Harborside Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for one (1) of eight (8) sampled residents, facility staff failed to provide Resident #67 with the necessary respiratory care per the residents comprehensive care plan and the facility's policy after decannulation of her tracheostomy (trach) tube. The findings included: The facility's Unplanned Decannulation: Risk Assessment, Precautions and Interventions policy with an effective date of December 2014 documented: - An unplanned decannulation is an unplanned removal or dislodgement of an artificial airway prior to its scheduled removal. - If unplanned decannulation occurs, the following will take place: call a Rapid Response (RRT); assess if the patient is stable without the trach tube, if not, the trach tube will be immediately reinserted to establish a patent airway by a qualified practitioner. Resident #67 was admitted to the facility on [DATE] with multiple diagnoses that included: Encounter for Tracheostomy, Acute and Chronic Respiratory Failure with Hypercapnia,…

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 eight (8) sampled residents, facility staff failed to demonstrate competencies and skills to provide safe nursing care and services as evidenced by a nurse, who was not trained to do so, reinserting Resident #67's tracheostomy tube after decannulation. The findings included: The facility's Unplanned Decannulation: Risk Assessment, Precautions and Interventions policy with an effective date of December 2014 documented: - An unplanned decannulation is an unplanned removal or dislodgement of an artificial airway prior to its scheduled removal. - If unplanned decannulation occurs, the following will take place: call a Rapid Response (RRT); assess if the patient is stable without the trach tube, if not, the trach tube will be immediately reinserted to establish a patent airway by a qualified practitioner. Resident #67 was admitted to the facility on [DATE] with multiple diagnoses that included: Encounter for Tracheostomy, Acute and Chronic Respiratory…

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 four (4) of fifty-five (55) sampled residents, the facility staff failed to ensure that a Resident's assessment accurately reflected the resident's nutrition status by documenting an inaccurate weight. Residents' #85, #71, #121 and #381. The findings included: 1. Resident #85 was admitted to the facility on [DATE] with diagnoses that included: Traumatic Subarachnoid Hemorrhage with Loss of Consciousness, Dislocation Of C1/C2 Cervical Vertebrae, Laceration of Diaphragm, Encounter for Attention to Tracheostomy, Encounter for Attention to Gastrostomy, and Dependence on Respirator/Ventilator. A review of Resident #85's medical record revealed the following: A census report that showed the resident was discharged from the facility to the hospital on [DATE] and was readmitted to the facility on [DATE]. A discharge minimum data set (MDS) assessment dated [DATE] documented that the Resident weighed 144 pounds. A nutrition assessment completed by Employee #29 (Dietician)…

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 four (4) of 55 sampled residents, facility staff failed to develop a person-centered care plan with goals and interventions for residents with bowel and bladder incontinence, a resident with hearing loss, a resident with fall mats on both sides of the bed and for a resident's refusal of respiratory care/treatments. Residents' #377, #381, #71 and #121. The findingd inclued: 1. Resident #377 was admitted to the facility on [DATE] with multiple diagnoses that included: Disorientation, Hemiplegia, Chronic Respiratory Failure, Dependence on Respirator and End Stage Renal Disease. A review of Resident #377's medical record revealed: An admission Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '15' indicating the resident was cognitively intact; Functional Abilities and Goals that documented: Dependent on staff for all Activities of Daily Living (ADLs) that included toileting,…

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 and resident interviews, for four (4) of 55 sampled residents, the facility staff failed to provide: (1) documented evidence that Resident #44 who was dependent on staff for toileting hygiene was provided incontinent care within 12 hours on 10/01/24 and with eight hours on 10/02/24, (2) activities of daily living (ADL) care assistance for Resident #10, #29, #68, (3) incontinent care and turn and repostion Resident #105 every two (2) hours as perscibed, and (4) incontinent care in a timely manner for Resident #377. The findings included: 1. Resident #44 was admitted to the facility on [DATE] with multiple diagnoses including Weakness and Obesity. A physician order dated 10/19/21 instructed, Apply hydra guard barrier cream to perineal, sacral, buttocks area after each incontinent care for skin maintenance. A quarterly Minimum Data Set assessment dated [DATE] documented in part that the resident had a Brief Interview for Mental Status summary score of 15 indicating 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, for two (2) of 55 sampled residents, the facility staff failed to: (1) follow Infection Prevention and Control measures. As evidenced by, a staff member placing a gallon of tea that was in Resident #8's room who was Enhanced Barrier Precautions in the community refrigerator. 2. maintain infection prevention and control to help prevent the transmission of communicable diseases and infections as evidenced by failing to don PPE prior to weighing Resident #277, who was on contact precautions and failing to disinfect equipment in between use. The findings included: 1. According to Center for Disease Control Prevention, Infection Control Guidance: Candid Auris documented in part, Environmental Disinfection: The fungus has been found on high-touch surfaces, such as bedside tables .Reducing Transmission: Clean and disinfect environment surfaces on a more frequent schedule .thoroughly clean and disinfect the areas in the facility the patient came in contact 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) out of 55 sampled residents, facility staff failed to ensure that the resident's preference/choice was honored as evidence by failing to get the resident out of bed and into the Geri chair. Resident #72. The findings included: Resident #72 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Dysphagia, Acute and Chronic Respiratory Failure with Hypoxia, and Dementia. Review of the resident's medical record revealed the following: A face sheet that showed that the resident's son is listed as Responsible Party (RP), care and financial power of attorney (POA); care conference person; and emergency contact #1. An Annual Minimum Data Set (MDS) dated [DATE] showed that facility staff coded: no speech; rarely/never makes self-understood; rarely/never makes understands others; severely impaired cognitive skills for daily decision making; no refusal of care behaviors; functional limitations in range of motion on one side 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 record reviews and staff interviews, for one (1) of 55 sampled residents, facility staff failed to have documented evidence that the resident or their representative (RP) were provided with written information concerning the right to accept or refuse to formulate an Advance Directive (AD). Resident #121. The findings included: Resident #121 was admitted to the facility on [DATE] with multiple diagnoses that included: Acute and Chronic Respiratory Failure, Gastrostomy Status, Dysphagia, and Anxiety Disorder. Review of the resident's medical record revealed the following: A face sheet that showed that the resident's father is his RP and emergency contact #1. A physician's order dated 08/20/24 directed, Full code. A care plan focus area: [Resident #121] wishes to remain a full code, was initiated on 08/21/24. - Goal: Interdisciplinary team (IDT) team will honor the resident wishes for end-of-life care. - Interventions: Offer 5 Wishes (the facility's AD form) quarterly. An admission Minimum Data (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 and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by a torn privacy curtain in one (1) of 18 resident's rooms, an entrance door in one (1) of 18 resident's rooms that would not stay open, and broken furniture such as two (2) of two (2) Geri chairs, and one (1) of one (1) broken desk that were stored in the dayroom located on resident care unit 3 West; and facility staff failed to exercise reasonable care for the protection of the resident's property from loss or theft when the resident was transferred to a local hospital. Resident #329. The findings included: During an environmental walkthrough of the facility on October 17, 2024, at approximately 11:00 AM, the following were observed: 1. The privacy curtain in resident room [ROOM NUMBER] A was torn at the mesh and hung loose from the curtain hooks. 2. The entrance door to resident room [ROOM NUMBER] would not stay open and was held in place with 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 record review and staff interviews, for one (1) of 55 sampled residents, facility staff failed to have documented evidence that they made any prompt efforts to resolve one resident's complaint/grievance regarding Americans with Disabilities Act (ADA) accessibility at the facility when resident alleged that hand was smashed in a door. Resident #71. The findings included: Review of the facility's Grievances policy dated 05/24/24 documented: - The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. - Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. - A written summary of the investigation will also be provided to the resident and a copy will be filed in the Administrator's office. Resident #71 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, for one (1) of 55 sampled residents, facility staff failed to ensure that 1 resident was free from any physical restraints imposed for purposes of convenience that was not required to treat the resident's medical symptoms. Resident #10. The findings included: Review of the facility's Restraints policy dated 05/24/24 documented: - Restraints shall only be used for the safety and well-being of the residents and only after alternatives have been unsuccessful. - Physical restraints are defined as a manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement. - The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which staff applied it given the residents physical condition (i.e. side rails are put back down, rather than…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility staff failed to implement it's Abuse Prevention Program policy, As evidenced by not having documented evidence of that an investigation was conducted for an allegation of missing items for one (1) of 55 sampled residents. (Resident #226) The findings included: Resident #226 was admitted on [DATE] with multiple diagnoses Dependence on Ventilator, Acute Respiratory Failure, and Morbidity Obesity. Please note the resident A policy titled, Abuse Prevention Program with a revision date of 12/01/22 documented in part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation .As part of the resident abuse prevention, the administration will .investigate .any allegation of abuse within the timeframes required by federal requirements . A State Survey Agency Facility Report Incident form DC~11781 dated 03/27/23 documented, March 23, 2023 - It was reported that resident was missing items from her room an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, for two (2) of 55 sampled residents, facility staff failed to report the results their investigation of alleged neglect to the State Agency within five (5) days; and failed to report the results of their investigation for one resident's allegation of abuse to the State Agency. Residents #68 and #276. The findings included: Review of the facility's Abuse Investigation and Reporting policy dated 05/24/24 documented: - All reports of resident abuse, neglect, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. - Findings of investigations will also be reported. - The Administrator, or his/her designee, provide the State Agency with written report of the findings of the investigation within five (5) working days of the occurrence of the incident. 1. Facility staff failed to report the results their investigation of Resident #68's alleged neglect to 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 interview, for two (2) of 55 sampled residents, the facility staff failed to ensure thorough investigations was conducted to adresss: (1) an allegation of missing items for Resident #226's; and (2) an allegation of abuse for Resident #276. (Residents #226 and #276) The findings included: 1. Resident #226 was admitted on [DATE] with multiple diagnoses Dependence on Ventilator, Acute Respiratory Failure, and Morbidity Obesity. A policy titled, Abuse Prevention Program with a revision date of 12/01/22 documented in part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation .As part of the resident abuse prevention, the administration will .investigate .any allegation of abuse within the timeframes required by federal requirements . A State Survey Agency Facility Report Incident form DC~11781 dated 03/27/23 documented, March 23, 2023 - It was reported that resident was missing items from her room an investigation is currently…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, for three (3) of fifty-five (55) sampled residents, the facility staff failed to provide written notification to a resident or the Resident's representative(s), which explained the reasons for a resident's transfer or discharge to the hospital. Residents #122, #328 and #67. The findings included: 1. Resident #122 was admitted to the facility on [DATE] with diagnoses that included: Metabolic Encephalopathy, Chronic Respiratory Failure, Atrial Fibrillation, Acute Kidney Failure, Respiratory Conditions Due To Smoke Inhalation Type 2 Diabetes Mellitus, and Anxiety Disorder. A review of Resident #122 's medical record revealed: A face sheet which documented that the Resident had a spouse who was the Representative. An admission minimum data set (MDS) assessment dated [DATE] documented that Resident #122 had a Brief Interview for Mental Status Summary Score of 12, indicating that the Resident had moderately impaired cognition, had impairment to upper and lower…

