations in performance and adverse events, and develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies. Specifically, the QAPI program committee failed to identify failures within their performance improvement plans for repeat deficiencies cited and make the necessary changes to ensure the plan was effective. Findings include: I. Facility policy and procedure The Quality Assessment and Assurance Committee policy and procedure, revised January 2018, was provided by the nursing home administrator (NHA) on 1/22/24 at 2:00 p.m. It revealed, in pertinent part, Purpose: to evaluate facility quality indicators, identify quality issues, develop corrective action plans and evaluate any action plans for continuous quality improvement. Any concerns, trends or clusters identified should be listed on the QA Concerns List. Document the concern, goal and approaches and interventions to correct the concern on 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 and interviews, the facility failed to ensure one (#18) out of 25 sample residents had the right to a dignified existence. Specifically, the facility failed to ensure facility staff respected Resident #18's right to refuse a shower and provide him dignity after a shower by ensuring he was not exposed to other residents on the unit by wrapping him in a see-through sheet. Findings include: I. Facility policy and procedure The Dignity policy and procedure, revised February 2021, was provided by the nursing home administrator (NHA) on 1/28/24 at 11:45 a.m. It revealed in pertinent part, Residents are treated with dignity and respect at all times. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility. When assisting with care, residents are supported in exercising…

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 (#27) of five residents reviewed for abuse out of 25 sample residents were kept free from abuse. Specifically, the facility failed to: -Investigate and implement measures to protect Resident #27 from Resident #46 on 12/5/23; and, -Ensure Resident #27 was kept free from physical abuse by Resident #46 on 12/5/23 and 12/21/23. Findings include: I. Facility policy and procedure The Abuse and Neglect policy and procedure, revised March 2018, was provided by the nursing home administrator (NHA) on 1/22/24 at 10:00 a.m. It revealed in pertinent part, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful, as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The physician and staff will help identify risk factors for abuse within 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 (#18) out of 25 sample residents were free from involuntary seclusion. Specifically, the facility failed to ensure Resident #18, who resided on the secured unit, had the required assessments and resident representative consent to justify such restrictions. Findings include: I. Facility policy and procedure The Wandering and Elopement policy and procedure, reviewed March 2019, was provided by the nursing home administrator (NHA) on 1/28/24 at 11:08 a.m. It revealed, in pertinent part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. II. Resident #18 status Resident #18, age [AGE], was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, Parkinson's disease and insomnia. According to the 10/11/23 minimum data set (MDS) assessment, 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 report abuse to State Survey and Certification agency in accordance with State law for one (#27) of six residents reviewed for abuse out of 25 sample residents. Specifically, the facility failed to report incidents of alleged abuse involving Resident #27 to the State Agency. 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 1/22/24 at 10:00 a.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 all investigations are documented and reported. The administrator of the individual making the allegation…

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 thoroughly investigate allegations of abuse involving one (#27) of six residents reviewed for abuse out of 25 sample residents. Specifically, the facility failed to conduct an investigation of bruising and scratches (injuries of unknown origin) to Resident #27. Cross-reference F609 the facility failed to injuries of unknown origin to Resident #27 were reported to the State Agency. 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 1/22/24 at 10:00 a.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…

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 proper treatment and assistive devices to maintain vision abilities for one (#50) resident of two residents reviewed for ancillary services out of 25 sample residents. Specifically, the facility failed to ensure Resident #50 was provided with an eye exam. Finding include: I. Facility policy and procedure The Care of Visually Impaired Resident policy, revised on March 2021, was received by the nursing home administrator (NHA) on 1/28/24 at 11:45 a.m. It revealed in pertinent part, Residents with visual impairment will be assisted with activities of daily living as appropriate. Assistive devices to maintain vision include glasses, contact lenses, magnifying lens and any other device used by the resident to assist with visual impairment. While it is not required that our facility provide devices to assist with vision, it is our responsibility to the resident and representatives in locating available resources (Medicare, Medicaid or local…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure two (#11 and #50) of two residents who entered the facility with limited mobility and range of motion received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrated as unavoidable out of 25 sample residents. Specifically, the facility failed to ensure: -Resident #11 received restorative services to prevent potential worsening of functional ability; and, -Ensure Resident #50 was provided with restorative services to help with mobility. Findings include: I. Facility policy and procedures The Resident Mobility and Range of Motion policy, revised July 2017, was provided by the nursing home administrator (NHA) on 1/28/24 at 11:45 a.m. It read in pertinent part, Resident will not experience an avoidable reduction in range of motion (ROM). Residents with limited range of motion will receive treatment and services to increase and/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 observations, record review and interviews, the facility failed to ensure two (#13 and #53) of three out of 25 sample residents received adequate supervision to prevent accidents. Specifically failed to: -Implement effective fall interventions for Resident #13 and Resident #53; -Update care plan with new interventions for Resident #13 and Resident #53; and, -Implement current fall interventions and supervision requirements for Resident #13 and Resident #53. Findings include: I. Facility policy and procedure The Falls and Fall Risk Management policy and procedure, revised March 2018, was provided by the nursing home administrator (NHA) on 1/28/24 at 11:45 a.m. It revealed in pertinent part, Based on previous evaluations and current data, staff may identify interventions related to the resident's specific risks and causes in the attempt to reduce falls and minimize complications from falling. According to the MDS (minimum data set, assessment), a fall is defined as: Unintentionally coming to rest on 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, observation and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain and maintain the highest practicable mental and psychosocial wellbeing for one (#50) out of 25 sample residents. Specifically, the facility failed to provide an ongoing assessment as to whether care approaches were meeting the emotional and psychosocial needs for Resident #50. Findings include: I. Resident #50 A. Resident status Resident #50, age under 65, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), the diagnoses included major depressive disorder and anxiety disorder. The 11/9/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of nine out of 15. No behaviors were indicated. A PHQ-9 (patient health questionnaire) was completed with a severity score of 13, indicating…

