Ascension Living Carroll Manor

Based on record review and staff interviews, facility staff failed to have sufficient nursing staff to provide nursing and related services to assure resident safety based on the Payroll Based Journal (PBJ). The census on the first day of the survey was 175. The findings included: During a Resident Council meeting on 08/27/24, residents complained of low staffing on the weekends causing a delay in getting activities of daily living (ADL) care and services. One resident stated, It's a ghost town in here. Another resident stated, There's hardly any staff here. When I call, they eventually come. They aren't deliberately taking their time, it's just not enough staff to go around. Review of the staffing data submitted via the PBJ system revealed that the facility triggered for excessively low weekend staffing for quarter 2, 01/01/24 to 03/31/24. Review of the staffing for weekends dates of 01/12/24 - 01/15/24, 02/02/24 - 02/04/24, 03/12/24 - 03/15/24, and 03/29/24 - 03/31/24 revealed that the facility failed to provide sufficient nurse staffing creating the risk for the potential 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, policy review and staff interviews, for one (1) out of 50 sampled residents, facility staff failed to ensure that licensed nurses had the specific competencies, and skill sets necessary to meet resident needs; and for failed to ensure that licensed nurses met the professional standards of quality for medication administration in three (3) out of seven (7) observations. Resident #64. The findings included: According to the manufacturer's instructions: - BREO (inhaler medication used to treat Asthma/Chronic Obstructive Pulmonary Disease/COPD) can cause serious side effects, including fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using BREO to help reduce your chance of getting thrush. - If you are using other inhalers at the same time, wait at least 1 minute between the use of each 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.

Based on observations, policy review and staff interviews, facility staff failed to ensure that the established a system for the reconciliation of controlled medications was followed. The findings included: Review of the facility's Controlled Substances policy dated 06/2022 documented: - An individual resident-controlled substance record is made for each resident's medication. - This record contains information to include name of resident, name and strength of the medication, time of administration and signature of nurse administering the medication. - The associate administering medications, who confirmed count at the start of the shift, will maintain the keys to controlled substance. Keys are passed from associate to associate at the time of count. - Associates are to count controlled mediations at the end of each shift. The associate coming on duty and the associate going off duty are to make count together. 1. During a controlled substance reconciliation on the 5th floor, of medication cart 2, with Employee # 8 (LPN) on 08/25/24 at 6:03 AM, it was observed that the [Facility…

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

Based on observations and interview, facility staff failed to store and distribute foods under sanitary condition as evidenced by food items such as one (1) of one (1) container of mashed potatoes, and one (1) of one (1) open pack of yellow cheese that were not labeled or dated in the walk-in refrigerator, one (1) of one (1) container of pineapple chunks, one (1) of one container of blueberries, and one (1) of one (1) container of canned peaches, that were expired in the walk-in refrigerator, two (2) of two (2) convection ovens that were in need of cleaning, and inadequate breakfast food temperatures from the second floor kitchen. The findings include: 1.Cooked food such as mashed potatoes and ready-to-eat food such as an open pack of yellow cheese stored in one (1) of one (1) walk-in refrigerator were not labeled or dated. 2.Ready-to-eat foods such as a container of pineapple chunks, a container of blueberries, and a container of canned peaches were stored beyond their expiration dated of August 21, and August 24, 2024, in the walk-in refrigerator. 3.Two (2) of two (2) convection…

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 interview, facility staff failed to store and distribute foods under sanitary condition as evidenced by food items such as one (1) of one (1) container of mashed potatoes, and one (1) of one (1) open pack of yellow cheese that were not labeled or dated in the walk-in refrigerator, one (1) of one (1) container of pineapple chunks, one (1) of one container of blueberries, and one (1) of one (1) container of canned peaches, that were expired in the walk-in refrigerator, two (2) of two (2) convection ovens that were in need of cleaning, and three (3) of seven (7) hot food items that tested below 140 degrees Fahrenheit (°) during a food temperature assessment on the second floor kitchen on August 25, 2024. The findings include: 1.Cooked food such as mashed potatoes and ready-to-eat food such as an open pack of yellow cheese stored in one (1) of one (1) walk-in refrigerator were not labeled or dated. 2.Ready-to-eat foods such as a container of pineapple chunks, a container of blueberries, and a container of canned peaches were stored beyond their expiration 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 record review, and resident and staff interviews for one (1) of 50 sampled residents, the facility staff failed to notify a resident's physician of the need to start treatment for a resident rash with newly opened lesions. Resident #19. The findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses that included: Congestive Heart Failure, Chronic Atrial Fibrillation, Unilateral Primary Generalized Osteoarthritis, Lymphedema, Presence of Automatic Implantable Cardiac Defibrillator, Diabetes Mellitus, and Difficulty in Walking. An observation on 08/27/24 at 01:33 PM showed Resident #19 lying on his back in bed. The bed linen was pulled up to the resident ' s chest with his upper extremities exposed. A rash with clusters of dry, intact blackhead pimples/lesions was on the resident's outer left upper extremity. During a face-to-face interview on 08/27/24 at 01:33 PM, the resident stated that a rash was also on his outer right thigh. He added that the rashes had been on his arm 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 observations, record reviews, and interview, the facility's staff failed to follow its Abuse policy regarding notifying the State Survey Agency immediately but no later than two hours of learning of an incident of abuse or neglect. In addition, the facility's staff failed to evaluate the resident's elopement risk 7 days after admission as per its Elopement policy. Subsequently, the resident had an elopement incident on 06/28/24. The findings included: Resident #165 was admitted to the facility on [DATE] with multiple diagnoses to include Major Depression, Syncope, and Disorientation. 1.The Abuse Prevention policy with a revision date of 06/20 documented in part, Neglect-means the failure of the community, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain mental anguish or emotional distress .Investigation-the community will investigate and report any allegations of abuse [neglect] within timeframes as required by federal,…

