Heights Care & Rehabilitation LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure one (#1) of three residents reviewed for abuse were kept free from abuse out of five sample residents. Specifically, the facility failed to protect Resident #1 from physical abuse by Resident #2. Findings include: I. Facility policy and procedure The Abuse, Neglect, and Exploitation policy and procedure, revised April 2024, was provided by the director of nursing (DON) on 7/11/24 at 12:39 p.m. The policy read in pertinent part, The nursing home administrator (NHA) is responsible for the overall coordination and implementation of the facility's policies and procedures against abuse, neglect, exploitation and misappropriation of resident's property. Policies are in place that prohibit and prevent resident abuse, neglect, exploitation and misappropriation of resident's property, establish processes to investigate such allegations, implement staff training and coordinate with the quality assurance and performance improvement (QAPI) committee.…

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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (#8) of three out of 14 sample residents. Specifically, the facility failed to follow infection control practices while providing wound care to Resident #8. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), Elsevier, St. Louis Missouri, page 1265, retrieved on 5/23/24 Clean away from the wound. Never use the same piece of gauze to clean across an incision or wound twice. II. Resident #8 status Resident #8, age less than 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included multiple sclerosis (disease affecting the central nervous system), stage 4 pressure ulcer of right hip, stage 4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#3) out of three out of seven sample residents. Specifically, the facility failed to ensure a self-administration assessment was completed for Resident #3 to perform her own wound care treatments. Findings include: I. Facility policy and procedure The Self-Administration of Medications policy and procedure, revised February 2021, was provided by the director of nursing (DON) on 3/19/24 at 4:33 p.m. It documented, in pertinent part, Residents have the right to self-administer medications if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so. As part of the assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate. If deemed safe and appropriate it is documented in the medical record, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure services provided to two (#3 and #4) of seven sample residents met professional standards of practice. Specifically, the facility failed to ensure wound care dressings were dated for Resident #3 and Resident #4. Findings include: I. Resident #4 status Resident #4, under age [AGE], was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), his diagnoses included cellulitis (skin infection) of the right and left lower legs and open wound to the right and left lower legs. The 2/25/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. A. Resident interview and observations Resident #4 was interviewed on 3/18/24 at 9:20 a.m. He said the nursing staff were not doing his wound care daily. He said his treatments were being done every couple of days. Resident #4 was observed for wound care on 3/19/24 at 11:00 a.m. with…

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

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 help prevent the development and transmission of disease and infection. Specifically, the facility failed to ensure infection control practices were observed during wound care for Resident #4 and Resident #3. Findings include: I. Facility policy and procedure The Handwashing/Hand Hygiene policy and procedure, revised October 2023, was received from the director of nursing (DON) on 3/19/24 at 4:33 p.m. It documented, in pertinent part, The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand hygiene is indicated immediately before touching a resident, before performing an aseptic (sterile) task, after touching a resident, after touching a resident's environment, before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal. The use of gloves does not replace hand washing/hand hygiene.…

