Pelican Pointe Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents and their representatives were provided prompt efforts by the facility to resolve grievances for one (#3) of eight residents reviewed for grievances out of 14 sample residents. Specifically, the facility failed to document and follow-up on grievances reported by Resident #3 regarding a missing cell phone and eye glasses. Findings include: I. Facility policy and procedure The Grievances policy, dated December 2024, was provided by the nursing home administrator (NHA) on 2/4/25 at 2:07 p.m. It read in pertinent part, It is the policy of this facility to establish a grievance process that allows residents a way to execute their right to voice concerns or grievances to the facility without fear of discrimination or reprisal. The facility will make information on how to file a grievance available to the residents and make prompt efforts to resolve grievances that the residents may have. The facility's grievance official is responsible for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to 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 three (#1, #3 and #5) of three residents reviewed out of 10 sample residents. Specifically, the facility failed to: -Ensure Resident #1, Resident #3 and Resident #5, who were dependent on staff for bathing, received their scheduled showers; and, -Ensure resident #5, who was dependent on staff for ADL care, received assistance with shaving. Findings include: I. Facility policy and procedure The Supporting Activities of Daily Living (ADL) policy, revised March 2018, was received from the regional director of operations (RDO) on 6/10/24 at 4:53 p.m. The policy documented in pertinent part, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including…

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 an environment as free of accident hazards as possible and ensure residents received adequate supervision and assistance devices to prevent accidents for four (#4, #7, #8 and #9) of five residents reviewed for accident hazards out of 10 sample residents. Specifically, the facility failed to: -Provide supervision to prevent the elopement of Resident #4; -Investigate how Resident #4, who had a wander prevention device, eloped from the facility in order to prevent a recurrence; -Complete accurate elopement risk assessments for Resident #7 and Resident #8; -Ensure Resident #8 and Resident #9's care plans were updated to include their wander risk and wanderguards; and, -Routinely check the function of wander prevention devices for Resident #7, Resident #8 and Resident #9. Findings include: I. Facility policy and procedure The Wandering and Elopement policy, dated 2/29/24, was received from the regional director of operations (RDO) 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.

Based on observations, record review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Ensure staff performed hand hygiene with blood glucose checks; and, -Ensure glucometers were cleaned and disinfected with appropriate disinfectant contact time between uses. Findings include: I. Facility policy and procedure The Handwashing Hand Hygiene policy, revised August 2019, was received from the regional director of operations (RDO) on 6/10/24 at 4:53 p.m. The policy documented in pertinent part, Use an alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after direct contact with residents, before performing any non-surgical invasive procedures, before moving from a contaminated body site to a clean body site during resident care, after…

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 staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included all resources, education, staff competencies and facility based risk assessments. Findings include: I. Facility policy and procedure The Facility Assessment policy, dated October 2018, was provided by the nursing home administrator (NHA) on 12/11/23 at 4:38 p.m. It revealed in pertinent part, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. The facility assessment includes a detailed review of the resident population. The facility assessment also includes a detailed review of the resources available to meet the needs…

