Cadia Rehabilitation Renaissance

Based on record review and interview, it was determined that for one (R106) out of one resident reviewed for lab services, the facility failed to promptly notify the ordering medical practioner of abnormal laboratory results. Findings include:Review of R106's clinical record revealed: 6/6/25 - R106 was admitted to the facility. 7/10/25 5:50 AM - A nursing progress note documented for R106 that a urine sample was collected and a dipstick resulted in positive blood and leukocytes. The nursing note further documented that a lab order to do urinalysis (UA) and culture and sensitivity (C&S) was placed, waiting to be picked up and that the NP was notified in the book. 7/10/25 12:01 PM - A physician's progress note documented that R106 complained of burning with urination, an in-house urine dipstick was positive for blood and leukocytes, and the lab picked up the urine in the morning, awaiting a culture and sensitivity. 7/12/25 1:19 PM - The lab results revealed the urine culture was positive for a urinary tract infection (UTI) with a positive growth of greater than 100,000 colony forming…

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 the facility failed to report an allegation of abuse to the state agency for one of one resident (R15) reviewed for abuse. Findings include: A facility policy titled Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, revised January 12, 2023, indicated, .Allegations of resident abuse shall be reported to the appropriate state regulatory authority within two hours .the named person accused of the act will be immediately suspended pending outcome of the investigation . Review of R15's clinical record revealed: 1/15/25 - R15 was admitted to the facility with diagnoses including Alzheimer's disease and Dementia with unspecified severity of behavioral disturbance. 1/21/25 - An admission MDS documented a BIMS score of 00, indicating R15 was severely cognitively impaired. 5/16/25 at approximately 9:10 PM - A facility investigation documented that E8 (CNA) informed E11 (LPN, supervisor) that E10 (CNA) had pushed R15. E11 instructed E8 to write a statement and place it under the DON's…

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

Based on observation, interview, and record review, it was determined that for one (R15) out of one resident reviewed for abuse, the facility failed to protect residents by not suspending the accused staff member pending the outcome of the investigation. Findings include: A facility policy titled Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, revised January 12, 2023, indicated, .Allegations of resident abuse shall be reported to the appropriate state regulatory authority within two hours .the named person accused of the act will be immediately suspended pending outcome of the investigation . Review of R15's record revealed: 5/16/25 at approximately 9:10 PM - A facility investigation documented that E8 (CNA) informed E11 (LPN, supervisor) that E10 (CNA) had pushed R15. E11 instructed E8 to write a statement and place it under the DON's door. 5/17/25 - The facility provided investigation packet documented the following: a statement written by E10 accused, wrote the accusation of rough is untrue. statement written by E18 (RN part time…

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, record review, and review of the facility's resident rights, the facility failed to ensure 1. residents were provided a homelike environment during meals for eight of eight residents (Resident (R) 46, R8, R25, R32, R36, R83, R111, R32, and R168) during dining; 2. privacy bags covered urinary catheter bags for R51; 3. and privacy with shower schedules was maintained. This failure placed the residents at risk of an undignified dining experience. Findings include: Review of the facility's Resident Rights, dated 06/01/24 revealed To promote the interest and well-being of the residents in long-term care facilities, all facilities must treat residents in accordance with the following resident rights: (1) Each resident shall have the right to receive considerate, respectful .services .recognizing each person's basic personal .which include dignity and individuality . 1. Residents were not served meals in a homelike environment. a. Review of R46's undated admission Record, located in the…

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

Based on interviews, record review, and review of the facility arbitration agreement, the facility failed to thoroughly explain the binding arbitration agreement to residents or their representative and provide an arbitration agreement that granted the resident or their representative the right to rescind the agreement within 30 days of signing it and communicate with federal, state, local officials and the ombudsman for three (Residents (R)11, R43, and R89) of three residents reviewed for arbitration in a sample of 34. This failure denied residents the opportunity to fully understand what the agreement meant and the ability to rescind the agreement within 30 days of signing. Findings include: Review of the facility arbitration agreement, dated 01/01/24, provided by the facility in the admission packet revealed .(3) this Agreement may be rescinded by written notice sent to the other party via Certified Mail, return receipt requested, within twenty-one (21) days of the date upon which it is signed. Rescission or waiver of this Agreement can only be effected in writing. If this…

