Thornton Care Center

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications in two of two medication storage rooms and two of four medication storage carts. Specifically, the facility failed to: -Dispose of medications from the medication storage refrigerators and medication carts after residents had been discharged ; -Ensure medications were labeled with dates opened; -Ensure expired medications were removed and discarded from medication carts and storage refrigerators; and, -Maintain temperature logs for the medication refrigerators. Findings include: I. Facility policy and procedure The Storage of Medications policy, revised November 2020, was provided by the director of clinical services (DOCS) on 12/17/24 at 9:39 a.m. The policy read in pertinent part, Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Discontinued, outdated, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide each resident with a nourishing, palatable and well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences for two (#48 and #61) of six residents out of 41 sample residents. Specifically, the facility failed to: -Provide a balanced menu with a variety; and, -Provide alternate items of preference for Resident #61 and #48 when requested. I. Provide a balanced menu with a variety of starch options A. Facility policy and procedure The Resident Food Preferences policy, revised July 2017 was provided by the director of clinical services (DOCS) on 12/18/24 at 9:42 a.m. The policy read in pertinent part, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. Upon the resident's admission or within 24 hours after his/her…

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

Based on interviews, observations and record review, the facility failed to ensure residents consistently received food prepared by methods that conserved nutritive value, were palatable in taste, appearance and temperature. Specifically, the facility failed to ensure the residents' food was palatable in taste, texture, appearance and temperature. Findings include: I. Resident interviews Resident #13 was interviewed on 12/11/24 at 10:38 a.m. Resident #13 said the food was not hot. Resident #35 was interviewed on 12/11/24 at 2:17 p.m. Resident #35 said the food was never hot. Resident #61's representative was interviewed on 12/11/24 at 2:45 p.m. The resident's representative said Resident #61 told her the food had no flavor. Resident #6 was interviewed on 12/11/24 at 3:25 p.m. Resident #6 said the food was not good. Resident #6 said the grilled cheese sandwiches were not cooked correctly and were not grilled, but microwaved instead. Resident #6 said the food was often served cold and had no flavor. Resident #24 was interviewed on 12/11/24 at 4:44 p.m. Resident #24 said the food 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 record review and interviews, the facility failed to ensure one (#13) of one resident out of 41 sample residents was compensated for paid services at or above prevailing rates. Specifically, the facility failed to ensure Resident #13 was paid in a timely manner. Findings include: I. Facility policy and procedure The Resident Therapeutic Stipend Program (TSP) policy, dated 6/1/23, was provided by the nursing home administrator (NHA) on 12/19/24 at 4:55 p.m. It read in pertinent part, The task/duties/activities performed by the resident are appropriate, and the resident has the mental and physical capacity to perform the task/duties/activities. The plan of care specifies the nature of the services performed. All services performed under TSP (therapeutic stipend program) are paid. Duties will be outlined, and the resident must agree to the description of duties prior to starting the program. The resident will be trained/educated on the program duties to be provided, as well as safety protocols and safe…

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 thoroughly investigate allegations of verbal abuse for two (#37 and #21) of five residents reviewed for abuse out of 41 sample residents. Specifically, the facility failed to thoroughly investigate allegations of verbal abuse for Resident #37 and #21. Findings include: I. Facility policy and procedure The Abuse policy, dated 2/29/24, was received from the nursing home administrator (NHA) on 12/11/24. The policy read in pertinent part, This community does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to, freedom from corporal punishment,…

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 permitted to remain in the facility and not transfer or discharge for one (#216) of three residents out of 41 sample residents. Specifically, the facility failed to provide Resident #216 with an appropriate discharge process. Findings include: I. Facility policy and procedure The Discharge Planning policy, dated 2/29/24 was provided by the director of clinical services (DOCS) on 12/19/24 at 1:34 p.m. It read in pertinent part, The facility will develop and implement an effective discharge planning process that focuses on the resident's discharge goals. This will include identifying ways for residents to be active participants and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The ongoing process of developing the discharge plan will include a regular re-evaluation of the resident to identity changes that require modification of the discharge plan, and updating…

