Durango Health And Rehabilitation

Based on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received the required 12 hours of training per year. Specifically, the facility failed to: -Ensure a system was in place to track CNA training to ensure they met the requirements; and, -Ensure CNA #9 and CNA #10 received the required 12 hours of training per year. Findings include: I. Record review A review of the CNA training records was completed on 6/27/24 at 2:00 p.m. -CNA #9's training records documented CNA #9 received seven hours of training in the previous calendar year. -CNA #10's training records documented CNA #10 received eight hours of training in the previous calendar year. II. Staff interviews The staff development coordinator (SDC) was interviewed on 6/27/24 at 4:04 p.m. The SDC said she did not have a system in place to monitor the CNAs yearly training. She said the CNAs were required to receive 12 hours of training per year. She said CNA #9 received seven hours of training in the calendar year and CNA #10 received eight hours of training in the calendar year, which did…

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 that the personal funds accounts were managed adequately for two (#2 and #30) of three residents reviewed for personal funds out of 45 sample residents. Specifically, the facility failed to notify Resident #2 and Resident #30, who were Medicaid funded, or their legal representative, when the resident's personal funds account reached $200.00 less than the eligibility resource limit for one person. Findings include: I. Record Review A. Resident #2 A review of the facility's current trust account on 6/27/24 revealed Resident #2 had $2,354.81 in her account, which was $354.81 dollars over the allotted $2000.00 eligibility limit for Medicaid funded residents. -There was no documentation to indicate the facility had notified Resident #2 or her legal representative when her personal funds account reached $200 less than the eligibility resource limit. B. Resident #30 A review of the facility's current trust account on 6/27/24 revealed Resident #30 had $3683.41in his account, which was $1,683.41 over the allotted $2000.00…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure three (#42, #52 and #68) of five residents reviewed for abuse out of 45 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #42 from physical abuse by Resident #25; and, -Protect Resident #52 and Resident #68 from physical abuse by Resident #24. Findings include: I. Facility policy and procedure The Abuse Policy, dated 5/3/23, was provided by the nursing home administrator (NHA) on 6/27/24 at 7:30 p.m. It read in pertinent part, Community does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including other residents. Residents have the right to be free from abuse. This includes physical abuse. Providing a safe environment for the resident is one of the most basic and essential duties of our facility. Resident abuse is defined as the willful Infliction of injury of a resident resulting in physical harm or pain and mental anguish. Physical…

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 and interviews, the facility failed to ensure that professional standards of practice were followed during medication administration for three (#67, #26 and #29) of nine residents reviewed out of 45 sample residents. Specifically, the facility failed to: -Ensure medications and insulin supplies, including sharps, were not left at the bedside; -Ensure medications were not dispensed and stored in medication cups in a nurse's pocket; and, -Ensure medications were not contaminated by placing dispensed medication back into the original bottle. Findings include: I. Facility policy and procedure The Medication Administration policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 6/27/24 at 7:29 p.m. It read in pertinent part, Resident medications are administered in an accurate, safe, timely and sanitary manner. Do not leave medications with the resident. Follow the medication/pharmacy guidelines for storage. II. Resident #67 A. Resident status Resident #67, age less than…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure one (#57) of six residents reviewed for activities out of 45 sample residents received an ongoing program of activities designed to meet needs and interests, and promote physical, medical and psychosocial well-being. Specifically, Resident #57 was not provided with meaningful activities or one-to-one activity staff visits per her individualized plan of care. Findings include: I. Resident #57 A. Resident status Resident #57, age less than 65, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included non-ischemic myocardial injury (non-traumatic injury to the heart), acute on chronic diastolic (congestive) heart failure, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side and type 2 diabetes mellitus with diabetic chronic kidney disease. The 5/27/24 minimum data…

