Winkler Court

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan reflective of the resident's choice of code status for 1 (Resident #78) of 3 residents reviewed for advanced directives care planning. The findings included: Review of Resident #78's record revealed a physician's order dated [DATE] for Do Not Resuscitate (DNR) status, meaning that if breathing or heart beats stop, cardiopulmonary resuscitation (CPR) would not be initiated. Review of the nursing progress note by Registered Nurse (RN) Staff G dated [DATE], shows Resident #78 wanted a DNR code status. Review of Resident #78's care plan for advanced directives initiated [DATE], the resident requests Full Code status, meaning CPR would be initiated. On [DATE] at 10:00 a.m., during an interview Resident #78 said she told the facility she wanted a change to DNR status. On [DATE] at 5:36 p.m., during an interview RN Staff G she said she did not revise the care plan for advanced directives as the resident requested on [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 Based on observation, interview, and record review, the facility failed to ensure that 1 (Resident #54) of 1 residents reviewed for activities received services designed to meet their interests, physical, mental, and psychosocial well-being. The findings included: Resident #54 was admitted to the facility with diagnoses including dementia and cognitive impairment. Review of the resident's care plan, initiated 2/25 and last revised 4/25, identified goals for Resident #54 to participate in activities of choice daily, with interventions including encouraging engagement with a general activities program and providing in-room activities if preferred. Observations across multiple days (4/21/25 at 8:15 a.m., 4/21/25 at 11:14 a.m., 4/21/25 at 3:00 p.m., 4/22/25 at 9:25 a.m., 4/22/25 at 10:39 a.m., 4/22/25 at 12:32 p.m., and 4/23/25 at 9:53 a.m.) demonstrated a lack of activities. Throughout these observations, no activity materials, music, television, or staff-led activities were present or offered 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and procedures and family and staff interviews, the facility failed to ensure the physician was notified and the residents spouse was properly trained to administer medications for 1 (Resident #93) of 5 residents reviewed for medication observation. The findings included: The facility policy 7.1 Medication Administration General Guidelines documented Medications are administered as prescribed in accordance with manufacturers specifications, good nursing principles and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of the prescriber. Medications are to be administered at the time they are prepared. The person who prepares the dose for administration is the person who administers the dose. Review of the clinical record revealed Resident #93 was [AGE] year old with an admission date of 12/20/24. Diagnoses include protein calorie malnutrition, convulsions, muscle weakness and the need 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical records and resident and staff interviews, the facility failed to assist in making an appointment with a practitioner specializing in the treatment of vision impairments and failed to ensure the resident's glasses were in good repair for 1 (Resident #50) of 1 resident reviewed for vision loss. The findings included: The facility policy Referral - Vision and Hearing Services documented The facility will assist residents in obtaining routine and prompt vision or hearing care period the social services department will work to assist and or coordinate services, such as but not limited to the following: 1. Appointments. 2. Prompt referrals (i.e , broken hearing aids glasses etcetera). 3. Identify those residents who require a prompt referral. Examples include but are not limited to: Damaged or broken hearing aids, glasses, or other assistive devices. Review of the clinical record revealed Resident #50 was [AGE] years old and had an admission date of 9/6/21 with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services and prevention of new ulcers from developing for 1 Resident (#68) of 3 residents reviewed. The findings included: Resident #68 was admitted on [DATE] with end stage renal disease, type 2 diabetes, weakness, cognitive communication deficit, heart failure, need for assistance with personal care, feeding tube, colostomy tube, and indwelling urinary catheter. He was admitted to the facility with multiple pressure wounds. He was also cognitively impaired based on a Brief Interview of Mental Status (BIMS) score of 3. He attends dialysis at an outside facility. Record review of the admission History and Physical said that Resident #68 was high risk for skin breakdown and unavoidable wounds due to malnourishment. Record review showed an admission skin assessment, completed by Staff M, Registered Nurse (RN) Unit Manager, did not find a wound on the coccyx or on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation, the facility failed to offer a therapeutic diet for 1 (Resident #60) of 2 reviewed for nutrition. The findings included: Resident #60 was admitted on [DATE] with muscle wasting and atrophy, type 2 diabetes, anemia, heart failure, chronic ulcers, and kidney failure. He goes to the dialysis center 3 times per week. He scored a 15 on his Brief Interview of Mental Status (BIMS) which indicates he is cognitively intact. On 4/21/25 at 4:08 p.m., Resident #60 was interviewed in his room after arriving from the dialysis center He stated, I'm waiting for dinner, they need to hurry I am starving. On 4/21/25 at 4:25 p.m., during an interview, Staff V, Registered Nurse (RN) said that he ate 100% of his breakfast and the facility provides him a lunch, she does not know why he is so hungry. Record review of the Dialysis Communication log dated 4/21/25 showed that at 8:30 a.m, Resident #60 ate breakfast at the facility, and he traveled to dialysis with a bagged lunch. 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 licensed nurses have the specific competencies and skill sets to provide nursing and related services to care for residents needs for 2 (Residents #1 and #2) of 3 residents reviewed for medication orders. The findings included: Facility policy Physician Orders 4.3.1 effective October 2021 indicated on page 3: The nurse will review each hard chart for new orders and compare to the electronic order listing report to ensure each written order has been entered into the electronic medical record. If a written physicians order is found on the chart and not on the order listing, transcribe the order and notify the resident/representative. Medication/Treatment variance may be completed if needed with physician notification. Facility Policy titled Event Reporting effective 2019, change date March 2022 indicated: An event report will be completed by the nurse assigned to the resident, for any occurrence outside the routine operational expectation 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 upon interview and record review, the facility failed to ensure residents were free from significant medication errors by not administering medications in accordance with prescribers' orders for 2 (Resident #1 and #2) of 3 residents reviewed for medication orders. The findings included: Facility policy Physician Orders 4.3.1 effective October 2021 indicated on page 3: The nurse will review each hard chart for new orders and compare to the electronic order listing report to ensure each written order has been entered into the electronic medical record. If a written physicians order is found on the chart and not on the order listing, transcribe the order and notify the resident/representative. Medication/Treatment variance may be completed if needed with physician notification. Facility Policy titled Event Reporting effective 2019, change date March 2022 indicated: An event report will be completed by the nurse assigned to the resident, for any occurrence outside the routine operational expectation 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, records review, and staff interviews the facility failed to ensure that staff were routinely monitored to ensure the safe use of mechanical lifts to transfer residents for 5 of 58 sampled Certified Nursing Assistants (Staff A, Staff B, Staff C, Staff H, and Staff I), and 2 of 17 sampled Registered Nurses (RN) (Staff K and Assistant Director of Nursing) RNs. The findings included: The facility policy and procedure titled, Back Injury and Body Mechanics effective March 2022 noted, Mechanical Lifts for Residents . Complete Mechanical Lift competency (Appendix B) at orientation and annually . The facility's Skills Check for Total Lift included to identify the correct lift and inspect the lift for condition. The facility's policy and procedure titled, Lock Out/ Tag out Policy effective March 2022 noted, The facility will use the Lock Out/ Tag Out practices to secure inoperable equipment . Other Physical Equipment . Mechanical lifts . When an issue is identified, remove the equipment from use . On 2/12/24, review of the facility's accident investigations revealed 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, record review, and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This had the potential to effect 105 residents who resided in the facility. Review of Food and Nutrition Services Manual - Topic: Storage (Effective January 2021. Refrigerator storage: 1. store perishable foods in refrigerator and/or foods marked keep refrigerated: by the manufacturer 7. Discard leftovers per use by date. 8. Discard refrigerated leftovers after 72 hours. Maintain food temperature at 41 degrees Fahrenheit (F) or less Review of policy and procedure for Dish Machine Temperature Log. Policy: To monitor dish machine temperatures and chemical saturation for both high and low temperature machines at each meal prior to dishwashing to assure proper cleaning and sanitizing of dishes Procedure: 2. Send an empty dish rack through the dish machine prior to recording temperatures. On 10/31/22 at 7:16 a.m., during a kitchen observation…

