Evergreen Post Acute

Based on record reviewed and interview it was determined that for one (R196) out of forty-three residents sampled, the facility failed to ensure the person centered care plan included necessary interventions. Findings include: The facility policy on dialysis care last updated, January 2025 indicated, The nurse will monitor and document the status of the resident's access site. Review of R196's clinical record revealed: 2/15/25 - R196 was admitted to the facility with multiple diagnoses including kidney disease. 2/16/25 - A task was added to R196's physicians orders for blood pressure medications for staff not to obtain blood pressures on the resident's right arm. 2/18/25 - A care plan was created for R196's renal disease. Interventions for the care plan included dialysis twice a week, monitor lab and report abnormal results, observe for and report any signs of infection/leaking/dislodgement of dialysis catheter and record weights and report changes. There was no evidence that the care plan included an intervention to avoid blood pressures to the right arm due to the dialysis…

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, observation and record reviews it was determined that for one (R132) out of one resident reviewed for communication the facility failed to provide assistive devices to support communication for R132 who was fluent only in Spanish. 3/8/25 - R132 was admitted to facility for rehabilitation. 3/8/25 - The care plan documented that R132's participation in activities was limited due to a language barrier, as the resident was fluent only in Spanish. R132 had difficulty communicating, as evidenced by a limited understanding and use of English. The care plan goal was to facilitate communication through alternative methods, such as a communication board, to express needs and wants. Interventions included teaching R132 how to use a communication book/board or electronic device and utilizing a Spanish interpreter as needed. 3/10/25 - A baseline care plan documented Spanish as the primary language for R132. 3/10/25 - A physician's order for speech therapy evaluation and treatment 1-3x per week for 41 days for dysphagia therapy and group therapy as indicated. 3/17/25 - An…

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

2. Review of R73's clinical record revealed: 1/2/20 - R73 was admitted to the facility. 1/4/20 - A care plan documented that R73 required assitance with all ADL's with the following interventions: assist with daily hygiene, grooming, oral care, and eating as needed; encourage to participate in self care; praise all efforts; report any changes or decline to provider. 2/25/25 - A quaterly MDS documented R73 required set up or clean up assistance of one staff member for oral hygiene. Additionally the MDS documented R73had a BIMS score of 15 meaning he was cognitively intact. 4/8/25 8:21 AM - An interview with R73 revealed the need for assistance with ADL's and he feels that staff is not attentive to his needs. 4/10/25 9:37 AM - An interview with R73 confirmed that he brushes his teeth after staff set up breakfast. Also, R73 confirmed he had not been set up at this time to bursh his teeth. 4/10/25 11:26 AM - An observation of R73 had not brushed his teeth and R73's toothbrush was sitting in cup in bathroom dry. 4/10/25 11:34 AM - An interview with E45 (CNA) confirmed that she did 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 interview and record review it was determined that for two (R112 and R644) out of forty three residents reviewed in the investigative sample, the facility failed to ensure received treatment and care in accordance with professional standards of practice and physician orders. Findings include: 1. Review of R112's clinical record revealed: Cross refer F603 and F880 7/30/24 - R112 was admitted to the facility. 8/27/24 3:12 PM - A physician's order documented that R112 was on contact isolation due to scabies for fourteen days. 11/9/24 - A physicians order was written for R112 consult to dermatology related to scabies. 11/13/24 - A specialist physician's (dermatologist) progress note documented that R112 was not contagious and to remove isolation precautions. 4/15/25 10:30 AM - An interview with C2 (NP) and C5 (NP) confirmed that R112 was on contact precautions from 8/27/24 to 11/13/24. There was a ten week delay in consulting the dermatologist resulting in R112 being in isolation for 78 days. 2. R644's clinical record revealed: Cross refer F760 9/12/24 - R644 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, record review and interview, it was determined that for one (R35) out of 11 resiedents reviewed for accidents the facility failed to implement a care planned fall intervention. Findings include: Review of R35's clinical record revealed: 6/27/24 - R35 was admitted to the facility. 6/27/24 - An admission MDS documented the resident required extensive to total assistance with most ADLs, including transfers and mobility. The resident was dependent for bed mobility, toileting, and dressing. 9/25/24 - R35 was readmitted to the facility from the hospital with diagnoses including a right broken leg from a fall at the facility. A care plan revised on 10/2/24 included a new intervention for fall mats to be placed at the bedside when R35 is in bed. 10/3/24 - A fall risk assessment scored R35 at 17, indicating a high risk. On the following dates, no fall mats were observed at the bedside while R35 was in bed: 4/8/25 at 7:46 AM 4/11/25 at 2:27 PM 4/15/25 at 10:25 AM On 4/15/25 from approximately 10:55 AM to 11:00 AM, during an interview and observation with E15 (CNA) 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 observation and interview, it was determined that for one (R3) out of ten residents sampled for dining, the facility failed to provide the therapeutic diet that was prescribed by the physician. The facility failed to provide R3 large portions. Findings include: Review of R3's clinical record revealed: 5/24/24 - R3 was admitted to the facility. 1/23/25 - A physician's order for R3 documented low concentrated sweets diet, regular texture, thin liquid consistency: give large portions for all three meals. 4/14/25 12:10 PM - An observation of R3's meal tray that contained one piece of chicken, mashed potatoes, string beans, fruit cup and drinks on tray. The mashed potatoes and vegetables were one serving and not large portions. 4/14/25 12:26 PM - An interview with E40 (CNA) confirmed that R3 was on large portions and if R3 wants them she will ask staff for more. E40 confirmed that the mashed potatoes and green beans were not large portion. 4/14/25 12:29 PM - An interview with E41 (FSD) confirmed that large portions refers to the sides and double portions refers to the entrees.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that for two (R18 & R33) out of five residents reviewed for antibiotic usage, the facility failed to monitor antibiotic usage. Findings include: Facility's Antibiotic Stewardship program Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of this program is to optimize the treatment of infections while reducing adverse events associated with antibiotic use . Rev. 12/2024 1. Review of R18's clinical record revealed: 9/9/21 - R18 was admitted to the facility. 12/10/24 - C5 (consultant NP) entered an order in R18's EMR stating, Metronidazole (antibiotic) oral tablet 500 mg- give 1 tablet by mouth two times a day for cellulitis of penis for 5 days. 12/12/24 - C3 (consultant MD) documented in R18's re-admission history and physical note, .admitted to [hospital] for penis necrosis, and underwent debridement of penis on 12/7/24 .Physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that for two (R33 and R96) out of twelve residents reviewed for pneumococcal vaccines, the facility failed to accurately assess the residents' pneumococcal vaccine status. Findings include: Facility's Pneumococcal Vaccine (Series) Policy: It is our policy to offer our residents immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations . Policy Explanation and Compliance Guidelines: 1. Each resident will be assessed for pneumococcal immunization upon admission .6. A pneumococcal vaccination is recommended for all adults 65 years and older and based on the following recommendations: . b. For adults 65 years or older who have only received a PPSV23: Give 1 dose PVC15 or PCV20. 1. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination . Rev 1/2025 1. Review of R33's clinical record revealed: 12/25/24 - R33,aged [AGE] years, was admitted to the facility. 12/25/24 -…