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 interview, the facility's staff failed to notify the State Survey Agency of the elopement (neglect) of a resident on 06/28/24 immediately or within two hours of the occurrence. As evidenced by a State Survey Agency Facility Reported Incident form (DC~12936) that documented notification occurred at 3:34 AM on 06/29/24 (6 hours after staff first learned of the incident). The findings included: The Abuse Prevention Policy with a revision date of 06/20 documented in part, Neglect-means the failure of the community, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain mental anguish or emotional distress .Investigation-the community will investigate and report any allegations of abuse [neglect] within timeframes as required by federal, state, and local requirements . Resident #165 was admitted to the facility on [DATE] with multiple diagnoses to include Major Depression, Syncope, and Disorientation. A State…

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 resident and staff interviews for one (1) of 50, the facility staff failed to provide written notification to a resident, their representative, or the Ombudsman of the reasons for the resident ' s discharge to the hospital on [DATE]. Resident #425. The findings included: 1.) Resident #425 was admitted to the facility on [DATE] with diagnoses that included: Metabolic Encephalopathy, Adult Failure to Thrive, Atrial Fibrillation, Diabetes Mellitus Type 2, and Chronic Kidney Disease. A review of Resident #425 ' s medical record revealed the following: A face sheet that showed that Resident #425 had a representative. A review of Resident # 425 ' s admission record showed that the Resident had no hospital admissions from 01/30/23 until 04/03/24. A physician's order dated 04/03/24 at 11:18 AM directed: Send pt (patient) to ED (Emergency Department) via 911 for AMS (altered mental status) AFTT (Adult failure to thrive). A Resident Transfer Form dated 04/03/24 at 12:24:18 PM by Employee # /LPN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews, for one (1) of 50 sampled residents facility staff failed to provide written notification of its bed hold policy and the number of bed hold days available to a resident who transferred from the facility to the hospital. Resident #425. The findings included: 1.) Resident #425 was admitted to the facility on [DATE] with diagnoses that included: Metabolic Encephalopathy, Adult Failure to Thrive, Atrial Fibrillation, Diabetes Mellitus Type 2, and Chronic Kidney Disease. A review of Resident #425 ' s medical record revealed the following: A face sheet showed that Resident #425 had a representative. A review of Resident # 425 ' s admission record showed that the Resident had no hospital admissions from 01/30/23 until 04/03/24. A Quarterly Minimum Data Set (MDS) for Resident #425 dated 03/26/24, revealed that facility staff coded the resident with a Brief Interview for Mental Status (BIMS) Summary Score was 5, indicating that the resident had severely impaired…

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 interview for one (1) of 50 sampled residents, facility staff failed to code a resident's quarterly Minimum Data Set Assessment accurately for diagnoses of Depression and Anxiety. Resident #104. The finding includes: 1.) Resident #104 was admitted to the facility on [DATE] with diagnoses that included: anxiety disorder unspecified; unspecified dementia, unspecified severity, without behavioral disturbance, Psychotic disturbance, mood disturbance, and anxiety; Major depressive recurrent. moderate; Major depressive disorder, single episode, severe without psychotic features; Paranoid personality. A review of Resident#104 's medical record showed the following: A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed no check mark documented in the boxes in Section G Active Diagnosis allotted for Anxiety Disorder and Depression. Both boxes next to Anxiety Disorder and Depression were left blank indicating not coded. The evidence showed that facility staff…

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 interview facility staff failed to update a resident's care plan with new goals and interventions following an allegation of resident-to-resident verbal abuse for two (2) residents. Residents' #27 and #132. The findings included: 1.) Resident #27 was admitted to the facility on [DATE] with multiple diagnoses that included: Traumatic Hip Fracture, Hypertension, Diabetes Mellitus Type 2 and Atrial Fibrillation. A review of Resident #27's medical record revealed: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '12,' indicating the resident was moderately impaired; Functional Abilities and Goals that documented: Setup or clean-up assistance with all Activities of Daily Living (ADLs), bed mobility, sit to stand, Chair/bed-to-chair transfer, toilet transfer and Walk 10 feet; uses a wheelchair for locomotion on and off the unit. A care plan dated 04/05/24 documented, Psychosocial…

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, policy review and staff interviews, facility staff failed to meet professional standards of quality in three (3) out of seven (7) medication administration observations. The findings included: According to the National Institute of Health (NIH): - It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. -Right patient- means ascertaining that the patient being treated is, in fact, the correct recipient for whom medication was prescribed. This is best practiced by nurses directly asking a patient to provide his or her full name aloud (if appropriate), checking medical wristbands for matching name and ID number as on a chart. - Depending on the unit that a patient may be in, some patients, may not wear wristbands or may have altered mentation to the point where they are unable to identify themselves correctly. In these instances, nurses are advised to confirm a patient's identity through alternative means 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 record review and staff interviews for (one) 1 of 50 sampled residents the facility staff failed to ensure that a resident received treatment and care in accordance with professional standards of practice, for using a full body sling (Hoyer) lift to transfer a resident from the resident ' s bed to the resident ' s wheelchair. Subsequently, the resident had a fall with injuries during a transfer. Resident #19. The findings included: The Food and Drug Administration ' s document entitled, Patient Lifts Safety Guide, recommended the following: Most lifts require two or more caregivers to safely operate lift and handle patient. (https://www.fda.gov/files/medical%20devices/published/Patient-Lifts-Safety-Guide.pdf) The Occupational Safety and Health (OSHA), Guidelines for Nursing Homes, under the section entitled: ' Identifying Problems and Implementing Solutions for Resident Lifting and Repositioning, ' recommended the following: For transfers to and from: Chair to Stretcher /(Same as Bed) [Figure 3.] .Can…

