City Park Healthcare And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#1) of three residents out of 3 sample residents did not experience a significant medication error. Specifically, the facility failed to ensure that Resident #1 received all doses of his prescribed kidney failure medication, Velphoro, which resulted in a significant medication error of omission. Findings include: I. Facility policy The Medication Administration policy, dated 7/25/19, was received on 1/11/24 at 3:00 p.m. from the nursing home administrator (NHA). The policy documented in pertinent part, Medications will be administered in accordance with written orders authorized by the attending physician. II. Resident status Resident #1, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included end stage renal disease. The 11/24/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental…

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 store, prepare, distribute and serve food in a sanitary manner in the kitchen. Specifically, the facility failed to: -Ensure proper hand hygiene and maintain a sanitary environment where food was being served; and, -Ensure the refrigerators on the units were cleaned properly. Findings include: I. Hand washing and use of hair nets A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: Vigorous friction on the surfaces of the lathered fingers, finger tips, areas between the fingers, hands and arms for at least 15 seconds, followed by;Thorough rinsing under clean, running…

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 prevent misappropriation of property for four (#19, #44, #48 and #49) of five residents reviewed for misappropriation out of 46 sample residents. Specifically, the facility failed to prevent staff members from exploiting money from Residents #19, #44, #48 and #49. Findings include: I. Facility policy The Abuse and Neglect policy and procedure, revised 1/16/23, was provided by the nursing home administrator (NHA) on 10/10/23 at 10:12 a.m. It read in pertinent part, Each resident has the right to be free from abuse, neglect, misappropriation of property, exploitation, involuntary seclusion, and physical or chemical restraints imposed for the purpose of discipline or convenience not required to treat the resident's medical symptoms. Residents will not be subjected to abuse by anyone, including staff (to include agency or contract vendors), residents, volunteers, consultants, family members /legal guardians, friends, or any other individuals. II. 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 interviews and record review, the facility failed to notify the state mental health agency promptly after a significant change in the mental condition of three (#33, #36 and #97) of seven residents reviewed for preadmission screening and resident review (PASRR) out of 46 sample residents. Specifically, the facility failed to: -Notify the state mental health agency of Resident #33, and Resident #97 necessity for inpatient psychiatric hospitalizations, and, -Notify the state mental health agency of worsening symptoms for Resident #36. Findings include: I. Resident #33 A. Resident status Resident #33, age under 70 years, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included bipolar disorder. The 9/29/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of 10 out of 15. It did not identify level II PASRR. B. Record review The comprehensive care plan, initiated…

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 safely store and properly dispose of medications in a manner consistent with standards of practice for two of four medication storage rooms. Specifically, the facility failed to ensure: -Expired medications were discarded and removed from the medication storage room refrigerators in a timely manner; -All drugs and biologicals were kept safe and secure in locked compartments when not in direct line of sight of nurse; and, -All refrigerated drugs and biologicals were monitored daily for proper temperature controls in accordance with manufacturers specifications Findings include: I. Facility policy and procedure The Medication Storage policy, revised October 2023, was provided by the nursing home administrator (NHA) provided on 10/12/23 at 4:33 p.m. it read in pertinent part: The director of nursing (DON)/designee is responsible for drug storage per regulatory requirements to promote safety and security of medications and biologicals. Expired or discontinued non-narcotic medication will be stored in a locked area.…

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 maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection. Specifically, the facility failed to: -Ensure continuous positive airway pressure (CPAP) masks were stored off the floor, in a clean bag and replaced when contaminated; -Ensure staff performed hand hygiene during medication administration; and, -Ensure staff disposed of needles appropriately. Findings include: I. Facility policy and procedure The Infection Control policy and procedure, revised 5/7/23, was provided by the nursing home administrator (NHA) on 10/9/23 at 10:15 a.m. It read in pertinent part, Standard precautions include: A group of infection prevention practices that apply to all resident's environments, regardless of suspected or confirmed infection status, in any setting where healthcare is delivered. Includes: resident care equipment likely to have been contaminated by bodily fluids must be handled in a manner to prevent…

