West Delray Nursing & Rehab Center

Based on interviews and record review, the facility failed to provide the minimum nursing staff daily for 3 of 28 days reviewed. The findings included: Review of the facility's policy, titled, Staffing Guidelines dated October 2019, included in part the following: It is the policy of the center to abide by the Federal and State staffing guidelines. Review of the facility's Nurse Staffing Calculations from 02/09/25 to 03/08/25 documented on 02/15/25 that the Certified Nursing Assistant (CNA) daily average was 1.99, on 03/01/25 the CNA daily average was 1.97. On 03/01/25, the Nursing daily average was 0.98 hours and on 03/08/25 the Nursing daily average hours was 0.93. In summary, the Nursing hours were below the minimum 1.0 on 2 of 14 days and the CNA hours were below the minimum 2.0 for 2 of 14 days. An interview was conducted on 03/12/25 09:23 AM with Staff G, Staffing Coordinator, who stated she has been working for the facility for almost 1 year. When asked about the staffing calculations, she stated the minimum daily average hours for nursing should be 1.0 or greater and 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 observations, interviews and record review, the facility failed to post complete staffing information in a timely manner on a daily basis for 4 of 4 days. The findings included: Review of the facility's policy titled, Staffing Guidelines, dated October 2019, included in part, the following: It is the policy of the center to abide by the Federal and State staffing guidelines. On 03/09/25 at 8:44 AM, an observation was made of the CMS (Center for Medicare & Medicaid) Staff Posting dated 02/28/25 located at the nursing station on Unit 1. The posting only listed hours, not the number of nursing staff. There was no name of the facility listed. On 03/09/25 at 8:55 AM, an observation was made of the CMS Staff Posting dated 02/28/25 located at the nursing station on Unit 2. The posting only listed hours, not the number of nursing staff. There was no name of the facility listed. On 03/10/25 at 9:30 AM, an observation was made of the CMS Staff Posting dated 03/09/25 located at the nursing station on Unit 1. The posting only listed hours, not the number of nursing staff. There was 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 interviews and record review, the facility failed to ensure residents receiving PRN (as needed) psychotropic medication are limited to 14 days or if extended beyond the 14 days, have documentation of the rationale and indicate the duration for the PRN order for 3 of 96 residents receiving psychotropic medications, Residents #11, #35, #15. The findings included: Review of the facility's policy titled, Psychopharmacologic Drugs, dated October 2019, included in part the following: PRN (as needed) orders for psychotropic drugs are limited to 14 days. Excluding Antipsychotic medications, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. 1. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses that included in part the following: Anxiety Disorder Unspecified and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure that the medication error rate was not 5% or greater. The medication error rate was 13.33 %. Four (4) medication errors were identified while observing a total of 30 opportunities, affecting Residents #85 and Resident # 11. The findings included: Record review of facility's policy titled, Administration of Drugs, dated 10/2019, revealed in part, that drugs will be administered in a timely manner. Number 7 of the policy interpretation and implementation revealed drugs must be administered within one (1) hour before or after their prescribed time. Review of Medline Plus website revealed Carbidopa Levodopa must be swallowed whole, to not crush, divide, and chew. An additional review revealed Venlafaxine extended-release capsule must be opened and poured on a spoonful of applesauce, if resident is unable to swallow the capsule whole. 1. Record review revealed Resident #85 was admitted on [DATE] with diagnoses that included…

