Red Cliffs Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure catheter care in accordance with professional standards of care for two (#50 and #58) of three residents reviewed for appropriate catheter use and care out of 32 sample residents. Specifically, the facility failed to: -Provide suprapubic catheter care to Resident #50; -Conduct a thorough assessment after Resident #58 completed antibiotics for a urinary tract infection (UTI) to ensure the resident did not display further signs or symptoms of an UTI. Findings include: I. Professional reference According to the National Institutes of Health Library of Medicine: Prevention of Dependent Loops in Urine Drainage Systems in hospitalized Patients, retrieved on 1/22/25 from https://pmc.ncbi.nlm.nih.gov/articles/PMC4423413/#F1. It revealed in pertinent part, A dependent loop is formed by excess drainage tubing in a urine drainage system where urine or liquid can accumulate. Dependent loops trap drained urine and are suspected of impeding bladder drainage…

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 a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (#53) of four residents reviewed for mood and behavior out of 32 sample residents. Specifically, the facility failed to effectively implement person-centered approaches for dementia care to prevent resident-to-resident altercations. Cross-reference: F600 failure to prevent resident abuse. Findings include: I. Facility policy and procedure The Dementia Clinical Protocol policy and procedure, revised November 2018 was provided by the nursing home administrator (NHA) on 1/16/25 at 3:29 p.m. The policy read in part, For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. The IDT will identify and document the resident's condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure one (#2) of four residents reviewed for abuse out of 13 sample residents was kept free from abuse. Specifically, the facility failed to: -Protect Resident #2 from verbal abuse from Resident #3 on two separate occasions (9/1/24 and 9/16/24); -Report an allegation of verbal abuse on 9/1/24 and 9/16/24; -Thoroughly investigate an allegation of verbal abuse of Resident #2 from Resident #3; and, -Initiate and implement interventions to prevent future resident to resident verbal altercations between Resident #2 and Resident #3. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation, Reporting and Investigating policy, dated 2001, was provided by the nursing home administrator (NHA) on 10/2/24 at 11:44 a.m. The policy read in pertinent part, All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of 13 sample residents received adequate supervision to decrease and/or prevent risk for accident hazards. Specifically the facility failed to: -Implement an effective plan of care that adequately addressed the risks posed to Resident #1 and other residents in the facility due to Resident #1's excessive alcohol consumption; -Provide adequate supervision for Resident #1, inside and outside the facility, due to the resident's excessive alcohol consumption; and, -Follow physician's orders for Resident #1 to have supervision when the resident was out of the facility. Findings include: I. Facility policy and procedure The Falls Clinical Protocol policy, dated 2001, was provided by the nursing home administrator (NHA) on 10/2/24 at 6:25 p.m. It read in pertinent part, The physician will help identify individuals with a history of falls and risk factors for falling. Staff will ask the resident and…

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

Based on observations and interviews the facility failed to prepare and serve food in a safe and sanitary manner to prevent cross-contamination and potential food borne illnesses, in one of one kitchens during meal services. Specifically, the facility failed to: -Ensure staff followed accepted hand hygiene practices during the meal service to prevent potential cross-contamination; -Ensure safe storage of food for resident use; and, -Ensure a clean environment and equipment where food was prepared. Findings include: I. Professional standards The Centers for Disease Control and Prevention (CDC), reviewed 9/3/23, retrieved on 11/7/23 from: https://www.cdc.gov/foodsafety/keep-food-safe.html, under Four Steps to Food Safety read to Wash your hands for at least 20 seconds with soap and warm or cold water before, during, and after preparing food and before eating. According to the Colorado Department of Public Health and Environment (CDPHE) The Colorado Retail Food Establishment Rules and Regulations, January 2019, retrieved on 11/7/23 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 resident, family, and staff interviews; and record review, the facility failed to act promptly upon the grievances of the resident council concerning issues of resident care and lift in the facility that were important to the residents. These failures affected the resident council vice president and other residents who participated in the resident council over the past three months, regarding call lights, staff not being friendly and providing follow-up on grievances. Findings included: I. Facility policy The Resident Concern or Grievance Program policy, revised 12/17/06, was provided by the social services director (SSD) on 10/25/23 at 2:36 p.m. which read: The facility observes the right of each resident, family member, responsible party, and staff member to voice concerns and grievances with respect to treatment or care and refusals to care. Accordingly, a formal system known as the Resident and Family Concern or Grievance Program is in place to review and act upon concerns or grievances expressed.…

