Encore At Boca Raton Rehabilitation And Nursing Ce

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to identify triggers for residents diagnosed with Post-Traumatic Stress Disorder (PTSD), for 2 of 2 residents sampled for mood and behavior, (Resident #72 and Resident #28). The finding include: 1.) Review of the facility's policy titled, Trauma Informed Care Proc with Document ID #98875710, published on 05/19/2023 revealed the following: Purpose: a. To guide Staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice: and b. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. General Guidelines: Triggers are highly individualized. Some common triggers may include: a. experiencing a lack of privacy or confinement in a crowded or small space. b. exposure to loud noises. c. certain sights such as objects; and or d. sounds, smells, and physical touch Resident Screening included the following: 1. Perform universal screening of residents,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review, the facility failed to ensure the controlled substance medication reconciliations were accurate for 6 of 12 sampled residents reviewed during the controlled substance record review (Residents #10, #51, #73, #88, #345, and #346). The findings included: Review of the facility's policy titled, Controlled Substances, dated November 2022, included the following: Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Dispensing and Reconciling Controlled Substances: 1.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2.The system of reconciling the receipt, dispensing and disposition of controlled substances includes 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure medication error rate was below 5 percent; a total of 32 opportunities were observed with 4 medication errors identified which yield a medication error rate of 12.50 percent, affecting 2 of 5 sampled residents reviewed for medication administration, Resident #63 and Resident #32. The findings included: Review of the facility's policy titled, Administering Medications, dated April 2019, included the following: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4.Medications are administered in accordance with prescriber orders, including any required time frame. 1) Record review for Resident #63 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Acute Leukemia of Unspecified Cell Type in Remission, Drug Induced Subacute Dyskinesia, Anxiety Disorder, and Major Depressive Disorder. Review of Section C of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to secure medications at bedside for 3 out of 34 sampled residents; (Residents #49, # 72, 115 ) and failed to secure 1 of 7 med carts; failed to secure medication left on top of 1 of 7 med carts; and failed to properly dispose of medication(s) during 2 out of 5 medication observations. The findings included: Review of the facility's policy titled, Medication Labeling and Storage with a published date of 05/19/23 included in part the following: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Review of the facility's policy titled, Self-Administration of Medications with a Published date of 05/19/23 included in part the following: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide food that meets residents' preferences, allergies and intolerances for 6 of 6 sampled residents observed during dining observation (Resident's #122, #54, #39, #69, #44, and #46). The findings include: 1) Record review revealed that Resident #122 was admitted to the facility on [DATE] with diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side and Non-traumatic Intracranial Hemorrhage. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score of 11, which indicates slight cognitive impairment. In an interview conducted on 12/02/2024 at 10:45 AM Resident #122 stated that breakfast was okay, but it would be great if only she could really get what is on her meal ticket. For example, this morning she didn't get the grits that were on the meal ticket. In a second interview conducted on 12/02/2024 at 1:30 PM Resident #122…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide special eating equipment (adaptive devices) who need them when consuming meals and snacks for 1 of 1 sampled resident reviewed for adaptive equipment, affecting Resident #46. The findings included: Review of the facility's policy titled, Adaptive Equipment Policy and Procedure with no dated (just the printed date of 12/05/24 included in part the following: Adaptive equipment refers to any device or tool that assists residents in performing activities of daily living (ADLs), mobility, or other functional tasks. This policy aims to ensure that residents receive appropriate adaptive equipment and that staff members are trained in its proper use. 3. Equipment Acquisition and Inspection a. The facility should maintain a designated inventor of commonly used adaptive equipment. b. Upon receipt of newly ordered equipment, it should be inspected for any damage, defects, or missing parts. c. Any concerns or issues with the equipment should…

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

