Mantey Heights Rehabilitation & Care Center

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.conditions in the kitchen. Specifically, the facility failed to: -Ensure the staff medications were not stored in the walk-in refrigerator with resident food; -Ensure the staff wore a beard net while preparing and serving meals; and, -Ensure the air vent above the food service line was free of dust and dirt. Findings include: I. Failure to ensure staff medications were not stored in the walk-in refrigerator A. Professional reference The Colorado Retail Food Establishment Rules and Regulations, Chapter 7-5, effective 3/16/24, was retrieved on 12/29/24, revealed in pertinent part, Medicines belonging to employees that require refrigeration and are stored in a food refrigerator shall be stored in a package or container and kept inside a covered, leakproof container that is identified as a container for the storage of medicines. B. Observations During the initial tour of the main kitchen on 12/16/24 at 9:57 a.m. the walk-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 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 implement an effective water management plan. Findings include: I. Professional reference According to Center for Disease Control (CDC), Controlling Legionella in Potable Water Systems, last reviewed 3/15/24, was retrieved on 12/31/24 from https://www.cdc.gov/control-legionella/php/toolkit/potable-water-systems-module.html It read in pertinent part, Operation, maintenance, and control limits guidance: Monitor temperature, disinfectant residuals, and pH frequently based on Legionella performance indicators for control. Adjust measurement frequency according to the stability of performance indicator values. For example, increase the measurement frequency if there's a high degree of measurement variability. Hot water:…

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 an environment free from risk of accident hazards for five (#63, #9, #2, #57 and #23) of ten residents out of 46 sample residents. Specifically, the facility failed to: -Implement and update fall care plans in a timely manner for Resident #63; -Ensure neurological checks were completed appropriately for Resident #63 and Resident #9 following an unwitnessed fall; -Ensure Resident #2 was safely transferred using a slide board; -Ensure Resident #57 was appropriately monitored while smoking; and, -Ensure safe transfer pole use for Resident #23. Findings include: I. Failure to initiate a timely fall care plan and interventions to prevent falls for Resident #63 and complete neurological assessments after a fall for Resident #63 and Resident #9. A. Professional reference According to [NAME], P.A., [NAME], A.G., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 1780, retrieved on 12/30/24, In the event of a fall,…

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

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure food was palatable and served at the appropriate temperature. Findings include: I. Facility policy and procedure The Food and Nutrition Services policy, revised October 2017, was provided by the nursing home administrator (NHA) on 12/19/24 at 5:38 p.m. It read in pertinent part, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive and it is served at a safe and appetizing temperature. If an incorrect meal is provided to a resident, or a meal does not appear palatable, the nursing staff will report it to the food service manager so that a new food tray can be issued. II.…

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 10 (#12, #64, #4, #15, #41, #55, #7, #44, #18 and #129) of 17 residents with an order for a mechanically altered diet texture out of 46 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 #12, #64, #4, #15, #41, #55, #7, #44 and #18 with the correct altered mechanical soft diet texture: and, -Provide Resident #129 with the correct altered pureed diet texture. Findings include: I. Professional reference The comparison of National Dysphagia Diet (NDD) and International Dysphagia Diet Standardization Initiative (IDDSI), reviewed July 2021, was retrieved on 12/29/24 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…

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 each resident had the right to formulate an advanced directive for one (#63) of two residents out of 46 sample residents. Specifically, the facility failed to ensure Resident #63's proxy selected or refused life-saving treatments within the power of a proxy. Findings include: I. Medical Orders for Scope of Treatment (MOST) form The MOST form documented that a Proxy-by-Statute (decision maker selected through a proxy process) may not decline artificial nutrition or hydration for an incapacitated resident without an attending physician and a second physician trained in neurology who certified that artificial nutrition or hydration would merely prolong the act of dying and was unlikely to result in the restoration of the resident to independent neurological functioning. II. Resident status Resident #63, age greater than 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included vascular dementia,…

