Paonia Care And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure two (#2 and #3) out of 10 residents reviewed for abuse were free from sexual abuse out of 13 sample residents. Specifically, the facility failed to protect Resident #2 and Resident #3 from sexual abuse by Resident #1. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, dated September 2022, was provided by the nursing home administrator (NHA) on 3/24/25 at approximately 1:30 p.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 thoroughly investigated by facility management. All findings of all investigations are documented and reported. II. Incident of sexual abuse of Resident #2 by Resident #1 on 12/20/24 A. Facility investigation The 12/20/24 investigation file of the incident involving Resident #2…

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

Based on record review and interviews, the facility failed to employ dietary staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 38 census residents. Specifically, the facility failed to: -Provide dietary competencies and skill tests to ensure staff could carry out the functions of the food and nutrition service according to professional standards of practice; and -Ensure the dietary supervisor was trained and certified as a dietary manager. Cross-reference F803 for dietary menus to meet residents' needs. Cross-reference F804 for food palatability and proper temperature. Cross-reference F805 for food prepared in a form to meet residents' needs. Cross-reference F806 for food prepared to accommodate residents' allergies. Cross-reference F812 for failure to prepare and serve food in a sanitary manner. Findings include: I. Record review -The dietary supervisor (DS) was unable to provide documentation that indicated she was a certified dietary manager. -The dietary supervisor (DS) was unable to provide copies of training…

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 menus met the needs of residents and were followed. Specifically, small portions were served to all residents and menu items were omitted without substitutions being made. Findings include: I. Observations A. Dinner on 2/28/24 At 4:35 p.m. cook (CK) #1 prepared a bacon, egg and cheese quiche for residents on a regular textured diet and an egg and cheese quiche for residents on a mechanical soft textured diet. The menu called for a bacon and cheddar quiche with oven-browned potatoes and parslied cauliflower and a tropical fruit parfait, however, CK #1 served peaches and omitted the cauliflower and said the residents did not like vegetables with dinner. -Resident #31 was served half of a portion of the mechanical soft quiche, although she did not have a physician's order for small portions. The vegetables were omitted. -Resident #15 was served half of a portion of the mechanical soft quiche, although he had a physician's order for extra portions. The vegetables were omitted. -Resident #8 was served half…

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

Based on observations, record review and interviews the facility failed to store, prepare, distribute, and serve food in a sanitary manner. Specifically, the facility failed to ensure: -Cold food items were held at the proper temperature to reduce the potential risk of foodborne illness; -Expired dry goods were disposed of; -Proper hand hygiene was performed during meal service; -Kitchen refrigerators were held at the appropriate temperature; and, -Food items were labeled with use-by dates. Findings include I. Food storage A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 3/9/24 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, A date marking system that meets the criteria stated in (2) of this section may include: Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; Marking the date 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.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, food and nutrition services and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to food and nutrition services, quality of care, resident safety and infection control. Findings include: I. Facility policy The Quality Assurance and Performance Improvement (QAPI) Program-Analysis and Action was received from the nursing home administrator (NHA) on 2/26/24. The policy read in pertinent part, Quality deficiencies that are identified through feedback and data and will undergo appropriate corrective action. Corrective actins are monitored against established goals and benchmarks by the QAPI committee. The QAPI program overseen by the QAPI committee is designed to identify and address quality…

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

Based on record review and interviews the facility failed to ensure that personal funds accounts were managed adequately for six (#19, #20, #1, #4, #10 and #138) of six residents out of 35 sample residents. Specifically, the facility failed to -Have signed written authorizations to manage the personal funds accounts for Residents #1, #4, #20, #138 and #19; and, -Have personal funds withdrawal sheets signed to ensure the residents' permission was obtained to withdraw funds from their personal needs accounts for Residents #1, #10, #4 and #138. Findings include: I. Lack of written authorizations -The facility was unable to provide written authorizations to manage the personal funds account for Residents #1, #4, #20, #138 and #19. The current balance in the personal needs account for Resident #1 was $105.56 as of 3/1/24. The current balance in the personal needs account for Resident #4 was $2,253.24 as of 3/1/24. The current balance in the personal needs account for Resident #20 was $7,180.40 as of 3/1/24. The current balance in the personal needs account for Resident #138 was $3,971.40…

