Legacy At Boca Raton Rehabilitation And Nursing Ce

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 on the B Wing (1 of 33 rooms), C Wing (17 of 33 rooms) and D Wing (1 of 39 rooms). The findings included: During the initial resident/room screenings conducted on 04/07/24 from 9 AM-3 PM, and the Environment Tour conducted on 04/10/24 at 10 AM, accompanied with the facility's Assistant Administrator and Corporate Housekeeping Manager, the following were noted: B Wing: room [ROOM NUMBER] - Electric bed (A Bed) not working, staff not able position resident for assistance with feeding the lunch meal. C Wing: room [ROOM NUMBER]: Nurse call bell cord was wrapped around the bed frame (W Bed) and the resident was not able to reach the call button; bathroom ceiling tiles (2) noted to have large black mold areas (5 X 7); and the filter of the O-2 concentrator was dust laden. room [ROOM NUMBER] - Portable toilet commode seat…

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 review of policy and procedure, the facility failed to: 1) ensure that residents medications were properly stored, as evidenced by over the counter medications being left in the resident's room for 5 of 5 sampled residents (Resident #119, #474, #473, #475, and #476); 2) ensure that residents prescription medication were properly stored at the B-wing, as evidenced by medications being left in a medication cup in the resident's room (Resident #129) 3) ensure that resident's medication were stored properly, as evidenced by an opened bottle of Nitroglycerin tablets being left in a drawer at the C-wing nurses station. 4) ensure that it secured 2 of 3 wound care supply carts, located in the C and D wing. The findings included: Review of the facility's policy titled, Medication Labeling and Storage with no revision dated provided by the Director of Nursing documented The facility stores all medications .in a locked compartments .the nursing staff is responsible for maintaining…

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 follow the approved menu for physician ordered Regular Diets for 133 residents ( including sampled Resident's #112, #162, #119), Mechanical Altered Chopped Diets for 24 residents (including sampled Residents #14, #17, #29, and 97), Mechanical Altered Ground Diets for 3 residents (including sampled Resident #116) , and Pureed Diets for 10 residents (including sampled Residents #7 and #92). The findings included: 1) During the review of the facility's approved menu for the lunch meal of 04/07/24 , the following were noted to be served: * Dinner Roll-Regular Diet * Chopped Dinner Roll-Mechanical Altered Chopped Diet * Pureed Dinner Roll-Mechanical Altered Ground Diet, and Pureed Diet < Observation of the lunch meal in the main kitchen on 04/07/24 at 11:30 AM, noted the following: * Dinner Roll-not available, no dinner roll substitute served * Chopped Dinner Roll-not prepared , no substitute prepared * Pureed Dinner-not…

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

Based on observation, interview, and record review, it was determined that the facility failed to prepare food by methods that conserve methods that conserve nutritive value, flavor, and appearance for 10 physician ordered pureed diets(including sampled Residents #7 and #92), 24 physician ordered Mechanically Altered Chopped Diet (including sampled Residents #14, #17, #29, #29, and #97), and 3 physician Mechanically Altered Ground Diet (including sampled Resident #116). The findings included: During the initial kitchen/food service observation tour conducted on 04/07/24 at 10 AM, it was noted that foods were being prepared in the small food preparation room by the Lunch [NAME] (Staff B). Further observation noted a large food preparation located on top of the stove top. Further investigation noted that the pan contained approximately 40 pounds of green beans that were boiling and were fully cooked and were also noted to begin breaking apart from overcooking. It was also noted that the oven contained a full steam table sized pan of Baked Vegetarian Ziti, and full pan of 20 fully…

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

Based on observation, interview, and record review, it was determined that the facility failed to prepare food in a proper pureed form to meet the needs of 10 facility residents with physician ordered Pureed Diet which included Sampled Resident's #7 and #92. The findings included: Review of the facility's Approved Diet Manual- Care Rite Diet Manual for Health Care Communities - 2023- * Pureed Diet noted: Indicated for difficulty in chewing or swallowing food items. Food are pureed in a blender or food processor to leave a smooth (pudding like texture) without lumps of large chunks. Nothing that required chewing is allowed. Pureed foods should be of one consistent texture and upon testing, fall off a spoon as an intact spoonful, and hold it's shape on a plate. * Review of main kitchen posting of (Pureed Diet noted: < All foods must be: * Pureed * Homogenous * Cohesive * Pudding-like * Requires no chewing During the observation of the lunch meal in the Main Kitchen on 04/07/24 at 11:30 AM, hot foods located on the steam tables were viewed by the surveyor. Observation of the pureed…

