Ventura Health And Rehabilitation Center

Based on observation and interview, the facility failed to submit required staffing information based on payroll based journal. The findings included: The facility triggered for excessively low weekend staff per the PBJ (payroll based journal) staffing data report for the 1st quarter of 2025. Review of the 2 week staffing hours for the 1st quarter of 2025 was conduycted. The document revealed low staffing hours on 12/22/24, 12/25/24, 12/26/24, and 12/27/24. An interview was conducted with the Nursing Home Administrator (NHA) on 04/29/25 at 12:00 PM. The NHA presented corrected hours on the 2 week staffing sheet, with corroborating payroll document. The NHA stated the information / hours was input incorrectly. The NHA acknowledged the information submitted to CMS was incorrect and prompted PBJ to trigger for low staffing.

Based on observation and interview, the facility failed to prepare, store and serve food in a sanitary manner; and failed to provide an appropriate cooling medium for a dialysis meal for 1 of 1 sampled residents reviewed for dialysis, Resident #55. The findings included: On 01/08/24 at 9:09 AM, a brief initial tour of the main kitchen was conducted accompanied by the Certified Dietary Manager (CDM). The following was observed: (1) a burnt pot on the pot shelf with the clean pots. (2) stove and oven is dirty, with burnt on food and grease, (3) The tabletop can opener holder was very dirty, with black grease (4) The ceiling vent near the dish washing area was dirty with black dust. On 01/08/24 at 9:30 AM, an interview was conducted with the CDM. The findings were reviewed. The CDM acknowledged the findings. 2. The facility's policy, titled, Food: Preparation, dated October 2019, documented, in part: Definitions: Ready-to-eat food - means food that is in form that is edible without additional preparation to achieve food safety. Time / Temperature Control for Safety Food (formerly known…

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 initiate baseline care plans that included provisions for Foley catheter care for 1 of 4 sampled residents reviewed for Foley catheter care, Resident #300. The findings included: Review of the Electronic Health Record (EHR) for Resident #300 revealed there were no physician orders for a Foley catheter and no baseline care plan for instructions to provide care for the catheter. The resident's care plans did not include Foley catheter care until 01/10/24. On 01/08/24 at 12:15 PM, Resident #300 was interviewed, who stated he was admitted to the facility 3 days ago from the hospital. He was observed with a Foley catheter with a bedside drainage bag. An interview was conducted on 01/08/24 at 12:54 with Staff G, Licensed Practical Nurse (LPN). Staff G was asked in front of the resident's room if Resident #300 had a Foley catheter. She looked at the resident's orders and stated that he did not. The baseline care plans were reviewed with the Director of Nursing who agreed there was no baseline care plan for Foley…

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, the facility failed to utilize necessary care and services to ensure the residents' ability to communicate did not diminish for 1 of 1 sampled resident reviewed for hearing, Resident #89. The findings included: Record review for Resident #89 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Chronic Kidney Disease Stage 4, Unspecified Hearing Loss, Dehydration and Adult Failure to Thrive. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #89 revealed in Section B under Hearing for the question Ability to hear (with hearing aid or hearing appliances if normally used was answered moderate difficulty. In Section C, a Brief Interview of Mental Status score of 13, indicating cognition was intact. Review of the 'Resident Personal Belonging Inventory', dated 09/27/23, indicated the resident did not have any hearing aids upon admission. Review of the Care Plan for Resident #89 dated 09/28/23 with a focus on the 'resident…

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 and policy review, the facility failed to ensure a resident received treatment and care in a timely manner for 1 of 19 sampled residents, (Resident #1). The findings included: The facility's policy, titled, Provision of Physician Ordered Services, implemented 11/3/20 and revised 11/29/22, revealed, Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate entity. 1. On 01/09/24 at 9:30 AM, Resident #1 was interviewed during the initial interview process, who stated she was supposed to go home yesterday. She had been in the facility since 12/15/23. Record review revealed she had been admitted with Viral pneumonia, Hypothyroid and Anxiety disorder. The documented Brief Interview for Mental Status (BIMS) was 15 on the Minimum Data Set (MDS) admission assessment with an assessment reference date of 12/19/23, indicating she was cognitively intact. She stated that she came in with pneumonia but was feeling much better. She lived at home with a disabled family…

