Regal Heights Healthcare & Rehab Center

Based on observation, interview and record review, it was determined that for one (R70) out of 35 sampled residents, the facility failed to provide incontinence care to a resident who was unable to carry out out activities of daily living. Findings include: Cross refer F604 Review of R70's records revealed: 9/24/19 - R70 was admitted to the facility. 9/25/19 (revised 5/1/20) - R70's ADL care plan stated, [R70] was unable to do own ADLs (Activities of Daily Living) without assist related to cognitive loss and interventions included . toileting schedule as resident allows . 9/25/19 (revised 10/18/23) - R70 was care planned for incontinence of bowel and bladder related to cognition and interventions included . encourage highest level of independence of toileting as possible and toilet at regular intervals if able. 2/21/25 - R70's quarterly MDS assessment indicated that R70's cognition was severely impaired with short and long term memory problems. R70 was dependent with toileting hygiene and was always incontinent of urine and bowel. 5/20/25 1:50 PM - During interview, E14 stated, . I…

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 interview, it was determined that for one (R22) out of one sampled resident reviewed for hearing/vision, it was determined that the facility failed to ensure that R22 received proper treatment and assistive device to maintain hearing abilities. Findings include: Review of R22's clinical record revealed: 12/13/22 - Resident was admitted to the facility. 12/19/22 - R22's admission MDS indicated that R22's cognition was intact, had adequate hearing and did not use a hearing aid. 1/18/23 - R22 had a care plan developed for impaired verbal communication related to hard of hearing with interventions including to assess [R22's] hearing and vision, and if deficits are noted, refer resident for further evaluation and treatment. 3/13/23 - R22's quarterly MDS indicated that R22 had minimal difficulty with hearing and did not use a hearing aid. 1/18/23 - R22 had a care plan developed for impaired verbal communication related to hard of hearing with interventions including to asses [R22's] hearing and vision, and if deficits are noted, refer resident for further…

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, interview and review of the facility's policy and procedures it was determined that the facility failed to provide the appropriate care and services to one (R163) out of one sampled resident who had a PEG/feeding tube through the abdomen into the stomach for medication administration. Findings include: Cross refer F759 Review of R163's clinical record revealed: 3/28/25 - R163 was admitted to the facility. 3/31/25 - R163 had a care plan developed for potential for alteration in nutrition/hydration related to NPO (eating nothing by mouth) status and traumatic brain injury requiring tube feeding for nutrition/hydration. R163's interventions included tube feeding and flushes as ordered. 3/28/25 - R163 had a physician's feeding tube order to flush tube with 5 ml (milliliters) of water between each medication. 3/28/25 - R163 had a physician's feeding tube order to flush with 30 ml of water before and after each medication. 4/3/25 - R163's MDS (Minimum Data Set) assessment indicated that R163 had an intact cognition and is dependent with the use of the feeding tube…

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 interview, it was determined that for two (R1 and R81) out of three residents reviewed for respiratory, the facility failed to have the CPAP( a repiratory device the deliers continuous positive airway pressure) settings written in the orders. Findings include: 1. Review of R21's clinical record revealed: 12/13/24 - R21 was admitted to the facility with diagnoses including but not limited to, obstructive sleep apnea. 12/13/24 - P2 (NP) ordered in R21's EMR, CPAP on at HS (hour of sleep), off in AM in the morning and at bedtime apply. The facility failed to order the CPAP machine settings required for R21's care. 2. Review of R81's clinical record revealed: 7/8/24 - R81 was admitted to the facility with diagnoses including but not limited to, obstructive sleep apnea. 8/3/24 - E5 (DO) ordered in R81's EMR, CPAP on at HS, off in AM, settings at bedtime apply and in the morning remove. The facility failed to order the CPAP machine settings required for R81's care. 5/22/25 11:07 AM - During a telephone interview, P5 (respiratory therapist) stated, Those two…

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 interview it was determined that the facility failed to ensure that it was free of medication error rate of 5 percent or greater. During medication pass observation on 5/16/25, 9 medication errors out of fourty four opportunities were identified, resulting in a medication error of 20.45% and affecting 1 resident (R163). Findings include: Cross refer F693 Observation of R163s' medication pass via the peg/feeding tube (a tube that is passed into a patient's stomach through the abdominal wall) revealed the following: 5/16/25 8:45 AM - E16 (LPN) opened the drawer of the medication cart and pulled out R163's morning medications. E16 proceeded to open the following medications and put into the medication cup: - Aspirin 81 mg capsule 1 cap - Multivitamin tablet 1 tab - Vitamin B12 1,000 mcg 1 tab - Vitamin D3 25 mcg 2 tablets - Gabapentin 300 mg 1 capsule - Magnesium Oxide 400 mg 1 tablet - Dantrolene Sodium 25 mg 1 capsule - Midodrine HCL 5 mg 1 tablet 5/16/25 8:48 AM - E16 poured the oral medications into the pill crusher pouch and then used 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 observation, interview, and review of facility documentation, it was determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to have proper PPE (Personal Protective Equipment) worn for two employees after direct resident contact during bedside patient care observations. In addition, the facility failed to perform hand hygiene and change gloves for one employee during a wound dressing change observation. Findings include: The facility policy titled, Enhanced Barrier Precautions (2001) documented, . 1. Enhanced barrier precautions (EBPs) are used as infection prevention and control interventions to reduce the spread of multi-drug resistant organisms (MDROs) to residents . 2. 3. Gloves and gowns are applied prior to performing the high contact resident care activities . 4. Personal protective equipment (PPE) is changed and hand hygiene performed before…