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, policy review and staff interviews, facility staff failed to adhere to professional standards of Practice for administering medication via G-tube for four (4) of seven (7) Medpass observations. The findings included: According to the ANA [America Nurses Association] standards of Practice, refers to the document, Nursing: Scope and standards of Practice, developed by American Nurses Association. This resource is meant to inform and guide registered nurses (RNs) in providing safe quality, and competent patient care. It is consistently updated to reflect the latest topics, technologies, and issues affecting nursing. This ANA resource is divided into two components as the title infers. The first is a scope of practice statement, which defines nursing care, processes, and methods discusses the different nursing professionals, and divulges the future of their work. The second is ANA's standard of practice for nurses today. The most recent edition reveals 18 standards of practice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, for one (1) of 55 sampled residents, the facility staff failed to: (1) have a physician order to irrigate and remove a urinary catheter for Resident #103 who was bleeding from thr catheter insertion site.(2). follow the physician's order to keep [fall] mats bilaterally on the floor for Resident #71, who has a history of falls with injury. The findings include: 1. Resident #103 was admitted to the facility on [DATE] with multiple diagnoses including Quadriplegia, Neurogenic Bladder, and Urinary Tract Infection. A physician order dated 03/31/24 documented in part, Change [brand name of urinary indwelling catheter] every last day of night shift at bedtime .to prevent infection. A review of a policy titled, Medication and Treatment Orders with a review date of 05/24/24 documented in part, Order for Medication and treatment will be consistent with principles of safe and effective order writing .verbal orders must be recorded immediately in the resident's chart by the person…

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 reviews, and staff interviews, for two (2) of 55 sampled resident the facility failed to ensure the residents received proper treatment and care to maintain good foot health. As evidenced by the residents were observed with elongated and thickened toenails. (Resident #7 and Resident #38) The findings included: 1. Resident #7 was admitted to the facility on [DATE] with multiple diagnoses including Type 2 Diabetes Mellitus and Generalized Muscle Weakness. A physician order dated 07/08/23 documented in part, Wash resident bilateral feet with soap and water .apply lotion .done by charge nurse one time a day. A physician order date 09/09/23 instructed, Podiatry consult and PRN (as needed). A podiatry progress note dated 03/01/24 documented in part, Patient seen today in facility with compliant of elongated and thickened toenails. They have been present for many years .Assessment/Plan 1). Painful mycotic toenails. All patient's toenails were debrided in thickness and length .follow-up in 9…

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 55 sampled residents, the facility staff failed to provide appropriate treatment and services for a resident with an indwelling catheter. As evidenced, by not having documented evidence that the resident's urinary put was monitored every shift, as ordered. The findings included: A policy titled, Urinary Catheter Care with a revision date of 12/20/23 documented in part, Purpose-the purpose of this procedure is to prevent catheter-associated urinary tract infections .Input/Output .maintain an accurate record of the resident's daily output, per facility policy and procedure . Resident #103 was admitted to the facility on [DATE] with multiple diagnoses including Quadriplegia, Neurogenic Bladder, and Urinary Tract Infection. A physician order dated 03/31/24 documented in part, Change [brand name of urinary indwelling catheter] every last day of night shift at bed time .to prevent infection. A quarterly Minimum Data Set assessment 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 55 sampled residents, facility staff failed to ensure Dialysis treatments were provided according to physician orders, subsequently the resident became increasingly confused and had to be transferred to the hospital for urgent dialysis. Resident #383. The findings included: Resident #383 was admitted to the facility on [DATE] with multiple diagnoses that included: End Stage Renal Disease dependence on Renal Dialysis, Seizure Disorder, Anemia, Hypertension and Type 2 Diabetes Mellitus. A review of Resident #383's medical record revealed: A review of a Dialysis Referral transmitted to the Skilled Nursing Facility (SNF) Admissions Team dated 10/12/23 at documented, [Resident #383's name], [Facility name], [Dialysis' company name] SNF Dialysis, First Request Treatment Date 10/17/23 and We are working to obtain all records. A Long Term Acute Care Hospital (LTACH) [Dialysis Name] Hemodialysis Flow Sheet dated 10/14/23 documented, [Resident #383's name], Tx.…

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, 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 112. The findings included: During a Resident Council meeting on 10/03/24 at 2:00PM, 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 takes up to 2hrs to get staff assistance after pressing call bell device especially on weekends. Another resident stated, There's hardly any staff here. When I call, they eventually come. They are not 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 3 2024, 04/01/24 to 06/30/24. Review of the staffing for weekends dates of 04/5/24, 4/6/24, 4/7/24, 4/12/24, 4/14/24,5/3/24, 5/5/24, 5/10/24, 5/12/24, 5/17/24, 6/22/24, 6/22/24, 6/28/24…

