Kutz Rehabilitation And Nursing

Based on interview, record review and identified deficiencies during the survey, it was determined that the facility's QAPI program failed to effectively address ongoing issues that impact quality of care with respect to staff to resident abuse, repeated medication errors by nursing staff and the continued lack of availability of medications from the pharmacy for multiple residents. Findings include: 3/25/25 1:08 PM - During a combined interview with E1 (CEO/LNHA) and E2 (DON), E1 stated that the QAPI Committee discusses all medication errors in their meetings. E1 mentioned that the 10/3/24 medication error incident involving four residents was reviewed and staff nurses were educated in November 2024. The Surveyor reviewed that there were additional medication errors on 1/3/25 and 2/11/25. E2 stated that the facility provided education in November 2024, December 2024 and again in February 2025. Also Supervisors started doing medication pass audits after the 2/11/25 incident. The Surveyor was informed that the facility has not had a consistent Staff Development nurse and they have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that for one (R45) out of ten residents reviewed for antibiotic use, the facility failed to ensure that an antibiotic stewardship program was implemented that consistently monitored prescription antibiotic usage. Findings include: Facility's Definitions Policy per McGreer's - It is the policy of this facility to adhere to the definition of infection listed below when conducting monthly surveillance of infections . Colonization - term used to describe the presence of bacteria, viruses, or other microscopic organisms that are not causing adverse clinical s/s [signs or symptoms], Fever - single oral T [temperature] 100 degrees F [Fahrenheit] or repeated oral T > [greater] 99 degrees F, or a single T > 2 degrees F over baseline from any site, . Leukocytosis - neutrophilia [> 14,000 leukocytes (white blood cells)/ mm3] or left shift [6 % bands or >/= 1,500 bands/mm3] . Facility's Antibiotic Stewardship Program - The purpose of the program is to reduce…

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 the facility failed to implement and maintain an effective training program for new LPN staff regarding intravenous medication administration prior to being assigned to independently provide this service to R68 on 2/11/25. Findings include: Cross refer F726, example 2 and F760, example 1 Review of R68's clinical record revealed: 3/17/25 1:34 PM - During an interview, E14 (LPN), who was a new nurse and was hired on 7/23/24, stated, [On 2/11/25] I was pulled to the 400 unit. It was the first time that I worked there. I had never given an IVSS antibiotic before . I was not trained about IV (intravenous) antibiotics during orientation because we did not have anyone in the building with IV antibiotics . 3/20/25 1:45 PM - Review of the Facility Assessment (dated [DATE]) revealed that administration of IV medication (page 12 of the Facility Assessment) occurs in only 0.5% of their admissions/stays, which is very low relative to the benchmark. 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 observation, record review and interview, it was determined that for one (R26) out of thirty-five sampled residents, the facility failed to treat R26 with dignity. Findings include: R26's clinical record revealed: 9/3/20 - R26 was admitted to the facility. 2/28/25 - R26's quarterly MDS documented that R26 was totally dependent for the functional ability to shower or bathe self. 3/13/25 10:32 AM - The surveyor observed R26, who was wearing only a hospital gown, being wheeled through the hallway on a shower transport stretcher by E17 (RN/UM) and E18 (CNA) to the shower room (about 500 yards) with R26's legs and feet exposed. 3/13/25 10:35 AM - During an interview, E18 confirmed that R26 did not have a blanket covering her legs and feet during transport. 3/26/25 11:45 AM - Findings were reviewed during the exit conference with E1 (CEO/LNHA), E2 (DON), E3 (SD/ICP) and nine department managers/representatives.

