Ingraham Manor Rehab And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews and facility documentation/policies, for one (1) of three (3) residents (Resident #1) reviewed for advance directives, the facility failed to ensure advance directives/code status were readily accessible to staff during an emergency. Resident #1 was documented as a Full Code; however, when Resident #1 was found unresponsive and without a pulse, licensed staff were unable to determine the resident's code status and did not initiate the facility's emergency response. The findings included:Review of the hospital Discharge summary dated [DATE] identified Resident #1 was a Full Code (medical order directing staff to initiate all resuscitative measures, including CPR and advanced life support, if a resident has no pulse or respirations).Resident #1 was admitted to the facility on [DATE] with diagnoses which included Type II diabetes, acute kidney injury, and atherosclerotic heart disease.The Nursing admission assessment by RN #2 dated [DATE] at 10:37 PM (created date [DATE]…

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 clinical record review, facility documentation/policies, and interviews for one (1) of three (3) residents (Resident #1) reviewed for cardiopulmonary resuscitation (CPR), the facility failed to ensure licensed nursing staff provided necessary emergency services when three (3) licensed nurses (LPN #1, LPN #2, and RN #1) did not initiate cardiopulmonary resuscitation (CPR) or activate emergency medical services (EMS) for a resident who was documented as a Full Code and the Registered Nurse pronounced the resident deceased without a physician order authorizing Registered Nurse Pronouncement (RNP). The findings included:Review of the hospital Discharge summary dated [DATE] identified Resident #1 was a Full Code (medical order directing staff to initiate all resuscitative measures, including CPR and advanced life support, if a resident has no pulse or respirations).Resident #1 was admitted to the facility on [DATE] with diagnoses which included Type II diabetes, acute kidney injury, and atherosclerotic heart…

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 review of the clinical record, facility documentation, facility policy, and interviews for one sampled resident (Resident #1) reviewed for wandering, the facility failed to ensure a wander assessment was completed accurately, and failed to ensure a resident with known wandering behaviors had a wander guard order in place for use, had the wander guard applied in accordance with the plan of care, and failed to ensure orders were initiated to check placement and function of a wander guard. The findings include: Based on review of the clinical record, facility documentation, facility policy, and interviews for one sampled resident (Resident #1) reviewed for wandering, the facility failed to ensure a wander assessment was completed accurately, and failed to ensure a resident with known wandering behaviors had a wander guard order in place for use, had the wander guard applied in accordance with the plan of care, and failed to ensure orders were initiated to check placement and function of a wander guard. The…

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

Based on observations, review of facility policy, and interviews for one of two shower rooms, the facility failed to ensure the shower/bathroom was free of odors and failed to ensure that dirty linen carts were not stored in the shower/bathroom where clean linen is stored. The findings include: Observation on 10/23/2023 at 11:45 AM of the 3rd floor bath/shower room (Windsor Unit) identified the room had a strong smell of urine and soiled laundry. The room also contained four wheelchairs, four laundry bins filled with soiled laundry/linens, a mechanical lift, an office chair, and two shower chairs. There was also a closet that contained clean briefs, a separate toilet room that was unflushed and appeared to contain feces, the floor around the toilet also appeared to be soiled. Observation on 10/24/23 at 9:00 AM of the 3rd floor bath/shower room (Windsor) identified three laundry bins containing soiled linen, and a garbage can less than a quarter full. The toilet was clean but there was an odor of urine and soiled linen. Interview on 10/24/23 at 9:40 AM with NA#3 indicated that dirty…

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 clinical record reviews, review of facility documentation, review of facility policy and interviews for four sampled residents (Resident #12, #21, #27 and #28) who had physician's orders for controlled medications, the facility failed to ensure resident specific controlled medications were not borrowed and administered to other residents. The findings include: Observation during the medication storage review on the third floor with LPN #6 on 10/26/23 at 2:00 PM of medication cart #2 identified the Controlled Substance and Disposition Records for Residents #12 and #21 contained entries indicating that their medications were borrowed for other residents. Interview at the time of the observation with LPN #6 identified that she was directed to borrow from another resident when Residents #11 and #107 did not have any medication available. Resident #12's diagnoses included chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, type 2 diabetes, chronic kidney disease, anxiety,…