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 reviews and interviews, the facility failed to ensure one (#55) of six out of 25 sample residents were as free from unnecessary drugs as possible. Specifically, the facility failed to ensure Resident #55's drug regimen prescribed was free from an excessive amount of Acetaminophen which exceeded the recommended daily consumption. Findings include: I. Resident #55 status Resident #55, age [AGE] was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included dementia, depression, aneurysm (ballooning and weakened area in artery) and high blood pressure. The 12/27/23 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He required physical set up assistance or supervision for eating, hygiene and dressing and was independent with mobility. II. Observation On 1/23/24 at 12:25 p.m., licensed practical nurse (LPN) #1 was observed…

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 two (#1 and #4) of four residents reviewed for abuse out of seven sample residents. Specifically, the facility failed to report incidents of alleged abuse to the State Agency involving Resident #1 and Resident #4. Findings include: I. Facility policy The Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised September 2022, was received on, 10/12/23 at 4:57 p.m. by the regional director of clinical services. It read 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 all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of…

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

Based on record review and staff interviews, the facility failed to investigate an allegation of abuse for two (#1 and #4) of three residents reviewed for abuse out of seven sample residents. Specifically, the facility failed to thoroughly investigate the following allegations of abuse for Resident #4 and Resident #1. Findings include: I. Facility policy The Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised September of 2022, was received on 10/12/23 at 4:57 p.m. by the regional director of clinical services. It read 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. All allegations are thoroughly investigated. The administrator initiates investigations. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to…

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

Based on observation, record review and interviews the facility failed to ensure one (#3) out of seven sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure blood pressure medication was consistently ordered for Resident #3 by the nursing staff. Findings include: I. Record review A review of the October 2023 computerized physician orders (CPO) revealed: -Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 milligrams (mg) Give one table. Give one tablet by mouth one time a day for hypertension, date started 7/19/23. A review of the October 2023 medication administration record (MAR) revealed: -Metoprolol was not given on 10/4/23 due to waiting for medication. -Metoprolol was not given on 10/6/23 because it was not available. -Metoprolol was not given on 10/9/23 due to waiting for medication. The medication was charted as administered on 10/5/23, 10/7/23, 10/8/23, 10/10/23, 10/11/23 and 10/12/23. -However, Resident #3's medication was not in stock 10/4/23, 10/5/23 and 10/9/23 and was not…

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

Based on record review and interviews, the facility failed to develop and implement appropriate quality assurance and performance improvement (QAPI) plans of action to correct identified quality deficiencies, potentially affecting all the residents in the facility. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify concerns and or implement effective action plans to mitigate the repetition facility failures in abuse and behavioral health. Findings include: I. Facility policy The QAPI Committee policy and procedure, undated, was provided by the nursing home administrator (NHA) on 9/26/22, and read in pertinent part: Quality Management and Quality Assurance and Performance Improvement (QAPI) Program designed to objectively and systematically monitor and evaluate the resident's care and health care services. The comprehensive program is designed to provide care that is optimal within available resources and is consistent with the achievable goals for the facility. Objectives: 1. To ensure that monitoring quality of residents' care is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to ensure that five (#32, #8, #11, #4, and #60) of 22 out of 33 sample residents were free from involuntary seclusion and were receiving the least restrictive approach for their needs. Specifically, the facility failed to ensure Residents #32, #8, #11, #4, and #60, residing on the secure locked unit, had the required documentation to justify such restrictions including documentation such as doctor orders, resident representative consents, and secure unit evaluations were not obtained. I. Facility policy The Secure Unit Placement policy, dated 11/4/13, was provided by the nursing home administrator on 9/29/22 at 10:52 a.m. It read in pertinent part, The Admissions Coordinator, Social Services or designees shall assess the potential resident to include: Dementia related diagnosis and diagnostic testing that substantiates the type of dementia. If the resident is being admitted to a secure unit, the Admissions Coordinator, Social Services 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 a resident who displayed or was 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 five (#60, #4, #20, #55 and #37) of 12 out of 33 sample residents. Specifically, the facility failed to consistently provide person-centered approaches to Resident #60, #4, #20, #55 and #37 who had diagnoses of dementia, involved in resident to resident altercations on the secured unit (cross-reference F600 for abuse). Findings include: I. Facility policy and procedure The Dementia-Clinical Protocol policy and procedure, revised November 2018, was provided by the nursing home administrator (NHA) on 9/27/22 at 2:30 p.m. It revealed in pertinent part, For the individual with confirmed dementia, the interdisciplinary team (IDT) will identify a resident-centered care plan to maximize remaining function and quality of life. Direct care 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.