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, the resident's care plan, goals and preferences for two (#32 and #70) of two residents reviewed for respiratory care out of 46 sample residents. Specifically, the facility failed to: -Implement a care plan focus with purpose, goals and interventions to document Resident #32 and Resident #70's goals for using a Continuous Positive Airway Pressure/Bi-level Positive Airway Pressure (CPAP/BiPAP) machine; -Develop and implement effective interventions to maintain and clean Resident #32 and Resident #70's CPAP/BiPAP machines to ensure the non-invasive mechanical ventilators were maintained in a hygienic manner; and, -Develop and implement effective interventions for oxygen therapy for Resident #32 and Resident #70. Findings include: I. Manufacturer's recommendations The ResMed AirSense10 manufactures User Guide, dated 2021, was provided by the nursing home…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal and influenza vaccinations for two (#28 and #43) of five residents out of 46 sample residents. Specifically, the facility failed to offer pneumococcal vaccinations to Resident #28 or Resident #43. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2022, retrieved on 1/2/25, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part, Routine vaccination-pneumococcal: For those ages 19 to 64 with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20). For those over…

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 resident and staff interviews and record review, the facility failed to promote resident dignity and respect for two (#1 and #2) of four residents reviewed for dignity out of 11 sample residents. Specifically, the facility failed to ensure Resident #1 and Resident #2 were treated and spoken to in a dignified manner. Findings include: I. Facility policy The Dignity policy, revised February 2021, was provided by the corporate clinical consultant (CCC) on 9/12/23. The policy read in part: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Residents may exercise their right without interference, corrosion, discrimination or reprisal from any person or entity associated with this facility. The Resident Rights policy, revised February 2021, was provided by the CCC on 9/12/23. The policy read in part: Employees shall treat…

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 staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness. Specifically, the facility failed to: -Ensure cold food items were at appropriate temperatures; -Ensure expired food was discarded; and, -Ensure food items removed from its original packaging and opened had a dating system. Findings include: I. Food temperatures of cold and hot food items were not held at the proper temperature to reduce the risk of food-borne illness. A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, The food shall have an initial temperature of 41ºF (Fahrenheit) or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control. (Retrieved 7/18/23). B. Ensuring holding temperatures…

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 staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure remedial actions were followed and timely implemented after the identification of Legionella was detected in the facility's water. Findings include: I. Professional reference The Center for Disease Control and Prevention (CDC) recommendations for Legionella, last reviewed on 3/25/21, was retrieved on 7/17/23 at https://www.cdc.gov/legionella/wmp/healthcare-facilities/healthcare-wmp-faq.html under Heathcare Water Mangement read in pertinent part: Healthcare facilities, such as hospitals and nursing homes, usually serve the populations at highest risk for Legionnaires' disease. These include older people and those who have certain risk factors, such as being a current or former…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure four (#4, #50, #125 and #36) of 11 residents reviewed out of 37 sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #4 did not suffer from verbal abuse by Resident #66. The facility failed to ensure effective personalized care planned interventions were in place for Resident #4 to prevent verbal abuse, who had a history of dementia and was exhibiting constant loud vocalizations. On [DATE] Resident #66 shouted at Resident #4, while in Resident #4's room, to shut up and stop yelling as she was disturbing him and the entire hallway. Resident #4 was observed hunched over in a wheelchair with hands covering her face. The facility further failed to ensure: -Resident #50 did not suffer from verbal/mental abuse by registered nurse (RN) #1; -Resident #125 did not suffer mistreatment/physical abuse by certified nurse aides (CNAs) #14 and #15; and, -Resident #36 did not suffer from verbal abuse by…

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 adequate assistance with activities of daily living (ADLs) for four (#8, #63, #50 and #7) of nine residents reviewed out of 37 sample residents. Specifically, the facility failed to ensure: -Resident #8 received adequate assistance with bathing, grooming and toilet use/incontinence; -Resident #63 received adequate assistance with bathing and grooming; -Resident #50 received adequate assistance with showers; and -Resident #7 received adequate assistance with showers. All the above residents needed physical assistance from staff with these ADLs. Residents #50 and #7 said the lack of showers affected their psychosocial well-being. Findings include: I. Facility policy The Activities of Daily Living (ADLs)-Supporting policy, provided by the nursing home administrator (NHA) on 7/13/23 at 6:00 p.m., documented in pertinent part: Residents will be provided with care, treatment and services as appropriate to maintain or improve their…

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 sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses of the facility's resident population in accordance with the facility assessment, resident census and daily care required by the residents. Cross-reference F689 accident hazards and F677 activities of daily living (ADLs). Findings include: I. Facility policy The Staffing, Sufficient and Competent Nursing policy, revised August 2022, read in pertinent part: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care services for all residents in accordance with resident care plans and the facility assessment. Staffing…