Based on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area as evidenced by repeated deficient practices for F755, Pharmacy services, procedures, pharmacist, records; and F810, assistive devices, eating equipment, utensils. These repeated deficient practices have the potential to affect all 146 residents residing in the facility at the time of this survey. The findings included: Review of the facility's survey history revealed the facility was cited F755 and F810 during the Recertification survey with an exit date of 08/24/23. During an interview with the facility's Administrator on 12/5/24 at 3:30 PM, the Administrator was apprised that these 2 deficiencies will be cited again on this current survey. The Administrator stated she will be working to remedy this issue.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to follow Standard Infection Control procedures while performing perineal care for 1 of 1 sampled resident (Resident # 28); failed to safely dispose of contaminated lancets used for glucose monitoring; and failed to maintain personal drink on a medication cart, in a manner to prevent contamination. The findings included: 1) A review of facility's policy (with no date) titled,Handwashing/Hand Hygiene, revealed the facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Page one of the policy, with letter c for Indications for Hand Hygiene, explained that hand hygiene is indicated after contact with blood, body fluids, or contaminated surfaces; and letter g, explaining hand hygiene is indicated immediately after glove removal. Review of the facility's policy titled, Perineal Care : Level II, revealed the purposes of perineal care procedure are to provide cleanliness and comfort 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to provide a safe environment to the residents as evidenced by allowing a visitor to enter the facility at 6:14 AM, without properly identifying the visitor. The findings included: Review of the facility's policy titled, Visitation revised on 08/2022 provided by the Administrator documented .the facility provides 24-hour access to individuals visiting .some visitation may be subject to reasonable clinical and safety restrictions that protect the health, safety, security and/or rights of the facility's residents such as: keeping the facility locked or secured at night with a system in place . On 06/25/24 at 6:14 AM, the surveyor arrived at the facility's main entrance, rang the doorbell and the automatic door opened. The surveyor walked up to the reception desk and completed the registration/sign-in using the facility's Advanced Registration machine at the reception desk. Observation revealed no staff member at the reception desk and no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure that a resident received wound care consistent with professional standards of practice for 1 of 1 sampled resident for wound care (Resident #3). The findings included: Review of the facility's policy titled, Wound Care revised on 10/2010 documented .use disposable cloth (paper towel is adequate) to establish a clean field on resident's overbed table, place all items to be used during the procedure on the clean field .put on exam glove, loosen tape and remove dressing, pull glove over dressing and discard into appropriate receptacle, wash and dry hands thoroughly, put on gloves .use no-touch technique .pour liquid solutions directly on gauze sponges .apply treatment as indicated .dress wound .be certain all clean items are on clean field .use clean field saturated with alcohol to wipe overbed table . take only the disposable supplies that are necessary for the treatment in the room . Review of Resident #3's clinical record documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide toileting/incontinence care to 3 of 3 sampled residents (Residents #1, #2 and #3), reviewed for toileting / incontinent care and failed to follow the physician orders regarding blood glucose results for 2 of 3 sampled residents (Resident #1 and #2). The findings included: 1) Review of Resident #1's clinical record documented an admission to the facility on [DATE] and a readmission on [DATE]. The resident's diagnoses included Cerebral Atherosclerosis, Diabetes Mellitus Type 2, Chronic Kidney Disease, Hypothyroidism, Dementia, Peripheral Vascular Disease and Anxiety. Review of Resident #1's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 3, indicating that the resident had severe cognition impairment. The assessment documented under Functional Status that the resident was totally dependent on the staff for the activities of the daily living including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide a safe and clean environment in resident rooms and common areas, as well as failed to maintain laundry equipment in a repair. The findings included: 1) On 08/21/23 at 9:30 AM, an observation was conducted inside the first-floor soiled utility room where the laundry shoot is located, it was noted that the ceiling vent was covered with dust, debris, and moldlike substance, there were stains on the ceiling, corner of wall had plaster and paint missing, the covering behind the wire shelf was pulling away from the wall, the wall behind the covered garbage container was dirty, and the sink was dirty, the laundry shoot was rusted and dirty (Photographic Evidence Obtained). 