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 obtain physician orders for catheter care for 1 of 4 sampled residents reviewed for catheter care, Resident #300. The findings included: Record review revealed Resident #300 was admitted to the facility post hospitalization on 01/05/24, with diagnoses that included Acute Kidney Failure, Pain in left knee, and Type 2 Diabetes Mellitus. The social service assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14 which indicated he is cognitively intact. Review of the Electronic Health Record (EHR) for Resident #300 revealed there were no physician's orders for the Foley catheter, no diagnosis for the catheter and no orders for catheter care. An interview was conducted on 01/08/24 at 12:54 with Staff G, Licensed Practical Nurse (LPN). Staff G was asked in front of the resident's room if Resident #300 had a Foley catheter. She looked at the resident's orders and stated that he did not. She turned around and looked at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #65 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], documented Resident #65 had a Brief Interview for Mental Status (BIMS) score of 02, indicating that the resident had severe cognitive impairment. The MDS documented the resident had no impairments to upper extremities, and was able to eat independently with setup and clean up assistance. Resident #65's diagnoses at the time of the assessment included: Anemia, Hypertension, Depression, Idiopathic Peripheral Autonomic Neuropathy, Cirrhosis of Liver, Hypothyroidism, Low back pain, Adjustment disorder with mixed disturbances of emotions and conduct, Paranoid Personality Disorder, presence of left artificial hip joint, Constipation, Long-term use of anticoagulants, History of malignant neoplasm of large intestine, and GERD (Gastroesophageal Reflux Disease). The MDS documented that the resident had no swallowing disorders and no dental concerns. Resident…

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 dispose of expired medication in 1 of 2 medication rooms, 100 Unit, reviewed for medication storage. The findings included: Review of the facility's policy, titled, Medication Storage, with a revised date of 05/04/22, included: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Unused medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drug Policy. On 01/10/24 at 4:15 PM, a review of the Medication (Med) Storage Room on the 100 unit was done with Staff A, Licensed Practical Nurse (LPN). The following expired items were…

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 diets as ordered for 1 of 7 sampled residents reviewed for nutrition, Resident #89; and failed to provide supplements as ordered for 2 of 7 sampled residents reviewed for nutrition, Residents #69, and #89. The findings included: 1. Record review for Resident #89 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Chronic Kidney Disease Stage 4, Unspecified Hearing Loss, Dehydration and Adult Failure to Thrive. Review of the Minimum Data Set (MDS) assessment for Resident #89 dated 12/31/23 revealed in Section C a Brief Interview of Mental Status Score of 13 indicating an intact cognitive response. In Section B, it revealed Ability to hear (with hearing aid or hearing appliances if normally used) is adequate. Review of the Physician's Orders for Resident #89 revealed an order dated 09/27/23 for Regular diet Regular texture, Thin consistency, large portions. Review of the Physician's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide adaptive eating equipment for 1 of 7 sampled residents reviewed for nutrition, Resident #87. The findings included: Record review for Resident #87 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission date of 12/27/23 with diagnoses that included: Multiple Sclerosis, Paraplegia, Neuromuscular Dysfunction of Bladder and Muscle Weakness. The Minimum Data Set (MDS) assessment for Resident #87 dated12/31/23 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15, indicating an intact cognitive response. In Section GG for eating and oral hygiene, the resident had an admission performance of dependent with a discharge goal of substantial / maximum assistance. Review of the Care Plan for Resident #87 dated 08/07/23 with a focus for at risk for malnutrition related to MS (Multiple Sclerosis) paraplegia, depression, sepsis, history of UTI (Urinary Tract Infection),…

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 maintain accuracy of medical records for 5 of 19 sampled residents, Residents #87, #1, #300, #250, and #39. The findings included: 1. Record review for Resident #39 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission date of 07/14/23 with diagnoses that included: Chronic Obstructive Pulmonary Disease and Gastrostomy Status. The Minimum Data Set (MDS) assessment for Resident #39 dated 10/18/23 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #39 revealed an order, dated 09/19/23, for enteral feed order two times a day Jevity 1.5 at 55ml per hour via G-Tube continuously x 20 hours. Start at 5:00 PM daily. Stop at 1:00 PM daily. Flush 50ml water before starting and after stopping feeds. Ensure to record the amount infused per pump reading once a shift. Review 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.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standard for food service safety that included: maintenance of refrigeration units, maintenance of air-conditioning systems, ensure only dietary staff in food preparation and serving area, proper covering of garbage and trash, and proper equipment to be used for food storage and clean dishware. The findings included: 1. During the initial observation tour of the main kitchen on 08/22/22 at 8:45 AM, accompanied with the facility's Food Service Manager (FSM), the following was noted: (a) Observation of the dish machine area noted that there was a ceiling mounted air-conditioning vent located directly over the machine. Further observation noted that the exterior of the vent was full of condensation that was dripping down onto clean dishes and staff working in the area. The surveyor informed the Food Service Manager (FSM) that the condensation was potentially hazardous and could potentially contaminate clean resident dishware. (b) Observation of reach-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 observation and interview, the facility to have a properly functioning call system affecting the 1 of 2 wings (100 wing), which included 34 rooms consisting of 60 residents. The findings included: An observation of the 100 unit was conducted on 08/22/22 at 10:00 AM. A continuous audible sound was heard throughout the unit and nurse's station. the surveyor questioned Staff Z, a Licensed Practical Nurse (LPN), Staff Y (LPN), and the Unit Manager (UM) of the sound. All staff referred to the noise as the ghost call light. The staff stated the sound had been going on for a while now, and they could hear the sound in their sleep. Staff Z explained they have had people come out to look at it and nothing had been done. Staff Z stated when a resident would utilize their call light, the call light would illuminate at their door, but there was no distinctive audible sound due to the ghost call light continuously sounding. Staff Z stated they have to monitor the halls frequently for call lights and make frequent rounds on residents to assist with needs. An interview was conducted with…

