Cedars Healthcare Center

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.

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. As a result of inadequate staffing, the facility had delayed call light response, failed to provide assistance with activities of daily living (ADLs ). Cross-reference F676 failure to provide assistance with activities of daily living and F688 for restorative services. Findings include: I. Resident census and conditions According to the 8/11/21 Resident Census and Conditions of Residents report, the resident census was 66 and the following care needs were identified: -54 residents needed assistance of one or two staff with bathing and 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, interviews, and record review, the facility failed to have an effective infection control program. Specifically, the facility failed to: -Ensure staff members were utilizing appropriate personal protective equipment (PPE). -Offer and assist Residents with hand washing prior to meals and have staff wash hands after providing care. -Conduct COVID-19 testing in appropriate locations with appropriate PPE. -Ensure housekeeping staff were trained in proper infection control. Findings include: I. Appropriate personal protective equipment A. Professional reference The Center for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, last updated 4/13/2020, retrieved 8/16/21 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#minimize, read in pertinent part, Healthcare Personnel as part of source control efforts, HCP should wear…

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 three (#50, #2 and #36) of four out of 32 sample residents reviewed had the right to participate in the development and implementation of their person-centered plan of care. Specifically, the facility failed to invite schedule a care conference with the Resident #50, #2 and #36. Findings include: I. Facility policy The care plan development and communication policy was provided by the regional nurse consultant on 8/17/21 at 3:00 p.m. It read, in pertinent part: The resident and/or responsible parties are invited in writing to the residents ' care plan meeting. Each resident and/or responsible party are invited and included at the specific time for the care conference. If the time is inconvenient for the resident and/or family member, a separate meeting is rescheduled to accommodate their needs. II. Residents not attending care conferences 1. Resident #50 A. Resident #50 status Resident #50, age [AGE], 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.

Based on interviews and record review, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances for all residents. The facility failed to develop and maintain a grievance process that ensured the residents received appropriate resolution to their identified concerns. Specifically, the facility failed to ensure residents' grievances and concerns were reported, tracked, investigated and enacted a plan for resolution. Findings include: I. Facility policy The Complaints and Grievances policy, last revised September 2019, was provided by the regional nurse consultant (RNC) on 8/17/21 at 5:00 p.m. The policy revealed in pertinent part, In a healthcare community, in most instances, the Complaint/Grievance Officer is the Social services director or other appropriate designee. The Complaint/grievance officer provides oversight of the grievance process, including: -Receiving and tracking grievances through their conclusions; -staying in periodic contact with the person who filed the grievance until the matter is investigated, and a plan 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, interviews and record review, the facility failed to provide the necessary assistance with activities of daily living (ADL) for five (#65, #50, #37, #20, #34) of eight residents reviewed for activities of daily living out of 32 sample residents. Specifically, the facility failed to provide bathing according to the resident's preferences for Resident #65, #50, #37, #20 and #34. Cross-reference F725 for sufficient staffing. Findings include: 1. Resident #65 A. Resident status Resident #65, age [AGE], was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), the diagnoses included Parkinson's disease, peripheral vascular disease, dementia, muscle weakness and hypothyroidism. The 7/28/21 quarterly minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) unknown out of 15 because resident was rarely or never understood. He required two or more persons total assistance with bed mobility,…

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, interview, and record review, the facility failed to ensure five (#18, #50, #35, #37, and #56) of five out of 32 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered plan. Specifically, the facility failed to: -Follow physician orders for medication administration for Resident #18, #50, and #1; -Ensure glucometer audits were completed to maintain accuracy for Resident #56; -Notify nurse regarding a change in condition for Resident #37 observed by two other staff members; and, -Provided needed resources to prevent a decline for Resident #35. Finding include: I. Need resources to prevent decline Resident #35 A. Resident status: Resident #35, age [AGE], was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), the diagnoses included chronic respiratory failure, hypertension, heart failure, peripheral vascular disease and obesity. The 6/16/21 minimum data set (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 ensure three (#24, #22 and #65) out of five residents with limited mobility received appropriate services, equipment and assistance to improve maintain and/or prevent further decrease in range of motion (ROM) out of 32 sample residents. Specifically the facility failed to: -Ensure Resident #24 and #65 received restorative range of motion exercises according to their plan of care; and, -Ensure Resident #22 received restorative nursing services and splinting assistance (palm guards) per therapy recommendations, to improve, maintain or prevent worsening of contractures and protect skin integrity. Findings include: I. Resident #24 A. Resident status Resident #24, under the age of 65, was most recently admitted on [DATE] from hospital after several years in the facility. According to the August 2021 computerized physician orders (CPO), the diagnoses included quadriplegia, hypertension, contractures of right and left hand, wrist, and feet 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 staff interviews, the facility failed to provide the appropriate care and services for one (#22) of two residents reviewed for enteral nutrition out of 32 sample residents. Specifically, the facility failed to provide enteral feedings according to the physician orders for Resident #22 Findings include: I. Facility policy and procedure The Enteral Nutrition Guidelines policy, last revised 9/1/18, was provided by the Nursing Home Administrator (NHA) on 8/24/21 at 8:41 a.m. It read in pertinent parts, The nurse administers the enteral feeding regimen according to formula, system, type and method of delivery ordered by the physician. Physician's orders are documented in the medical record and include the following: -Size and type of tube; -Insertion of tube and frequency of change (if applicable); -Name of formula, total calories, and flow rate. Total volume in a 24 hour period; -Method of administration (gravity, bolus, pump); -Amount and frequency of water to flush the tube…