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 interviews and record review, the facility failed to ensure the arbitration agreement provided for the selection of a neutral arbitrator without stipulations and the selection of a venue that is convenient for three (Residents (R)11, R43, and R89) of three residents reviewed for arbitration in a total sample of 34 residents. This placed residents at risk not having the opportunity to choose an arbitrator or venue. Findings include: Review of the facility arbitration agreement, dated 01/01/24, provided by the facility in the admission packet revealed All arbitrators must be a retired state or federal court judge or a member of the state bar with at least ten (10) years of experience as an attorney. There was no mention of a venue that is convenient to both parties. 1. Review of R11's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 07/25/24, located in the MDS tab of the electronic medical record (EMR), revealed an admission date of 07/18/24. R11 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R11's cognition…

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, document review, and policy review, the facility failed to develop and implement infection control protocols for 1. failed to ensure COVID19 infection control processes were followed by facility staff within a secured unit and soiled PPE was not kept out of reach for resident (Resident (R) 89); and 2. infection control was maintained during wound care for R104. These failures had the potential to affect all 116 residents in the facility. Findings include: Review of the facility's policy titled, COVID-19, initiated March 23, 2020, and last revised October 19, 2022, revealed The DON and the Infection Control Preventionist (IP) will conduct monitoring and surveillance in the facility for early detection and recognition of potential outbreaks of Coronavirus including all respiratory infections. 1. During an observation on 09/16/24 at 9:40 AM, a sign was posted on the outside of the secured 300-unit doors, near the main dining room. An isolation cart was placed in front of the door as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's resident rights, the facility failed to honor a resident's right to 1. choose their preferred method of transferring for one of 34 sampled residents (Resident (R) 43) and 2. choose to go outside for one of 34 sampled residents (R42). This failure placed the residents at risk for psychosocial harm by diminishing their independence. Findings include: Review of the facility's Resident Rights, dated 06/01/24 revealed To promote the interest and well-being of the residents in long-term care facilities, all facilities must treat residents in accordance with the following resident rights: .(6) Each resident may refuse medication or treatment and must be informed of the medical consequences of all medication and treatment alternatives .(21) Each resident has the right, personally, through other persons, or in combination with others to do any of the following: a. Exercise the resident's own rights .(31) Each resident shall be free to make choices regarding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from physical restraints by applying a Wanderguard to prevent leaving the facility for one of 34 sampled residents (Resident (R) 43). R43 was outside in the facility's parking lot when the nursing staff physically pulled the resident back into the facility against his will while he was in his wheelchair. This deficient practice had the potential to cause psychosocial and physical harm to the resident. Findings include: Review of the facility's policy titled, Restraint and Seclusion Policy, reviewed 01/03/24 revealed It is the policy of [Facility Name] that residents have the right to be free from any physical or chemical restraints .imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms .Definitions: 'Physical Restraints' are defined as any manual method or physical or mechanical device, material, or equipment attached to or adjacent 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.

Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement person centered comprehensive care plans for side rails and weight monitoring for palliative care for two (Resident (R) 62 and R51) of 34 sampled residents. This placed the residents at risk for decreased quality of life and quality of care and further exacerbation of an illness. Findings include: Review of the facility policy titled Care Planning, reviewed 01/03/24, provided by the facility revealed A comprehensive care plan should be developed to address medical, nursing, nutritional, and psychosocial needs within 7 days of completion of the comprehensive assessment . Care plans should include: . Services furnished to maintain highest practical well-being . The resident's preferences. Review of the facility titled Palliative Care/ Hospice, reviewed 01/03/24, provided by the facility revealed The palliative care treatment decision is communicated through Care Plans and Physician Orders. 1. Review of R62's quarterly Minimum Data Set (MDS) with an Assessment Reference…