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 feed residents in a dignified manner for 2 of 3 sampled residents reviewed for dining (Resident #28 and #223). The findings included: 1. Review of facility policy, titled, Adaptive Feeding Equipment, dated 11/2020, revealed that residents requiring assistance in feeding are potential candidates for adaptive utensils use, as determined by the occupational therapist. Any staff member may refer a resident for a feeding evaluation. Adaptive devices (special eating equipment and utensils) shall be provided for residents who need or request them. These may include but not limited to devices such as silverware with enlarged / padded handles, plate guards, and/or specialized cups. The dietary department. Appropriate utensils shall be placed on the resident's food tray at each meal, and returned to the dietary department, on the food tray, for sanitation. Review of the facility policy, titled, Promoting/Maintaining Resident Dignity During…

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, interviews, record review and policy review, the facility failed to initiate a baseline care plan for 1 of 24 sampled residents (Resident #221). The findings included: A review of the facility's policy, titled, Baseline Care Plan, and implemented 11/2020, revealed, in part, The baseline care plan shall be developed within 48 hours of a resident's admission A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. Resident #221 was admitted to the facility from an acute care facility on 08/20/22 with diagnoses that included Urinary Tract Infection (UTI), Type 2 Diabetes Mellitus (DM) and Hemiplegia and Hemiparesis following a Cerebral Infarction affecting left non-dominant side. An interview was conducted with Resident #221 on 08/22/22 at 10:30 AM who revealed she was alert and oriented and in this facility to have physical therapy. A review of the Electronic Health Record (EHR) revealed no baseline care plan. A review of the medical chart revealed no paper baseline care plan. On 08/24/22 at 8:39 AM, the medical chart and EHR…

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 and policy review, the facility failed to obtain physicians' orders for oxygen for 2 of 2 sampled residents (Resident #20 and Resident #34) and failed to obtain physicians' orders for insulin for 1 of 1 sampled resident (Resident # 20). The findings included: The facility's policy, titled, Oxygen Administration, implemented 11/2020, revealed Oxygen is administered under orders of a physician. 1. On 08/22/22 at 10:00 AM, Resident #20 was observed and interviewed during the initial pool process. The resident was observed using oxygen via nasal cannula which was set at 3 liters. The resident stated he has been using oxygen all of the time since he came back from the hospital at the end of July [2022]. On 08/23/22, the resident was again observed at 11:26 AM with oxygen on 3 liters via nasal cannula. Review of the resident's Electronic Health Record (EHR) was conducted and revealed Resident #20 was transferred to an acute care facility on 07/14/22 and readmitted to this…