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

Based on interviews, observations and record review, the facility failed to ensure that residents had reasonable access to send and receive mail and packages at the facility. Specifically, the facility failed to ensure residents' personal mail was delivered timely on all days Monday through Saturday. Findings include: I. Resident group interview and observations The resident group interview was conducted on 1/9/24 at 3:08 p.m., with six (#39, #58, #71, #19, #74 and #69) alert and oriented residents. The residents said they had never received mail on Saturdays at the facility. The residents said they would like to receive their mail on Saturdays. The resident's said the mail would sit over the weekend in the mail box and the receptionist would pick it up on Monday morning when she arrived and then distribute it. II. Record review On 1/9/24 at 4:15 p.m. a poster of resident rights were observed posted on the wall by the entrance to the facility. It documented that the residents had the right to receive mail during the weekdays and weekends. III. Staff interviews The receptionist was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain a clean, comfortable and homelike environment for the residents on four out of four hallways. Specifically, the facility failed to ensure resident rooms, bathrooms and shower rooms were odor free and received necessary repairs. Findings include: I. Observations Observations throughout the survey, conducted on 1/8, 1/9, 1/10 and 1/11/24, revealed the following: A. Individual resident rooms 1. room [ROOM NUMBER] had broken blinds; the wall was scraped where the headboard was placed. There was an odor in the bathroom which smelled of urine, the ceiling fan was not working, the floor was dirty and had not been swept and there was missing tile at the base of the floor. 2. room [ROOM NUMBER] had paint chipped walls where the bed was placed. The bathroom had an odor of urine and the ceiling fan was not working. 3. room [ROOM NUMBER] had chipped tile at the entrance of the room. The bathroom ceiling fan was not working. 4. room [ROOM NUMBER] had 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 record review, observations and interviews, the facility failed to the facility made to make prompt efforts to resolve grievances. Specifically, the facility failed to address and provide resolutions to resident grievances expressed by the resident group and individual residents. Findings include: I. Facility policy and procedure The Grievances/Complaints Filing policy and procedure, revised April 2017, was received on 1/11/24 at 2:22 p.m. by the nursing home administrator (NHA). It revealed, in pertinent Residents and their representative have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (the State Ombudsman). The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure three (#6, #63 and #47) of three residents reviewed for activities of daily living were provided with services or treatments to prevent the reduction in range of motion out of 44 sample residents. Specifically, the facility failed to ensure a restorative program was in place for Residents #6, #63 and #47. Findings include: I. Facility policy and procedures The Restorative Nursing Services policy, revised July 2017, was provided by the nursing home administrator (NHA) on 1/11/24 at 2:00 p.m. The policy revealed residents may be started on a restorative nursing program upon admission, during the course of stay. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. Restorative goals include but are not limited to supporting and assisting the resident in participating in the development and implementation of the resident's plan of care. II. Resident #6 A. 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, interview, and record review the facility failed to ensure the environment remained as free from accident hazards as possible for three (#2, #14 and #67) of three residents reviewed for falls out of 44 sample residents. Specifically, the facility failed to: -Ensure Resident #67 had effective fall interventions implemented and that the fall interventions in place were consistently implemented; -Ensure post-fall documentation and interventions were added to Resident #67's care plan; and, -Consistently implement fall interventions for Resident #14 and Resident #2. Findings include: I. Facility policy and procedure The Falls and Fall Risk Management Guidelines, dated 2001 and revised in March 2018, was received from the nursing home administrator on 1/11/24. It read 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. Fall…

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 residents received food prepared in a form designed to meet their needs. Specifically, the facility failed to provide meals prepared according to the prescribed food orders. Findings include: I. Facility policy and procedure The Therapeutic Diets policy, revised October 2017, was received from the nursing home administrator on 1/11/24. It read in pertinent part: Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. If a 'mechanically altered diet' is ordered, the provider will specify the texture modification. The facility was utilizing the International Dysphagia Diet Standardisation Initiative (IDDSI) standards for their residents. The Soft & Bite-Sized IDDSI standard, dated January 2019, was received from the facility on 1/11/24. It read in pertinent part: Soft & Bite-Sized food may be used if you are not able to bite off pieces of food safely but are able to chew bite-sized pieces…

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

Based on observations, record review and interviews, the facility failed to provide snacks for residents who ate at non-traditional times or outside of scheduled meal times. Specifically, the facility failed to ensure snacks were consistently available according to resident preferences on the units. Finding include: I. Facility policy The Food and Nutrition Services policy, revised October 2017, was provided by the director or nurses on 1/11/24 at 2:00 p.m. It revealed in pertinent part, Nourishing snacks are available to the residents 24 hours a day. The resident may request snacks as desired, or snacks may be scheduled. II. Resident group interview The resident group interview was conducted on 1/9/24 at 3:08 p.m., with six alert and oriented residents (#39, #58, #71, #19, #74 and #69) selected by the facility. All six residents said they did not always get snacks. It depended on which staff was working that day. All six residents said that snacks were not offered to them during the day. The group said snacks were passed out to everyone in the evening after dinner between 7:30 p.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 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 diseases and infection. Specifically, the facility failed to: -Ensure residents received hand hygiene prior to meals; and, -Ensure residents' items were labeled and stored appropriately in shared rooms. Findings include: I. Facility policy and procedure The Infection Control policy and procedure, revised October 2018, was provided by the nursing home administrator (NHA) on 1/10/24. It read in pertinent part: The facility's infection control policies and practices apply equally to all personnel and the general public. The objectives of our infection control policies and practices are to: -prevent, detect, investigate and control infections in the facility; -maintain a sanitary and comfortable environment for personnel and the general public; and, -provide guidelines for the safe cleaning and…