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, facility staff failed to ensure one resident controlled medications were accurately recorded by documented as given and accurately reconciled controlled medications showing amount remaining for one (1) of three (3) sampled resident controlled drug records reviewed. Residents #76. The findings included: Resident #76 was admitted to the facility on [DATE] with diagnoses that included Respiratory failure, Cerebrovascular Disease, Acute Kidney Disease, Congestive Heart Failure, Diabetes Mellitus, and Dependent on a respirator. According to the physician's order dated 09/30/23 the resident is to receive Tramadol HCI (used to relieve wound pain prior to wound care) 50 mg (milligram) one tablet via G-tube every day shift give prior to wound care for pain. During an observation on 10/01/24 at 2:04 PM one (1) of two (2) Medication Carts on unit 3, there was one resident (Resident #76) with a physician's order that directed, Tramadol 50 mg take 1 tablet via G-tube every day…

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

Based on observation, record review and staff interview two (2) of three (3) medication storage rooms observation, facility staff failed to ensure proper and accurate temperature control for one refrigerator used for storing the resident's medication was maintained and the daily documentation of glucometer calibration record for use was completed on the date and in the space allotted to do so. The findings included 1.During an observation of the 2 south medication room refrigerators on 10/02/2024, at approximately 10:45 AM, it was observed that one (1) refrigerator storing residents medication temperature showed reading 49-50, this was out of the required range of 34 - 41syringe. The form used to log refrigerator temperature showed documentation for the day was read at 49. The reading at the time of observation was 50. Documented policy stated Call for maintenance/RCC if temperature out of range 34-41 degrees. Employee #23 acknowledged the finding at the time of the observation and stated that I will call for maintenance now. 2. During observation of the 1 South and 2 South…

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 food under sanitary condition as evidenced by a clogged floor drain line on the cook line, two (2) of approximately ten (10) dented cans of Sharp Aged Cheddar Cheese in dry food storage, one (1) of one (1) soiled food slicer, disposable items that were stored uncovered in dry food storage, ready-to-eat cold foods and drinks that tested above 41degrees Fahrenheit (F), and a frozen condensate pipeline in one (1) of one (1) walk-in-freezer. The findings include: During an initial visit of dietary services on October 1, 2024, and a follow-up visit on October 3, 2024, between the hours of 9:00 AM and 12:15 PM. 1. The floor drain on the cook line was clogged during observations on October 1, 2024, at approximately 9:00 AM. The drain was immediately repaired by the maintenance department. 2. Two (2) of approximately ten (10), 6.69 pounds (lb.) cans of Sharp Aged Cheddar Cheese stored in dry food storage were dented. 3. One (1) of one (1) food slicer was soiled with leftover food residue. 4. Disposables such…

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 resident and staff interviews, for one (1) of 55 sampled residents, the facility staff failed to be compliance with the District of Columbia's state regulation (3211.1). As evidenced by staff not promptly responding to an activated call bell. Consequently, a resident waited 41 minutes for staff to answer the call light. (Resident #103) The findings included: A review of a policy titled, Response to Patient Call Light Activation dated 12/23 documented in part, The purpose of this procedure is to respond to the resident's requests and needs General guidelines .answer the resident's call as soon as possible . Resident #103 was admitted to the facility on [DATE] with multiple diagnoses including Quadriplegia, Neurogenic Bladder, and Urinary Tract Infection. During an observation on 10/04/24 starting at 1:30 PM the resident was observed in bed, alert, oriented to name, place and time. Also observed on the floor was the resident's urinary catheter drainage bag with privacy…

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 interviews for two (2) of 55 sampled residents, facility staff failed to ensure that the call bell device was within reach that would allow residents to call for staff assistance, as evidenced by the call bell device found hanging on the oxygen flow meter attached to the wall behind the resident's bed. Residents' #376 and #378. The findings included: 1.Resident #376 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia, Schizophrenia and Seizure Disorder. A review of Resident #376's medical record revealed: A care plan dated 05/18/17 documented, Focus- [Resident's name] has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) h/o (history of) seizures, dementia (with h/o alcohol abuse)Myopia & Nuclear sclerosis cataract, psychosis and anxiety and Goal-[Resident's name] will maintain his current level of independence and ADL needs will be met daily with the appropriate staff assistance through the next review 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 review, and interviews, for one of fifty-five (55) sampled residents, the facility staff failed to provide documented evidence that they provided education and training to a staff that was investigated for an incident of alleged staff-to-resident abuse. Resident # 122 Resident # 122 was admitted to the facility on [DATE] with diagnoses that included: Metabolic Encephalopathy, Chronic Respiratory Failure, Atrial Fibrillation, Acute Kidney Failure, Respiratory Conditions Due To Smoke Inhalation Type 2 Diabetes Mellitus, and Anxiety Disorder. The State Agency received a facility-reported (FRI), (Incident DC ~13151), submitted on 09/21/24 at 10:39 PM that documented: Initial Investigation Report Administrator received a call tonight that resident listed above reported to a nurse that she was hit in the face earlier today around 4 pm or 5 pm by the nurse who was providing care. Investigation initiated. The facility submitted its final report to the investigation on 09/26/24 at 3:11 PM…

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 three (3) sampled residents, facility staff failed to develop a care plan with goals and approaches to address Resident #1 being discharged from the facility. The findings included: Resident #1 was admitted to the facility on [DATE], with diagnoses that included Cardiac Arrest, Hypertension, Autistic Disorder, Anxiety Disorder, Adjustment Disorder with Mixed Anxiety and Depressed Mood. Review of Resident #1's progress notes showed: 04/12/2024 at 15:37 [03:37 pm]: Writer contacted (Name of psychiatric institute) regarding steps for admission. Writer will have to contact the (Name of Organization) the county in which the family lives in to see what steps can be taken to have resident transferred to a Virginia facility closer to residents' home. 04/15/2024 at 14:41 [02:41 pm]: Social Services Progress Note- .once resident returns to the facility he will be connected to a core service agency for regular psych visits the family has a preference to move 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 staff interview for one (1) of three (3) sampled residents, facility staff failed to maintain accurate medical records for Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Cardiac Arrest, Hypertension, Autistic Disorder, Anxiety Disorder, Adjustment Disorder with Mixed Anxiety and Depressed Mood. Review of the resident's medical record showed: 05/09/2024 at 19:58 [07:58 pm]: Social Services Progress Note- The writer witnessed the resident attempt to hit a staff person. (Name of Doctor), the facility psychiatrist, was contacted. The DC mobile crises unit was also contacted; they came to the facility to assess the resident and Fd-12ed him to (Name of Hospital). Several attempts have been made to contact the resident's brother . 05/09/2024 at 23:20 [11:20 pm] - The patient transferred to (Name of Hospital). Review of the Discharge MDS dated [DATE], showed that under section Type of Assessment-F. Entry/Discharge reporting…

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 11 sampled residents, facility staff failed to code a resident's quarterly Minimum Data Set (MDS) Assessment accurately after a fall. Resident #2. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included: Hemiplegia/Hemiparesis, Seizure Disorder, Unspecified Psychosis, and Schizophrenia. Review of Resident #2's medical record revealed: An SBAR Communication Form and Progress Note dated 12/16/23 that documented: - Situation: Resident was observed in a sitting position on the floor mat. - Nursing notes - Resident was observed in a sitting position on the floor mat beside her bed facing the door. - Head to toe assessment done, no apparent injury or open area noted. Resident denies pain, no s/s of pain noted. Resident was assisted off the floor with 3 staff assistance. - Neuro check initiated. [Doctor's name] made aware. A MDS assessment dated [DATE] documented that the resident had no falls since…

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 11 sampled residents, facility staff failed to update/revise a resident's care plan interventions after a fall. Resident #2. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included: Hemiplegia/Hemiparesis, Seizure Disorder, Unspecified Psychosis, and Schizophrenia. Review of Resident #2's medical record revealed: A physician's order on 06/01/23 that directed, Floor mats bilaterally to the resident's bedside when resident is in bed, to minimize fall related injuries. Licensed Nurse to check for placement when resident is in bed every shift to minimize fall related injuries. A Situation Background Assessment Request (SBAR) Communication Form and Progress Note dated 12/16/23 documented: - Situation: Resident was observed in a sitting position on the floor mat. - Nursing notes - Resident was observed in a sitting position on the floor mat beside her bed facing the door. - Head to toe assessment done, no apparent…

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 11 sampled residents, facility staff failed to include accurate documentation for Resident #1's frequent monitoring from 03/09/24 to 03/20/24 in the resident's medical record. The findings included: Review of a Complaint, DC~12580, received by the State Agency on 03/14/24 documented: - I received a call from [Registered Nurse's name] reporting that grandma has fallen with bleeding head injuries. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including Age-Related Physical Disability, Unspecified Fall sequela, Unspecified Fracture of Right Femur sequela, Hypertension, Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of Resident #1's medical record revealed the following: A Quarterly Minimum Data Set (MDS), with an Assessment Reference dated 02/02/24 documented the following: - Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) summary score of 06, indicating severe 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.

