Complete Care At Fox Hill

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 three (3) of six (6) residents (Resident #2, #3 and #4) reviewed for oxygen, the facility failed to ensure the residents' care plan included oxygen use per facility policy. The findings include: 1. Resident #2 was admitted to the facility with diagnoses that included acute respiratory failure and diastolic heart failure. The nursing admissions assessment dated [DATE] identified Resident #2 had oxygen at 1 liter per minute via nasal cannula. A physician's order dated 4/29/23 directed oxygen via nasal cannula 1 to 4 liters to maintain an oxygen saturation greater than ninety (90) percent. The Resident Care Plan (RCP) dated 4/29/23 identified Resident #2 had an ADL self-care performance deficit related to activity intolerance, fatigue and limited mobility. Interventions included to provide Resident #2 with limited assist of one staff for bed mobility and staff assistance with personal hygiene and oral…

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 (1) of two (2) residents (Resident #2) reviewed for facility discharge, the facility failed to provide a medically necessary walker for a resident upon discharge. The findings include: Resident #2 was admitted to the facility with diagnoses that included acute respiratory failure and congestive heart failure. The care plan dated 4/29/23 identified Resident #2 had the potential for discharge. Interventions included to evaluate discharge planning needs taking into consideration care plans, resident/patient goals, cognitive skills, functional mobility and need for assistive devices. The occupational therapy discharge summary for dates of service 5/1/23 - 5/12/23 identified Resident #2 demonstrated an increase in active tolerance and balance using the walker for mobility. The physical therapy discharge summary for dates of service 5/1/23 - 5/12/23 identified the discharge recommendations were for an assistive…

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 policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for hospitalizations, the facility failed to ensure the resident, who was admitted with multiple cardiac diagnoses and an internal cardiac defibrillator (a battery powered device that corrects irregular heart rhythms), followed up with cardiology per hospital discharge paperwork and physician's order. The findings include: Resident #1's diagnoses included ventricular tachycardia (an abnormal heart rhythm that causes the heart to beat too fast in the lower chambers to pump well and the body doesn't receive enough oxygenated blood), congestive heart failure (heart doesn't pump blood adequately to the body), hypertensive heart disease with heart failure (high blood pressure that damages the heart muscle over time leading to the inability of the heart to pump blood to the body effectively) and presence of an automatic implantable cardiac defibrillator. The admission Minimum Data Set (MDS)…

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, review of facility documentation, and interviews for 2 of 5 residents (Resident #27 and 83) reviewed for dining, the facility failed to ensure a dignified dining experience when breakfast was served and utensils were not provided to residents for 35 minutes, and for 3 of 5 residents (Resident #54, 63, and 67) reviewed for dining, the facility failed to ensure a dignified dining as the necessary assistance for residents who were dependent for eating was not provided, and for 1 of 2 residents (Resident #22) reviewed for urinary devices, the facility failed to ensure the urinary device had a privacy cover for dignity. The findings include: 1. Resident #27 was admitted to the facility in November 2023, with diagnoses which included dementia with agitation, dysphagia, diabetes, dysarthria and anarthria, and traumatic brain injury. The care plan dated 2/15/24 identified Resident #27 has an ADL self-care performance deficit related to activity intolerance, dementia,…

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 review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to ensure sufficient nurse staffing levels to care for residents' needs. The findings include: Interview with Resident #14 on 5/19/24 at 9:00 AM indicated that his/her shower day was scheduled for Tuesdays. On Tuesday 5/14/24 he/she was out of the facility for an appointment and upon return the staff informed him/her that a shower would have to be given on Wednesday, instead. Resident #14 identified that on Wednesday the nurse indicated that his/her shower was scheduled for Tuesday, and a shower would not be given on Wednesday. Interview with NA # 3 on 5/21/24 at 8:40 AM indicated that on 5/14/24 she was assigned to Resident #14 but did not give Resident #14 a shower due to short staffing. NA #3 further indicated that she was the only nursing assistant on that unit, so she did not have time to give showers. Interview with NA #7 on 5/21/24 at 11:57 AM identified that staffing at the facility has been terrible, especially on the weekends. NA #7 further identified that…