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

Based on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNA) consisted of at least 12 hours of annual training, including continuing competence. Specifically, the facility failed to ensure CNAs had completed competencies prior to providing skilled services for five out of five CNAs. Findings include: I. Record review The employee files for CNA #7, CNA #8, CNA #9, CNA #10 and CNA #11 were requested on 1/10/23 at 3:26 p.m. The employee files provided by the nursing home administrator did not contain documentation of the demonstration of knowledge that was assessed and evaluated as part of a training, lecture or in service for staff. II. Staff interviews The nursing home administrator (NHA) was interviewed on 1/10/24 at 4:00 p.m. He said he would work on getting the requested information. -The facility was not able to provide the requested information before the exit of the survey 11/11/24.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure consent was obtained for the use of psychotropic medications for one (#180) of five residents reviewed for unnecessary medication of out 44 sample residents. Specifically, the facility failed to obtain consent for psychotropic medications from Resident #180 prior to the use of a psychotropic medication for Resident #180. Findings include: I. Facility policy and procedure The Antipsychotic Medication Use policy, revised in July 2022, was received from the nursing home administrator (NHA) on 1/11/24 at 2:00 p.m. It read in pertinent part: Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. The interdisciplinary team will complete PASRR screening (preadmission…

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 written notification of room change for one (#54) out of one out of 44 sample residents. Specifically, the facility failed to provide Resident #54 and his family with written notification upon moving the resident to another room. Findings include: I. Facility policy and procedure The Room Change/Roommate Assignment policy and procedure was provided by the nursing home administrator (NHA) on 1/11/24 at 2:00 p.m. and read in pertinent part, Changes in room or roommate assignment shall be made when the facility deems it necessary or when the resident requests the change. The facility reserved the right to make the resident room changes when the facility deemed it necessary or when the resident requested the change. Prior to changing a room, all parties involved and their representatives would be given advance notice of such change unless medically necessary or for the safety and well-being of the resident, a resident would be provided with 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 observation, interview and record review, the facility failed to protect residents from abuse for one (#36) of seven residents reviewed for abuse out of 44 sample residents. Specifically, the facility failed to protect Resident #36 from an altercation with Resident #48. Findings include: I. Facility policy and procedure The Abuse and Neglect-Clinical Protocol policy, revised March 2018, was received from the nursing home administrator on 1/10/24. It read in pertinent part: The physician and staff will help identify risk factors for abuse within the facility; for example, significant numbers of residents/patients with unmanaged problematic behavior; significant injuries in physically dependent individuals; problematic family relationships; issues related to staff knowledge and skill; or performance that might affect resident care. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The physician and staff will…

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 alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for three (#13, #72 and #7) of seven residents reviewed for abuse out of 44 sample residents. Specifically, the facility failed to: -Ensure an allegation of sexual abuse made by Resident #13 was reported to the State Agency timely; and, -Ensure an incident of verbal aggression by Resident #72 to Resident #7 was reported to the State Agency. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation policies and procedure, revised April 2021, was provided by the nursing home administrator (NHA) on 1/10/24 at 1:10 p.m. It revealed in pertinent part, The administrator is responsible for the overall coordination and implementation of our facility's policies and procedures against abuse, neglect, exploitation and misappropriation of resident property. The management and staff, with physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to investigate an allegation of abuse for two (#72 and #7) of seven residents reviewed for abuse of 44 sample residents. Specifically, the facility failed to ensure an investigation was conducted for a resident to resident incident between Resident #72 and Resident #7 on 12/20/23. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation policies and procedure, revised April 2021, was provided by the nursing home administrator (NHA) on 1/10/24 at 1:10 p.m. It read, in pertinent part, the staff, with physician input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. II. Incident between Resident #7 and Resident #72 A. Resident #7 1. Resident status Resident #7 age less than 65, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), the diagnosis included major depressive disorder. The 12/11/23 minimum data set (MDS)…

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 two (#80 and #281) of two out of 44 sample residents to return to the facility following a facility initiated transfer. Specifically, the facility failed to readmit Resident #80 and Resident #281 to the facility following a facility initiated transfer. The facility failed to provide the residents with an involuntary discharge notice prior to or after the transfer and did not permit the residents to be readmitted to the facility. Cross-reference F740: The facility failed to ensure residents received the proper care and services to maintain highest psychosocial well-being. The facility failed to ensure residents were protected by identifying and implementing safety interventions with residents who voiced they were suicidal, ensuring lethality assessments were completed upon suicidal ideations; ensure timely referrals to behavioral health and ensure a person-centered comprehensive care plan was developed to address the residents' suicidal…