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, clinical record reviews, facility policy review and interviews for eight sampled residents (Residents #1, #10, #11, #13, #46, #52, #58, and #86) reviewed for oxygen administration and respiratory treatments, the facility failed to label and date oxygen tubing and failed to store nebulizer mask, oxygen and nebulizer tubing appropriately to prevent contamination and failed to follow the physician's orders for the correct oxygen setting The findings include: 1. Resident #1 's diagnoses included chronic obstructive pulmonary disease, heart failure, and cerebral infarction. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact, and required extensive assistance for bed mobility, toileting and was totally dependent for transfers. A physician's order dated 2/15/23 directed to change oxygen tubing weekly, every Saturday night, using a label with date and initials. Treatment administration record dated 10/21/23, identified the oxygen tubing 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.

Based on observations, facility documentation, facility policy and interviews for 1 of 2 sampled nourishment room refrigerators the facility failed to accurately check temperature and identify that the temperature that was tracked was too high per safe food storage parameters. The findings include: Observation on 10/25/23 at 10:25AM of the 2nd floor Nourishment Refrigerator identified no temperature was tracked for 10/25/23. The temperature of the refrigerator was set at 42 degrees and no thermometer was located. Interview on 10/25/23 at 10:30 AM with Dietary Assistant #1 identified that housekeeping is responsible for taking the temperature and that there should be a thermometer present, however none was located. Observation on 10/26/23 at 9:00AM of the temperature log identified no temperature was written in for 10/25/23 for the second floor Nourishment Refrigerator. The temperature was still set to 42 degrees. Interview with Housekeeper #1 on 10/26/23 at 9:45 AM identified that the temperature was recorded by opening the nourishment refrigerator on the 2nd floor hitting 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 clinical record review, facility documentation review, facility policy review, and interviews for one of three Residents (Resident #1) reviewed for accidents, the facility failed to ensure adequate supervision for a resident identified at risk for wandering. The findings include: Review of the hospital Discharge summary dated [DATE] identified Resident #1 was seen for evaluation of chest pain after Resident #1 eloped from his/her home during the middle of the night and was discharged from the hospital to a skilled nursing facility. Resident #1 was admitted to the facility with diagnoses that included dementia, visual hallucinations, and delusional disorders. Clinical record review identified Resident #1 had a court appointed Conservator of Person and Estate. A physician order dated 7/1/2023 directed transfers and ambulation inside room independent without assistive device and ambulate in hallway with supervision without assistive device. Additional order dated 7/1/2023 directed use of wanderguard…

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 review of facility documentation, the facility failed to maintain the kitchen in a clean and sanitary manner. The findings include: A tour of the kitchen with the Food Service Director (FSD) on 8/16/21 at 10:27 A.M. and the following was identified: 1. The kitchen exhaust hood, located over the food preparation area was coated with thick and grimy dust material 2. The juice cooler shelves sides and bottom were noted with thick caked on dried brown substance. 3. The exhaust fan in the window was noted to be on and noted with coated thick layer of dust that adhered to the wiring vent and wires. Interview with FSD on 8/16/21 at 10:27 A.M. identified the kitchen exhaust hood was last cleaned on 3/17/21 and is scheduled to clean every six months but will be cleaned more frequently as needed going forward. The hood cleaning company was called and scheduled cleaning on 8/19/21. Further, interview with FSD identified the cook is responsible for cleaning the refrigerators during their shift and any spills should be cleaned immediately. The FSD…