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, facility policy, and interviews, the facility failed to ensure dietary staff were wearing beard restraints, opened food and beverage items in the refrigerator were dated, the kitchen refrigerators were free of employee's personal beverages, and frozen food items were properly sealed. The findings include: 1.During an initial tour of the facility kitchen on 5/19/24 from 6:58 AM through 7:40 AM with cook #1, the following were identified: a. Observation of dietary aide #2 and cook #1 identified that they were without the benefit of a beard restraint while prepping for breakfast service. Interview with dietary aide #2 identified that he usually wears a beard restraint; today he was unable to obtain a beard restraint because they were stored in the food service manager's office and the office door was locked. Dietary Aide #2 indicated that he would not have access to a beard restraint until the manager arrived. Interview with cook #1 identified that this was his first day at the facility, as he was covering for the facility's full-time morning cook. [NAME] #1…

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, facility documentation, facility policy, and interviews, the facility failed to ensure ongoing surveillance of staff/resident COVID-19 testing was maintained, failed to ensure a nurse aide performed hand hygiene after exiting the room of a resident on contact precautions, and failed to ensure the resident-care equipment was sanitized upon leaving the room of a resident on contact precautions. The findings include: 1.A request was made on 5/20/24 to the facility to provide documentation identifying surveillance of staff and resident COVID-19 testing. Interview with the Infection Control Nurse (RN) #2 on 5/20/24 at 10:00 AM identified that the COVID-19 staff and resident testing logs were last updated in September 2023, but she would update the logs with information from the current outbreak, which began on 5/12/24. RN #2 indicated that prior to this outbreak, there had been no recent reports of staff having Covid-like symptoms and therefore no staff testing had been completed, except for one nursing staff member who reported a positive COVID test, earlier in 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 review of the clinical record, facility documentation, facility policy, and interviews the facility failed to ensure 3 of 5 residents (#75, 79, and #88) were provided with education and consented to receive the COVID-19 vaccine and failed to ensure 2 of 5 residents (Resident # 62 and 80) were provided education about the COVID-19 vaccination and consented or refused to receive the COVID-19 vaccine. The findings include: 1.Resident #75's immunization record identified the COVID-19 vaccine additional dose/booster was last administered on 1/5/24. Resident #75's clinical record failed to show that he/she was provided with education on the COVID-19 vaccine or provided consent. 2.Resident #79's immunization record identified the COVID-19 vaccine additional dose/booster was last administered on 1/5/24. Review of Resident #79's clinical record failed to show that he/she was provided with education on the COVID-19 vaccine or provided consent. 3. Resident #88's immunization record identified the COVID-19 vaccine additional dose/booster was last administered on 1/5/24. Resident #88's…

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 2 of 2 residents (Resident #100 and #160) reviewed for notify of change, the facility failed to notify the resident representative of the new physician orders and changes in condition for (Resident #100) and the facility failed to ensure the resident representative was notified of a change in skin condition, new antibiotic/diuretic medication orders, and blood work in a timely manner for (Resident #160). The findings include: 1. Resident #100 was admitted to the facility on [DATE] with diagnoses that included dementia and hypertension. The admission MDS assessment dated [DATE] identified Resident #100 had severely impaired cognition, was always incontinent of bowel and bladder and required total assistance with eating, toileting, bathing, dressing, and personal hygiene. Additionally, Resident #100 was at risk of developing a pressure ulcer. There were no pressure ulcers on admission. Furthermore, skin treatment…

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, review of facility documentation, and interviews for 1 of 4 residents (Resident # 7) reviewed for abuse, the facility failed to ensure the resident was free from abuse. The findings include. Resident #7 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, delusional disorders, and muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #7 had moderately impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance with turning from side to side and positioning. The MDS failed to identify any behaviors exhibited for Resident #7. The care plan dated June 2022 identified a concern with ADL assistance related to cellulitis, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and pressure ulcer left hip, osteomyelitis left thigh, and cognitive loss. Interventions included to provide assistance of 1 for toileting in bed, and an assist of 1…