Based on observations, record review and interviews, the facility failed to develop and implement a COVID-19 staff vaccination process to address all facility staff, including agency staff who provided care, treatment and other services to facility and/or residents. Specifically, the facility failed to obtain the vaccination status of outside providers. The facility did not have the vaccination status for all of the outside providers listed on the matrix. The facility was unable to provide a listing of the vaccination status of all contracted providers/staff who enter the facility on a regular basis and provide direct care to residents. Cross-reference F880 infection control. Findings include: I. Facility policy The COVID-19 Vaccine policy, revised 4/22/22, was provided by the nursing home administrator (NHA) on 9/29/22 at 1:05 p.m. It read in pertinent part, It is required that all individuals in the community receive the designated COVID-19 vaccination and recommended boosters or provide evidence of vaccine receipt or exemption. II. Record review Staff vaccination matrixes were…

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 had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for two (#39 and #262) of eight out of 33 sample residents. Specifically, the facility failed to: -Have accurate physician orders regarding code status for Resident #39; -Indicate code status, and have physician orders, in the electronic medical record (EMR) for Resident #39; and, -Initiate and formulate a medical orders for scope of treatment (MOST) form for Resident #39 and #262, used by the facility to form the resident's advance directives. Findings include: I. Facility policy and procedure The Advanced Directive policy, reviewed [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 2:10 p.m. It read in pertinent part, If the resident has executed any advance directive documents, or if he/she executes any such documents while living in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#24) of three residents reviewed for respiratory services out of 33 sample residents, received respiratory care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, Resident #24 was admitted with a laryngectomy (removal of all or part of the larynx /voice box), which was completed several years ago. Resident #24 did not have physician orders, respiratory assessment, and a person-centered care plan regarding his respiratory needs. Findings include: I. Facility policies and procedures The Care and Treatment of the Established Stoma policy, developed 11/23/19 and reviewed 9/29/22 (at the time of the survey), was provided by the nursing home administrator (NHA) on 9/29/22. The policy read, Laryngectomy stomas are formed following excision of the larynx, usually for the treatment of an underlying malignancy. This is a permanent stoma in which the…

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

Based on observations, and interviews, the facility failed to ensure medication error rate was not greater than five percent. Specifically, the facility's medication error rate was 20 percent with five errors out of 25 opportunities. Findings include: I. Facility policy The Medication Administration policy, revised on 11/26/19, was provided by the nursing home administrator (NHA) on 9/29/22. The policy read: Medications are administered in an accurate, safe,timely, and sanitary manner. Medications are administered in accordance with written orders of the attending physician. Prior to administration, verify the medication label against the medication administration record (MAR) for accuracy. Be sure you have the right residency before administering the medications by means of a photograph ID (identification), bracelet ID in resident, verification with another staff member familiar with the resident. If the resident is alert and oriented you can verify with the resident by having the resident state their full name. II. Medication administration to Resident #45 On 9/26/22 at 11:50 a.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to keep one (#15) of 11 out of 33 sample residents fwere [NAME] of any significant medication errors. Specifically, the resident's identity was not checked prior to medication administration. Resident #15 was going to be administered medications that were not intended for him which included hypertension, anti seizure and thyroid medication. Findings include: I. Facility policy The Medication Administration policy. revised on 11/26/19, was provided by the nursing home administrator (NHA) on 9/29/22. The policy read: Medications are administered in an accurate, safe,timely, and sanitary manner. Medications are administered in accordance with written orders of the attending physician. Prior to administration, verify the medication label against the medication administration record (MAR) for accuracy. Be sure you have the right residency before administering the medications by means of a photograph ID (identification), bracelet ID in 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, 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 one (#53) of two residents reviewed for hospice care services out of 33 sample residents. Specifically, the facility failed to collaborate with the hospice provider and maintain an effective plan of communication for the coordinated plan of care for Resident #53. Findings include: I. Resident status Resident #53, age [AGE] was admitted to the facility on [DATE]. According to the 8/15/22 computerized physician orders (CPO), diagnoses included Lewy body dementia, encephalopathy (brain disorder), bipolar disorder with depression, hypothyroid, and gastroesophageal reflux disease (GERD). The 8/29/22 minimum data set (MDS) documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS documented that the resident required extensive assistance…

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

Based on observations, record review and interviews, the facility failed to develop and maintain an infection prevention and 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 proper wearing of masks and eye protection for staff. Findings include: I. Personal protective equipment (PPE) A. Professional reference The Centers for Disease Control and Prevention (CDC), (updated 2/2/22) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, retrieved on 10/3/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, read in pertinent part, Implement universal use of personal protective equipment for HCP (healthcare personnel). If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if…

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.