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 resident and staff interviews for one (1) of 50, the facility staff failed to ensure that a resident received proper treatment to maintain vision by failing to assist the resident with scheduling an ophthalmology appointment. Resident #55 The findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses that included: Non- Traumatic Brain Dysfunction, Peripheral Vascular Disease, Renal Insufficiency, Diabetes Mellitus, and Hemiplegia or Hemiparesis. An observation on 08/28/24 at 2:03 PM showed Resident #55 sitting in his wheelchair beside his bed in his room with the lights turned off. When asked if he had any problems with his vision, the resident stated that he had difficulty seeing. He added that he could recall when his last eye appointment was, and he needed an appointment with the ophthalmologist. He further added, that he wears glasses and had them at one time, but did not know what happened to them. A review of Resident #55 ' s medical record revealed…

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 the record review and staff interviews, for one (1) of 50 sampled residents, the facility staff failed to ensure a resident was assessed for pain management as per a physician order and professional standard of practice. (Resident #81). Findings included: According to National Institute of Health (NIH): - Assessment of pain is a critical step to providing good pain management. - Nurses working with patients with acute pain must select the appropriate elements of assessment for the current clinical situation. - The most critical aspect of pain assessment is that it is done on a regular basis (e.g., once a shift, every 2 hours) using a standard format. The assessment parameters should be explicitly directed. - To meet the patients' needs, pain should be reassessed after each intervention to evaluate the effect and determine whether modification is needed. The time frame for reassessment also should be directed. - Pain assessment should include intensity, location, and quality. - Pain assessment should be…

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 interview, for two (2) of 50 sampled residents the facility's staff failed to: ensure the pharmacist conducted a resident's monthly medication regimen; and provide documented evidence that a resident's medication irregularities identified by the pharmacist were reviewed and provide the rationale for not changing a resident ' s medication. (Residents #19 and #157) The findings included: A review of the Medication Regimen Review Nursing policy with a review date of 09/23 documented in part, The medication regimen of each resident is reviewed by a licensed pharmacist according to fedreal, stated, and local regulations . 1.Resident #157 was admitted on [DATE] with multiple diagnose including Vascular Dementia, Anxiety, Agitation, Unspecified Mood Disorder, and Paranoid Personality Disorder, Vitamin B Deficiency, Hypercholesterolemia, Chronic Back Pain. A review of a physician's order dated 11/22/23 instructed, Folic Acid 1mg (milligram) tablet po (by mouth) QD (every day) 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 and staff interviews, facility staff failed to ensure that the medication error rate was not five (5) percent or greater. The findings included: Seven (7) medication administration observations were conducted at the facility from 08/25/24 through 08/27/24. The total number of errors observed were four (4) out 31 opportunities, for error which equates to a medication error rate of 12.9%. During a telephone interview on 09/05/24 at approximately 2:30 PM, these findings were brought to the attention of Employee #1 (Administrator) and Employee #12 (Assistant Director of Nursing/ADON). The employees acknowledged the findings and made no additional comments. Cross Reference F658 and F726

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, facility staff failed to ensure that medications and biologicals, that were stored for use, were not expired and failed to ensure that medications were properly stored. The findings included: 1. During an observation of the 5th floor clean supply room on [DATE] at 6:16 AM, fourteen (14) Mesalt dressing packets (used to treat wounds with heavy discharge) were noted stored for use that had an expiration date of [DATE]. During a face-to-face interview at the time of the observation, Employee #8 (LPN) stated, Distribution department is responsible for stocking this room. 2. During an observation of the 2nd floor medication refrigerator on [DATE] at 7:00 AM, two (2) Pneumovax vaccines were stored for use that had an expiration date of [DATE]. During a face-to-face interview at the time of the observation, Employee #10 (LPN) stated, All nurses are responsible for checking the expiration date of the medications in the fridge. I did not check for any expiration dates for 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 record review, and resident and staff interviews for one (1) of 50, the facility staff failed to assist a resident with obtaining an appointment with the dentist for Resident #19. The findings included: A review of the facility ' s Dental Services policy approved on 01/2024 documented: 1. Oral health services are available to meet the resident ' s needs. 2. Routine and 24-hour emergency dental services are provided to our residents Resident #19 was admitted to the facility on [DATE] with diagnoses that included: Congestive Heart Failure, Chronic Atrial Fibrillation, Unilateral Primary Generalized Osteoarthritis, Lymphedema, Presence of Automatic Implantable Cardiac Defibrillator, Diabetes Mellitus, and Difficulty in Walking. A review of Resident #19 ' s medical record revealed the following: An admission MDS assessment dated [DATE] documented Resident#19 as having a BIMS of 15, indicating intact cognition. A care plan initiated on 09/30/21 documented, Category: Dental Care: [First Name of Resident #19]…