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, record review and review of the facility policy, the facility failed to ensure residents' medications were properly supervised and stored as evidenced by Over The Counter (OTC) medications left unattended on the resident's bedside table (Resident #16) and in the bed (Resident #307) as observed during multiple observations for 2 of 2 sampled residents; and failed to ensure that it secured the residents' medications in 1 of 4 Medication carts (Unit 1), 1 of 2 treatment cart (Unit 1), and 1 of 1 wound treatment cart. The findings included: Review of the facility's policy provided, titled, Self-Administration of Medication, dated October 2019, documented .a resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care team .medications shall not be retained by the resident after the expiration date . Review of the facility's policy provided, titled, Storage of…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 2 of 3 visits to the main kitchen. The findings included: 1. In the Initial tour to the main kitchen on 03/09/25 at 9:05 AM, the following issues were noted: a. A round garbage bin located in the food production area noted with food debris and no lid. b. The first red sanitation bucket was tested using a facility's sanitizing solution strips which showed blue indicating 0 concertation solution in the bucket. c. A second red sanitation bucket was tested using a facility's sanitizing solution strips which showed blue indicating 0 concertation solution in the bucket. d. The third sanitation bucket was tested using a facility's sanitizing solution strips which showed blue indicating 0 concertation solution in the bucket. e. A square container with unidentified food in the reach in Traulsen Refrigerator which was not dated or labeled. f. A jar of milk in the reach-in Refrigerator with an expiration date…

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. Record review for Resident #97 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Traumatic Subdural Hemorrhage with Loss of Consciousness Status Unknown Subsequent Encounter. The Minimum Data Set assessment dated [DATE] documented in Section C, a Brief Interview of Mental Status score of 4 indicating severe cognitive impairment. Review of the Medical Practitioner Note (Physician/NP) for Resident #97 from 12/06/24 to 03/09/25 lacked any documentation from Staff H, the Attending Physician, indicating he had performed a visit of the resident. Review of the Medical Practitioner Note (Physician/NP) for Resident #97 from 12/06/24 to 03/09/25 documented the following: On 12/31/24 authored by Staff I Nurse Practitioner listed position as Physician. On 01/03/25 authored by Staff I Nurse Practitioner listed position as Physician. On 01/07/25 authored by Staff I Nurse Practitioner listed position as Physician. On 01/10/25 authored by Staff I Nurse…

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 (QAPI) Program failed to demonstrate that an effective plan of action was implemented to correct identified quality deficiencies in the problem area as evidenced by repeated deficient practices for F759, Free of Medication Errors. The repeated deficient practice involved 10 medication errros identified while observing a total of 31 opportunites, affecting 4 residents, Residents #2, #3, #5, and #6, at the time of the revisit survey. The finding included: Review of the facility's survey history revealed the facility was cited at F759, Free of Medication Errors, during the recertification survey, with exit date of 03/12/25. On 04/16/25 at 3:25 PM, an interview was conducted with the Director of Nursing (DON) who was apprised of the medication administration errors. See F759 for details. The DON stated that a plan of correction was completed on 04/11/25 for 'Free of Medications Errors' and the last meeting for Quality Assurance and Performance Improvement (QAPI) was held 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines for Standard Precautions during resident personal care for 1 of 1 sampled resident, Resident #25, observed following care; and failed to disinfect essential vital signs equipment used for Resident #31 and #72. The findings included: Review of the Center for Disease Control and Prevention (CDC) guidelines for Standard Precautions Core Practices included: a) Hand Hygiene: involves washing hands with soap and water or using alcohol-based hand rub before and after patient contact, before and after gloving, and after touching contaminated surfaces; b) Personal Protective Equipment (PPE): Using appropriate PPE, such as gloves, gowns, masks, and eye protection, to protect healthcare workers from potential exposure to infectious materials; c) Safe Handling of Potentially Contaminated Equipment: Cleaning and disinfecting equipment and surfaces that may be contaminated 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.