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 interview, it was determined that for five (R119, R143, R158, R160 and R267) out of ten residents reviewed for vaccines, the facility failed to ensure that these residents' vaccination status was accurately documented. For four (R119, R143, R158, R267) out of ten residents reviewed for vaccines, the facility failed to offer the four residents the pneumococcal vaccine. For six (R119, R143, R158, R160, R267) out of ten residents reviewed for vaccines, the facility failed to assess and document the residents' influenza vaccine. For R267, the facility failed to check Delvax, where there was documentation of a flu vaccine on 9/18/2024. Findings include: 1. Review of R119's clinical record revealed: 2/20/25 - R119 was admitted to the facility. 5/19/25 11:25 AM - A review of R119's EMR revealed no evidence of the facility assessing and offering R119 the influenza and the pneumococcal vaccines. 2. Review of R143's clinical record revealed: 4/14/25 - R143 was admitted to the facility. 5/19/25 11:28 AM - A review of R143's EMR revealed no evidence of the facility…

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

Based on record review and interviews, it was determined that for three (R143, R158, R160) out of ten residents reviewed for vaccines, the facility failed to assess and offer the COVID vaccine. Findings include: 1. Review of R143's clinical record revealed: 4/14/25 - R143 was admitted to the facility. 5/19/25 11:28 AM - A review of R143's EMR revealed no evidence of the facility assessing and offering R143 the COVID vaccine. 2. Review of R158's clinical record revealed: 2/26/25 - R158 was admitted to the facility. 5/19/25 11:32 AM - A review of R158's EMR revealed no evidence of the facility assessing and offering R158 the COVID vaccine. 3. Review of R160's clinical record revealed: 2/27/25 - R160 was admitted to the facility. 5/19/25 11:35 AM - A review of R160's EMR revealed no evidence of the facility assessing and offering R160 the COVID vaccine. 5/20/25 2:45 PM - The facility was unable to provide evidence of these residents' vaccination or declination of the vaccines when documentation was requested. 5/21/25 11:30 AM - During an interview, E2 (DON) stated that the facility 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.

Based on record review and interview, it was determined that for one (R65) out of thirty-five sampled residents, the facility failed to provide and evaluate staff for appropriate competencies and skill sets regarding R65's LVAD (left ventricular assist device) as identified in the resident assessment. Findings include: 5/19/25 1:30 PM - A review of the facility assessment, Section III Resources Needed documented the facility as having Special Care Needs population regarding: dialysis, hospice, ostomy care, tracheostomy care, bariatric care, palliative care, end of life care and LVAD (left ventricular assist device). 5/19/25 4:21 PM - During an interview, E1 (NHA) stated, I don't have competencies for the LVAD. [E41], the unit manager, has started some education for the LVAD but we don't have anything formalized. We need to get the staff more education on this. 5/20/25 2:15 PM - During an interview, R65 stated that the staff were knowledgeable about his LVAD. R65 stated that during the weekly drive line exit site dressing change, the staff wear the gowns and gloves. 5/20/25 2:35 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.

Based on interview and record review, it was determined that for one (R167) out of six (6) residents reviewed for abuse, the facility failed to ensure that R167 was protected from verbal abuse. Findings include: Review of R167's clinical records revealed: 11/12/24 - R167 was admitted to the facility with diagnoses including end stage renal failure, heart failure and morbid obesity. 2/11/25 - R167's quarterly MDS documented a BIMS score of 15, indicating a cognitively intact status. The MDS also documented that R167 was independent with activities of daily living. 4/2/25 8:00 PM - The facility's investigation documented that R167 wanted to take a shower but there were used towels on the bathroom floor. He requested that the bathroom be cleaned. E6 (CNA) told R167, If you don't think I am doing my job, then speak to the supervisor. Approximately one hour later, E6 overheard R167 telling his significant other on the phone about the dirty towels in the shower. E6 stated, Why are you still talking about it? It was a mistake. E6 began to yell profanities at him. Both E6 and R167 then…

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, it was determined that for two (R6 and R22) of six residents reviewed for abuse, the facility failed to report an allegation of abuse within two hours. Findings include: 1. Review fo R22's clinical record revealed: 5/3/25 8:30 AM - A facility incident report documented, . [R22] presents wit (sic) 2 bruises on the the inner side of the left arm above the elbow. Main bruise is 13.0 x 10.5 and smaller bruise above it is 2.5 x 3.0. [R22] did not know how it occurred. RCA (Root Cause Analysis) Summary: . bruises appear that they may have been caused by a hand that may have been facilitating a transfer . [R22] also noted to have been transported to the dentist by family on 4/30/25 .also noted to be on aspirin therapy . 5/20/25 3:00 PM - Review of the state incident report database lacked evidence that the facility reported the incident to the state incident reporting center. 5/22/25 - A written statement by E2 (DON) documented, I have observed family both daughter and son, 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.

