Polaris Healthcare And Rehabilitation Center

Based on record review and interview it was determined that for two (R43 and R79) out of three residents reviewed for personal funds the facility failed to ensure residents had access to the their funds. Findings include: The facility policy entitled, Deposit of Resident Funds last updated March 2021 indicated, Should the resident permit the facility to hold, safeguard, and manage his or her personal funds, the facility will: provide the resident access to funds of fifty dollars or less within twenty four hours, and access to funds in excess of fifty dollars within three banking days. 1. 11/2/24 - An MDS assessment documented that R79 was cognitively intact. 12/23/24 - A receipt in the facility records documented that R79 received 50.00 in personal funds from E17 (BOM). 1/13/25 10:48 AM - During an interview R79 stated, They had a change in the person who was disbursing the money and she had to be oriented. I wanted it for Christmas and I got it two days before Christmas. Which was too late because I wanted to send Christmas cards. I made the request at least the beginning of the…

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

Based on interview and record review, it was determined that for one (R81) out of five residents reviewed for Advance Directives, the facility failed to offer an opportunity to formulate an advance directive. Findings include: Review of R81's clinical record revealed: 3/25/24 - R81 was admitted to the facility. 3/30/24 - An admission packet for the facility was completed for R81 and revealed that Exhibit G: advanced directed form documented R81 was a full code. The remainder of the form was left blank relating to questions regarding formulating an advanced directive. 10/2/24 - A quarterly MDS assessment documented a BIMS score of 15 indicating R81 was cognitively intact. 1/13/25 11:34 AM - An interview with R81 revealed that he was not offered to formulate an advanced directive. 1/14/25 1:35 PM - An interview with E41 (SW) revealed that advanced directives get discussed during the initial care plan meeting. 1/14/25 2:33 PM - An interview with E6 (Admissions) revealed that nursing staff is expected to ask resident questions on admission sheet regarding advanced directive. E6…

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 (R64) out of two residents reviewed for change in condition, the facility failed to consult the provider and notify the responsible party when R64 experienced a significant change in condition and plan of care. Findings include: Cross refer F773 Review of R64's clinical record revealed: 11/27/24 - R64 was admitted to the facility. 12/4/25 - An admission MDS documented R64 was a BIMS of 7 indicating severe cognitive impairment. 1/10/25 - A progress note documented that FM3 reported that R64 was lethargic and not at her baseline. E27 (RN) documented R64's assessment and called the on-call provider. 1/10/25 1:34 PM - A progress note documented that R64 had a non-productive cough, mild confusion, speech unclear at times, elevated heart rate, was drowsy nd not her usual self. Additionally, R64 was given cough medicine, Tylenol, and Tums per provider order. 1/10/25 7:56 PM - A progress note documented that R64 refused dinner and continued with an elevated heart rate. Additionally, the progress note documented the on call…

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, record review and review of other facility documentation, it was determined that for one (R64) out of one reviewed for grievances, the facility failed to ensure that resident concerns received by the facility included prompt efforts to resolve the resident's problems. Findings include: Review of R64's clinical record revealed: 11/27/24 - R64 was admitted to the facility. 12/30/24 - A grievance form was filed by FM3 regarding missing clothing for R64 and a complaint related to staff care. The form documented that the grievance was resolved on 1/6/25 by E2 (DON). 1/13/25 12:33 PM - An interview with FM3 revealed that R64 was missing a pair of pajama bottoms and that a staff member threw them away. FM3 stated that on 12/30/24 she was in to visit R64 and she told FM3 about her pants being missing. FM3 stated that R64 was very upset and told her that the person who threw the pants away was not nice to her on the date in question. FM3 also stated that the facility did not rectify the missing pants with her or offer to replace them. 1/15/25 11:23 AM - An interview 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.

Based on record review and interview, it was determined that for one (R18) out of two (2) residents reviewed for misappropriation of resident property, the facility failed to recognize and consequently report an allegation of misappropriation of resident property/funds no later than 24 hours. Findings include: The facility policy on abuse dated 12/2016 indicated Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Investigate and report any allegations of abuse within timeframe's as required by federal requirements. 3/4/25 - A grievance form was completed on behalf of R18 by E8 (AD) that documented, [R18] said he saw charges that were not his own on his credit card. He also said that someone has taken out a loan in his name. He was assisted with calling customer service. Further documentation on the grievance indicated the investigation was assigned by E7 (SW) to E5 (BOM) to complete the investigation of the grievance. E5 documented, [R18] was approached by BOM and a security officer. We asked if he would like to call…