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 following a facility-initiated transfer to the hospital for one (#216) of three residents reviewed for discharge out of 41 sample residents. Specifically, the facility failed to reassess Resident #216's status at the time the resident sought to return to the facility after a facility-initiated transfer to the hospital, and directed the hospital that the resident was not allowed to return to the facility. Findings include: I. Facility policy and procedure The Discharge Planning policy, dated 2/29/24 was provided by the director of clinical services (DOCS) on 12/19/24 at 1:34 p.m. It read in pertinent part, The facility will develop and implement an effective discharge planning process that focuses on the resident's discharge goals. This will include identifying ways for residents to be active participants and effectively transition them to post-discharge care, and the reduction of factors leading to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (#32 and #48) of eight residents reviewed out of 41 sample residents. Specifically, the facility failed to: -Ensure Resident #32, who was dependent on staff for bathing, received her scheduled showers. -Ensure Resident #48, who was blind, received meal assistance. Findings include: I. Facility policy and procedure The Bath, Shower/Tub policy, revised February 2018, was provided by the director of clinical services (DOCS) on 12/17/24 at 6:58 p.m. The policy read in pertinent part, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation: The date and time the shower/tub bath was performed, the name and title of the individual(s) who assisted the resident, all assessment data,…

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 one (#9) of four residents reviewed for activities of 41 sample residents received an ongoing program of activities designed to meet needs and interests, and promote physical, medical and psychosocial well-being. Specifically the facility failed to offer and provide a personalized activity program for Resident #9. Findings include: I. Resident #9 A. Resident status Resident #9, age greater than 65, admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included acute kidney failure, history of falling and dementia. The 9/20/24 minimum data set (MDS) assessment revealed the resident had both short term and long term memory impairments and had severely impaired decision making skills through staff assessment. The resident was dependent on staff for activities of daily living (ADL). The 12/23/23 MDS assessment revealed it was very important for the resident to have books, newspapers and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#24) of two residents out of 41 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure treatment was provided to Resident #24's skin injury in a timely manner. Findings include: I. Resident #24 A. Resident status Resident #24, age less than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes, history of other venous thrombosis (a condition where a blood clot, or thrombus, forms in a vein and blocks blood flow) and embolism (occurs when a blockage, called an embolus, lodges in a blood vessel and prevents blood from flowing). The 11/13/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15 The resident was independent with activities of daily living (ADL). B. Observations 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 observation, record review and interviews, the facility failed to ensure proper treatment and services to maintain vision abilities for one (#23) of seven residents reviewed for vision services out of 41 sample residents. Specifically, the facility failed to ensure Resident #23's new glasses were obtained in a timely manner. Findings include: I. Resident #23 A. Resident status Resident #23, age [AGE], was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis or weakness on one side of the body), peripheral vascular disease (disorder of the blood vessels), mood disorder and chronic obstructive pulmonary (lung) disease. The 9/26/24 minimum data set (MDS) assessment revealed Resident #23 had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was independent with eating and dressing and required supervision or substantial assistance with most other activities of daily living…

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 who required dialysis received dialysis services consistent with professional standards of practice for one (#1) of two residents out of 41 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to: -Consistently and accurately monitor pre- and post-dialysis weights for Resident #1; -Consistently document Resident #1's post-dialysis weight from the dialysis communication form in the resident's electronic medical record (EMR); and, -Ensure communication forms between the facility and the dialysis center were obtained consistently and completed thoroughly for Resident #1. Findings include: I. Facility policy and procedure The Hemodialysis Residents policy, dated 2/29/24, was provided by the director of clinical services (DOCS) on 12/17/24 at 10:30 a.m. It read in pertinent part, The facility provides residents with safe, accurate, and appropriate care,…

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 significant medication errors for two (#6 and #44) of six residents reviewed for medication errors out of 41 sample residents. Specifically, the facility failed to: -Order and administer the correct medication (hydroxyzine) for Resident #6's itching, and not the incorrect medication (hydralazine), for high blood pressure. -Ensure Resident #44 did not receive excessive dosage of acetaminophen. Finding include: I. Failed to ensure the correct medication was ordered and administered A. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed., E.[NAME], St. Louis Missouri, pp. 606-607. 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…