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 two (#58 and #67) of two sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan out of 45 sample residents. Specifically, the facility failed to: -Notify the physician for high blood sugar readings for Resident #58; and, -Consistently monitor blood sugars according to the physician's order for Resident #67. Findings include: I. Facility policy and procedure The Diabetic Management policy, dated 3/19/24, was provided by the nursing home administrator (NHA) on 6/27/24 at 7:29 p.m. It read in pertinent part, Diabetic management involves both preventative measures and treatment of complications. The interdisciplinary team evaluates the diabetic resident and implements a plan of care: to ensure orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#57) of five residents reviewed for pressure injuries out of 45 sample residents received care consistent with professional standards of practice to prevent pressure injuries. Specifically the facility failed to implement timely interventions to prevent Resident #57 from developing a Stage 2 pressure injury to her right lateral ankle on 5/25/24 and to prevent the potential for further pressure injuries to occur. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved from https://www.internationalguideline.com/guideline on 7/1/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#45) of two residents with limited range of motion received appropriate treatment and services out of 45 sample residents. Specifically, the facility failed to offer restorative nursing services as recommended by physical therapy to prevent decline in physical function for Resident #45. Findings include: I. Professional Reference According to the American Association of Post-Acute Nursing (AAPACN) Guidelines for Restorative Nursing Programs, retrieved on 7/1/24 from aapacn.org/restorative-programs-guide/, The risk for functional decline in long term care residents is a serious issue that often leads to falls, pressure ulcers/injuries, weight loss, depression, and other negative outcomes. To ensure quality outcomes and to comply with federal regulation, nursing facilities must have a comprehensive and effective restorative therapy program that encourages each resident's highest level of function. II. Resident #45 A. Resident status 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 provide necessary respiratory care consistent with professional standards of practice in coordination with the resident plan of care for two (#4 and #3) out of four residents reviewed for respiratory care out of 45 sample residents. Specifically, the facility failed to: -Ensure Resident #4 received supplemental oxygen therapy per the physician's orders; and, -Ensure Resident #3 could safely and appropriately perform her tracheostomy care independently. Findings include: I. Supplemental oxygen failure A. Professional reference According to [NAME], B. B. (2022, November 23). Oxygen saturation, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK525974/ on 7/8/24, Cyanosis (bluish discoloration) may not develop until oxygen saturation reaches about 67%. As such, pulse oximetry is extremely useful because the signs and symptoms of hypoxemia may not be visible on physical examination. There is no set standard of oxygen saturation where…

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 manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for three (#57, #58, #11) of three residents reviewed for pain out of 45 sample residents. Specifically, the facility failed to ensure as needed (PRN) pain medications had established parameters for Resident #57, Resident #58 and Resident #11. Findings include: I. Professional reference The American Medical Directors Association (AMDA) The Society for Post-Acute and Long-Term Care Medicine Pain in the Post-Acute and Long-Term Care Setting Clinical Practice Guideline. [NAME], MD (2021) was retrieved on 7/7/24 from https://paltc.org/sites/default/files/2024-02/PainManagement2021CPGFinal.pdf. It read in pertinent part, PRN doses are offered or considered at specified intervals and given as needed, requested, or determined to be indicated. When several options for administering analgesics are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure one (#67) of nine residents out of 45 sample residents were free from significant medication errors. Specifically, the facility failed to ensure Resident #67 was administered the correct insulin. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 7/9/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose…

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 medications and biologicals were properly stored and labeled in accordance with professional standards in two of six medication carts and one of two medication storage rooms. Specifically, the facility failed to: -Ensure medications were properly labeled with open dates; and, -Ensure expired medications were removed from the medication cart and storage rooms. Findings include: I. Professional reference The United States Food and Drug Administration (USFDA) (2/8/21) Don't Be Tempted to Use Expired Medicines, retrieved on 7/2/24 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure one (#50) out of one resident reviewed for mechanically altered diets out of 45 sample residents received food prepared in a form designed to meet her needs. Specifically, the facility failed to provide Resident #50 the correct mechanically-altered diet as prescribed. Findings include: I. Facility policy and procedure The Diet and Nutrition Care Manual- Chapter two: Consistency alterations, revised in 2019, was provided by the dietary consultant (DC) on 6/27/24 at 12:02 p.m. It read in pertinent part, Dysphagia advanced diets: Vegetables included cooked, tender, chopped, shredded; protein foods included chopped or ground as tolerated. To achieve optimal intake, diets should be planned with the individual's preferences in mind. II. Resident # 50 A. Resident status Resident #50, age [AGE], was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included Parkinson's disease (disorder of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to maintain medical records on each resident that were accurately documented for one (#78) of one resident out of 45 sample residents. Specifically, the facility failed to ensure Medical Orders for Scope of Treatment (MOST) forms were not destroyed when residents were discharged from the facility. Findings include: I. Facility policy and procedure The Advanced Directives policy and procedure, dated [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 4:24 p.m. It revealed in pertinent part, The resident or legal responsible party will be provided with written information that explains their rights under law to give informed consent and to either refuse or accept health care and treatment. All advanced directives forms shall be kept in a binder at the nurses station. II. Resident #78 A. Resident status Resident #78, age [AGE], was admitted on [DATE] and passed away on [DATE]. According to the [DATE] computerized physician orders…