Based on observation, interview and record review, it was determined that for one (R23) out of thirty-five residents sampled, the facility failed to provide a special need for a larger bed. R23 rolled out of the bed on to the floor during incontinence care and was transported to the emergency room for evaluation and treatment. Findings include: Cross Refer F689, example 2 A review of R23's clinical record revealed: 8/24/23 - R23 was admitted to the facility with the following diagnoses including, but were not limited to, large body habitus, anxiety, compressed lower back nerves, muscle weakness, nerve pain and osteoporosis. 12/22/24 3:55 AM - A facility incident report documented R23 had a fall that a (CNA) did not assure positioning safety prior to attempting to provide care therefore contributing to the resident's fall onto floor. Resident taken to the ER (sic) for evaluation for complaints of pain returned in 24 hours with no acute findings. 12/22/24 - A facility statement for E40 documented, I was giving [R23] care this morning at 4AM she went to turn to her left side 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 interview and review of clinical record and other documentation as indicated, it was determined that for one (R7) out of thirty-five sampled residents, the facility failed to consult the provider of the significant change in R7's physical status with her heart rate (HR) running in the 40's. Findings include: Cross refer F684, F726, F755 and F760 R7's clinical record revealed: 1/10/20 - R7 was admitted to the facility with diagnoses including, but were not limited to, seizure disorder and hypopituitarism. 10/16/24 12:22 AM - E24 (RN/shift supervisor) documented in R7's EMR progress note, Fall details: Date/Time of fall: 10/15/24 11:50 PM fall was not witnessed . Provider: [E4, contracted Physician] Time notified 10/16/24 Notified of: fall . Resident found sitting on the floor legs facing the head board of the bed . Resident stated she was self transferring from wheelchair to the bed, when she fell. VS (vital signs) 154/66 (blood pressure), p (pulse) 43, 97.6 T (temperature), 18 rr (respiratory rate), bs (blood sugar) 89 . 10/16/24 1:13 AM - R7's heart rate was documented in…

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

Based on review of the facility's Resident Abuse Policies and Procedures, last revised 12/2023, it was determined that the facility failed to develop a written policy and procedure that clearly addressed sections under Identification and Reporting. Findings include: Review of the facility's Resident Abuse Policies and Procedures included, but was not limited to, the following: POLICY . Any allegation of abuse, neglect, mistreatment, injury of unknown origin, suspected commission of a crime, misappropriation of resident property or financial exploitation will be thoroughly investigated and reported . While the facility policy under the separate section for Definitions listed the different types of abuse, neglect, exploitation of residents, the section for Identification lacked evidence that the facility addressed in the written procedures how staff can identify different types of abuse by resident outcomes, such as an unwitnessed injury that was suspicious or multiple injuries over time or unexplained changes in resident behaviors or activities. Under the section for Reporting, the…

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

Based on record review and interview, it was determined that for one (R26) out of fourteen residents reviewed for abuse, the facility failed to report their investigation results to the State Agency within 5 working days of the incident. Findings include: The facility's Resident Abuse Policies and Procedures: . Investigation . Within five days, a follow-up State Incident Report is completed indicating the results of the investigation and sent to the Division of Long Term Care Residents Protection electronically . Revised 12/2023 Review of R26's clinical record revealed: 9/3/20 - R26 was admitted to the facility with diagnoses including, but were not limited to, Parkinson's disease and dementia. 2/19/25 4:10 PM - E21 (LSW) reported an alleged incident of neglect to the State Agency. The report stated that on 2/18/25 at approximately 1 PM, R26 had to wait for an hour to be changed by her assigned CNA on 7-3 PM shift. F3 (R26's POA) reported this incident to the facility on 2/19/25 at 3:23 PM. The five day follow up report to the State Agency was due on 2/26/25. 3/14/25 1:54 PM - E21…

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

Based on observation, interview and record review, it was determined that for two (R17 and R23) out of thirty-five residents sampled, the facility failed to develop and implement a comprehensive person-centered care plan for R17 that included specific directions for taking vital signs on a resident with a dialysis fistula. For R23, the facility failed to include bed enablers as an intervention on the care plan. Findings include: 1. Review of R17's clinical record revealed: 11/13/23 - R17 was admitted to the facility with diagnosis including, but was not limited to, end stage renal (kidney) disease with a dialysis fistula on his left arm. R17's most current orders included dialysis three times a week, on Mondays, Wednesdays, and Fridays, check vital signs pre- and post-dialysis on these days on both the day and evening shifts. And monthly vital signs on the first three days of each month during the evening shift. R17's most recent care plan included, Monitor vital signs as ordered. R17's dialysis care plan failed to include that the blood pressure should not be taken on the left arm…

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 (R11) out of four residents sampled for range of motion, the facility failed to provide R11 with a right-hand palm guard that was ordered on 5/2/24. Findings include: A review of R11's clinical record revealed: 3/24/21 - R11 was admitted to the facility. 5/2/24 - An order was written in the EMR for R11 to have a right palm guard, to put the palm guard on after morning care, and to take the palm guard off before bedtime. 3/7/25 10:10 AM - During an observation, R11 was not wearing a right-hand palm guard. R11's right hand was contracted, with his fingers pressing into the palm of his hand. The following document review, observation and interviews occurred on 3/10/25: -A review of R11's care plan revealed that R11 was at risk for pain because of . and multiple contractures and decreased mobility. R11 had a diagnosis of a right hand contracture listed on the care plan. -9:30 AM - During an observation, R11 was not wearing a right-hand palm guard. R11's right hand was contracted with his fingers pressing into the palm…