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 two (#66 and #2) of three residents reviewed for visual problems out of 44 sample residents. Specifically, the facility failed to ensure: -Resident #66 had an eye exam; and, -Resident #2 was provided and encouraged to wear her glasses. Finding include: I. Facility policy and procedure The Hearing and Vision Services policy, dated 2023, was provided by the director of nurses (DON) on 1/11/24 at 9:43 a.m. It revealed in pertinent part, It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. The facility will utilize the comprehensive assessment process for identifying and assessing a resident's vision and hearing abilities in order to provide person-centered care. This process includes: -Obtaining history from medical records, the family, and the resident regarding hearing and vision…

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 residents received person-centered dementia care that met their needs for two (#2 and #72) of three residents reviewed for dementia care out of 44 sample residents. Specifically, the facility failed to: -Develop and implement individualized interventions for Resident #2 and Resident #72, who had a dementia diagnosis; and, -Provide meaningful activities that promoted Resident #2 and Resident #72's interests and preferences. Findings include: I. Facility policy and procedure The Dementia-Clinical Protocol, revised November 2018, was received from the nursing home administrator on 1/11/24. It read in pertinent part: For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. Nursing assistants will receive initial training in the care of residents with dementia and related behaviors. In-services will be conducted at least…

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 residents maintained adequate hydration for one (#2) out of one resident reviewed for hydration out of 44 sample residents. Specifically, the facility failed to encourage fluid intake for Resident #2. Findings include: I. Facility policy and procedure The Hydration-Clinical Protocol, revised 2017, was received from the nursing home administrator on 1/11/24. It read in pertinent part: The physician and staff will identify significant risk for subsequent fluid and electrolyte imbalance; for example, individuals with prolonged vomiting, diarrhea, or fever, or who are taking diuretics and/or ACE (angiotensin-converting enzyme) inhibitors and who are not eating or drinking well. The staff will provide supportive measures such as supplemental fluids and adjusting environmental temperature, where indicated. The physician and staff will monitor for the subsequent development, progression, or resolution of fluid and electrolyte imbalance in…

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 designate a registered nurse (RN) to serve as the director of nursing (DON) on a full time basis. Specifically, the facility utilized the nurse home administrator (NHA) to also serve as the DON and she was unable to work full time hours as the DON. Findings include: I. Record review Review of the staffing list demonstrated that the full time position of DON was filled by the same person as full time NHA. II. Staff interviews The assistant director of nursing (ADON) was interviewed on 10/18/23 at 12:15 p.m. She said the current director of nursing was the same person as the administrator. She said she shared the responsibilities with the DON and followed her direction on what needed to be done. She said the NHA who was filling in as the DON was present in the building daily and she was always available for assistance and questions. Registered nurse (RN) #1 was interviewed on 10/19/23 at 2:30 p.m. She said she knew who was the DON in the building. She said DON was always available for support. Licensed practical nurse (LPN)…

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

Based on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support. Findings include: I. Professional reference According to the National Certification Council of Activity Professionals (NCCAP) at www.nccap.org, an activity director must meet specific qualifications in education, certification and/or experience. The qualifications read in part: The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist; or an activities professional who is licensed or registered, if applicable, by the State in which practicing; and -Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body; or -Has two (2) years of experience in a social or recreational program within the last 5 years, one of which was full-time in a…

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

Based on observations, record review and interviews, the facility failed to ensure a resident with limited mobility receives appropriate services, equipment and assistance to maintain or improve mobility for three (#15, #9 and #8) of five residents reviewed for activities of daily living out of 16 sample residents. Specifically, the facility failed to provide restorative care services to Resident #15, #9 and #8 on a regular basis, recommended by physical or occupational therapy. Findings include: I. Resident #15 A. Resident status Resident #15, age under 65, was admitted to the facility 7/7/23. According to the October 2023 computerized physician orders (CPO), diagnoses included cerebral palsy, epilepsy, chronic pain syndrome, muscle weakness, reduced mobility and muscle spasm. The 10/12/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 11 out of 15. She had no behavioral problems, psychosis or rejection of care. She required extensive assistance of two people with bed mobility, transfers,…