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 self-administration of medications was clinically appropriate for one (#39) resident out of 46 sample residents. Specifically the facility failed to: -Ensure Resident #39 was assessed for the appropriateness and safety of self-administration of oral medications; and, -Ensure there was a physician order for self-administration of oral medications. Findings include: I. Facility policy and procedure The Medication- Self Administration policy and procedure, dated 2/24/14, received from the nursing home administrator (NHA) on 10/12/23 at 4:45 p.m. revealed in pertinent part an assessment will be completed prior to self administering medications to ensure residents safety. If the nurse and/or interdisciplinary team (IDT) deems the resident safety and competent, a physician order will be obtained containing specifics about the medications itself and an order for the medication to be self-administered by the resident. The Medication…

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

Based on observations, interviews, and record review, the facility failed to provide a clean, comfortable, homelike environment. Specifically, the facility failed to ensure resident rooms were clean to minimize odors and in good repair. Findings include: I. Facility policy On 10/12/23 at 3:33 p.m. A request was made for the facility's home like environment policy, the nursing home administrator (NHA) said the facility did not have a homelike environment policy. II. Resident #100 A. Observation and interviews On 10/9/23 at 3:01 p.m. Resident #100 was observed laying in bed with a bedpan containing feces. A trash can beside the bed contained multiple wipes stained brown matter. There were two urinals that were half full with urine hanging on the side of the waste basket. The room had the odor of urine and stool. On 10/10/23 at 10:53 a.m. to 4:10 p.m. Resident #100 was observed laying in bed. The bed pan was covered with brown paper towels and was on the resident's bed leaning against a pillow pushed against the wall. The resident has two urinals with one urinal completely full and 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 (#48) of two residents reviewed for abuse out of 46 sample residents were free from abuse. Specially, the facility failed to prevent a resident to resident altercation between Resident #48 and Resident #66. Findings include: I. Facility policy The Abuse and Neglect policy, dated 7/11/21, was received from the nursing home administrator (NHA) on 10/12/23. It read in pertinent part: Physical abuse is defined as including hitting, slapping, pinching, and kicking of residents. The two elements needed are: -Intent or knowingly or recklessly -Bodily injury and/or serious bodily injury, and/or -Unreasonable confinement or restraint. II. Resident to resident physical altercation between Residents #48 and #66. A. Facility investigation Incident 9/2/23 The incident between Resident #48 and Resident #66 occurred in the room where both residents reside. Resident #48 alerted the nurse Resident #66 had punched him in the nose after Resident #48…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure a resident was free from physical restraints imposed for purposes of convenience, and that are not required to treat the resident's medical symptoms, the least restrictive alternatives was not used for one (#102) of one resident reviewed for restraint use out of 46 sample residents. Specifically, the facility failed to -Attempt to assess less restrictive alternatives to prevent Resident #102 from falling out of his wheelchair; -Evaluate the risks and benefits for using a lap belt or personal restraint on Resident #102; -Obtain a physician's order before implementing the use of a lap belt personal restraint on Resident #102 while in his wheelchair; -Re-evaluate the ongoing use of a lap belt personal restraint on Resident #102; and -Perform periodic removal/release of Resident #102's lap belt personal restraint to assess for continued need. Findings include: I. Facility policy and procedure The Restraint Assessment and Consent…

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, observations and record review, the facility failed to incorporate the recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation report into the assessment, care planning and transitions of care for one (#83) of four residents reviewed for PASRR out of 46 sample residents. Specifically, the facility failed to take steps to: -Ensure services were timely provided as recommended in Resident #83's PASARR level II; and, -Develop a PASARR level II care plan for Resident #83. Findings include: I. Resident status Resident #83, under the age of 65, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included major depressive disorder and post-traumatic stress syndrome (PTSD). According to the 9/10/23 minimum data set (MDS) assessment, the resident had a moderate cognitive impairement with a brief interview for mental status (BIMS) score of 10 out of 15. He required set up help only for walking…