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

Based on record review and interview, it was determined that for one (R641) out of the seven residents reviewed for advanced directives, the facility failed to ensure that R641's' representative was included in the advanced directive acknowledgment as R641 had cognitive impairment. Findings include: Review of R641's clinical record revealed: 7/5/24 - R641 was admitted to the facility. 7/11/24 - R641's admission MDS documented a BIMS score of 11, which was reflective of moderate cognitive impairment. 4/11/25 10:05 AM - A review of R641's EMR revealed that R641's face sheet listed F4 (R641's daughter) as the emergency contact #1. The EMR also contained documentation of a signed and notarized POA with two witnesses dated from 2006 that named F4 as the sole POA for both durable medical and financial issues. 4/11/25 10:25 AM - A review of R641's admission paperwork revealed that E6 (SW) completed the Advance Directive Acknowledgment form with R641 on 7/5/24. A review of the form revealed that R641 printed her name on the signature line using a different first name and mispelling her last…

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 (R188) out of four residents reviewed for Beneficiary Notification Review, the facility failed to ensure the resident was informed in advance of a change that occurred to their bill. Findings include: Review of R188's clinical record revealed: 5/2/24 - R188 was admitted to the facility. 6/1/24 - An Eligibility Verification Notice was provided to the facility by R188's insurance that indicated the resident had 0 days remaining for nursing home stay. 6/3/24 11:15 AM - A SNFABN notice was read over the telephone to R188's Responsible Party (RP)(R188's daughter) that explained beginning on 6/4/25 R188 and RP would be responsible to pay out of pocket for the R188's facility stay. The notice was completed by E5 (SW) and witnessed by E6 (SW). 4/11/25 8:15 AM - During an interview, E4 (BOM) confirmed that R188 and RP were not made aware of the change in billing in advance. E4 explained that the facility was made aware of R188's change in coverage on 6/3/24 and provided the SNFABN notice that same day, then charged R188…

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

Based on record review and interviews, for one (R112) out of five sampled for abuse, it was determined that R112 was not free from involuntary seclusion. Findings include: Cross refer F684 and F880. Review of R112's clinical record revealed: 7/30/24 - R112 was admitted to the facility. 8/18/24 - A SBAR (physician's communication tool) documented that R112 had a rash on both arms and upper thighs. 8/18/24 3:15 PM - A nursing skin observation tool documented R112 had the following skin conditions noted: right antecubital rash, left antecubital rash, bilateral thighs front. 8/27/24 - A care plan documented that R112 was placed on isolation precautions related to scabies. 8/27/24 3:12 PM - A physician's order documented that R112 was on contact isolation due to scabies for fourteen days. R112's 8/24 MAR documented that Ivermectin oral tablets and Permethrin external cream for scabies were started on 8/29/24. 9/3/24 - A physician (C5 NP) progress note documented that R112 was seen and examined for a scabies. C5 documented for R112 to continue on Permethrin external cream to skin at…

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

Based on record review and interview, it was determined that for one (R79) out of five residents reviewed for hospitalizations, the facility failed to notify R79's responsible party in writing of the reason for transfer to the hospital. Findings include: Review of R79's clinical record revealed: 11/6/20 - R79 was admitted to the facility, with diagnoses including but not limited to, dementia. 4/1/25 - R79's quarterly MDS documented a BIMS score as three, which reflected severe cognitive impairment. 4/5/25 9:38 PM (Saturday) - E9 (LPN) documented in R79's EMR progress note, .Resident vomited again a large amount of brown colored vomit. Resident with change in LOC .order to send to ER via 911 .Emergency contact [F1] notified. 4/14/25 1:32 PM - A review of R79's EMR revealed F1 (R79's responsible party) was listed as the Emergency Contact #1. 4/15/25 10:14 AM - A review of R79's transfer notice, dated 4/7/25 (Monday) and signed by E10 (Admissions Director), failed to document to whom the notice of transfer was presented. 4/15/25 12:03 PM - During an interview, E10 stated, The bed hold…

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 (R136) out of forty-three sampled residents, the facility failed to complete a comprehensive assessment after R136 had a significant change in status. Findings include: Review of R136's clinical record revealed: 11/7/24 - R136 was admitted to the facility. 12/6/24 - R136 was admitted to hospice care. 1/2/25 - C2 (consultant NP) entered an order into R136's EMR, Hospice [local hospice service] every shift. This was twenty-seven days after R136 was admitted to a hospice service. 4/9/25 1:44 PM - A review of R136's EMR MDS schedule revealed there was no significant change MDS completed within fourteen days of R136's hospice admission. 4/10/25 11:02 AM - In a telephone interview, C1 (hospice office staff) confirmed. [R136] was admitted to our hospice service on 12/6/2024. 4/10/25 11:27 AM - During an interview, E4 (Business Office Manager) confirmed, [R136] went on hospice care on 12/6/24. 4/10/25 1:23 PM - During an interview, E11 (RNAC) confirmed that R136's MDS for a significant change was completed on 1/3/25, 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.