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 a review of the facility's records and a staff interview, the facility failed to comply with the State Regulation (22B DCMR sect. 3211.5) for daily staffing ratios,as evidenced by not providing the minimum daily average of four and one tenth (4.1) hours of direct nursing care per resident per day, with at least six tenths (0.6) hours being provided by a registered nurse for 12 of 12 sampled days. The findings included: A review of the facility's daily staffing sheets revealed the following: On 10/16/24 the facility's resident census was 182. In addition, residents received 3.5 hours of direct nursing care with .35 of those hours being provided by a registered nurse. On 10/18/24 the facility's resident census was 184. In addition, residents received 3.4 hours of direct nursing care with .26 of those hours being provided by a registered nurse. On 10/19/24 the facility's resident census was 184. In addition, residents received 3.1 hours of direct nursing care with .21 of those hours being provided by a registered nurse. On 10/20/24 the facility's resident census was 184. 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.

Based on record review and staff interview, facility staff failed to ensure that infection control policies and procedures were reviewed annually. The findings included: Review of the Infection Prevention and Control Program (IPCP) policy last approved 05/2023 documented: - The IPCP is based on the Facility Assessment and is reviewed annually and as needed. Review of the Infection Preventionist Policy dated 07/2023 documented: - The infection Preventionist is responsible for coordinating the implementation and updating of our established infection control policies and practices. Review of the Infection Prevention and Control Committee policy last approved on 01/2024 documented - Meet at least quarterly. - Functions: develop, recommend, review and set policies specific to infection prevention and control practices During a review of the facility's infection control policies and procedures on 08/26/24 at 2:40 PM, the following policies and procedures were noted to not have been reviewed within the last year: - Transmission-Based Precautions, last approved 05/2023, next review due…

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, for one (1) out of 50 sampled residents, facility staff failed to have documented evidence that they provided a resident or the resident's representative education regarding the benefits and potential side effects of the COVID-19 booster vaccine to either consent or refuse the immunization. Resident #160. The findings included: Resident #160 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia and Type 2 Diabetes. Review of the resident's medical record revealed the following: A face sheet that showed the resident had legal guardian. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff documented a Brief Interview for Mental Status (BIMS) summary score of 10, indicating moderately impaired cognitive status. During an observation of Resident #160 on 08/26/24 by the survey team, it was noted that the resident had audible wheezing and nasal congestion. The survey team alerted facility staff. Upon testing,…

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 interview, it was determined that facility staff failed to provide housekeeping services necessary to maintain a safe, and comfortable environment, as evidenced by privacy curtains that were hanging loose, detached from curtain hooks, in 75 of 192 residents' rooms. The findings include: During an environmental tour of the facility on May 19, 2023, between 9:15 AM and 11:30 AM, privacy curtains in residents' rooms were hanging loose off curtain tracks, and detached from curtain hooks on all occupied floors. The observations included: -Fifth floor: 35 of 48 residents' rooms; -Fourth floor: 18 of 48 resident's rooms; -Third floor: unoccupied; -Second floor: 17 of 48 residents' rooms; -First floor: five (5) of 48 residents' rooms. These observations were acknowledged by Employee #11 during a face-to-face interview on May 19, 2023, at approximately 2:00 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews for two (2) out of 41 sampled residents, facility staff failed to provide notification to resident representatives that included the facility's bed hold policy or the number of bed hold days available for each Resident when they transferred to the hospital. (Resident #94 and #139) 1. Resident #94 was admitted to the facility on [DATE] with diagnoses including: Cerebral Infarct, Metabolic Encephalopathy, Altered Mental Status, Generalized Muscle Weakness, and Age-Related Cognitive Decline. A review of Resident #94's medical record showed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] showing that the Resident had severely impaired cognition, exhibited trouble falling asleep or sleeping too much for 2-6 days poor appetite or overeating for 7-11 days, required extensive assistance for assisted daily living skills, (transfers. Eating, grooming, toileting, personal hygiene). A Nurses Note on 04/18/23 at 8:55 AM documented, .around 10:00 am resident('s) son came…

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 interview, the facility staff failed to have documented evidence that residents' representatives were provided with a copy of the Base Line Care Plan for two (2) of 41 sampled residents (Residents #28 and #323). Findings included: 1. Resident #28 was admitted to the facility on [DATE] with multiple diagnoses including Abnormalities of Gait Mobility, Repeated Falls, Pain in Right Hip, Sever Protein-Calorie Malnutrition. and Dementia. A review of Resident #28's face-sheet showed the resident had a legal guardian. A review of the resident's medical record revealed a baseline care plan dated 02/13/23. However, review of the progress notes from 02/13/23 to 02/23/23 lacked documented evidence that Resident #28's representative received a copy of the previously mentioned Baseline Care Plan. 2. Resident #323 was admitted to the facility on [DATE] with multiple diagnoses including Vascular Dementia, Type 2 Diabetes mellitus, and Chronic Kidney Disease Stage 3 . A review of Resident #323'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 record review and staff interview, for three (3) of 41 sampled residents, the facility staff failed to develop person-centered care plans with goals and interventions to address (1) a resident's choking incident, (2) a resident's recent right femur (hip) fracture and (3) a resident who had a UTI. (Residents #20, #28, and #139). The findings included: 1. Facility staff failed to update a care plan for a resident that included Resident #139's dysphagia and risk for aspiration after choking in the facility's first-floor dining room on 04/03/23. Resident #139 was admitted to the facility on [DATE] with diagnoses including: Alcohol Dependence with Alcohol-Induced Dementia, Delusional Disorders, Personal History of Other Mental and Behavioral Disorder, and Restlessness and Agitation. A review of Resident #139's medical record showed: A Nurses Note dated 04/02/23 at 4: 49 PM documented: During lunchtime, around 12:50 pm, I was in the dining room serving residents their meal and sitting with other residents.…