Based on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by loose, torn, privacy curtains in 30 of 75 resident's rooms. The findings include: During an environmental walkthrough of the facility on July 10, 2023, between 10:00 AM and 4:00 PM, privacy curtains were torn or separated from curtain tracks in 30 of 75 resident's rooms. Unit 3 East: Six (6) of 24 resident rooms (#301, #302, #304, #311, #321, #324). Unit 3 West: (12) of 15 resident's rooms (#330, #331, #332, #333, #334, #336, #337, #338, #340, #341, #343, #344). Unit 2 East: Five (5) of 20 resident's rooms (#213, #217, #220, #221, #224). Unit 2 South: Four (4) of eight (8) resident's rooms (#252, #257, #258, #259). Unit 1 South: Three (3) of eight (8) resident's rooms (#152, #157, #158). These findings were acknowledged by Employee # 27 during a face-to-face interview on July 10, 2023, at approximately 3:00 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews for 1 (one) of 45 sampled residents, the facility staff failed to report the results of its investigation regarding a Resident's injury of unknown origin to the State Survey Agency within 5 (five) working days of the incident. Resident #83. The findings included: Resident # 83 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Hypertension, Cognitive Communication Deficit, Age-related Physical Debility, Weakness, Fracture of the Right Femur, and Unspecified Fall. A review of Resident #83's medical record revealed an admission Minimum Data Set (MDS) assessment dated [DATE] documenting the following: the Resident had a Brief Interview for Mental Status (BIMS) score of 03, indicating the Resident had severely impaired cognition, required extensive assistance for bed mobility, transfers, dressings, toilet use, and personal hygiene, required limited assistance for eating, was totally dependent on staff for bathing and was always…

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 1 (one) of 45 sampled residents, the facility staff failed to notify the Resident, the Resident's representative(s), and the Office of the State Long-Term Care Ombudsman of the reason for a resident's transfer to the hospital (in detail), before the Resident's transfer. Resident #84. The findings included: Resident #84 was admitted to the facility on [DATE] with the following diagnoses: Acute Infarction of the Spinal Cord, Acute and Chronic Respiratory Failure, Type 2 Diabetes, Chronic Kidney Disease, Dysphagia, Dependence on Respirator, Gastrostomy and Tracheostomy. A review of Resident #84's medical record revealed: A Quarterly Minimum Data Set (MDS) dated [DATE] documented that the Resident had a Brief Interview for Mental Status (BIMS) summary score of 7, indicating that the Resident required moderately impaired cognition. In addition, facility staff coded that the Resident required extensive assistance for most ADLs (grooming, personal hygiene), had received…

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 two (2) of 45 sampled residents, the facility staff failed to provide bed hold notices that included the number of bed hold days and/or the facility's bed hold policy to residents or their representatives at or before the residents' transfers to the hospital. Residents #84 and #97. The findings included: 1. Resident #84 was admitted to the facility on [DATE] with the following diagnosis Acute Infarction of Spinal Cord, Acute And Chronic Respiratory Failure, Type 2 Diabetes Cardiogenic Shock Chronic Kidney Disease, Dysphasia, Dependence on a Respirator, Gastrostomy and Tracheostomy. A review of Resident #84's medical record revealed a face sheet that documented that the Resident had a representative. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the Resident had a brief interview for a mental status summary score of 7, indicating moderately impaired cognition, required extensive assistance for most ADLs had received antibiotics for 6…

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 ensure a resident's Significant Change MDS (Minimum Data Set) contained accurate information related to skin condition for one (1) of 45 sampled residents. (Resident #107) The findings included: Resident #107 was re-admitted to the facility on [DATE] with multiple diagnoses including Anoxic Brain, Acute Respiratory Failure, Weakness, and Type 1 Diabetes. A review of an admission nursing progress note dated 03/07/23 at 2:28 AM, Resident is .admitted from [Name of hospital] .Resident is alert, non-verbal. Skin warm and dry to touch .Skin color is normal, no cyanosis noted. Cap [capillary] refills is less than 3 sec. [seconds]. Skin in non-tenting . A review of an admission wound team note dated 03/10/23 at 3:03 PM documented, At risk for pressure ulcers/skin breakdown given immobility, dependence on oxygen, malnutrition/ dependence on TF (tube feeding), incontinence, and anoxic brain injury. No open wounds on today's skin assessment . 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 observation, record review, and staff interview, the facility's staff failed to develop a resident's comprehensive person-centered care plan with goals and interventions to address a resident's unplanned weight loss of 11 percent in 30-Days, a resident use of a Ventilator/Trach, and a resident use of hand mittens, use of anticoagulant (Warfarin) and use of nine (9) or more medications for three (3) of 45 sampled residents. (Resident #105, #109 and #111). The findings included: 1. Facility staff failed to develop a comprehensive person-centered care plan with goals and interventions to address Resident #105 unplanned weight loss of 11 percent in 30-Days. Resident #105 was admitted to the facility on [DATE] with multiple diagnoses including Protein-Calorie Malnutrition, Dysphagia, Percutaneous Endoscopic Gastrostomy, Gastro-Esophageal Reflux Disease, Multiple Sclerosis, and Quadriplegic. A review of the facility's Weight Assessment and Intervention policy dated 12/01/22 documented, Care Planning 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 observation, record review and interviews for one (1) of 45 sampled residents, facility staff failed to update the person center comprehensive care plan with goals and approaches to address Resident #111's use of vent/trach. Findings included: Resident #111 was admitted to the facility on [DATE]. The resident had a history of multiple including Chronic Respiratory Failure, Dependence on Respirator (Ventilator Status), Dementia, and Anxiety. A review of Resident #111's comprehensive care plan showed a focus area stating, [Resident #111] has ADL self-care performance deficit related disease process of respiratory failure, bed bound, and vent dependent . The care plan was initiated on 05/06/2023 with the following goals and interventions: Goals: The resident will maintain the current level of function; Interventions: Bedfast- The resident is bedfast all or most of the time. Oral care routine q shift. Monitor/document/ report PRN any changes, any potential for improvement reason for self-care deficit,…

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, residents' interviews, and staff interviews, the facility staff failed to ensure residents who were dependent on staff for activities of daily living received incontinent care, regularly scheduled showers, and foot care to maintain good personal hygiene for five (5) of 45 sampled residents. (Residents #29,#8, #33, #68, and #76) The findings included: A review of the Activities of Daily Living Policy dated 12/01/22 instructed that Residents will [be] provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living . Appropriate care and services will be provided for residents who are unable to carry out ADLs (activity of daily living) independently, with the consent of the resident an in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, grooming) .eliminating (toileting) . 1.The facility's staff failed to ensure Resident #29's personal hygiene was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, staff, and resident interviews for four (4) of 45 sampled residents, facility staff failed to ensure that residents received the treatment and care per standards of practice as evidenced by: 1) failure to provide a Gastro-Intestinal Consultation in a timely manner for one (1) resident #105 who had a 11 percent unplanned weight loss in 29 days 2) failure to follow physicians' orders for three residents. Residents #18, #53, and #97. The findings included: 1. Resident #105 was admitted to the facility on [DATE] with multiple diagnoses including Protein-Calorie Malnutrition, Dysphagia, Percutaneous Endoscopic Gastrostomy, Gastro-Esophageal Reflux Disease, Respiratory Failure, Multiple Sclerosis, Quadriplegic, and Depression. A review of a care plan dated 01/23/23 revealed the following: Focus - [Resident 105] has a BMI indicative of underweight. Goal- [Resident 105] will have a gradual weight gain. Interventions- RD [registered dietician] to evaluate quarterly and PRN (as…