Based on observation, interview, and record review, it was determined that for one resident (R108) out of four (4) residents reviewed for accidents, the facility failed to ensure that R108 received adequate supervision and assistance to prevent accidents to the extent possible. R108 was left sitting on the side of the bed during care and fell to the floor. R108 sustained a large hematoma on her forehead and was sent emergently to hospital. Findings include: Review of R108's clinical records revealed: 3/22/24 - R108 was admitted to the facility with diagnoses including dementia, major mood disorder and age-related osteoporosis. 3/24/24 - R108's fall care plans included, Potential for (actual) falls r/t (related to) poor safety awareness Resident will not sustain or be injured from falls X 90 days. The interventions included, Bed in lowest position when care is not being provided. 2/24/25 - E108's annual MDS documented a BIMS score of 00, indicating a completely impaired cognitive status, and was completely dependent on staff for dressing and undressing of both lower and upper…

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 interview it was determined that for three (R15, R19, R20) out of seven residents reviewed for falls, the facility failed to meet professional standards of the Delaware Board of Nursing Scope of practice by failing to have a registered nurse (RN) complete and document an RN post- fall assessment . Findings include: Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2024 . RN (registered nurse) .post-fall assessment and documentation . 1. Review of R15's clinical record revealed: 3/31/18 - R15 was admitted to the facility with diagnoses, including but not limited to, stroke and difficulty walking. 4/28/24 5:40 AM - E12 (LPN) documented in R15's EMR (electronic medical record), While standing at the med cart, a loud thump could be heard .she [R15] could be seen laying on the floor, the supervisor was then called to the room to assess the resident. The resident was assessed and vitals were taken . 4/28/24 6:30 AM - E12 (LPN) documented in R15's EMR, left with EMS (emergency medical services). Review of R15's EMR progress notes after the 4/28/24 fall…

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, interview and review of other facility documents as indicated, it was determined that the facility failed to ensure that one (R14) out of one resident was provided respiratory care consistent with physician's orders. Findings include: 6/6/22 - R14 was admitted to the facility with multiple diagnoses, including Chronic Obstructive Pulmonary Disease (COPD), and dysphonia (difficult speech). R14's admission MDS documented R14's speech clarity as being no speech, absence of spoken words. On 6/7/24 the following progress notes were written: 10:37 AM - E14 (LPN) wrote that at 10:30 AM R14 wrote a note was complaining of having a hard time breathing and that E14 and E15 (RN) assessed [R14's] oxygen level to be in the low 70's, with an elevated heart rate of 104. We got her to calm down so she could control her breathing which worked her 02 started increasing to low 80's, reached out to NP to obtain a stat chest x-ray and some oxygen. 10:51AM - E14 wrote that R14 was still having a hard time breathing, after taking a listen to her he (sic) is wheezing and her 02 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 interview and record review, it was determined that for one (R12) out of one residents sampled for pain management, the facility failed to monitor the resident's pain to the extent possible in accordance with the comprehensive assessment and care plan, and current professional standards of practice. Findings include: 4/4/22 - R12 admitted to the facility with a diagnosis of dementia. 2/5/25 - a review of R12's care plan dated 4/4/22 reveals that staff should assess for verbal or non-verbal signs and symptoms of pain. A review of R12's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS)could not be conducted because the resident is rarely/never understood. The same MDS identifies R12's Speech Clarity: Unclear speech - slurred or mumbled words; Ability to express ideas and wants: Rarely/never understood; Ability to Understand others: Rarely/never understands. 8/29/24 - R12 admitted to hospice. 9/22/24 - At approximately 7:20 PM, nurse aides providing care…

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 interview and record review, it was determined that for one (R1) out of seven residents reviewed for falls, the facility failed to have complete, readily accessible medical records regarding the required post-fall assessment. Findings include: Review of R1's clinical record revealed: 12/10/07 - R1 admitted to facility for CAD (coronary artery disease), HTN (hypertension), PVD (peripheral vascular disease), and right-sided hemiplegia. 10/2/24 - Progress note entered by E11 (RN, charge nurse) at approximately 8:45 PM revealed R1 was found on the floor of his room. He explained to staff that he was removing the footrests from his wheelchair in preparation for going to bed as he does every night. He leaned forward too far and fell out of his chair and onto the floor. R1 has a BIMS of 15 (indicating a resident is cognitively intact), according to his MDS dated [DATE]. 10/2/24 8:56 PM - Progress note entered by E11 (RN, charge nurse) states Resident assessed with small skin tear to right lower leg .resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that for one (R10) out of twenty-eight residents reviewed for environment, the facility failed to maintain the water supply/patient care equipment was in safe operating condition. Findings include: Facility 's Safety of Water Temperatures policy- Domestic water in the facility shall be kept within a temperature range of 95-110 degrees to prevent scalding of residents and to maintain temps (temperatures) for infection control and good handwashing practices . 2. Mixing valves are to be set at 110 degrees to ensure domestic water temperatures are provided to resident rooms, bathroom common area fixtures and shower/tub rooms . 3. Maintenance staff are responsible for checking thermostats, mixing valves and temperature controls in the facility. 4. Maintenance staff shall conduct daily water temperature checks and record the water temperature in a water temperature log . 6. Recordings will be taken on each wing or floor, the date, time and location is to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that for four out of five unit's nourishment areas the facility failed to ensure unit refrigerator food items were dated and labeled. Findings include: The facility policy on Food brought by family/visitors last updated March 2024 indicated, Food bought in by family/visitors that is left with the resident to consume later is labeled, resident name and date. The following observations were made during unit refrigerator tours: - 4/24/24 11:08 AM - The [NAME] unit refrigerator contained one undated, unlabeled garden salad. Finding immediately confirmed by E10 unit clerk. - 4/24/24 11:10 AM - The Eastburn unit freezer/refrigerator contained an undated and unlabeled bag of frozen food, a tea bag, and a bowl of cold cereal. E46 (RN) immediately confirmed the finding. - 4/26/24 1:54 PM - The [NAME] unit refrigerator contained an unlabled and undated pint of fresh strawberries and a Tupperware inside a Ziploc bag. E45 (RN) immediately confirmed the finding. - 4/26/24…