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

Based on record review and interviews, the facility failed to ensure money from personal funds accounts was managed accurately for two (#138 and #4) out of seven residents reviewed for personal funds accounts out of 35 sample residents. Specifically, the facility failed to: -Were dispersed within 30 days after discharge for Resident #138; and, -Notify Resident #4, who was Medicaid funded, or his legal representative when the resident's personal funds account reached $200.00 less than the eligibility resource limit. Findings include: I. Record review A. Resident #138 A review of the current trust account balance provided by the facility revealed Resident #138, who had been discharged over 30 days before, had a remaining balance of $3,971.40 in his personal funds accounts. -There was no documentation the facility had attempted to disperse the funds to the resident. B. Resident #4 A review of the current trust account balance revealed Resident #4 had $2,253.24 in his account which was $253.24 over the allotted limit for Medicaid funded residents. -There was no documentation 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 and interviews, the facility failed to provide a functional, sanitary and comfortable environment for residents on two of two units. Specifically, the facility failed to: -Provide linens to residents; and, -Mitigate unpleasant odors throughout the facility; and, -Ensure ceiling fans in resident areas were working. Findings include: I. Observations On 2/26/24 at 9:15 a.m. there was a urine smell on the 200 wing of the building. At 9:20 a.m. in room [ROOM NUMBER] there were no hand towels or washcloths. At 11:39 a.m. there was a strong body odor near the exit door of the 200 wing of the building, specifically coming from room [ROOM NUMBER]. At 2:24 p.m. in room [ROOM NUMBER] there were no hand towels or washcloths and the paper towel dispenser did not function when tested. On 2/27/24 at 8:41 a.m. there was a strong odor of urine throughout the 200 wing of the building. At 9:47 a.m. room [ROOM NUMBER] smelled strongly of urine. There were no hand towels or washcloths in the room and no soap in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to provide person-centered, individualized activities to meet the psychosocial needs of five (#1, #28, #20, #29 and #10) out of eight residents reviewed for activities out of 35 sample residents. Specifically, the facility failed to: -Create a program of Spanish-language activities for Resident #10 in order to support his physical, cognitive, social and emotional health; -Provide person-centered activities to accommodate Resident #28's preferences; -Create a program of activities that were accessible for Resident #20 with visual impairment; and, -Provide meaningful, engaging activities for Resident #1 and Resident #29. Findings include: I. Facility policy The Activity Programs policy, no date of creation or revision, was received from the nursing home administrator (NHA) on 3/6/24 at 12:34 p.m. It read in pertinent part: Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being 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 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) (2023), retrieved on [DATE] from www.nccap.org, An activity director must meet specific qualifications in education, certification and/or experience. 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; and, -Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body; or -Has two (2) years of experience in a social or recreational…

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, observations and interviews, the facility failed to ensure an environment free from risk of accidents and hazardous situations for four (#1, #27, #25 and #6) of four residents reviewed for accident hazards out of 35 sample residents. Specifically, the facility failed to: -Implement appropriate safety devices when assisting Resident #1 and Resident #25 in their wheelchairs; -Safely transfer Resident #27 and Resident #1 using an appropriate transfer device; and, -Ensure speech therapy recommendations were implemented for Resident #6. Findings include: I. Resident #1 A. Resident status Resident #1, age [AGE], was admitted to the facility on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia, osteoarthritis and intervertebral disk disorder. The 1/16/24 minimum data assessment (MDS) assessment revealed the resident was severely cognitively impaired. The resident was dependent and required supervision and assistance with all activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent. Specifically, the facility had a medication error rate of 17.86%, which was five errors out of 28 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 3/8/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient,…

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, attractive, and at the appropriate temperature. Specifically, the facility failed to: -Ensure food was palatable and attractive when delivered to residents; and, -Ensure food was served at the appropriate temperature. Findings include: I. Resident interviews Resident #5 was interviewed on 2/26/24 at 3:50 p.m. Resident #5 said the kitchen mainly prepared eggs, chicken and pork. She said she rarely received beef. Resident #5 said she did not like the eggs the kitchen prepared and the eggs were served as the main source of protein. She said she told the kitchen not to serve her eggs because she disliked them. Resident #5 said the facility served french fries, potatoes and corn a lot. She said she was not provided with salt and pepper and the meals were often served not seasoned. The resident said her food was ice cold when she received it. Resident #8 was interviewed on 2/26/23 at 2:11 p.m. Resident #8 said the food was often served cold and the staff did not warm it…

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

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 two units. Specifically, the facility failed to: -Ensure staff followed proper hand hygiene procedures when moving from task to task; -Ensure frequently touched surfaces were cleaned; and, -Ensure surface disinfectant times were adhered to for disinfecting products by all staff. Findings include: I. Failed to ensure staff performed hand hygiene and residents were offered hand hygiene prior to meals. A. Professional reference The Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings (1/30/2020), retrieved on 3/12/24 from https://www.cdc.gov/handhygiene/providers/guideline.html, included the following recommendations, in pertinent part for hand hygiene, Use an alcohol-based hand sanitizer immediately before touching a patient, before…