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 (R18) out of two (2) residents reviewed for allegations of misappropriation of resident property, the facility failed to provide evidence that the allegation was thoroughly investigated. Findings include: The facility policy on abuse dated 12/2016 indicated Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Investigate and report any allegations of abuse within timeframe's as required by federal requirements. 3/24/25 - The facility submitted an incident report to the State Agency that alleged [R18] reported a previous employee was stealing money. Investigation started immediately. Police contacted. 4/1/25 9:07 AM - The surveyor requested a copy of the investigation related to R18's allegation of misappropriation of property. 4/3/25 12:32 PM - During an interview E4 (DON) confirmed the facility did not conduct interviews, obtain statements or complete an investigation regarding R18's allegation of misappropriation of property. E4 stated, We called 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, record review and review of other facility documents it was determined that for one (R148) out of three residents reviewed for discharge the facility failed to ensure that discharge requirements were met when the facility initiated discharge regarding R148 occurred on 10/9/24 without notice to the resident. Findings include. Cross refer to F626. Review of R148's clinical record revealed: 8/23/24 - R148 was admitted to the facility with multiple diagnoses including a history of major depressive disorder with severe psychotic symptoms, anxiety, and suicidal ideation. 8/26/24 - A five day MDS assessment documented that R148 was cognitively intact with a goal of remaining in the facility. 10/9/24 7:53 AM - A note in R148's clinical record documented that the resident was sent to the hospital for suicidal ideation. 10/9/24 - The Transfer/Discharge notice indicated the reason for R148's transfer as it is necessary for your welfare and needs cannot be met at the facility. The location of the transfer was to hospital ER. The notice was signed by R148. Accompanying 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, it was determined that for three (R35, R46 and R61) out of three sampled residents for hospitalization, the facility failed to provide written bed hold notice to the resident and/or the resident's representative when transferred to the hospital. Findings include: A facility policy and procedure titled Bed-Holds and Returns revised 10/2022 documented . 1. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Resident's regardless of payor source, are provided written notice about these policies at least twice. 1. Review of R35's clinical record revealed: 12/23/24 - R35's MDS 5 day admission assessment revealed the resident was cognitively intact with a BIMS score of 15. 1/10/25 - R35 was transferred to the hospital. 1/16/25 10:44 AM - During an interview E6 (AD) confirmed E35 had been transferred…

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 (R148) out of three residents reviewed discharge the facility failed to ensure R148 was readmitted to the facility or that the facility complied with discharge requirements. R148 was sent to the hospital on [DATE] and was not permitted to return to the facility. Findings include: Review of R148's clinical record revealed: 8/23/24 - R148 was admitted to the facility with multiple diagnoses including a history of major depressive disorder with severe psychotic symptoms, anxiety, and suicidal ideation. 8/26/24 - A five day MDS assessment documented that R148 was cognitively intact with a goal of remaining in the facility. 10/9/24 7:53 AM - A note in R148's clinical record documented that the resident was sent to the hospital for suicidal ideation. 10/9/24 - The Transfer/Discharge notice indicated the reason for R148's transfer as it is necessary for your welfare and needs cannot be met at the facility the location of the transfer was to hospital…

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 has been determined that the facility failed to review and revise for one (R85) out of thirty-seven sampled residents' care plans. Findings include: A facility policy and procedure titled Using the Care Plan last revised 8/2006 documented . 1. Other facility staff noting a change in the resident's condition must also report those changes to the Nurse Supervisor and or the MDS Assessment Coordinator . 2. Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made. Cross refer F697 1. Review of R85's clinical record revealed: 12/12/24 - R85 was admitted to the facility with the diagnoses including but not limited to low back pain, fibromyalgia, muscle weakness, and unspecified abnormalities of gait. 12/12/24 11:09 PM - An admission assessment documented R85 had no complaints of pain, lacked an acceptable level of pain, and lacked treatment for pain. 12/15/24 - A care plan was initiated for R85 that documented potential for alteration in comfort…

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 (R6 and R27) out of thirty seven residents sampled, the facility failed to provide services that meet professional standards of quality by having Licensed Practical Nurses (LPN) complete admission assessments and admission progress notes. Findings include: Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2024 . admission Assessments * - RN .* = Once a care plan is established, the LPN may do assessments . 1. Review of R6's clinical record revealed: 12/12/24 - R6 was admitted to the facility. 12/12/24 - E45 (LPN) completed the following assessments: admission evaluation, bowel and bladder continence evaluation, elopement risk evaluation, fall risk evaluation, pain evaluation, side rail evaluation, transfer evaluation, and Braden scale assessment. An LPN, not an RN, as required by the Delaware State regulation for Board of Nursing Scope of practice, completed the admission process for R6. 1/21/25 10:47 AM - An interview with E17 (UM RN) confirmed that R6's admission assessments were completed by an LPN. 2.…

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 (R6) out of nine residents reviewed for ADLs, the facility failed to ensure ADLs were provided to dependent residents. Findings include: Review of R6's clinical record revealed: 12/12/24 - R6 was admitted to the facility. 12/13/24 - A care plan was initiated and documented that R6 was unable to do own activities of daily living (ADLs) without assistance related to general weakness and goal that R6 will be well groomed and odor free with the assist of staff while participating to their best ability for ninety days. The care plan documented interventions to assist R6 to pick out clothes, assist to attend activities, and toileting schedule as R6 allows. 12/19/24 - An admission MDS documented that R6 had an impairment to lower extremity on one side and also documented R6 was dependent for showering. 1/13/25 2:34 PM - An interview with R6 revealed that she had a shower on the previous day and no one had assisted her to clip her nails. R6 stated that no one had offered to clip her nails. 1/14/25 10:19 AM - An observation…

