Westwood Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY IV. Resident #20 A. Resident status Resident #20, age less than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included dementia, quadriplegia, contractures of the left and right hands, diabetes and anoxic brain injury. The 3/19/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of six out of 15. The resident had impairments of both upper extremities, used a wheelchair to ambulate and was always incontinent of bowel and bladder. The resident was dependent on staff for eating, toileting, personal hygiene, shower, dressing and transfers. B. Resident observation During a continuous observation on 4/7/25, beginning at 11:41 a.m. and ending at 2:49 p.m., the following was observed: At 11:41 a.m. the resident was sitting in his wheelchair in the dining room. At 12:33 p.m. a staff member took the resident from the dining room to a television room. At 1:32 p.m. a staff member took Resident #20 to the activities room for an activity. At 2:49 p.m. the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide one (#30) out of five residents out of 31 residents with an ongoing program of activities designed to meet needs and interests and promote physical, medical and psychosocial well-being. Specifically the facility failed to ensure Resident #30 received a personalized activity program. Findings include: I. Resident #30 A. Resident status Resident #30, age [AGE], was admitted on [DATE]. According to the April 2025 computerized physician ' s orders (CPO), diagnoses included dementia without behavioral disturbance, anxiety and mood disturbance and hypertensive heart disease with heart failure. The 1/7/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The resident required partial to moderate assistance with activities of daily living (ADL). She required set up assistance for eating. The 1/27/25 MDS assessment revealed it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#30) of one resident reviewed for vision out of 31 sample residents. Specifically, the facility failed to follow up on Resident #30's referral for cataract surgery. Findings include: I. Facility policy and procedure The Hearing and Vison policy, undated, was provided by the nursing home administrator (NHA) on 4/14/25 at 1:47 p.m. It read in pertinent part, The facility ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. The social worker/social service designee is responsible for assisting residents and their families in location and utilizing any available resources, for the provision of the vision services that the resident needs. Once vision or hearing services have been identified, the social worker will assist the resident by making appointments and arranging for transportation. II. Resident #30 A.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#9) of three residents who required respiratory care received care consistent with professional standards of practice out of 31 sample residents. Specifically, the facility failed to follow physician's orders to maintain, clean, sanitize and store Resident #19's continuous positive airway pressure (CPAP) mask and machine. Findings include: I. Facility policy and procedure The CPAP/BiPAP support policy and procedure, revised March 2015, was provided by the nursing home administrator (NHA) on 4/14/25 at 1:47 p.m. It revealed in pertinent part, To provide the spontaneously breathing resident with continuous positive airway pressure (CPAP) with or without supplemental oxygen. General guidelines for cleaning the machine: wipe machine down with warm soapy water and rinse at least once a week and as needed. Clean humidifier weekly and air dry. Masks, nasal pillow, and tubing: clean daily by placing in warm water, soapy water and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#112) of one resident reviewed for dialysis care out of 31 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to ensure the resident's arteriovenous fistula (AVF) shunt was assessed on a daily basis. Findings include: I. Facility policy and procedure The Hemodialysis Catheters-Acccess and Care policy, dated February 2023, was received from the nursing home administrator on 4/11/25 at 4:03 p.m. The policy read in pertinent parts, Care of AVFs: -Keep the access site clean at all times; -Check the color and temperature of the fingers and the radial pulse of the access arm when performing routine care at regular intervals; -Check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access. The nurse should document in the resident's medical record every…

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 who were trauma survivors, received culturally competent, trauma-informed care in accordance with professional stands or practice and accounting for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for two (#40 and #42) of four residents reviewed out of 31 sample residents. Specifically, the facility failed to: -Identify Resident #40 and Resident #42's history of trauma and identify triggers which may retraumatize them; and, -Ensure services and individualized care approaches were provided for Resident #40 and Resident #42. Findings include: I. Facility policy and procedure The Trauma Informed Care and Culturally Competent Care policy, revised August 2022, was provided by the nursing home administrator (NHA) on 4/11/25 at 3:53 p.m. It revealed in pertinent part, Purpose: to guide staff in providing care that is culturally competent and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide one resident (#30) with professional quality of care out of 31 residents. Specifically, the facility failed to ensure Resident #30 received timely dental service. Findings include: I. Resident #30 A. Resident status Resident #30, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician's orders (CPO), diagnoses included dementia, dysphagia (difficulty swallowing) and adult failure to thrive. The 1/27/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The resident required assistance with all of her activities of daily living. The MDS assessment was not completed for the resident's dental status. -However, the resident was edentulous. B. Resident #30's representative interview The resident representative was interviewed on 4/10/25 at 1:00 p.m. The resident representative said she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for one (#30) of five residents reviewed for immunizations out of 31 sample residents. Specifically, the facility failed to ensure consent was obtained from Resident #30's representative prior to administering the pneumococcal vaccination. Findings include: I. Resident #30 A. Resident status Resident #30, age [AGE], was admitted on [DATE]. According to the April 2025 computerized physician's orders (CPO), diagnoses included dementia without behavioral disturbance, anxiety and mood disturbance and hypertensive heart disease with heart failure. The 1/7/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The resident required partial to moderate assistance with ADLs. The MDS assessment indicated the resident was not up to date on the pneumococcal vaccine because it 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.