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 observation and interview, it was determined that for two (R154 and R28) out of 40 residents observed the facility failed to ensure the residents right for a dignified existence and privacy was upheld. Findings include: 1. 4/18/24 12:11 PM - During a lunch observation on the [NAME] unit E43 (LPN) referred to R154 as a feeder when removing the resident's lunch tray from the dining care. E43 then stood over R154 while assisting R154 with her meal. E43 immediately confirmed the finding. 2. 4/25/24 11:22 AM - 11:58 AM- During a dressing change observation the privacy curtain to R28's room remained opened. Additionally, E44 (RN) placed a bandage on R28's foot and buttocks. After placing the bandage on R28, E44 then signed and dated the bandages while they were already on the resident. E44 immediately confirmed the finding. 5/1/24 at 1:30 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E28 (CRM) and representatives with the Ombudsman's Office.

Based on interview and record review, it was determined that for one (R35) out of four residents reviewed for advance directives, the facility failed to offer R35 the opportunity to formulate an advanced directive. Findings include: R35's clinical record revealed: 1/29/24 - R35's quarterly MDS assessment documented that she was cognitively intact with a BIMS (Brief Interview of Mental Status) of 15. Review of R35's clinical record lacked evidence that R35 was offered the opportunity to formulate an advanced directive. 4/26/24 at 2 PM - During an interview, E42 (SW) reviewed the facility's process and acknowledged that R35 was not offered the opportunity to formulate a written advanced directive. E42 stated that she would check with R35 right now and offer the opportunity. 5/1/24 at 1:30 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E28 (CRM) and representatives with the Ombudsman's Office.

Based on interview and record review, it was determined that for one (R130) out of six residents sampled for nutrition and one (R146) out of seven residents sampled for hospitalization, the facility failed to ensure accuracy of the MDS assessments for each resident. Findings include: 1. R130's clinical record revealed: 12/11/23 - R130's physician ordered diet was mechanical soft texture. 4/16/24 - R130's quarterly MDS assessment was not accurately coded to reflect his mechanical diet. 4/24/24 at 10:01 AM - During an interview, finding was confirmed with E48 (RNAC). 2. R146's clinical record revealed: 2/23/23 (revised) - R146 was care planned for requiring hemodialysis for a diagnosis of end stage renal disorder with an approach that specified the offsite location and the treatment days: Tuesday, Thursday and Saturday. 2/16/24 - R146's quarterly MDS assessment was not accurately coded to reflect his required ongoing dialysis treatment under Section O - Special Treatments, Procedures, and Programs. 5/1/24 at 10:42 AM - During an interview, finding was confirmed with E48 (RNAC). 5/1/24…

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.

Based on observation and interview, it was determined that for one (R29) out of three residents reviewed for dental services the facility failed to develop a care plan to address the resident's missing teeth. Additionally, for one (R169) out of three residents reviewed for behavior, the facility failed to develop a person centered care plan to address R169's new medical diagnoses of depression and anxiety disorder. Findings include: 1. 12/5/23 - An admission MDS assessment documented R29 had obvious cavity or broken natural teeth. During initial pool screening on 4/18/24 at 12:18 PM, R29 was observed to have missing teeth. During an interview on 4/19/24 at 10:43 AM, FM1 stated, He is losing teeth like crazy and I am worried about that. 4/20/24 - Review of R29's clinical record lacked evidence of a care plan that addressed the resident's broken teeth. During an interview on 4/24/24 at 12:33 PM, E17 (RN) and unit manager confirmed a care plan for R29's missing teeth had not been created but that one would be created immediately. 2. Review of R169's clinical records revealed 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 observation, interview and record review, it has been determined that for one (R41) out of one resident reviewed for range of motion and mobility, the facility failed to provide appropriate services, equipment and assistance to maintain function and mobility or prevent further decrease in range of motion to R41's left wrist and hand. Findings include: Review of R41's clinical record revealed: 3/14/24 - R41 was readmitted to the facility with diagnoses including but not limited to stroke, left side weakness and contractures. 2/9/23 - A review of the facility contracture measurement comparison evaluation revealed R41 has severe contractures to the left wrist and left hand. 2/2/24 - A review of the facility contracture measurment comparison evaluation revealed R41 has severe contractures to the left wrist and left hand. 3/13/24 3:00 PM - A treatment order for R41 documented adaptive equipment left hand/wrist orthotic to be donned for five hours as tolerated, with skin checks performed every shift for hand therapy. 4/18/24 11:01 AM - R41 was observed in bed and did not have 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 interview, it was determined that for three (R91, R132 and R136) out of five residents reviewed for abuse, the facility failed to ensure that each resident were free from abuse. Findings include: A facility policy dated 2001, revised 4/21, and titled, Abuse, Neglect .Prevent Program, documented, Residents have the right to be free from abuse . Review of R136's clinical records revealed: 1. 6/18/22 - R136 was admitted to the facility with diagnoses including right sided weakness, anxiety, and depression. R136's BIMS score was 13 (cognitively intact). 6/21/22 - R136's care plan documented, Approach calmly and give empathy, support and compassion. a. 8/18/23 4:30 PM - R136 reported that he felt that E27 (LPN) was disrespectful and rude to him when she told him she was not going to bring his medications out to the front of the building anymore. 4/21/24 10:20 AM - During an interview, R136 stated, I live at this facility because I can't remember to take my medications at home. I tried to…