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, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to: -Obtain committee feedback; collect data; monitor adverse events; identify areas for improvement; prioritize improvement activities; implement corrective and preventative actions; and conduct performance improvement projects related to problem-prone areas identified; and, -Address concerns related to the facility's failure to provide pneumonia vaccines as requested and per physician's orders. Findings include: I. Facility policy The Quality Assurance and Performance Improvement (QAPI) policy, dated 9/29/23, was provided by the nursing home administrator (NHA) on 12/4/23 at 9:30 a.m., it read in part: Purpose: (facility name) have an ongoing 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure tracking, offering and administration of the COVID-19 vaccination; -Ensure professional standards of infection control were followed while cleaning resident rooms and resident room bathrooms, so they did not contaminate surfaces with water from the inside of the toilet bowl; -Ensure razors and sharps were disposed of properly in a biohazard container; -Ensure that foley catheter care and incontinence care were performed in a sanitary manner; and, -Ensure a used suction canister was disposed of in a sanitary manner. Findings include: I. Tracking of COVID-19 vaccinations for residents A. Facility policy and procedure The Immunization policy, dated 7/28/23, was provided by the nursing home administrator (NHA) 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 implement policies and procedures related to pneumococcal immunizations for 12 (#6, #59, #42, #47, #76, #75, #17, #35, #5, #27, #232 and #233) of 12 residents reviewed for immunizations out of 40 sample residents. Specifically the facility failed to: -Offer Resident #6 an annual influenza vaccination; -Offer Resident #59 and Resident #75 a pneumococcal vaccination upon admission; -Ensure Resident #42, Resident #47, Resident #76 and Resident #5's electronic medical records (EMR) were up to date with immunization records; -Determine if additional doses of the pneumococcal vaccination were needed and offer the additional doses of the pneumococcal vaccination as needed to Resident #42, Resident #47, Resident #76, Resident #35, Resident #5, Resident #232 and Resident #233; and, -Document declination forms, document risk versus benefit education and re-offer the pneumococcal vaccination annually for Resident #6, Resident #75, Resident #17 and 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 observations and interviews, the facility failed to maintain emergency response carts and equipment in safe operating condition for four of four emergency (crash) carts. Specifically, the facility failed to: -Ensure staff completed daily equipment checks; -Ensure expired items were removed from the crash cart; -Ensure missing items were replaced on the crash cart; -Ensure staff knew how to open the crash carts; and, -Ensure staff were trained on how to use the emergency oxygen cylinders. Findings include: I. Professional reference According to [NAME], [NAME], (2022). Crash cart preparedness and failure to rescue Retrieved on 12/14/23, from https://www.researchgate.net/publication/360555126_Crash_cart_preparedness_and_Failure_to_rescue_A_case_study_review and read in pertinent part, A crash cart is a mobile cabinet on wheels that contains equipment required for emergency cardio-pulmonary resuscitation. The carts are individualized and conveniently located throughout healthcare facilities for rapid access…

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 provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and resident abuse prevention; for 17 of 17 nursing staff hired between 10/1/23 and 12/6/23 out of 49 nursing staff members. Specifically, the facility failed to ensure that 11 certified nurse aides (CNA) (#4, #8, #10, #13, #15, #16, #17, #18, #19, #20, #21), four resident aides (RA) (#1, #2, #3 and #4) one registered nurse (RN) (#6) and one licensed practical nurse (LPN) (#2) received training on abuse identification, prevention and reporting. Findings include: I. Facility policy and procedures The Staff Training policy, revised 6/4/19, was provided by the corporate nurse consultant (CNC) on 12/11/23 at 10:49 a.m. It revealed in pertinent part The community recognizes the importance of having a skilled workforce in order to achieve…

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 develop, implement, and maintain a mandatory effective training program for all staff, which includes, at a minimum, training on the facility's quality assurance and performance improvement (QAPI) program, including the goals and various elements of the program, how the facility intends to implement the program the staff's role in the facility's QAPI program and how to communicate concerns, problems or opportunities for improvement to the facility's quality assessment and assurance (QAA) committee for 17 of 17 nursing staff hired between 10/4/23 and 12/6/23 out of 49 nursing staff members. Specifically, the facility failed to ensure that 11 certified nurse aides (CNA) (#4, #8, #10, #13, #15, #16, #17, #18, #19, #20, #21); four resident aide (RA) (#1, #2, #3 and #4); one registered nurse (RN) (#6); and, one licensed practical nurse (LPN) (#2) received training on the facility's QAPI program. Findings include: I. Facility policy The Quality Management Plan/Quality Assurance and Performance Improvement Plan policy, dated…