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 an observations, record reviews, and staff interviews, the facility's staff failed to ensure a resident's wound care was provided in consistency with professional standards, as evidence by not providing wound treatment as ordered for one (1) of 45 sampled residents. (Resident #105) The findings included: Resident #105 was admitted to the facility on [DATE]. The resident had a history of Multiple Pressure Ulcers to include a Stage 4 Left Trochanter and Left Buttocks Pressure Ulcer, Protein-Calorie Malnutrition, Dysphagia, Percutaneous Endoscopic Gastrostomy, Gastro-Esophageal Reflux Disease, Respiratory Failure, Multiple Sclerosis, and Quadriplegic. A review of Resident #105's care plan dated 01/27/23 documented the following: Focus area- the resident has potential/actual multiple areas of skin integrity .Interventions: keep skin clean and dry .weekly treatment documentation to include .any notable changes or observations . A review of a Quarterly Minimum Data Set, dated [DATE] revealed Resident #105 did…

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 reviews, staff, and resident interviews for one (1) of 45 sampled residents, the facility staff failed to follow professional standards of practice when administering medication to a resident. Resident #18 Resident #18 was admitted to the facility on [DATE] with diagnoses including Other Sequelae of Cerebral Infarction, Hemiplegia, Unspecified Affecting Left Nondominant Side, Schizophreniform Disorder, Tremor, Unspecified, Vitamin Deficiency, Unspecified, and Hypomagnesemia. A review of Resident #18's medical record revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] documenting the Resident had a Brief Interview for Mental Status Summary (BIMS) score of 14, indicating the Resident had intact cognition; the assessment also revealed that the Resident required extensive assistance from staff for bed mobility, transfers, locomotion off unit, dressing, toilet use, personal hygiene, was totally dependent on staff for bathing, used a wheelchair for mobility, ended physical…

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 serve foods under sanitary conditions as evidenced by hot foods temperatures that were below 135 degrees Fahrenheit (F) on seven (7) of seven (7) observations, four (4) of four (4) convection ovens that were soiled throughout, and cooking equipment such as two (2) of two (2) grease fryers, one (1) of one (1) tilt skillet, and one (1) of one (1) grill that were exposed to potential food contamination. The findings include: 1. Test tray food temperatures were inadequate as puree hot foods such as chicken (114.0 F), green beans (131.0 F), rice (131.3 F), and regular hot foods such as chicken (125 .0 F), green beans (119.6 F), rice (122.5 F) and soup (117.8 F) tested at less than 135 degrees F. 2. Four of four convection ovens were soiled throughout. 3. Cooking equipment such as two (2) of two (2) grease fryers, one (1) of one (1) tilt skillet, and one (1) of one (1) grill were positioned unprotected, at less than 12 inches from the back of four (4) of four (4) convection ovens with no barrier in between. The motors…

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, staff, and resident interviews for three (3) of 45 sampled residents, the facility staff failed to provide restorative nursing services for three residents. Residents #18, #22, and #53. 1. Facility staff failed to offer Resident #18 restorative nursing for donning and doffing an orthotic to the Resident's left elbow which was contracted. Resident #18 was admitted to the facility on [DATE] with diagnoses including Other Sequelae of Cerebral Infarction, Hemiplegia, Unspecified Affecting Left Nondominant Side, Schizophreniform Disorder, Contracture, Right Hand. A review of Resident #18's medical record revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] documenting that the Resident had a Brief Interview for Mental Status Summary (BIMS) score of 14, indicating the Resident had intact cognition; the assessment also revealed that the Resident required extensive assistance from staff for bed mobility, transfers, locomotion off unit, dressing, toilet use, personal…

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 staff failed to ensure medical record (Treatment Administration Record) for two (2) of 45 sampled resident were complete. (Resident #5, and #104) The findings included: 1. Resident #5 Treatment Administration Record (TAR) showed failed to complete documentation in the allotted area as evidence below: Resident #5 was admitted to the facility on [DATE] with diagnoses that included: Acute Respiratory Failure, Pneumonia, Chronic Obstructive Pulmonary Disease, Heart Failure, Hypertension, and Hyperlipidemia. Review of a physician's orderd dated 4/12/23 instructed, Record urine output every shift. Review of a physician's orderd dated 4/12/23 instructed, Bilateral hand mittens to prevent trach decannulation, check and monitor blood circulation q2 hours and PRN. Review of a physician's orderd dated 4/12/23 instructed, Mouth care q4hrs and PRN. However, a review of the June 2023 TAR lack documented evidence that staff initial the designated area for 6/09/23 evening shift…

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 maintain Infection Control and Prevention Practices during wound care for one (1) of 45 sampled residents. (Resident #107). The findings included: Resident #107 was admitted to the facility on [DATE]. The resident had a history of multiple diagnoses including Stage 4 Sacrum Pressure Ulcer, Anoxic Brain, Acute Respiratory Failure, Weakness, and Type 1 Diabetes. A review of the policy titled, Wound Management, instructed staff to .Perform hand hygiene, put on gloves and remove old dressing and discard, take off gloves and perform hand hygiene .put on [clean] gloves and perform wound [care] . A review of Resident #107's care plan dated 03/07/23 documented the following: Focus area- [Resident #107] has potential for pressure ulcer development related to disease process .Interventions: Administer treatments as ordered and monitor effectiveness . A review of a Significant Change Minimum Data Set, dated [DATE] revealed Resident #107 did not have…

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 five (5) of 11 complaints and facility reported incidences, facility staff failed to thoroughly conduct an investigation: for three (3) residents who alleged physical abuse from an employee; for an allegation of misappropriation of one (1) resident's property; and for improper use of a restraint for one (1) resident. (Residents' #23, #37, #95, #102 and #105). The findings include: Review of the facility's policy entitled, Abuse Investigation and Reporting with a review date of 08/2020 revealed, .The individual conducting the investigation will, as minimum . interview the resident (as medically appropriate) interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident . interview other residents to whom the accused employee provides care or services . 1. Facility staff failed to thoroughly investigate an incident for Resident #23 who alleged physical abuse. Resident #23 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, facility staff failed to maintain sufficient nursing staff to provide a shower to resident; to turn and reposition two (2) of 44 sampled residents as prescribed for wound prevention; and failed to ensure that staff were reporting and documenting changes in resident skin condition as so identified. Subsequently, five (5) of five (5) residents identified by the facility as high risk for developing pressure ulcers had pressure ulcers/injuries first observed by staff at an advance stage (Stage 3, Stage 4 and Unstageable). The findings include: Review of the facility policy entitled, Activities of Daily Living (ADLs), Supporting with a revision date of 03/2018 documented, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently . including appropriate support and assistance with . hygiene (bathing, dressing, grooming, and oral care) . 1. Facility staff failed to bathe, provide oral and nail care to 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.

Based on staff interview, Administration failed to ensure that action plans were developed and implemented to ensure freedom from abuse, neglect and exploitation, to ensure a resident was restraint free, to thorough investigate all allegations of abuse, failed to implement measures to protect a resident involved in the abuse investigation, and to ensure that staff were reporting and documenting changes in resident skin condition as so identified. The resident census was 122. Findings include: 1.In the area of 42 CFR§ 483.12, Freedom from Abuse, Neglect, and Exploitation, the Administration failed to ensure that action plans were developed and implemented to protect and provide a safe environment for one (1) resident from the likelihood of abuse and failed to ensure one (1) resident was free from a physical restraint. Based on the facility's failures, an Immediate Jeopardy (IJ)-K in 42 CFR (Code of Federal Regulations) § 483.10 Abuse, Neglect, and Exploitation on 09/08/2021 at 1:55 PM. A face-to-face interview was conducted with Employee #1 on 8/30/21 at 9:06 AM. The employee…