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 four (#4, #36, #50 and #125) of 11 residents reviewed out of 37 sample residents had personalized behavioral interventions in place. Specifically, the failed to ensure: -Resident #4, who had a history of dementia, had effective personalized behavioral interventions care planned and in place who was exhibiting verbally disruptive behaviors and was at risk for abuse; and -Residents #36, #50 and #125 had personalized behavioral interventions care planned for dementia and trauma informed care for these residents that were difficult to redirect and had triggered behaviors. Findings include: I. Facility policy and procedure The Dementia Clinical Protocol policy and procedure, reviewed [DATE], and was provided by the nursing home administrator (NHA) on [DATE] at 6:00 p.m. It revealed in pertinent part, The staff and physician will review the current physical, functional, and psychosocial status of individuals with dementia, and will summarize the…

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

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, texture, temperature and appearance. Findings include: I. Resident group interview A group interview was conducted on 7/12/23 at 9:56 a.m. with four alert and oriented residents (#7, #26, #30 and #40). All the residents in the group interview said that the food was not palatable. Some of the comments were as follows: -The food was salty. -Chicken was dry and fatty. -The food was institutional food (lacked quality, variety and value). -The food came at room temperature. II. Resident interviews Resident #72 was interviewed on 7/10/23 at 9:10 a.m. The resident said he wanted eggs over medium but he was served runny eggs and scrambled eggs. Resident #43 was interviewed on 7/10/23 at 1:56 p.m. The resident said the food was bland and he would love to have a burrito or Thai chili. Resident #47's family representative was interviewed on 7/10/23…

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 its quality assurance and process improvement (QAPI) committee prioritized its improvement activities, developed and implemented action plans, measured the success of those actions, tracked performance, regularly reviewed and analyzed and acted on data collected. Specifically, the facility failed to identify and implement effective action plans to address repeat deficiencies and resident quality of life and quality of care issues related to abuse prevention, activities of daily living, dementia care, quality assurance and infection control. Findings include: I. Repeat deficiencies A. Abuse: cross-reference F600 abuse and F609 failure to report abuse allegations. Failure to investigate abuse allegations was cited at a harm level during the previous recertification survey on 5/19/22, 3/24/22 and was cited again during the current recertification survey on 7/13/23. B. Activities of daily living (ADLs): cross-reference F677. Failure to provide assistance with ADLs in keeping with resident needs and preferences was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to accommodate the needs of two (#63 and #16) of seven residents reviewed for environmental concerns out of 37 sample residents. Specifically, Residents #63 and #16, who used wheelchairs for ambulation, were unable to access their bathrooms, have privacy while in their bathrooms and/or fully utilize their toiletry items at the sink in shared rooms. Findings include: I. Resident #63 A. Resident status Resident #63, under age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disorder (COPD), pulmonary hypertension, hypoxic respiratory failure and stage 4 kidney disease. According to the 5/3/23 minimum data set (MDS) assessment, he was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He had verbal behaviors directed toward others but no rejection of care. He required extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure resident room temperatures were comfortable and safe for residents in one of three neighborhoods. Specifically, the residents who lived in two of eight resident rooms on the west side of Grand Mesa Hall experienced uncomfortably hot room temperatures when outdoor temperatures were high. Residents said all the rooms in that area of the building were uncomfortably hot and the facility's evaporative cooling system was ineffective. Findings include: I. Observations and resident interviews On 7/10/23 at 8:00 a.m. the facility hallways were observed with signs posted explaining why nursing facilities needed to have the room temperatures kept between 71 and 81 degrees Fahrenheit. High outdoor temperatures during the survey, conducted 7/10 through 7/13/23, ranged from 98 to 101 degrees Fahrenheit, according to the National Weather Service website. room [ROOM NUMBER] was observed on 7/10/23 at 9:32 a.m. Her bedroom was uncomfortably hot and she said it…

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

Based on record review and interviews the facility failed to report incidents of potential abuse to the State Survey and Certification agency in accordance with State law for three (#4, #66 and #50) of 11 residents reviewed for abuse out of 37 sample residents. Specifically, the facility failed to report: -An incident of verbal abuse involving Resident #4 and Resident #66; and, -Incidents involving verbal/mental abuse by registered nurse (RN) #1 toward Resident #50 to the State Survey and Certification Agency. Cross-reference F600, failure to ensure residents were free from abuse. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation and Misappropriation Prevention policy and procedure, last reviewed April 2021, was provided by the nursing home administrator (NHA) on 7/18/23 at 4:06 p.m. It read in pertinent part: Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegations within timeframes required by federal requirements. II. Abuse incident involving…