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

Based on record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine and identify what resources were necessary to care for its residents appropriately during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment to include an evaluation of diseases, acuity of the population and the training and competency required by staff to care for the resident population. Cross-reference F684, quality of care for failure to identify education, training and other resources needed to care for a resident who had an acute alcohol withdrawal. Findings include: I. Record review and interviews The facility's assessment was requested from the operations manager (OP) on 8/16/23 at 9:11 a m. The facility's assessment was requested again on 8/16/23 at 1:17 p.m. from the OP. The OM was interviewed on 8/16/23 at 10:38 a.m The OM said the facility was acquired by a new owner on 3/1/23. The OP said he started at the facility in April 2023. He said he was not the licensed nursing home…

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

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 staff performed proper hand hygiene in the dining room when serving and assisting residents to eat; and, -Ensure residents were offered hand hygiene before meals. Findings include: I. Facility policy and procedures The Standard Precautions policy, revised September 2022 was received from the operations manager (OM) on 8/16/23 at 3:27 p.m. The policy documented in pertinent part, Personnel assist the residents with hand hygiene before meals, after toileting and when indicated. Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or the use of alcohol-based hand rub (ABHR), which does not require access to water.Hand hygiene is performed with ABHR or soap and water: before and after contact with the resident; before performing an aseptic task; before moving from work on 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 interviews and record review, the facility failed to ensure residents and or there representatives were provided prompt efforts by the facility to resolve grievances for two (#1 and #2) of three residents reviewed out of 13 sample residents. Specifically, the facility failed to: -Ensure Resident #1's representative received follow up regarding grievances for lack of oxygen for Resident #1 and a refund of the residents funds after his death; and, -Ensure Resident #2 and his representative received follow up regarding grievances related to his call light not being answered timely and delay in medications. Findings include: I. Facility policy and procedure The Grievances, Complaints, Recording and Investigating policy, dated April 2017, was received from the operations manager (OM) on 8/16/23 at 3:27 p.m. The policy documented in pertinent part, Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations. The department director(s) of any named…

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 interview and record review the facility failed to provide an environment free from accident hazards and risks as possible for one (#6) of three residents reviewed for accidents/hazards out of 13 sample residents. Specifically the facility failed to: -Investigate the root cause and implement interventions for Resident #6's 12 falls in less than two months; and, -Document neurological checks for Resident #6 after unwitnessed falls and falls with head injury. Findings include: I. Facility policy and procedure The Assessing Falls and Their Causes policy and procedure, revised March 2018, was provided by the operations manager (OM) on 8/16/23 at 3:27 p.m. It read in pertinent part, to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes. Falling may be related to underlying clinical or medical conditions, overall functional decline, medication side effects 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 observation, interviews, record review, document review, and review of the facility policies, the facility failed to ensure 5 of 18 sampled residents were free from physical abuse (Residents #2, #24, #48, #69, and #173). Resident #26 displayed physically aggressive/abusive behavior toward residents and staff. The facility failed to modify/revise Resident #26's care plan and implement adequate supervision for the resident to protect other facility residents from abuse. From 04/14/2022 through 09/14/2022, Resident #26 had physically abused (hit/kicked/grabbed/pushed) Residents #2, #24, #48, and #173; and physically abused Resident #69 twice. Findings included: A review of the facility's Abuse Policy revised 05/15/2018 indicated the facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, 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 interview and record review, it was determined the facility failed to provide written notice to the resident and the resident's representative(s) of a hospital transfer for three (3) of three (3) residents (Resident #72, Resident #172, and Resident #67) reviewed for hospitalization. Findings included: A policy was requested from the facility, but the facility did not have a policy related to resident transfers. 1. A record review of Resident 72's progress notes indicated that on 08/04/2022 at 4:21 PM, the resident was transferred from the facility to the hospital. In a record review of Resident #72's electronic health record, there was no documentation related to notifying the resident and/or resident representative of the resident's transfer to the hospital. In an interview on 09/14/2022 at 1:48 PM, the Social Service Director (SSD) and Social Service Assistant (SSA) were interviewed together due to the SSD being employed with the facility only two weeks. The SSD stated that when a resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and policy review, it was determined the facility failed to provide the resident and/or the resident's representative(s) written noticed of the bed hold policy when a resident was transferred to the hospital for three (3) of three (3) residents (Resident #72, Resident #172, and Resident #67) reviewed for hospitalization. Findings included: A review of the policy Bedhold, developed on 11/04/2013, indicated, The resident and/or responsible party shall be notified of Bedhold policies of the facility. The notification will be provided in writing upon admission and upon transfer for medical leave. 1. A record review of Resident 72's progress notes indicated that on 08/04/2022 at 4:21 PM, the resident was transferred to the hospital. In a record review of Resident #72's electronic health record, there was no documentation related to providing the resident and/or resident representative of the facility's bed hold policy when the resident was transferred to the hospital. In an interview…

