Martin Coast Center For Rehabilitation And Healthc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure offering and provision of the pneumococcal vaccine for 1 of 5 sampled residents, Resident #48.The findings included:Review of the record revealed Resident #48 was admitted to the facility 04/20/23. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact.Review of the electronic medical record under the immunization tab revealed documentation Resident #48 had refused the pneumococcal vaccine on 06/28/23. The record lacked any further documentation related to that vaccine.During a side-by-side record review and interview on 04/08/26 at 3:17 PM, when asked how often the pneumococcal vaccine was offered to residents, the Infection Preventionist (IP) stated upon admission and annually when they are obtaining consents for the flu vaccine. The IP was unable to find any evidence of a current…

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 follow the approved menu for lunch on 11/06/24, and failed to notify the residents of the change in the menu. The findings included: 1. The approved menu for the lunch being served on 11/06/24 documented that residents were to be served 'Golden Fried Chicken'. The approved recipe for the 'Golden Fried Chicken' (no reference date) provided instructions that were documented as: Procedures: 1. For Frying: Fry at 350 degrees Fahrenheit (F) for 10-12 minutes, or until done. 2. For baking: place pieces in a single layer on a parchment paper lined sheet pan sprayed with pan release. Heat at 350 degrees F for 20-25 minutes or until done. 3. Serve 3 oz (ounces) portion. 4. CCP (Critical Control Point): [NAME] to a minimum internal temper of 165 degrees F. Notes: 3. Note: fry in batches; overcrowding the chicken will lower the oil's heat, leading to greasy chicken. 4. Note: Product is fully cooked. Do not overheat. During the follow up kitchen tour, on 11/06/24 at 11:30 AM, accompanied by the Dietary Manager 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 reviews, the facility failed to provide meals prepared, served and stored in a sanitary manner in accordance with standards for food safety. The findings included: 1. During the initial kitchen tour, on 11/04/24 at 8:43 AM, accompanied by the Dietary Manager, Staff A, Dietary Aide, was observed handling open foods and working with food equipment without wearing any kind of restraint over his beard. The Dietary Manager instructed Staff A to put on an appropriate hair restraint. 2. During the follow up kitchen tour, on 11/06/24 at 11:30 AM, accompanied by the Dietary Manager and the Registered Dietitian, the internal temperature of cut melons on fruit plates was 51 degrees Fahrenheit (F) and the internal temperature of deli sandwiches (sliced ham) was 49 degrees F. It was noted that the fruit plates and the sandwiches were kept on a speed rack that was located directly next to the hot holding area at an ambient temperature with no additional cooling mediums to ensure that the foods are maintained at a safe temperature. The Dietary Manager…

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 speak in a dignified manner during care, activities, and meals for 4 of 4 sampled residents (Resident #36, #86, #8, and #83), reviewed for dignity The findings included: 1) Record review revealed Resident #36 was admitted to the facility 06/26/24. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #36 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. The MDS, section D, for Mood documented she sometimes felt lonely or isolated from those around her. Review of the Care Plan dated 10/15/24, documented Resident #36 had diagnoses of Major Depressive Disorder, Anxiety Disorder, and Schizoaffective Disorder. During an interview on 11/04/24 at 12:59 PM, when asked if she was being treated with dignity and respect, Resident #36 voiced that sometimes the Certified Nursing Assistants (CNAs) spoke another language in front of her. 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 reviews, the facility failed to provide showers per resident's preferences and according to the shower schedule for 1 of 2 sampled residents reviewed for choices, (Resident #309). The findings included: Record review for Resident #309 revealed that the resident was admitted to the facility on [DATE] and moved to her current room on 10/11/24. According to the resident's most recent complete assessment, a Medicare 5-Day Minimum Data Set (MDS), dated [DATE], Resident #309 had a Brief Interview for Mental Status score of 14, indicating that the resident was 'cognitively intact'. The assessment documented that Resident #309 required 'substantial/maximal assistance' for bed transferring from the bed, and 'partial/moderate assistance' for bed mobility. Resident #309's diagnoses at the time of the assessment included: Hypertension, UTI (Urinary Tract Infection) (last 30 days), DM (Diabetes Mellitus), Hyponatremia, Hyperlipidemia, Malnutrition, Anxiety disorder, Depression, Polyneuropathy,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide housekeeping and maintenance services as a means to provide a clean, safe, and home like environment on 3 of 4 units, in the Shower room and the outside patio. The findings included: During a tour of the facility, conducted on 11/04/24 from 9:00 AM to 4:00 PM, the following was observed: On the 200 unit: In room [ROOM NUMBER], the wall behind the head of the B (window) bed was damaged. In room [ROOM NUMBER], the wall to the left of the hand sink in the shared restroom was damaged and the wall to the resident's right side of the bed (A bed) was damaged. On the 300 unit: In room [ROOM NUMBER], the seat of the wheelchair for the resident in the D bed (closest to the door and on the right) was worn and there were multiple black marks on the floor. In room [ROOM NUMBER], the laminate surfaces of the over bed tables were damaged to a point where the particle board underneath was exposed. In room [ROOM NUMBER], the over bed table 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 interview and record review, the facility failed to ensure the participation of the resident in the development of the resident's care plan and ongoing participation in resident care planning meetings for 1 of 2 sampled residents reviewed for Care Planning (Resident #34). The findings included: On 11/04/24 at 9:14 AM during the initial resident interview with Resident #34, he stated that he was very upset at being unable to leave the facility. I want to get out of here. I am here against my will. As far as I know, I am still responsible for my own health care decisions, but no one lets me make decisions about my health care. I do not have a power of attorney or a health care surrogate. I have never been invited to any care plan meetings. All decisions are made by my sister, and I don't want anything to do with her. A review of Resident #34's Minimum Data Set (MDS) assessment showed that Resident #34 was assessed to have a Brief Interview Mental Status score of 13 out of a possible 15 (mildly impaired).…