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 one (#50) of two residents reviewed for PASRR out of 37 sample residents. Specifically, the facility failed to submit another PASRR assessment when Resident #50's diagnosis changed in June 2023. Finding include: I. Facility policy The policy regarding PASRR assessments was requested from the nursing home administrator (NHA) on 7/12/23 at 2:40 p.m. The NHA said the facility did not have a policy for PASRRs. II. Resident status Resident #50, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO) diagnoses included unspecified dementia, major depressive disorder (recurrent and moderate), anxiety disorder, and chronic post-traumatic stress disorder (C-PTSD). The 7/5/23 minimum data set (MDS) assessment showed the resident had a mild cognitive impairment, with a brief interview for mental status (BIMS) score of 10 out of 15.…

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 an individualized activity program to meet the psychosocial needs of one (#8) of six residents reviewed out of 37 sample residents. Specifically, Resident #8 had specialized activity needs due to diagnoses of autism and major depression. Resident #8 was deaf and did not speak. The facility failed to develop effective methods to communicate with the resident, family and interdisciplinary team to assess, develop and implement activities in keeping with his preferences and communication needs to ensure he reached his highest practicable psychosocial potential and well-being. The facility failed to meet Resident #8's specialized, person-centered activity needs which contributed to his isolation. Findings include: I. Resident status Resident #8, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders, diagnoses included autistic disorder, legal blindness, hearing loss and major depression. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide the necessary behavioral healthcare and services to attain or maintain the highest practical physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (#7) of four residents reviewed for behavioral services out of 37 sample residents. Specifically, the facility failed to document Resident #7's suicidal ideation and self-harm tendencies to ensure staff knew what behaviors or statements to watch for and how to help Resident #7 with her increased anxiety and depression. Findings include: I. Facility policy The Suicide Threats policy, revised in December 2007, was provided by the nursing home administrator (NHA) on 7/13/23 at 6:00 p.m. The policy included: Resident suicide threats shall be taken seriously and addressed appropriately. 1. Staff shall report any resident threats of suicide immediately to the nursing supervisor or the charge registered nurse (RN). 2. The nursing supervisor…

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 ensure the medication error rate was not greater than five percent. Specifically the facility's medication error rate was 7.41% with two errors out of 27 opportunities. Findings include: I. Facility policy and procedure The Administering Medications policy and procedure, reviewed April 2019, provided by the nursing home administrator (NHA) on 7/13/23 at 6:00 p.m. It revealed in pertinent part, The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. II. Professional reference According to the Levemir FlexPen manufacturer guidelines, updated December 2022, retrieved from https://www.mynovoinsulin.com/content/dam/diabetes-patient/mynovoinsulin/branded/Levemir/Downloads/US22LV00014_LEV_FlexPen_Quick_Guide.pdf on 7/20/23 included the following recommendations, Before each injection, prime your pen by performing an airshot. Turn the dose selector…

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 that residents were free from significant mediation errors for one (#3) of four residents reviewed for medication errors out of 37 sample residents. Specifically, the facility failed to ensure that Resident #3 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration. Findings include: I. Professional reference According to the Levemir FlexPen manufacturer guidelines, last updated, December 2022, retrieved from https://www.mynovoinsulin.com/content/dam/diabetes-patient/mynovoinsulin/branded/Levemir/Downloads/US22LV00014_LEV_FlexPen_Quick_Guide.pdf on 7/20/23 included the following recommendations, Before each injection, prime your pen by performing an airshot. Turn the dose selector to select 2 units. Holding your pen with the needle pointing up, tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Press and hold the…

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

Based on observations and staff interviews, the facility failed to ensure all drugs and biologicals were properly stored in one of three medication storage rooms. Specifically, the facility failed to: -Ensure expired medications were timely removed from the medication storage area and refrigerator; and, -Ensure expired tuberculin purified protein derivative (PPD) was removed timely from the medication storage refrigerator. Findings include: I. Professional reference Sanofi Pasteur. (2020). Package insert. Tuberculin Purified Protein Derivative (Mantoux): Tubersol. Food and Drug Administration (FDA). https://www.fda.gov/media/74866/download, retrieved on 7/20/23 at 1:38 p.m. A vial of Tubersol (tuberculin purified protein derivative) which has been entered and in use for 30 days should be discarded. Do not use it after the expiration date. U. S. Food and Drug Administration (FDA). (2/8/21). Don't be tempted to use expired medications.…