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

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all staff, which includes, at a minimum, training on behavioral health based on requirements and as outlined in the facility's assessment, for 17 of 17 nursing staff hired between 10/4/23 and 12/6/23 out of 49 nursing staff members. Specifically, the facility failed to ensure that 11 certified nurse aides (CNA) (#4, #8, #10, #13, #15, #16, #17, #18, #19, #20, #21), four resident aides (RA) (#1, #2, #3 and #4), one registered nurse (RN) (#6) and one licensed practical nurse (LPN) (#2) received training on behavioral health issues to include care specific to the individual needs of residents that are diagnosed with dementia and how to promote meaningful activities which promote engagement and positive meaningful relationships. Cross-reference F744 failure to provide dementia focused care. Findings include: I. Facility policy The Dementia Clinical Protocol, revised November 2018, was provided by the clinical nurse consultant (CNC) on 12/11/23 at 3:52 p.m. 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, record review and interviews, the facility failed to effectively address the care and treatment needs of residents in the secured dementia care unit for the residents to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being; and provide person-centered care for three (#30, #40 and #4) of three residents reviewed for dementia care out of 40 sample residents. Specifically, the facility failed to provide the residents living in the Mountain View South with consistent and engaging activity programming of interest that was meaningful and person-centered. Additionally, the facility failed for Residents #30, #47 and #4 to: -Identify, address, and/or obtain necessary services to effectively meet the interests of the residents; and, -Implement person-centered approaches for residents with a dementia diagnosis to alleviate boredom and reduce the risk of the development of negative and or aggressive behaviors. Findings include: I. Facility policy 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 ensure one (#5) of one resident reviewed for grievances out of 40 sample residents was provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to provide a resolution to Resident #5's grievance, which the resident had communicated to staff on multiple occasions. Findings include: I. Facility policy and procedure The Grievance policy, dated 5/8/23, was provided by the corporate director of clinical risk management (CDCRM) on 12/11/23 at 10:49 a.m. It revealed in pertinent part, To provide residents and responsible party with information on the facility grievance procedure. To ensure that residents are afforded their right to file a grievance without discrimination or reprisal and that such grievance shall be responded promptly and in written form. Administrator's review: the Grievance and Complaint Investigation Report must be filed with the administrator within five (5) working days of the receipt 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 observation, record review and interviews, the facility failed to ensure residents were free from abuse, neglect and exploitation for two (#30 and #75) of two residents in two allegations of abuse reviewed out of 40 sample residents. Specifically, the facility failed to provide adequate supervision to prevent: -Resident #30 from being a victim of physical abuse by Resident #47; and, -Resident #75 from being a victim of physical abuse by Resident #12. Findings include: I. Facility policy The Abuse policy, dated 5/3/23, was provided by the nursing home administrator (NHA) on 12/4/23 at 9:36 a.m. It revealed in pertinent part: 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,…

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 staff interviews and record review, the facility failed to report alleged violations of potential abuse to the proper authority, including the policy and state oversight agency in accordance with state law for one alleged violations; involving one (#12) of one resident reviewed for allegations of abuse out of 40 sample residents. Specifically, the facility failed to report one allegation of resident abuse by staff to the facility administrator, director of nursing, local police or the State Agency, in a timely manner. Findings include: I. Facility policy and procedure The Abuse policy, dated 5/3/23, was provided by the nursing home administrator (NHA) on 12/4/23 at approximately 9:35 a.m. It revealed in pertinent part, Reporting abuse: If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Reporting can be completed verbally 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 staff interviews the facility failed to provide services for one (#6) of two reviewed out of 40 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #6 vital signs-blood pressure and heart rate/pulse were monitored and assessed for irregularities immediately before the administration of a blood pressure medication. Findings include: I. Professional reference According to Khashayar, F., [NAME], J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK532906 retrieved on 12/19/23. Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur. The patient's heart rate and blood pressure require monitoring while using…

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 and implement an effective discharge plan for two (#60 and #78) out of three residents reviewed for discharge planning out of 40 sample residents. Specifically, the facility failed to ensure the discharge planning process was documented in Resident #60 and Resident #78's medical record. Findings include: I. Facility policy and procedure The Discharge Planning policy, revised 5/17/23, was provided by the corporate director of clinical risk management (CDCRM) on 12/11/23 at 10:49 a.m. It revealed in pertinent part, The facility will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge. The facility will evaluate the resident's expected goals for discharge upon admission, then routinely in accordance with the MDS assessment cycle and as needed. Initial information and discharge goals will be included in the resident's baseline care plan. Subsequent information…