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 assistance with grooming, including hair washing and nail care to 3 of 5 sampled residents, who were dependent upon staff for care (Resident #28, #40, and #44). The findings included: 1) Review of the record revealed Resident #28 was admitted to the facility on [DATE] and resided in the secured memory care unit. Review of Minimum Data Set (MDS) assessment dated [DATE] lacked a Brief Interview for Mental Status (BIMS) score as the resident was rarely understood. This MDS documented the resident needed partial to substantial assistance from staff for Activities of Daily Living (ADLs). Review of a care plan initiated 03/18/23 documented Resident #28 had a communication problem and impaired ability to make self understood and another initiated on 06/07/23 that she needed the assistance of staff for all ADLs. Review of the Certified Nursing Assistant (CNA) tasks indicated the resident had only had one shower in the past month.…

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, facility staff failed to assess lung sounds and vital signs pre and post nebulizer treatments for 3 of 3 sampled residents reviewed for nebulizer treatments (Residents #42, 95 and #63). The findings included: 1) Review of the policy titled, Respiratory Care and Oxygen Administration revised 10/2022 documented, in part, 12. Evaluation of respiratory status and breath sound and response to treatment should be documented in the clinical record. Review of the record revealed Resident #42 was ordered a nebulizer treatment, Ipratropium-Albuterol, every four hours for lung congestion. This order dated 11/05/24 specifically instructed to assess and document the resident's lung sound, pulse and respiration rates, and oxygen saturation level pre and post treatment. During an observation on 11/06/24 beginning at 4:18 PM, Staff N, Licensed Practical Nurse (LPN), obtained the nebulizer treatment for Resident #42 from the medication cart, placed the medication…

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

Based on observation, record review, and interview, the facility failed to ensure pain management for 1 of 5 sampled residents, as evidenced by the failure to administer a lidocaine patch, as per physician order for Resident #99. The findings included: Review of the record revealed Resident #99 had an order initiated on 10/31/24 for a lidocaine 5% patch, to be applied to the lower back daily at 9 AM and removed daily at 9 PM. A medication pass observation was made for Resident #99 on 11/06/24 at 8:57 AM, with Staff K, Licensed Practical Nurse (LPN). The LPN obtained a lidocaine 5% patch from the medication cart, took a piece of paper tape and applied to the outside of the patch, and wrote the date on the piece of tape, using a thick black marker. The LPN entered the resident's room, and upon pulling up the back of the resident's shirt, a lidocaine patch with the initials of Staff K and the date of 11/04/24 was noted on the resident's lower back. The LPN confirmed that was the patch she had placed on the resident's back on Monday 11/04/24, and that she did not work on Tuesday…

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 sufficient and appropriate social services are provided to meet the needs of 1 of 1 sampled resident (Resident #34), related to the following: 1) Advocating for resident and assisting in the assertion of their rights within the facility; 2) Assisting resident in voicing and obtaining resolutions to grievances about discharge wishes; 3) Assisting resident with financial and legal matters (e.g., referrals to lawyers); and 4) Assisting with transitions of care services (e.g., assisting the resident with identifying community placement options and completion of the application process, arranging intake for home care services for residents returning home, assisting with transfer arrangements to other facilities. The findings included: On 11/04/24 at 9:14 AM during the initial resident interview with Resident #34, he stated that he was very upset at being unable to leave the facility. I want to get out of here. I am here against my will. As far as I…