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 staff interview and policy review the facility failed to maintain an antibiotic stewardship program that includes antibiotic use protocols and system to monitor antibiotic use. The findings included: Reviewed policy and procedure titled, Antibiotic Stewardship, Tracking, Monitoring Antibiotic Prescribing, Use and Resistance, effective April 2017 which stated, Residents will have a complete clinical assessment documentation at the time of the antibiotic prescription. Audits of antibiotic prescriptions for completeness of documentation, regardless of whether the antibiotic was initiated in the facility or a transferring facility. Monthly prevalence studies regarding antibiotic usage will be presented to quality assurance and performance improvement committee (QAPI). This information can also be in the infection prevention and control monthly summary manuals. Reviewed policy and procedure, titled Infection Prevention and Control Program, effective October 2021 which stated, The Infection Prevention and Control Program is comprehensive program that addresses detection,…

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 staff interview, the facility failed to provide the necessary repairs to maintain the building in a safe and comfortable environment for residents and visitors. The findings included: On 10/31/22 at 7:30 a.m., during initial tour of the Memory Care Unit, the following observations were made: A pungent smell of urine and other odors was noted immediately upon entering the unit. Bathroom trash cans were full of garbage and overflowing onto the floor in several bathrooms. room [ROOM NUMBER] there was an uncovered toothbrush resting on the bottom of the hand soap dispenser in a shared bathroom. room [ROOM NUMBER] had a broken nightstand with the top drawer missing for bed A. The blinds in the room were broken, missing sections and in disrepair. There were air-conditioning parts on the floor in the corner of the room. On 10/31/22 at 9:45 a.m., observed in the Memory Care Unit dining room were small flying insects flying over the food as the residents were eating. The flying pests were landing…

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

Based on interview and record review the facility failed to ensure a process was in place to assess parameters of nutritional status by not monitoring resident's weights on admission and thereafter for 6 ( Residents #91, #94, #96, #253, #351, and #402) admitted in past 30 days of 6 residents reviewed. This had the potential to affect all 84 residents residing in the facility. The findings include, Review of facility policy and procedure (Effective October 2021) - Topic: Weight management - states, weights are completed on admission and re-admissions, then weekly for 4 weeks and then monthly unless physicians' orders more frequently. On 11/1/22 during initial review of admission weights of sample residents, weights were not found for Residents #91, #94, #96, #253, #351, and #402 admitted in past 30 days. On 11/1/22 at 2:47 p.m., in an interview, the RN MDS Coordinator stated, We don't get the weight upon admission. I use the hospital weight as the admission weight. The MDS coordinator said the Restorative Certified Nursing Assistant (CNA) used to do the weights but as of March, we…

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, review of policy and procedure, review of the Center for Disease Control and staff interview, the facility failed to ensure all staff followed infection prevention measures to prevent the spread of disease-causing organism when caring for 3 (Resident #3, #31, and #351) of 3 sampled residents reviewed on contact precaution. The findings included: The facility's policy and procedure, titled Clostridium-difficile: Prevent Spread, effective October 2021 stated, Residents diagnosed with Clostridium-difficile whose stool is not contained shall be placed on Contact Precautions. The Centers for Disease Control and Prevention (Page last reviewed July 12, 2021) notes C. diff. is a germ that causes diarrhea and inflammation of the colon. C. diff. can be life-threatening. The steps to prevent spread include to wear gloves and a gown when treating patients with C. diff., even during short visits. Gloves are important because hand sanitizer doesn't kill C. diff. and hand washing might not be sufficient alone to eliminate all C. diff. spores.…

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, observation, resident and staff interviews, the facility failed to provide care in a dignified manner by dressing a resident in a hospital gown instead of regular clothes which resulted in feelings of embarrassment for 1(Resident #91) of 2 residents reviewed for dignity. The findings included: On 10/31/22 at 11:02 a.m., record review revealed Resident #91 was admitted to the facility on [DATE] with diagnoses which included pleural effusion, diabetes, assistance with personal care, and chronic kidney disease. The admission Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact and required extensive assistance of 1 staff member for dressing and personal hygiene. On 10/31/22 at 9:30 a.m., 11/01 at 9:01 a.m. and 11:58 a.m. and 11/2/22 at 10:01 a.m., observations were made of Resident #91. The resident was observed in his room dressed in a hospital gown. On 10/31/22 at 11:58 a.m., Resident #91 said staff had not offered to get him dressed in regular clothes.…