Based on record review and interview it was determined that for one (R188) out of three residents reviewed for discharge the facility failed implement a discharge planning process that prepared the resident/RP to effectively transition to post-discharge care. Findings include: The facility policy on transfer and discharge undated indicated, Anticipated transfers or discharges - A post discharge plan of care that is developed with the participation of the resident and the residents representative which will assist the resident to adjust to his or her new living environment. Review of R188's clinical record revealed: 5/2/24 - R188 was admitted to the facility. 5/3/24 - A care plan for discharge documented that R188 expressed wish for discharge to home. 5/3/24 12:34 PM - A social work progress note written by E6 (SW) in R188's clinical record documented, Resident is short term care at our facility. Resident will be discharged back to prior living arrangement once therapy is completed. The note did not document R188's actual discharge date . 5/9/24 - An admission MDS assesment…

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 a review of other facility documentation, it was determined that for one (R1) out of three sampled residents reviewed abuse, the facility failed to report an allegation of abuse. Findings include: Cross refer to F610 The facility policy titled Abuse, Neglect, Exploitation last updated, May 2024 indicated, .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . Review of R1's clinical record revealed: 1/2/25 - R1 was admitted to the facility with a diagnosis including Alzheimer's disease. 1/3/24 - A Brief Interview for Mental Status (BIMS) was completed for R1 and showed a score of 8 out of 15 indicating that the resident was moderately cognitively impaired. 1/13/25 11:57 AM - During an interview, E7 (CNA) stated that on 1/5/25 F1 reported to her that a staff member was being mean to R1. E7 further stated that R1…

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 (R1) out of three sampled residents for investigating an allegation of abuse, the facility failed to protect residents from abuse and investigate an allegation of abuse. Findings include: Cross refer to F609 The facility policy Abuse, Neglect, Exploitation last updated, May 2024 indicated, . An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur . Review of R1's clinical record revealed: 1/2/25 - R1 was admitted to the facility with diagnosis of Alzheimer's disease. 1/3/24 - A Brief Interview for Mental Status (BIMS) was completed for R1 and showed a score of 8 out of 15 indicating that the resident was moderately cognitively impaired. 1/13/25 11:43 AM - During an interview E6 (LPN) stated that on 1/5/25, F1 reported that a staff was inappropriate to R1. E6 stated that E8 (Supervisor) did not request that they write a statement. 1/13/25 11:57 AM - During an interview E7 (CNA) stated that on…

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

Based on 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: 5/9/24 9:35 AM - During a tour of the kitchen, the surveyor observed E48 (Dietary Services Manager) test the sanitizer level of the solution in two red sanitizing buckets. When E48 tested the sanitizing solution in both buckets, the test strips from each of the two buckets indicated that the level of chemical concentration in the buckets was not at a sufficient level to provide proper sanitization. 5/9/24 9:42 AM - A container of dry rice was spilled on the floor near the sink in the kitchen and left for over an hour. 5/9/24 10:27 AM - Observation of nourishment refrigerator in the Aspen unit revealed an opened carton of Nutritional Shake that was undated. The instructions on the carton indicate that once opened, any remaining product should be discarded after four (4) days. 5/9/24 11:53 AM - Observation of nourishment refrigerator in the Seaside Unit revealed an opened bottle…

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

Based on record review and interview, it was determined that for five (R2, R32, R55, R88 and R120) out of five sampled residents for care plan timing and revision, the facility failed to have input from all required interdisciplinary team (IDT) members at the residents' care plan meetings. Findings include: The facility policy entitled Comprehensive Care Plans, last reviewed 4/24, indicated 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: a. The attending physician or non-physician practitioner designee involved in the resident's care, if the physician is unable to participate in the development of the care plan. b. A registered nurse with responsibility for the resident. c. A nurse aide with responsibility for the resident. d. A member of the food and nutrition services staff. e. The resident and the resident's representative, to the extent practicable. f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Examples include, but are 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 observation and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment. Findings include: 1. 5/9/24 10:49 AM - Laundry Aide (E41) was observed placing soiled laundry into the washing machine using ungloved hands. An interview revealed that E41 was not aware of safe handling practices for general soiled laundry or for laundry belonging to residents who were on various types of precautions due to illness. 2. A facility policy titled Infection Prevention and Control Program with a revision date of 1/2024 documented This facility has established and maintains an infection prevention and control program designed to provide a .sanitary .environment to help prevent the development and transmission of .infection . Review of R113's clinical record revealed: 9/1/23 - R113 was admitted to the facility. 5/20/24 9:10 AM - During an interview, R113 stated on 10/18/23 E24 (CNA) was cleaning out the toilet bowl from her bedside commode over the sink in her room which is located opposite the…

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

Based on observation, interview and record review, it was determined that the facility failed to promote R18's dignity by keeping R18's urinary collection bag in a privacy bag. Findings include: Review of R18's clinical record revealed: 12/13/20 - R18 was admitted to the facility. 3/26/24 - A significant change MDS indicated R18 has an indwelling urinary catheter. 5/9/24 10:06 AM - An observation of R18 sitting by the nurses station and the urine collection bag was uncovered. 5/10/24 1:16 PM - An observation of R18 sitting by the nurses station and the urine collection bag was uncovered. 5/13/24 9:09 AM - An observation of R18 sitting by the nurses station and the urine collection bag was uncovered. 5/14/24 2:13 PM - An interview with E36 (CNA) confirmed R18's urinary collection bag was covered at this time and confirmed the privacy bag was put in place today. 5/20/24 1:35 PM - Findings were reviewed with E2 (DON), E4 (Consultant), and E21 (Corporate Clinical Nurse).