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 meet all the requirements for the provision of hospice care for one (#9) of two residents out of 41 sample residents. Specifically, the facility failed to ensure the hospice agency notes regarding Resident #9's care were easily accessible to the facility staff in an attempt to effectively coordinate care with the hospice agency. Findings include: I. Resident #9 A. Resident status Resident #9, age greater than 65 was admitted [DATE]. According to the December 2024 computerized physician orders (CPO) diagnoses included acute kidney failure, history of falling and dementia. The 9/20/24 minimum data set (MDS) assessment documented the resident had both short term and long term memory impairments and had severely impaired decision making skills per staff assessment. The resident was dependent on staff for activities of daily living (ADL). The MDS assessment indicated the resident was receiving hospice services. B. Resident representative interview 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 three (#1, #2 and #3) of five residents received treatment and care in accordance with professional standards of practice out of five sample residents. Specifically, the facility failed to administer pain medications in a timely manner per the physician orders for Resident #1, Resident #2 and Resident #3. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.[NAME], St. Louis Missouri, pp. 606-607. 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…

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 an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life and quality of care. Findings include: I. Cross-referenced citations Cross-reference F686: The facility failed to ensure pressure injuries were assessed and interventions were implemented timely to prevent worsening of the wounds and infection. The facility failed to ensure wound treatment was implemented as ordered for a resident who developed a wound infection with osteomyelitis (inflammation of the bone due to infection). The facility's failure to assess and treat pressure injuries created an immediate jeopardy (IJ) situation with actual serious harm. Cross-reference F600: The facility failed 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, record review and interviews, the facility failed to ensure menus were followed to meet the residents' nutritional needs. Specifically, the facility failed to follow the correct portion sizes to ensure adequate nutrition was provided to the residents. Findings include: I. Facility policy and procedure The Menu policy, revised September 2017, was provided by the director of clinical services (DCS) on 10/26/23 at 12:28 p.m. It read in pertinent part: Menus will be planned in advance to meet the nutritional needs of the residents in accordance with established national guidelines. A registered dietitian/nutritionist (RDN) or other clinically qualified nutrition professional reviews and approves the menus. The RDN or other clinically qualified nutrition professional will adjust the individual meal plan to meet the individual requests, including cultural, religious or ethnic preferences, as appropriate. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. II. Failure to follow…

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

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive. Specifically, the facility failed to ensure food was palatable in taste, texture and appearance. Findings include: I. Facility policy and procedure The Food and Palatability policy, revised in September 2017, was provided by the director of clinical services on 10/26/23 at 12:28 p.m. It read, in pertinent part: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. The cook(s) prepare food in accordance with the recipes, and season for region and/or ethnic preferences, as appropriate. Cook(s) use proper cooking techniques to ensure color and flavor retention. II. Resident interviews Resident #56 was interviewed on 10/23/23 at 12:24 p.m. Resident #56 said the food did not taste good and he did not like it. Resident #56 said because if he did not like the food served, he did not eat consistently. Resident #14 was interviewed on 10/23/23…

