Cedars Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one (#7) of two residents reviewed for ancillary services of 55 sample residents. Specifically, the facility failed to ensure Resident #7 received follow-up from the audiologist.Findings include:I. Resident #7A. Resident statusResident #7, age less than 65, was admitted [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included major depressive disorder, hemiplegia (weakness) and hemiparesis (paralysis) following cerebral infarction (stroke), type 2 diabetes mellitus, epilepsy, generalized anxiety disorder and chronic pain syndrome.The 4/8/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff for toileting, showering, dressing and transferring between surfaces. The 4/8/26 MDS assessment also revealed…

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 accidents and hazards for two (#55 and #93) of seven residents reviewed for accident hazards out of 55 sample residents.Specifically, the facility failed to:-Ensure Resident #55 was not vaping in the dining room near other residents wearing oxygen; and, -Implement a smoking care plan to ensure safe smoking habits for Resident #93. Finding include: I. Facility policy and procedure The Smoking policy, revised October 2023, was provided by the nursing home administrator (NHA) on 6/11/26 at 3:38 p.m. It read in pertinent part: Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Smoking is not allowed inside the facility under any circumstances. Electronic cigarettes and smokeless tobacco are permitted in designated areas only. The staff consults with the attending physician and director of nursing services to determine if safety restrictions need…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure two (#53, and #70) of four residents who required respiratory care received care consistent with professional standards of practice out of 55 total sample residents. Specifically, the facility failed to:-Ensure Resident #53 and Resident #70's oxygen flow rate was set per physician`s order; and,-Ensure Resident #70's oxygen concentrator was functioning. Findings include:I. Resident #53 A. Resident statusResident #53, age greater than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and dependence on supplemental oxygen (02).The 5/20/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident was independent with all her activities of daily living (ADL). The MDS assessment…

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 manage pain in a manner consistent with professional standards of practice, resident-centered care plans and resident's goals preferences for one (#2) of two residents reviewed for pain out of 55 sample residentsSpecifically, the facility failed to:-Complete a thorough assessment of the residents pain, including the site and pain goals; and,-Include person-centered non pharmacological pain interventions on the resident's care plan.Findings include: I. Facility policy and procedure:The Pain-clinical protocol policy, revised in April 2025, was received from the nursing home administrator (NHA) on 6/11/26 at 4:22 p.m. It read in pertinent part, The provider and staff will identify individuals who have pain or who are at risk for having pain. This includes reviewing known diagnoses and conditions that commonly cause pain. It also includes a review for any treatments the residents currently are receiving for pain, including complementary and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#7) of two residents reviewed for ancillary services out of 55 sample residents received dental services timely. Specifically, the facility failed to ensure Resident #7 was provided with assistance to obtain replacement dentures.Findings include:I. Facility policy and procedureThe Availability of Dental Services policy, revised August 2007, was provided by the nursing home administrator (NHA) on 6/11/26 at 4:22 p.m. It read in pertinent part, Oral healthcare and dental services will be provided to each resident. Dental services are available to all residents requiring routine and emergency dental care. Social services will be responsible for making necessary dental appointments. All requests for routine and emergency dental services should be directed to social services to assure that appointments can be made in a timely manner. Residents with lost or damaged dentures will be promptly referred to a dentist.II. Resident #7A.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices for two (#1 and #2) of six residents out of seven sample residents.Specifically, the facility failed to accurately document the administration of scheduled medications for Resident #1 and Resident #2. Findings include:I. Facility policy and procedureThe Administering Medications policy, dated April 2019, was provided by the director of nursing (DON) on 7/15/25 at 10:06 a.m. The policy read in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted may prepare, administer, and document the administration of medications. The director of nursing services (DON) supervises and directs all personnel who administer medications and/or have related functions. Medications are administered by prescriber orders, including any required time frame. Medication administration times are determined by resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#1) of three residents out of five sample residents received treatment and care for optimal skin condition of a contracted hand, in accordance with professional standards of practice. Specifically, the facility did not provide adequate skin care to prevent skin breakdown in Resident #1's contracted hands and between the resident's fingers and the thumb. Findings include: I. Professional reference According to the [NAME] Health NHS Foundation Trust Hand Contractures, February 2022, retrieved on 8/28/24, from https://www.oxfordhealth.nhs.uk/wp-content/uploads/sites/24/2023/06/1.6.3-Hand-Contractures-Advice-Sheet-for-Care-Homes.pdf, It is vital to adequately manage this condition in order to prevent pressure sores and skin breakdown in the palm and fingers. Once a hand contracture is present it can become very painful. Movements can be uncomfortable, but it is essential to maintain adequate hand hygiene; Hand hygiene is essential management…

