Brookwood Gardens Rehabilitation And Nursing Cente

Based on observation, interview and record review the facility failed to ensure 1) food items in the walk-in refrigerator that were opened were labeled and dated, 2) to store food under sanitary conditions and maintain the food safely using a method to determine the temperatures in the milk box and 3) failure to ensure the proper cleaning and maintenance of exhaust hoods and vents to prevent food contamination. This has the potential to affect one-hundred and thirty-two out of one-hundred and forty-two residents who eat orally residing in the facility. The findings included: 1) Record review of the Food from Home and Outside Sources Policy and Procedure (written date November 2017); Policy Statement-Food and Beverage not procured by the Food and Nutrition Services department shall adhere to the same uniform handling procedures established by the center to ensure that the food or beverage is wholesome and safe to consume; Policy Interpretation and Implementation-2) If the food or beverage items require refrigeration or freezer storage, the item must be stored in an appropriate area…

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 provide advance directives documentation for seven out of seven sampled residents (Resident #102, Resident # 137, Resident # 305, Resident # 307, Resident # 65, Resident # 76 and Resident # 77). The findings included: Record review of Resident #102's demographic face sheet noted an admission date of 03/20/2024. Review of Resident # 102's clinical records showed no written documentation related to advance directives. Record review of Resident #137's demographic face sheet noted an admission date of 03/05/2024. Review of Resident # 137 clinical records showed no written documentation related to advance directives. Record review of Resident # 305's demographic face sheet noted an admission date of 04/12/2024. Review of Resident # 305's clinical records showed no written documentation related to advance directives. Record review of Resident # 307's demographic face sheet noted an admission date of 03/29/2024. Review of Resident # 307's clinical records…

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 ensure an effective Quality Assessment and Assurance (QAA) committee/ Quality Assurance/Performance Improvement (QAPI) as evidenced by not implementing corrective plans of action for correcting repeated deficiencies related to labelling and storage of drugs and biologicals, sanitary food handling and infection control and sanitary food handling. Cross reference F761 Label/Store Drugs & Biologicals; Cross reference of F880 for Infection Prevention and Control and F812 for Sanitary Food Handling and Cross reference of F880 for Infection Prevention and Control and F867 QAPI/QAA. These repeated deficient practices have the potential to increase the risk of negative resident outcomes. There were 142 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's survey history revealed, during the last recertification survey with exit dated 12/15/2022, F761 Label/Store Drugs & Biologicals, F812- Food Procurement, store/ prepare/serve-Sanitary, F880-Infection Prevention 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 and interview facility failed to properly dispose biohazard material for one resident (Resident#74) out of seven sampled residents as evidenced by an observation of staff placing biohazard bag in bin with white lid, after a wound care observation for R#74. There were 142 residents residing in the facility at the time of the survey. The Findings Included: On 4/24/2024 at 10:57 AM After a wound care observation of R#74, Staff D, Certified Nursing Assistant, (CNA) entered The Soiled Utility room and disposed of the biohazard trash bag into a bin with a white lid. (see photo evidence) On 4/24/2023 at 10:58 AM Staff D, CNA When asked where biohazard bag was placed, stated I placed the biohazard bag into the bin with the white lid bin. Stated I am supposed to put in into the bin labeled biohazard box. Stated I placed into the other bin because I didn't see the biohazard bin because I am nervous. On 4/24/2024 at 11:00 AM Staff D, CNA removed biohazard bag from bin with white lid and plaed into carton labeled Biohazard. On 4/25/2024 at 12:01 PM The Director of Nursing…