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 resident interviews, the facility failed to promptly address and attempt to resolve resident group complaints and grievances concerning issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to: -Ensure food was constantly palatable or available as requested; and, -Ensure residents felt their concerns with food temperatures were timely corrected. Findings include: I. Facility policy and procedure The Resident Group Grievance policy, dated 11/15/23, was provided by the nursing home administrator (NHA) on 3/7/24 at 1:35 p.m. The policy identified the facility would respond promptly to grievances. The grievances identified in a resident group meeting would be brought back up under old business as the group approves. The Statement of Resident Rights, undated, was provided by the nursing home administrator (NHA) on 3/7/24 at 1:35 p.m. The statement read the facility must make prompt efforts to resolve grievances. II. Resident interviews Resident #7 was interviewed on 3/5/24 at 1:25 p.m. 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, interviews and record review, the facility failed to maintain a sanitary, orderly, and comfortable homelike environment for residents in the dining room and an outdoor resident door. Specifically, the facility failed to: -Ensure cigarette butts were properly disposed of and not littered on the ground in a resident outdoor space; and, -Ensure residents in the facility were not subjected to a ceiling that leaked water and in poor condition. Findings include: I. Facility policy The Statement of Resident Rights, undated, was provided by the nursing home administrator (NHA) on 3/7/24 at 1:35 p.m. The statement identified residents had the right to a safe, clean, comfortable environment. The Traditional Tobacco and Electronic Smoking Device policy, dated 5/10/23, was provided by the NHA on 3/7/24 at 1:35 p.m. The policy identified all residents who smoked or desire to smoke at the facility would be assessed under a smoking risk assessment. The resident would then be educated on safe smoking…

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 VI. Resident #25 A. Resident status Resident #25, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbances, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. The 9/23/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. He required extensive assistance from two or more persons for bed mobility, transfers, toileting, dressing and personal hygiene. He required extensive physical assistance from one person for locomotion on and off the unit. B. Observations and resident interview Resident #25 was interviewed on 11/9/21 at 8:45 a.m. Resident #25 said he was bored to death. He said he missed having people to talk to and has not had activities offered to him inside or outside of his room for awhile. He said he also missed talking to his friends at…

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

Based on observations, interviews and record review, the facility failed to provide food and drinks that were palatable, attractive and served at appetizing temperatures in four of four resident hallways. Specifically, the facility failed to: -Ensure food was prepared in a palatable manner, including over-cooking certain foods, especially meat; -Ensure foods such as green beans were seasoned in a flavorful manner; and -Ensure resident's choices of beverages were being honored. Findings include: I. Facility policy and procedure The Food: Quality and Palatability policy and procedure, revised 9/2017, was provided by the nursing home administrator (NHA) on 11/11/21. It documented the policy was created to ensure food would be prepared by methods that conserve nutritive value, flavor and appearance. Food would be palatable, attractive and served at a safe and appetizing temperature. It documented the dining services director and cook (s) were responsible for food preparation. It documented that menu items would be prepared according to the menu, production guidelines and standardized…

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 each resident was treated with dignity and respect and cared for in a manner and in an environment that promoted maintenance or enhancement of quality of life for three (#58, #65, #17) of six residents reviewed for dignity out of 34 sample residents. Specifically, the facility failed to ensure Residents #58, #65, and #17 were treated with respect and dignity while receiving care from staff. Findings include: I. Facility policy and procedure A policy for promoting/maintaining resident dignity was provided by the staff development coordinator (SDC) on 11/11/21 at 2:54 p.m. The policy was not dated and read: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. II. Resident #58 A. Resident status Resident #58,…