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 prevent verbal abuse towards a resident from a staff member for 1 of 1 sampled resident, (Resident #54). The findings included: Record review revealed the facility's policy titled, 'Identifying Types of Abuse' (no reference date documented on the policy) documented, in part: Policy Interpretation and Implementation 1. Abuse of any kind against residents is strictly prohibited. 2. Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur. 3. It is understood by the leadership in this facility that preventing abuse requires staff education, training and support, and a facility-wide culture of compassion and caring. 4. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. c. Abuse includes verbal abuse. 5. Abuse toward a resident can occur as: b. staff-to-resident abuse. Mental and Verbal…

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

Based on observations, interviews, and record review, the facility failed to report an injury of unknown origin in a timely manner for 1 out of 1 sampled resident reviewed for skin discoloration (Resident #104). The findings included: Review of the facility's policy/Job description titled, Job description: Certified Nursing Assistant, undated, included the following: Job Summary: The purpose of this position is to assist the nurses in the providing of resident care primarily in the area of the daily living routine. Main Duties: H. Report any changes in resident's condition-e.g. eating habits, behavior, temperature, etc. to the charge nurse of the unit. M. Be responsible for well-being and nursing care of all residents assigned to his/her unit while on duty. P. Detect and report situations that have a high probability of causing accidents or injuries to residents and/or staff. During an observation on 04/10/24 at 8:40 AM of the Dining Room located at the C-Unit, the surveyor noted Resident #104 was yelling and crying out that her hands hurt. Further observation revealed her right…

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 and identify the need for psychosocial assessments in a timely manner for 1 out of 1 sampled resident reviewed for disruptive yelling out behaviors (Resident #104). The facility also failed to follow Physician's orders to report blood sugar readings of 400 and above to the Physician for 1 out of 1 sampled resident reviewed for insulin (Resident #323). In addition, the facility failed to perform a skin assessment in a timely manner for 1 out of 1 sampled resident reviewed for skin condition (Resident #71). The findings included: 1) Record review for Resident #104 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction, Dementia, and Depression. Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #104 had a Brief Interview for Mental Status score of 6, which indicated that she had severe cognitive impairment. Review of Section…

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 ensure that a resident receives wound care consistent with professional standards of practice for 1of 1 sampled residents reviewed for wound care (Resident #30). The findings included: Review of Resident #30's clinical record documented an admission to the facility on [DATE] with a readmission on [DATE]. The resident's diagnoses included, in part, Atherosclerosis Heart Disease, Diabetes Mellitus Type 2, Peripheral Vascular Disease, Dysphagia, Atrial Fibrillation, Neuromuscular Dysfunction of the Bladder, Anxiety, Heart Failure, Depression, Sacral PU (pressure ulcer) stage 4 and [NAME] Prostatic Hyperplasia. Resident #30's Bowel and Bladder Evaluation dated 04/09/24 documented, the resident was incontinent of urine. Review of Resident #30's physician order dated 02/02/24 documented, cleanse sacrum (wound) with normal saline solution (NSS) and apply Collagen Powder to wound bed then pack with Calcium Alginate every day shift for pressure…

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 review of policy and procedure, observation, interview and record review, the facility failed to ensure that it performed appropriate hand hygiene, care and cleanliness to avoid cross-contamination, per professional standards, during Perineal and Foley Catheter care for 1 of 1 sampled residents observed, (Resident #97). The findings included: Review of the facility policy and procedure provided by the Director of Nursing (DON), titled, 'Perineal Care' revised February 2018, documented in the Policy Statement: Purpose: the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition For a female resident: (2) Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. Review of the un-dated facility policy and procedure provided by the DON, titled, 'Infection Control' related to Perineal Care, revised February 2018, documented in the Policy Statement: Infection Control…

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 reimburse a resident's representative for monies spent on the resident from the resident's trust fund for 1 of 1 sampled resident, reviewed for personal funds (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease and Dementia. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment, and required total dependence of two-persons for activities of daily living. A phone interview was conducted with Resident #3's representative on 11/20/23 at 10:00 AM. The representative stated he provided the facility a copy of receipts for food delivered to Resident #3. The resident's representative stated he was denied because he was told the resident needed to keep money in his account for things needed such as a hair cut. Resident #3's representative further stated he had been reimbursed previously for food delivered to the resident. The…