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

2. 9/4/23 - R174 was admitted to the facility. A review of the clinical record revealed the following 9/4/23 facility admission assessments conducted by E68 (LPN): admission evaluation, AIMS (Abnormal Involuntary Movement Scale) evaluation, Bladder and Bowel Continence evaluation, Braden (scale for predicting pressure ulcer risk) evaluation, Elopement evaluation, Fall Risk evaluation and Skilled Nurse admission note. Of note, E40 (RN) completed the Side Rail/Restraint evaluation and E47 (RN) completed the Skin Only evaluation. 3. 11/27/23 - R176 was admitted to the facility. A review of the clinical record revealed the following 11/27/23 facility admission assessments conducted by E64 (LPN): admission evaluation, AIMS evaluation, Bladder and Bowel Continence evaluation, Braden evaluation, Elopement evaluation, Fall Risk evaluation, Side Rail/ Restraint evaluation, Smoking Screen evaluation and Skilled Nurse admission note. Of note, E19 (RN) did complete the Skin Only evaluation. 4. 11/1/23 - R177 was admitted to the facility. A review of the clinical record revealed the following…

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 interview, it was determined that for three (R12, R165, R174) out of five reviewed for Accidents, the facility failed to ensure that the physician conducted the required visits. Findings include: 1. Review of R12's clinical record revealed: 1/24/14 - R12 was admitted to the facility, with diagnoses including but not limited to, dementia and atrial fibrillation. 6/20/23 - R12 was examined by E52 (MD). 1/20/24 - R12 was examined by E52 (MD). R12 went 213 days between physician visits instead of the 120 days as required 2. Review of R174's clinical record revealed: 9/4/23 - R174 was admitted to the facility. 9/6/23 - R174 was examined by E52 (MD). 12/7/23 - R174 was examined by E52 (MD). R174 went 92 days between physician visits. During the first 90 days of an admission to a skilled nursing facility, by regulation a patient should be examined every 30 days. 3. Review of R176's clinical record revealed: 11/27/23 - R176 was admitted to the facility. 11/28/23 - R176 was examined by E52 (MD). R176 was not seen by a physician during December 2023. During 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 interview and review of facility and other documentation as indicated, it was determined that for one (R132) out of five residents reviewed for abuse, the facility failed to report staff to resident abuse to the State Agency within the two hour requirement. Findings include: Cross refer to F600, example 3 The facility's policy and procedure entitled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, stated, . 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials . 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; . 3. 'Immediately' is defined as: a. within two hours of an allegation involving abuse . Review of the facility's investigation revealed: 7/24/23 - On the 3-11 PM shift, a…

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

Based on interview and record review it was determined that for one (R35) out of six residents reviewed for communication-sensory, the facility failed to ensure nursing staff provided communication assistive devices. Findings include: R35's clinical record revealed: 6/16/22 (revised) - R35 was care planned for impaired verbal communication related to dsyarthria (speech disorder caused by muscle weakness or control problems in the mouth, face or throat) and she can write on paper with a pen. One intervention was to provide paper and pen for the resident to communicate with. 1/29/24 - The quarterly MDS assessment documented that R35 has no speech, but she has the ability to express her ideas/wants and to understand others. R35 was cognitively intact and used a walker. On 2/1/24, according to the Prehospital Care Report documented by the Basic Life Safety (BLS) crew: - at 11:27 AM - 911 was called by the facility for medical transport to the ER for R35's pain; - at 11:41 AM - Upon arrival the patient was found sitting outside of (name of facility) with staff. Staff advised the patient…

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

Based on interview and record review, it was determined that for two (R53 and R120) out of six residents reviewed for ADLs (activities of daily living), the facility failed to ensure each resident was provided toileting care per each resident's care plan. Findings include: 1. R53's clinical record revealed: 11/17/23 - R53 was admitted to the facility with diagnoses that included, but were not limited to, cancer, heart failure, depression, Post Traumatic Stress Disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event that can last from months or years, with triggers that can bring back the memories of the trauma accompanied by intense emotional and physical reactions) and diabetes. 12/1/23 - R53 was care planned for incontinence of bowel and bladder with interventions that included, but were not limited to: - check resident every two hours and PRN (as needed); - incontinence care after each incontinent episode; - toilet after meals - urinal and bedpan (date initiated 12/6/23); and - use absorbent products as needed. 1/23/24 -…

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.

