Eagle Ridge Post Acute

Based on observations and interviews, the facility failed to ensure a qualified infection preventionist (IP) was in place for providing guidance to the facility on the infection control policy and programs which had the potential to affect all 74 residents residing in the facility at the time of the survey. Specifically, the facility failed to have a designated IP who had the time necessary to properly assess, develop, implement, monitor, and manage the infection prevention and control program (IPCP) for the facility. Findings include: I. Facility policy and procedure The Infection Prevention and Control Program policy, revised October 2018, was received from the nursing home administrator (NHA) on 6/10/24 at 10:24 a.m. It documented in pertinent part, Policies and procedures reflect the current infection prevention and control standards of practice. II. Observations Observations throughout the survey (from 6/5/24 to 6/12/24) revealed multiple infection control failures within the facility. Cross-reference F880 for failure to implement an effective infection prevention and control…

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 act promptly upon the grievances concerning issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to timely create effective interventions and maintain a systematic approach to ongoing resident grievances of call light response times addressed in resident council. Findings include: I. Facility policy and procedure The Resident Council policy, revised April 2017, was provided by the nursing home administrator (NHA) on 6/12/24 at 11:23 a.m. The policy read in pertinent part, The purpose of the resident council is to provide a forum for: -Residents, families and resident representatives to have input in the operation of the facility; -Discussion of concerns and suggestions for improvement; -Consensus building and communication between residents and facility staff; and, disseminating information and gathering feedback from interested residents. A resident council response form will be utilized to track issues and their resolution. The facility department…

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 coordinate assessment with the preadmission screening resident review (PASRR) program for five (#26, #36, #4, #18 and #22) of eight residents reviewed for PASRR out of 45 sample residents. Specifically, the facility failed to coordinate a PASRR Level II evaluation for Resident #26, #36, #4, #18 and #22. Findings include: I. Resident #26 A. Resident status Resident #26, age [AGE], was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included generalized anxiety disorder and bipolar disorder (mental illness that causes shifts in a person's behaviors). The 2/26/24 minimum data set (MDS) assessment documented Resident #26 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #26 experienced feeling down, depressed or hopeless for several days during the review period. B. Record review Resident #26 had a PASRR Level I identification screen approved on 5/31/23 that…

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

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four out of five staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #2, CNA #5, CNA #4 and CNA #3. Findings include: I. Record review CNA #2 (hired on 5/16/23), CNA #5 (hired on 8/18/21), CNA #4 (hired on 4/6/17), and CNA #3 (hired on 2/1/23) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. Staff interviews The director of nursing (DON) was interviewed on 6/6/24 at 4:25 p.m. The DON said she was the staff development coordinator because the facility just hired someone who was still in training. The NHA and the DON were interviewed together on 6/11/24 at 4:10 p.m. The DON said she was unaware when she provided CNAs with…

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

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and three of three unit refrigerators. Specifically, the facility failed to: -Ensure staff followed appropriate hand washing and glove usage in the main kitchen; and, -Ensure food was labeled and stored appropriately in the main kitchen refrigerator and freezer and in three unit refrigerators. Findings include: I. Staff hand hygiene A. Professional reference According to The Colorado Department of Public Health and Environment (2024) The Colorado Retail and Food Establishment Rules and Regulations, retrieved on 6/24/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to maintain all mechanical, electrical and patient care equipment in safe operating condition. Specifically, the facility failed to ensure facility staff used a blood pressure cuffs which were rated for medical use. Findings include: I. Professional reference According to the [NAME] Advantage for Basic Nursing handbook, third edition, retrieved on 6/17/24 from Treas, [NAME] S., et al. [NAME] Advantage for Basic Nursing: Thinking, Doing, and Caring. F. A. [NAME] Company, 2022., Blood Pressure - Practical Knowledge, Electronic blood pressure monitors may be less accurate than those with an aneroid monitor (a manual blood pressure measuring device). To ensure accuracy, you should auscultate (listen to) a baseline blood pressure before initiating automatic monitoring. Ensure devices are rated for medical use. The width of the blood pressure cuff bladder of a properly fitting cuff will cover approximately two-thirds of the length of the upper…