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, record review and review of facility policy, the facility failed to ensure the Comprehensive Care Plan was accurate and updated for one resident (Residents (R)265) in a total resident sample of 34 whose Care Plans were reviewed. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings include: Review of the facility policy titled, Care Planning, dated January 3, 2024, revealed, .To establish guidelines for developing and implementing person-centered care plans that are consistent with resident's rights that includes measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs .Care plans should include .Services furnished to maintain highest practical well-being . 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R265 was admitted to the facility on [DATE] with diagnoses that included chronic gout and diabetes. Review of R265's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to provide assistance with dining for one of three residents (Resident (R) 106) reviewed for activities of daily living (ADLs) of 34 sampled residents. This failure increased the potential for R106 to have a significant weight loss. Findings include: Review of R106's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed R106 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. Review of R106's Care Plan located in the EMR under the Care Plan tab, dated 08/09/24, revealed R106 had an ADL (activities of daily living) performance deficit related to activity intolerance and dementia. Interventions included to assist with hygiene, grooming, toileting, dressing, oral care, and eating as needed. Review of R106's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/14/24 and located under the MDS tab of the EMR, revealed R106 had a Brief…

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, the facility failed to provide a safe toilet for one of two residents (Resident) R 42) reviewed for accident hazards out of a total sample of 34 residents creating the potential for a fall or skin injuries. Findings include: Review of R42's admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R42 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included type II diabetes mellitus and acute kidney failure. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/24, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R42 was cognitively intact. Review of R42's Care Plan, updated 07/31/24, located under the Resident Assessment Instrument (RAI) tab revealed R42 had a Self-care deficit r/t (related to) deconditioned status secondary to weakness, cognitive decline. (R42) will maintain her current level of function with staff…

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

Based on observation, interview, and record review, the facility failed to assess the need for side rails and obtain informed consent for one (Resident (R)62) of one resident reviewed for side rails out of a total sample of 34 residents. This failure increased the risk that residents would have side rails without evaluation for the need and without making an informed decision knowing the risks and benefits. Findings include: Review of R62's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 08/14/24, located in the MDS tab of the electronic medical record (EMR), revealed an admission date of 03/03/21. R62 had a Brief Interview for Mental Status (BIMS) score of eight out of 15 indicating R62's cognition was moderately impaired and had diagnoses of cerebrovascular disease, dementia, and dependence on supplemental oxygen. For mobility, R62 required partial/moderate assistance to roll left and right and R62 required partial/moderate assistance- helper does less than half the effort for lying to sitting on side of bed. Review of R62's orders, located in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of facility policy, the facility failed to ensure one of one resident (Resident (R)80) reviewed for a diagnosis of with post-traumatic stress disorder (PTSD) out of a total sample of 34 residents, received appropriate treatment and services to attain his highest practicable mental and psychosocial well-being. This failure placed the resident at risk of unmet needs and a diminished quality of life. Findings include: Review of the facility policy titled, Trauma-Informed Care, dated January 11, 2024, revealed .It is the policy of [facility] to provide trauma-informed care to all residents .To address the trauma in the lives of the residents served by [facility]; to promote the understanding of trauma and its impact; to eliminate or mitigate triggers that may cause re-traumatization .SCREENING: Screening will be completed upon admission to determine if an individual has a history of trauma .A positive screen will warrant further evaluation by the provider…

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, record review, and facility policy review, the facility failed to contact the pharmacy to ensure medications were available for administration for one of seven residents (Resident (R) 92) reviewed for medication administration out of a sample of 34 residents. Findings include: Review of the facility's policy titled, Electronic Interim Box, initiated 09/18 and last revised 08/20, revealed The provider pharmacy will utilize an electronic interim box .to provide an interim supply of medications for use in emergency and non-emergency dosing for nursing facility residents until the pharmacy is able to provide a regular supply of medication to the nursing facility resident. Review of R92's admission Record, found in the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE]. R92 was admitted with diagnoses including Parkinson's disease, hemiplegia and hemiparesis (paralysis and weakness on one side) following cerebral infarction (stroke) affecting…