Based on interview and record review, it was determined that for one (R120) out of six residents reviewed for ADLs, the facility failed to ensure there was sufficient staff on 12/17/23 day shift to provide toileting care in accordance with the resident's care plan. Findings include: Cross refer to F677, example 2 R120's clinical record revealed: 12/1/22 - R120 was care planned for incontinence of bowel and bladder with the following interventions: - check resident every two hours and PRN; - incontinence care after each incontinent episode; - offer toileting before/after meals and at bed time (initiated 1/8/23, revised 8/2/23); - toilet at regular intervals if able; and - use absorbent products as needed. 4/30/23 at 10:23 AM - During an interview with the Surveyor, E36 stated that she was the assigned CNA on 12/17/23 (Sunday) day shift. E36 stated that the Unit was short staffed that day, only three CNAs when usually it was four. E36 stated that when this happens, the resident workload goes from eight residents to 10-12 residents. E36 explained that the CNAs try to get up the…

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

Based on observations and interviews, it was determined that the facility failed to ensure proper food storage, food handling, and food service worker and Nursing staff personal hygiene. Findings include: The following were observed on 5/25/23 during the initial kitchen tour from 8:40 AM to 9:30 AM: 1. All the hand sinks were dirty and not cleaned; 2. The walk-in refrigerator floor was dirty; 3. The walk-in refrigerator was pooling water from the condenser; 4. The walk-in refrigerator was using dirty trays to hold vegetables; 5. The walls in the facility were not kept clean; Findings were reviewed and confirmed by E1 (NHA) on 5/25/23 at approximately 10:00 AM. Findings were reviewed during the Exit Conference with E1, E2 (DON), and E3 (ADON) on 6/8/23, at approximately 2:30 PM.

Based on observations and interviews, it was determined that the facility failed to effectively monitory and timely clean and sanitize areas of pest droppings. Findings include During the initial kitchen tour on 5/25/23 from 8:40 AM to 9:30 AM, it was observed that the dry storage shelf containing sugar had mouse dropping, mouse prints, and urine trails. E1 (NHA) was made aware and confirmed the finding at 10:00 AM. A second observation of the same location in the dry storage room was made on 5/31/23 at approximately 11:00 AM, and some of the original mouse droppings discovered on 5/25/23 were still there. E1 was made aware and confirmed the finding at 11:10 AM. Findings were reviewed during the Exit Conference with E1, E2 (DON), and E3 (ADON) on 6/8/23 at approximately 2:30 PM.

Based on observation and interview, the facility failed to ensure that the QAA committee measured the success of actions, track performance and regularly review, analyze, and act on data collected. Findings include: 6/8/23 9:08 AM - An observation of the facility's Quality Assurance Performance Improvement (QAPI) binder revealed the lack of audit tools for performance improvement project analysis. 6/8/23 9:45 AM - During an interview, E1 stated that performance project audit tools had not been created consistently for the analysis of performance projects in progress. Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON) and E3 (RN Risk Manager) on 6/8/23 at approximately 2:30 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation of three out of five units toured, it was determined that the facility failed to provide a safe, clean, and homelike environment. Findings include: 1. 6/1/23 12:03 PM - During an observation of the Ashland unit, room A16 was observed with the air conditioning unit having a broken cover. 2. 6/1/23 12:17 PM - During an observation of the [NAME] unit, room C9's bathroom floor was observed to be sticky with a strong smell of urine. 3. 6/1/23 12:27 PM - During an observation of the [NAME] unit, room H101 was observed to have brownish/black discoloration on the floor underneath a supply cart, and dust/grime on the floor near the radiator. Lastly, it was observed that room H104's air conditioning unit's cover was off, laying against the wall and bedside table revealing a dirty filter that was black in color. 6/1/23 12:47 PM - E32 (Maintenance Supervisor) confirmed findings. Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), and E3 (ADON) on 6/8/23, 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 observation, interview, and record review, it was determined that for four (R6, R24, R80 and R89) out of five sampled residents for respiratory care, the facility failed to change the oxygen tubing, in addition, the facility failed to follow the manufacturer's instructions for cleaning the oxygen concentrator's filter for R80 and R89. For R6, the facility failed to ensure that staff used sterile gloves when providing respiratory care to R6 during a procedure that required the use of sterile gloves. For R24, the facility failed to provide emergency tracheostomy (trach- an opening surgically created in the neck into the windpipe to allow air to fill the lungs) and as needed (PRN) oxygen supplies for trach care. Findings include: Review of the manufacturer's recommended instructions to clean the oxygen concentrator filter included: 1. Remove the filter and clean at least once a week depending on environmental conditions. 2. Clean the cabinet filter with a vacuum cleaner or wash in warm soapy water and rinse thoroughly. Note environmental conditions that may require more…