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 resident interviews, the facility failed to document, investigate and communicate resolution of a grievance voiced by the spouse of 1(Resident #91) of 4 residents reviewed for grievances. The findings included: Review of the facility's Grievance/Concern Management Policy and Procedure (Effective February 2021) indicated: Social Services #5. will monitor and document resident/family satisfaction upon completion of the investigation and the summary of the findings/conclusion #12. Complete a concern report investigation with summary and conclusion On 10/31/22 at 11:02 a.m., record review revealed Resident #91 was admitted to the facility on [DATE] with diagnoses which included pleural effusion, diabetes, assistance with personal care, and chronic kidney disease. The admission Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact and required total dependence of 2 staff members toileting. On 10/31/22 at 11:58 a.m., Resident #91 said he had been left in feces 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 observation, review of the clinical record, review of facility policy and resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 2 (Resident #7, and #49) of 3 residents reviewed for activities of daily living. The findings included: The facility policy 5.5.1 ADL: Assistance, effective July 2022, documented Each resident will be encouraged to be as independent as possible with activities of daily living (ADL's). Staff will provide assistance with ADLs per plan of care. 1. A review of Resident #7's clinical record showed a significant change minimum data set (MDS) (a tool used to gather resident information) with assessment reference date (ARD) 7/28/22. The MDS documented Resident #7 required limited assistance of 1 for dressing, personal hygiene, and toileting. The Minimum Data Set (MDS) assessment showed a brief interview for mental status (BIMS) score of 7, indicating moderate cognitive impairment. The care plan documented 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, review of facility policy, clinical record review, and staff interviews, the facility failed to implement meaningful activity programs for 2 (Resident #48 and #302) of 2 residents reviewed with dementia on the secured Memory Care Unit. A lack of structured activities has the potential to cause boredom, agitation, and anxiety. The findings included: The facility policy 6.1.1, Dementia Related Programs, documented, Specialized support, maintenance, and empowerment activity programs are provided for residents with cognitive impairments. The activities are based on the level of dementia and functional ability.Review interdisciplinary data. Interview resident or representative to determine which activities interest the resident. Provide specialized activities based on the resident population with dementia and the various functional abilities of the residents. The activity calendar must include activities appropriate for dementia residents. 1. A review of Resident #48's clinical record showed a…

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 Facility failed to provide appropriate supervision to prevent falls for 1 resident (Resident #57) of four surveyed for falls. The findings included: Resident #57 was admitted to the facility on [DATE] with a history of displaced fracture of the right tibia. The resident has a history of chronic kidney disease, anemia and arrhythmia. The Minimum Data Set assessment completed on 9/11/22 shows the resident had a brief mental interview score of 12 indicating mild cognitive loss. On 8/31/26 at 2:26 p.m., Resident #57 said a staff member had rolled her out of the bed when she was changing her sheets. Resident #57 stated she had hit her head and she was still having headaches due to the fall. Review of the fall investigation completed on 10/18/22 shows Registered Nurse Staff V documented, Observed Resident lying on the floor on her left side Resident states she was turned to be changed and she rolled too far off the bed and fell to the floor. Resident stated she hit her head. On 10/18/22 Certified Nursing Assistant…

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 staff interview and record review the facility failed to ensure competency and performance reviews are completed every 12 months for 2 (Staff B and Staff BB) of 6 staff sampled for performance review and competencies. The findings included: 1. Record review revealed Certified Nursing Assistant (CNA) Staff B's permanent date of hire was listed on the facility rooster as 7/10/12. Review of the competency review record provided by the Director of Nursing (DON) revealed Staff B's last competency/performance review was completed on 5/12/21. On 11/2/22 at approximately 3:30 p.m., the DON verified Staff B's competency/performance review had not been completed within the last 12 months. 2. Record review revealed CNA Staff BB's permanent date of hire was listed on the facility rooster as 2/23/10. Review of the facility provided documentation revealed Staff BB had not had a competency/performance review completed since 2/16/18. On 11/2/22 at approximately 3:30 p.m., the DON verified Staff BB had not had a competency/performance review completed within the last 12 months.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident and staff interviews, the facility failed to secure medications in a locked storage area consistent with state or federal requirements and professional standards of practice for 2 (Resident #6 and #65) of 2 residents reviewed for medication storage. The findings included: Review of facility policy 7.1 Medication Administration General Guidelines policy dated 9/18 noted: Medications are administered in accordance with written orders of the prescriber. 7.1 (#3) notes that medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access Section 7.1 (#15) notes residents are allowed to self-administer medications when specifically authorized by the prescriber, the nurse care centers interdisciplinary team (IDT), and in accordance with procedures for self-administration of medications and state regulations. 1. On 10/31/2022 at 10:27 a.m., during a tour of the facility, one bottle of family care…