Based on observations, interviews and record review, it was determined that for one (R65) out of one sampled resident reviewed for choices and preferences, the facility failed to accommodate R65's preference for showers. Findings include: Review of R65's clinical record revealed: 6/2/20 - R65 was admitted to the facility. 11/30/23 - A significant change MDS assessment revealed that R65 was dependent for transfers and showering and also revealed it was very important for R65 to be able to chose a bath or a shower. 5/9/24 11:33 AM - An interview with R65 revealed that R65 has not had a shower or washed her hair since September 2023. R65 stated that staff told her the bariatric shower bed was broken and she was unable to shower. A review of CNA documentation from August 2023, September 2023, October 2023, November 2023, December 2023, January 2024, February 2024, March 2024, April 2024, and May 2024 revealed that R65 has been only receiving bed baths from staff. 5/14/24 10:57 AM - An interview with E19 (RN) revealed that she was unaware of R65's preference for showers and could 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 interview and record review, it was determined that for three (R18, R65 and R116 ) out of six residents reviewed for Advance Directives, the facility failed to offer an opportunity to formulate an advance directive. Findings include: 1. Review of R18's clinical record revealed: 12/13/20 - R18 was admitted to the facility. 3/26/24 - A significant change MDS revealed R18 was cognitively intact with a BIMs score of 15. 5/9/24 10:06 AM - An interview with R18 confirmed the facility did not offer to assist in formulating an advanced directive for him upon admission. 5/13/24 - A review of the electronic medical records lacked evidence that R18 had an advanced directive on file. 5/14/24 11:47 AM - An interview with E1 (NHA) confirmed that R18 did not have an advanced directive and was not previously offered to formulate one upon admission. 2. Review of R65's clinical record revealed: 6/2/20 - R65 was admitted to the facility. 2/29/24 - A quarterly MDS revealed that R65 was cognitively intact with a BIMs score of 15. 5/9/24 10:42 AM - An interview with R65 confirmed the facility…

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

Based on record review and interviews, it was determined that for one (R80) out of two reviewed for Personal Property, the facility failed to maintain evidence demonstrating the result of R80's grievance regarding her missing personal items. The facility grievance policy also lacked documentation a specific process for how the resident/family were informed of the results of the grievance investigation. Findings include: Resident and Family Grievance Policy .1. Director of Social Services has been designated as the Grievance Official . 4. Grievance may be voiced in the following forums: a. Verbal complaint to a staff member of Grievance Official . Review of the facility Resident and Family Grievance Policy revealed the policy lacked a documented, specific process for how the resident/ family were informed of the results of the grievance investigation. 1/14/24 - R80 was admitted to the facility with diagnoses, including but not limited to, end stage renal disease, diabetes and difficulty walking. 5/10/24 10:53 AM - During an interview, R80 stated that she (R80) was transferred 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.

2. Review of R46's clinical record revealed: 9/11/15 - R46 was admitted to the facility with diagnoses including but not limited to anxiety. 5/7/24 - An quarterly MDS revealed that R46 had no behavioral occurrences during the review period. 5/2024 - A review of the CNA behavior flow sheet revealed that R46 had verbal aggression from 5/1/24 to 5/7/24. 5/16/24 10:35 AM - An interview with E37 (RNAC) revealed that she is not responsible for the section documenting the behaviors in the MDS. 5/16/24 10:42 AM - Interview with E7 (SW) confirmed that social services is responsible for documenting the behavior section of the MDS. E7 confirmed that R46 had documented behaviors and the MDS was inaccurate. 3. Review of R98's clinical record revealed: 7/24/23 - R98 was admitted to the facility. 4/25/24 - A quarterly MDS revealed that R98 had no behavioral occurrences during the review period. 4/2024 - 5/2024 - A review of the CNA behavior flow sheet revealed that R98 had verbal and physical aggression from 4/18/24 to 4/25/2024. 5/16/24 10:42 AM - Interview with E7 (SW) confirmed that social…

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 (R2, R28, R46 and R116) out of six residents reviewed for PASARR, the facility failed to ensure that a referral for a PASARR screening was completed. Findings include: 1. Review of R2's clinical record revealed: 12/1/21 - R2 was admitted to the facility. 8/4/22 - A review of R2's medical record revealed that R2 had a PASRR level 1 that indicated the following: The Level 1 screen indicates that a PASRR disability is not present because of the following reason: A neurocognitive disorder/dementia is primary and progressed . 6/21/23 - A diagnosis of major depressive disorder, recurrent, severe with psychotic symptoms was added to R2's diagnoses, yet there was no request for an updated PASRR since the one completed in 2022. 5/13/24 11:07 AM - S1 (PASRR State Authority) confirmed that a resident review PASRR should have been completed due to this new mental health diagnosis as it suggested a new primary mental illness. 5/14/24 approximately 11:50 AM - An interview, E7 (Social Services Director) and E14 (Social Work…

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 (R47) out of six residents sampled for PASARR review, the facility failed to provide evidence that a Delaware State PASARR was obtained prior to admission. Findings include: Review of R47's clinical record revealed: 12/15/15 - R47 was admitted to the facility with diagnoses including but not limited to major depressive disorder. 9/19/16 - R47 was diagnosed with delusional disorder, anxiety disorder and mood disorder due to unknown physiological condition. 2023 - 2024 - A review of clinical records lacked evidence of a level I PASARR and a referral for update to the State PASARR authority. 5/17/24 1:15 PM- An interview with E7 (SW) confirmed that R47 was admitted without a PASARR level I or any PASARR review and will submit one today. E7 confirmed that she contacted the State PASARR authority and a level I was not on file. 5/20/24 1:35 PM - Findings were reviewed with E2 (DON), E4 (Consultant), and E21 (Corporate Clinical Nurse).