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 provide care and services for activities of daily living including speech, language and other communication systems for one (#12) resident of one reviewed out of 46 sample residents. Specifically, the facility failed to: -Ensure Resident #12 was able to communicate in her preferred language; and, -Ensure the communication book was available for Resident #12 use. Findings include: I. Facility policy and procedure The Dignity, Voice and Choice policy and procedure, dated 2/28/23, was received from the nursing home administrator (NHA) on 10/12/23 at 4:45 p.m. It revealed in pertinent part, Residents will be cared for in a manner and environment that maintains or enhances their dignity, privacy, and respect in full recognition of their individuality. Residents were addressed by their preferred name in respectful and in a language they understand. II. Resident #12 A. Resident status Resident #12, age [AGE], 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 record review, and staff interviews, the facility failed to clarify resuscitation choices and document them accurately in the medical record for one (#70) of three residents reviewed for advance directives out of 46 sample residents. Specifically, the facility failed to ensure the medical orders for scope of treatment forms (MOST) form matched the physician's orders for Resident #70's cardiopulmonary resuscitation (CPR) wishes. Findings include: I. Facility policy and procedure The Advance Directives and Resident Representative policy and procedure, dated [DATE], was received from the nursing home administrator (NHA) on [DATE] at 4:45 p.m. It revealed in pertinent part, A facility representative usually social services or nursing will provide advanced directive information as needed to assist with health care decisions prior to or upon admission, with potential changes of condition, and as needed based on resident and representative needs. The physician should discuss choices offered on the MOST form…

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 activities designed to support residents' physical, mental and psychosocial well-being were provided for two (#11 and #83) of four residents reviewed for meaningful activity programming activities out of 46 sample residents. Specifically, the facility failed to ensure: -Resident #11 received individualized meaningful activities to meet her social, emotional and recreational needs; and, -Resident #83 received a schedule of upcoming activities and was invited to activities and informed where the activity would be occurring. Findings include: I. Facility policy and procedure A request was made for the activities policy on 10/12/23 at 4:33 p.m. The nursing home administrator (NHA) said the facility did not have and activities policy. II. Resident #11 A. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included chronic respiratory failure,…

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 one (#99) of five residents reviewed for pressure injuries out of 46 sample residents with the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing. Specifically,the facility failed to: -Reposition the resident, who had pressure injuries; -Follow orders specifically to float heels while the resident was in bed; and, -Follow current orders for supplements to assist with wound healing and minimize further skin breakdown. Findings include: I. Professional reference A. The National Pressure Injury Advisory Panel, NPIAP Pressure Injury Stages 2016,http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ revealed the following pertinent information: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical…

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 (#99) resident of two out of 46 sample residents had pain management services consistent with professional standards of practice. Specifically, the facility failed to: -Ensure as needed (PRN) pain scale was implemented and followed for administration of morphine for Resident #99; and, -Pain medication was not administered according to the physician's orders for Resident #99. Findings include: I. Resident status Resident #99, age [AGE], was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbances, major depressive disorder, anxiety disorder, and pancolitis (affects the entire colon and causes bouts of bloody diarrhea that may be severe, abdominal cramps and pain). According to the 9/23/23 minimum data set (MDS) assessment, the resident was cognitively severely impaired with a brief interview for mental status (BIMS) score of two out of 15. She required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services for s to attain and maintain the highest practicable mental and psychosocial wellbeing for two (#33 and #97) of three residents reviewed out of 46 sample residents. Specifically, the facility failed to ensure individualized, non-pharmacological approaches to care were being identified and promoted to meet the mental and psychosocial needs for Resident #33 and Resident #97. Findings include: I. Resident #33 A. Resident status Resident #33, age under 70 years, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included bipolar disorder. The 7/23/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of 10 out of 15. Her depression assessment score was two indicating no depression. B.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to consistently provide appropriate treatment and services for dementia care for one (#99) of two residents with dementia out of 46 sample residents. Specifically, the facility failed to: -Provide a person-centered approach, individualized approach and treatment to Resident #99; and, -Have consistent, purposeful and meaningful activity for Resident #99. Findings include: I. Resident #99 A. Resident status Resident #91, age [AGE] was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbances, major depressive disorder and anxiety disorder. According to the 9/23/23 minimum data set (MDS) assessment, the resident was cognitively severely impaired with a brief interview for mental status (BIMS) score of two out of 15. She required extensive assistance of two people with toileting, bed mobility and dressing. She required extensive assistance of one person…