2) On 08/21/23 at 9:40 AM, an observation was conducted of the drainage behind the washing machines which had a buildup of debris on the sides that was approximately 2 inches thick (Photographic Evidence Obtained). 3) On 08/21/23 at 9:44 AM, an observation was conducted in the…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for potentially 141 of the 145 facility residents that included; elimination of potential use of dented cans of food, maintenance of refrigeration units, maintenance of exhaust hoods, proper cleaning and maintenance of food preparation equipment, proper labeling and dating of opened food packages, and maintaining regulatory chemical levels in the 3-compartment sink. The findings included: During the initial observation tour of the main kitchen on 08/21/23 at 8:45 AM, and accompanied with the Food Service Director (FSD) and Administrator, the following were noted: (a) The door gaskets of Reach-in refrigerator #1 (Traulsen) were noted to have a build-up of a black mold substance and the front of the unit was full of condensation. It was discussed with the FSD that the gaskets were old and door was not shutting tightly resulting the condensation issues. Photographic Evidence Obtained. (b) The exhaust hood…

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

Based on observations and interviews the facility failed to assure that staff handle, store, process, and transport laundry to prevent the spread of infection and failed to implement a surveillance plan to accurately identify, track, and report a Covid outbreak infection. The findings included: Review of the facility's policy titled, Laundry and Bedding, Soiled with a published date of 05/18/23 included: Soiled laundry/bedding shall be handled, transported, and processed according to best practices for infection prevention and control. Under Transport 6. Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness. Under Section Laundry Processing 3. When using fans in laundry processing areas, the ventilation does not flow from soiled processing areas to clean laundry areas. 8. If laundry chutes are used, they are designed and maintained so as to minimize dispersion of aerosols from contaminated laundry (e.g., no loose items in the chute and bags are closed before tossing into the chute). Review of the facility's policy titled, FL Covid-19…

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 and policy review; the facility failed to administer a psychotropic medication ordered upon admission for 1of 2 sampled residents reviewed for admission orders (Resident #299). The findings included: The facility's policy titled, Physician Services published 10/20/2022 revealed the The medical care of each resident is supervised by a licensed physician. Supervising the medical care of residents includes prescribing medications and therapy. Resident #299 was admitted to the facility on [DATE] at 4:00 PM, per admission evaluation. He had a Brief Interview of Mental Status score of 12, per a social service evaluation dated 08/20/23. This indicated the resident is mildly impaired in his cognition. Medical diagnoses included Anemia, Dysphagia due to Throat Cancer, Anxiety, and Pneumonitis. On 08/21/23 at 11:55 AM, Resident #299 was interviewed and stated he was upset and anxious because he did not get his Xanax the past couple of nights. A review of the physician orders…

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, records review, and interviews, the facility failed to follow the order and facility protocol for enteral feeding for 1 of 1 sampled residents reviewed for tube feeding (Resident #50). The findings included: Review of the facility for enteral feeding documented in part, the following: 1) Staff caring for residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and or use of a feeding tube, such as: e) Esophageal swelling, strictures, fistulas; and f) clogging of the tube. On 08/21/23 at 12:15 PM, it was observed that Resident #50 was lying in bed. The tube feeding meal for Resident #50 was attached to the pole, but the pump was off. According to the writing on the bag, the feeding started on 08/20/23, no time indicated. There were 600 ml out of 1000 ml left to be infused. Photographic Evidence Obtained. On 08/21/23 at approximately 1:41 PM, meals were observed on Resident #50's bedside table, placed before the resident while she sat on the bed. Resident #50 was not feeding herself. Soon after 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 observation, interview, and record review, the facility failed to provide medications to meet the needs for 1 of 13 sampled residents reviewed during medication reconciliation of controlled substances (Resident #349); and failed to provide medications to meet the needs for 1 of 7 sampled residents observed for medication administration (Resident #297). The findings included: Record review for Resident #349 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission date of 03/15/23 with diagnoses that included: Type 2 Diabetes Mellitus with Other Skin Complications, Recurrent Depressive Disorders, and Anxiety Disorder. Review of the Minimum Data Set assessment for Resident #349 dated 08/18/23 revealed in Section C a Brief Interview of Mental Status score of 11, indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #349 revealed an order dated 03/31/23 for Alprazolam 0.25 mg given 1 tab by mouth two times a day for anxiety.