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 diseases and infection on two of three units. Specifically, the facility failed to: -Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touch areas (call lights, door handles and handrails); -Ensure housekeeping staff were trained appropriately on housekeeping procedures; and, -Ensure surface disinfectant times were adhered to. Findings include: I. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. 2021 Jul;113:104-114, retrieved on 3/22/24, revealed in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently…

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 residents were free from physical restraints for two (#180 and #40) of six residents out of 34 sample residents. Specifically the facility failed to: -Ensure Resident #180 was evaluated on admission for use of a restraint; -Ensure a consent was signed for use of a restraint for Resident #180 and #40; -Ensure there was a physician's order for restraints for resident #180 and #4; and, -Ensure there was a quarterly wander risk evaluation completed for Resident #40. Findings include: I. Facility policy and procedure The Use of Restraint policy, revised April 2017, was received from the nursing home administrator (NHA) on 3/18/24 at 8:04 a.m. It revealed in pertinent part, Restraints shall only be used for the safety and well being of the residents. Prior to placing a resident in a restraint, there shall be a pre-restraining assessment and review to determine the need for restraint. Restraints shall only be used upon the written order…

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 conduct a preadmission screening resident review (PASRR) for individuals remaining in a facility 30 days past provisional admission approval for one (#56) of one resident reviewed for PASRR out of 34 sample residents. Specifically, the facility failed to submit a new PASRR level I once an automatically approved provisional admission from a hospital had expired for Resident #56 after she had resided in the facility for more than 30 days. Findings include: I. Facility policy The admission Criteria policy, revised [DATE], was received from the nursing home administrator (NHA) on [DATE] at 11:15 a.m. It read in pertinent part: This facility coordinates assessments with the preadmission screening and resident review (PASRR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Exceptions to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (#64) of three residents reviewed out of 34 sample residents. Specifically, the facility failed to ensure Resident #64, who was dependent on staff for bathing, received her scheduled showers. Findings include: I. Facility policy The Activities of Daily Living (ADL) policy, revised March 2018, was provided by the director of medical records (DMR) on 3/18/24 at 4:48 p.m. It read in pertinent part: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). II. Resident #64 A. Resident status Resident #64, age below 65, was admitted on [DATE]. According to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents with indwelling catheters received the appropriate care and services according to professional standards for one (#74) of two residents reviewed for catheters of 34 sample residents. Specifically, the facility failed to: -Obtain physician orders for catheter use for Resident #74; -Ensure Resident #74 had a clinical indication (diagnosis) for catheter use prior to administration; -Ensure Resident #74 had a person centered care plan to address all care needs related to the resident indwelling catheter; and, -Ensure Resident #74's catheter drainage bag was not touching the floor. Findings include: I. Facility policy and procedure The Urinary Catheter Care policy, revised August 2022, was provided by the director of medical records (DMR) on 3/19/24 at 10:21 a.m. It read in pertinent part: The purpose of the policy was to prevent infection of the resident's urinary tract. Review and document the clinical indication for catheter use prior…

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 that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#56) of one resident out of 34 sample residents. Specifically, the facility failed to identify Resident #56's post-traumatic stress disorder (PTSD) and identify triggers which may retraumatize her. Findings include: I. Facility Policy The Trauma Informed Care policy and procedure, undated, was provided by the nursing home administrator (NHA) on 3/19/24 at 11:25 a.m. It read in pertinent part: It was the policy of the facility to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards. The facility will account for residents' experiences, preferences, and cultural…