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 (R64) out of two residents reviewed for change in condition, it was determined that the facility failed to follow physician orders. Findings include: Review of R64's clinical record revealed: 11/27/24 - R64 was admitted to the facility. 12/4/24 - An admission assessment for documented that R64 was independent for eating. 1/14/25 7:23 PM - A physician's order documented that R64 was on thickened liquids. 1/15/25 1:15 PM - An observation of R64's lunch tray revealed that R64 was served water, coffee, and juice all thin liquids. R64 was actively eating and drinking when observation occurred, during this time an observation of R64 drinking the thin liquids resulting in coughing. 1/15/25 1:30 PM - An interview with E48 (CNA) revealed that E48 was not informed that R46 was on thickened liquids during report and E48 went to replace the thin liquids with thickened. 1/15/25 1:35 PM - An interview with E51 (LPN) and E35 (RN) revealed that when a new diet is ordered the order gets entered in the electronic medical record…

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 (R37) out of two residents reviewed for ROM the facility failed to ensure that R37 received appropriate treatment and services to prevent further decrease in range of motion when the annual contractures measurement comparison evaluation was not completed on time. Findings include: The facility policy on Prevention and screening for contractures management last updated January 2025, indicated Secondary prevention targets early identification of a contractures to limit it's course and complications through scheduled screenings such as annual screenings or during clinical reviews. 1. Review of R37's clinical record revealed: 12/15/23 - An entry MDS assessment was created for R37. 12/18/23 - A contractures measurement comparison evaluation was completed for R37 that documented the resident had All joints within functional limits. 12/19/23 - A discharge return not anticipated MDS assessment was completed for R37. 1/2/24 - R37 was readmitted to the facility with several diagnoses including history of stroke, generalized…

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 (R47) out of two residents reviewed for accidents the facility failed to provide supervision for R47 to prevent an accident. The resident was left unsupervised during care and fell off the bed resulting in a head injury and needed to be sent to the hospital for evaluation and treatment. Findings include: R47's clinical record revealed: 12/18/23 - R47 was admitted to the facility with diagnoses including but not limited to multiple sclerosis, paraplegia and hypothyroidism. 12/19/23 - A review of R47's care plan for falls documented . 1. Potential for falls r/t (sic) decreased mobility . 2. Bed in lowest position when care is not being provided .3. Bed mobility extensive assist . 4. Increased rounding (was added to the interventions on 7/16/24 as a result of the fall). 12/19/23 - A review of R47's care plan for ADLs (Activities for Daily Living) revised 1/13/25 dcoumented . 1. Unable to do own ADLS without assistance R/T (sic) MS (sic) and generalized weakness. 1/16/24 - A review of R47's care plan for…

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

Based on interview and record review it was determined that for four (R4, R27, R61, R64 and R3) out of seven residents reviewed for bowel and bladder, the facility failed to respond to or provide services to maintain or restore bowel and bladder continence. Findings include: 1. Review of R4's clinical record revealed: 12/5/24 - R4 was admitted to the facility. 12/5/24 - A care plan was initiated for R4 but lacked evidence of addressing continence and plan of care related to continence. 12/5/24 3:30 PM - A bowel and bladder evaluation documented that R4 was continent of urine and lacked documentation regarding bowel continence. 12/12/24 - An admission MDS documented that R4 was always continent of bladder and occasionally continent of bowel and that no toileting program was indicated. The MDS also documented that R4 required partial or moderate assistance for toileting. 12/2024 - A review of the December CNA documentation record revealed that R4 was continent of bowel four times out of eighty opportunities. 1/2025- A review of the January CNA documentation record revealed that R4 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 two (R11 and R91) out of two residents reviewed for tube feeding the facility failed to implement current professional standards of practice, to maintain acceptable parameters of nutritional status. Findings include: for R11 the facility failed to label R11's tube feeding bottle to discern the tube feeding's date and time of expiration per standard of care. For R91, the facility failed to obtain an order for R91 to resume her tube feeding at the time of readmission to the facility. Findings include: 1. Review of R11's clinical record revealed: 10/2/23 - R11 was admitted to the facility with quadriplegia. 12/22/24 - A discharge MDS assessment documented that R11 required tube feeding for nutrition. 1/14/25 10:40 AM - An observation of R11's tube feeding bottle not labeled with a time or date of when the tube feeding had been initiated. 1/14/25 10:42 AM - During an interview, E12 (LPN) confirmed that the tube feeding was not labeled with date and time that the bottle had been hung and started. 2. Review of R91's clinical…

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 (R10, R29, R67 and R80) out of seven residents sampled for respiratory care the facility failed to provide respiratory care based on professional standards for R10, R29, R67 and R80's nebulizer mask was not dated and not in a plastic bag when not in use. R10's nebulizer mask was dated 12/26/24. Further review of R10, R29, R67 and R80's records lacked evidence of orders to change and store nebulizer masks. Findings include: A policy and procedure titled Aerosol Nebulizer Compressor undated documented 1. Proper cleaning, maintenance and storage will be followed to prevent infections and ensure the longevity of equipment . 2. Follow standard infection control precautions to prevent the spread of infections. 1. R10's clinical record revealed: 9/27/23 - R10 was admitted to the facility. January 2025 - Review of R10's TAR lacked orders when to change and how to store R10's nebulizer mask when not in use. 1/13/25 8:59 AM - An observation of R10's nebulizer mask was dated 12/26/24 and laying on top of the…