Based on observations and interviews, the facility failed to provide a safe, sanitary, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure the residents' shower room was maintained in a safe and sanitary condition. Findings include: I. Observations On 4/8/25 at 2:13 p.m. the facilities shower room was observed. There was black residue on the surface of the grout lines going around the perimeter of the inside of the shower. II. Resident representative Resident #30's representative was interviewed on 4/8/25 at 9:43 a.m. She said the shower room was not clean and needed to have a good cleaning. She said it had been like that for some time. III. Staff interviews and observations The shower room was observed with the maintenance director (MTD) and the nursing home administrator (NHA) on 4/8/25 at 2:45 p.m. The MTD said the housekeeping staff cleaned the shower daily and deep cleaned the shower once a week. The MTD said the black residue could be soap (however the liquid body soap in the shower room was orange) or it…

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

Based on record review and interviews, the facility failed to develop and implement appropriate quality assurance and performance improvement (QAPI) plans of action to correct identified quality deficiencies, potentially affecting all the residents in the facility. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to medication errors. Findings include: I. Facility policy The Quality Assurance and Performance Improvement (QAPI) Program policy, revised February 2020, was provided by the interim director of nursing (IDON) on 3/7/24 at 2:40 p.m. It revealed in pertinent part, The objectives of the QAPI Program are to: Provide a means to measure current and potential indicators for outcomes of care and quality of life. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. Reinforce and build upon effective systems and processes related to the delivery of quality care and services. Establish systems through which to monitor and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure care for residents was provided timely and in a manner that maintained or enhanced the residents' dignity. Specifically, the facility failed to provide residents with a dignified existence by ensuring that call lights were consistently answered in a timely manner. Findings include: I. Facility policy The Call Lights: Accessibility and Timely Response policy, revised February 2023, was received from the corporate nurse consultant (CNC) #1 on 2/20/24 at 12:10 p.m. It read in pertinent part, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, 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 interviews and record review, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to follow up with residents' concerns regarding meals, staff cell phone usage, batteries not being charged and trash not being taken out. Findings include: I. Facility policy and procedure The Grievances/Complaints, Filing policy, revised April 2017, was provided by corporate nurse consultant (CNC) #1 on 2/15/24 at 10:00 a.m. It read in pertinent part, Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. Any resident, family member, or appointed resident representative may file a grievance or complain concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been…

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 IV. Falls A. Facility policy and procedure The Fall Risk Assessment policy, revised March 2018, was provided by CNC #1 on 2/19/24 at 4:30 p.m. It read in pertinent part, The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition. The staff and attending physician will collaborate to identify and address…

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 staff interviews and record reviews, the facility failed to ensure certified nurse aides and licensed nurses were able to demonstrate competency skills and techniques necessary to care for residents' needs. This placed all residents at the facility at risk of receiving inadequate care. Specifically, the facility failed to conduct staff competency evaluations for all certified nurse aides (CNA), licensed practical nurses (LPN) and registered nurses (RN). Cross-reference F677: failure to provide adequate assistance for activities of daily living for a resident who was dependent on staff for all care. Cross-reference F684: failure to provide diabetic care per standards of care. Cross-reference F689: failure to ensure the needs of a resident with substance use disorder. Cross-reference F690: failure to provide catheter care per standards of care. Cross-reference F691: failure to provide colostomy care per standards of care. Cross-reference F692: failure to implement effective interventions to ensure resident nutrition needs were met. Cross-reference F760: failure to ensure…