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 interview, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and dementia management and resident abuse prevention. Specifically, the facility failed to: -Ensure the activities assistant (AA), the cook (CK) and housekeeper (HSKP) #1 received annual training that covered abuse, reporting incidents of abuse and resident abuse prevention over the last 12 months; and, -Ensure the CK, dietary aide (DA) #2 and the maintenance assistant (MA) received annual training that covered dementia management. Findings include: I. Facility policies The Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, was provided by the nursing home administrator (NHA) on 6/6/24 at 2:40 p.m. It read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation 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 interviews and record review, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training and resident abuse prevention training to ensure continued competence for four out of five staff reviewed. Specifically, the facility failed to ensure CNA #2, #5, #4 and #1 received 12 hours of continuing education annually in all required training topic areas, including dementia management training and resident abuse prevention training. Findings include I. Training record review Five randomly selected CNA training records were reviewed on 6/10/24. Of the five employees reviewed, four of the CNAs (#2, #5 #4 and #1) did not receive a full 12 hours of annual training. A. CNA #2 -CNA #2, hired on 5/16/23, had participated in six hours and 45 minutes of training during the annual training year. B. CNA #5 -CNA #5, hired on 8/18/21, had participated in a four-hour dementia class. The nursing home administrator (NHA) was unable to provide her complete training record, including completed…

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 personal funds accounts were managed adequately for one (#19) of five residents out of 45 sample residents. Specifically, the facility failed to have personal funds withdrawal sheets signed to ensure the Resident #19' s permission was obtained to withdraw funds from his personal needs account. Findings include: I. Personal funds withdrawal The Personal Funds Withdrawal sheet was reviewed for Resident #19 on 6/10/24. The resident was found to have three withdrawals from his account with no signed authorization. The withdrawals were as follows: -On 5/7/24 a withdrawal was made for $94.00; -On 4/11/24 a withdrawal was made for $105.00; and, -On 3/4/24 a withdrawal was made for $110.00. -The facility failed to provide receipts or signed authorization from the resident for the withdrawals. II. Staff interviews The business office manager (BOM) was interviewed on 6/11/24 at 11:45 a.m. The BOM said Resident #19' s legal representative requested the resident' s funds from the resident' s personal needs account each…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to inform one (#216) of three residents reviewed for beneficiary notices out of 45 sample residents of changes in their services covered by Medicare in a timely manner. Specifically, the facility failed to provide a Notice of Medicare Provider Non-Coverage (NOMNC) to Resident #216 two days prior to discharge of Medicare Part A funded services. Findings include: I. Facility policy and procedure The NOMNC procedure was provided by the nursing home administrator (NHA) on [DATE] at 10:15 a.m. It read in pertinent part, A Medicare provider must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries or enrollees receiving covered skilled nursing, home health, comprehensive outpatient rehabilitation facility and hospice services. The NOMNC must be delivered at least two calendar days before Medicare-covered services end. II. Record review A. Resident #216 The electronic medical record (EMR) revealed Resident #216 was discharged…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to investigate an allegation of abuse for one (#17) of three residents reviewed for abuse out of 45 sample residents. Specifically, the facility failed to investigate an incident where Resident #17 reported a staff member threatened him. Findings include: I. Facility policy The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) on 6/6/24 at 2:40 p.m. It read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The program consists of a facility-wide commitment and resource allocation to support the following objectives: -Protect residents from abuse, neglect,…

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 discharge summary was in place for one (#65) of three residents reviewed for discharge out of 45 sample residents. Specifically, the facility failed to ensure Resident #65's discharge summary included a recapitulation of the resident's stay and a complete final summary of the resident's status. Findings include: A. Resident status Resident #65, age [AGE], was admitted on [DATE] and discharged to another long-term care facility on 4/5/24. According to the April 2024 computerized physician orders (CPO), diagnoses included hyperkalemia (higher than normal potassium in the blood), benign prostatic hyperplasia (enlargement of the prostate) and major depressive disorder. The 2/6/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required supervision with activities of daily living (ADL). B. Record review The Discharge summary dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#19) of one resident reviewed for vision problems out of 45 sample residents. Specifically, the facility failed to ensure Resident #19 was assisted to receive his new glasses. Findings include: I. Resident #19 A. Resident status Resident #19, age greater than 65, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease with exacerbation and malignant neoplasm of the prostate. The 4/30/24 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required substantial assistance with activities of daily living (ADL). The MDS assessment documented the resident had adequate vision with eye glasses. B. Resident interview Resident #19 was interviewed on 6/6/24 at 9:52…