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. The findings included: 1. Review of facility policy, titled, Date Marking for Food Safety, date implemented: 04/07/23 included: Policy: Facility adheres to a date marking system to ensure the safety of ready-to-eat, time / temperature control for food safety. Policy Explanation: #2: The individual opening or preparing a food shall be responsible for date marking the food at the time the food is open or prepared. #3: The marking system shall consist of a label , the day/date of opening. #4: The discard day or date may not exceed the manufacturer's use-by-date. #5: The cook , or designee shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. #6: The Dietary Manager , or designee shall spot check refrigerators for compliance, and document accordingly. During the initial Kitchen / Food Service observation tour conducted on 11/27/23 at 9:00…

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, the facility failed to provide housekeeping and maintenance services necessary to maintain sanitary, orderly interiors for resident rooms (Unit 1 and Unit 2), resident lounge areas, main dining room, and laundry area. The findings included: 1. During observation of the lunch meal in the main dining room on 11/27/23 at 12:30 PM, it was noted that the exteriors of 10 of 19 dining room chairs were heavily worn and had large amounts of a white substance dripped over the entire wood chair frame. Photographic evidence Obtained. 2. During resident screening conducted by surveyors on 11/27/23 and the Environment Tour conducted on 11/29/23 at 2:00 PM, accompanied with the Director of Maintenance and Director of Housekeeping, the following were noted: Unit 1: West Community Shower Room: Two of two shower stall lights were not working. South Community Shower Room: One of three shower stall lights was not working. room [ROOM NUMBER]: Room window glass was covered with a white stain. room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, records review, and the facility's resident account management policy, the facility failed to ensure effective management of 1 of 1 sampled resident's funds to prevent misappropriation of funds, Resident #189. The findings included: Review of the facility policy relating to management of resident's account page 2 documented that funds of discharged or expired residents must be disposed of within 30 days. On page 3, it delineates that the authority of a resident's legal representative (e.g. guardian, conservator, custodian, representative payee, and trustee) ends upon the resident's death. On [DATE] at 12:38 PM, in interview with the Business Office Manager (BOM), the BOM esplained she had assumed this role since [DATE], but has worked at this facility for nearly nineteen years, in different capacities. The BOM stated Resident #189 was admitted to the facility in [DATE]. review of the record documented Resident #189 had multiple admissions and readmissions to the facility. The last admission,…

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 records review and interviews, the facility failed to ensure Minimum Data Set (MDS) assessments, related to significant change and discharge with a non-anticipated return, were completed accurately for 1 of 1 sampled resident, Resident #33. The findings included: On 08/14/23, the facility completed a Significant change assessment update related to Resident #33's health decline. The clinical records showed that Resident #33 refused to be weighed for 4 consecutive months and had a history of weight decline. When the significant change assessment was completed, Resident #33 was a hospice care recipient, so a significant change was not warranted since health decline was expected due to Resident #33's terminal diagnosis. On 08/14/23, the facility initiated a MDS discharge assessment. The Nursing progress notes documented Resident #33 was transferred out of the facility to a Hospice Unit at a local Hospital, on crisis. The MDS Coordinator who completed the assessment indicated that the resident was discharged and the resident's return was anticipated. Further record review…

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 and record review, the facility failed to provide fingernail grooming for 2 of 2 sampled residents, Residents #72 and #86. The findings included: Review of the facility's policy, titled, Nail Care, revised on 04/03/22 documented, The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health .routine cleaning and inspection of nails will be providing during ADL (activities of daily living) care on an ongoing basis to trimming and filing .principles of nail care: nails should be kept smooth to avoid skin injury . 1. Review of Resident #72's clinical record documented an admission on [DATE] with no readmissions, with diagnoses that included Cerebral Infarction, Cognitive Communication Deficit, Urinary Tract Infection, Heart Failure, Wedge Compression Fracture Of Fifth Lumbar Vertebra, Fracture Of Sacrum, Subsequent Encounter For Muscle Weakness, Personal History Of Transient Ischemic Attack (TIA), and Scoliosis.…

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 that a resident who enters the facility with an indwelling catheter was assessed for the removal of the catheter, failed to ensure the involvement of the resident's representative in the discussion of the use of the catheter, and failed to submit documented evidence of the medical justification for the catheter as evidenced by the lack of written documentation in the resident's clinical record of attempts to remove the catheter (voiding trials), a consultation with a specialist (Urologist) and lack of written discussion with the resident's representative. The findings included: Review of the facility's policy, titled, Indwelling Catheter Use and Removal, revised on 05/08/23 documented, It is the policy of this facility to ensure that indwelling catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice .residents that admit with an indwelling catheter or…