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 (R17) resident out of three residents reviewed for tube feedings, the facility failed to consistently and correctly label R17's tube feeding solution. Findings include: 3/6/25 10:06 AM - The Surveyor observed that R17's tube feeding solution was not labeled with the resident's name, the room number, the date and time that the tube feeding was given, or flow rate for the feeding to be administered. 3/7/25 9:04 AM - R17's tube feeding solution was labeled improperly, missing the date and the time that the tube feeding was started, as well as the flow rate for the feeding to be administered. 3/14/25 9:29 AM - R17's tube feeding solution and water bag were unlabeled. Findings were confirmed with E3 (SD/ICP) 3/26/25 11:45 AM - Findings were reviewed during the exit conference with E1 (CEO/LNHA), E2 (DON), E3 and nine department managers/representatives.

Based on observation, record review and interview, it was determined that for one (R72) out of one resident reviewed for respiratory, the facility failed to ensure R72's O2 tubing was replaced weekly as per professional standards of care. Findings include: Facility's Oxygen Administration policy - Oxygen is administered to residents who need it, consistent with professional standards of practice . Policy Explanation and Compliance Guidelines: . 5. Staff shall perform hand hygiene . when in contact with oxygen equipment. Other infection control measures include: . b. Change oxygen tubing and mask/cannula weekly and as needed . 2/5/25 - R72 was admitted to the facility with diagnoses including, but was not limited to, acute respiratory failure with hypoxia. 2/5/25- E4 (contracted MD) ordered in R72's EMR, Oxygen 2-4 liters via nasal cannula or facemask for dyspnea . as needed for pulse ox to remain above 92% . change oxygen tubing weekly on Wednesday 11-7 shift . every night shift every Wednesday for oxygen therapy. 3/5/25 night shift - E10 (LPN) signed off in R72's MAR that she had…

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 (R72) out of thirty-five residents reviewed for physician services, the facility failed to ensure that the physician reviewed the residents' total program of care. Findings include: Review of R72's clinical record revealed: 2/5/25 - R72 was admitted to the facility with diagnosis including, but was not limited to, acute respiratory failure with hypoxia. 2/13/25 10:30 AM - E4 documented in R72's EMR physician progress note, . Assessment/Plan: . has been weaned off O2 . This physician note inaccurately documented that R72 had been weaned off of her supplemental oxygen. 2/13/25 11:16 AM - E35 (LPN) documented in R72's EMR progress notes, Resident continues on O2 at 4L N/C. Pulse ox is at 99 at rest. Res stated that she got sob [short of breath] while in the middle of therapy. Resident stated that she was on O2 at the time. Resident was able to catch her breath once at rest. 2/14/25 10:46 PM - E29 (LPN) documented in R72's EMR progress notes, . Oxygen via nasal cannula . 2/16/25 10:39 PM - E48 (LPN) documented in R72'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 record review and interview, it was determined that for three (R14, R17 and R23) out of three residents reviewed for pharmacy services, the facility failed to provide pharmaceutical services to meet the needs of each resident. Findings include: 1. Review of R17's clinical record revealed: 11/23/20 - R17 was admitted to the facility. 12/28/23 - A physician's order was written for R17 to receive sevelamer carbonate oral packet 2.4 grams give one packet via Peg-Tube (medical device used to provide nutrition) with meals for dialysis, must be given with meals. 5/19/25 6:35 PM - A progress note for R17 documented that sevelamer carbonate is not available. 5/20/25 11:37 AM - A progress note for R17 documented that sevelamer carbonate is unavailable. Medication supplied by a dialysis facility. The RN supervisor was made aware and contacted the dialysis facility. 5/21/25 8:57 AM - A progress note for R17 documented that sevelamer carbonate is not available, supervisor made aware. 5/29/25 - Review of R17's medication administration record (MAR) documented the following missed doses…