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 2 of 4 residents (Resident # 7 and Resident #24) reviewed for abuse, the facility failed to implement their policy when investigating an allegation of abuse and an injury of unknown origin. The findings include. 1. Resident #7 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, delusional disorders, and muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #7 had moderately impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance with turning from side to side and positioning of body. The care plan dated June 2022 identified a concern with ADL assistance related to cellulitis, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and pressure ulcer left hip, osteomyelitis left thigh, and cognitive loss. Interventions included to provide assistance of 1 for toileting 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 review of the clinical record, facility documentation, facility policy, and interviews for 3 of 4 residents (Resident # 7, Resident #24, Resident #25) reviewed for abuse, the facility failed to report an allegation of abuse, failed to report an injury of unknown origin, and a fall from a mechanical lift to the state agency in a timely manner. The findings include. 1. Resident #7 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, delusional disorders, and muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #7 had moderately impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance with turning from side to side and positioning of body. The care plan dated June 2022 identified a concern with ADL assistance related to cellulitis, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and pressure ulcer left hip, osteomyelitis left thigh, and cognitive loss.…

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 1 of 4 residents (Resident # 7) reviewed for abuse, the facility failed to investigate an allegation of abuse in a timely manner and 1 of 3 residents (Resident #100) reviewed for pressure ulcer, the facility failed to conduct an investigation for an injury of unknown origin. The findings include. 1. Resident #7 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, delusional disorders, and muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #7 had moderately impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance with turning from side to side and positioning of body. The care plan dated 6/6/22 identified a concern with ADL assistance related to cellulitis, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and pressure ulcer left hip, osteomyelitis left thigh, 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 review of the clinical record, facility documentation review and interviews for 1 of 5 residents (Resident #89) reviewed for Preadmission Screening and Resident Reviews (PASRR), the facility failed to ensure a resident with an intellectual disability had a Level of Care rescreen or PASRR level II, completed timely. The findings include: Resident #89 was admitted to the facility on [DATE] with a diagnosis that included unspecified lack of expected normal physiological development in childhood. The admission MDS assessment dated [DATE] identified Resident #89 had moderately impaired cognition, had been evaluated by Level II PASRR, and was determined to have a Level II PASRR condition of mental retardation. The care plan dated 1/18/24 identified Resident #89 met PASRR II Level of determination secondary to a diagnosis of intellectual disability. Interventions included coordinating and/or informing the appropriate agency to conduct the PASRR evaluation and obtain results if it is learned that the PASRR 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #210) reviewed for respiratory care, the facility failed to ensure a baseline care plan reflected the use of oxygen. The findings include: Resident #210 was admitted to the facility on [DATE] with diagnoses that included pneumonia, acute respiratory failure, asthma exacerbation, and sepsis. The Hospital Discharge summary dated [DATE] identified Resident #210 had a diagnosis of pleural effusion, asthma exacerbation, and acute hypoxic respiratory failure. Resident #210 will continue to use supplemental oxygen and wean as tolerated as resident continues to improve. The admission Nursing assessment dated [DATE] identified Resident #210 was admitted from the hospital on oxygen at 2 liters per minute via nasal cannula. The admission MDS assessment dated [DATE] identified Resident #210 had intact cognition and requires total assistance with toileting and dressing, and moderate assistance with…

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, and facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #22) reviewed for accidents, the facility failed to ensure a comprehensive care plan was developed and implemented for a resident who experienced multiple falls. The findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included urinary retention, obstructive uropathy, benign prostatic hyperplasia, and depression. The admission MDS assessment dated [DATE] identified Resident #22 had moderately impaired cognition, requires maximum assistance with toileting, bathing, showering, dressing upper and lower body, and personal hygiene. Resident #22 had no falls prior to admission in the last 6 months. Resident #22 had 1 fall with no injury since admission. The care plan dated 3/27/24 identified resident was at risk for falls Interventions included to offer toileting after lunch, encourage resident to use call light, and provide verbal cues 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 review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents and (Resident #14 and Resident #160) reviewed for activities of daily living, the facility failed to provide weekly showers. The findings include: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses that included right ankle fracture and diabetes. The admission MDS assessment dated [DATE] identified Resident #14 had intact cognition and requires moderate assistance with bathing, showering, and dressing. The April 2024 care plan identified activities of daily living. Interventions included providing extensive assistance with bathing. Additionally, it was important for Resident #14 to have showers per his/her preference. The Unit Shower Assignment Sheet (not dated) identified Resident #14 was to be offered showers on Tuesdays 3:00 PM -11:00 PM shift. The nurses note written by LPN #3 on 5/15/2024 at 11:31 PM indicated that Resident #14 had missed shower date on 5/14/24. Interview…