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, interview, document and policy review, it was determined the facility failed to ensure a communication system relayed a call light directly to a staff member or to a centralized staff work area for two (halls 100 and 200) of four halls observed. Findings included: A review of Answering the Call Light, Version 1.2, revised 03/2021 revealed the policy did not indicate any information related to the functionality of the facility call light system. A review of a document Arial Emergency Call & Nurse Call, which was the call light system the facility used, revealed the system had the ability to have Centralized notifications and safety management: Integrated directly with Foresite fall management and WanderGuard BLUE wander management. Arial becomes the only application caregivers need to quickly identify residents who need care. Integrate EHR [electronic health records] systems such as PointClickCare, even and alarm management from motion detectors, smoke detectors, door and window sensors, temperature and humidity monitors and more. During an interview 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 interviews, record review, and a review of facility policy, it was determined the facility failed to protect one (Resident #66) of 18 residents' rights to formulate an advanced directive. Specifically, the facility failed to ensure Resident #66's advanced directive and/or the Medical Orders for Scope of Treatment (MOST) was completed and available in the resident's medical record. Findings included: A review of the facility's policy for Advanced Directives, reviewed on [DATE], revealed, 2. If the resident has executed any advanced directive documents, or if he/she executes any such documents while living in the Community, a copy will be requested and placed in the Resident's record. b. If the resident has such documents, and has provided a copy to the Community, the Community will place a copy of the document in the Resident's record so the Community can readily access such documents. Further review of the policy indicated, 5. All MOST forms shall be kept in a binder at the nurses station. A review 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 interview, record review, document review, and review of facility policies, the facility failed to thoroughly investigate one of three abuse allegations, which involved a resident-to-resident altercation between Resident #26 and Resident #48. Findings included: A review of the facility's Abuse Policy revised on 05/15/2012 revealed In addition to an investigation by the Police Department, the facility conducts an internal investigation. That investigation includes interviewing any staff members, residents, or family members who may have knowledge of the incident. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. A review of the facility policy titled, Resident to Resident Altercations, (2001 MED PASS Inc. Revised December 2016) revealed, 2.…

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 facility policy review, the facility failed to ensure that a comprehensive care plan was developed for one (Resident #58) of four residents reviewed for pain management. Specifically, Resident #58 had pain in the left arm and back and required pain medication. The resident's pain evaluation revealed the resident required a pain management care plan; however, the facility failed to develop a care plan to manage Resident #58's pain. Findings included: A review of the facility policy titled, Care Plans, Comprehensive, Person-Centered, revised March 2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Further review of the policy revealed The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. In an interview on 09/12/2022 at 2:49…

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 interview, record review, document review, and review of facility policies, the facility failed to review and revise the plan of care for one (Resident #26) of 18 residents reviewed following resident-to-resident altercations. The facility developed a care plan with interventions to minimize Resident #26's physically aggressive behavior; however, Resident #26 continued to exhibit aggressive/abusive behavior and the facility failed to review/revise Resident #26's to prevent further potential abuse. Resident #26 abused five residents (Residents #2, #24, #48, #69, and #173) from 04/14/2022 through 09/14/2022. Findings included: A review of the facility's Care Plans, Comprehensive Person-Centered policy revised March 2022 revealed 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition;…

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, record review, and review of facility policy, it was determined the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs), received assistance with hygiene, specifically shaving, for one (1) of one (1) resident (Resident #19) reviewed for activities of daily living (ADLs). Findings included: A review of policy Activities of Daily Living (ADLs), Supporting, Version 1.0, dated revised 03/2018, revealed, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care). A review of an admission Record revealed the facility admitted Resident #19 with diagnoses including major depressive disorder, muscle weakness, and intervertebral disc degeneration. The quarterly Minimum Data Set (MDS), dated [DATE], revealed 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.