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

Based on observations and staff interviews, the facility failed to ensure safe practices were implemented to prevent the potential contamination of food and spread of food-borne illness through proper kitchen sanitation procedures. Specifically, the facility failed to ensure appropriate use of gloves when handling ready-to-eat foods. I. Professional reference The Colorado Retail Food Establishment Rules and Regulations, revised January 2019, read in pertinent part, Employees prevent bare hand contact with ready-to-eat food by properly using suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task, such as working with ready-to-eat food. Single-use gloves shall be used for no other purpose, and discarded when damaged, when interruptions occur in the operation, or when the task is completed. Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure one (#14) out of 41 sample residents were compensated for paid services at or above prevailing rates. Specifically, the facility failed to for Resident #14: -Ensure the resident was paid a fair and decent wage for a therapeutic work program; -Ensure there was a care plan for the work program; -Ensure the contract matched what workload the resident performed; and, -Allowed the resident to work without a signed contract. Findings include: This deficiency was cited previously during a recertification survey 7/21/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. I Resident status Resident #14, age under 65, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included generalized anxiety disorder, borderline personality disorder and diabetes. The 7/5/22 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 one (#170) of one resident reviewed out of 41 sample residents was provided personal privacy in her room. Specifically, the facility failed to provide a privacy curtain to ensure Resident #170 had privacy while in bed. Findings include: I. Facility policy and procedure The Resident Rights policy, revised in February 2021, was provided by the director of clinical services on 10/26/23 at 12:28 p.m. It read in pertinent part: Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality. II. Resident status Resident #170, age [AGE], was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis (mild to severe loss of strength) on right side, overactive bladder, localized swelling, mass 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 ensure two (#1 and #53) residents reviewed of five sample residents received treatment and care in accordance with professional standards of practice out of 41 sample residents. Specifically, the facility failed to: -Have a registered nurse assess Resident #1 after the fall; and, -Administer pain medications on time to Resident #53. Findings include: I. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included history of stroke, atrial fibrillation and diabetes type two. The 10/3/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required assistance from one person with most activities of daily living. He did not display behaviors and did not refuse the care. B. Resident interview Resident #1 was interviewed on 10/23/23 at 12:43 p.m. He…

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 (#15 and #6) of five residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene out of 41 sample residents. Specifically, the facility failed to provide consistent bathing to maintain good personal hygiene for Resident #15 and Resident #6. Findings include: I. Resident #15 A. Resident status Resident #15, under the age of 65, was admitted to the facility on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbances, bipolar disease and anxiety disorder. According to the 8/3/23 minimum data set (MDS) assessment, the resident was moderately cognitively impaired with a brief interview for a mental status score of 11 out of 15. The resident required extensive assistance from one person for all activities of daily living (ADLs). The resident was dependent…

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 resident environment was as free from accident hazards as possible for one (#15) of five out of 41 sample residents. Record review revealed Resident #15 fell repeatedly. The facility failed to ensure effective interventions were developed, that care-planned interventions were implemented and that neurological checks were consistently initiated when the resident's falls were unwitnessed. I. Resident #15 A. Resident status Resident #15, under the age of 60, was admitted to the facility on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbances, bipolar disease, and anxiety disorder. According to the 8/3/23 minimum data set (MDS) assessment, the resident was moderately cognitively impaired with a brief interview for a mental status score of 11 out of 15. The resident required extensive assistance from one person for all activities of daily living (ADLs).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles in two out of four medication carts. Specifically, the facility failed to label insulin pens with an open date and store them according to the manufacturer's recommendation. Findings include: I. Manufacturer's recommendations Insulin Glargine package insert read in pertinent part: Insulin Glargine pen should be stored at room temperature, below 86°F and must be used within 28 days or be discarded. Insulin Lispro package insert read in pertinent part: Insulin Lispro pen should be stored at room temperature, below 86°F and must be used within 28 days or be discarded. II. Observations of medications stored improperly and interviews 1.Cart #1 on [NAME] hallway On [DATE] at 2:30 p.m. the medication cart was inspected in the presence of the registered nurse (RN)# 2. The following observations were made: -Two open pens of Insulin…

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 the resident was assisted in making transportation arrangements to and from appointments for two (#52 and #53) of two out of 41 sample residents. Specifically, the facility failed to assist Resident #52 and Resident #53 with transportation for ongoing outside medical appointments. Findings include: I. Resident #52 A. Resident status Resident #52, age [AGE], was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included peripheral artery disease (circulatory condition) and hypertension. The resident was hit by a car while riding her bicycle before moving to the facility. The 7/5/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. She was independent with all activities of daily living. She used a wheelchair. B. Resident interview Resident #52 was interviewed on 10/24/23 at 4:12 p.m. Resident #52 said…

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 had a right to participate in the development and implementation of their person-centered plan of care for seven (#43, #11, #48, #16, #59, #21 and #30) of eight out of 47 sample residents. Specifically, the facility failed to invite and conduct regular care conferences to review the resident's plan of care with Resident #43, #11, #48, #16, #59, #21 and #30. Findings include: I. Facility policy and procedure The Care Planning-Resident Participation policy and procedure, undated, was provided by the nursing home administrator (NHA) on 7/21/22 at 1:33 p.m. It revealed, in pertinent part, This facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care). The facility will inform the resident, in a language he or she can understand, of his or her rights regarding planning and implementing care, including the right to be informed of his or her total health…