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to provide special drinking equipment while consuming meals for 3 (Resident #30, #92, and #94) of 3 sampled residents. The findings included: 1) During the observation of the lunch meal on 08/21/23 at 12:15 PM, it was noted that the meal tray card of Resident #30 documented to provide 2 Handled Cup With Lid for tray beverages. Observation of the lunch meal tray noted that only 1 adaptive drinking cup was sent for the 3 beverages (Cranberry Juice (2) and Water) on the meal tray. The surveyor brought the issues to the attention of the Charge Nurse who stated the adaptive cups lessen spillage during independent drinking and called the dietary department for additional adaptive cups. Observation of the breakfast meal on 08/22/23 at 9:30 AM noted that the meal tray included a carton of milk, however an adaptive 2-handled cup with lid was not included on the meal tray. It was noted that Resident #30 was required to drink…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide ceiling suspended curtains, to provide total visual privacy for 2 of 145 residents. The findings included: 1) Record review for Resident #7 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnoses included: End Stage Renal Disease and Dependence on Renal Dialysis. Review of the Minimum Data Set for Resident #7 dated 07/01/23 revealed in Section C a Brief Interview of Mental Stats score of 13 indicating a cognitive response. During an observation conducted on 08/21/23 at 11:10 AM Resident #7 was not in her semi-private room and there was no privacy curtain for Resident #7. During an observation conducted on 08/22/23 at 10:15 AM of Resident #7 was lying in her bed in her semi-private room with no privacy curtain for the resident. During an observation conducted on 08/23/23 at 9:40 AM of Resident #7's semi-private room and there continued to be no privacy…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety that include, proper storage of foods to prevent contamination, maintenance of ceiling air-conditioning vents to prevent contamination, maintain floor cleanliness, proper cleaning of ice machine filters to prevent contamination, and ensure sanitation buckets contain required levels of chemical sanitizing agents. The findings include: 1) During the initial kitchen observation conducted on 04/18/22 at 9 AM, accompanied with the Kitchen Supervisor, the following were noted: (a) Observation of the walk-in kitchen noted that there was a large pan of raw chicken (30 pounds) in a large commercial mixing bowl ,that was located on the second shelf on a food storage rack. Further observation noted that there was a pan of individual juice portions (20) and individual yogurt portions (20). It was discussed with the supervisor that there was a potential that spillage from the raw chicken could contaminate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide drinking cups with cartons of milk for the breakfast meal on 04/19/22, for 32 residents on the [NAME] Unit. The findings included: Review of the approved breakfast menu for 04/19/22 documented that 8 ounces of milk was to be served. Review of the Production Count for the breakfast meal dated 04/19/22 documented that 98 residents received whole milk, 24 residents received skim milk, 4 residents received 2% milk, and 3 residents received lactaid milk. During an observation of the breakfast meal on 04/19/22 at 8:56 AM, it was noted that 32 residents on the [NAME] Unit who received a carton of milk with their meal did not receive a drinking cup. In an interview conducted on 04/20/22 at 7:43 AM, the Dietary Supervisor stated that most residents receive milk cartons with their breakfast meals. When asked why the milk cartons were not served with drinking cups, the Dietary Supervisor stated that most of the drinking cups were used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior that included the Central Supply Rooms (2), [NAME] Unit, [NAME] Unit , and Windsor Unit. The findings included: 1) During observation conducted on 04/18/22 at 2 PM of the central Supply Rooms (2) , accompanied by the Central Supply Supervisor, the following concerns were noted: room [ROOM NUMBER]: (a) The air-conditioning vent located on the ceiling in the middle of the room was noted to have the entire exterior and surrounding area covered in a black mold type substance. It was discussed with the supervisor that the vent was blowing the suspected mold onto nursing supplies located in the room. The supervisor stated she was aware of the condition of the vent but had not reported it to maintenance. (b) The entire floor area of the supply room was covered with dirt, dust, trash, and areas of black mold type matter. 