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 a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for three (#44, #13 and #40) of three residents reviewed for dementia care out of 30 sample residents. Specifically, the facility failed to: -Effectively implement a meaningful activity program for Resident #44; -Implement person centered interventions for Resident #13's behaviors; and, -Implement person centered interventions and care plan for Resident #40. Findings include: I. Facility policy The Dementia policy, revised November 2018, was provided by the administrator in training (AIT) on 10/26/23 at 6:20 p.m. The policy read in pertinent part: As part of the initial assessment, the physician will help identify individuals who have been diagnosed as having dementia and those with otherwise impaired cognition. For the individual with confirmed…

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 care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for one (#13) of two residents reviewed for respect and dignity out of 30 sample residents. Specifically, the facility failed to: -Treat Resident #13 with respect and dignity when she requested pain medication after identifying her preferences of no males in her room; and -Communicate Resident #13's preference for no male caregivers. Findings include: I. Facility policy The Resident Rights policy, revised December 2016, was provided by the administrator in training (AIT) on 10/26/23 at 6:20 p.m. The policy read staff should treat all residents with kindness, respect, and dignity. The policy read in pertinent part: Federal and state laws guarantee certain basic rights to all residents in this facility. these rights include the residents right to: -A dignified existence;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure one (#30) of four residents were free from abuse from staff members out of 30 sample residents. Specifically, the facility failed to ensure Resident #30 was free from abuse from a staff member. Findings include I. Facility policy The Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating policy, revised September 2022, was provided by the director of nursing (DON) on 10/25/23 at 2:30 p.m. which read in pertinent: Policy statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. II. Resident status Resident #30, age over 65, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews, the facility failed to coordinate and obtain the Preadmission screening and resident screening review (PASRR) screening for one (#20) of two residents reviewed for PASRR out of 30 sample residents. Specifically, the facility failed to obtain a PASRR level II screening, which was used to determine whether or not the facility could adequately care for certain medical or mental health conditions for Resident #20. Findings include: I. Facility policy A. The PASRR policy, dated 2023, was received by the nursing home administrator (NHA) on 10/26/23. The policy read in pertinent part: Per the title, delegated staff will; Follow the state guidelines in terms of completion for admissions and discharges. When triggered level II's, social services will set up meetings with assessment scheduled to complete level II assessments and update the resident's care plan accordingly. B.The admission Criteria policy, dated March 2019, was received by the NHA on 10/26/23. The policy read 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 record review and interviews, the facility failed to ensure level I preadmission screening and resident review (PASARR) were completed for two (#41 and #44) residents of five residents reviewed for PASARR to gain and maintain their highest practical medical, emotional and psychosocial well-being out of 30 sample residents. Specifically, the facility failed to ensure Resident #41 and #44 had a level I PASARR screening completed timely. Findings include: I. Facility policy The Admissions policy, revised March 2019, was provided by the facility on 10/26/23. According to the policy, all new admissions and readmissions are screened for mental disorders (MD) and intellectual disabilities (ID) or related disorders (RD) per the Medicaid pre-admission screening and resident review process (PASARR). The PASARR I and PASARR II policy, was dated 2023. The policy identified delegated facility staff will: Follow the state of Colorado guideline in terms of completion, admissions and discharges. Monthly audit for new…

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 facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#40) of three resident reviewed for change of condition out of 30 sample residents. Specifically, the facility failed to assess Resident #40's rashes on both of her arms and have a physician order for treatment provided. Findings include: I. Facility policy The Change in a Resident's Condition or Status policy, revised February 2021, was provided by the director of nursing (DON) on 10/25/23 at 2:30 p.m. read in pertinent: Policy statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical or mental condition and/or status. Policy interpretation and implementation: 1. The nurse will notify the resident's attending physician or physician on call when there has been a(n): a. Accident or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY II. Smoking A. Facility policy and procedure The Smoking policy, revised August 2022, was provided by the DON on 10/25/23 at 2:30 p.m. which read in pertinent: Policy statement: This facility has established and maintains safe resident smoking practices. Policy interpretation and implementation: 1. Prior to, and upon admission, residents are informed of the facility's smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Electronic cigarettes are permitted in designated areas only. Smoking is not allowed inside the facility under any circumstances. 3. Oxygen use is prohibited in smoking areas. 6. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. Current level of tobacco consumption; b. Method of tobacco consumption (traditional cigarettes, electronic cigarettes, 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 record review and interviews, the facility failed to ensure nutritional parameters were maintained for one resident (#52) of two residents reviewed for nutrition out of 30 sample residents. Specifically, the facility failed to: -Consistently respond to an identification of a significant weight loss or gain even though the resident had health conditions that could affect his body fluid levels for Resident #52; and, -Ensure the accuracy of the weight of Resident #52. Findings include: I. Facility policy and procedure The Facility Nutrition program policy, revised April 2007, was provided by the director of nursing (DON) on 10/26/23. According to the policy, the facility would have an organized nutritional-related program. The nutrition program identified the following: -Direct Care staff, assisted by the facility's clinical dietitian, will evaluate each individual's physical functional and psychosocial factors that affect eating and nutritional intake and utilization. -Physicians and related healthcare…