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 for the residents on eight out of eight hallways. Specifically, the facility failed to ensure temperatures in the hallways and in resident rooms were in the safe range of 71 degrees F (Fahrenheit) and 81 degrees F. Findings include: I. Facility observations A tour was conducted with the environmental services director (ESD) on 7/18/22 at 2:07 p.m. The following was observed throughout the facility: -The lobby of the facility registered at 82.6 degrees F. -The main dining room registered at 81.9 degrees F. A. The [NAME] unit -The hallway near room [ROOM NUMBER] registered 83.0 degrees F. -room [ROOM NUMBER] registered at 83.1 degrees F. -The hallway near room [ROOM NUMBER] registered at 81.2 degrees F. -room [ROOM NUMBER] registered at 81.9 degrees F. -The hallway near room [ROOM NUMBER] registered at 81.4 degrees F. -room [ROOM NUMBER] registered at 82.9 degrees F. -The hallway near room [ROOM NUMBER]…

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 three (#39, #21 and #18) of four residents reviewed out of 47 sample residents for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to: -Provide Resident #39 bathing in accordance with their plan of care; -Ensure Resident #18 was transferred back to bed upon his request and timely incontience care; and, -Provide Resident #21 with nail care. Cross reference F676: the facility failed to ensure bathing was provided to dependent residents in accordance with their plan of care. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) Care of Residents policy and procedure, undated, was provided by the nursing home administrator (NHA) on 7/21/22 at 1:33 p.m. It read, in pertinent part It is the policy of this facility to provide appropriate treatment and services in relation to ADL…

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 proper treatment and assistive devices to maintain vision abilities for three (#11, #30 and #60) of three residents out of 47 sample residents. Specifically, the facility failed to: -Follow up on optometry services for Resident #11 timely; and, -Ensure optometry services were arranged for Resident #30 and Resident #60. Findings include: I. Facility policy and procedure The Hearing and Vision Services policy and procedure, undated, was provided by the interim nursing home administrator (INHA) on 7/21/22 at 1:30 p.m. It revealed, in pertinent part, It is the policy of this facility to ensure that residents have access to and receive proper treatment and assistive devices to maintain vision and hearing abilities. The facility will utilize the comprehensive assessment process for identifying and assessing a resident's vision and hearing abilities in order to provide person-centered care. Employees should refer any identified need for hearing or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and interviews, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, in three out of four medication carts. Specifically, the facility failed to: -Label insulin pens with an open date and store them according to manufacturer's recommendation; and, -Label eye drops with an open date. Findings include: I. Manufacturer's recommendations Insulin Glargine package insert read in pertinent part:Insulin Glargine pen should be stored at room temperature, below 86°F and must be used within 28 days or be discarded. Latanoprost eye drops package insert read in pertinent part:Store the unopened bottle in the refrigerator. You may keep the opened bottle in the refrigerator or at room temperature for up to 6 weeks. II. Observations of medications stored improperly and interviews 1.Cart on East hallway On [DATE] at 8:30 a.m. the medication cart on the East hallway was inspected in the presence 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 interviews and record review, the facility failed to assist residents in obtaining routine or emergency dental services, as needed for three (#48, #30 and #21) of four out of 47 sample residents. Specifically, the facility failed to: -Ensure dental recommendations were followed up on timely for Resident #48 and Resident #30; and, -Provide dental services for Resident #21. Findings include: I. Facility policy and procedure The Dental Services policy and procedure, undated, was provided by the interim nursing home administrator (INHA) on 7/21/22 at 1:30 p.m. It revealed, in pertinent part, It is the policy of this facility, in accordance with residents' needs, to assist residents in obtaining routine (to the extent covered under the state plan) and emergency dental care. Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments,…