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 ensure appropriate use of Personal Protective Equipment (PPE) during the use of a tracheostomy (artificial opening in the neck) and percutaneous endoscopic gastrostomy (PEG/surgical placement of a feeding tube) use for 1 of 1 sampled resident (Resident #95); and failed ensure timely contact isolation for 1 of 1 sampled resident (Resident #57). The findings included: 1) Review of the policy Enhanced Barrier Precautions revised 04/01/24 documented, in part, Enhanced Barrier Precautions (EBP) consists of the use of gowns and gloves for high-contact care activities which include but may not be limited to Device care or use: . feeding tube, tracheostomy . Review of the record revealed Resident #95 was admitted to the facility on [DATE] to received care and services, in part, related to a tracheostomy and PEG tube. A care plan initiated on 06/14/24 documented the resident required EBPs related to the tracheostomy and PEG tube.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide an appropriate mattress for 1 of 26 sampled residents (Resident #309). The findings included: Review of Resident #309's record revealed the resident was admitted to the facility on [DATE] and moved to her current room and bed on 10/11/24. According to the resident's most recent complete assessment, a Medicare 5-day Minimum Data Set (MDS), dated [DATE], Resident #309 had a Brief Interview for Mental Status score of 14, indicating that the resident was 'cognitively intact'. The assessment documented that Resident #309 required 'substantial/maximal assistance' for transferring and required 'partial/moderate assistance' for bed mobility. Resident #309's diagnoses at the time of the assessment included: Hypertension, UTI (Urinary Tract Infection) (last 30 days), Diabetes Mellitus, Hyponatremia, Hyperlipidemia, Malnutrition, Anxiety disorder, Depression, Polyneuropathy, Immunodeficiency, Muscle weakness, Dysphagia, Abnormalities 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 record review and interview, the facility failed to develop a protocol for the release of medical records requested on behalf of the resident's legal representative, failed to verify if the request was legitimate; and failed to release the resident's records for 1 of 2 sampled residents (Resident #1). The findings included: Record review revealed the medical record request log dated 01/2024 thru 09/2024 lacked evidence of entries related to Resident #1. Interview with the Medical Records staff conducted on 09/04/24 at 12:21 PM, revealed she recalls receiving two requests for release of medical records regarding Resident #1. The staff explained the requests were forwarded to the former owners, any record request prior to March 2024 would be handled by the previous owner, and there is no tracking mechanism to verify if the request was completed. The Director of Nursing, who was present during the interview, discussed implementing a process to ensure medical records has a protocol for handling requests that cannot be honored by them and when she sends them to the previous…

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 record review, policy review, and interview, it was determined, the nursing staff failed to accurately document wound care treatment orders and the provision of wound care for 2 of 2 sampled residents (Resident #1 and #4). The findings included: Review of the facility policy titled, Wound Care revised October 2010 documented, as follows: Purpose The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess any special needs of the resident. Documentation The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8.…

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 prepare, serve and store foods under sanitary conditions. The findings included: 1). During the initial kitchen tour, on 08/21/23 at 9:27 AM, accompanied by the Food Service Manager, the following were noted: a.) The instructions for the operation of the mechanical ware washing machine documented that the minimum water temperature was to be 120 degrees Fahrenheit and final Rinse solution should be tested 3 times daily using Chlorine test strips and recording results. For proper sanitation levels, readings should be between 50-100 ppm (parts per million) or as required by local and state health codes. During an observation of the mechanical ware washing machine, it was noted that the temperature of the wash cycle was 100 degrees F and the temperature of the rinse cycle was 110 degrees F, according to the temperature gauge installed on the machine and confirmed by use of the facility's metal stemmed probe style thermometer. During the same observation, the concentration of the chlorine based sanitizer was less…