Based on record review and interview, it was determined that for two (R40 and R106) out of three residents reviewed for bowel and bladder, the facility failed to develop a person centered care plan to address incontinence. Findings include: 1. Review of R40's clinical record revealed: 1/23/20 - R40 was admitted to the facility. 2/6/24 - An admission assessment documented R40 was cognitively intact , always incontinent of bowel, bladder was not rated, and no toileting plan initiated. 4/30/24 - A quarterly MDS documented R40 was cognitively intact, always incontinent of bowel and bladder, and no toileting plan in place. 5/10/24 - Review of R40's care plan revealed a lack of evidence that a person centered care plan with interventions was developed to address R40's incontinence. 5/13/24 9:23 AM - During an interview, E39 (LPN) confirmed that R40 is incontinent of bowel and bladder she calls for help when she needs to be changed. 5/13/24 approximately 11:30 AM - During an interview E48 (RN/UM) confirmed R40's care plan lacked evidence that a person centered care plan was developed 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 and interviews, it was determined that for one (R3) out of four residents reviewed for Medication Administration, the facility failed to ensure that R3's care met accepted, professional standards. The nurses documented signing out multiple medications as being administered via the oral route when in fact, the medications were being given via the enteral route due to R3 being NPO. Findings include: Nursing Rights of Medication Administration . It is the standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the five rights or five R's of medication administration .The traditional five rights in traditional sequence include: right drug, right patient, right dose, right route, and right time. National Library of Medicine, September 4, 2023. Review of R3's clinical record revealed: 7/5/18 - R3 was admitted to the facility with diagnoses, including but not limited to, multiple sclerosis. 2/14/24 - R3 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, it was determined that for four (R18, R54, R65, and R79) out of six residents reviewed for ADLs, the facility failed to ensure ADLs were provided to dependent residents. Findings include: 1. Review of R18's clinical record revealed: 12/13/20 - R18 was admitted to the facility. 3/26/24 - A significant change MDS revealed that R18 was dependent for toileting hygiene which includes perineal hygiene and using the toilet, commode or urinal. R18 was also dependent for chair to bed to chair transfer. R18 has a BIMS score of 15 and is alert and oriented. 5/9/24 10:56 AM - An interview with R18 revealed that he has been up in his chair since 6:00 AM and requested for his CNA to change him. R18 stated, She told me I have to wait until after lunch to be changed. 5/9/24 12:56 PM - An observation of R18 following the CNA to his room to receive care. 5/9/24 - A review of the CNA documentation flow sheet revealed that E43 (CNA) only provided perineal hygiene once during the shift. 5/9/24…

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.

3. Review of R397's clinical record revealed: 10/26/23 - R397 was admitted to the facility with diagnoses including type II diabetes and morbid obesity due to excess calories. 10/27/23 12:30 PM - A physician's order was written for Humalog quick pen inject 25 units intramuscularly three times a day for diabetes. 10/28/23 - A care plan was written for potential/alteration in Nutritional status related to a need for therapeutic, fluid restricted diet secondary to DM, cardiac dx, morbid obesity. Expected weight variances related to diuretic use. Interventions included record percent of each meal and/or supplement consumed and Record weight and notify physician, patient, family or significant other of any significant change as needed. 11/3/23 to 11/7/23 - A review of the CNA task sheet revealed that R397's meal consumption was documented as 0% from 6 PM on 11/4/23 through 6 PM on 11/7/23. 11/7/23 12:30 PM - A physician's order was written for Humalog quick pen inject 20 units intramuscularly three times a day for diabetes. Blood glucose check revealed a blood glucose level of 99 mg/dL.…

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

Based on record review and interviews, it was determined that for one (R3) out of four residents reviewed for Medication Administration, the facility failed to ensure that R3's monthly medication review was completed. Findings include: Medication Regimen Review (MRR) Policy- the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart . 7/5/18 - R3 was admitted to the facility with diagnoses, including but not limited to, multiple sclerosis. 2/14/24 - R3 was admitted to the hospital for an altered mental status. 3/1/24- While hospitalized , R3 underwent placement of a percutaneous endoscopic gastrostomy tube (PEG- a feeding tube) for a diagnosis of malnutrition/failure to thrive. 3/7/24 - R3 was re-admitted to the facility. 3/7/24 10:26 PM - E15 (RN Nursing supervisor) entered orders for acetaminophen, atorvastatin, bisacodyl, cholecalciferol, clopidogrel, cyanocobalamin, labetolol, losartan, Maalox, metformin, milk of magnesium, pantoprozole, polyethylene glycol and senna. All fourteen medications…

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.