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 interviews, record reviews, and policy review, the facility failed to ensure that one of seven residents reviewed for unnecessary medications (Resident (R) 16) out of a total sample of 34 residents received antibiotics with diagnoses of tooth abscess and moderate protein-calorie malnutrition. This failure had the potential to increase the risk of infection, pain, and weight loss. Findings include: Review of the facility's policy titled, Electronic Interim Box, initiated 09/18 and last revised 08/20, revealed The provider pharmacy will utilize an electronic interim box .to provide an interim supply of medications for use in emergency and non-emergency dosing for nursing facility residents until the pharmacy is able to provide a regular supply of medication to the nursing facility resident. Review of R16's admission Record, found in the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] and last readmitted on [DATE]. R16 was admitted with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure: 1. an insulin pen was not expired when used for one resident (Resident (R) 66) of four insulin pens reviewed on three medication carts and This failure increased the risk of insulin not being effective. Findings include: Review of the pharmacy policy titled, Storage of Medications, dated [DATE] revealed, .Outdated, contaminated, or deteriorated medication .are immediately removed from inventory, disposed of according to procedures for medication disposal and reordered from the pharmacy . 1. On [DATE] at 7:42 AM a review of the Bethany Medication Cart 1 with Licensed Practical Nurse (LPN) 1 revealed a Humalog (short-acting insulin) Kwik pen for R66 with approximately 61 units remaining in the pen. The expiration date on the pen was [DATE]. LPN 1 was asked if R66 had received any Humalog insulin since [DATE]. LPN 1 stated, Yes, at least five times. LPN 1 confirmed that the Humalog insulin should not have been…

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, the facility failed to have menu extensions for finger foods for one (Resident (R)89) of three residents reviewed for diets in a total sample of 34 residents. The failure had the potential to cause R89 to lose weight by not receiving foods easy to eat. Findings include: On 09/19/24 at 1:45 PM, a policy for menus and menu development was requested. The Administrator stated at this time the facility did not have a policy for menus and menu development. Review of the LTC [Long Term Care] dietary manual Dining RD.com 2017, provided by the facility, revealed The Finger Food Diet is used for individuals with dementia or cognitive impairment, such as Alzheimer's disease resulting in a loss of ability to recognize and use utensils, or for neuromuscular diseases affecting muscle coordination such as in Parkinson's disease. The diet allows independence in eating, regardless of a decline in cognition or muscle coordination. The Finger Foods Diet is designed to promote self-feeding for individuals who have difficulty using utensils due 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 record review, interviews, facility reportable incidents (FRIs), and facility policy review, the facility failed to ensure two of four residents (Resident (R) 2 and R6) reviewed for abuse and neglect were free from abuse. Specifically, R2 was involved in a resident-to-resident altercation initiated by R1, and R6 was verbally abused by Registered Nurse (RN) 1. Findings include: Review of the facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, dated 01/03/24, documented It is the policy of [facility name] to protect residents and prevent occurrences of abuse, neglect, mistreatment, mis appropriation of resident property, exploitation, and crime. The policy defines Abuse as the willful infliction of injury, unreasonable confinement, intimidation .with resulting physical harm, pain or mental anguish . 1. a. Review of R1's undated admission Record located in the electronic medical record (EMR) under the Profile tab, indicated R1 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 interviews, facility document review, and facility policy review, the facility failed to ensure that an allegation of abuse for one of one resident (Resident (R) 6) reviewed for an allegation of verbal abuse, was reported to the State of Delaware, Department of Health and Social Services, Division of Health Care Quality within two hours of the allegation of abuse being identified. Findings include: Review of the facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, review date of 01/03/24, instructed Reporting and Response: witnessed or suspected incidents of abuse or reasonable suspicions of crime are to be reported immediately .Allegations of resident abuse shall be reported to the appropriate state regulatory authority within (2) hours. Review of the facility's Incident Report provided by the facility, documented on 03/11/24 at 9:00 AM, Registered nurse [(RN) 1] was witnessed speaking to a resident [R6] in a negative manner this am by other staff members. Further review of the Incident Report revealed…

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

Based on observation and interview, it was determined that the facility failed to maintain essential kitchen equipment in safe operating condition. Findings include: 8/1/23 10:24 AM - During a tour of the kitchen, the surveyor observed three areas of ice build-up in the walk-in freezer on the floor below the fans, behind the fans, and under a black pipe that runs from the fan area to the wall. An interview with E6 (Dietary Director) revealed the ice build-up had been ongoing for the last two months. 8/1/23 10:37 AM - Findings were confirmed with E6 (Dietary Director). 8/7/23 2:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (Corporate) during the exit conference.