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 pain was adequately managed for one (#27) of five residents reviewed for pain out of 30 sample residents. Specifically, the facility failed to: -Manage Resident #27's chronic back pain; -Provide Resident #27 with her as-needed (PRN) pain medication timely; and, -Provide non-pharmacological interventions to help Resident #27's pain. Findings include: I. Facility policy The Pain Assessment and Management policy, revised October 2022, was provided by the director of nursing (DON) on 10/25/23 at 2:30 p.m. which read in pertinent: The purpose of this procedure is to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General guidelines: 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide trauma informed care in order to eliminate or mitigate triggers that caused re-traumatization for two of three (#20 and #23) residents reviewed trauma informed care out of 30 sample residents. Specifically, Residents #20 and #23 admitted with post traumatic stress disorder (PTSD) and the facility failed to: -Include PTSD in the resident's comprehensive care plans; -Identify and control individual traumatic triggers; and, -Involve the residents with the development of their plan of care including plans for medication adjustments. Findings include: I. Professional reference Guidelines for Trauma-Informed Care in Behavioral Health Services were reviewed on 11/5/23 at the Substance Abuse and Mental Health Services Administration (SAMHSA) website: https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4420.pdf which documented: Although many people exposed to trauma demonstrate few or no lingering symptoms, individuals who have…

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 have a qualified infection preventionist on staff. Specifically, the facility failed to have a qualified infection preventionist on staff. Findings include: I. Facility policy and procedure The Infection Prevention and Control Program (IPCP) Description policy, revised 6/7/21, was provided by the health information manager (HIM) on 7/28/22 at 5:00 p.m. It read, Design and Role Responsibilities the IPCP was facilitated through a coordinated effort between the designated infection preventionist, center executive director, center nurse executive, and nurse practice educator/staff development coordinator, and the entire health care team. The infection preventionist develops, implements, and monitors and maintains the IPCP and fulfills the basic requirement for the role. II. Interviews The director of nursing (DON) and interim assistant director of nursing (IADON) were interviewed on 7/28/22 at 2:21 p.m. They said neither of them had completed the Nursing Home Infection Preventionist Training course provided by the Centers 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to test facility staff, and individuals providing services under arrangement and volunteers for COVID-19 which had the potential to affect all 69 residents residing in the facility at the time of the survey. Specifically, the facility failed to complete weekly lab based PCR (polymerase chain reaction) testing for COVID-19, and rapid molecular or antigen test consistently prior to the start of their shift, based on the facility's county positivity rate. Findings include: I. Professional reference The healthcare community transmission levels for the facility ' s county of residence, obtained from https://covid19.colorado.gov/healthcare-providers/long-term-care-facilities/healthcare-community-transmission-levels, were reviewed for the time of survey (7/25-7/28/22) and found to be in High levels of transmission. Facilities should use their community transmission level as the trigger for staff testing frequency…

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

Based on observations, record review and interviews, the facility failed to develop and implement a COVID-19 staff vaccination process to address all facility staff, including agency staff who provided care, treatment and other services to facility and/or residents. Specifically, the facility failed to obtain the vaccination status of other outside providers. The facility did not have the vaccination status for all of the outside providers. The facility was unable to provide a listing of the vaccination status of all contracted providers/staff who enter the facility on a regular basis and provide direct care to residents. Cross-reference F886 (COVID-19 testing) Findings include: I. Facility policy and procedure The Universal COVID-19 Vaccination policy, revised 4/1/22, provided by the nursing home administrator (NHA) on 7/28/22 at 12:00 a.m. read in pertinent part The company requires that all personnel are fully immunized against COVID-19 as follows. All center based personnel or national, market, or divisional personnel who regularly work in or visit centers or company offices,…