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 consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, texture and appearance. Findings include: I. Facility policy and procedure The Food and Nutrition Services policy, revised October 2017, was provided by corporate nurse consultant (CNC) #1 on 1/19/24 at 4:30 p.m. It read in pertinent part, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. II. Observations A test tray for a regular diet was evaluated by three surveyors immediately after the last resident had been served their room tray for lunch on 2/14/24 at 1:05 p.m. The test tray consisted of a sloppy joe sandwich, a bag of potato chips and coleslaw. -The individual bag of potato chips was set directly on top of the sloppy joe sandwich. -The cole slaw was 48.4 degrees fahrenheit (F). The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interview, the facility failed to ensure a clean, safe and homelike environment for two (#19 and #11) of 29 sample residents. Specifically, the facility failed to: -Ensure a system was implemented to clean and maintain Resident #19's chew and spit discarded food bucket; and, -Maintain a clean room environment for Resident #19 and Resident #11, who were roommates. Findings include: I. Facility policies The Safe and Home Like Environment policy, revised April 2019, was provided by corporate nurse consultant (CNC) #1 on 2/20/24 at 12:10 p.m. It read in pertinent part: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Housekeeping and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure one (#4) of three residents out of 29 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to provide a resolution to Resident #4's grievance, which he had communicated to staff on multiple occasions, regarding the resident's missing cigarettes and money. Findings include: I. Facility policy and procedure The Grievances/Complaints, Filing policy, revised April 2017, was provided by corporate nurse consultant (CNC) #1 on 2/15/24 at 10:00 a.m. It read in pertinent part, Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. 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 record review and interviews, the facility failed to ensure one (#4) of three sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan of 29 sample residents. Specifically, the facility failed to provide regular and consistent supervised guidance to assist Resident #4 to make educated decisions on determining an appropriate sliding scale insulin dose based on blood glucose assessment and carbohydrate intake and document those efforts per physician's orders. Findings include: I. Facility policy and procedure The Diabetes-Clinical Protocol, revised November 2020, was provided by the corporate nurse consultant (CNC) #1 on 2/19/24 at 4:30 p.m. It read in pertinent part, The Physician and staff will summarize factors that are contributing to, or conditions that are affected by the residents diabetes or glucose intolerance and will assess the impact of diabetes on the individual's function and quality of life. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure that residents who require colostomy services receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. for two (#15 and #11) of two residents reviewed for colostomy care out of 29 sample residents. Specifically, the facility failed to ensure Resident #15's and Resident #11's colostomy bags were maintained per physician's guidance and professional standards of practice. Findings include: I. Professional reference The American Cancer Society's Caring for a Urostomy (10/16/19), retrieved on 2/27/24 from https://www.cancer.org/cancer/managing-cancer/treatment-types/surgery/ostomies/urostomy/management.html, read in pertinent part, During the day most people need to empty the pouch about as often as they used the bathroom before they had urostomy surgery or other bladder problems-for many people, this might mean every 2 (two) to 4 (four)…

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 menus were followed to meet the residents nutritional needs. Specifically, the facility failed to: -Follow correct portion sizes to ensure adequate nutrition was provided to the residents; and, -Follow recipe modifications for the texture modified diets. Findings include: I. Facility policy and procedure The Kitchen Weights and Measures policy, revised April 2007, was provided by corporate nurse consultant (CNC) #1 on 2/15/24 at 10:00 a.m. It read in pertinent part, Food services staff will be trained in proper use of cooking and serving measurements to maintain portion control. Staff will be trained in the appropriate measurement and type of serving utensil to use for each food. Signs or posters explaining coded measurement indicators (color-coded) on utensils will be prominently displayed for reference. The Therapeutic Diets policy, revised October 2017, was provided by CNC #1 on 2/19/24 at 4:30 p.m. It read in pertinent part, Therapeutic diets are prescribed by the attending physician to support…