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, review of the clinical record, facility documentation, facility policy, and interviews for one sampled resident, (Resident #42) reviewed for positioning, the facility failed to develop and implement a comprehensive person-centered plan of care for positioning. The findings include: Resident #42 was admitted to the facility with diagnoses that included [NAME] Pick Disease, apraxia and cerebellar ataxia. An Occupational therapy note dated 8/25/20 identified the resident was referred for OT for custom wheelchair delivery, assessment of seating and positioning, adjustments, modifications and staff training. Skilled therapy services are medically necessary in order to address deficits, improve quality of life, and assist patient in returning to prior level of function. The new custom wheelchair included : headrest, Roho cushion, pelvic positioning belt with harness type front support, left side hemi tray, added right side hemi tray and non elevating bilateral leg rests. The care plan for 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 observation, review of the clinical record, facility policy, and interviews for one of two residents (Resident #101) reviewed for respiratory care, the facility failed to ensure an order was obtained for oxygen and that the resident's oxygen tubing was dated. The findings include: Resident #101 was admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. The hospital Discharge summary dated [DATE] identified chronic obstructive pulmonary disease on 2 liters of oxygen at baseline. The nursing admission note dated 7/28/21 indicted oxygen saturation of 91% on 2 liters via nasal cannula. Subsequent nursing notes indicated continued use of the oxygen. The care plans dated 7/29/21 identified a self-care deficit related to limited mobility and congestive heart failure. Intervention includes to provide the assistance of one staff with rolling walker while on O2 at 2 liters. The admission MDS assessment dated [DATE] identified 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 observation, review of the clinical record, facility policy and interviews for one of two residents observed during a blood sugar collection via a glucometer for (Resident #15), the facility failed to implement infection control practices related to use of gloves. The findings include: Resident #15's diagnoses included type 2 diabetes mellitus with hyperglycemia, heart failure and dementia. The admission Minimum Data Set assessment dated [DATE] identified Resident #15 had severely impaired cognition and diabetes mellitus, required extensive assistance with mobility, dressing, toilet use, personal hygiene and total dependence for bathing. The care plan dated 6/8/21 identified Resident #15 has diabetes mellitus. Interventions directed staff to monitor the resident, to document and report any signs and symptoms of infection to any open areas such as redness, pain, heat, swelling and/or pus formation. The physician's order dated 8/5/21 directed staff to obtain finger stick blood sugar before meals and at…

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, review of the clinical record and policy and/or procedures and interviews for one sampled resident reviewed for self-administration of a medication (Resident #1), the facility failed to ensure a medication was administered in accordance with professional standards.The findings include: Resident #1 diagnoses included Chronic Obstructive Pulmonary (COPD), disease, nicotine dependence and anxiety. An admission MDS assessment dated [DATE] identified the resident as cognitively intact requiring supervision for most and/or extensive assistance from staff for some activities of daily living. The RCP updated on 4/17/19 noted behaviors secondary to medication adjustments, pain and anxiety for the focus. Interventions included : to administer medications as ordered, monitor and/or document for side effects and effectiveness. A physician's orders for April 2019 directed Ipratroplum-Albuterol Solution 0.5-2.5 (3mg /3ml) inhale orally four times a day for COPD. The nursing-medication…

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, review of the clinical record and interviews for one sampled resident who required a nebulizer treatment (Resident #1), the facility failed to ensure the medication was administered in accordance to physician's orders .The findings include: Resident #1 diagnoses included Chronic Obstructive Pulmonary (COPD), disease, nicotine dependence and anxiety. An admission MDS assessment dated [DATE] identified the resident as cognitively intact requiring supervision for most and/or extensive assistance from staff for some activities of daily living. The RCP updated on 4/17/19 noted behaviors secondary to medication adjustments, pain and anxiety for the focus. Interventions included: to administer medications as ordered, monitor and/or document for side effects and effectiveness. A physician's orders for April 2019 directed Ipratroplum-Albuterol Solution 0.5-2.5 (3mg /3ml) inhale orally four times a day for COPD. The nursing-medication self-administration assessment dated [DATE] identified in part,…

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.