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, record review, and staff interviews, the facility failed to provide therapeutic and mechanically altered diets consistent with physician orders for five residents on altered diet and one resident on altered texture out of 47 sample residents. Specifically, the facility failed to: -Serve the appropriate main dish for residents on a consistent carbohydrate diet (CCD) renal, CCD two gram sodium, two gram sodium, or renal diet; and, -Prepare a dysphagia advanced diet texture correctly (an altered diet for residents with difficulty swallowing). Findings include: A. Facility policy and procedure The Therapeutic Diet Orders policy and procedure, undated, was provided by the interim nursing home administrator on 7/21/22 at 1:33 p.m. It read, in pertinent part, The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. Mechanically Altered Diet…

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 develop, implement, monitor and reevaluate its quality assurance performance improvement (QAPI) program to ensure the unique care and services the facility provided were maintained at acceptable levels of performance and continuously improved. Specifically, the facility's QAPI program failed to systematically self-identify, investigate, analyze and correct problems relating to resident safety, staffing, and quality of care. Findings include: I. Facility policy The QAPI Committee plan, dated 6/28/22, was provided by the nursing home administrator (NHA) on 7/21/22, and read in pertinent part: Objectives of the QAPI plan included: -Establish a facility-wide process to identify opportunities of improvement through continuous attention to quality of care, quality of life and resident safety; -Address gaps in systems or process; -Ensure adequate provision of staffing, time, equipment and technical training resources; -Establish clear…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for one (#42) resident of four residents reviewed for dignity out of 47 sample residents. Specifically, the facility failed to ensure Resident #42 was treated with respect and dignity by other residents. Resident #55 entered Resident #42 's room during a family visit and urinated on the floor. Cross-reference F744 for failure to provide dementia care for Resident #55's wandering into other resident rooms. I. Resident status Resident #42, age [AGE], was admitted on [DATE]. According to the July 2022 computerized physician orders (CPO), pertinent diagnoses included heart failure, neurogenic bladder, deep vein thrombosis, aphasia (loss of ability to understand or express speech), and history of stroke. The 5/31/22 minimum data set (MDS) assessment revealed the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure the resident's right to receive services in the facility with reasonable accommodation of the resident needs and preferences for two (#71 and #21) of three residents out of 47 sample residents. Specifically, the facility failed to -Ensure proper wheelchair positioning at the dining table for Resident #71; and, -Ensure Resident #21 was provided with a bed that was long enough to fit his height. Findings include: I. Failure to ensure proper wheelchair position at the dining table A. Resident #71 status Resident #71, under the age of 65, was admitted on [DATE]. According to the July 2022 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), morbid obesity, diabetes mellitus type two, bipolar disorder, schizoaffective disorder (hallucinations and delusions), anxiety, abnormal posture, and anxiety. The 6/28/22 minimum data set (MDS) assessment revealed the resident was cognitively intact…

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 (#43) out of 47 sample residents were compensated for paid services at or above prevailing rates. Specifically, the facility failed to ensure Resident #43 was paid a fair and decent wage for a therapeutic work program. Findings include: I. Resident #43 A. Resident status Resident #43, age [AGE], was admitted on [DATE]. According to the July 2022 computerized physician orders (CPO), the diagnoses included fusion of the spine, spinal stenosis and depression. The 7/5/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required supervision with all activities of daily living. It indicated it was very important to the resident to have items to read, listen to music he likes, being around animals, keeping up with the news, doing things with groups of people, doing his favorite activities, and going outside to get fresh air when the weather is good. B.…

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 two (#30 and #21) out of 47 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to: -Provide a resolution to Resident #30 filed grievance form; and, -Provide a resolution to Resident #21's voiced concern during the resident council meeting. Findings include: I. Facility policy and procedure The Resident and Family Grievances policy and procedure, dated 10/2/21, was provided by the interim nursing home administrator on 7/21/22 at 1:33 p.m. It revealed, in pertinent part, It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The Grievance Official is responsible for overseeing the grievance process; receiving and tacking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record review, the facility failed to take steps to protect one (#38) of three residents out of 47 sample residents. Specifically, the facility failed to ensure Resident #38 was free from physical abuse from Resident #45, on two occasions, when Resident #45 acted with physical aggression towards Resident #38. Findings include: I. Facility policy and procedure The Abuse policy and procedure, undated, was provided by the interim nursing home administrator (INHA) on 7/18/22 at 10:00 a.m It revealed, in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an…