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 2 of 3 residents (Resident #22) reviewed for reviewed for accidents, the facility failed to ensure neurological assessments after falls were completed per facility policy and 1 of 3 resident's reviewed for pressure ulcers, (Resident #100) the facility failed to perform and RN assessment following the discovery of a new bruise. The findings include: 1. Resident #22 was admitted on [DATE] with diagnoses that included urinary retention, obstructive uropathy, benign prostatic hyperplasia, and depression. A physician order dated 3/11/24 indicated Resident #22 was to wear non-skid footwear for safety. The admission MDS assessment dated [DATE] identified Resident #22 had moderately impaired cognition, requires maximum assistance with toileting, bathing, showering, dressing upper and lower body, and personal hygiene. Resident #22 had no falls prior to admission in the last 6 months. Resident #22 had 1 fall with no injury…

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 2 of 3 residents (Resident #95 and #100) reviewed for pressure ulcer, the facility failed ensure the air mattress settings were per the manufacturer recommendations and failed to have a treatment in place for a new facility acquired pressure ulcer. The findings include: 1. Resident #95 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease, adult failure to thrive, and osteoporosis. A physician's order dated 4/3/24 directed to apply air mattress to bed, assess function, and integrity every shift. The admission MDS assessment dated [DATE] identified Resident #95 had intact cognition, was always incontinent of bowel and bladder and required total assistance with toileting, shower/bath, dressing, and personal hygiene. Additionally, Resident #95 had a stage 3 pressure ulcer to the sacrum. The care plan dated 4/16/24 identified Resident #95 as at risk for skin breakdown related…

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 1 of 2 residents (Resident #210) reviewed for respiratory care, the facility failed to ensure there was a physician order for administration of oxygen and the oxygen tubing and humidifier canister were not labeled and dated when changed. The findings include: Hospital Discharge summary dated [DATE] identified Resident #210 had a diagnosis of pleural effusion, asthma exacerbation, and acute hypoxic respiratory failure. Resident #210 will continue to use supplemental oxygen and wean as tolerated as resident continues to improve. Resident #210 was admitted to the facility on [DATE] with diagnoses that included pneumonia, acute respiratory failure, asthma exacerbation, and sepsis. The admission Nursing assessment dated [DATE] identified Resident #210 was admitted from the hospital on oxygen at 2 liters per minute via nasal cannula. Review of the physician's order dated 5/9/24 until 5/20/24 did not reflect 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #212) reviewed for pain management, facility failed to ensure the pain management medication was available to meet residents preference and provided in a timely manner. The findings include: Resident #212 was admitted to the facility on [DATE] with diagnoses that included right femur fracture, right hip cemented hemiarthroplasty. hypertension, and pain management. The hospital Discharge summary dated [DATE] identified Resident #212 was receiving Naproxen 500 mg twice a day last dose given 5/17/24 at 2:41 PM. The nursing admission assessment completed by RN #5 dated 5/17/24 at 9:42 PM identified Resident #212 as alert and oriented to person, place, time, and situation. RN #5 noted Resident #212 was receiving scheduled pain medications, and prn (as needed) pain medications, and non-medication interventions for pain. RN #5 noted Resident stated pain was almost always constant, occasionally…