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 (#54) of three residents with limited range of motion received appropriate treatment and services out of 45 sample residents. Specifically, the facility failed to provide restorative therapy services to Resident #54. Findings include: I. Professional Reference According to the American Association of Post-Acute Nursing (AAPACN) Guidelines for Restorative Nursing Programs, retrieved on 6/17/24 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 #54 A. Resident status Resident #54, age greater than 65, was admitted to the facility on [DATE] 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 residents were free from unnecessary psychotropic medications for one (#22) of five residents reviewed for medications out of 45 sample residents. Specifically, the facility failed to ensure as needed (PRN) psychotropic medications were discontinued after 14 days for Resident #22. Findings include: I. Resident status Resident #22, age over 65, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder and chronic systolic (congestive) heart failure. The 3/15/24 minimum data set (MDS) assessment documented Resident #22 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment documented Resident #22 had felt down, depressed or hopeless, felt tired or had little energy, had a poor appetite, felt bad about himself and had trouble concentrating nearly every day during the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in accordance with professional standards in one of two medication storage rooms and one of two medication storage carts. Specifically, the facility failed to: -Ensure all medications and biologicals were stored appropriately in a secure location; and, -Maintain a medication refrigerator temperature log for one of three medication refrigerators. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), Elsevier, St. Louis Missouri, pp. 1976, retrieved on 6/19/24, All drugs are secured in designated areas only accessible to nurses. II. Observations On 6/10/24 at 8:59 p.m., the central hall medication cart was observed in the unlocked position. At 9:02 p.m., registered nurse (RN) #1 approached the medication cart and locked it. III. Record Review The East nursing station refrigerator medication log records from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to ensure two (#62 and #4) of six residents with an order for an altered mechanical soft texture, out of 45 sample residents received food and fluids prepared in a form designed to meet their needs per physician orders. Specifically, the facility failed to provide Resident #62 and Resident #4 the correct mechanically altered diet texture. Findings include: I. Professional reference The Common Ground Between National Dysphagia Diet (NDD) and International Dysphagia Diet Standardisation Initiative (IDDSI), reviewed July 2021, retrieved on 6/17/24 from https://iddsi.org/IDDSI/media/images/CountrySpecific/UnitedStates/NDD-to-IDDSI-Implementation.pdf . It read in pertinent part NDD of 2002 is being replaced by the IDDSI Framework, founded in 2013. This is the only professionally recognized and supported diet framework as of October 2021. NDD level three dysphagia advanced is now IDDSI soft and bite-sized level six. The NDD description stated…

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 meet all the requirements for the provision of hospice care for one (#19) of four residents out of 45 sample residents. Specifically, the facility failed to ensure the hospice agency notes regarding Resident #19's care were easily accessible to the facility staff in an attempt to effectively coordinate care with the hospice agency. Findings include: I. Resident #19 A. Resident status Resident #19, age greater than 65, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD) with exacerbation and malignant neoplasm of the prostate. The 4/30/24 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required substantial assistance with activities of daily living (ADL). The assessment documented the resident was receiving hospice services. B. 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: -Ensure housekeeping staff changed gloves and performed hand hygiene consistently when appropriate during resident room cleaning; -Ensure housekeeping staff properly used a disinfectant chemical per manufacturer's instructions when cleaning resident rooms; -Ensure staff donned (put on) the appropriate personal protective equipment (PPE) when providing direct care to residents on enhanced barrier precautions (EBP); -Ensure a process was in place to ensure staff were aware of which residents required EBP; -Provide clean linens after performing wound care and a wound dressing change; -Offer hand hygiene to residents before meals; and, -Implement an effective water management plan. Findings include: I. Housekeeping…

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

Based on observations, record review and interviews, the facility failed to ensure residents consistently received food prepared by methods that conserve nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure food was served palatable, attractive and served at the appropriate temperature. Findings include: I. Resident interviews Resident #4 was interviewed on 6/5/24 at 10:25 a.m. Resident #4 said the food was not always good. Resident #4 said the food was under seasoned at times and sometimes he received his meal cold. Resident #22 was interviewed on 6/5/24 at 11:00 a.m. Resident #22 said the food was awful and tasted bad. He said he ate his meals in his room and the food was delivered to him cold. Resident #22 said the food looked how it tasted. He said the food was undercooked and over-seasoned. Resident #57 was interviewed on 6/5/24 at 3:35 p.m. Resident #57 said the food was awful and his lunch on 6/5/24 had no seasoning to it. The resident said his food was normally bland and he did not like to eat it. Resident #17…