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 maintain communication with the hospice provider, including how the communication would be documented between the facility and the provider for one (#47) of four residents reviewed for hospice care services out of 37 sample residents. Specifically, the facility failed to for Resident #47: -Demonstrate documentation of a collaboration of care between the facility and the hospice provider; -Delineate care responsibilities between facility care staff and hospice care staff and the frequency of the hospice staff visits; and, -Documentation of hospice staff visits and the hospice plan of care. Findings include: I. Facility policy The Hospice Program policy, revised July 2017, was provided by the nursing home administrator (NHA) on 7/12/23 at 4:51 p.m. The policy read in pertinent part: In general, it is the responsibility of hospice to manage the resident's care as it relates to the terminal illness and related conditions, including:…

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 mechanical equipment was in safe, operational condition. Specifically, the facility failed to ensure necessary kitchen equipment was maintained in safe, working condition. Findings include: I. Observations On 7/10/23 at 8:10 a.m. a kitchen inspection revealed the hand washing sink and a food preparation sink had low pressure and was not warm to touch. At 4:21 p.m. the hand washing sink and food preparation sink had low pressure and was not warm to touch. On 7/11/23 at 11:19 a.m., the hand washing sink and food preparation sink had low pressure and was not warm to touch. On 7/12/23 at 7:02 a.m. the hand washing sink and food preparation sink had low pressure and was not warm to touch. II. Staff interviews Cook #3 was interviewed on 7/10/23 at 4:21 p.m. She said the maintenance department was aware that the hand washing sink did not have enough pressure and did not get as hot as she wanted it to be. She said sometimes her hands did not feel as clean as they should be after she washed her hands. Cook #1 was interviewed…

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 an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify concerns and or implement effective action plans to mitigate the repetition facility failures including quality of care and infection control. Findings include: I. Facility policy The Quality Assurance and Performance Improvement (QAPI) Program policy, revised February 2020, was proved by the nursing home administrator (NHA) on 5/16/22.The policy read in pertinent parts, The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. According to the policy, the QAPI program objectives were to: -Provide a means 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.

Based on interviews and record review, the facility failed to take action on grievances of the resident group. Specifically, resident council members brought forward the following concerns: -Some certified nurse aides (CNAs) were being a little rough (cross-reference F610 to investigate allegations of abuse); -Call light response was too slow, and as a result residents did not receive timely assistance to the bathroom, and did not receive baths/showers; -Water cups were not being changed enough and the water got warm or their cups were empty; -Laundry service was slow and clothing items were missing and not returned; -Food orders were not being taken correctly, so residents were not receiving their food choices; and -Food and coffee needed to be hotter. The facility failed to initiate, document and investigate grievances associated with resident council concerns, take action, and report back to residents to ensure the issues were resolved. The facility further failed to communicate to residents their rights to file grievances orally and in writing, and contact the State Agency 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, interviews and record review, the facility failed to provide necessary assistance with activities of daily living (ADLs) for four (#11, #14, #3 and #8) of six residents reviewed out of 30 sample residents. Specifically, the facility failed to provide timely: -Incontinence care, grooming and bathing for Resident #11; -Incontinence care, assistance with toilet use and bathing for Resident #14. -Baths/showers for Resident #3; and, -Incontinence care, grooming and showers for Resident #8. Findings include: I. Facility policy The Activities of Daily Living (ADLs), Supporting policy was provided by the nursing home administrator (NHA) on the afternoon of 5/19/22. The policy statement included: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent 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 staff interviews, observations and record review, the facility failed to ensure four (#6, #8, #14 and #38) reviewed for accident hazards of six residents out of 30 sample residents, were provided adequate supervision and a safe environment to prevent accidents and the re-occurrence of accidents. Specifically, the facility failed to: -Comprehensively review, implement effective interventions and update the resident's care plans after multiple falls for Resident #6, #8 and #14; and, -Provide a safe environment with adequate supervision to avoid potential safety hazards for Resident #38. Findings include: I. Facility policy The Fall Management and Investigation policy, effective 9/1/18, was provided by the facility on 5/19/22. The policy read in pertinent part: The (facility) utilizes all reasonable efforts to provide a system to review residents 'potential risk for falls and provide a proactive program of supervision, assistive devices and interventions to manage and minimize falls and identify residents'…