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 can communicate in their native language for one (#10) resident reviewed for language services out of 35 sample residents. Specifically, the facility failed to provide a system for Resident #10 to receive medical information in his native language. Findings include: I. Facility policy The Resident Rights policy, not dated, was obtained from the nursing home administrator (NHA) on 2/28/24 at 5:46 p.m. failed to document the resident's right to receive information in their primary language. II. Resident status Resident #10, over the age of 65, was admitted on [DATE]. According to the February 2024 computerized physician order (CPO), diagnoses included Alzheimer's dementia, anxiety, diabetes and high blood pressure (hypertension). According to the 1/23/24 minimum data set (MDS) assessment Resident #10 had significant cognitive impairment and was unable to complete the brief interview for mental status (BIMS) score. The 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 record review and interviews the facility failed to permit a resident to return to the facility after going to the hospital for one (#137) of two residents reviewed for discharge out of 35 sample residents. Specifically, the facility failed to allow Resident #137 to return to the facility once he was medically cleared by the hospital to return. Findings include: I. Facility policy The Discharge Summary and Plan policy, revised October 2022, was received from the nursing home administrator (NHA) on 2/29/24 at 2:39 p.m. It read in pertinent part: The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing the release of the resident information and as permitted by the resident. A member of the (interdisciplinary team) reviews the final post-discharge plan with the resident and family at least twenty-four hours before the discharge is to take place. II.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop a comprehensive care plan for services that were to be provided in order to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for four (#3, #4, #5 and #6) residents of four residents reviewed for care planning out of 35 sample residents. Specifically, the facility failed to: -Develop a bathing care plan focus for Resident #4; -Develop a nutrition care plan focus for Resident #3; -Develop a care plan to include speech therapy interventions at meals for Resident #6; and, -Develop an oral hygiene assistance care plan focus for Resident #5. Findings include: I. Facility policy The Care Planning policy, not dated, was received from the nursing home administrator on 3/6/24 at 12:34 p.m. It read in pertinent part: Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). -The policy did not include any guidelines or timeframes 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 develop and implement an effective discharge plan that focused on each resident's goals and involved the resident in the development of the discharge plan for one (#36) of two residents reviewed for discharge planning out of 35 sample residents. Specifically, the facility failed to: -Ensure Resident #6's discharge planning needs were identified and documented in order to develop an appropriate discharge plan; and, -Involve the interdisciplinary team in the ongoing discharge process. Findings include: I. Facility policy The Discharge Summary and Plan policy, revised October 2022, was received from the nursing home administrator (NHA) on 2/29/24 at 2:39 p.m. It read in pertinent part: The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing the release of the resident information and as permitted by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) for two (#5 and #10) of two residents reviewed for ADLs out of 35 sample residents. Specifically, the facility failed to: Provide set-up teeth brushing assistance for Resident #5; and, Provide set-up bathing assistance for Resident #10. Findings include: I. Facility policy The Activities of Daily Living (ADLs) policy, dated March 2018, was received from the nursing home administrator (NHA) on 2/28/24 at 5:46 p.m. It documented that residents who are unable to complete activities of daily living will receive appropriate care and services, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with mobility (transfer and ambulation, including walking). II. Resident #5 A. Resident status Resident #5, over the age of 65, was admitted on [DATE]. According to the February 2024 computerized physician order (CPO), diagnoses…

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

Based on observation and interviews, the facility failed to ensure residents were free from significant medication errors for one (#19) of 11 residents reviewed for medication errors out of 35 sample residents. Specifically, the facility failed to ensure Resident #19 was administered insulin according to the manufacturer's guidelines. Findings include: I. Manufacturer's guidelines The How to Use your Lantus Solostar Pen manufacturer's procedure guide, dated 2022, was received from the nursing home administrator (NHA) on 2/28/24 at 5:30 p.m. It documented in pertinent part: -Dial a test dose of two units. -Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needs. This will help you get the most accurate dose. -Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. -If no insulin comes out, repeat the test two more times. If there's still no insulin coming out, use a new needle and do the safety test again.…

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 food that accommodated resident allergies, intolerances, and preferences for one (#20) of three residents reviewed for dietary preferences out of 35 sample residents. Specifically, the facility failed to provide meals and snacks according to Resident #20's lactose and gluten allergy. Findings include I. Resident status Resident #20, age over 65, was admitted on [DATE]. According to the February 2024 computerized physician order (CPO), diagnoses included unspecified anxiety disorder, other unspecified depressive disorder and underweight. According to the 11/28/23 minimum data set (MDS) assessment, Resident #20 had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. II. Resident interview Resident #20 was interviewed on 2/26/24 at 9:28 a.m. Resident #20 said one cook at the facility was good at accommodating her lactose and gluten allergies. She said she needed to gain weight because she…