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 reviews and staff interviews for three (3) out of 41 residents, facility staff failed to update and revise person-centered care plans. (Residents #6, #375 and #35). The findings included: 1.Facility staff failed to update and revise the interventions on a Resident's person-centered care plan after the Resident had a second fall and sustained an injury. Resident #6. Resident #6 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD), Volume Overload, and Generalized Muscle Weakness. A Nurse's Note dated 03/28/23 at 3:41 pm documented: .At 11:30 nurse was called to [Resident #6's room] by assigned Certified Nurse Aide (CNA) that [Name of Resident #6] is on the floor. The nurse went to [pronoun] room and found Resident in a sitting position, leaning back on the commode .RN and nurse assessed the Resident; no apparent injury was noted .The Resident was encouraged to use the call light to call for help A Nurse'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 observation, record review, and interviews, facility staff failed to adequately monitor and provide supervision to a Resident who was a smoker. Resident #136. Resident #136 was admitted to the facility from the hospital on [DATE] with diagnoses including: Hemiplegia following Cerebral Infarct, Atrial Fibrillation, Essential Hypertension, Abnormal Levels of Serum Enzymes, and Anxiety Disorders. A review of Resident #136's medical record revealed the following: A Hospital Discharge summary dated [DATE] that documented Discharge Diagnosis: Smoking Hx (History) .Hospital Course: History of cigarette smoking- Nicotine patch d/c discharge as patient refusing . An admission assessment dated [DATE] at 7:51 pm documented that the Resident had no desire to smoke: .Smoking Evaluation: Resident desires to smoke(?): No. Of note, Resident #136's medical record lacked documented evidence that facility staff conducted any subsequent smoking evaluations/assessments for the Resident after admission. A review 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, medical record review, and staff interview for one (1) of 41 sampled residents, facility staff failed to obtain physician orders that include the resident ' s use of continuous oxygen therapy. Resident #143. Findings included: Resident #143 was admitted to the facility on [DATE] with diagnoses that include Heart Failure, Pulmonary Hypertension, Respiratory Failure, Hyperlipidemia, Peripheral Vascular Disease, Anemia, Chronic Kidney Disease, and Dementia. Review of the Quarterly Minimum Data Set, dated [DATE] showed that under Section C [Cognition] resident is coded as 7 to indicate severely impaired cognition. Review of the pulmonary Critical Care Associates consultation report dated 04/20/2023 at 12:18 PM showed Very elderly woman brought from [facility name] in wheelchair without oxygen alert, conversant, breathing regularly; lungs good airflow. A/P [action/plan] Chronic Obstructive Pulmonary Disease [COPD], use face mask for nebulizer machine and for inhalers for better delivery.…

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 for one (1) of four (4) nursing units, the facility staff failed to ensure the system used for an acceptable standard of practice to account for the receipt, usage, disposition, and reconciliation of controlled medications was being followed by staff. Findings included . Review of the Controlled Drug Shift Change Audit Sheet on unit #5 on the fifth floor showed that the controlled drugs (scheduled II to schedule V) system that is to be counted by two nurses at the change of shift, the nurse going off duty and the nurse coming on was not being followed. Further Review of the Controlled Drug Shift Change Audit Sheet showed the spaces allotted for nurse signature going off duty and coming on duty to reconcile the narcotic count for the 3:00 PM to 11:00 PM shift on the following dates was done by the same nurses signatures on the folowing dates and shift. 05/13/2023 3p -11p 05/14/2023 3p-11p 05/17/2023 3p-11p 05/19/2023 3p-11p The evidence showed that the system used for acceptable standard of practice to account for the receipt, usage,…

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

Based on observations and staff interview, facility staff failed to store and prepare foods in accordance with professional standards of practice for food services safety as evidenced by eight (8) of nine (9) four-inch-deep soiled bullet pans and two (2) of five (5) two-inch deep soiled bullet pans stored on a ready-for-use shelf, one (1) of one (1) six-pound, four-ounces can of Sysco Fancy Shredded Sauerkraut labeled with a best-by date of October 2022, six of six (6) six-pound, four-ounces cans of Jalapeno slices with a best-by date of January 21, 2023, and fire sprinkler blow off caps that were soiled with grease and/or foreign substances. The findings include: During a walkthrough of the facility's kitchen on May 16, 2023, at approximately 9:00 AM, the following observations were made: 1. Eight (8) of nine (9) four-inch-deep bullet pans and two (2) of five (5) two-inch deep bullet pans stored in the designated clean, and ready for use area of the kitchen, were stained throughout. 2. One (1) of one (1) six-pound, four-ounces can of Sysco Fancy Shredded Sauerkraut stored in dry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview for one (1) of 41 sampled residents, facility staff failed to maintain accurate documentation in a resident's medical record as evidenced by not completing the physician's tube feeding order at the time ordered to take it down. (Resident #50) The findings included: Resident #50 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia, Metabolic Encephalopathy, Adult Failure to Thrive, Gastrostomy Status, Dysphagia, Malignant Neoplasm of Major Salivary Gland, Flaccid Hemiplegia of Right Side, Type 2 Diabetes Mellitus, Hypertension. A Physician's Order dated 12/03/22 documented Glucerna 1.5 @ 40 ml/hr x 10 hrs (40 milliliter per hour for 10 hours) to provide 400ml (milliliter) total volume, 600kcal (kilocalories), 33g (grams) pro (protein), 303ml (milliliter) free H2O (water) Up @ (at) 8:00PM and Down @ (at) 06:00 (6:00AM) - Every Day for Nutritional Support. A Care Plan dated 12/06/21 documented, .EATING: on G-tube feeding . 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.