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

Based on interview and review of a clinical record and the Medication Regimen Review (MRR) policy and procedure, it was determined that the facility failed to ensure the MRR policy had specified response time frames included for the different steps. In addition, for one (R48) out of eight residents reviewed for pharmacy, the facility failed to ensure that R48's pharmacy recommendation was acted upon before a second recommendation was made. Findings include: 1. A facility policy titled Policy & Procedures Pharmaceutical Services revised 2/2025 documented . 1. Steps to performing DRR (drug regimen review) c. The next time the physician is in the building, they will check their communication book for any orders. The physician will then document directly on the resident's DRR form, sign off that identified irregularities have been reviewed, and list any actions taken. 3/18/25 1:35 PM - During an interview with E2 (DON) the Surveyor asked, what is the facility's expectation for the physician to respond to the pharmacist consultant's monthly recommendations and medication irregularities?…

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 (R48) out of five residents reviewed for unnecessary medications, the facility failed to identify and clarify a drug allergy with a medication ordered by a consultant physician before administering it to R48. Findings include: Review of R48's clinical record revealed: Review of R48's Allergy Report in the electronic health record documented that the resident had an allergy to NSAIDs (Nonsteroidal anti-inflammatory drugs/class of medications used to relieve pain, including Ibuprofen) on 11/2/22. 2/25/25 4:35 PM - A physician order was entered to give one Ibuprofen 800 mg tablet every 6 hours as needed for pain for five days. 2/25/25 4:35 PM - An auto-populated new physician's order note stated, The system has identified a possible drug allergy for the following order: Ibuprofen Oral Tablet 800 MG . 2/25/25 4:55 PM - A nurse's note documented that R48 was seen by the in house dental [doctor] . New order . Ibuprofen 800mg . 5 days PRN [as needed] . Review of R48's clinical record lacked evidence that a physician 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 interview, it was determined that for one out of three medication carts observed, the facility failed to adhere to proper labeling and storage practices for insulin pens as per regulatory standards and best practices. Findings Include: [DATE] 12:00 PM - Upon observation of insulin administration for R61, the surveyor observed that the insulin aspart pen was open and used, but there was no indication of an open date on the medication. The absence of an open date on the insulin pen created a risk of using expired medication, which could compromise resident safety and treatment efficacy. [DATE] 12:01 PM - Interview with E8 (LPN) confirmed that no open date was labeled on the pen. [DATE] 11:45 AM - Findings were reviewed during the exit conference with E1 (CEO/LNHA), E2 (DON), E3 (SD/ICP) and nine department managers/representatives.

Based on record review and interview, it was determined that for two (R27 and R42) out of eight residents reviewed for falls, the facility failed to ensure that each resident had a complete and accurate medical record. Findings include: 1. Review of R27's clinical record revealed: 4/12/21 - R27 was admitted to the facility with multiple diagnoses, including a history of falls, history of a fracture, osteoporosis and arthritis. 7/3/24 - A MDS assessment completed for R27 documented that she was frequently incontinent of bowel and bladder. 7/11/24 10:30 AM - R27 had a fall out or bed as she was being provided personal hygiene. 7/12/24 - A post fall risk assessment was completed for R27 which documented that she had 1-2 predisposing diseases that could contribute to a fall. R27 actually had three (3) predisposing disease (arthritis, osteoporosis and previous fractures) that would contribute to her increased fall risk. 8/9/24 - R27 experienced a fall while she was being showered. A post fall risk assessment was completed for R27 that documented the following: -R27 did not have any falls…

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 one (R78) out of ten residents reviewed for Infection Control, the facility failed to order and maintain Enhanced Barrier Precautions (EBP) for R78 when he had an indwelling catheter from [DATE] to [DATE]. Findings include: Facility's Enhanced Barrier Precaution policy - . refer to infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and gloves use during high contact resident care activities . 2. Initiation of Enhanced Barrier Precautions: . b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds And /or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO . 4. High-contact resident care activities include: . g. Device care or use: central lines urinary catheters . [DATE] - R78 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 observation, interview, and record review, it was determined that for one (R17) out of thirty-five (35) sampled residents reviewed, the facility failed to ensure that R17 had functioning call bell systems to request staff assistance. Findings include: Review of R17's clinical record revealed: 11/13/23 - R17 was admitted to the facility with diagnosis including, but was not limited to, end stage renal (kidney) disease. 11/13/23 - R17's admitting MDS score was 00 for ADL's, meaning he was completely dependent for care by the facility. 3/6/25 10:05 AM - The surveyor observed that R17 did not have a call bell available in his room. 3/7/25 12:00 PM - The surveyor observed that R17 did not have a call bell available in his room. 3/10/25 1:40 PM - The surveyor observed that R17 did not have a call bell available in his room. The facility failed to provide R17 a call bell in three out of three observations. 3/10/25 1:44 PM - During an interview, E13 (CNA) stated that R17 previously had a touch call bell, but it was removed because it was not functioning properly. 3/10/25 3:18 PM -…