3. Review of R47's clinical record revealed: 12/15/15 - R47 was admitted to the facility. 1/11/16 - A care plan was initiated for R47's use of anticoagulant therapy with an intervention of observing and monitoring for side effects such as blood in urine/stool, gums/nose bleeding, bruising. 10/21/22 - A physician's order for R47 was written for Pradaxa capsule (anticoagulant) one capsule by mouth twice a day related to chronic atrial fibrillation. 8/2023 - A review of the August MAR revealed no documentation related to adverse effects of anticoagulant therapy. 5/20/24 9:27 AM - An interview with E38 (UM) confirmed adverse effects were not being monitored for R47. 4. Review of R98's clinical record revealed: 7/24/23 - R98 was admitted to the facility with a diagnosis of major depressive disorder, concurrent. 4/25/24 - A quarterly MDS revealed R98 is prescribed an antidepressant. 5/2024 - A review of R98's MAR revealed a lack of monitoring for adverse effects of trazodone. 5/20/24 9:27 AM - An interview with E38 (UM) confirmed R98 was prescribed trazodone and confirmed lack 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 and interview it was determined the facility failed to receive and document narcotic medications per professional standards of care. Findings include: Review of R65's clinical record revealed: 6/2/20 - R65 was admitted to the facility. 4/4/24 11:15 AM - A physician's order was written for oxycodone (narcotic pain medication) give one tablet by mouth every eight hours. 5/17/24 - A review of R65's narcotic count verification sheets revealed that for the months of November 2023, December 2023, January 2024, February 2024, March 2024, and April 2024 the verification sheets lacked evidence of date, time, and a nurse's signature of receipt. 5/20/24 9:27 AM - An interview with E38 (RN UM) confirmed the narcotic count verification sheets lacked the date, time, and a nurse's signature. 5/20/24 1:35 PM - Findings were reviewed with E2 (DON), E4 (Consultant), and E21 (Corporate Clinical Nurse).

Based on record review and interview, it was determined, for one (R79) out of one resident sampled for laboratory services, the facility failed to promptly notify the ordering medical practitioner of laboratory results that fell outside of clinical reference ranges. Findings include: Review of R79's clinical record revealed: 1/2/20 - R79 was admitted to the facility. 5/9/24 9:47 AM - In an interview with R79 revealed he had pain when urinating and the facility collected urine this morning for analysis and culture. 5/10/24 3:49 PM - A review of lab results revealed that R79 was positive for a urinary tract infection. The culture was still pending at this time. 5/11/24 (Saturday) 2:52 PM - A review of lab results revealed the urine sample from R79 was positive for growth. 5/13/24 (Monday) - A physicians order was written for Bactrim DS (antibiotic) by mouth daily for urinary tract infection. 5/14/24 11:04 AM - An interview with E39 (LPN) confirmed if lab results posted during weekend hours and were out of range the on call provider should be notified of the results. The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of other facility documentation it was determined that the facility failed to ensure, in accordance with professional standards and practices, that medical records for two (R40 and R106) out of five residents of the investigative sampled residents were accurate. Findings include: Review of R40's clinical record revealed: 1/23/24 - R40 was admitted to the facility with diagnoses, including but not limited to, bipolar disorder, schizoaffective disorder bipolar type, and depression. 2/22/24 - E8 (NP) documented in R40's electronic medical record (EMR), Risperdal (an anti-psychotic agent) 1 mg (milligram)- Give 1 tablet by mouth at bedtime for total 5 mg and Risperdal 4 mg - Give 1 tablet at bedtime for total 5 mg. 5/16/24 12:45 PM - During an interview, E1(NHA) confirmed that R40's Risperdal orders in the EMR did not contain a diagnosis. 5/20/24 1:35 PM - Findings were reviewed with E2 (DON), E4 (Consultant), and E21 (Corporate Clinical Nurse). 2. Cross Refer F689 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 record review and interview, it was determined that for one (R294) out of one sampled resident reviewed for reporting of alleged violations, it was determined that the facility failed to identify and immediately report an injury of unknown source. Findings include: 10/11/2023 - Resident was admitted to facility status post C2-T1 fusion and C2-C7 laminectomy on 10/3/23. 11/1/23 6:18 AM - A wound care note written by E40 (NP) revealed the following: This is the first assessment of R294's surgical wounds by me. Patient reports hearing a popping/crack sound yesterday during a transfer but did not report it to staff. Her shirt and bed linens were soaked in blood at the time of my exam. Significant surgical dehiscence to the mid upper back wound was found on exam 911 was called by staff nurse for immediate referral to the hospital. 11/1/23 11:30 AM - A nursing note revealed: Patient resting in bed at start of shift. Tolerated meal and all medication as prescribed. Resident voiced no c/o (complaints of) pain. Resident transferred to hospital for dehiscence of surgical site…

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, as indicated, it was determined that for one (R294) out of one sampled resident for investigate/correct alleged violation, the facility failed to thoroughly investigate an injury of unknown source. The facility policy on Abuse, Neglect and Exploitation last reviewed on 4/2/24 indicated the following: B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation .3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. 10/11/2023 - Resident was admitted to facility status post C2-T1 fusion and C2-C7 laminectomy. 11/1/23 6:18 AM - A wound care note written by E40 (NP) revealed the following:…

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

Based on record review and interview, it was determined that for one (R297) out of four residents reviewed for respiratory care the facility failed to properly administer oxygen. Findings include: Review of R297's clinical record revealed: 2/21/24 - R297 was admitted to the facility with a diagnosis of emphysema (a chronic lung disease causes shortness of breath). 2/23/24 - A care plan documented R297 is at risk for respiratory impairment related to congestive heart failure (the heart is unable to pump enough blood to meet the body's needs), emphysema. Interventions included: - elevate the head of the bed. - evaluate lung sounds and vital signs, report any abnormalities to the physician. - labs per physician orders. - obtain pulse oximetry (measures blood oxygen saturation levels - desired range 94% to 100%) and report abnormal findings. 2/24/24 - A nursing progress note documented that R297 was having breathing difficulties and E19 (RN/Sup UM) placed a non-rebreather mask (enables delivery of high concentrations of oxygen) on R297 and set the flow rate to 4L/minute (correct flow…