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 staff interview, the Governing Body failed to ensure that action plans were developed and implemented to ensure freedom from abuse, neglect and exploitation, to ensure a resident was restraint free, to thorough investigate all allegations of abuse, failed to implement measures to protect a resident involved in the abuse investigation, and to ensure that staff were reporting and documenting changes in resident skin condition as so identified. The resident census was 122. Findings include: 1.In the area of 42 CFR§ 483.12, Freedom from Abuse, Neglect, and Exploitation, the governing body failed to ensure that administration developed and implemented actions to developed and implemented to protect and provide a safe environment for one (1) resident from the likelihood of abuse and failed to ensure one (1) resident was free from a physical restraint. Based on the facility's failures, an Immediate Jeopardy (IJ)-K in 42 CFR (Code of Federal Regulations) § 483.10 Abuse, Neglect, and Exploitation on 09/08/2021 at 1:55 PM. A face-to-face interview was conducted with Employee #1 on…

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

Based on observations, record review, resident and staff interview, the facility failed to maintain and implement an effective, comprehensive quality assurance and performance improvement (QAPI) program inclusive of all systems as evidenced by failing to ensure that they developed plans of action to identify quality deficiencies. The resident census during the survey was 122. Findings include: A review of the facility's previous survey dated 11/19/2019 showed that the facility was cited for the following deficiencies: F578 Request/Refuse/Discontinue/Treatment; Formulate Advance Directive F584 Safe/Clean/Comfortable/Homelike Environment F656 Develop/Implement Comprehensive Care Plan F600 Free from Abuse and Neglect F610 Investigate/Prevent/Correct Alleged Violation F641- Accuracy of Assessments F655 -Baseline Care Plan F656 Develop/Implement Comprehensive Care Plan F657 Care Plan Timing and Revision F677- ADL care Provided for Dependent Residents F684 - Quality of Care F686- Treatment/Services to Prevent/Heal Pressure Ulcer F732- Posted Nurse Staffing Information F812- Food…

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 interview, for three (3) of 44 sampled residents, the facility's staff failed to maintain Infection Control Practices when: preparing, serving, and distributing foods under sanitary conditions, as evidenced by using a cooling fan in the kitchen; while providing wound care for one (1) resident, administering medications to one (1) resident; and not sanitizing their hands before entering a resident's room to provide care. (Residents' #87 #47 and #100). The findings include: 1.Facility staff failed to prepare, serve, and distribute foods under sanitary conditions, as evidenced by a cooling fan that was in use, in the kitchen. During a walkthrough of dietary services on 08/23/2021, at approximately 6:45 AM, three cooling fans were being used in the food preparation area. The temperature in the main kitchen at the time of the observation was 86 degrees Fahrenheit. During a face-to-face interview with Employee #1 (Administrator) and Employee # 37, Employee #1 stated The air is…

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 seven (7) of 44 sampled residents, the facility's staff failed to inform residents or their representatives of their rights to formulate Advance Directives for six (6) residents and failed to confirm one (1) resident's code status. (Residents' #3, #5, #21, #37, #76, #95 and #105) The findings include: 1. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses that included: Morbid Obesity, Obstructive Sleep Apnea, Cellulitis, Fibromyalgia, and Lymphedema. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed in section C ( Brief Interview for Mental Status) the resident was given a summary score of 15 indicating that the resident was cognitively intact. Review of the resident's face sheet revealed she was her own responsible party. Review of Resident #3's medical record documented, Full Code. However, the record lacked documented evidence that the facility's staff provided the resident with verbal or written information regarding…

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 Surveyor: [NAME], [NAME] Based on record reviews and staff interviews, for seven (7) of 44 sampled residents, facility staff failed to develop and implement comprehensive person -centered care plans. (Residents' #56, #68, #87, #95, #100, #102 and #105) The findings include: 1.The facility's staff failed to develop and implement a comprehensive person-centered care plan that included Resident #56's smoking preference. Resident #56 was admitted to the facility on [DATE] with the following diagnoses: Peripheral Vascular Disease (PVD), Diabetes Mellitus, Acquired Absence of Right Foot, Opioid Dependence, Cirrhosis, Chronic Pancreatitis, Chronic Viral Hepatitis C, and Depression. During an entrance conference on 08/23/2021 at approximately 9:00 AM, Employee #1 (Administrator) stated that the facility did not have residents that smoke. Review of the care plan revealed it was last updated on 08/24/2021 lacked documented evidence the facility's staff developed a comprehensive, person-centered care plan with goals 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 observation, record review and staff interview, for five (5) of 44 sampled residents, the facility's staff failed to ensure residents received treatment and care in accordance with professional standards of practice and in accordance with residents' choices as evidenced by: facility staff failed to turn and reposition two (2) residents as prescribed for wound prevention; failed to elevate head of bed at a 45-degree angle while one (1) resident's tube (enteral) feeding was infusing; failed to ensure one (1) received restorative nursing for contracture management; failed to follow the physician's orders to obtain one (1) resident's trough levels (lab value). (Residents' #68, #76, #87, #100 and #372) The findings include: 1. The facility ' s staff failed to turn and reposition Residents #68, as prescribed for wound prevention. Review of the Comprehensive Care Plan revealed a focus area of: Activity of Daily Living .Deficit related to Immobility with a revision date on 04/01/2021. The care plan outlined…

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 staff and resident interview, for one (1) of 44 sampled, residents, facility staff failed to provide respiratory care consistent with the professional standards of practice as evidenced by failure to ensure one (1) resident receiving oxygen therapy had physician's orders to direct the amount of oxygen to be delivered to the resident. Resident #21. The findings include: Resident #21 was readmitted to the facility on [DATE], with multiple diagnoses that included: Respiratory Failure, Encounter for Attention to Tracheostomy and Degenerative Joint Disease. Review of the admission MDS dated [DATE] revealed that facility staff coded the following: In Section I (Active Diagnoses), dependence supplemental oxygen . In Section O (Special Treatments, Procedures and Programs), Oxygen, Yes. On 08/2520/2021 at approximately 09:45 AM the resident was observed in bed with a tracheostomy and oxygen in place. Review of the physician's orders revealed no documented evidence of oxygen orders 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 record review and staff interview for two (2) of 44 sampled residents, facility staff failed to accurately reassess and evaluate the resident pain after administering her pain medication. Residents' #56 and #87. The findings include: Review of the facility's policy entitled: Pain Assessment and Management revised March 2015, documented: Assessing Pain 1. During the comprehensive pain assessment [staff is to] gather the following information as indicated from the resident (or legal representative): a. History of pain (as measured on a standardized pain scale); b. Characteristics of pain: (1) Intensity of pain (as measured on a standardized pain scale); (2) Descriptors of pain; (3) Pattern of pain (e.g. constant or intermittent); (4) Location and radiation of pain; and (5) Frequency, timing and duration of pain. c. Impact of pain on quality of life; d. Factors that precipitate or exacerbate pain; e. Factors and strategies to reduce pain; and f. Symptoms that accompany pain (e.g., nausea, anxiety) .…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews, for one (1) of 44 sampled residents, the facility staff failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety as evidence by: failure to maintain Infection Control Practices when administering medications to Resident #47. The findings include: 1.Employee #36 failed to maintain Infections Control Standards of Practice when administering medications for Resident #47. Review of the Administering Medication policy with a revised date of December 2012 instructed staff to .to follow established facility infection control procedures (e.g . antiseptic technique .) for the administration of medications, as applicable. During an observation on 08/23/21 starting at 9:28 AM, Employee #36 (RN) failed to maintain Infection Control Standards of Practice while administering Resident #47 ' s medications, as evidenced below: The employee removed the resident ' s 10 AM…

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, facility staff failed to safely store medications. The findings include: During an observation of 3 west, Team 2 medication cart on [DATE] at 10:50 AM, three (3) resident's Glucagon (treatment for low blood sugar) pens documented an expiration date of 01/2021. During a face-to-face interview conducted at the time of the observation, Employee #21 (Registered Nurse) stated that she would remove the expired Glucagon pens from the medication cart.