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 an acute/baseline care plan for one (#43) reviewed for baseline care plans out of 47 sample residents. Specifically, the facility failed to ensure resident involvement in the development, review and provide a copy to Resident #43 of the baseline care plan. Cross reference F553: the facility failed to invite and conduct care conferences. Findings include: I. Facility policy and procedure The Care Planning-Resident Participation policy and procedure, undated, was provided by the nursing home administrator (NHA) on 7/21/22 at 1:33 p.m. It revealed, in pertinent part, This facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care). The facility will inform the resident, in a language he or she can understand, of his or her rights regarding planning and implementing care, including the right to be informed of his or her total health status. The facility will discuss…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations and record review, the facility failed to ensure two (#48 and #59) of eight residents reviewed for activities of daily living of 47 sample residents were provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to ensure Resident #48 and Resident #59 received regular bathing in accordance with their plan of care. Cross reference F677: the facility failed to ensure bathing was provided to dependent residents in accordance with their plan of care. Findings include: I. Facility policy and procedure The Resident Showers policy and procedure, undated, was provided by the nursing home administrator on 7/21/22 at 2:00 p.m. It revealed, in pertinent part, It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided showers as per request or as per facility schedule protocols…

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 (#21 and #8) of five residents with limited range of motion received appropriate treatment and services out of 47 sample residents. Specifically, the facility failed to: -Ensure Resident #21 received services to help prevent progression of a contracture to his left upper extremity; and, -Ensure Resident #8 received passive stretching to maintain range of motion in his contracted upper extremity. Findings include: I. Facility policy and procedure The Prevention of Decline in Range of Motion policy and procedure, undated, was provided by the interim nursing home administrator (INHA) on 7/21/22 at 1:33 p.m. it revealed, in pertinent part, Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. Range of motion means the full movement potential of a joint. The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services to prevent complications for one (#130) of one reviewed out of 47 sample residents. Specifically, the facility failed to ensure Resident #130 received his tube feeding as ordered by the physician. Findings include: I. Facility policy and procedure The Appropriate Use of Feeding Tubes policy and procedure, undated, was provided by the interim nursing home administrator (INHA) on 7/21/22 at 1:33 p.m. it revealed, in pertinent part, It is a policy of this facility to ensure that a resident maintains acceptable parameters of nutritional hydration status. Feeding tubes will be used only as necessary to address malnutrition and dehydration, or when the resident's clinical condition deems this intervention medically necessary. II. Resident status Resident #130, age [AGE], was admitted on [DATE]. According to the July 2022 computerized physician orders (CPO),…

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 one out of three nurses were able to demonstrate skills and techniques necessary to care for residents' needs for one out of five nursing staff reviewed. Specifically, the facility failed to ensure competencies were completed annually for licensed practical nurse (LPN) #3. Findings include: I. Record review LPN #3's personnel record documented LPN #3 was hired by the corporation of the facility in 2013. -A review of LPN #3 personnel record failed to have documentation that indicated LPN #3 had not completed an annual competency for 2021 or 2022, per the federal requirement. II. Staff interviews The interim nursing home administrator (INHA) was interviewed on 7/21/22 at 5:15 p.m. She said competencies for nursing staff should be conducted annually. She confirmed LPN #3's personnel record did not include documentation to indicate she had completed an annual competency for 2021 or yet in 2022. III. Additional information On 7/25/22 at 3:48 p.m., the INHA sent an email with a statement that said LPN #3 was hired 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 and staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections in one out of three units. Specifically, the facility failed to: -Conduct proper hand hygiene when administering tube feed; -Administer medications in a sanitary manner; and, -Make sure oxygen tubing was clean prior to application. Findings include: I. Failure to conduct proper hand hygiene when administering a tube feed A. Professional reference According to the Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last updated 1/31/2020, retrieved from https://www.cdc.gov/handhygiene/providers/index.html on 7/25/22, it included the following recommendations: Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer immediately…

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.