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

Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards that include: failure to maintain refrigeration units, failure to ensure washing in the 3-compartment sink, failure to maintain and clean ceiling and light fixtures, and failure to clean and sanitize commercial food preparation equipment. The findings included: 1) During the initial kitchen/food service sanitation tour conducted on 01/30/23 at 9 AM, accompanied with the Food Service Supervisor (FSS), the following were noted: (a) Observation of the walk-in freezer noted that thermometer gauge to be 40 degrees F and also noted that the entry/exit door was ajar and would not close tightly and noted a heavy, large build-up of ice around the entire door threshold area. The FSS stated that the door is new, however, it has not been able to shut for weeks. Further stated that the issues had been reported to maintenance but has not been addressed. The surveyor informed the FSS that the internal thermometer…

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 serve residents in a manner to enhance or maintain the dignity of the residents during dining. The findings included: Review of the facility's policy titled Dignity published on 11/30/22 documented Residents are treated with dignity and respect at all times .provided with a dignified dining experience .staff are expected to treat cognitively impaired residents with dignity and sensitivity . 1). During an observation of lunch being served on to the residents in the dining room of the C-Wing (Rooms 300 to 332), on 01/30/23 12:48 PM, staff were observed removing the trays from the covered speed rack that was used to transport the meals from the kitchen to the units. Staff were noted to remove the tray from the speed rack and place the meal in front of the residents and remove the covers from the meal and the lids from the containers and open the cartons of various fluids. Once the staff had completed setting up the meals for the 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 interview and record review, the facility failed to act on and resolve grievances voiced by the Resident Council, with the potential to effect residents in the facility that prefer meals in the Dining Rooms(s) and the timing of the meals being served. The findings included: During an interview, on 01/30/23 at 11:59 AM, with Resident #13, when asked about dining, Resident #13 replied, We used to have dinner in the main dining room, but we don't anymore because there is not enough staff. I don't like eating dinner in my room. Lunch, we eat in the main dining room Monday through Friday. During a review of the Resident Council Meeting Minutes and the Menu Committee Meeting minutes, on 02/01/23 at 12:15 PM, the following grievance was noted: 09/15/22: - Main Dining Room is now open to residents for lunch only. - Main Dining Room is requested to be open for [NAME] Hashana dinner - Main Dining Room is to be served first before the units receive lunch trays Action taken 09/19/22, The Main Dining room is being…

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 maintain the facility's laundry services in a clean and sanitary manner. The findings included: A tour of the laundry room was conducted on 02/02/23 at 11:00 AM with a fellow surveyor and Staff S, Laundry Aide and Staff T, Housekeeping Manager. The following areas of concern were observed, and photographic evidence was obtained: 1) In the dirty linen sorting area, it was observed that 2 of the 3 dirty laundry carts had interior build-up of dust, dirt, and debris; and the exteriors of the carts were worn, ripped, and rusty. This could potentially contaminate the soiled linens. 2) In the dirty linen sorting area, it was observed that 2 used isolation gowns were hanging on the wall on hooks, indicating the staff intended to re-use them. Staff T stated the staff members do re-use the isolation gowns. The surveyors explained that it is best practice for the staff members to wear new isolation gowns for each load of laundry to ensure they are not cross-contaminating loads. 3) In the dirty linen sorting area, it was observed that…

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 1) ensure expired supplements and medical/biologicals supplies were removed from 2 of 3 medications/supplements storage room reviewed (Cambridge Unit, [NAME] Unit, and the Biological Storage Room); 2) keep medications carts free from loose pills/tablets noted in the drawers for 2 of 4 medications carts reviewed; and 3) ensure that 1 of 3 treatment carts (Berkshire Unit) and 1 of 3 respiratory care carts were kept secure/locked. The findings included: Review of the facility's policy titled Storage of Medications published on 11/30/22 documented .Drugs and biologicals used in the facility are stored in locked compartments .Drugs and Biologicals are stored in the packaging, containers or other dispensing systems in which they are received .the nursing staff is responsible for maintaining medication storage .in a clean, safe and sanitary manner .outdated drugs or biologicals are returned to the dispensing pharmacy or destroyed .unlocked…

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 physician ordered Purred Diet, Chopped Diet, and Ground Diet which effected 8 of 8 sampled (Resident #10, #14, #70, #81, #87, #92, #98, and #213). The findings included: 1) During the review of the approved menu for the lunch of 01/30/23 noted the following to be served to residents with a physician ordered Pureed Diet and Ground Diet: * 3 ounces Pureed Fish * 4 ounces Pureed beets * Pureed Garlic Bread * Tomato Puree 3 ounces Ground Fish 4 ounces Ground Beets Observation of the tray line assembly of the lunch meal in the main kitchen on 01/30/23 at 11:30 AM, noted the following: * Pureed Fish - unavailable and not prepared for the lunch meal * Pureed Beets - unavailable and not prepared for the lunch meal * Pureed Garlic Bread - unavailable and not prepared for the lunch meal * Tomato Puree (smooth consistency) - unavailable and not prepared got the lunch meal * Ground Fish - unavailable and not prepared for the lunch meal * Ground Beets - unavailable not prepared for…