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 inform the resident's representative of a change of condition for one (#173) of four residents reviewed for notification of change out of 45 sample residents. Specifically, the facility failed to ensure Resident #173' s responsible party was notified after an unwitnessed fall. Findings include: I. Facility policy The Fall and Fall Risk, Managing policy, revised March 2018, was provided by the facility on 6/12/24. According to the policy, a fall was: Unintentionally coming to rest on the ground, floor or lower level, but not as a result of an overwhelming external force. An episode where a resident lost his or her balance and would have fallen, if not for another person or if he or she had not caught himself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. II. Resident #173 A. Resident status Resident #173, age…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide adequate supervision and assistance to prevent falls, and failed to assess, implement and monitor interventions consistent with resident needs for one (#173) of four residents reviewed for falls out of 45 sample residents. Specifically, the facility failed to: -Assess Resident #173 after a potential fall and after injuries were identified and report the potential fall; -Monitor Resident #173 after facial injuries were identified; -Ensure safe smoking practices were conducted for Resident #173 and care planned; and, -Ensure interventions were care planned for Resident #173 who was identified at moderate risk for falls. Findings include: I. Facility policy The Fall and Fall Risk Managing policy, revised March 2018, was provided by the facility on 6/12/24. The policy documented in pertinent part, Based on previous evaluations and current data, the staff will identify interventions related to the resident specific risk and cost to prevent 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 take steps to prevent one (#2) of three residents reviewed for wandering of 12 sample residents safe from eloping from the facility. Specifically, the facility: -Failed to identify goals and interventions on the baseline care plan to ensure Resident #2 ' s health and safety related to elopement; -Failed to ensure a thorough shift report was provided to the oncoming nurse during change of shift to inform of Resident #2 ' s wandering activities, and -Failed to ensure Resident #2 did not elope from the facility. Findings include: I. Facility policy and procedure The Elopement, Risk Reduction Strategies, and Management of Missing Residents policy, dated 7/17/23, was provided by the director of nursing (DON) on November 22, 2023 at 6:57 a.m. It included the following: An elopement risk assessment is completed by the nursing staff on all residents at admission, readmission, quarterly, upon change of condition, and after an elopement event. The initial…

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 resident, family and staff interviews and record review, the facility failed to ensure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for nine (#60, #36, #63, #13, #29, #14, #24, #34, #43) of 31 sample residents. Resident, family, and staff interviews revealed the facility failed to consistently provide adequate nursing staff resulting in delayed call light response, and prolonged wait times for assistance with activities of daily living such as assistance to and from the toilet. Findings include: I. Facility policy and procedure The Staffing policy, revised 10/2017, provided by the director of nursing (DON) on 2/13/2020 at 12:00 p.m. read, our facility provides sufficient number of staff with the skills and competency necessary to provide care and services for all resident in accordance with resident care plans and the facility assessment. II. Resident census and conditions According to the resident census and conditions report signed by 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 a safe, clean, comfortable and homelike environment in two (east and west) of three resident hallways. Specifically, the facility failed to ensure residents had adequate access to clean bath linens at all times. Findings include: I. Facility policy and procedure The Quality of Life - Homelike Environment policy, revised May 2017, was provided by the nursing home administrator (NHA) on 2/13/2020 at 1:30 p.m. It documented the purpose of this policy was to provide the residents with a safe, clean, comfortable and homelike environment by maximizing the characteristics of the facility which reflected a personalized, homelike environment. One of those characteristics included clean bath linens that were in good condition. II. Resident council interview During the resident council interview conducted on 2/12/20 from 10:00 a.m. through 11:00 a.m., Resident #34 showed a picture he had taken on his cell phone at 9:25 a.m. that morning of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure one (#46) of three residents reviewed for bathing and grooming received the necessary assistance with activities of daily living (ADLs) of 31 sample residents. Specifically, the facility failed to ensure Resident #46 received timely assistance with wheelchair positioning, and clothing and eye cleanliness. Findings include: I. Facility policy and procedures A. The Activities of Daily Living, Supporting policy and procedure, dated November 2019, was provided by the director of nurses (DON) on 2/13/2020 at 1:15 p.m. It included residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to monitor and document pain management for one (#20) of four residents reviewed for pain management of 31 sample residents. Specifically, the facility failed to implement the resident's pain management care plan, and monitor, document and assess Resident #20's level of pain at least every shift. Findings include: I. Facility policy and procedure The pain management policy, revised 10/11/19, was provided by the nursing home administrator (NHA) on 2/12/20 at 1:30 p.m. It documented the purpose of this policy was to accurately assess and achieve pain control for the facility's residents. It documented a pain evaluation should include the following: location(s), quality, intensity, associated symptoms, precipitating, aggravating and relieving factors, chronology, pattern (frequency, onset and duration of pain), medication regimen and other treatment modalities used for pain management and their degree of effectiveness. It documented all subsequent pain…