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, interview, and review of other facility documentation, it was determined that for two (R3 and R294) of five sampled residents, the facility failed to ensure the medical care of the resident was supervised by the physician regarding the evaluation of administration of medications by a PEG tube (a feeding tube) and the provision of care for a surgical wound. Findings include: 1. 10/11/23 - Resident admitted to facility status post C2-T1 fusion and C2-C7 laminectomy. 5/15/24 11:59 AM - In an interview, E9 (NP) stated that whoever does the resident's admission would enter wound care and then wound care NP's would then follow the resident. E9 stated that when surgical glue is used, it doesn't require any overt treatment plan, but staff would still need to ensure that the wound was still intact. E9 would expect the cervical collar to be removed daily for skin inspection. E9 stated that the surgeon drives the care for surgical wounds and facility providers would not make these orders. 5/16/24…

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

Based on observation and interview, it was determined that the facility failed to ensure that all staff employ hygienic practices, ensure the safe storage of food and beverages, and ensure food storage and preparation equipment is kept clean. Findings include: 4/03/23 8:32 AM - During the initial tour of the Kitchen, the Surveyor observed significant amounts of food crumbs, dried food particles and other small pieces of debris on the floor and shelves of the walk-in refrigerator. 4/03/23 9:25 AM - During a follow-up visit to the Kitchen, the Surveyor observed a foil covered tray with large amounts of food debris on it under an oven, a damaged support pad under the sanitizer delivery tube above the third compartment of the three (3) compartment sink and several areas of cracked and peeling paint adjacent to the three (3) compartment sink and the cooking equipment. 4/03/23 11:10 AM - During a follow-up visit to the Kitchen, the Surveyor observed a staff person enter the Kitchen to assist with serving lunch. The staff member did not have a hair net on. When the staff person 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 interview and observation of one out of two units toured, it was determined that the facility failed to provide a clean and homelike environment. Findings include: 4/6/23 1:37 PM - An observation on the Sierra unit revealed the following: black matter in the shower stall to the back right, black matter on the shower curtain, and a brown substance caking up the drain. 4/10/23 9:24 AM - An interview with E18 (Housekeeping) revealed there was not a set schedule to clean the shower rooms, however, E18 said that the showers could be cleaned daily. Observation in the shower room with E18 confirmed there was mildew and mold in the shower, there was build up around the drain, and build up on the grout. Furthermore, E18 added that the shower room needs to be scrubbed up. Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), and E3 (Regional Nurse) on 4/11/23, at approximately 1:30 PM.

Based on record review and interview, it was determined that for one (R49) out of three residents reviewed for hospitalization, the facility failed to ensure the Ombudsman was notified of the residents transfer to the hospital. Findings include: Review of R49's clinical record revealed: R49 was transferred to the hospital on 3/8/23 - 3/9/23 and then again on 3/23/23 - 3/25/23. 3/31/23 - E7 (SSD) sent an email of monthly transfer notices to the Ombudsman's office. R49's transfers were not listed on the notice. During an interview on 4/10/23 at 1:48 PM, E7 confirmed the finding. E7 reported she was unaware of the requirement to notify the Ombudsman of residents transferred to the hospital and was only providing notice of residents who were discharged . Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), and E3 (Regional Nurse) on 4/11/23, at approximately 1:15 PM.

Based on observation, interview, and record review, it was determined that for one (R98) out of five sampled residents for ADL's (activities of daily living), the facility failed to provide oral hygiene and grooming of facial hair for a resident that required extensive assistance. Findings include: A facility policy and procedure titled, ADL Care undated, documented: To gather detailed information that will help to develop a plan of care that is appropriate for the resident in their ADL care; the process is continuous from admission and continues until the resident is discharged . 4. Grooming and Dressing includes: As you provide the resident with personal care needs, you should note .b. Assistance needed with bathing, hair, and nail care, dressing and undressing, mouth care. Review of R98's clinical record revealed: 2/1/21 - R98 was admitted to the facility with a diagnosis of Parkinson's Disease (a progressive disorder of the nervous system that affects movement or a disorder of the brain that leads to shaking (tremors) and difficulty in walking, movement, and coordination).…

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 documentation, it was determined that for one (R128) out of one resident reviewed for skin conditions, the facility failed to initiate timely treatment to R128's pinky toe. Findings include: Review of R128's record revealed the following: 1/19/23 - R128 was admitted to the facility. 1/19/23 - An admission MDS revealed that R128 was severely cognitively impaired, totally dependent on staff for bed mobility, transfers, toilet use, and eating, requiring extensive assistance of one person. 1/20/23 10:49 PM - An SBAR documented that R128 had a fluid filled blister on the right pinky toe. The facility lacked evidence of initiating a treatment to R128's right foot from 1/20/23 to 1/22/23, despite the above notification to the Physician. 1/22/23 - A treatment order was initiated for skin prep to both feet for blisters every shift. 1/24/23 8:39 AM - A review of progress notes revealed that R128 was evaluated by E25 (WCNP) who documented, Right lateral foot fluid filled vesicle, left lateral foot fluid filled vesicle with what appears 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 and record review, it was determined that for one (R15) out of one resident reviewed for dialysis, the facility failed to monitor the residents dialysis catheter. Findings include: 6/12/21 - R15 was admitted to the facility. 6/14/21 - A care plan initiated for R15's dependency on hemodialysis revealed that the AV fistula (dialysis catheter in arm) should be checked per Physician's order and any abnormalities are to be reported to the Physician. 4/6/23 - A review of R15's Physicians orders lacked evidence of an order to check R15's dialysis catheter. 4/6/23 10:35 AM - An interview with R15 revealed that staff do not assess the dialysis catheter before leaving the facility or upon return from dialysis. 4/6/23 10:40 AM - An interview with E16 (LPN) confirmed that staff do not assess the dialysis catheter pre and post dialysis. 4/6/23 10:50 AM - An interview with E17 (LPN UM) confirmed there was no Physician's order to assess the dialysis catheter. Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), and E3 (Regional Nurse) on 4/11/23, at…