Based on observations and staff interview, the facility failed to prepare, serve, and distribute foods under sanitary conditions, as evidenced by a cooling fan that was in use in the kitchenh and food temperatures that were below 135 degrees Fahrenheit (F) on three (3) of nine (9) observations. The findings include: 1. During an observation on 08/23/2021 at approximately 6:00 AM, a cooling fan was noted being used in the kitchen. 2. During food test tray assessment on 08/30/2021, at approximately 1:15 PM, and on 09/01/2021, at approximately 1:30 PM, hot foods such as noodles (110 F), spinach (120 F), and puree fish (114 F) tested below the required 135 degrees Fahrenheit (F). These observations were acknowledged by Employee #46 (Food Service Employee) on 09/01/2021 at approximately 3:00 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for three (3) of 44 sampled residents, facility staff failed to: (1) document in the resident's medical record the information/education provided regarding the benefits and risks of immunization. (2) ensure eligible residents received their immunizations. Residents' #21, #95 and #105. The findings include: Review of the facility's policy entitled, Influenza Vaccine revised 07/2020, revealed, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually . A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record . 1. Resident #21 was readmitted to the facility on [DATE], with multiple diagnoses that included: Degenerative Joint Disease, Respiratory Failure, Dysphagia, and Cerebral Vascular Accident. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed that the facility staff coded the resident as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, facility staff failed to maintain mechanical/electrical equipment in safe operating condition as evidenced by: failure to ensure the air handler was working as intended, and failed to ensure a residents's low-air pressure bed was operating as intended. Resident # 68. The findings include: 1. During a walkthrough of dietary services on August 23, 2021, at approximately 6:45 AM, a cooling fans were being used in the food preparation area. The temperature in the main kitchen at the time of the observation was 86 degrees Farenheit. During a face-to-face interview on 8/23/2021 at approximately 6:45 AM, with Employee #1 and Employee #37, Employee #1 stated, The air is not sufficient in the kitchen. Employee #37 stated, The air handler that services the kitchen, 2 [NAME] and 3 [NAME] is not working. The air handler has been down prior to 5/25/2021. We are losing 25-40% of the air from the unit . During a walkthrough of unit 3 west on 08/23/2021 at approximately 8:30 AM…

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 all staff participated in an abuse, neglect, and exploitation prevention training program and failed to have a process in place to track attendance. The census on the first day of survey was 122. The findings include: Review of the 2020 Skills Competency Packet included training and skills check-off on subjects to include, abuse policy and reporting, restraints, infection control and wound care. Review of the document entitled, 2020 Skills Fair . sign in sheet revealed that 19 out of 135 staff signatures were missing from required training ( that included: two (2) Nurse Supervisors, five (5) Registered Nurses, one (1) licensed Practical Nurse and eight (8) Certified Nurse's Aides) indicating that they did not participate in the annual skills annual fair. During a face-to-face interview conducted on 09/08/2021 at 11:30 AM, Employee #2 (Director of Nursing) stated, All nursing staff are required to attend the annual skills fair. It is mandatory. When asked about the staff who did not sign in, she stated, 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 record review and staff interview, facility staff failed to provide sufficient training to nurse's aides after it found that residents were observed/being treated in a manner that indicated additional training was needed. The resident census on the first day of survey was 122. The findings include: 1. Review of Employee #5's personnel file revealed a facility document dated 07/20/2020 that showed, . This is the second occurrence within the week where [Employee #5] provided care to residents in a manner previously instructed to [Employee #5] should not provide to the residents. The type of care provided by [Employee #5] to the residents is Acting in away that can be considered abuse or neglect or mistreatment of a patient/resident either physically, mentally, or verbally. Review of Employee #5's education and training file lacked documented evidence that any additional training was conducted after these incidences occurred, yet he was allowed to return the unit(s) to perform resident care. During a face-to-face interview conducted on 09/08/2021 at approximately 12:15 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews for one (1) of 44, sampled residents the facility ' s staff failed to ensure a resident was provided dignity and privacy due to not covering the urine collection bag. (Resident #102). The findings include: Resident #102 was re-admitted to the facility on [DATE] with multiple diagnoses including Stage 4 Pressure Ulcer of sacral area, Stage 4 bilateral buttocks pressure ulcers, Multiple Fractures of Ribs, and Unspecified Fracture of lower end of right Femur. On 08/24/2021 at approximately 4:00 PM, Resident #102 was observed in his room with his urine collection bag uncovered and filled to capacity with urine. Review of a physician order dated 06/26/2021, directed - Foley (catheter) size # 18 .Measure urine output every shift . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section H (Bladder and Bowel) the resident was coded as A indicating the presence of an indwelling catheter. During a face-to-face interview on 08/24/2021 at…

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

Based on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by five (5) ceiling tiles in the supply room that were stained throughout and two (2) ceiling tiles in the staff breakroom that were also soiled. The findings include: During an environmental walkthrough of the facility storage room in material management on September 1, 2021, at approximately 1:00 PM, five (5) ceiling tiles in the main supply room and two (2) ceiling tiles in the staff break room were marred with dark stains throughout. Employee #37 acknowledged the findings during a face-to-face interview on 09/01/2021, at approximately 4:00 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 44 sampled residents, facility staff failed to ensure that one resident was free from a physical restraint. (Resident #95) The findings include: Resident #95 was admitted to the facility on [DATE], with multiple diagnoses that included: Cerebral Infarct due to Embolism of Left Middle Cerebral Artery, Restlessness and Agitation, Attention for Encounter Gastrostomy and Attention for Encounter Tracheostomy. Review of the facility's policy, Use of Restraints with a revision date of 04/2017 revealed, . Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted . Review of a facility reported incident (FRI) on 01/27/2021 documented, . During rounds on 1-27-2021 her (Resident #95) mitten was found tied to the rail. It was immediately released, and the patient was assessed .Investigation is ongoing . Review of Resident #95's admission Minimum Data Set)dated 01/26/2021, revealed that facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: [NAME], Gemina Based on record review and staff interview, facility's staff failed to ensure all the required documents were conveyed to the receiving health care provider for two (2) of 44 sampled residents that were transferred from the facility. (Residents' #97, and #103) The findings include: 1. Resident #97 was admitted to the facility on [DATE] with multiple diagnoses that included: Acute and Chronic Respiratory Failure and Encounter for Tracheostomy. Review of the physician's order dated 08/17/2021 at 10:57 AM, directed, Transfer to hospital to [Hospital's name] via 911. Review of Resident #97's transfer documents dated 08/17/2021, lacked documented evidence that the facility's staff included the care plan goals with the resident's transfer packet. During a face-to-face interview conducted on 08/26/2021 at approximately 10:30 AM, Employee #2 (Director of Nursing) stated that care plan goals were not part of the documents included in the transfer packet. 2. Resident #103 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility's staff failed to ensure a Minimum Data Set Assessment accurately reflected a resident's mental status for one (1) of 44 sampled residents. (Resident #87) The findings include: Resident #87 was re-admitted to the facility on [DATE]. The medical record showed the resident had several diagnoses including Dependency on Respirator [Ventilator], Tracheostomy, Obesity, Gastrostomy and Stage 4 Sacral Pressure Ulcer. Review of the History and Physical dated 03/01/2021, the physician documented, .On February 2nd 2021 she (Resident #87) suffered a cardiopulmonary arrest .Currently, the patient appears to be in a vegetative state and on full mechanical support (Ventilator) . Review of a Quarterly Minimum Data Set, dated [DATE] revealed, In Section C (Brief Interview of Mental Status) [BIMS] the resident was given a summary score of 11 for the indicating that Resident #87 was moderately impaired cognitively. During a face-to-face interview conducted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for three (3) of 44, sampled residents, facility staff failed to develop and implement a baseline care plan within 48 hours of admission. (Residents' #95, #105 and #372). The findings include: 1. Resident #95 was admitted to the facility on [DATE], with multiple diagnoses that included: Restlessness and Agitation, Attention for Encounter Gastrostomy and Attention for Encounter Tracheostomy. Review of the physician's orders revealed the following: 01/19/2021-Assess left wrist restraint q (every) 2 hours and document any findings every 2 hours 01/19/2021- Keep left wrist restraint in place to prevent patient from pulling on her trach (tracheostomy) or G (gastrostomy)- Tube q shift Review of Resident #95's admission Minimum Data Set (MDS) dated [DATE] revealed that facility staff coded the following: In Section P (Restraint), Limb restraint [hand mitten] . Used daily During a review of Resident #95's care plan, there was no documented evidence 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 for three (3) of 44 sampled residents, the facility's staff failed to revise the person-centered care plan to address resident needs and diagnoses. (Residents' #56 #78, #87) The findings include: 1A. The facility's staff failed to revise and update the comprehensive care plan to address Resident's #56 discontinued use of an indwelling urinary catheter. Resident #56 was admitted to the facility on [DATE] with the following diagnoses: Peripheral Vascular Disease , Diabetes Mellitus, Acquired Absence of Right Foot, Opioid Dependence, Cirrhosis, Chronic Pancreatitis, Chronic Viral Hepatitis C, and Depression. Review of the Quarterly Minimum Data Set, dated [DATE] revealed in Section C (Cognitive Patterns), that Resident #56 was documented as having a Brief Interview for Mental Status Summary Score of 15 indicating the resident was intact cognitively. In Section H (Bowel and Bladder), the resident was not coded for the use of an indwelling urinary catheter. During a tour of…