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 (#69) of two residents reviewed for abuse out of 34 sample residents was kept free from abuse. Specifically, the facility failed to protect Resident #69 from verbal abuse by registered nurse (RN) #1. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy, revised 10/19/21, was provided by the nursing home administrator (NHA) on 11/9/21. It documented that the policy was created to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. It documented the facility would establish policies and procedures to investigate any such allegations and include training for new and existing staff on activities that constituted abuse, neglect, exploitation and misappropriation of resident property, including reporting procedures and 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 provide catheter care in a sanitary manner to prevent infection and promote comfort for one (#52) of one resident reviewed for catheters out of 34 sample residents. Specifically, the facility failed to ensure nursing staff used the proper technique and products in keeping with professional standards when providing indwelling Foley catheter care for Resident #52. Findings include: I. Facility policy The Catheter Care policy, undated, was provided by the director of nursing (DON) on 11/10/21 at 1:39 p.m. The policy included the following: -Catheter care will be performed every shift and as needed by nursing personnel. -Empty drainage bags when bag is half-full or every 3 to 6 hours. -Compliance guidelines for catheter care: Gently separate the labia to expose the urinary meatus. Wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap). Use a new part of the cloth or different cloth for each side. With 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 staff interviews, the facility failed to minimize the risk for foodborne illness in a highly susceptible population in one of one facility kitchen. Specifically, the facility failed to follow industry standards for: -Proper hand hygiene and glove use; -Properly date marking and discarding expired foods; and -Ensuring stored utensils and dishware were dry and clean. Cross reference F802, sufficient and competent dietary support personnel. Findings include: I. Hand hygiene and glove use A. Professional references According to the Food and Drug Administration (FDA) Food Code (2017), pp. 48-50, foodservice staff shall use the following handwashing procedures: -Rinse under clean, running warm water; -Apply an amount of cleaning compound recommended by the cleaning compound manufacturer; -Rub together vigorously for at least 10 to 15 seconds while paying particular attention to removing soil from underneath the fingernails and creating friction on the surfaces of the hands and arms fingertips, and areas between the fingers; -Thoroughly rinse under…

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

Based on observations, record review, and interviews, the facility failed to develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies, potentially affecting all the residents in the facility. Findings include: I. Failure to prevent repeat citations Cross-reference F550, (resident rights/exercise of rights), F689 (accident hazards), F761 (label/store drugs and biologicals), F804 (nutritive value/appearance, palatable foods), and F812, (food procurement, store/prepare/serve-sanitary). These deficiencies were cited previously during a recertification survey ending 10/4/18. Although the facility corrected the deficiencies, based on the findings below, the facility had not maintained compliance with these regulatory requirements with the additional failures of self-determination, advanced directives, personal privacy and confidentiality, minimum data set (MDS) quarterly assessments, pre-admission screening and resident review (PASARR), care plan timing and revision, services provided met…

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 ensure dignified care for seven of seven (#98, #45, #24, #256, #44, #52, and #83) residents reviewed for dignity of 46 sample residents, and several residents who actively participated in resident council. Specifically, the facility failed to: -Ensure residents were spoken to in a dignified, respectful manner; -Provide resident cares with dignity; and -Pass medications in a dignified manner. Residents used words such as rude, condescending, undignified and hateful to describe how some staff treated them. Residents said as a result they felt, as stated in their words, bad, angry, invisible, weird, and like I'm nobody. Findings include: I. Facility policy and procedure The facility's Resident Dignity & Personal Privacy policy, revised June 2007, provided by the district director of clinical services (DDCS) on 8/21/19 at 1:20 p.m. read, the facility provided care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy. Each resident's right 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 observations, record review, and interviews, the facility failed to honor bathing, food and snack preferences for one (#256) of two residents reviewed for choices, and for residents who resided on the secured unit and main living area of the facility, out of 46 sample residents. Specifically, the facility: -Failed to offer and provide bathing opportunities for Resident #256; and -Failed to offer and provide food and snack preferences for the residents who resided on the secured unit and main living area of the facility. Findings include: I. Bathing choices A. Facility policy and procedure The Resident Rights policy and procedure, dated February 2017, was provided by the director of nurses (DON) on 8/21/19 at 3:51 p.m. It documented the facility protected and promoted the rights of each resident and ensured residents enjoyed freedom of choice regarding their daily existence and healthcare, to the maximum extent possible. B. Resident #256 status Resident #256, age [AGE], was admitted on [DATE]. According…