Based on observations and staff interview, facility staff failed to maintain the call bell system in good working condition as evidenced by call bells in two (2) of 43 resident's rooms that failed to initiate an alarm when tested. The findings include: During an environmental tour of the facility on May 22, 2023, at approximately 2:00 PM, call bells in two (2) of 48 resident's rooms (#129, #455) did not alarm when tested. These breakdowns could prevent or delay staff from responding to residents' needs in a timely manner. These observations were acknowledged by Employee #13 during a face-to-face interview on May 25, 2023, at approximately 11:00 AM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by a dome cover that was missing from one (1) of 10 ceiling lights in the fifth floor dining room, dome covers that were missing from two (2) of nine (9) ceiling lights in the second floor dining room, a dome cover that was missing from one (1) of 10 ceiling lights in the first floor dining room, two (2) stained ceiling tiles in the Activity's room on the fifth floor, one (1) of eight (8) electrical outlets in the second floor dining room that lacked an outside cover, low water temperatures in 10 of 47 resident's rooms, and missing dresser knobs from one (1) of 47 resident's rooms. The findings included: During an environmental walkthrough of the facility on 07/21/2021 and 07/22/2021, the following was observed: 1. One (1) of 10 ceiling light dome cover located in the dining room on the fifth floor was missing. 2. Two (2) of nine (9) ceiling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, for six (6) of 60 sampled residents, facility staff failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and/or personal hygiene. Residents' #61, #109, #116, #123, #127, and #144. The findings included: 1. Resident #61 was admitted to the facility on [DATE], with multiple diagnoses that included: Dementia, Anxiety Disorder, Tinea Unguium, Unspecified Mood Disorder and Restlessness and Agitation. During a tour of unit 5 north on 07/26/2021, at 2:57 PM, Resident #61 was observed in bed with her heels offloaded on pillows. A head-to-toe skin assessment of the resident was conducted with Employee #19 (Licensed Practical Nurse). The resident ' s fingernails were observed to be long. Toenails on bilateral feet were noted to be very long, thick and yellow. Review of the Quarterly Minimum Date Set (MDS) dated [DATE], revealed the following: In Section C (Cognitive…

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 reviews and staff interviews, facility staff failed to: (1) administer medications in accordance with professional standards of practice, (2) dispose of medications in a timely manner and (3) accurately reconcile narcotics. Residents ' #67 and #123. The findings included: 1. Facility staff failed to ensure medication was administered in accordance with professional standards of practice. Review of the facility ' s policy entitled, Medication Administration Policy 5.2 PAXIT MED-Pass Procedure revealed, .Explain to the resident the type of medication to be administered. The resident has the right to be informed of all medications that are administered. 1a. Resident #67 was admitted to the facility on [DATE], with multiple diagnoses which included: Hypertension, Renal Insufficiency, Acute Cholecystitis, Diabetes Mellitus, Hyperlipidemia, Seizure disorder, and Hemiplegia or Hemiparesis. On 7/20/2021, at 10:30 AM, during a medication administration observation, Employee #22 (Licensed…

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

Based on observations and staff interview, facility staff failed to distribute and serve foods under sanitary conditions as evidenced by 10 of 11 steam pans that were stacked wet, two (2) of two (2) convection ovens that were soiled throughout, 14 of 42 plastic dinner plates that were soiled, seven (7) of seven (7) food tray transport carts that were marred, two (2) of two food tray transport carts plastic coverings that were torn and soiled, and one (1) of 14 baffle filters from the kitchen range hood that was damaged. The findings included: 1. 10 of 11 full steam pans were stored wet, on a shelf, ready for use. 2. Two (2) of two (2) convection ovens were soiled throughout with leftover burnt food deposits. 3. 14 of 42 dinner plates were soiled throughout. 4. Seven (7) of seven (7) enclosed food tray transport carts located on the second (2), third (1), fourth (2), and fifth floor (2), were soiled on the outside 5. Two (2) of two plastic covers to open food tray transport carts on the first-floor unit were torn and soiled. 6. Stainless-steel/aluminum panels to one (1) of 14 baffle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, for five (5) of 60 sampled residents, facility staff failed to maintain infection prevention and control practices to minimize the potential spread of infections during medication administration, while providing wound care and not continuing transmission-based precautions. Residents' #61, #64, #67, #168, and #370. The findings included: 1. Facility staff failed to maintain infection prevention and control practices during medication administration for Residents' #61 and #67. Review of the facility ' s policy and entitled, Medication Administration Policy . documented, . never touch any of the medication with fingers . 1a. During an observation of medication administration on 07/21/2021 at 8:15 AM, Employee #19 (Licensed Practical Nurse) performed hand hygiene, poured five (5) tablets into a 30cc (cubic centimeters) plastic cup, introduced herself to Resident #61. As the employee was administering the pill, two (2) pills fell on to the resident ' s gown.…