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, staff and resident interview, for two (2) of 44 sampled residents, facility staff failed to ensure residents who are unable to carry out Activities of Daily Living (ADL) received the necessary personal hygiene. (Residents ' #25 and #37) The findings include: Review of the facility's policy entitled, Activities of Daily Living (ADLs), Supporting with a revision date of 03/2018 documented, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently . including appropriate support and assistance with . hygiene (bathing, dressing, grooming, and oral care) . 1. The facility's staff failed to empty the urinal (urine collection device) for Resident #25. Resident #25 was admitted to the facility on [DATE] with multiple diagnoses that included: Blindness Right Eye Category 4, Muscle Weakness, Anemia, Hypertension, and Type 2 Diabetes Mellitus with Hyperglycemia. During a face-to-face interview on 08/23/2021 at 4:46 PM, Resident #25…

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 44, sampled residents, facility staff failed to implement the use of orthotics to prevent decrease in range of motion and mobility. Resident #48 The findings include: Resident #48 was admitted to the facility on [DATE], with multiple diagnoses including: Paraplegia, Muscle Weakness, Other Muscle Spasm, Pain Unspecified, Aphasia and Respiratory Failure. Resident #48 was observed on 08/23/2021 at approximately 9:05 AM receiving care from Employee #43 (Licensed Practical Nurse) and it was noted that Resident #48's hands were tightly clasped in a fist like position and residents arms were stiff and difficult for staff to move. Review of Resident #48's Quarterly Minimum Data Set (MDS) dated [DATE], revealed: In Section C (Cognitive Patterns) C0100 facility staff coded resident as a 0 meaning resident is rarely/never understood. In Section G (Functional Status) G0110 facility staff coded resident a 4 for bed mobility meaning resident is totally…

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 record review for one (1) of 44 sampled residents, facility staff failed to provide adequate supervision to monitor the residents whereabout in and out of the facility for Resident #93 who left the facility without the staff knowledge; and facility staff failed to provide an environment free from accident hazards as evidenced by a portable space heater that was seen in one (1) of 76 resident's rooms. The findings include: 1.Resident #93 was admitted to the facility on [DATE] with diagnoses that included: Fracture of the Lower End of Right Tibia, Anemia, Unsteadiness on Feet, Weakness, Schizoaffective Disorder, and Bipolar Type. According to the Quarterly Minimum Data Set (MDS) dated [DATE] the resident's Brief Interview for Mental Status (BIMS) Score was 15 indicating that the resident was cognitively intact. In Section G (Functional Status), the resident was coded as requiring supervision and set up help only for bed mobility; he was coded as independent in transferring, eating, toilet…

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 record review, for two (2) of 44 sampled residents, facility staff failed to weigh a resident every 30 days as ordered and verify accurate weights were being obtained. Residents' #37 and #95. The findings include: Review of the facility's policy entitled, Charting and Documentation revised 07/2017, revealed, . Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . 1. Facility staff failed to weigh Resident #37 every 30 days as ordered by the physician. Resident #37 was re-admitted to the facility on [DATE]. The record showed resident had the following diagnoses: Anemia, Hypertension, Diabetes Mellitus, Hyperlipidemia, Cerebral Vascular Accident (CVA), Hemiplegia, Seizure Disorder, Depression, Schizophrenia, and Paranoid Personality Disorder. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the following: In Section C (Cognitive Patterns), Resident #37 had a Brief Interview for Mental Status (BIMS) Summary…

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 and staff interview, it was determined that the facility failed to ensure that the required daily nurse staffing information was posted. The findings include: An observation on unit 1 south on 08/23/2021 [08/22/2021 night shift] at 6:00 AM, revealed the posted daily nurse staffing information on the wall board across from the nurse's station on unit 1 south that was dated 08/20/2021. However, Employee #48 (Night Supervisor) provided the surveyor with a written daily assignment sheet for the current shift (night dated 08/22/2021). During a face-to-face interview conducted at the time for the observation, Employee #48 failed to provide a comment to address why the most current daily nurse staffing information was not posted (08/22/2021).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for two (2) of 44 sampled residents facility, staff failed to: monitor for side effects and effectiveness of the resident's prescribed psychotropic medications for depression and anxiety; and ensure a resident was evaluated by a psychiatrist, as ordered by the physician. Residents' #100 and #102. The findings include: 1. The facility's staff failed to monitor Resident #100 for side effects and effectiveness of his prescribed psychotropics medications. Resident #100 was admitted to the facility on [DATE] with multiple diagnoses including Anxiety and Depression. Review of physician orders revealed the following: 04/26/2021- Diazepam (antianxiety) 5 mg (milligram) 1 tablet via G(Gastrostomy) tube every twelve hours for anxiety. 04/27/2021- Antipsychotic medication-monitor for dry mouth, constipation, blurred vision, disorientation/confusion difficulty urinating, hypotension, dark urine, yellow skin . 07/09/2021-Quetiapine Fumarate (antipsychotic) 25 mg Give 3 tablet via…

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

Based on observation, record review and staff interview, facility staff failed to accurately reconcile narcotics. The findings include: During a review of the narcotic storage box on 08/23/2021 at 6:51 AM on Unit 3 West, it was observed that a resident's medication blister packet labeled, Diazepam (antianxiety) 2 mg (milligram) tab (tablet) 1 tab by mouth at bedtime, had 20 remaining tablets. However, the narcotic book documented, 21 tablets should be remaining. During a face-to-face interview conducted at the time of the observation, Employee #31 (Registered Nurse) stated, I gave the resident one tablet last night at 10:00 PM but I forgot to sign it off in the book.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, facility staff failed to ensure two (2) of 44 sampled residents were free from unnecessary pain medications. Resident #56 and #87. The findings include: Review of the facility's policy entitled: Pain Assessment and Management revised March 2015, documented: Assessing Pain 1. During the comprehensive pain assessment [staff is to] gather the following information as indicated from the resident (or legal representative): a. History of pain (as measured on a standardized pain scale); b. Characteristics of pain: (1) Intensity of pain (as measured on a standardized pain scale); (2) Descriptors of pain; (3) Pattern of pain (e.g. constant or intermittent); (4) Location and radiation of pain; and (5) Frequency, timing and duration of pain. c. Impact of pain on quality of life; d. Factors that precipitate or exacerbate pain; e. Factors and strategies to reduce pain; and f. Symptoms that accompany pain (e.g., nausea, anxiety) . Implementing Pain Management Strategies: .6.…

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 44 sampled residents, facility's staff failed to: accurately document the resident's weight for one (1) resident; accurately document the side effects as ordered by the physician and as directed in the care plan for a resident receiving psychotropic medications for one (1) resident; and record the administration of the resident receiving Symbicort Aerosol and Peri trach care on the Treatment Administration Record and Respiratory Medication Administration for one (1) resident. Residents' #3, #5 and #119. The findings include: 1.Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including Morbid Obesity, Cellulitis, and Lymphedema . Review of the medical record showed a hospital discharge summary from a local hospital that documented Resident #3 ' s weight as 179.7 kilogram (396 pounds) on 07/02/2021. Review of Resident #3 ' s Weight Summary List revealed that the resident weighed 285 pounds on 07/10/2021 and 497.5 pounds on…

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