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 ensure safe narcotic and vaccine storage for four of six medication carts and two of two medication storage refrigerators. Specifically, the facility failed to: -Ensure double locking of schedule II narcotics; and -Store vaccines in a non-dormitory style refrigerator. Findings include: I. Facility policy and procedure The facility Storage and Expiration Dating of Medications, Biological, Sringes, and Needles policy, revised October 2016, provided by the director of nursing (DON) on 8/21/19 at 1:20 p.m. read to store all drugs and biologicals in locked compartments, including the storage of schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access. The facility should ensure that medications and biologicals for each resident are stored at their appropriate temperature according to the united states pharmacopeia guidelines for temperature ranges. Facility staff should monitor the temperature of vaccines twice a day for refrigeration…

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

Based on observations, staff interviews and record review, the facility failed to employ sufficient dietary support staff to carry out the functions of the food and nutrition services department in one of one facility kitchen. Specifically, insufficient numbers of adequately trained food and nutrition staff contributed to prolonged wait times for meals and overall decreased resident satisfaction with dining. Cross reference F804, food palatability. Findings include: I. Food production and service The facility had one production kitchen. Posted dining room meal times were: Breakfast: 8:00 a.m. Lunch: 12:00 p.m. Supper: 6:00 p.m. Two resident hallways were served room trays prior to the posted dining room meal times and two hallways were served following dining room service. There were no scheduled or posted times for the delivery of room trays. Dietary staff prepared resident plates and trays for delivery to dining rooms or resident rooms by nursing staff. II. Facility policies and procedures A. The Food and Nutrition Services policy and procedure, revised February 2017, was provided…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations and record review, the facility failed to consistently provide palatable foods for 10 (#45, #49, #73, #64, #24, #12, #37, #98, #91, #90) of 46 sample residents, residents who participated in resident council, and potentially all facility residents. Cross reference F802, sufficient dietary support staff. Findings include: I. Facility policies and procedures A. The Meal Service policy and procedure, revised March 2012, was provided by the nursing home administrator (NHA) on 8/20/19 at 11:20 a.m. The policy stated: Whether the resident meal is served in the dining room or in the resident's room, measures are taken to ensure a positive dining experience. B. The Food and Nutrition Services policy and procedure, revised February 2017, was provided by the nursing home administrator (NHA) on 8/20/19 at 11:20 a.m. The policy stated the facility took steps to ensure: -Each resident received received three meals per day at regular times; -Foods were palatable, attractive and at the proper…

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 clarify resuscitation choices and document them accurately in the medical record for one (#305) of one resident reviewed for advanced directives of 46 sample residents. Specifically, the facility failed to ensure the current physician orders (CPO) for Resident #305's code status accurately reflected the resident's choices for advanced directives. Findings include: A. Facility policy and procedure The Advanced Directives policy and procedure, revised February 2017, was provided by the district director of clinical services (DDCS) on [DATE] at 1:15 p.m. It documented the facility was responsible for notification of the resident's physician of a resident's choices for resuscitation, and was responsible to obtain and enter the information in the electronic health record (EHR). B. Resident #305 status Resident #305, age [AGE], was admitted on [DATE]. According to the [DATE] CPO, diagnoses included psoas muscle abscess, pneumonia and type two diabetes. 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 timeliness of minimum data set (MDS) assessments for one (#2) of two residents reviewed of 46 sample residents. Specifically, more than 120 days elapsed since Resident #2's most recent quarterly MDS. Findings include: I. Facility policy and procedure The Resident Assessment Instrument (RAI) Process policy, revised February 2017, provided by the facility on 8/21/19, included: The facility must assess a resident using the quarterly review instrument . at least once every 3 months . II. Resident #2 Resident #2, age [AGE], was admitted on [DATE]. According to the 3/17/19 MDS assessment, diagnoses included anemia, hypertension and Parkinson's disease. The resident needed extensive assistance with activities of daily living. Record review on 8/21/19 revealed no evidence of a quarterly MDS assessment for Resident #2 since 3/17/19, more than five months before. III. Staff interviews The care management director and MDS coordinator were interviewed 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 record review and interviews, the facility failed to ensure a preadmission screening/resident review (PASRR) Level II screen was completed for one (#17) of one resident reviewed for PASRR of 46 sample residents. Findings include: I. Facility policy and procedure The Pre-admission Screening and Resident Review (PASRR) policy, dated November 2017, was provided by the nursing home administrator (NHA) on 8/19/19 at 3:35 p.m. It documented pre-admission screening was coordinated for residents who were identified as having a mental disorder and recommendations from the PASRR Level II determination and the PASRR evaluation report were to be incorporated in the resident's assessment, care planning and transitions of care. The purpose of the policy was to ensure individuals with mental disorders received the care and services they needed. II. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the August 2019 computerized physician orders (CPO), diagnoses included…