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 provide an ongoing program to support residents in their chosen activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three (#43, #28, #24) of five out of 29 sample residents. Specifically, the facility failed to offer and provide personalized activity programs for Resident #43, #28, and #24. Findings include: I. Facility policy and procedure The Recreation Services policies and procedure, revised 4/1/18, provided by the nursing home administrator (NHA) on 7/28/22. It was documented in the pertinent part, Residents have the right to participate or not participate in leisure and recreation of their choosing. The purpose is to provide leisure, recreation, and social involvement opportunities. Residents should be invited to participate in activities. Assistance will be offered to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews and observations the facility failed to ensure proper monitoring and assessments of pressure injuries for three (#56, #18, and #24) of five residents reviewed for pressure injuries of 29 sample residents. Specifically, the facility failed to continuously monitor and assess wound measurements for residents. Findings include: I. Professional reference The NPUAP Pressure Injury Stages,The National Pressure Ulcer Advisory Panel, was retrieved on 8/2/22 at http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages read in pertinent part: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable erythema. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed…

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 proper storage of pharmaceuticals for one of one medication storage rooms. Specifically, the facility failed to ensure proper temperatures for refrigerated pharmaceuticals. Findings include: I. Facility policy and procedure The Medication and Vaccine Refrigerator/Freezer Temperatures policy, revised 11/15/2020, provided by the NHA on 7/28/22 at 12:00 p.m. read in pertinent part, refrigerators and freezers used to store medication and vaccines will operate within acceptable temperatures ranges and will be checked twice a day for proper temperatures. The acceptable refrigerator temperature range for meditation and vaccine storage is 36-46 degrees fahrenheit. II. Observations The facility medication storage room was inspected with licensed practical nurse (LPN) #1 on 7/27/22 at 5:00 p.m. The medication storage refrigerator internal temperature was observed to be 26.2 degrees fahrenheit and this was confirmed with the LPN, which was not within the acceptable refrigerator range of 36-46 degrees fahrenheit.…

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 consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure that residents' food was papatable in taste, texture, appearance and temperature. Findings include: I.Facility policy and procedure The Food and Nutrition Service policy, revised 7/15/18, was delivered by the nursing home administrator (NHA) on 7/1/22 at 12:32 p.m. It read in pertinent part: Critical food functions are continuously measured as part of the quality improvement program. Food service quality includes meal delivery, meal quality, meal accuracy and meal satisfaction.The director of the dining service is responsible for communicating department quality indicators to the executive director, quality assurance and registered dietitian. Meal quality standards:foods are held at appropriate holding temperatures, Foods have an acceptable taste and are of appropriate texture for the food or for the diet modification. All meals are attractively garnished. Meal/Tray is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection, including COVID-19 for three of four units. Specifically, the facility failed to: -Ensure equipment and supplies were disinfected between resident uses; -Ensure residents were offered hand hygiene before meals in both the dining rooms and room trays; -Ensure personal protective equipment were worn properly; and, -Ensure proper disposal of medication syringes. Findings include: I. Cleaning equipment A. Professional reference According to the Centers for Disease Control and Prevention (last reviewed 5/24/2019) Disinfection of Healthcare Equipment, retrieved 8/4/22 from https://www.cdc.gov/infectioncontrol/guidelines/disinfection/healthcare-equipment.html, read in part, Medical equipment surfaces (e.g., blood pressure cuffs, stethoscopes, hemodialysis machines, and X-ray machines)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record review, the facility failed to take steps to protect one (#19) from resident to resident abuse out of 29 sample residents Specifically, the facility failed to ensure Resident #19 was free from physical abuse from Resident #43 that occured on 7/8/22. Findings include: I. Facility policy and procedure The Abuse policy and procedure, revised on 5/11/22, was provided by the nursing home administrator (NHA) on 7/27/22. It revealed in pertinent part: The center will implement an abuse prohibition program through the following: screening of potential hires, training of employees, prevention of occurrences, identification of possible incidents or allegations which need investigation. Investigation of incidents and allegations, protection of patients during the investigation, and reporting of incidence, and investigations. And agency response to the results of their investigations. If the suspected abuse is patient to patient: The patient who has in any way threatened or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for two (#8 and #51) of two residents out of 29 sample residents. Specifically, the facility failed to: -Ensure the Resident #8's edema was routinely monitored and documented; -Ensure Resident #8 had interventions in place and timely to prevent the worsening of edema; -Ensure Resident #8 had opportunities and assistance to elevate her legs to prevent the worsening of the edema that were based on her preferences of daily routine; and, -Ensure physician's orders were followed for Tylenol administration for Reident #51. Findings include: I. Facility policy The Skin/Wound Management policy, undated, was provided by the nursing home administrator (NHA) on 7/28/22. The policy identified staff should provide weekly skin/wound status updates to the Interdisciplinary team members including therapists and dieticians. They should notify skin ruin status updates to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure two (#51 and #36) of seven residents with limited range of motion received appropriate treatment and services out of 29 sample residents. Specifically, the facility failed to establish a consistent restorative nursing program within the facility to ensure Resident #51 and #36 did not have a potential decline in activities of daily living (ADL). Findings include: I. Resident #51 A. Resident status Resident #51, age [AGE], admitted on [DATE]. The July 2022 computerized physician orders indicated a diagnosis of unspecified chronic pain, colostomy status, restless leg syndrome, Alzheimer's disease, anxiety disorder, and dysphagia (swallowing difficulty). The 6/23/22 minimum data set (MDS) assessment included the resident having no cognitive impairment with a brief interview for mental status of 15 out of 15. The resident required supervision with toileting, dressing or personal hygiene, and one person assistance with bathing. The resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to ensure one (#34) of two residents observed for nutrition/hydration maintained acceptable parameters of nutritional status to avoid unintended weight loss out of 29 sample residents. Specifically, the facility failed to timely address Resident #34's weight loss. Findings include: I. Facility policy and procedure The Nutrition/Hydration Management policy, revised 6/1/21, was provided by the nursing home administrator (NHA) on 7/28/22. According to the policy, staff would consistently observe and monitor residents for changes and implement revisions to the plan of care as needed. The policy identified staff should: -Review appropriate assessment information. -Address and new changes pertinent to the resident's nutritional needs/status with dietitian and physician. -Review the dietitian's recommendations. -Develop an interdisciplinary plan of care for enhancing oral intake and promoting adequate nutrition and hydration. -Monitor…