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

Based on interview and record review and other documentation as indicated, it was determined that for one (R300) out of five reviewed residents for pressure ulcers, the facility failed to ensure that R300's medical care was supervised by a physician for the care of pressure ulcers. Findings include: Cross refer F686 Review of R300's clincal record revealed: 8/28/24 - R300 was admitted to the facility. 11/4/24 10:40 PM - A practioner (E11) progress note documented that R300 was seen for a follow up visit wound to right heel. The progress note documented that nursing reported black heel with a small amount of drainage and treatment was betadine and dry dressing to cover. The physical exam documented skin as warm and dry. The progress not lacked evidence of physical characteristics of the wound care assessment by the provider. 11/5/24 2:05 PM - A pracitioner (E11) progress note documented that R300 was seen for follow up up visit for antibiotics and ESRD (end stage renal disease). The progress note documented that R300 was started on Keflex for the right heel wound and had no adverse…

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 (E39) out of five CNA's reviewed for annual performance reviews, the facility failed to ensure that the annual performance review was completed at least once every twelve months. Findings include: 1/2/23 - E39's most recent performance review was completed on 1/17/25. The facility lacked evidence of a performance review completed in 2024. 1/15/25 1:21 PM - During an interview E1(NHA) confirmed the findings. 1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).

Based on record review and interview it was determined that for one (R32) out of one resident reviewed for medication administration, the facility failed to provide pharmacy services to refill medications to avoid missed doses. Findings include: Review of R32's clinical record revealed: 9/1/23 - R32 was admitted to the facility with multiple diagnoses including cirrhosis of the liver. 8/27/24 - A physician's order was written for R32 to receive lactulose 45ml twice a day for cirrhosis of the liver. 12/7/24 - A quarterly MDS assessment documented that R32 was cognitively intact. 12/30/24 9:02 AM - An order administration note in R32's clinical record documented, medication (lactulose) ordered not delivered, nurse called pharmacy. 12/31/24 9:59 AM - An order administration note in R32's clinical record documented, medication (lactulose) ordered, not delivered, will notify supervisor and call pharmacy. 12/31/24 3:09 PM - An order administration note in R32's clinical record documented, med (lactulose) not delivered, pharmacy called and said it would arrive by 3:00 pm, was not…

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 (R27) out of five residents reviewed for unnecessary medications, the facility failed to limit an as needed (PRN) psychotropic medication to 14 days. Findings include: Review of R27's clinical record revealed: 10/14/24 - R27 was admitted to the facility diagnoses including but not limited to visual hallucinations, auditory hallucinations, and vascular dementia with psychotic disturbance. 10/21/24 - An admission MDS assessment documented a BIMS score of 14 indicating R27 is cognitively intact and also documented R27 had physical, verbal, and other behaviors not directed at others. 11/13/24 8:49 PM - A physician's order documented alprazolam (anti-anxiety) 0.5mg: Give 0.5mg by mouth every eight hours as needed for anxiety with an indefinite stop date. 1/17/25 2:57 PM - An interview with E11 (NP) confirmed the order did not have a fourteen day stop date. 1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview and review of other facility documentation, it was determined that for three out of five medication storage refrigerators, the facility failed to facilitate the safe administration of medication to residents and staff. In addition, the facility failed to ensure that testing materials for COVID-19 would accurately reflect residents and employees COVID status. Findings include: [DATE] 9:02 AM - An observation of the back-up medication refrigerator in the facility conference room revealed that the temperature monitoring logs were incomplete. The following are the incomplete daily temperature log monitoring for the medications stored in the facility conference room refrigerator. - [DATE] - 18 out of 31 days were incomplete. - [DATE] - 10 out of 30 days were incomplete - [DATE] - 8 out of 31 days were incomplete. - [DATE] - 19 out of 31 days were incomplete. - [DATE] - 16 out of 30 days were incomplete. - [DATE] - 9 out of 31 days were incomplete. - [DATE] - 27 out of 30 days were…

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, for one (R64) out of four residents sampled for laboratory services, the facility failed to promptly notify the ordering medical practitioner of laboratory results. Findings include: Cross refer to F580 Review of R64's clinical record revealed: 11/27/24 - R64 was admitted to the facility. 1/10/25 11:00 PM - A physician's order for R64 documented complete blood count (CBC), comprehensive metabolic panel (CMP), and infuse normal saline at 100 mL/hr total 1 liter. 1/11/25 1:37 PM (Saturday) - A lab result report for R46 documented the white blood cell count was high. 1/13/25 4:30 PM - A physician's order for R64 documented a chest xray with two views and rocephin (antibiotic) inject one gram intramuscularly immediately (STAT) for white blood cell elevation. 1/14/25 3:25 PM - A physician's order for R64 documented Bactrim (antibiotic) 800-160mg give one tablet two times a day for left base infiltrate (pneumonia) for five days. 1/15/25 2:13 PM - Interview with E17 (RN UM) confirmed that the progress notes lacked evidence 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.