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 housekeeping and maintenance services necessary to maintain a sanitary, safe, clean, comfortable home like environment, and failed to ensure comfortable water temperatures for bed baths and showers. The findings included: 1). In room [ROOM NUMBER], the wall mounted air conditioning unit was not fully secured in the opening that created a gap around the unit, large enough to accommodate the migration of pests. The arms of the wheelchair for the resident in the B bed (window bed) were damaged to the point that the foam underneath the covering was exposed. In room [ROOM NUMBER], there was tape along the top edge of the air conditioner, and the electronic control panel was not sitting correctly on the face of the unit. There was a strong smell of urine in the room. The legs of the over bed table were rusted. In room [ROOM NUMBER], the laminated edging was missing from the over bed table for Bed A (door bed), exposing the particle board…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, grievance review, and policy review, the facility failed to report 2 of 2 credible allegations of misappropriation of property to the State Agency and Law Enforcement, affecting 2 of 2 sampled residents (Resident #51 and #76). The findings included: Review of the policy titled, Investigating Incidents of Theft and/or Misappropriation of Resident Property revised December 2006 documented, 2. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 4. Should an alleged or suspected case of misappropriation of resident property be reported, the facility Administrator, or his/her designee, will notify the following persons or agencies within two (2) hours of such incident, as appropriate: a. State Licensing and Certification Agency; . d. Adult Protective Services as required; e. Law Enforcement Officials as required . 1) During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, grievance review, and policy review, the facility failed to investigate 1 of 2 credible allegations of misappropriation of property affecting 1 of 2 sampled residents (Resident #76). The findings included: Review of the policy titled, Investigating Incidents of Theft and/or Misappropriation of Resident Property revised December 2006 documented, 2. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 3. The investigation shall consist of at least the following: a. An interview with the person(s) reporting the missing items; b. An interview with any witnesses that may have knowledge of the missing items; c. An interview with the resident (as medically appropriate); . e. A review of the resident's personal inventory record to determined if the missing items were recorded on the report; f. Interviews with staff members (on all shifts)…

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, interview and record review, the facility failed to complete a Level II PASSAR (Preadmission Screening and Resident Review) for 1 of 1 sampled residents reviewed, as required according to the information documented on the resident's Level I PASSAR Screening (Resident #54). The findings included: Resident #54 was admitted to the facility on [DATE] with diagnoses which included Dementia, Anxiety Disorder, Chronic Psychosis, and Bipolar II Disorder. A review of Resident #54's Level I PASSAR indicates in Section I that this resident had Mental Illness related to diagnoses of Anxiety Disorder, Bipolar Disorder, Depressive Disorder, and Mood Affective Disorder. In Section II of the Level I PASSAR, it is documented that Resident #54 has a secondary diagnosis of Dementia and the Primary Diagnosis is a Serious Mental Illness. According to the directions listed on the PASARR worksheet, a Level II should be completed if the individual has a primary or secondary diagnosis of Dementia, or related…

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 policy review, the facility failed to ensure appropriate care and services were provided for 1 of 1 sampled residents with an indwelling urinary catheter, (Resident #106) who was diagnosed with two urinary tract infections (UTIs), while residing at the facility. The findings included: Review of the policy titled, Urinary Catheter Care dated September 2014 documented, Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Maintaining Unobstructed Urine Flow . 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Infection Control . 2b. Be sure the catheter tubing and drainage bag are kept off the floor. Steps in the Procedure . 3. fill the wash basin one-half full of warm water. 7. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel…

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 reassess and implement nutritional interventions in a timely manner after a significant weight loss and continued decline for 1 of 6 sampled residents reviewed for weight loss (Resident #54). The findings included: A review of the facility's policy for Weight Assessment and Intervention (Revised September 2008) documented: Weight Assessment 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. 4. The dietitian will respond within 24 hours of receipt of written notification. 5. The dietitian will review the unit weight record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 6. The threshold 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 record review and interview, the facility failed to ensure a complete record for 1 of 6 sampled residents reviewed for nutrition. Specifically, Resident #55 had a nurse witnessed concern with a subsequent referral to therapy, and the record lacked any documentation of the event or follow through. The findings included: During an interview on 08/21/23 at 4:08 PM, Resident #55 voiced concern about an incident from the previous week, when she had trouble when she choked on hard rice. The resident stated she walked over to the therapy room during the incident, but nobody would hit her on the back to dislodge the food. Review of the record revealed Resident #55 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the orders revealed a regular diet with a regular texture and fluid consistency. Further…

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 convey within 30 days the resident's funds and a final accounting of those funds to the residents, or in case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law, for 2 of 3 sampled residents reviewed, that are due refunds (Resident#1 and Resident#2). The findings included: 1). Review of Resident #1's record revealed the resident was admitted to the facility on [DATE] and expired on [DATE]. Further review revealed during her stay at the facility, she was on Medicare and Medicaid, and on Hospice Medicaid at the time of her death. Review of Resident#1's accounting records from the business office revealed that she has a credit in her account in the amount of $2436.38. This is 315 days since the resident expired. 2). Review of Resident #2's record revealed the resident was initially admitted to the facility on [DATE], with a readmission on [DATE] and expired on [DATE]. Further review revealed…

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.