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 observation and interview, it was determined that the facility's environment on the [NAME] Unit (first floor) which houses 40 residents, was not free of accident hazards. The findings included: During there environment tour of the [NAME] Unit located on the first floor on 04/20/22 at 2 PM, conducted with the Director of Maintenance and Director of Housekeeping, the following were noted: 1) Noted large areas (5) of cut up rolled up floor carpeting around North side of nurses station. Further observation noted the rolled carpeting to be protruded out and was a tripping hazard to resident and staff. The Director agreed with the surveyor's observation. 2) Observation of Community Shower #1 noted new floor tiles installed. Further observation noted that 4 floor tiles around the floor drain were raised and protruding sharp edges. It was discussed with the Mangers that the tiles were a hazard to residents feet and staff when utilizing the shower stall. The Managers agreed with the surveyors observation. 3)…

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 approved menu was not followed for 6 residents (including Resident #26) receiving physician ordered pureed diets and 8 residents (including Resident #141) receiving physician ordered Mechanically Altered Ground Diet. The findings included: During follow-up visits to the kitchen to observe the food tray line on 04/19/22, 04/20/22, and review of the approved facility menu, the following were noted: (a) Observation of the breakfast tray line on 04/19/22 at 7:30 AM noted that 2 Turkey Sausage Links were being served as a standard sized portion for Regular, No Added Salt, and Low Concentrated Sweets Diets. At the request of the surveyor, the standard portion of the Sausage Links were weighed utilizing the facility's portion scale. It was noted that 2 Sausage Links were weighed at 1 ounce. A review of the approved breakfast menu for 04/19/22 documented that 2 ounces of Sausage Links to be served, as a standard portion size. Interview conducted with the Kitchen Supervisor at the time of the observation noted 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 observations, interviews, and record review, the facility failed to provide privacy for telephone communications for 1 of 1 sampled residents reviewed for privacy (Resident #12). The findings included: Review of the facility's policy titled, Confidentiality of Information and Personal Privacy, dated 04/11/22, documented the following: The facility will strive to protect the resident's privacy regarding his or her written and telephone communications. Review of the facility's policy titled, Telephones, Resident Use Of, dated 04/11/22, documented the following: Designated telephones are available to residents to make and receive private telephone calls. The telephones at the nursing stations should ordinarily be reserved for staff use, unless no other alternative is available. Residents should use telephones at the nursing stations for as brief a period as possible. Telephones will be in areas that offer privacy and accommodate the hearing impaired and wheelchair bound residents. Review of the record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to provide necessary care and services to ensure that 1 (Resident #192) of 12 sampled residents ability to eat did not diminish. The findings included: During the observation of the lunch meal on 04/18/22 at 12:30 PM, the [NAME] Unit, it was noted that the lunch meal was placed on the over-bed tray table in front of Resident #192, however the resident was not eating. Interview with Resident #192 at the time of the observation noted the resident to be very alert and orientated and stated that she is blind and requires extensive to total assist with meals. The resident further stated that she tells aides when delivering the meal that she needs help eating, but they never return. The surveyor inquired if she complained to Administration and stated I have been here 3 weeks without assistance and I am used to eating the foods cold. Resident #192 stated that she has total blindness in the left eye and blurred vision in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a midline intravenous (IV) catheter was assessed for 1 of 1 sampled residents reviewed for IV catheters, Resident #104, as evidenced by no documentation Resident #104's midline IV catheter was being assessed or checked for patency since the insertion date. The findings included: Review of the facility policy titled Midline Dressing Changes states in part, 'Purpose: The purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened or soiled catheter site dressings. General Guidelines: Change midline dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way.' Review of the facility policy titled Central Venous and Midline Catheter Flushing states in part, 'Purpose: The purpose of this procedure are to maintain patency of midline and central venous catheters. Flushing Protocol: Flush catheters at regular intervals to maintain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure splint devices were applied for 1 of 1 sampled residents reviewed for Position/Mobility, Resident #104, as evidenced by failing to apply a left hand splint, left elbow splint and bilateral lower extremity boots for Resident #104 to prevent further contractures. The findings included: Review of the facility policy for Restorative Nursing Services states in part, 'Residents will receive restorative nursing care as needed to help promote optimal safety and independence Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g. physical, occupational or speech therapist). Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care.' On 04/18/22 at 10:00 AM, 12:20 PM and 2:40 PM, Resident #104 was observed in her room in bed in a hospital gown. Resident #104's left hand 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 observations, interviews, and record review, the facility failed to address significant weight loss in a timely manner for 3 of 12 sampled residents reviewed for nutrition (Resident #12, Resident #25 and Resident #125). The findings included: Review of the facility's policy titled, Weight Assessment and Intervention, dated 04/11/22, documented the following: Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If they weight is verified, nursing will immediately notify the dietitian in writing. The dietitian will respond within 24 hours of receipt of written notification. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month - 5% weight loss is significant, greater than 5% is severe; 3 months - 7.5% weight loss is significant, greater than 7.5% is severe; 6 months - 10% weight loss is significant, greater than 10% is severe. 1) Review of the record documented that Resident #12 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, interview, and record review, it was determined the medication error rate was 7 percent. 2 medication errors were identified while observing a total of 26 opportunities, affecting Resident #26. The findings included: Review of the facility's policy titled Administering Medications published 04/11/2022 documented Medications are administered in a safe and timely manner and as prescribed. Review of Resident #26's clinical record documented an initial admission to the facility on [DATE] with diagnoses including Dementia without behavioral disturbances, Type 2 Diabetes Mellitus, and Polyosteoarthritis. A quarterly Minimum Data Set (MDS) assessment was done with an assessment reference date of 02/07/22. Section C of the assessment included a Brief Interview for Mental Status of 9, which indicated the resident has moderate cognitive impairment. Review of Resident #26's physician orders for April 2022 documented Artificial Tears Solution 5-6 milligram (mg)/milliliter Instill 1 drop in both eyes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to secure and obtain an order for self-administration of prescription oral rinse for 1 of 1 sampled residents reviewed for self-administration of medications (Resident #84) and failed to secure medications in 2 of 2 nursing stations on the second floor. The findings included: Review of the facility's policy titled, Self-Administration of Medications, dated 04/11/22, documented the following: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. 1) Review of the record documented that Resident #84 was re-admitted to the facility on [DATE] with diagnoses which included: Anxiety…

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, interviews, record review and policy review; the facility failed to provide a resident with snacks to consume at dialysis for 1 of 1 sampled residents (Resident #20) reviewed for dialysis. The findings included: The facility's policy titled Dialysis created on 2/2019 states Dietician will be made aware to provide meals/snacks as needed. Resident #20 was admitted to the facility on [DATE] with recent readmission post hospitalization on 04/01/22. Medical diagnoses include end stage renal disease, anemia, type 2 diabetes and dependence on renal dialysis. He is on a Renal diet, regular texture, thin liquids consistency. The Medicare 5 day Minimum Data Set assessment with an assessment reference date 04/04/22 reveals a Brief Interview of Mental Status (BIMS) score of 7, indicative the resident has severe cognitive impairment. The chart review revealed the resident goes to the Dialysis Center for dialysis on Tuesday, Thursday, and Saturday approximately 5:00 AM with a chair time of 5:40 AM and he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 1 of 2 sampled residents receiving a Puree Diet, Resident #64, did not have access to food items not recommended for residents on a Puree Diet. The findings included: Review of the facility policy for Therapeutic Diets states in part, 'Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care in accordance with his or her goals and preferences A therapeutic diet is considered a diet ordered by a physician, practitioner or dietician as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet.' Review of the facility definition of Puree Diet states 'The puree diet is for residents who have difficulty chewing and/or swallowing. Foods allowed on this plan must be pureed, pudding like food that is in the form of an easy to swallow bolus with moist, pudding-like consistency without particles. Foods to Avoid…

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.