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, document review, interviews, and review of the facility policy, the facility failed to ensure food items were stored, prepared, distributed, and served in accordance with professional standards for food safety in 1 of 1 kitchen. Specifically, the facility failed to ensure: 1. the kitchen staff dated, labeled, and covered food items in storage. 2. raw foods were not stored next to ready-to-eat foods. 3. dented cans were discarded. 4. kitchen staff wore a complete hair covering at all times when in the kitchen. 5. kitchen staff maintained the overall cleanliness of the kitchen. 6. kitchen staff maintained complete and accurate refrigerator and freezer temperature logs. This had the potential to affect all residents. Findings included: 1. A review of the undated Food Storage policy revealed, Food should be dated as it is placed on the shelves. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated; foods should be covered, labeled, and dated. Kitchen observations made 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.

Based on observations, interviews, record review, and policy review, the facility failed to ensure residents were assessed for self-administration of medications for 2 (Residents #99 and #100) of 5 residents observed during medication administration. Findings included: A review of the facility policy titled, Medication- Self Administration, effective 02/24/2014, revealed, The resident who chooses to self-administer medications will be evaluated by a nurse for safe self-administration of medications and findings will be documented on the appropriate form and saved in the resident's record. 1. A review of the admission Record revealed Resident #100 had a diagnosis of allergic rhinitis. A review of the current Order Summary Report revealed a physician order, dated 07/23/2020, for azelastine hydrochloride solution 137 microgram (mcg) per spray. The order directed staff to spray one spray in each nostril once a day for allergies. There was also an order, dated 11/12/2020, for fluticasone propionate (Flonase) 50 mcg per actuation. The order directed staff to spray two sprays in each…

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, record review, and policy review, the facility failed to ensure an allegation of verbal abuse was thoroughly investigated for 1 of 3 facility reported incidents for verbal abuse that were reviewed. This failed practice affected Resident #257. Findings included: A review of the facility policy titled, Abuse and Neglect, last revised 03/2021, indicated, Definitions: .5. Investigation: All potential abuse allegations will be investigated. The Nursing Home Administrator is ultimately responsible for abuse prevention, timely identification of potential abuse, the investigative process, and reporting results to the proper authorities based on regulatory time frames and requirements .Procedure .5. A. Investigations will be coordinated by the Nursing Home Administrator or designee. B. The individual coordinating the investigation, or their designee will: .Interview staff members who have had contact with the resident during the period of the alleged incident or who may have knowledge of 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, interviews, and review of the facility policy, the facility failed to ensure care and services were provided in accordance with the comprehensive care plan for 1 (Resident #57) of 5 sampled residents reviewed for supplemental nutritional items. Findings included: A review of the Care Plans, Person-Directed policy, reviewed 07/12/2022, revealed, Care plans will be developed consistent with the residents' specific conditions, risks, needs, behaviors, preferences, and current standards of practice. Measurable goals and individualized interventions will be identified. A review of the admission Record revealed the facility admitted Resident #57 with diagnoses of Lewy body dementia, dysphagia, and hypertension. A review of the resident's quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Resident #57 required a mechanically altered diet and limited one-person assistance with meals.…

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, interviews, and policy review, the facility failed to ensure care plans were revised when needed for 1 (Resident #96) of 1 residents reviewed for oxygen administration. Cross reference F695, Respiratory Care. Findings included: A review of the facility policy titled, Care Plans, Person-Directed, reviewed 07/12/2022, revealed, The care plan will be revised and updated as necessary to reflect the resident's current status. A review of Resident #96's admission Record revealed a diagnosis of chronic obstructive pulmonary disease (COPD). A review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The resident was receiving supplemental oxygen therapy. A review of a care plan, dated 01/03/2022, indicated Resident 96 received oxygen at 3-4 liters per minute via nasal canula. A review of a physician order, dated 06/13/2022, indicated the physician had directed the facility staff members…