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 reviews, and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#43) of one out of 29 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders for Resident #43. Findings include: I. Professional reference According to [NAME]/[NAME], Fundamentals of Nursing, ninth edition, Elsevier, Canada, 2017, p 900, Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider's order. II. Facility policy The Oxygen Concentrator policy, revised on June 6, 2022, was provided by the nursing home administrator (NHA) on 7/28/22. The policy read in pertinent part, Verify order, set liter flow per order, document, the date and time oxygen started, method of administration, liter flow, and patient's response to therapy. III. Resident #43 A. Resident status Resident #43, age [AGE], was admitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure for one (#30) of five residents reviewed for the use of unnecessary medications out of 29 residents were free from unnecessary drugs. Specifically, the facility failed to ensure gradual dose reduction (GDR) was attempted for Resident #30 who was administered psychotropic medications. Findings include: I. Facility policy and procedure The Unnecessary Medication policy, revised 7/1/21, was received from the nursing home administrator (NHA) on 8/1/22 at 12:32 p.m. It read in pertinent part: Patients who exhibit behavioral symptoms will be individually evaluated to determine the behavior. Based on the comprehensive assessment, staff must ensure that a patient: Who displays or is diagnosed with mental disorders receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Staff will use non-pharmacological interventions as the first line of approach to managing…

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

Based on observations, interviews and record review the facility failed to ensure residents were kept free from significant medication errors for two out of 29 sample residents. Specifically, the facility failed to ensure insulin pens were primed prior to medication administration on two occasions. Findings include: I. Professional reference According to Novo Nordisk, Novolog Flexpen, 2022, https://www.novolog.com/type-2-diabetes/just-heard-about-novolog-t2/novolog/using-flexpen.html (Obtained 8/3/22): Preparing your (insulin pen) -Wash your hands. Check the label to make sure that you are using the right type of insulin. This is especially important if you take more than 1 type of insulin -Pull off the pen cap. Wipe the rubber stopper with an alcohol swab -Remove the protective tab from the needle and screw it onto your FlexPen® tightly. It is important that the needle is placed on straight -Never place a disposable needle on your FlexPen® until you are ready to take your injection -Pull off the big outer needle cap and then pull off the inner needle cap. Throw away the inner…

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.