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

Based on observation, interview, and record review, it was determined that the facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance for physician ordered Pureed Diets which included 13 facility residents (Sampled Resident's #10, #78, #87, and #92). The findings included: 1) Review of the: Facility Standardized Recipe for Roasted Red Potatoes, documented the following: (a) Cut potatoes into wedges, slightly boil or steam potatoes before placing in roasting pan. (b) Bake at 375 F for 30 minutes until tender and lightly browned. (c) For Pureed: Measured desired servings into food processor. Blend until smooth. Add liquid for thinning and commercial thickener if product needs thickening. During the review of the approved menu for the lunch meal of 01/31/23, it was noted that a 4 ounce portion of Roasted Potatos was to be served for all Regular/No Added Salt Diet, and Carbohydrate Controlled/No Concentrated Sweet Diet (CCHO/No Concentrated Sweets). It was also noted that a 4 ounce portion of Mashed Potatoes be served for Ground Diet and Pureed…

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 assess 2 of 2 sampled residents for self-administration of medications for Resident #79 to safely store, transport and administer mediations at dialysis, and for Resident #34 to safely to store, and administer medications in the resident's room. The findings included: 1. Review of the Facility's Policy & Procedure for Self Administration of Medications, documented, in part: * Policy Heading: Resident have the right to self-administer medication if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. * The medication is appropriate for self-administration. * The resident is able to read and understand medication labels. * The resident can comprehend the medications purpose, proper dosage, timing, signs of side effects and when to report these to staff. * The resident has the physical capacity to open medication bottles, remove medication from a container, and ingest and swallow…

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, record review and interviews, the facility failed to provide foot care to 2 of 2 sampled residents reviewed for foot care (Resident #39 and #78). The findings included: 1) Review of Resident #39's , clinical record documented an initial admission on [DATE] and a readmission on [DATE]. The resident was under hospice care since 10/14/22. The resident diagnoses included Coronary Artery Disease (CAD), Atrial Fibrillation, Peripheral Vascular Disease (PVD), Diabetes Mellitus, Gout, Osteomyelitis of the lumbar sacral region and Stage IV Pressure Ulcer to the Sacrum. Review of Resident #39's Minimum Data Set (MDS) significant change assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 12 indicating that the resident was moderately impaired. The assessment documented under Functional Status that the resident needed extensive to total assistance from the staff for all activities of daily living (ADL). Review of Resident #39's care plan titled ADL initiated on…

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

Based on observation, interview, and record review, it was determined that the facility failed to follow physician ordered Fluid restriction for 1 (Resident #79) 5 sampled residents reviewed for nutrition. The findings included: Review of facility policy for Restricted Fluids , noted the following: * Guidelines: 1) Follow specific instructions concerning fluid restrictions. 2) Record fluid intake on the intake output record. 3) Document the amount of fluids consumed by the resident during the shift. 4) Report information in accordance with facility and professional standards of practice. Review of the clinical record of Resident #79 on 01/31/23, revealed the following: 11/27/21 - Renal Diet - End Stage Renal Disease 11/29/21 - Sugar Free Prostat 30 ml TID (Three Times Daily) in beverage of choice 12/1/21 - Nepro 8 oz TID 11/29/21 - Fluid Restriction 1500 cc - Dietary 1020, Nursing = 480 11/30/21 - Fluid Restriction Day = 240 cc /Shift, Eve =120 cc/ Night Shift = 120 cc Dialysis M/W/F chair Time = 11:30 AM - Return 4:30 PM, WT before and after During the observation of the breakfast…

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 maintain resident's private health information in a secure manner and the facility failed to follow physician's orders for Resident #415. The findings included: 1) An observation was conducted on 02/01/23 at 8:36 AM in which Staff F, Licensed Practical Nurse, left the computer on top of her medication cart open with resident information visible along with a piece of paper containing resident information left face-up on her medication cart in the hallway outside of room [ROOM NUMBER]. This was also observed by Staff G, Risk Manager. Staff G promptly covered the computer screen with the piece of paper while Staff F was in a resident's room administering medications. When Staff F returned to the medication cart, Staff G reminded her that the computer screens need to be turned off and any papers should be left face-down. Staff F acknowledged her, saying I should have minimized it (regarding the computer screen). 2) During a medication…

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.