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 Intravenous (IV) lines and dressings for 2 of 3 sampled residents reviewed for IV lines, Resident #52 and #12. The findings included: 1. Record review for Resident #52 revealed that an initial admission to the facility on [DATE] and was the last readmission on [DATE]. Upon returning from the hospital, Resident #52 had a PICC (peripherally inserted central catheterline), a midline intravenous line used for long term medications such as antibiotics, in her left upper arm. Resident #52 had a medical history significant for a Left Heel Wound Infection for which she was receiving intravenous (IV) antibiotics. During the initial tour of the facility conducted on 11/27/23, the surveyor observed Resident #52's PICC line dressing was dated 11/14/23. Review of the physician orders revealed an order was written on 11/15/23 for PICC to upper left change dressing every Wednesday night. Review of the Treatment Administration Record (TAR)…

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 medication error rate was 6.45 percent (%). Two (2) medication errors were identified while observing a total of 31 opportunities, affecting Resident #12. The findings included: Review of the facility's policy, titled, Medication Administration, revised on 04/14/23 documented, .compare medication source (bubble pack, vial etc.) with MAR [medication administration record] . administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician .sign MAR after administered . Review of Resident #12's clinical record documented an admission on [DATE] with no readmissions, and diagnoses that included Cognitive Communication Deficit, Dementia, and Anxiety Disorder. Review of Resident #12's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 7, indicating the resident had severe cognition impairment. Review of Resident #12's clinical record revealed a physician…

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 physician ordered pureed diets that were prepared in a smooth form and texture and free from whole, minced or ground pieces to meet the needs of 6 facility residents on a specialized diet, that included Resident #3. The census at the time of survey was 95 residents. The findings included: Review of the facility's Purred Diet (References: American Dietetic Association, National Dysphagia Diet Task Force) noted the following: Description: Pureed diet is used for patients with swallowing and chewing difficulties. All foods are smooth in texture and free from whole, minced or ground pieces. 1. During the observation of the Tray Assembly Line in the Main Kitchen on 11/28/23 at 7:30 AM, it was noted that the Approved menu documented Purred Diet to receive 4-oz serving of Pureed Hashbrown Potatoes. Observation of the Pureed hashbrown potatoes on the steam table noted large pieces of potatoes with the pureed mixture. At the request 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 interviews and record review, the facility failed to appropriately consult the responsible party regarding residents' vaccine status for 1 of 5 sampled residents reviewed for vaccines, Resident #62. The findings included: Review of the vaccination status revealed Resident #62 was not properly reviewed by the facility for vaccines. Resident #62 was admitted to the facility on [DATE], with a medical history significant for Dementia, Parkinson's Disease, Depression, and Pneumonia. Review of the quarterly Minimum Data Set (MDS), dated [DATE], documented Resident #62 had a Brief Interview of Mental Status (BIMS) score of 0, indicating he was severely cognitively impaired and unable to make his own healthcare decisions. During Resident #62's admission, the admitting nurse documented Patient Vaccination, in part, as follows: Information Acknowledgment Forms which showed vaccination education was given to the resident, despite him being unable to make his own healthcare decisions. An interview was conducted…