Based on interview, record review and review of other facility documentation, it was determined that for one (R264) out of one resident reviewed for grievances, the facility failed to ensure that concerns received by the facility were timely and thoroughly investigated to resolve the grievance. Findings include: Review of R264's clinical record revealed: 4/5/23 - admission to the facility. 4/5/23 - A review of the inventory of personal effects form revealed no evidence it was completed upon admission. 4/9/23 - A review of the inventory of personal effects form revealed son brought one pair of black pants and one shift labeled with black marker. 4/23/23 - A review of an Employee Concern/ Complaint form revealed that R264 had the following missing items: blue sweatshirt, black sweatpants, pack of ten contact lenses, and dark green blanket. A response noted from the facility, blue sweatshirt, black sweatpants, and green blanket were found. Son notified and will pick up on Friday. 8/3/23 9:15 AM- An interview with E1 (NHA) confirmed that the contact lenses for R264 were not found and…

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

Based on observations, interview and record review, it was determined that for one (R18) out of twenty-two residents reviewed for care plans, the facility failed to develop a care plan for the use of oxygen. Findings include: Cross refer F695 Review of R18's clinical record revealed: 6/6/23 - R18 was re-admitted to the facility with acute respiratory failure with hypercapnia. 6/12/23 - R18 had a documented BIMS score of 15/15, revealing an intact cognitive state. 8/1/23 10:59 AM - An interview with R18 stated she uses oxygen only at night and has been using oxygen for a few weeks. 8/1/23 through 8/4/23 - Random observations of R18's room revealed an oxygen concentrator with nasal cannula oxygen tubing and a zip lock bag taped to the side of the concentrator with R18's name. 8/4/23 10:32 AM - An interview with E5 (LPN) confirmed there were no physician orders or nursing measures for R18 relating to the use of oxygen. A record review lacked evidence of a person-centered care plan for R18's oxygen administration. 8/7/23 2:00 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3…

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 (R66) out of one resident reviewed for pressure ulcers the facility failed to ensure that the resident received the necessary treatment and services to promote healing and prevent new pressure ulcers from developing. For R66, a dependent resident with a pressure ulcer the facility failed to ensure that R66 was turned and repositioned every two hours. Findings Include: National Pressure Ulcer Advisory Panel (NPUAP), Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, second edition, published 2014, stated Do not position an individual directly on a pressure ulcer .Continue to turn and reposition the individual regardless of the support surface in use .No support surface provides complete pressure relief. A facility policy (last revised 1/17/2023) Pressure Ulcer prevention and Management included: Interventions for dependent residents may include, but are not limited to: Turning and repositioning every two hours; Use of pillows to aid in positioning. Review of R66's clinical 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 observation, interview and record review, it was determined that for one (R18) out of one resident reviewed for respiratory care, the facility failed to provide professional standards of practice by ensuring the oxygen tubing was changed weekly. Findings include: Cross refer F656 Review of R18's clinical record revealed: 6/6/23 - R18 was re-admitted to the facility with acute respiratory failure with hypercapnia. 6/12/23 - R18 had a documented BIMS score of 15/15, revealing an intact cognitive state. 8/1/23 10:59 AM - An interview with R18 stated she uses oxygen only at night and has been using oxygen for a few weeks. 8/1/23 through 8/4/23 - Random observations of R18's oxygen tubing revealed no label with a date. 8/4/23 1:05 PM - During a joint observation and interview, E4 (CNA) stated she was not sure when the tubing was changed last and confirmed the oxygen tubing was not labeled for R18. A review of the Treatment Administration Record (TAR) indicated no documentation of oxygen tubing being changed. A review of R18's Physician orders revealed no orders to change oxygen…

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 facility documentation, it was determined that for one ( R262) out of twenty-one (21) sampled residents, the facility failed to ensure accurate and complete records. 1. Review of R262's clinical record revealed: 3/6/23 - admission to facility. 8/7/23 - 9:03 AM- A review of R262's Medication Administration Record (MAR) lacked documentaion of the administration of Zosyn (antibiotic medication) on 3/16/23 and 3/23/23. R262 was receiving his antibiotic through a PICC (peripheral inserted central catheter) line. 8/7/23 10:01 AM - An interview with E4 (LPN) revealed that if a medication is unavailable, staff would notify the pharmacy and the on-call provider to get a hold order. Also, if there is an issue with the PICC line staff would notify the IV team. 8/7/23 10:22 AM - An interview with E5 (UM) confirmed that the MAR lacked a signature for the administration of Zosyn. E2 (DON) was present and confirmed there was no medication variance noted for the dates 3/16 and 3/23/23. There was a lack of evidence of complete and accurate…

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.