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

Based on observation and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly on one of two medication carts and one medication storage room of two medication storage rooms. Specifically the facility failed to: -Ensure insulin (medications used for glucose control) pens and vials were labeled with open dates; and, -Ensure expired or discontinued medications were removed from the medication room and medication cart. Findings include: I. Professional reference According to the Lantus glargine package insert, retrieved 3/19/24 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf, When not in use store in refrigerated temperatures of 36 to 46 degrees. When in use, it can be kept at room temperature for up to 28 days. According to the Humalog (lispro insulin) package insert, retrieved 3/19/24 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020563s115lbl.pdf, Should be used within 28 days or be discarded, even if they still contain Humalog. According to the Novolog package insert, retrieved 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 observations, record review and interviews, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) receives the necessary services and assistance with mobility for one (#4) of three out of eight sample residents. Specifically, the failed to provide necessary care and services to ensure for mobility consistent Resident #4's needs and choices. Findings include: I. Facility policy The Activities of daily living (ADLs) policy, reviewed March 2018, was provided by the nursing home administrator (NHA) on 10/17/23 at 12:53 p.m. The policy read in part, Residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Appropriate care and services will be provided for residents who are unable to cany out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: mobility (transfer 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 staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for five (#1, #2, #3, #5 and #8) of eight residents reviewed for immunizations out of eight sample residents. Specifically, the facility failed to: -Administer the pneumococcal vaccine after consent signed for Resident #2 and #5; and, -Offer the pneumococcal vaccination to Resident #1, #3 and #8 yearly after a refusal. 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, 2023, retrieved on 9/27/23, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part: Routine vaccination - pneumococcal -For those ages 19 or older with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal…

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 provide a comfortable and homelike environment on one out of three units. Specifically, the facility failed to ensure resident rooms were kept clean and residents had their belongings unpacked during a facility renovation. Findings include: I. Observations During the initial tour on 11/28/22 at 9:30 a.m. of the University unit, the following was observed: -Wheelchairs, mechanical lifts and cardboard boxes were observed stored on both sides of the hallway. -room [ROOM NUMBER] had food debris and trash including paper, tissues and linens lying on the floor. The A side of the room had corrugated cardboard boxes stored on top of the empty bed with a mattress propped up next to the bed. -room [ROOM NUMBER] A side had food debris lying on the floor around and underneath the bed. Trash, including tissues and paper, was observed lying on the floor next to the bed. -At 11:37 a.m. room [ROOM NUMBER] was observed with boxes and plastic bags placed in front 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 observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental, and psychosocial well-being were provided for three (#48, #45 and #5) of three residents out of 42 sample residents. Specifically, the facility failed to: -Ensure there was a system in place to identify residents in need of one-to-one activities and developed a comprehensive care plan which addressed Resident #48, #45, #5's socialization and activity needs; and, -Provide the residents with a one-to-one activities plan. Findings include: I. Facility policy and procedure The Activities Program policy and procedure, revised September 2014, was provided by the nursing home administrator (NHA) on 12/5/22 at 12:12 p.m. It revealed, in pertinent part, Ensure there are a variety of activities available in outings, social, health and fitness, education, crafts and that they reflect the constantly changing needs of the resident based on their abilities and preferences Meet one 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 observations, interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support. Findings include: I. Professional reference According to the National Certification Council of Activity Professionals (NCCAP) at www.nccap.org, accessed 12/5/22, an activity director must meet specific qualifications in education, certification and/or experience. The qualifications read in part: The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who is: Licensed or registered, if applicable, by the State in which practicing; Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body. Has 2 years of experience in a social or recreational program within the last 5 years, one of which 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 staff interviews, the facility failed to ensure one resident (#177) was free from significant medication errors out of 42 sample residents. Specifically, the facility failed to ensure the resident was administered her morning medications before she left at 7:00 a.m. for a scheduled blood infusion at a hospital. Findings include: I. Facility policy The Administering Medications policy, revised April 2019, was provided via email by the nursing home administrator (NHA) on 12/5/22 at 12:12 p.m. It revealed in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 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 observations, interviews and record review, 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 in two out of three units. Specifically, the facility failed to: -Ensure resident rooms were cleaned in a sanitary manner; -Ensure hand hygiene was performed in between gloves changes and that gloves were changed throughout the cleaning process of resident rooms; -Ensure manufacturer recommended surface contact times were followed for effective disinfection; and, -Ensure oxygen tubing and nasal cannulas were stored off the floor, in a clean bag and replaced when contaminated. Findings include: I. Housekeeping A. Manufacturer's recommendations According to the Ecolab Peroxide Multi Surface Cleaner and Disinfectant manufacturer guidelines, revised on July 2019, was provided by the housekeeping supervisor (HSS) on 12/1/22 at 3:55 p.m. included the following…