Based on observation, interview and record review, it was determined that for one (R27) out of seven sampled residents for dental services, the facility failed to assist the residents in obtaining routine dental services. Findings include: Review of R27's clinical record revealed: 10/12/24 - An admission packet for R27 documented that R27 elected to receive dental services through the facility. 10/14/24 - R27 was admitted to the facility with vascular dementia. 10/21/24 - An admission MDS documented R27 was cognitively intact and diagnosis of non-alzheimers dementia. The MDS also documented that R27 does not have dentures, broken teeth, or any abnormal mouth issues. 1/13/25 9:11 AM - An interview revealed that R27 wanted to see the dentist and stated she had not seen one since before she was admitted to the facility. 1/15/25 3:29 PM - A review of the electronic medical records lacked evidence that R27 had received dental services. 1/21/25 8:26 AM - An interview with E1 (NHA) confirmed that R27 had not received dental services because the dentist only comes to the facility once 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 observation and interview it was determined that for one (R64) out of one residents reviewed for nutrition the facility failed to provide fluid in a form designed to meet the individuals needs. Findings include: Review of R64's clinical record revealed: 11/27/24 - R64 was admitted to the facility. 12/4/24 - An admission MDS assessment documented that R64 was independent for eating. 1/14/25 7:23 PM - A physician's order documented that R64 was on thickened liquids. 1/15/25 1:15 PM - An observation of R64's lunch tray revealed that R64 was served water, coffee, and juice that were all thin liquids. R64 was actively eating and drinking when observation occurred; During this time R64 was observed drinking the thin liquids resulting in coughing. 1/15/25 1:30 PM - An interview with E48 (CNA) revealed that E48 was not informed that R46 was on thickened liquids during report and E48 went to replace the thin liquids with thickened. 1/15/25 1:35 PM - An interview with E51 (LPN) and E35 (RN) revealed that when a new diet is ordered the order gets entered in the electronic medical…

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 the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents. Findings include: 1/13/25 10:26 AM - During a tour of the kitchen, the surveyor observed E15 (Account Manager) test the sanitizer level of the solution in two red sanitizing buckets. When E15 tested the sanitizing solution, the test strips from each of the buckets indicated that the level of chemical concentration in the buckets was not at a sufficient level to provide proper sanitization. 1/13/25 10:28 AM - During a tour of the walk-in freezer there were several discarded food items, including a breaded fish patty, a hash brown, and several other debris items laying on the freezeer floor. 1/13/25 10:53 AM - During the rinse cycle the automatic dishwashing machine temperature was too low. Several test trials revealed a max temp of 130 degrees Fahrenheit. The temperature in this type of warewashing machine must be [NAME] 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.

Based on record review and interview, it was determined that for one (R500) out of thirty-four (34) residents reviewed, the facility failed to ensure the residents medical record was complete, accurately documented and readily accessible. Findings include: The facility policy on charting and documentaion last updated 2001 indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Review of R500's clinical record revealed; 3/21/25 7:45 PM - A fall incident report documented, that R500 a resident with some baseline confusion experienced an unwitnessed fall. 3/21/25 7:45 PM - A neurological assesment form was initiated by E6 (RN) related to R500's unwitnessed fall to be completed through 3/24/25. 3/21/25 7:45 PM - A progress note written by E6 (RN) in R500's clinical record documented, Post fall this shift .Neuro checks done and in progress. Will continue to monitor. The progress note lacked specific information regarding the neurological checks. 3/21/25 7:47 PM - A progress note written by E6 (RN) in R500's clinical…

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 (E28 and E49) out of six employees reviewed, the facility failed to ensure that mandatory communication training was completed. Findings include: 1/15/25 - A review of the facility training worksheets lacked evidence of required communication training for the following staff: E28 date of hire 6/29/23 - no record of communication training. E49 date of hire 12/11/23 - no record of communication training. 1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the findings. 1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).

Based on record review and interviews it was determined that for two (E29 and E30) of out of six employees reviewed, the facility failed to ensure resident rights training was ongoing. Findings include: 1/15/25 - A review of the facility training worksheets revealed lack of evidence of ongoing training on resident's rights for the following staff: E29 date of hire 4/10/23 -most recent date of residents rights training 4/11/23. E30 date of hire 10/23/23- most recent date of residents rights training 10/23/23. 1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the findings. 1/24/25 1:30 PM - Findings were reviewed with E1, E2 (DON) and E4 (CCS).

Based on record review and interview it was determined that for two (E28 and E47) out of six employees reviewed, the facility failed to ensure that staff completed QAPI training. Findings include: 1/15/25 - A review of the facility training worksheets lacked evidence of required QAPI training: E28 6/29/23 date of hire, no record of training. E47 7/19/23 date of hire, no record of training. 1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the findings. 1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).

Based on record review and interview it was determined that for two (E29 and E30) out of six employees reviewed for required training the facility failed to ensure that infection control training was completed and consistent with policy standards. Findings include: The facility policy on Infection Prevention and Control Plan last updated 2024, indicated there would be ongoing education for all facility personnel. 1/15/25 - A review of the facility's training worksheet lacked evidence of ongoing infection control training for the following staff: E29 date of hire 4/10/23 most recent infection control training completed on 4/10/23. E30 date of hire 10/23/23 most recent infection control training completed on 10/23/23. 1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the findings. 1/24/25 1:30 PM - Findings were reviewed with E1, E2 (DON) and E4 (CCS).

Based on record review and interview it was determined that for three (E28, E29, and E30) out of six employees reviewed, the facility failed to ensure that annual training of the compliance and ethics program was completed for an organization operating five or more facilities. Findings include: 1/15/25 - A review of the facility's training worksheet lacked evidence of required training on the facilities compliance and ethics programs for the following staff: E28 6/29/23 date of hire, no record of training. E29 4/10/23 date of hire, last date of training 4/10/23. E30 10/23/23 date of hire, last date of training 10/23/23. 1/23/25 4:34 PM - During an interview E1(NHA) confirmed the findings. 1/24/25 1:30 PM - Findings were reviewed with E1, E2 (DON) and E4 (CCS).