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

Based on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored and labeled in one of two medication carts and two of four medication refrigerators. Specifically, the facility failed to: -Ensure that expired medications were removed from the medication carts and disposed of in a safe manner; -Ensure that an open tuberculin vial was dated upon opening; and -Ensure that an expired Pneumovax 23 vaccine was removed from the medication refrigerator in a timely manner. Findings include: I. Professional reference Sanofi Pasteur. (2020). Package insert. Tuberculin Purified Protein Derivative (PPD)(Mantoux): Tubersol. Food and Drug Administration (FDA). https://www.fda.gov/media/74866/download, retrieved on 12/14/23 at 9:52 a.m. read in pertinent part, A vial of Tubersol (tuberculin PPD) which has been entered and in use for 30 days should be discarded. Do not use it after the expiration date. Merck & Co., Inc. (2023). Package insert. Pneumovax 23. Food and Drug Administration (FDA).…

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 preferences for one (#58) of two residents out of 40 sample residents. Specifically, the facility failed to offer food choices according to resident preferences for Resident #58. Findings include: I. Facility policy The Resident Food Preferences policy, revised July 2017, was provided by the corporate director of clinical risk management (CDCRM) on 12/11/23 at 10:49 a.m. It revealed in pertinent part, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team (IDT). When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and meal times. Nursing staff will document the resident's food and eating preference in the care plan. II. Resident Representative Interview The resident's representative was interviewed on 12/4/23 at 3:27 p.m. He said that the facility 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 observations and interviews the facility failed to ensure residents had the right to a safe, clean and comfortable homelike environment in their rooms. Specifically, the facility did not facilitate the necessary housekeeping and maintenance services to maintain the resident rooms on two of five halls in a sanitary and comfortable manner. Findings include: I. Facility policies and procedures The Maintenance Service policy, revised December 2009, was provided by the director of nursing (DON) on 8/2/23 at 3:29 p.m. The policy revealed that services should be provided to all areas of the building, grounds, and equipment. The maintenance personnel should maintain the facility in compliance with current federal, state and local laws, regulations and guidelines. The facility should be maintained in good repair and free from hazards. The maintenance director was responsible for developing and maintaining a schedule of maintenance service, to assure that the buildings, grounds, and equipment were maintained in 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 Based on observations, record review and interviews, the facility failed to ensure the highest practicable quality of care for one (#10) of three out of eight sample residents that were reviewed for falls and post-fall assessments. Specifically, the facility failed to ensure neurological assessments were started and completed for Resident #10's three unwitnessed falls in his room. On 4/24/23, the resident sustained fractures of the left frontal process of the maxilla (a major bone of the face below the nose that forms the upper jaw) and nasal bones. The resident also had a laceration and a contusion to the forehead. On 4/28/23, the resident fell and did not sustain any injuries. On 7/21/23, the resident sustained a contusion with a laceration to his forehead. Neurological assessments were not conducted following any of these falls to identify potential head injuries. Findings include: I. Facility policies and procedures The Neurological Check Sheet, undated, was provided by the director or nursing (DON) 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.

Based on record review, observations, and staff interviews, the facility failed to ensure food items were stored and served under sanitary conditions. Specifically, the facility failed to ensure proper cleaning of the facility ice machines located in the main kitchen and main dining room according to manufacturer recommendations and facility policy. Findings include: I. Professional reference According to the Food and Drug Administration (2017), retrieved on 8/30/22, from, https://www.fda.gov/downloads/food/guidanceregulation/retailfoodprotection/foodcode/ucm595140.pdf. Read in pertinent part: The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. -Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated…

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

Based on observations, interviews and record review, the facility failed to ensure an effective program of pest management. Specifically, the facility failed to ensure the main kitchen, dining room, resident rooms and hallways were free from flies. Findings include: I. Professional references According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended 1/1/19) page 186, retrieved on 8/30/22, from https://cdphe.colorado.gov/retail-food/retail-food-resources The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: -Routinely inspecting incoming shipments of food and supplies -Routinely inspecting the premises for evidence of pests -Using methods, if pests are found, such as trapping devices or other means of pest control as specified under; and -Eliminating harborage conditions. According to the Center for Disease Control's (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities,…