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 reviews and staff interviews, facility staff failed to ensure all required documents were conveyed to the receiving health care provider for three (3) of 60 sampled residents that were transferred from the facility to the hospital. Residents' #1, #92 and #145. The findings included: 1. Resident #1 was admitted to the facility on [DATE], with diagnoses of Peripheral Vascular Disease Unspecified, Vitamin D Deficiency, Muscle Weakness, and Hypertension. Review of the physician's order dated 05/23/2021, directed, Send Resident to ER (emergency room) for s/p (status post) fall and fracture Review of Resident #1's transfer documents dated 05/23/2021, lacked evidence that the facility staff included the care plan goals with the transfer documents. During a face-to-face interview conducted on 07/28/2021, at 4:21 PM, Employee #28, acknowledged the finding and stated, The care plan is separate, we did not send it with them. 2. Resident #92 was readmitted to the facility on [DATE], with diagnoses 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 60 sampled residents, facility staff failed to accurately code a resident's assessment on the Minimum Data Set (MDS). Resident #152. The findings included: Resident #152 was admitted to the facility on [DATE], with multiple diagnoses that included: Parkinson's Disease, Malnutrition, Adult Failure to Thrive and Dehydration. Review of the Quarterly MDS dated [DATE], revealed in Section P (Restraints) that facility staff coded Resident #152 as, Physical Restraints- Bed rail- used less than daily, indicating that the bedrail was being used as a restraint. During a face-to-face interview conducted on 07/28/2021, at 1:30 PM, Employee #11 (MDS Coordinator) acknowledged the finding and stated, That assessment [MDS dated [DATE]] was coded in error. We don't use restraints in this facility. It needs to be modified.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, for two (2) of 60 sampled residents, facility staff failed to develop and implement a baseline care plan within 48 hours of two (2) residents' admission. Residents' #87 and #367. The findings included: 1. Resident #87 was admitted to the facility on [DATE], with multiple diagnoses that included: Renal Insufficiency, Urinary Retention, Benign Prostatic Hypertrophy (BPH), and Non-Alzheimer's Dementia. Review of the Significant Change Minimum Data Set (MDS) dated [DATE], revealed the following: In Section H (Bowel & Bladder), . Appliances- Indwelling catheter Review of the physician's orders revealed: 05/19/2021 Foley: Change Foley Catheter- 16 Fr (French) 10 ml (milliliters) every month . 05/19/2021 Indwelling catheter every shift due to urinary retention/BPH . Review of the progress notes revealed: 05/19/2021 at 1:53 PM (nursing note) [Resident #87] . readmitted on [DATE] . Foley catheter 16 F (French) in place secondary to prostate CA (cancer) and urinary retention .…

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 interview, for one (1) of 60 sampled residents, facility staff failed to develop and implement a comprehensive person-centered care plan. Resident #87. The findings included: Resident #87 was admitted to the facility on [DATE], with diagnoses that included: Renal Insufficiency, Urinary Retention, Benign Prostatic Hypertrophy (BPH), and Non-Alzheimer's Dementia. Review of the Significant Change Minimum Data Set (MDS) dated [DATE], revealed in Section H (Bowel & Bladder), . Appliances- Indwelling catheter. Review of the physician's orders revealed: 05/19/2021 Foley: Change Foley Catheter- 16 Fr (French) 10 ml (milliliters) every month . 05/19/2021 Indwelling catheter every shift due to urinary retention/BPH . Review of the progress notes revealed: 05/19/2021 at 1:53 PM (nursing note) [Resident #87] . readmitted on [DATE] . Foley catheter 16 F (French) in place secondary to prostate CA (cancer) and urinary retention . During a review of Resident #87's care plan on the 07/28/2021,…

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 interview, for three (3) of 60 sampled residents, the facility staff failed to update/revise the resident's care plan to include person-centered aspects of care. Residents' #2, #51 and #92. The findings included: 1. Facility staff failed to update/revise the resident's care plan to include person-centered aspects of care for the resident's ileostomy. Resident #2 was admitted to the facility on [DATE], with diagnoses that include: Ileostomy, Renal Insufficiency and Gastroesophageal Reflux Disease. The Annual Minimum Data Set completed on 07/06/2021, showed the resident was coded as having an ostomy (ileostomy) under Section H (Bladder and Bowel); and Section I (Active Diagnoses) was coded encounter for attention ileostomy. Review of the physician's orders dated and signed on 06/02/2021, directed the following: Ostomy site .cleanse stoma site with water and pat dry and apply powder Cleanse stoma site with skin prep with each ileostomy bag change as needed nurses to supervise .use…