Based on record review and interview it was determined that for four (E30, E32, E39, and E40) out of five CNA'S reviewed, the facility failed to ensure that the required minimum twelve hours of in-service training was completed. Findings include: 1/15/25 - A review of the facility training worksheet lacked evidence of the required twelve hours minimum in-service training for the following CNA's: E39 had a hire date of 1/2/23. From 1/2/24 - 1/2/25, 1.05 hours of training were completed. E32 had a hire date of 9/26/23. From 9/26/23 - 9/26/24, 0.0 hours of training were completed. E40 had a hire date of 10/9/23. From 10/9/23 - 10/9/24, 0.0 hours of training were completed. E30 had a hire date of 10/23/23. From 10/23/23 - 10/23/24, 0.0 hours of training were completed. 1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the findings. 1/24/25 1:30 PM - Findings were reviewed with E1, E2 (DON) and E4 (CCS).

Based on record review and interview it was determined that for two (E28 and E29) out of six staff reviewed, the facility failed to ensure that required behavioral health training was completed in accordance with the Facility Assessment. Findings include: The Facility Assessment last updated December 2024, indicated that the facility maintained an average of one to ten residents with behavioral symptoms. Staff training, education and competencies, indicated that All staff are assigned training and attend training sessions in the facility annually and as designated. 1/15/25 - A review of the facility training worksheet lacked evidence of behavioral health training for the following staff: E28 (DA)- date of hire 6/29/23 no documented behavioral health training. E29 (RN) - date of hire 4/10/23 no documented behavioral health training. 1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the missed training's. 1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).

Based on record review and interview it was determined that for one (R2) out five residents reviewed for discharge the facility failed to implement an effective discharge plan that addressed R2's needs related to a community primary care physician, open wounds, insulin dependence, and visual impairment. Findings include: The facility policy on resident initiated discharge last updated October 2022, indicated Residents may initiate a discharge from the facility. For resident intiated discharges the medical record contains: documented discussions with the resident containing details of discharge planning and arrangements for post-discharge care. Review of R2's clinical record revealed: 2/21/23 - R2 was admitted to the facility with multiple diagnoses including diabetes, and unspecified cataracts. R2 was listed as their own responsible party. CW1 was listed as a care conference person. 2/21/23 (initiated) - R2's care plan for discharge planning uncertain; patient has voiced desire to discharge back to the community was reviewed on 4/17/24. Goal will be discharge to a safe environment…

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 (R2) out of five residents reviewed for discharge the facility failed to ensure continuity of medically related social services upon the residents discharge. R2 discharged from the facility on 5/17/24 and was not connected with the community caseworker for an estimated four days. Findings include: The facility policy on social services last updated September 2021, indicated, Social services is responsible for meeting or assisting with the medically related social service needs of residents .helping residents with transitions of care services (for example, community placement options, home care services, transfer agreements etc.); Not all medically related social servcies are provided by the a qualified social worker. However the facility is responsible for ensuring that all residents are provided these services by staff or through referrals made to an outside agency. Review of R2's clinical record revealed: 2/21/23 - R2 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.

Based on observation it was determined that the facility failed to ensure that all nourishment refrigerators were maintained in a sanitary condition and food is stored safely to prevent food-borne illness. Findings include: 1. 4/7/24 8:45 AM -The following was observed in the Reserve Unit nourishment refridgerator: -Boost dated 10/17/23. -Sandwich in green and white wrapper dated 2/21. -Brown paper bag unmarked. -Partially eaten pretzel salad undated. -Cheese doodles opened unlabeled. -Salad dressing dated 9/8/23. 4/7/24 9:47 AM - The above was confirmed and removed from the refridgerator by E38 (Supervisor). 2. 4/8/24 - The nourishment refrigerated adjacent to the small dining room in the Riverside unit had a large semi-dried spill of orange liquid on the middle and bottom shelves of the door, and the full-sized refrigerator located in that same dining room contained an undated unlabeled small plastic food storage bowl of leftover food. These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 and E2 (DON).

Based on observations, interviews and record review, it was determined that for three (R7, R23 and R57) out of three sampled residents reviewed for dignity, the facility failed to promote care in a manner and environment that maintained or enhanced their dignity and respect. Findings include: 1.Review of R7's clinical record revealed: 2/23/24 - R7 was admitted to the facility. 4/10/24 10:08 AM - An observation of E33 (CNA) and E34 (CNA) in room with R7 providing care with door open. R7's unclothed, lower body from thigh down to feet was able to be observed from open door. 4/10/24 10:50 AM - An interview with E33 and E34 confirmed that care was completed with the door open leaving R7 exposed to the hallway. 2. Review of R23's clincal record revealed: 5/24/23 - R23 was admitted to the facility. 4/11/24 10:17 AM - An observation of E35 (CNA) in room with R23 providing care with the door open. R23's care occurred till 10:27 AM. R23's unclothed, lower body from thigh down to feet was able to be observed from hallway. 4/11/24 10:28 AM - An interview with E35 confirmed that R23's care 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.