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

Based on interviews and review of the Resident Council Meeting Minutes, the facility failed to provide feedback and/or resolutions to resident complaints and/or grievances discussed in the monthly resident council meetings in 12 of 13 resident council meetings. Findings include: Review of the ''Resident Council'' meeting minutes for 01/18/23 revealed ''.Residents report CNAs [certified nursing assistants] are still on their phones while providing care . Residents report call lights are not being left within reach .'' There were no documented actions taken by staff to resolve these issues in the resident council minutes and there was not a documented thorough investigation or resolution provided to the group. Review of the ''Resident Council'' minutes for 02/28/23 revealed ''. CNAs are still using phones during care - Residents report CNAs are stopping care to answer their phones - Residents report CNAs take 25-30 minutes to answer call lights .'' The meeting was led by the Social Services Director (SSD) and the residents were asked if staff using cell phones had improved because the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed facility failed to thoroughly investigate and document abuse investigations for three of 25 sampled residents (Resident (R) 8, R27, and R48). 1. Review of the undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R8 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, weakness, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/23, located in the EMR MDS tab, revealed R8's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R8 required substantial/maximal assistance with toileting hygiene, and she was always incontinent of bowel and bladder. During an interview on 02/12/24 at 1:11 PM, R8 stated a male staff member disconnected her call light at the wall on 01/12/24. R8 stated her call light was on because she had a bowel movement, and she was sitting…

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, record review and policy review, the facility failed to ensure the kitchen was maintained in a sanitary condition for 79 out of 82 total residents (three residents received nutrition via feeding tubes). Specifically, foods and utensils were not stored appropriately and kitchen surfaces were not clean. Findings include: 1. The initial kitchen inspection was conducted without the Dietary Manager (DM); he was not in the facility when the inspection was completed. During the initial inspection on 02/12/24 from 9:06 AM through 9:26 AM the following concerns were noted: a. Observations revealed there were three lids (that covered plates for meal service to residents' rooms) stored on the shelf for clean items that had food residue and crumbs on the interior surface of the lids. In addition, there was a large tray, stored as clean, with scattered food crumbs on the surface. b. Observations in the dry food storeroom revealed there were two spoodles stored on top of two five-gallon buckets with bulk foods. There was a box of cornstarch with the top of the box…

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 policy review, the facility failed to ensure one of 25 sampled residents' (Resident (R)11) physicians was notified of a change in condition. R11 was documented as refusing to wear her left resting hand splint most of the time over the past two weeks. R11's Physician had not been notified creating the potential that the need for treatment to be modified would not occur. Findings include: Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R11 was admitted to the facility on [DATE]. Diagnoses included hemiplegia (severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/23, located in the EMR under the MDS tab, revealed R11 was unimpaired in cognition with a Brief Interview for Mental…

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 policy review, the facility failed to make prompt efforts to resolve grievances and report the findings in writing to the resident/family for one of 25 sampled residents (Resident (R) 8). Findings include: Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R8 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, weakness, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/23, located in the EMR under the MDS tab, revealed R8's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R8 required substantial/maximal assistance with toileting hygiene and she was always incontinent of bowel and bladder. During an interview on 02/12/24 at 1:11 PM, R8 stated she and two of her family members ((F)8 and F88) had reported numerous instances when staff did not answer her call light timely,…