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 three (#225, #49, #35) of five residents with dementia out of 38 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to develop person-centered interventions to prevent the resident to resident altercations. Resident #225 was admitted to facility from another facility with known behaviors of sexual abuse towards female residents on his prior memory care unit. Upon admission, the resident was assessed by a medical director, who recommended increasing the number of staff on the secure unit to monitor the resident for his behaviors. He communicated his recommendations to the nursing home administrator (NHA). The facility stated that admitting to an all-male unit would mitigate resident's behaviors and did not put any additional steps in place to protect the other residents on the unit. Cross-reference F600 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.

Based on observations, record review and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment where resident's equipment necessary for the completion of activities of daily living was free from the potential spread of disease causing organisms for five (#3, #21, #57, #36, and #64) of 14 fourteen residents of 38 sample residents. Specifically, the facility failed to: -Follow the facility cleaning schedule for resident wheelchairs and walkers on memory care units; -Identify and clean unsanitary wheelchairs and walkers as needed. Findings include: I. Observations On 8/25/22 at 8:15 a.m. Resident #3's wheelchair was observed while resident out of the chair. The cross bars underneath the seat of the wheelchair had an excessive collection of unknown crust, dust, lint, and black grim. The area underneath the resident wheelchair cushion was soiled with dirty napkins, food wrappers and utensils. On 8/25/22 at 8:20 a.m. Resident #21's wheelchair was observed while the resident was out of the chair. The cross bars underneath the seat, the wheel brakes…

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 each resident received adequate supervision and assistance devices to prevent accidents for one (#8) of six out of 38 sample residents. Specifically, the facility failed to ensure Resident 8's Wanderguard was observed for placement and electronically checked for functionally as physician orders. Findings include: I. Facility policies and procedures The Elopement and Wandering Residents policy, implemented 8/24/21, was provided by the nursing home administrator (NHA) on 8/23/22 at 10:33 a.m. The policy revealed the facility ensured that residents who exhibited wandering behaviors and/or were at risk for elopement received adequate supervision to prevent accidents, and received care in accordance with their person-centered plan of care that addressed the unique factors that contributed to wandering or elopement risk. Wandering was described as a random or repetitive locomotion that might be goal-directed or non-goal directed or aimless. Elopement…

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 interview, the facility failed to ensure one (Resident #46) of one resident out of 38 sample residents did not experience a significant medication error. Specifically, the facility failed to ensure that Resident #46 received a prescribed monthly dose of long acting Haldol on three occasions (2/14/22 or 3/14/22 and 7/4/22), as ordered by the resident's physician. I. Professional reference According to [NAME] Nursing Drug Handbook 2020, Kizior, R. J. and [NAME], K.J., St. Louis Missouri 2020, revealed the following pharmaceutical information: -Page (pp). 561-563 read in part: Haloperidol (Haldol). Classification: First generation antipsychotic. Clinical: antipsychotic, .Uses: treatment of schizophrenia. Treats Tourette's disorder (controls tics and vocal utterances, .Management of psychotic disorder Therapeutic effect: Produces tranquilizing effects on muscle weakness. Strong extrapyramidal (involuntary muscle movements) effect.Full therapeutic effect may take up to six weeks. Side…

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 collaborate with the hospice provider to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one (#53) resident out of 38 sample residents. Specifically, the facility failed to ensure for Resident #53: -Communication with the resident's hospice provider to obtain the providers care plan and treatment notes; and, -Failed to develop a comprehensive care plan to include the hospice provider's plan of care. Findings include: I. Facility policy The Hospice Services Facility Agreement policy, dated 2022, provided by the corporate nurse consultant (CNC) #2 on 8/25/22 at 3:40 p.m. read in pertinent part: It is the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. The facility will, under a written agreement, ensure…

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.