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 standards for food service safety. The findings included: 1. During the initial kitchen / food service observation tour conducted on 7/25/22 at 9 AM, the following were noted (The Dietary Manager was not in the facility at the time of the observation tour): (a) Observation of the walk-in freezer noted that the internal temperature was not being maintained at the regulatory zero degrees F (Fahrenheit) or below. Food items located on freezer shelves were not soft and not frozen solid. An observation of the thermometer located within the unit was recorded at 30 degrees F. Further observation noted that there was not a freezer log sheet for review of daily temperatures. (b) Observation of Reach-in refrigerator #1 noted that the internal temperature of the unit was not being maintained at the regulatory temperature of 41 degrees F or below. The internal temperature of the unit was noted to be at 46 degrees F. Temperatures of milk and juice portion 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 observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 (100 Unit & 200 Unit) of 2 residential units. The findings included: 1. During during environment observation tours conducted on 07/27/22 and 07/28/22, accompanied with the Director of Housekeeping and Director of Maintenance, the following were noted: 100 Unit: Handrails: The wall mounted wood handrails were noted to be heavily worn and exposing the wood base. The handrails were noted to be located in the the following hallways: Rooms #101-116, Rooms #117-#124, and Rooms #125 - 134. The Director of Maintenance was stated that the handrails are original and are in need of refurbishment. Hallways: The carpeting located in all 3 hallways were noted to have numerous areas of large and small staining. The Director of Housekeeping stated that numerous attempts to eliminate the stains have failed and new carpeting is necessary. room [ROOM…

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 approved residents' menu was not being followed for physician ordered purred diets, mechanical soft diets, cardiac diets, and regular diets. The failure to follow the approved menu potentially affected 40 of the facility residents. The census at the time of the survey was 95. The findings included: During the observation of the breakfast meal in the main kitchen on 07/26/22 at 7:30 AM and review of the approved menu for the breakfast meal of 07/26/22, the following were noted: (a) Review of the approved menu noted 4 ounce serving of Chilled Fruit Cocktail for residents with physician ordered Cardiac Therapeutic Diet. Observation of the breakfast meal noted that portions of the fruit cocktail were not prepared or served to these residents. Interview with the facility's Breakfast [NAME] at the time of the observation noted to state that the canned fruit cocktail was not delivered. Interview with the Dietary Manager (DM) also at the time of observation revealed that he failed to substitute another canned fruit in place 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 observation, interview, and record review, the facility failed to ensure residents received appropriate treatment and services to maintain or improve the ability to eat and to maintain nutrition status, for 1 of 4 sampled residents, Resident #48. The findings included: Review of clinical record for Resident #48 revealed the following: Date Of admission: [DATE] with readmission on [DATE]. Diagnoses included: UTI {urinary tract infection), Sepsis, Covid-19, Atrial Fibrillation, and Calculus of Kidney. Current MD Orders included: 06/09/22 - No Added Salt Diet 05/30/22 - Nutritional treat 07/26/22 - Ensure Plus BID [twice daily] 07/27/22 - Hospice Consult 05/31/22 - Prosource ZAC 30 ml QD [daily] 06/07/22 - Ferrous Sulfate 3256 mg BID - Anemia Weight (wt) History as provided: 07/27=126 pounds (#) (surveyor requested weight) 07/12= 127# 06/17=132.8# 06/02=153.8# Height= 69 inches BMI [Basal Metabolic Index]=18.8 Review of Minimum Data Set (MDS) assessment, dated 06/04/22,00 for Significant Change: Sec B:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of policy and procedure, the facility failed to provide care and services in accordance with activities of daily living, related to nail grooming, for 2 of 2 sampled residents observed for fingernail care, Resident #33 and Resident #85. The findings included: Review of the facility policy and procedure on 07/27/22 at 2:00 PM for Nail Care, provided by the Director of Nursing (DON), revised 01/2014, indicated: Purpose: To provide for personal hygiene needs and prevent infection. Note: Precaution should be used when trimming nails of a patient with Diabetes and should be done by a licensed nurse or physician Procedure 6. Carefully brush nails with nailbrush to remove dirt or clean with orange stick 9. Trim nails and file for smoothness, as needed .Suggested Documentation: Completion of Procedure. Unusual observations and/or complaints and subsequent interventions including communications with physician. Review of facility's Certified Nursing Assistant (CNA)…