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

Based on observation, interview, and record review, the facility failed to provide treatment and services necessary to maintain or improve foot care for 1 of 1 sampled resident, reviewed for and requiring podiatry care (Resident #43). The findings included: During a screening of Resident #43 on 08/23/22 at 8:00 AM, it was noted the resident was in bed with both feet exposed. Further observation of the feet and specifically the toes noted that toes nails were exceptionally long and discolored gray / black. In particular, the resident's great toes (Left and right) toenails were over 1 inch long from the top of the toe. Interview at the time of the observation, 08/23/22 at 8:00 AM, noted the resident to have mild confusion and noted to state that his toenails are too long and has requested to cut but could no recall the staff that he told. The resident requested the surveyor's assistance in scheduling Podiatry care. Following the observation and interview with Resident #43, an interview was conducted with the Director of Nursing (DON) concerning the toenail issue. The DON stated 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 observation, interview, and record review, the facility failed to provide restorative care for 1 of 1 sampled resident, Resident #58, reviewed for range of motion. The findings included: A review of the facility's policy, titled, Restorative Nursing Program, dated 11/2020, documented: The Restorative Nurse is responsible for maintaining a current list of residents who require restorative nursing services, and for ensuring that all elements of each resident's program are implemented. The discharging therapist, Restorative Nurse, or designated licensed nurse will communicate to the appropriate restorative aid, the provisions of the resident's restorative nursing plan, providing any necessary training to carry out the plan. Record review revealed Resident #58 was admitted to the facility on [DATE] with diagnosis included stroke, with weakness/paralysis affecting the right dominate side. A comprehensive assessment, dated 07/29/22, documented the resident was cognitively intact, and required extensive 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, interview, and record review, the facility failed to prevent falls and perform post fall evaluations for 1 of 5 sampled residents, reviewed for falls (Resident #331). The findings included: A review of the facility's Fall Prevention Program, dated 11/01/20 and revised 04/09/21, documented: Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. The nurse shall indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. When any resident experiences a fall, the facility will: Assess the resident, complete a post fall assessment, initiate neuro checks if resident hits head and/or unwitnessed fall, notify physician and family, review the resident's care plan and update as indicated, and document all assessments and actions. Record review revealed Resident #331 was admitted to the facility on [DATE]. An Admit / Readmit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide medication as scheduled on dialysis days for 1 of 1 sampled resident reviewed for dialysis (Resident # 50). The finding included: Review of the Electronic Health Record for Resident #50 revealed she has a Brief Interview for Mental Status of 13, per her admission Minimum Data Set with an assessment reference date of 07/22/22, which indicates she is cognitively intact. She was admitted to the facility on [DATE] with diagnoses that included Dependence on Renal Dialysis, Cellulitis of Right Lower Limb and End Stage Renal Disease (ESRD). Resident #50 was interviewed on 08/22/22 at 9:00 AM as part of the initial pool process. The resident stated that she goes to dialysis on Monday, Wednesday and Friday in Delray Beach. She stated she leaves for dialysis at 10:45 AM and returns at 4:45 PM. She takes a chicken salad sandwich with her to dialysis and a ginger ale. Review of the Medication Administration Record (MAR) for Resident #50 indicated she 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 observations, interviews, and record review, the facility failed to secure medications for 1 of 24 sampled residents reviewed for medications located at the bedside (Resident #10). The findings included: Review of the facility policy, titled, Resident Self-Administration of Medication, dated 11/20, revealed: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely, the residents ability to ensure that medication is stored safely and securely. Bedside medication storage is permitted only when it does not present a risk to confused residents. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective. The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy. All nurses and sides are required to report to the charge nurse on duty any…

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 that therapeutic diets (Fluid Restriction) were followed as per physician order for 1 of 1 sampled resident, (Resident #50), reviewed for dialysis. The findings included: Review of facility Policy for 'Fluid Restriction' (Implemented 11/2020 and Revised 2/2021), documented, in part: It is the policy of this facility to ensure that fluid restrictions will be followed in accordance with physician's orders. Compliance Guidelines: 1. Verify the physician's order for the fluid restriction and an order written to include the breakdown of the amount of fluid per 24 hours to be distributed between the food and nutrition department and the nursing department. and will be recorded on the medical record. 2. The fluid restriction distribution will take into consideration the amount of fluid to be given at meal times, snacks, and medication passes. 3. The food and nutrition department will be notified by facility communication methods 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 provide physician ordered special eating equipment for 1 of 8 sampled residents reviewed for nutrition (Resident #28). The findings included: Review of facility policy, titled, Adaptive Feeding Equipment, dated 11/2020, revealed, in part, that residents requiring assistance in feeding are potential candidates for adaptive utensils use, as determined by the occupational therapist. Any staff member may refer a resident for a feeding evaluation. Adaptive devices (special eating equipment and utensils) shall be provided for residents who need or request them. These may include but not limited to devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups. The dietary department. Appropriate utensils shall be placed on the resident's food tray at each meal, and returned to the dietary department, on the food tray, for sanitation. Review of the facility policy, titled, Promoting/Maintaining Resident Dignity…

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 contact precautions for 1 of 1 sampled resident reviewed for transmission-based precautions (Resident #30). The findings included: A review of the facility's policy Transmission- Based Precautions (TBP), dated 11/2020, documented: An order for isolation will be obtained for residents who are known or suspected to be infected or colonized with infectious agents that require additional controls to prevent transmission effectively. Make decisions regarding private room on case-by-case basis, balancing infection risks to other residents. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. TBP remain in effect for limited periods (i.e. while the risk of transmission of the infectious agent persists or for the duration of the illness) and per physician orders. 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.