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 (#45) of one resident out of 42 sample residents had the right to participate in the development and implementation of her person-centered plan of care. Specifically, the facility failed to conduct consistent care plan meetings for Resident #45 and ensure either the resident or the responsible party was involved in the conferences. Findings include: I. Facility policy and procedure The Comprehensive Care Plan policy and procedure, revised March 2022, was provided by the nursing home administrator (NHA) on 12/12/22 at 12:12 p.m. It revealed, in pertinent part, The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Care plan meetings are scheduled at the best time of the day for the resident and family when possible. If it is determined that the participation of the resident or representative is not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure two (#40 and #32) of four residents remained free from resident-to-resident abuse, out of 42 sample residents. Specifically, the facility failed to: -Prevent resident-to-resident physical abuse between Residents #40 and #74; and, -Prevent resident-to-resident physical abuse between Residents #18 and #32. Findings include: I. Facility policy The Abuse Prevention Program policy, revised December 2016, was provided by the nursing home administrator (NHA) on 11/29/22 at 9:00 a.m. It revealed in pertinent part, Our residents have the right to be free from abuse; this includes physical abuse. As part of the resident abuse prevention, the administrator will: Protect our residents from abuse by anyone, including but not limited to, facility staff, (and) other residents. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. II. Incident of physical abuse between Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Basedonobservations recordreviewandinterviewsthefacilityfailedtoensurethatactivitiesofdailyliving(ADL fordependentresidentswereprovidedforthree(#42, #14 and#65) oftenoutof42 sampleresidents Specifically thefacilityfailedto -EnsurethatResident#42 and#14, whowereatriskforskinbreakdown wererepositionedtimely and -Resident#65 wasofferedandprovidedshowers Findingsinclude I Professionalreference AccordingtoPechlivanoglou P etal Turninghighriskpatients Aneconomicevaluationofrepositioningfrequencyinlongtermcare JournaloftheAmericanGeriatricsSociety 2018 July 66(7): 1409-1414. https//wwwncbinlmnihgovpmcarticlesPMC097929/ retrievedon12/5/22. AccordingtocurrentUS(UnitedStates practiceguidelines nursinghomeresidentsshouldberepositionedasfrequentlyasrequiredbytheircondition PracticeguidelinesinCanadaandtheUSrecommendthatpatientsathighriskofpressureulcersberepositionedeverytwohours II Facilitypolicyandprocedure TheRepositioningpolicyandprocedure revisedinMay2013, wasprovidedbythenursinghomeadministrator(NHA on12/5/22 at12:12…

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 that the residents environment was free from accident hazards and received supervision and assistance to prevent accidents and hazards for one (#37) out of 42 sample residents. Specifically, the facility failed to ensure that Resident #37 did not keep medications at the bedside. Findings include: I. Facility policy and procedure The Self-Administration of Medications policy and procedure, reviewed February 2021, was provided by the nursing home administrator (NHA) on 12/5/22 at 12:12 p.m. It revealed in pertinent part, Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision making capacity to do so safely. The interdisciplinary team considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: The medication is appropriate 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 observations, record review and interviews the facility failed to provide person centered interventions for one (#28) resident, who was diagnosed with dementia, to maintain her highest physical, mental and psychosocial well being out of 42 sample residents. Specifically, the facility failed to ensure that effective person centered interventions for Resident #28 with a dementia diagnosis and who wandered. Findings include: I. Facility policy and procedure The Wandering and Elopement policy and procedure, revised March 2019, was provided by the nursing home administrator (NHA) on 12/5/22 at 12:12 p.m. It read, in pertinent part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. II. Resident status Resident #28, age…

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