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 care and services to ensure orthotic devices were applied as ordered to ensure there was support and no decline in range of motion (ROM) for 1 of 1 sampled resident, Resident #55. The findings included: Record review on 07/27/22 revealed Resident #55 was admitted to the facility on [DATE] and had been in a different rehabilitation facility immediately after the stroke in October of 2021.The most recent comprehensive MDS (Minimum Data Set) assessment showed a BIMS (Brief Interview for Mental Status) exam score of 14 out of 15, which indicated little to no cognitive deficit. The relative diagnoses included Hemiplegia and Hemiparesis following cerebrovascular disease affecting the right / dominant side; Osteoarthritis; Muscle Weakness; repeated Falls; abnormalities of gait and mobility, foot drop, and Diabetes. On 07/25/22 at 11:09 AM, Resident #55 reported she has foot drop on the right side from a stroke last fall. She said there is…

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, interview and policy review, the facility failed to obtain physician orders for a Foley catheter, failed to perform catheter care in a manner to prevent infection, and failed to maintain Foley drainage bags off the floor for 3 of 4 sampled residents reviewed for urinary catheters, Residents #19, #306 and #352. The findings included: Review of the facility provided policy, titled, Bed Bath, dated May 20, 2022, instructs the care provider to wash, rinse and dry the patient's abdomen and then groin and perineum, remove and discard gloves, perform hand hygiene, don new gloves, wet a clean washcloth and apply cleanser then wash, rinse, and dry the patient's legs. Review of the facility provided policy titled Indwelling Urinary Catheter (Foley) Care and Management last revised on 11/19/2021, reads: don't place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI (Catheter Associated Urinary Tract Infection). 1. Resident #19 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents received services consistent with professional standards of practice that included review and clarification of physician ordered medications, for 1 of 1 sampled resident, Resident #53, reviewed for dialysis. The findings included: Review of the clinical record of Resident #53 on 07/26/22 noted the following: Date Of admission: [DATE] Diagnoses included: End Stage Renal Disease, Dependence of Renal Dialysis, DM 2 and Cognitive Impairment. Current Physician Orders included: Dialysis: Monday / Wednesday / Friday (M/W/F) - leave facility at 5:30 AM - Chair time 6 AM. Interview with medication nurse on 07/26/22 confirmed the resident's dialysis days and schedule as M/W/F, leaves facility between 5:00-5:30 AM on these days and returns at approximately 1:00 PM. Review of current physician ordered medications and review of July 2022 Medication Administration Record (MAR) noted numerous doses of medications not administered, due to 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, interviews and record review, the facility failed to ensure controlled substance medication reconciliations were accurate for 2 of 9 sampled residents reviewed during the controlled substance record review at the facility's unit one and unit two, for Residents #93 and 82. The findings included: Review of the facility's policy, titled, Medication Reconciliation, provided by the Director of Nursing (DON), did not address controlled substance reconciliation. Review of the facility's policy, titled, Medication Administration: Medication Pass, documented .under administer medication .document initials on MAR (Medication Administration Record) for each medication administered. 1. On 07/26/22 at 2:07 PM, a side by side review of the facility's unit two medication cart and its controlled substance record for Resident #93, was conducted with Staff I, a Registered Nurse (RN). The resident's controlled substance record for Clonazepam 0.5 mg (milligrams) twice a day daily as needed for anxiety, documented that one tablet was removed from the controlled locked box 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to ensure that residents' personal medications were properly supervised / stored as evidenced by over the counter medications observed on the residents' bedside table for 1 of 1 sampled resident (Resident #101); failed to ensure that residents' medications were labeled as evidenced by unlabeled medications noted in the medication cart in the facility's Unit Two; and failed to ensure the facility's treatment carts were secured on Unit One and Unit Two. The findings included: 1. Review of Resident #101's clinical record lack evidence of documentation that the resident can self-administer the medications observed on her table. The clinical record documented an initial admission to the facility on [DATE] with no readmissions. Review of the resident's Minimum Data Set (MDS) assessment, dated 07/07/22, documented a Brief Interview of Mental Status (BIMS) score of 14 of 15 indicating no cognitive impairment. On 07/25/22 at 9:45 AM, during tour to the facility's…

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