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 five (#56, #50, #35, #31, #61) of seven out of 32 sample residents received the necessary respiratory care as ordered by the physician. Specifically, the facility failed to: -Ensure oxygen tubing was replaced and labeled for Resident #56, #50, #31, and #61; -Replace damaged oxygen tubing for Resident #35; and, -Ensure residents oxygen administration orders were followed for Resident #31, #56, and #61. I. Facility policy The care and handling of respiratory equipment policy, last updated on 9/17/18, was provided by the regional nurse consultant on 8/17/21 at 11:00 a.m. by the regional nurse consultant (RNC). It indicated, in pertinent part: Equipment should be changed based on the following schedule/manufacturers recommendation or state regulations: Change weekly: Nasal cannula and humidifier. Nasal cannulas were required to be changed weekly. When the oxygen tubing or other respiratory equipment was changed the staff were 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 provide appropriate social services for six (#2, #16, #44, #35, #18 and #31) out seven of 32 sample residents to meet the needs and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the facility failed to: -Ensure Resident #2 received eye glasses; and, -Ensure Resident #16, #44, #35, #18 and #31 received timely dental services. Findings include: I. Facility policy The Concrete Needs Policy, last revised on 9/2/18, was received by the regional nurse consultant (RNC) on 8/17/21 at 5:00 p.m. It read in pertinent part that the social services department was dedicated to assist the residents to obtain needed adaptive and other medical necessary items, with an example of dentures. II. Eye glasses 1. Resident #2 A. Resident status Resident #2, age [AGE], was admitted [DATE]. According to the August 2021 computerized physician orders (CPO) diagnoses included, unspecified fracture of shaft…

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 all drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional standards in three out of five medication carts. Specifically, the facility failed to label inhalers, insulins, eye drops and remove expired medication from three medication carts according to manufacturer instructions. Findings include: I. Facility policy and procedure The Storage of Medications policy and procedures, revised 1/1/13, was provided by the regional nurse consultant (RNC) on 1/18/21 at 1:00 p.m. It read in pertinent part, Facility should ensure medications and biologicals: have an expiration date on the label, have not been retained longer than recommended by manufacturer or supplier guidelines or have not been contaminated or deteriorated, are stored separated from other medications until destroyed or returned to the pharmacy or suppliers. Once any mediation or biological package is opened, the facility should follow manufacturer/suppliers guidelines with respect 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 interview and record review the facility failed to report an alleged violation of abuse to the State survey and certification agency in accordance with State law for one resident (#2) out of three residents reviewed for abuse out of 32 sample residents. Findings include: I. Facility policy The Abuse policy, dated 3/13/13, was received on 8/18/21 by a regional nurse consultant. The policy read in pertinent parts, the following qualify for reportable incidents, allegations of abuse or neglect, which includes physical, verbal and neglect. II. Failure to report alleged violations of abuse to the State Survey and Certification Agency involving Resident #2. (Cross-reference F610) The Grievance Form for Resident #2, dated 6/1/21, was provided by the social service director (SSD) on 8/11/21 at approximately 2:00 p.m. The grievance form revealed it was reported to the social service director on 6/1/21, documented, Resident #2 said a licensed nurse shook his fists at me. The form documented this had been going on for a while. The documentation of follow-up revealed the director 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 interviews and record review, the facility failed to timely and thoroughly investigate an alleged violation of physical abuse for one (#2) of two allegations reviewed out of 32 sample residents. Specifically, the facility failed to timely and thoroughly investigate an allegation of physical abuse reported by Resident #2. Findings include: I. Facility policy and procedure The Abuse policy, dated 3/13/13, was received on 8/18/21 by a regional nurse consultant. The policy read in pertinent part, An investigation is a formal and systematic collection and review of available evidence and factual information that seeks to describe or explain an event or series of events. The goal of every investigation are to: (1) Obtain as much factual information as possible in an effort to reconstruct and evaluate an incident, event or circumstance; (2) provide the possible, as to how and why an incident occured or whether an allegatio can or cannot be substantiated; (3) determine what remedial and/or corrective action ,…

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 choice 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 two (#12 and #22) of three out of 32 sampled residents. Specifically, the facility failed to offer and provide personalized activity programs for Resident #12 and #22 as documented in the care plan. Findings include: I. Facility policy and procedure The Activity policy, initiated on 9/1/14, was provided by the nursing home administrator (NHA) on 8/24/21 at 9:00 a.m. It documented in pertinent partthe community will provide space, supplies, equipment and the staff support necessary for social physical, educational and leisurely activities, both within and outside the community, that are planned according to the preferences, needs and abilities of residents. The community will…

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 supervision and assistive devices to prevent accidents for one (#12) of five residents reviewed for falls out of 32 sample residents. Specifically, the facility failed to ensure the fall mat was in place when the resident was in bed to prevent injury as according to the care plan. Findings include: I. Facility policy and procedure The Fall management and investigation policy dated 9/18/18 was provided by the nursing home administrator (NHA). It read in pertinent parts, Five stars 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 resident's continued needs. Care plan is developed that addresses potential risk factors for falls and recommended interventions. Fall interventions are documented in the resident record. II. Resident status Resident #12, 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.