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 provide housekeeping and maintenance services necessary to maintain a sanitary and orderly interior in three of three hallways for residents residing in the facility. Findings include: I. Observations A. Resident rooms in the [NAME] hallway On 12/11/18 at 9:49 a.m., in room [ROOM NUMBER] there were approximately 10 one and one half inch x shaped marks on the north facing wall where nails had been in the wall. The white caulking in the lower left corner of the window had black streaks on the edges with a solid black center. On 12/12/18 at 12:56 p.m. in room [ROOM NUMBER] the toilet seat was loose and moved side to side. B. Resident rooms in the Center hallway On 12/10/18 at 9:16 a.m., in room [ROOM NUMBER] there was a large crack in the wall next to the resident's mirror. On 12/11/18 at 8:51 a.m., additional cracks in the wall were observed in the resident bathroom. The bottom shelf of the medicine cabinet was rusted and not a cleanable…

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 that all drugs and biologicals were properly stored in three of three medication storage refrigerators. Specifically, the facility failed to ensure that vaccines were stored according to practice standards and manufacturer guidelines. Findings include: I. Professional reference According to the Centers for Disease and Control and Prevention (CDC) Vaccine Storage and Handling (2018), retrieved from https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf, do not store any vaccine in a dormitory style or bar-style combined refrigerator/ freezer unit under any circumstances. These units have a single exterior door and an evaporator plate/cooling coil, usually located in an ice maker/freezer compartment. These units have been shown to pose a significant risk of freezing vaccines, even when used for temporary storage. All staff members who receive deliveries and/or handle or administer vaccines should be familiar with storage and handling policies and procedures at your facility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure the resident's environment remained as free from accident hazards as possible for one (#45) of six residents reviewed for falls of 32 sample residents. Specifically, the facility failed to ensure the call light was placed in a safe position and remained within reach for Resident #45. Findings include: I. Facility policy and procedure The Fall Management policy, dated 2/4/16, was provided by the medical records coordinator (MR) on 12/13/18 at 3:02 p.m., and documented a fall reduction program would be established and maintained, to assess all residents to determine their risk for falls. The facility was to identify risk factors that included the resident's physical health, functional status, and environmental conditions, which were followed by timely and appropriate interventions. II. Resident #45 status Resident #45, age [AGE], was admitted on [DATE]. According to the December 2018 computerized physician orders, diagnoses…

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 accuracy of the electronic medical record (EMR) for two (#63 and #45) of four residents reviewed for weight discrepancies of 32 sample residents. Specifically, the facility failed to ensure that resident weights were both timely and accurately documented for Residents #63 and #45. Findings include: I. Facility policy and procedure The Weight Management policy, dated 10/1/13, was provided by the director of nursing (DON) on 12/13/18 at 1:25 p.m., and documented all residents were to be weighed upon admission, then monthly or as indicated by physician orders, and document the results in the medical record. Residents were monitored for significant weight change on a regular basis. Results were reviewed and analyzed by the facility for intervention as appropriate. II. Record review A. Resident #45 Resident #45's weights were reviewed from 9/3/18 through 12/3/18. The weights were documented in three separate places in the medical record including the bath sheets, a Master Sheet that was sent to the dietary department,…

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 infection control standards of practice were followed for one of three blood glucose monitoring devices. Specifically, the facility failed to properly disinfect and store the blood glucose monitoring device after use on Resident #48. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (2017) Injection Safety, retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html, blood glucose meters are devices that measure blood glucose levels. Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. II. Facility policy and procedure According to the Cleaning and Disinfecting Glucometers policy…

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.