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 each resident with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for one (#11) of three residents out of 29 sample residents. Specifically, the facility failed to ensure Resident #11's requests and preferences for a vegetarian diet were served to him. Findings include: I. Facility policy and procedure The Resident Food Preferences policy, Revised July 2017, was provided by corporate nurse consultant (CNC) #1 on 2/19/24 at 4:30 p.m. It read in pertinent part, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Upon the resident's admission (or within 24 hours after his/her admission the dietitian or nursing staff will identify the resident's food preferences. Nursing staff will document the resident's food and eating preferences in the care plan. If the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Follow aseptic technique when replacing Resident #15's suprapubic catheter; and -Follow aseptic technique when performing Resident #18's wound care. Findings include: I. Suprapubic Catheter insertion procedure for Resident #15 A. Professional references According to [NAME], B.C. 2001, (8/16/21) Nursing Standards, How to Change a Suprapubic Catheter Effectively, retrieved on 2/27/24 from https://journals.rcni.com/nursing-standard/how-to-series/how-to-change-a-suprapubic-catheter-effectively-ns.2021.e11766/abs, A suprapubic catheter is inserted through the lower abdominal wall, above the pubic bone and below the navel, and into the bladder. A suprapubic catheter change is an aseptic procedure that was undertaken to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure three (#32, #41 and #272) of five residents reviewed for psychotropic medications out of 28 sample residents had the right to be informed of, and participate in, his or her treatment including the right to be informed, in advance, of the care to be furnished. Specifically the facility failed to ensure Resident #32, #41 and #272 were made aware of the risk/benefit and side effects of prescribed psychotropic medications. Findings include: I. Facility policy and procedure The Antipsychotic Medication Use policy, revised July 2022, was provided by the case manager on 9/28/23 at 1:15 p.m. it read in pertinent part, residents and or resident representatives will be informed of the recommendation, risks, benefits, purpose and potential adverse consequences of antipsychotic medication use. Residents and or resident representatives may refuse medications of any kind. Nursing staff shall monitor for and report any side effects and or adverse effects of…

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

Based on observations and interviews the facility failed to provide a homelike environment, including but not limited to receiving treatment and support for daily living safely in two out of two units. Specifically, the facility failed to: -Ensure smoking residents smoked in designated areas; -Ensure non-smoking residents were protected from smoking odors. Findings include: I. Observations Three residents were observed on 9/27/23 at 12:40 p.m. smoking cigarettes under the gazebo in a non-designated area. II. Resident interviews Resident #3 was interviewed on 9/27/23 at 12:15 p.m. She said her room constantly smelled like smoke and it bothered her. She said residents were allowed to smoke in non-designated smoke areas. Resident #37 was interviewed on 9/27/23 at 12:20 p.m. She said the smoke smell always entered her room and it bothered her because the smokers were allowed to smoke in non-designated areas. The smoke that entered her room made it hard for her to breathe at times. Resident #10 was interviewed on 9/27/23 at 11:11 a.m. She said smoke constantly entered her room and she…

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

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in two of three medication carts. Specifically, the facility failed to ensure medications were properly labeled with open dates for insulin (medication used for blood glucose management) pens and vials. Findings include: I. Professional reference According to the Lantus insulin package insert, retrieved on 10/3/23 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf After Lantus solo star pens have been opened they can be stored at room temperature for up to 28 days. The Lantus solo star pen should be thrown away after 28 days, even if it still has insulin left in it. According to the Humalog insulin package insert, retrieved on 10/4/23 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020563s115lbl.pdf In use humalog vials stored at room temperature must be used within 28 days or be discarded. II. Facility policy The Insulin Administration policy and procedure, revised September 2014, was received from the nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations 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 Insulin (medication used for blood glucose management) pens and vials were properly cleaned prior to drawing up medications; -Ensure wound care was provided in a hygienic manner; and, -Ensure hand hygiene was performed when changing gloves. Findings include: I. Failure to wipe insulin vials and pens appropriately A. Professional reference According to the Lantus Insulin package insert retrieved on 10/4/23 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf wipe the rubber seal of the insulin pen with an alcohol swab before use. Wipe the top of the insulin vial with an alcohol swab prior to drawing up insulin. B. Facility policy and procedure The Insulin Administration policy and procedure, revised…

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 staff interviews, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety in one of one kitchen. Specifically, the facility failed to: -Ensure the kitchen and food equipment was clean; -Prevent potential contamination; -Ensure proper food temperatures were taken for tray line service. Findings include: I. Facility policy and procedure The Food Sanitary and Service policy was requested from the nurse consultant (NC) on 2/27/2020 at 3:14 p.m. The NC said the facility did not have a policy on kitchen sanitation and cleanliness. II. Initial walkthrough The initial walkthrough of the kitchen was conducted on 2/24/2020 at 8:45 a.m. The dishwashing section contained several cooking utensils, plates, cups, and bowls piled up on the counter. The ice machine filters were covered in dust colored brown debris. The two drying fans in the dishwashing room were covered in dust and brown debris. III. Cleanliness The main kitchen was observed on 2/26/2020 at 11:05 a.m. The dish machine room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY III. Appropriate clothing for the weather A. Resident #49 Resident #49, age [AGE], was admitted on [DATE]. According to the January 2020 computerized physician orders (CPOs), diagnoses included multiple sclerosis, anxiety disorder, and nicotine dependence to cigarettes. According to the 12/7/19 minimum data set (MDS) assessment, the resident had minimum cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. She required supervision for activities of daily living (ADL's) such as dressing that required additional time to complete. The care plan initiated 6/26/18 identified Resident #49 as a safe smoker and capable of smoking without physical assistance but must be supervised. B. Observation 2/25/2020 -At 8:35 a.m., Resident #49 was observed through windows sitting outside in the courtyard, the temperature was 27 degrees with 12 mile per hour wind. Resident #49 wore a lightweight jacket. Resident #49's left arm was not in the jacket, and the jacket was not zipped up. -At 9:00…