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 (#19, #20 and #43) of five residents reviewed for medications of 30 sample residents were free from unnecessary medications. Specifically, the facility failed to: -Obtain an informed consent for Residents #19, #20 and #43 for the use of antipsychotic medication; and, -Create a care plan that addressed the use of an antipsychotic medication for Resident #20. Findings include: I. Facility policy and procedure The Antipsychotic Medication Use policy and procedure, dated December 2016, was provided by the assistant director of nurses (ADON) on 5/19/22 at 5:09 p.m. It included residents who would only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and affected. Based on assessing the resident's symptoms and overall situation, the physician would determine whether to continue, adjust, or stop existing antipsychotic medication. -The policy and procedure did not include guidance for…

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 implement an effective infection prevention and control program to prevent the potential spread of infection. Specifically, the facility failed to: -Provide wound care in a sanitary manner for Resident #8; -Provide hand hygiene for residents before meal service; -Maintain a clean and sanitary environment for residents in their rooms; and, -Ensure staff used appropriate personal protective equipment (PPE). Findings include: I. Facility policy The Hand Washing policy, revised 10/1/17, provided by the staff development coordinator (SDC) on 5/19/22 at 1:22 p.m. included: Hand washing is the most important component for managing the spread of infection. Hand washing is one of the most crucial measures in reducing transmission of pathogens in healthcare settings. The use of gloves does not eliminate the need to wash hands. Hand washing is performed: -If moving from a contaminated-body site to a clean-body site during resident care. -After contact with an object or source where there is a concentration 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 allow residents to make choices about aspects of their life in the facility that were significant to them for two (#39 and #46) out of 30 sample residents. Specifically, the facility failed to provide routine bathing consistent with the residents' preferences for Resident #39 and #46. Findings include: I. Facility policy The Person-Centered Care Plan Guidelines policy and procedure, dated 9/1/18, was provided by the assistant director of nurses (ADON) on 5/19/22 at 5:09 p.m., in lieu of a policy and procedure for resident choices. It documented that interventions that accounted for each residents' life story and identity should be included in their preferences and choices. These offered the resident control in their life throughout the day, helped the resident feel safe, and supported in their surroundings. II. Failure to provide bathing according to preference A. Resident #39 Resident #39, age [AGE], was admitted [DATE] and readmitted…

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 interview, the facility failed to protect a resident's right to formulate advance directives for one (#43) of one resident reviewed out of 30 sample residents. Specifically, although Resident #43 was facility assessed as cognitively intact, her power of attorney (POA)/family signed her advance directives and designated her status as do not resuscitate (DNR). Findings include: I. Facility policy The Resident Rights policy, revised December 2016, was provided by the nursing home administrator on the afternoon of 5/19/22. The policy documented in pertinent part: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: -Exercise his or her rights as a resident of the facility; and -Be supported by the facility in exercising his or her rights. -The policy did not mention advance directives and the facility did not have a specific policy regarding advance directives. II. Resident status Resident #43, age [AGE], was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#19) of five residents reviewed for dementia care of 30 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to comprehensively identify person-centered approaches for dementia care for Resident #19. Findings include: I. Professional standard The Gerontologist (February 2018), retrieved from on 6/1/22: https://academic.oup.com/gerontologist/article/58/suppl_1/S1/4816759?login=true The Alzheimer's Association Dementia Care Practice Recommendations included the following foundations for person-centered care: 1. Know the person living with dementia. It is important to know the unique and complete person, including his/her values, beliefs, interests, abilities, likes, and dislikes-both past and present. This information should inform every interaction and experience. 2. Recognize and accept 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 resident and staff interviews, the facility failed to provide routine and emergency dental services to meet the needs of each resident for one (#38) of one resident reviewed for dental out of 30 sample residents. Specifically, Resident #38 was not timely offered the opportunity to see a dentist, impacting his ability to safely chew all his food and receive food choices of his preference. Findings include: I. Resident status Resident #38, age [AGE], was admitted on [DATE]. According to the May 2022 computerized physicians orders (CPO) diagnoses included heart failure, muscle weakness, atrial fibrillation, major depressive disorder, and gastro-esophageal reflux disease without esophagitis. According to the 4/7/22 minimum data set (MDS) assessment, the resident's brief interview for mental status (BIMS) score was four out of 15 and indicated severe cognitive impairment. He required supervision with set only for all his activities of daily living (ADL). The resident's oral and dental…

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.