Review of the facility policy titled, Change in a Resident's Condition or Status last dated 2/2021 documented . 1. Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status, changes in level of care, billing/payments, resident rights, etc. Review of R8's clinical record revealed: 7/1/21 - R8 was admitted to the facility with a diagnosis including but not limited to hypertension, stroke, left side weakness and depression. 1/5/24 - Review of the facilities diet requisition form revealed R8 was on a regular textured diet and thin liquids. 2/15/24 12:47 PM - A physician's order written by E4 (MD) for R8 documented . 1. Regular diet dysphagia mechanical soft texture thin liquids consistency. Patient may have regular pleasure foods. 2/15/24 1:25 PM A plan of care note written by E14 (RD) revealed that R8's diet was downgraded for safety. In addition, a facility diet requisition form revealed R8's diet was changed to dysphagia mechanical soft texture on 2/15/24. 4/9/24…

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.

2. Review of R57's clinical record revealed: 10/11/22 - R57 was readmitted to the facility with diagnoses including but not limited to quadriplegia, spinal muscular atrophy, morbid obesity and tracheostomy. 1/18/24 - MDS quarterly documented R57 as totally dependent. 4/7/24 1:00 PM - An observation and interview with R57 revealed the sip and puff (type of call bell) was next to the bed in a position that R57 was unable to use. 4/7/24 1:44 PM - An observation of E37 (CNA) leaving the room with R57's lunch tray and the sip and puff was next to the bed in a position that R57 was unable to use. 4/7/24 1:53 PM - During an observation and interview with E36 (Respiratory Therapist) it was confirmed that the resident did not have her sip and puff, but she would be able to call out for help. These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON). Based on observation, record review and interview it was determined that for two (R131 and R57) out of 40 initial pool residents screened the facility failed to ensure that the residents call bell…

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 (R287) out of three residents reviewed for discharge the facility failed to provide R286 the Notice to Medicare Provider Non-Coverage (NOMIC) form before services were terminated. Findings include: R287's clinical record revealed: 3/20/24 R287 was discharged to home. 4/11/24 approximately 10:30 AM - During an interview, E1 (NHA) confirmed that the NOMIC form was not provided to R287. As part of R287's resident rights, the NOMIC form notifies the beneficiary of his or her right to an expedited review of the service termination. These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).

Based on record review and interview it was determined that for one (R53) out of three residents reviewed for abuse the facility failed to recognize and immediately report an allegation of abuse. Findings include: The facility policy on Abuse, last updated April 2021 indicated that staff, Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegations within timeframe's required by federal requirements. 3/25/24 - The facility reported an incident to the State Agency that alleged, On 3/21/24 there was a disagreement between roommates and a room change was recommend by the on call nurse for that shift. 4/11/24 9:00 AM - Review of the facility incident report and investigations revealed a statement dated 3/12/24 written by E24 (LPN) that documented, [R17] said he threw soda cans at [R53] and called him an asshole and a retard I heard [R53's] wife yelling but I am not sure what was said I heard both residents yelling at each other. Another statement dated 3/21/24 written by E25 (RN)…

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 on record review and interview it was determined that for one (R42) out of five residents reviewed for medication review the facility failed to ensure accuracy of the MDS assessment. Findings include: Review of R42's clinical record revealed: 5/9/23 - R42 was admitted to the facility. 5/15/23 - An admission MDS assessment for R42 documented that the cognitive, behaviors, mood and pain level sections, were not assessed. During an interview on 4/9/24 at 1:22 PM, E15 (Director of Reimbursement Services) confirmed the finding. E15 stated, it was missed, we didn't get to it. [R42] should've been interviewed. These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).

Based on interview, and record review it has been determined that for one (R68) out of one resident reviewed for PASARR, the facility failed to ensure a referral for a new PASARR Level I and II screening occurred by or before the 60th day. R68 was remained in the facility beyond the authorization timeframe. Findings include: A facility policy and procedure titled, admission Criteria, documented . 1. All new admissions and readmissions are screened for mental disorders, intellectual disabilities or related disorders per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. Review of R68's clinical record revealed: 7/26/23 - A review of R68's PASARR Level I screen outcome revealed an approval period of 60 days for R68 a resident with a mental health disability in the nursing facility. 8/30/23 - R68 was admitted to the facility with diagnoses including but not limited to bipolar disorder, anxiety disorder and major depressive disorder. 11/6/23 - A review of R68's PASARR Level I screen outcome determination revealed R68 was referred for a PASARR Level II for 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 record review and interview it was determined that for one (R42) out of five residents reviewed for medication review the facility failed to develop a care plan to address the residents use of an anticoagulant. Findings include: Review of R42's clinical record revealed: 5/9/23 - R42 was admitted to the facility. 5/9/23 - A physicians order was written for R42 to receive an anticoagulant medication one tablet by mouth two times a day for blood clot prevention. 5/15/23 - An admission MDS assessment documented R42 received anticoagulant medication. 2/15/24 - A quarterly MDS assessment documented R42 received anticoagulant medication. Review of R42's care plans lacked evidence that care plan was created that addressed the residents use of an anticoagulant medication. During an interview on 4/9/24 at 1:25 PM E15 (Director of Reimbursement Services) confirmed the finding. These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for four (R33, R45, R55, and R75) out of of twenty-three (23) sampled residents, the facility failed to have input from all required interdisciplinary team (IDT) members at the residents' care plan meetings. Findings included: 1. Review of R33's clinical record revealed: 7/31/20 - R33 was admitted to the facility. 4/9/24 - A review of quarterly care plan meetings for 12/13/23 and 3/6/24 lacked evidence of input from the Physician and the CNA. 2. Review of R45's clinical record revealed: 6/13/23 - R45 was admitted to the facility. 4/9/24 - A review of quarterly care plan meetings for 1/3/24 and 4/3/24 lacked evidence of input from the Physician and the CNA. 3. Review of R55's clinical record revealed: 8/24/22 - R55 was admitted to the facility. 4/9/24 - A review of quarterly care plan meeting for 12/20/23 lacked evidence of input from the Physician, nurse and the CNA. A review of the quarterly care plan meeting for 3/24/24 lacked evidence of input from the Physician and CNA. 4/10/24 9:25 AM - In an interview, E6 (CNA)…