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 interview, for one (1) of 60 sampled residents, facility staff failed to demonstrate evidence that Resident #1 received assistance with meals as directed by the care plan and physician ' s orders to maintain the resident ' s ability to carry out ADLs (activities of daily living). The findings included: Resident #1 was admitted to the facility on [DATE], with the following diagnoses of Anemia, Vitamin D Deficiency, Chronic Kidney Disease Stage 3 Moderate and Hypertension. During an observation on 7/19/2021, at 1:05 PM, the writer observed Resident #1 in her room, the head of the bed was raised and the resident was asleep. Her lunchtime meal tray was on the over-the-bed table that was placed to the right side of the resident ' s bed. A lid was covering the plate of food, a roll/bread was wrapped in plastic and two beverages were unopened and lying flat on the tray. At 1:17 PM, the writer observed the staff remove the tray from Resident #1 ' s room and place it on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews, for three (3) of 60 sampled residents, facility staff failed to ensure that residents received treatment and care in accordance with the professional standards of practice, the comprehensive person-centered care plan, as evidenced by: failure to ensure one (1) resident ' s blood sugar was obtained in accordance with the professional standards of practice and the physician ' s order; failed to administer hydrocortisone (used to treat redness, swelling, itching, and discomfort of various skin conditions) as ordered by the physician for one (1) resident; and failed to follow the physician ' s orders and care plan approaches for bowel regimen for one (1) resident. Residents' #67, #106, and #369. The findings included: 1. Facility staff failed to ensure Resident #67 ' s blood sugar was obtained in accordance with the professional standards of practice and the physician ' s order. Resident #67 was admitted to the facility on [DATE], with multiple diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, for one (1) of 60 sampled residents, the facility staff failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase their range of motion. Resident #92. The findings included: Resident #92 was readmitted to the facility on [DATE], with multiple diagnoses that included: Cancer, Hypertension, Diabetes Mellitus, Dementia, Dysphagia and Gastrostomy status. According to the Minimum Data Set completed on 06/08/2021, Resident #92 ' s Brief Interview for Mental Status (BIMS) score was coded as 99, indicating the resident was unable to complete the interview. The resident was coded as having impairment to one side of her upper extremity (shoulder, elbow, wrist, hand) under Section G0400 Functional Limitation in Range of Motion. On 07/19/2021, at approximately 3:50 PM and on 07/21/2021, at 12:07 PM, Resident #92 was observed lying in bed with her left hand in a closed position. Review of the physician ' 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 observation and staff interview, for one (1) of 60 sampled residents, facility staff failed to ensure that a resident ' s respiratory care was consistent with professional standards of practice. Resident #8. The findings included: Review of the facility ' s policy entitled, Respiratory Care - Prevention of Infection, documented, . Change the oxygen cannula and tubing every seven (7) days, or per state regulations (whichever is more strict), or as needed . On 07/20/2021, at approximately 11:30 AM, Resident #8 was observed lying down in her bed and wearing a nasal cannula. There was no labeling noted on the resident ' s nasal cannula tubing to indicate the last date and time that either was changed. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses that included: Shortness of Breath, Heart Failure, Gastroesophageal Reflux Disease and Non-Alzheimer's Dementia. During a face-to-face interview conducted at the time of the observation, Employee #28 (2nd floor Unit Manager), she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, for one (1) of 60 sampled residents, the facility staff failed to attempt a gradual dose reduction for a resident who used Bupropion (antidepressant) HCL (hydrochloride) SR (sustain released tablet) daily for depression. Resident #123. The findings included: During observations from 07/19/2021 to 07/29/2021, Resident #123 was observed in her room, alert, oriented to name, place, time, very pleasant watching movies and interacting with staff. Resident #123 was admitted to the facility on [DATE]. The medical record revealed the resident had multiple diagnoses including Major Depression. Review of the physician ' s order dated 02/12/2021, ordered, Bupropion HCL SR 150 milligrams by mouth one time a day for depression. Review of the psychotherapy progress notes from 02/16/2021 to 07/20/2021, lacked documented evidence that Resident #123 was observed or verbalized she had any signs/symptoms of depression. Review of the Annual Minimum Data Set, dated [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 record review and staff interview, for one (1) of 60 sampled residents, facility staff failed to accurately document resident assessments in the medical record in accordance with professional standards and practice. Resident #3. The findings included: Resident #3 was admitted to the facility on [DATE], with diagnoses that included: Non-Alzheimer's Dementia, Psychotic Disorder, Muscle Weakness and Chronic Kidney Disease. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the following: In Section E (Behavior) - . Wandering- Presence and Frequency- Has the resident wandered? the resident was coded 2 indicating, Behavior of this type occurred 4 to 6 days, but less than daily. In Section I (Active Diagnoses) - Hypertension, Insomnia Unspecified. Review of the physician ' s orders revealed: 04/12/2018 Check wander guard (roam alert) for safety risk placement q (every) shift . Review of the care plan revealed the following problem areas: 12/17/2014 [Resident #3] wanders r/t (related to)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interview, the facility staff failed to maintain a low air loss mattress (for pressure redistribution) in a safe operating condition for one (1) of 60 sampled resident ' s using a low air loss mattress, Resident #64; and failed to maintain essential equipment in safe condition as evidenced by one (1) of 14 baffle filters from the kitchen range hood that was damaged. The findings included: 1. Facility staff failed to maintain a low air loss mattress in a safe operating condition for Resident #64. During observations on 07/23/2021 at 8:30 AM, 10:30 AM and 12:23 PM, Resident #64 ' s low air loss mattress was inflated, but the mattress pump ' s operating light was off. Resident #64 ' s medical record revealed the resident was admitted to the facility on [DATE] with multiple diagnoses including Generalized Muscle Weakness, Mild Cognitive Impairment, and Acute Kidney Failure. A review of the current physician ' s orders showed the following: 10/21/2020 Low air mattress 3…

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

Based on observations and staff interview, the facility failed to maintain the call bell system in good working condition as evidenced by call bells in three (3) of 43 resident's rooms that failed to alarm when tested. The findings included: During an environmental tour of the facility on 07/21/2021, at approximately 3:00 PM, and on 0722/2021, at approximately 11:00 AM, call bells in three (3) of 47 resident ' s rooms (#215, #455, #555) failed to initiate an alarm when tested. These breakdowns could prevent or delay staff from responding to resident ' s needs in a timely manner. During a face-to-face interview on 07/22/2021, at approximately 12:30 AM, Employee #7 acknowledged the findings.