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 interview, it was determined that for three (R34, R117 and R222) out of six residents sampled for medication review, the facility (Nursing and/or Physician) failed to consistently act on irregularities identified during Medication Regimen Reviews (MRRs) by the Pharmacist. Findings include: Review of the Medication Regimen Review (MRR) policy, dated May 2019, stated, The consultant pharmacist reviews the medication regimen of each resident at least monthly .the attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. The consultant pharmacist provides the director of nursing services and medical director with a written, signed and dated copy of all medication regimen reports. Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record. 1. Review of R222's clinical record revealed: 6/7/23 - R222's MRRs from November 2022 - February 2023 were reviewed. The Pharmacist identified irregularities on 12/31/22,…

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

Based on interview and review of the facility's Infection Control records, the facility failed to ensure that monthly tracking and surveillance data was collected and entered into the monthly Infection Control Logs and reviewed, analyzed and acted upon, if indicated. In addition, the facility lacked evidence that their IPCP (Infection Prevention and Control Program), including standards, policies and procedures were reviewed annually. Findings include: 1a. The facility's policy and procedure entitled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, last revised on 12/2016, stated, . All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: a. resident name .; b. unit and room number; c. date symptoms appeared; d. name of antibiotic .; e. start date of antibiotic; f. pathogen identified .; g. site of infection; h. date of culture; i. stop date; j. total days of therapy; k. outcome; and l. adverse events. Review of the following months of surveillance data…

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 reviews and interviews, it was determined that the facility failed to provide training to three out of four of the Unit Managers (E6, E9, and E66) regarding the procedure for reporting incidents of abuse or neglect as evidenced by the Unit Managers (UM) being unable to or incorrectly state the time frame that such incidents need to be reported to the State Agency. Findings include: Cross refer F609 1a. 10/4/22 - E6 (RN/Unit Manager) completed Abuse and Neglect training inservice. 11/10/22 - E6 completed Abuse and Neglect training inservice. 5/15/23 4:45 PM - E6 completed Relias' Preventing, Recognizing and Reporting Abuse training. 6/5/23 10:21 AM - During an interview, E6 (RN), whose hire date was 4/27/2009, stated, The DON reports cases of suspected abuse or neglect during day shift. On the off shift or weekends when covering, I would report it. When asked about specific time frames for reporting, E6 stated, I did not know there is one. 1b. 12/23/22 11:57 AM - E9 (LPN/Unit Manager) completed Relias' Preventing, Recognizing and Reporting Abuse training. 6/5/23 10:56…

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, facility policy review, and interview, it was determined that the facility lacked evidence that two (R34 and R154) out of four residents reviewed for care planning, was afforded the opportunity to participate in their care planning conference. Findings include: The facility's policy on care planning titled, Care Plans, Comprehensive Person-Centered, last revised December 2016, reads, .The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care .The resident will be informed of his or her right to participate in his or her treatment . 1. Review of R154's clinical record revealed: 9/28/22 - R154 was admitted to the facility with a past medical history of brain damage and was assessed to have a BIMS (brief interview of mental status) score of 14 (13…

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

Based on record review and interviews, it was determined that the facility failed to develop a care plan and/or add interventions as needed related to smoking for two (R22 and R84) out of five residents sampled for smoking. Findings include: 1. R84's clinical record revealed: 6/4/18 - R84 was admitted to the facility. 9/23/22 - R84's care plan review lacked smoking as a focus area. 3/6/23 - The Minimum Data Set (MDS) assessment documented R84 as having mild cognitive impairment. 5/26/23 11:52 AM - R84's Smoking Screen Evaluation answered Safety question 10 Plan of care is used to assure resident is safe while smoking? Yes. 5/29/23 - R84's care plan was revised, however, it continued to lack smoking as a focus area. 2. R22's clinical record revealed: 4/5/18 - R22 was admitted to the facility. 3/30/23 13:23 PM - R22's Smoking Screen Evaluation answered Safety question 8 Resident need for adaptive equipment 8b. smoking apron (checked), 8c. supervision (checked). 3/31/23 - The MDS assessment documented that R22 was cognitively intact. 4/24/23 - R22's at risk for injury related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, it was determined that for one (R60) out of 32 sampled residents for care plan review, the facility failed to revise the care plan to reflect an identified need. Findings include: Review of R60's clinical record revealed: 2/14/23 - R60 was admitted to the facility. 2/15/23 - R60 had a care plan problem for inability to do her own ADLs without assistance related to weakness, with interventions that included requiring total care for her weekly shower two days per week and to clean and check fingernails and toenails. 5/30/23 9:10 AM - R60 was observed in bed with very long fingernails on both hands; dirty fingernails were also observed on her left contracted hand. 6/1/23 9:51 AM - R60 was observed in bed with long fingernails on both hands; dirty fingernails were also observed on her left hand. 6/1/23 11:06 AM - R60 was observed in bed with long fingernails on both hands; dirty fingernails were also observed on her left hand. 6/1/23 11:35 AM - E52 (CNA) 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.