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

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns were implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and implement an effective system to identify facility concerns or address need for quality improvement in their QAPI program. Findings include: I. Review of the facility's regulatory record revealed the facility failed to operate a quality assurance (QA) program in a manner to prevent repeat deficiencies. Repeat deficiencies included: A. F600 Free from Abuse and Neglect During the recertification survey on 7/29/21, failure to prevent abuse was cited at an K scope, immediate jeopardy at a pattern. The 6/15/22 compliant survey identified deficient practices abuse prevention and again cited abuse at a K scope, immediate jeopardy at a pattern.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents were free from abuse for six (#18, #10, #33, #7, #1, #22) of nine residents reviewed for abuse out of 19 sample residents. Specifically, the facility failed to ensure residents were free from resident-to-resident abuse. Findings include: I. Facility policy and procedure The Abuse Prevention Program policy, no date of inception or revision, provided by the nursing home administrator (NHA) on 10/31/22 at 4:00 p.m. read in pertinent part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. II. Physical abuse 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 record review and staff interviews, the facility failed to report allegations of abuse to the State Survey and Certification Agency in accordance with State law involving seven (#1, #7 #10, #18, #22, #33, and #35) of nine residents reviewed for abuse out of 19 sample residents. Specifically, the facility failed to timely report allegations of: -Resident to resident physical abuse for Residents #1, #7, #10, #18, #22, #33 and #35; and, -Staff to resident physical abuse for Resident #35. Cross-reference F600, failure to protect residents' rights to be free from abuse. Findings include: I. Facility policies and procedures The Reporting Abuse to State Agencies and Other Entities/Individuals policy, initiated 11/1/17, was provided by the nursing home administrator (NHA) on 10/31/22. The policy read in pertinent part: All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Should a…

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 VII. Resident #18 A. Resident status Resident #18, age [AGE], was admitted [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included unspecified dementia, anxiety disorder, and bipolar disorder with psychotic features. According to the 8/30/22 minimum date set (MDS), the resident was unable to complete the brief interview for mental status exam (BIMS). The resident had memory problems with both short and long term memory. B. Record review A behavior progress note dated 8/18/22 showed a monthly review of psychotropic medications related to the resident. Target behaviors being monitored were delusional ideations, agitation with not receiving immediate gratification, sudden mood changes, temper tantrums, screaming uncontrollably, aggressive behaviors towards others, physical acts of aggression, negative statements, and weeping/crying. The resident had improved during the end of June and through July, but the resident in the last few weeks appeared to have more outbursts 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 observation, interviews and record review, the facility failed to ensure residents were free from unnecessary restraints for one (#186) of three residents out of 19 sample residents. Specifically, the facility failed to use a position change alarm restraint appropriately, to use an appropriately approved type of restraint, attempt to use the least restrictive alternative restraint, and to follow the physician orders for appropriate use of a restraint, for Resident #186. Since the resident's admission on [DATE], the facility had implemented personal alarms to the resident's wheelchair and bed, a gait belt that was inappropriately used to restrain Resident #816 to her wheelchair, and an alarming seat belt to her wheelchair. Cross-reference F689, failure to prevent accidents and/or hazardous conditions. Findings include: I. Facility policy The Use of Restraints policy, dated 11/1/17, provided by the nursing home administrator (NHA) on 11/7/22 at 11:10 a.m., revealed in pertinent part: Restraints shall only…

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 allegations of abuse were investigated for three (#25, #13, and #35) of nine residents reviewed for abuse allegations of 19 sample residents. Specifically, the facility failed to: -Conduct a comprehensive investigation into allegations of abuse for Residents #25 and #13; and, -Conduct a comprehensive investigation into Resident #35's skin tears obtained during bathing. Findings include: I. Facility policy and procedure The Abuse Investigations policy, no date of inception or revision, provided by the nursing home administrator (NHA) on 10/31/22 at 4:00 p.m. read in pertinent part, all reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the administrator, or his/her designee, will appoint a member of management to investigate the alleged…

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 therapy and restorative services to maintain highest practicable level of functioning for three (#25, #186, #7) of three residents reviewed for rehab and restorative services of 19 sample residents. Specifically, the facility failed to ensure services to maintain residents' highest practicable levels of functioning. Findings include: I. Facility policy and procedure The Restorative Nursing Services policy, revised July 2017, provided by the staff development coordinator (SDC) on 11/3/22 at 4:00 p.m. read in pertinent part, residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy interpretation and implementation included: -Restorative nursing care consisted of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupation, or speech therapies); -Residents may be started on a restorative nursing program upon admission, during the…

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