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

Based on review of facility documentation and interview, it was determined that for six (E8, E9, E10, E11, E12 and E21) out of six employee evaluations reviewed, the facility failed to ensure that performance evaluations were conducted every 12 months. Findings include: 1. E8 was due for an evaluation on 11/3/22 and it was not conducted until 2/25/23. 2. E9 was due for an evaluation on 8/14/22 and it was not conducted until 1/29/23. 3. E10 was due for an evaluation on 7/2/22 and it was not conducted until 2/3/23. 4. E11 was due for an evaluation on 8/6/22 and it was not conducted until 2/1/23. 5. E12 was due for an evaluation on 9/10/22 and it was not conducted until 2/3/23. 6. E21 was due for an evaluation on 4/7/22 and it was not conducted until 2/1/23. During an interview with E13 (Human Resources) on 4/11/23 at 10:00 AM, E13 acknowledged that the six performance evaluations were late. Findings were reviewed with E1 (NHA), E2, (DON) and E3 (Regional Nurse) during the exit conference, beginning at approximately 1:15 PM.

Based on observation and interview, it was determined that the facility failed to ensure that it was free of a medication error rate of 5% or greater. Medication pass observations identified three (3) errors out of twenty-six (26) opportunities, resulting in a medication error rate of 11.5%. Findings include: Cross refer to F760 Review of R116's clinical record revealed: 1/2/23 - A Physician's order was written for Galantamine Hydrobromide 8 mg, give two tablets (tabs) by mouth daily related to Alzheimer's Disease. 1/3/23 - Physician's orders were written for Potassium Chloride 20 MEQ Extended Release, give one tab by mouth daily for nutritional supplementation and for Levetiracetam 500 mg, give one tab by mouth twice a day for seizures. 4/5/23 9:00 AM - During a random medication pass observation, E20 (RN) administered the above medications to R116 after crushing the medications. 4/5/23 10:30 AM - During an interview, E20 confirmed that the medication instructions for Galantamine Hydrobromide, Potassium Chloride Extended Release and Levetiracetam stated the medications should 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility failed to ensure that one (R116) out of eight (8) sampled residents reviewed for medication (med) review was free from significant medication errors. During a med pass observation, R116 was administered three oral meds in a crushed form that did not follow the manufacturer's instructions to not crush the meds prior to administration. Findings include: Galantamine Hydrobromide tablet is an enteric coated tablet; crushing enteric coated tablets releases the drug into the stomach where it may be destroyed by stomach acid and not be absorbed into the body. Potassium Chloride is an Extended Release tablet, designed to slowly release the drug in the body over an extended period of time instead of all at once when crushed; high potassium levels may cause life threatening heart rhythm problems, muscle weakness and/or paralysis. Crushing Levetiracetam tablets can produce a bad taste in the mouth. Review of R116's clinical record revealed: R116…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that for one (R98) out of two sampled residents for dental services, the facility failed to assist the resident in obtaining routine dental services. Findings include: A facility policy and procedure titled, Resident Dental Care, undated, documented: It is the policy of this facility, in accordance with residents' needs, to assist residents in obtaining routine (to the extent covered under State Plan) and emergency dental care. 1. The dental needs of each resident are identified through the physical assessment and are addressed in each resident's plan of care. 1. Oral/dental status shall be documented according to assessment findings. R98's clinical record revealed: 2/1/21 - R98 was admitted to the facility with a diagnosis of Parkinson's Disease (a progressive disorder of the nervous system that affects movement or a disorder of the brain that leads to shaking (tremors) and difficulty in walking, movement and coordination). 4/3/23 10:00 AM - During 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 (R7) out of five residents reviewed for unnecessary medication administration, the facility failed to properly identify the appropriate indication for which the medication Tamsulosin was being administered. Findings include: 1/3/23 - admission to the facility with a history of neuromuscular dysfunction of the bladder, unspecified. 4/6/23 untimed - Review of R7's chart revealed that R7 was prescribed Tamsulosin HCl Oral Capsule 0.4 MG, Give 0.4 mg by mouth at bedtime for Benign Prostate Take 1 capsule (0.4 mg total) by mouth once a day after breakfast. 4/6/23 2:20 PM - During an interview with E19 (LPN), he/she stated that R7 was prescribed Tamsulosin for benign prostate. The Surveyor said to E19 (LPN), But this resident is a woman, noting that females do not have a prostate. E19 (LPN) then confirmed benign prostate was the wrong indication for R7 to receive this medication. 4/11/2023 approximately 1:30 PM - Findings were reviewed at the Exit Conference with E1 (NHA), E2 (DON) and E3 (Regional Nurse).

Based on interview and record review, it was determined that the facility failed to provide one (R98) out five sampled residents for immunizations, an informed consent for four administered doses of the COVID-19 vaccine. Findings include: A facility policy and procedure titled, Infection Prevention and Control Program, revised 10/2022, documented: The facility has established and maintains an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help to prevent the development and transmission of communicable diseases and infection. 8. COVID-19 Immunization: c. Education about the vaccine, risks, benefits, and potential side effects will be given to residents or resident representatives and staff prior to offering the vaccine. R98's clinical record revealed: - 6/30/21 Dose 1 SARS-COV-2 (COVID-19) Moderna US Inc. 053C21A; - 7/28/21 Dose 2 SARS-COV-2 (COVID-19) Moderna US Inc. 006D21A; - 3/15/22 Moderna Booster 033K21; - 8/16/22 Pfizer Booster. 4/10/23 1:30 PM - During a review of R98's immunization record, E24 (LPN) confirmed…

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.