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 resident and staff interviews, the facility failed to accommodate residents with food allergies/intolerances for 1 (Resident #65) of 1 resident reviewed. The findings included: On 10/31/22 at 12:18 p.m., during a tour of the facility Resident #65 was observed eating lunch. Resident #65 said she needs a gluten free diet but was given soggy toast and pasta for lunch. Resident #65 said she has reported this issue to multiple staff and during several care conferences. The dietary admission note dated 3/15/22 noted Resident #65 had a food allergy/intolerance to gluten. On 11/2/22 at 8:13 a.m., Resident #65 was observed in her wheelchair trying to eat breakfast in the dark. The blinds were closed, and lights were off. Resident #65 stated she can't eat most of what was sent for breakfast: white toast, potatoes, scrambled eggs. The meal ticket did not list toast, or scrambled eggs but baked omelet with cheese. Resident #65 stated Last night I sent my tray back, everything was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policies, and staff interviews, the facility failed to maintain an effective pest control program and failed to provide a sanitary environment free from pests. The findings included: The facility policy 8.33.1 Pest Control documented, The facility strives to promote good sanitation practices to protect its residents and employees. The maintenance staff shall make every effort to inspect, identify, monitor, evaluate and control pests as their method of entry into the building. On 10/31/22 at 9:45 a.m., observation in the Memory Care Unit dining room revealed small flying insects flying over the food as the residents were eating. During random observations over 4 days on all units of the facility and in the conference room, small flying pests were noted daily. On 11/2/22 at 1:20 p.m., while in the office of the Director of Nursing, small flying pests were observed. The Care Plan Coordinator was in the office and began to swat at the insects with her hand and confirmed 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, record review, review of policies and procedures, and staff interview, the facility failed to implement meaningful and empowerment activity programs to meet the assessed needs of 8 (Resident #5, #19, #39, #41, #58, #60, #62, and #64) of 8 residents identified with emotional and psychological needs. The lack of an individualized activity program has the potential to cause social isolation, boredom, agitation, and frustration. The findings included: The facility policy 6.1.1, Dementia Related Programs (1/2021) documented: Specialized support, maintenance and empowerment activity programs are provided for residents with cognitive impairments. The activities are based on the level of dementia and functional ability .Dementia related programming should be activities that can be broken down into small segments. The activity calendar must include activities appropriate for dementia residents. The facility policy 1.1.1 Activities Overview documented: Activities department employees will provide…

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, resident and staff interview the facility failed to have documentation of description of grievances, investigation and prompt interventions for 4 (Resident #19, #34, #64 and #202) of 4 residents who voiced grievances. The findings included: The policy for Grievance and concern management (August 2017) read, Residents/representative has the right to present concerns on behalf of themselves, and/or others to the staff and/or administrator of the facility . or to any other person. The concern may be filed verbally or in writing, and the reporter may request to remain anonymous. The NHA (Nursing Home Administrator) is responsible for oversight of the concern process . The social Services Representatives/Grievance official in collaboration with the NHA will be responsible for assigning the concern to the appropriate department for investigation. Social Services will monitor and document resident/family satisfaction upon completion of the investigation and the summary of findings/conclusion.…

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, review of the facility's abuse and neglect policy, residents and staff interviews, the facility failed to implement their policy and procedure and document thorough investigation of resident complaints of staff treatment for 4 (Resident #19, #34, #64, and #202) of 4 residents with documented grievances reported to management. The findings included: The facility's policy and procedure titled Abuse Prevention Program, From Risk Management Manual last updated 1/2020, specified: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and…

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

Based on observation, record review, and staff interview, the facility failed to provide oxygen therapy, in accordance with physician orders, for 2 (Residents #24 and #60) of 2 residents sampled for oxygen administration. Failure to follow prescribed oxygen therapy may result in inadequate oxygen treatment or an increased risk of side effects and complications. Findings included: Requested and received a copy of Oxygen Therapy Policy and Procedure. Received document titled: The Oxygen Therapy. (SMS O2 ED 2013). States: Definition of Oxygen 1) Oxygen is a drug which must be ordered by physician. Clinical Consideration: Clinical Consideration: 1) CO2 retainers- Some patients are sensitive to O2 and have the potential to stop breathing if their blood oxygen becomes elevated. These patients should be maintained with their O 2 saturations near 90% and monitor closely for sensorium change. 1. Observation on 4/5/21 at 12:05 a.m., found Resident #24 in bed receiving oxygen via a nasal cannula connected to an oxygen concentrator set on 3 liters per minute (LPM). Resident #24 was observed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and procedures, and staff interviews the facility failed to ensure timely access to locked emergency-controlled substance medications located in 1 of 2 medication storage rooms. The facility also failed to have a system to audit and reconcile the disposition of discharged controlled substances and failed to ensure secured and locked medication carts for 1 of 6 carts at the facility. The findings included: Facility policy and procedure 4.2 Controlled Medication Storage dated 2007 item 6 states At each shift change or when keys surrendered, a physical inventory of all Schedule II, including refrigerated items, is conducted by two licensed nurses per state regulation and is documented on the controlled substance accountability record or verifications of controlled substances count report. The nursing care center may elect to count all controlled medications at shift change. 1. On 4/6/21 at 4:27 p.m., during an observation of the medication room Ford Hall with Unit…

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.