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 and interviews the facility failed to ensure infection control practices were followed to prevent the spread of infection. Specifically the facility failed to: -Follow proper hand hygiene with glove use when working between dirty to clean processes. Finding include: I. Hand hygeine A. Facility policy The handwashing / hand hygiene policy revised August 2019 provided by nursing home administrator (NHA) on 2/26/2020 at 4:00 p.m., read in pertinent part: by the nursing home administor read in pertinent part: All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections. The standard precautions policy revised October 2018 provided by NHA on 2/26/2020 at 4:00 p.m., read in pertinent part: Gloves are changed during the care of a resident to prevent cross-contamination from one body site to another (when moving from dirty site to a clean site). B. Observations Certified nurse aide (CNA) #4 was observed on 2/25/2020 at 4:11 p.m. to assist Resident #29 with peri care. He had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews the facility failed to provide an ongoing program of activities to meet the interests of and support the wellbeing of one (#46) out of three residents out of 31 sample residents reviewed. Specifically the facility failed to -Provide a resident centered activity program for Resident #46 Finding include I. Resident status Resident #46, age [AGE], was readmitted on [DATE]. According to the February 2020 computerized physician orders (CPOs), diagnoses included dementia, aphasia, respiratory failure and arthritis. The 1/9/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired and a brief interview for mental status (BIMS) score was not completed. She required extensive assistance with two persons for bathing, transfers, toileting, dressing and personal hygiene. She required supervision at meals with cueing. Her skin was at risk for breakdown. The MDS activities interview and preference form dated 1/7/2020 provided by the Activities…

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, resident and staff interviews, the facility failed to ensure one (#57) of one out of 31 sample residents received treatment and care in accordance with professional standards of practice, comprehensive care plan and resident choices. Specifically, the facility failed to: -Ensure proper wheelchair positioning to address improper postioning for Resident #57. Findings include: I. Facility policy and procedure The Repositioning Policy, revised May 2013 and provided on 2/27/2020 at 4:00 p.m. by the Nursing consultant (NC) documented the following pertinent information: . 1. Encourage the chair-bound resident, who is able to move, to change positions or shift weight at least every fifteen minutes or as often as possible. 2. Check the care plan, assignment sheet or the communication system to determine resident-specific positioning needs including special equipment; resident level of participation and the number of staff required to complete the procedure. 3. Ask the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews the facility failed to ensure the hydration needs were met for one (#46) out of three residents out of 31 total sampled residents reviewed. Finding include: I. Facility policy The hydration policy dated 1/12/16 was provided by the nursing home administrator (NHA) on 2/26/2020 at 4:00 p.m., read in pertinent part: The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. Provide at least 1500 milliliters (ml) daily to each resident unless otherwise indicated by assessment with the registered dietitian or medical order. II. Resident's status Resident #46, age [AGE], was readmitted on [DATE]. According to the February 2020 computerized physician orders (CPOs), diagnoses included dementia, aphasia, respiratory failure and arthritis. The 1/9/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired and a brief interview for mental status (BIMS) score was not completed. 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 observations, record review and interviews, the facility failed to ensure one (#39) of two residents out of 31 sample residents received respiratory treatments in a manner of care consistent with professional standards of practice. Specifically the facility failed to: -Follow physician oxygen orders -Clean and store the continuous positive airway pressure (CPAP) equipment properly Findings include: I. Facility policy The facility oxygen administration policy, revised October 2010 provided by the nursing home administrator (NHA) on 2/26/2020 at 4:00 p.m., read in pertinent part: The purpose of this is to provide guidelines for safe oxygen administration. Verify that there is a physician's order, review the physician's orders or facility protocol for oxygen administration. The CPAP support policy, revised March 2015, read in pertinent part: Masks, nasal pillows and tubing were to be cleaned daily with warm soapy water and soaking/agitating for five minutes. Mild dish detergent was recommended. Rinse 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.