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 1 of 5 residents (Resident #14) reviewed for unnecessary medications, the facility failed to ensure a pharmacy medication review was addressed in a timely manner. The findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses that included right ankle fracture and diabetes. A physician's order dated 4/14/24 directed to inject Humalog insulin 100 units per 1 ml per sliding scale if blood sugar was 150-200 give 2 units, 201-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, 351 or greater give 10 units and notify the physician or APRN. If blood sugar is less than 70 notify physician. The care plan dated 4/16/24 does not reflect Resident #14 was diabetic and receiving insulin. The admission MDS assessment dated [DATE] identified Resident #14 had intact cognition and requires a high risk drug insulin. A pharmacy progress note dated 5/4/2024 at 9:50 AM identified there was 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 clinical record review, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for activities of daily living, the facility failed to ensure showers were documented. The findings include: Resident #1's diagnoses included chronic kidney disease, chronic obstructive pulmonary disease, diabetes, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of twelve out of fifteen, indicative of moderate cognitive impairment and required partial/moderate assistance with ADL care. The Resident Care Plan (RCP) dated 2/14/24 identified risk of distressed/fluctuating mood symptoms related to depressive disorder as evidenced by refusal of care and/or showers. Interventions directed re-approach resident after refusal of care or changing of clothing. Review of the documentation survey report for February, March and through April 25, 2024 indicated that 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 clinical record reviews, review of facility documentation, review of facility policies and interviews for ten sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8. #9, and #10) who received a narcotic medication for pain, the facility failed to prevent the misappropriation of the residents' controlled narcotic medications by a licensed nurse. The findings include: 1. Resident #1's diagnoses included cerebral palsy, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic pain, and muscle weakness. The Resident Care Plan (RCP) dated 6/8/23 identified chronic pain. Interventions directed to administer pain medications per order and notify the physician if the goal was not met with the medication regime. A physician's order dated 10/10/23 directed Oxycodone HCL 5 milligrams (mg) take two (2) tablets by mouth every four (4) hours as needed for severe pain and Oxycodone HCL 5 mg take one (1) tablet every four (4) hours as needed for mild to moderate pain with a discontinuation date of 11/17/23. A physician's order dated 11/17/23…

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.

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 resident (Resident #85) reviewed for advanced directives, the facility failed to ensure the resident was provided an opportunity to formulate advance directive timely. The findings include: Resident #85 was admitted on [DATE] with diagnoses that included adult failure to thrive, chronic kidney disease, coagulation defect, chronic atrial fibrillation, hypothyroidism, dysphagia and hypertension. Review of the physician's orders dated [DATE] failed to identify an order for Resident's #85's code status. Review of the clinical record identified Resident #85 was responsible for him/herself, and had an emergency contact (Person #1) listed in the record. Review failed to identify the record included a living will and failed to identify that a discussion was held with Resident #85 or his/her emergency contact (Person #1) regarding Advanced Directives and code status. The admission Minimum Data Set (MDS)…

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 review, and interviews for dietary review, the facility failed to ensure food preparation areas were maintained in a clean manner and freezers were free of ice build-up. The findings include: Observations and interview during a tour of the kitchen with the Food Service Director (FSD) on 11/3/2021 at 10:28 AM the following was identified: 1. Debris, cups, lids and utensils were observed on the floor under the food prep table in the center of the kitchen, that was currently in use by dietary staff for food preparation. 2. A thick layer of ice buildup was noted on the upper aspect of the door frame of the two-door freezer currently in use with food stored inside. 3. A floor fan in dishwasher area (not in use) was observed plugged in and was coated with a thick layer of dust, grease and hair adhered to the fan blades, fan cover and the attached stand. This fan was also noted to be pointed directly at the drying area where cleane flatware and utensils were kept. Interview with FSD on 11/3/2021 at 10:30 AM identified the floors in the kitchen…

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 On 11/03/21 during document review, the surveyors were not provided with documentation from the facility, to show that the facility's water management committee annual sign off and review of the water management book had been conducted along with documented meetings of the facility Water Management Committee. Based on observations, facility policy review, and interviews for infection control review, the facility failed to ensure staff used Personal Protective Equipment (PPE) in accordance with accepted guidelines for residents on precautions. The findings include: Resident #201 was admitted on [DATE]. Physician orders date 10/30/2021 directed a 10-day observation for COVID-19. Resident #151 was admitted on [DATE]. Physician orders date 11/6/2021 directed a 10-day observation for COVID-19. Observations of the admission Observation Unit identified some rooms had isolation precautions signs posted at the door to alert staff/visitors to wear PPE, and some rooms had no signs posted. Observations of the admission…

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.