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 review, and policy review, the facility failed to protect the resident's right to be free from neglect when eight residents (Resident (R) 65, R12, R26, R30, R38, R68, R70, and R233) were not provided care on the 100 B Unit out of 73 residents that resided in the facility on 02/01/23. Certified Nursing Assistant (CNA) 1 left the facility without informing staff he was refusing to care for the residents. During this time, R65 sustained a fall in her room and was found by restorative certified nursing assistants. Findings include: Review of R65's undated ''admission Record'' located in the electronic medical record (EMR) under the ''Profile'' tab, revealed the resident was admitted to the facility on [DATE] with diagnosis of other sequelae of cerebral infarction (stroke). Review of R65's quarterly ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 04/11/23, located in the EMR under ''MDS'' tab, revealed a ''Brief Interview for Mental Status (BIMS)'' score of six out of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to implement policies and procedures for ensuring the reporting of potential neglect and abuse within two hours for two allegations of neglect/abuse involving nine of twenty-five sampled and four supplemental residents (Resident (R) 8, R65, R12, R26, R30, R38, R68, R70, and R233). The facility failed to report to the State Survey Agency (SSA) an allegation made by R8 that her certified nursing assistant (CNA) unplugged her call light and failed to report when a CNA did not provide care for eight assigned residents for on hour on 02/01/23. Findings include: 1. Review of the undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R8 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, weakness, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/23, located in the EMR under the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two out of four residents (Resident (R) 35 and R51) reviewed for hospitalization were provided with a written transfer notice upon emergent transfer to the hospital. Findings include: 1. Review of the undated ''Profile Face Sheet,'' provided by the facility, revealed R35 was admitted to the facility on [DATE] with diagnoses including in pertinent part Parkinson's disease, a jejunostomy (J) feeding tube (tube placed through the skin of the abdomen into the midsection of the small intestine), and a gastrostomy (G) feeding tube (tube placed into the stomach). Review of the quarterly ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 11/01/23, located in the electronic medical record (EMR) under the ''MDS'' tab, revealed R35 was moderately impaired in cognition with a ''Brief Interview for Mental Status (BIMS)'' score of 11 out of 15. Review of a ''Nurse's Note,'' dated 01/25/24 and located in the EMR under the ''Progress Notes''…

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 policy review, the facility failed to ensure two out of four residents (Resident (R) 35 and R51) reviewed for hospitalization were provided with bed hold notices within 24 hours of emergent transfer to the hospital. Findings include: 1. Review of the undated Profile Face Sheet provided by the facility revealed R35 was admitted to the facility on [DATE] with diagnoses included in pertinent part Parkinson's disease, a jejunostomy (J) feeding tube (tube placed through the skin of the abdomen into the midsection of the small intestine), and a gastrostomy (G) feeding tube (tube placed into the stomach). Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/01/23, located in the electronic medical record (EMR) under the MDS tab, revealed R35 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. Review of a Nurse's Note, dated 01/25/24 and located in the EMR under the Progress Notes tab,…

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 policy review, the facility failed to ensure the care plan was updated for one out of 25 sampled residents (Resident (R) 8) following a change in the resident's ability to ambulate, transfer, use the toilet, and remain continent of urine. This created the potential R8 would not receive appropriate care and services to reach her highest practicable level. Findings include: Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R8 was admitted to the facility on [DATE]; diagnoses included anxiety disorder, weakness, and chronic kidney disease. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/21/23 in the EMR under the MDS tab revealed R8 used a walker for ambulation, and walked in her room with extensive assistance of one person and required extensive assistance from one person for toilet use. R8 was coded as being always continent of urine. Review of the quarterly Minimum Data Set…

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 facility policy review, the facility failed to notify the wound nurse practitioner when an alteration in skin was identified so wound treatment could be ordered and followed by staff for one of three residents (Resident (R) 7) reviewed for pressure ulcers. This failure had the potential to cause infection, and worsening of a pressure ulcer when treatment was not provided to R7's unstageable sacral wound for six days. Findings include: Review of R7's undated ''admission Record,'' located in the electronic medical record (EMR) under the ''Profile'' tab, revealed R7 was admitted to the facility on [DATE] with diagnoses that included heart failure, Parkinson's disease, and vascular dementia. Review of R7's annual ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 07/10/23, located in the EMR under the ''MDS'' tab, revealed a ''Brief Interview for Mental Status (BIMS)'' score of 14 out of 15 which indicated she was cognitively intact. The ''MDS''…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure one of one resident (Resident (R)11) reviewed for range of motion (ROM) received services to maintain range of motion ROM. R11's hand splint was not applied in accordance with Physician's orders. Findings include: Review of the undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R11 was admitted to the facility on [DATE] with diagnoses including hemiplegia (severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/23, located in the EMR under the MDS tab, revealed R11 was unimpaired in cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R8 required substantial/maximal assistance with upper and lower…

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