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 honor the residents' right to participate in the development and implementation of the person centered care plan process for two (#12 and #64) of two residents reviewed for participation in care planning of 46 sample residents. Specifically, the facility: -Failed to invite Resident #12 and #64 to their care planning conferences; and -Failed to hold quarterly care conferences for Resident #12. Findings include: I. Policy and procedure The Care Plan Conference policy and procedure, dated November 2017, was provided by the director of nurses (DON) on 8/21/19 at 3:51 p.m. It documented the interdisciplinary team (IDT), in conjunction with the resident and/or resident representative, would develop the plan of care based on the comprehensive assessment. The care plan conference was held to identify resident needs and establish attainable goals. Since the comprehensive care plan must be developed within seven days of completion of the comprehensive…

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 services to meet professional standards of quality, affecting two (#44 and #73) of nine residents reviewed for medication administration of 46 sample residents. Specifically, the facility failed to ensure medications were handled in a sanitary manner during preparation for Residents #44 and #73. Findings include: I. Professional standard According to the 2009 American Society of Consultant Pharmacist (ASCP), Passing Medications: ASCP's Medication Administration Video Series handout, Tips for Administering Oral Medications, dated 2009, was provided by the nursing home administrator (NHA) on 8/20/19 at 11:22 a.m. It included the following recommendations: When using a standard pill crusher, place the tablet in a mediction cup, place another cup on top, then use the crusher device. This keeps the crushing device clean while preventing medication loss. Wear gloves whenever the handling of a medication is required. II. Facility policy and procedure The Medication Administration policy and procedure,…

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 adequate supervision to ensure freedom from falls and accidents for two (#40 and #89) of five residents reviewed for accidents and hazards of 46 sample residents. Specifically, the facility failed to ensure thorough and timely interventions to prevent falls for Resident #89. The facility failed to thoroughly assess and implement all possible fall interventions for Resident #89 in a timely manner, which included using a male certified nurse aide (CNA) for Resident #89's cares, moving the resident closer to the nurses' station to assist with frequent rounding in a timely manner, and ensuring appropriate footwear was maintained consistently. As a result, Resident #89 sustained 13 falls within the previous two months, five falls within the previous week. The resident sustained skin tears, bruising, head and facial injuries, and a visit to the local emergency room, after which the resident continued to fall. The facility further…

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 acceptable parameters of nutritional status for one (#12) of five residents reviewed for nutrition out of 46 sample residents. Specifically, the facility failed to: -Adequately assess, monitor, and address the nutritional needs for Resident #12; -Obtain Resident #12's weight when he was readmitted to the facility; and -Identify and assess a weight loss of 8.76 percent (%) over a six-month period for Resident #12. Findings include: I. Facility policy and procedure The Weight Management policy, dated July 2017, was provided by the director of nurses (DON) on 8/21/19 at 3:51 p.m. It included a resident's nutritional status would be monitored on a regular basis to aid in the maintenance of acceptable parameters, such as body weight and protein levels, unless the resident's clinical condition demonstrates this is not possible. Residents are offered a therapeutic diet when there was a nutritional concern. The measurement of weight…

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 it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 7.69%, or two errors out of 26 opportunities for error. Findings include: A. Facility policy and procedure The Medication Administration policy and procedure, dated June 2008, provided by the nursing home administrator (NHA) on 8/20/19 at 11:22 a.m., included medications were administered in accordance with written orders of the attending physician. For tablet form of medications, when possible, request that the provider pharmacy package tablets already scored for administration. Since unscored tablets may not be accurately broken, their use is discouraged if a suitable alternative is available. Use a tablet-splitter to avoid contact with the tablet if the tablet must be broken in order to administer the proper dose. If applicable and/or prescribed, take vital signs or tests prior to administration of the dose, e.g., pulse with digitalis, blood pressure 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.