Based on record review and interview, it was determined that for one (R154) out of two sampled residents reviewed for vision and hearing, the facility failed to ensure that the resident received proper treatment to maintain vision. Findings include: Review of R154's clinical record revealed: 5/2/23 - Due to a complaint of a decrease in vision, R154 received an eye exam in the facility from the facility's vision provider. The eye exam found R154 to have cataracts (clouded, blurred, and/or dimmed vision) in both eyes. The vision provider gave the facility a copy of the eye exam result, which included a referral for R154 to have eye surgery. 5/25/23 - During an interview with R154, he stated, I have cataracts. I am supposed to have surgery. I don't know when, they never told me. I cannot see well. 6/1/23 10:00 AM - E29 (Social Service) described how the facility carries out recommendations made by their vision provider and stated that the vision provider, comes into the building, Social Services receives the consults/recommendations and places it in the Dr.'s book for the NP (Nurse…

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, interview, and record review, it was determined that for two (R27 and R154) out of four residents reviewed for ROM (Range of Motion)/mobility, the facility failed to provide restorative nursing services to maintain or prevent further decline in function/mobility. The facility failed to provide R154 with restorative services while R154's orthotic devices (an artificial support or brace for the limbs or spine) for contracture management were in the laundry. For R27, the facility failed to ensure that R27 received PROM (Passive Range of Motion) exercise daily as prescribed. Findings include: 1. Review of R154's clinical record revealed: 9/28/22 - R154 was admitted to the facility with contractures (the shortening of certain tendons, muscles or other connective tissues causing loss of full extension of the affected joints) of both hands. 3/13/23 - R154's Physician orders read, Left Upper extremity wrist hand orthotic devices on as tolerated to a maximum of 1 hour. 4/6/23 - R154's Physician orders read, Upper extremity orthotic devices on as tolerated. Right hand…

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, observations and interviews, it was determined that for one (R1) out of three residents reviewed for accidents, the facility failed to ensure that the resident's environment remained free of accident hazards when R1 was incorrectly transferred from a bed to a wheelchair with a Hoyer full body mechanical lift with the use of a sling. Findings include: 5/26/23 - R1 was admitted to the facility. 6/14/23 -The EMR CNA Care Plan History Task List ([NAME]) documented R1's transfer status is a 2- person assist. 7/26/23 - The Facility Plan of Correction from the survey ending 6/8/23 documented that staff educator/designee will educate nursing staff on ensuring residents environment remains free of accident hazards. Education will include: following each residents proper mobility status that is listed on the [NAME] in POC, ensuring that proper lift slings are being used for residents requiring a mechanical lift for transfers. 8/9/23 12:50 PM - R1 was observed in the [NAME] Wing small dining room in…

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

Based on record review and policy review, it was determined that for one (R34) out of six residents reviewed for MRR, the facility failed to ensure for R34 that the PRN psychotrophic medication, Xanax, was limited to a 14 day duration or to have the Provider document the reason for a prolonged period of PRN psychotrophic medication (30 days). Findings include: Cross refer to F756 Review of the Medication Regimen Review (MRR) policy, stated, The consultant pharmacist reviews the medication regimen of each resident at least monthly .The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example: .a. medications ordered in excessive doses or without clinical indications .g). incorrect medications, administration times or dosage forms; or . R34's clinical record revealed: 2/1/22- R34 was admitted to the facility. 5/8/23 1:00 PM- E48's (NP) Progress note documented, Resident lying in bed in no acute distress . Assessment: .Generalized anxiety disorder Zoloft…

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, interview and review of a clinical record and other resources as indicated, it was determined that for one (R93) out of five sampled residents for medication review, the facility failed to store R93's insulin medications in a locked compartment in her room as she was under transmission-based precautions for Candida auris (C. auris). In addition, the facility failed to ensure that the [NAME] wing wound care cart was secured (locked) and accessible only to designated staff. Findings include: 1. According to the Centers for Disease Control and Prevention's (CDC) fact sheet posted on their website, Candida auris is an emerging multi-drug-resistant yeast (a type of fungus). It can cause severe infections and spreads easily between . nursing home residents. (https://www.cdc.gov/drugresistance/pdf/threats-report/candida-auris-508.pdf) R93's clinical record revealed: 8/29/22 - R93 was care planned for C. auris colonization (bacteria existing in an area [wound] that cause local or systemic symptoms)…

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 interview, it was determined that the facility failed to ensure that one (R154) out of seven residents received the correct meal as issued on their meal ticket. Findings include: Review of R154's clinical record revealed: 9/28/22 - R154 was admitted to the facility with a past medical history that included Dysphagia (difficulty swallowing). 11/12/22 - A diet requisition form for R154 that was signed off by the facility read, Nutrient Content - Regular, Texture - Dysphagia Puree. 6/1/23 8:48 AM - During a random dining observation of R154's breakfast tray, the resident received a breakfast tray of regular consistency (all solids), despite his meal ticket reading, Regular - Puree texture. 6/1/23 8:50 AM - An interview with E33 (CNA) confirmed that R154 was not provided the correct tray and removed the breakfast tray. 6/1/23 9:02 AM - E33 returned with a new breakfast tray with the correct consistency of Regular-Puree for R154. Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), and E3 (ADON) on 6/8/23, at approximately 2:30 PM.