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, interviews, and review of the facility policy, the facility failed to ensure care and services were provided in accordance with physician orders and accepted standards of practice for 1 (Resident #57) of 1 sampled resident reviewed for the use of straws for the oral intake of fluids. Findings included: A review of the facility's policy titled, Care Plans, Person-Directed, reviewed 07/12/2022, indicated, Physician's orders, medication and treatment administration records, care conferences meeting minutes and Certified Nurse Aide (CNA) cards are considered components of the care plan. A review of the admission Record indicated the facility admitted Resident #57 with diagnoses which included Lewy body dementia, dysphagia, and hypertension. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The resident required a mechanically altered diet and limited one-person…

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, interview, and policy review, the facility failed to ensure oxygen was administered at the flowrate prescribed by the physician for 1 (Resident #96) of 1 sampled resident reviewed for oxygen administration. Findings included: A review of a facility policy titled, Oxygen Titration, last revised on 03/04/2020, indicated, Oxygen will be administered per physician order .Residents with the following diagnoses or histories will be carefully evaluated: .Residents with a COPD [chronic obstructive pulmonary disease], sleep apnea, morbid obesity, or congestive heart failure diagnosis will be evaluated based on severity of disease process. A review of Resident #96's admission Record revealed the resident had a diagnosis of chronic obstructive pulmonary disease (COPD). A review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The resident was receiving supplemental oxygen…

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, record review, and policy review, the facility failed to ensure a medication error rate of less than 5% for 2 (Resident #75 and Resident #100) of 5 residents observed during medication administration. Observations during medication administration revealed there were two medication errors out of 32 opportunities, which resulted in a 6.25% medication error rate. Findings included: A review of the facility policy titled, Medication Administration General Guidelines, last revised 07/25/2019, revealed, Medications will be administered in accordance with written orders authorized by the attending physician or designee .Medications will be administered based on the resident's schedule and preferences as well as specific medication and physician requirements. 1. A review of Resident #75's admission Record revealed a diagnosis of congestive heart failure. A review of current Order Summary Report revealed a physician order, dated 02/19/2022, for furosemide solution. The order directed staff to administer 80 milligrams (mg) one time a day. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure a resident was not served food items that had been reported as a dislike and/or allergy for 1 (Resident #40) of 4 sampled residents reviewed for food concerns. Findings included: A policy related to food allergies was requested from the facility, but the facility did not have a policy that addressed food allergies. A review of Resident #40's quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score 12, which indicated moderately impaired cognition. The MDS indicated Resident #40 was independent for eating. A review of Resident #40's care plan, dated 05/17/2022, revealed the resident had an intolerance to carrots, carrot soup, corn, bananas, and pineapple. A review of Resident #40's electronic health record revealed the resident had allergies listed as ibuprofen, bananas, carrot, corn, and pineapple. A review of Resident #40's admission Nutrition Assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and policy review, the facility failed to ensure hand hygiene was performed between dirty and clean tasks during wound care for 1 (Resident #60) of 1 sampled resident who was reviewed for wound care. Findings included: A review of a policy titled, Dressing change: Aseptic, last revised on 05/07/2021, revealed, Procedure: .6. Set up barrier, located conveniently near wound so aseptic technique is not broken. Set up supplies, open packages, prepare dressings, date, pre-cut packing dressings, pull and or pre-cut Iodoform etc [et cetera] .9. With resident in appropriate position, don gloves, remove old dressing, discard in plastic or red bag, observe wound, measure, etc. 10. Remove dirty gloves, place in plastic bag, wash hands. 11. [NAME] the second pair of gloves and begin the treatment. 12. Observe for breaks in aseptic technique, changing gloves, and washing hands if necessary. A review of Resident #60's admission Record indicated a diagnosis of Stage 4 pressure…

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.