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

Based on observations, interviews and record review, it was determined that for two (R24 and R57) out of four residents reviewed for position and mobility, the facility failed to turn and reposition the resident in accordance with professional standards of practice to prevent skin breakdown. Findings include: 1. Review of R24's clinical record revealed: 11/19/23 - R24 was readmitted to the facility with diagnoses including but not limited to hypoxic ischemic encephalopathy, anoxic brain damage and persistent vegetative state. 9/3/23 - An annual MDS assessment documented that R24 was totally dependent for turning and repositioning with two person physical assist. R24 had impairments on both sides for upper and lower extremities. 3/4/24 - A nursing Braden Scale documented R24 with a score of 10 (10 - 12 is considered high risk of skin breakdown). 3/14/24 - A care plan for R24 last included to turn and reposition at least every two hours while in bed. On the following dates and times, R24 was observed lying in bed on her back with the head of the bed upright at approximately a 45 -…

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 (R75) out of one resident reviewed for incontinence, the facility failed to respond to or provide services to restore bladder continence. Findings include: A facility policy titled, Urinary Continence and Incontinence assessment and management revised August 2022 stated the staff will appropriately screen for, and manage individuals with urinary incontinence. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. Review of R75's clinical record revealed: 3/8/24 - R75 was admitted to the facility. 3/8/24 4:39 PM - A admission bowel and bladder continence evaluation documented R75 was incontinent. 3/12/24 11:31 AM - Review of R75's bowel and bladder program evaluation revealed R75 was a candidate for scheduled prompted voiding. 3/14/24 10:02 AM - An admission MDS revealed that R75 is frequently incontinent and a toileting program was not attempted. 4/9/24 10:37 AM - - During…

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. Review of R3's clinical record revealed: 8/25/22 - R3 was admitted to the facility with diagnoses including but not limited to acute respiratory failure, difficulty swallowing and hypertension. 11/28/23 5:20 PM - A physician's order documented . 1. Tracheostomy care change oxygen tubing, canister and humidifier bottle one time a day every Monday and as needed. 4/7/24 10:08 AM - R3 was observed sitting in the wheelchair in her room, further observations revealed that R8's tracheal suction machine equipment had not been changed, the suction canister had thick secretions and had a date of 1/26/24 and tubing for the suction equipment was not dated. 4/8/24 12:34 PM - Day 2 observations revealed R3's tracheal suction machine equipment had not been changed and the canister contained the same thick secretions as observed and dated 1/26/24. 4/9/24 12:59 PM - During an interview and observation E13 (LPN) confirmed R3's suction machine equipment had not been changed and the suction canister contained secretions and was dated 1/26/24. E13 stated, I'm not sure why it has not been changed, but…

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 (R42) out of five residents reviewed for medication review the facility failed to ensure pharmacist recommendations were reviewed by the attending physician. Findings include: The facility policy for MRR's last updated May 2019, indicated The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. 2/5/224 11:47 - A Pharmacist Consultant Note documented, Medication Regimen Reviewed: Recommendations Made. Review of R42's 2/5/24 MRR revealed a lack of physician response to the recommendations to evaluate and consider discontinuing use of vitamin c and to consider switching timeframe of laxative. During an interview on 4/10/24 at 1:07 PM, E1 (NHA) confirmed the facility was unable to locate a physician response to the February 2024 MRR. These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).

Based on record review and interview it was determined that for one (R42) out of five residents reviewed for medication review the facility failed to complete AIMS testing every six months for a resident on antipsychotic medications. Findings include: The facility policy on psychotropic medication use, last updated July 2022 indicated, Psychotropic medication is any medication that affects brain activity associated with mental processes and behaviors. Psychotropic medications are monitored with AIMS testing as required. Review of R42's clinical record revealed: 7/18/23 - A physicians order was written for R42 to receive an antipsychotic medication daily. 7/18/23 - R42 received an AIMS test assesment for side effects related to antipsychotic medication use. 7/2023 - A care plan for use of antipsychotic medications included the intervention for - AIMS testing per facility protocol. 4/10/24 - Review of R42's clinical revealed AIMS testing had not been completed for R42 in nine months. During an interview on 4/11/24 at 8:30 AM, E3 (ADON) confirmed the findings. These findings were…

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.