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 ensure the high temperature dish machine for the wash cycle and the final rinse cycle was working properly. This has the potential to affect one-hundred and thirty-two out of one-hundred and forty-two residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the Dish Machine Temperatures Policy and Procedure (written date November 2017); Policy Statement-Temperatures will be recorded daily in all Dish machine units that are utilized in the dietary department; Policy Interpretation and Implementation-1) A log will be maintained for all Dish machine equipment daily. Temperatures for wash cycle, rinse cycle will be recorded daily as assigned by the dietary department supervisor; 3) If wash temperatures are noted to be outside the safe zone of 160 degrees Fahrenheit (High Temperature Machine), the dietary supervisor must be immediately notified and 5) Rinse Cycle must reach 180 degrees Fahrenheit for (High Temperature Machine). Notify Dietary Supervisor…

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 provide dignity while dining for one resident (Resident #27) out of seven residents sampled, as evidenced by staff standing while assisting Resident #27 to eat breakfast. There were 142 residents residing in the facility at the time of the survey. The findings included: Observation on 04/24/2024 at 8:46 AM, revealed Staff E, a Certified Nursing Assistant (CNA) was standing while assisting Resident #27 to eat breakfast. Record review of Resident #27's demographic sheet revealed an admission date of 12/19/2018 and readmission on [DATE] with diagnosis that included Morbid obesity. Record review of Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] section C for cognitive status revealed a Brief Mental Status (BIMS) score of undetermined. Section GG for functional status revealed set up clean up assistance for eating. Section K for swallowing status revealed no or unknown. Record review revealed a care plan initiated on 3/1/2023…

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 accurately code the Minimum Data Set (MDS) for one resident (Resident #149) out of five residents reviewed for discharges. As evidenced Resident #149 was discharged to home; but the MDS indicated the resident was discharged to hospital. The finding included: Record review of Resident #149's admission record revealed the resident was admitted to the facility on [DATE] and discharged home on [DATE]. Record review of Medical Diagnosis revealed the resident's diagnosis included, but were not limited to, Malnutrition and chronic obstructive pulmonary disease with (acute) exacerbation, Record review of Resident #149's Care Plan initiated on 04/12/2024 revealed Focus: The resident wishes to return/be discharged to home with sister-in-law. Record review of progress notes dated 4/4/2024 at 18:33 revealed Discharge Summary Resident is going home discharge in stable condition . discharge instructions signed by patient. Record review of Discharge Return Not…

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

Based on observation, record review and interview, the facility failed to ensure that a splint device was in place/worn to prevent worsening of left hand and left elbow contractures for one (Resident #12) out of one resident reviewed for positioning and mobility out of twelve residents with contractures. The findings included: An initial observation of Resident #12 was conducted on 4/22/2024 at 8:47 AM. The resident was sitting up in bed, watching television, the resident had contractures on the right elbow, right hand, left elbow and left hand. No hand rolls were noted on the right or left hand and no splints were noted on the right or left elbows. Second observation of Resident #12 was conducted on 4/23/2024 at 8:40 AM. The resident was sitting up in bed eating breakfast, television. No hand rolls were noted on the right or left hand and no splints were noted on the right or left elbows. Third observation of Resident #12 was conducted on 4/24/2024 at 10:03 AM. The resident was sitting up in bed asleep, television was o. No hand rolls were noted on the right- or left-hand…

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 facility failed to keep drug records in an order that an account of all controlled drugs is maintained and periodically reconciled for one resident (Resident #74) out of seven residents sampled as evidenced by total number of pills in bingo card labeled Clonazepam Tab 0.5 mg (milligrams), less than the amount recorded on Controlled Drug Receipt/Proof of use/Disposition form. There were 142 residents residing in the facility at the time of the survey. The findings included: On 04/24/24 at 3:37 PM a narcotic count was completed with Staff C, a Licensed Practical Nurse (LPN) for South cart in nursing section 300. Resident #74's Clonazepam 0.5 mg (milligrams) tablet blister pack count was 33 tablets and the Controlled Drug Receipt/Proof of use/Disposition form for Resident #74's Clonazepam 0.5 mg tablet was 34, last signed on 4/23/2024. (photo evidence) Record review of electronic medication administration record revealed Staff C, LPN signed that Clonazepam 0.5 mg tablet was administered to Resident #74 on 4/24/2024 at 1:16 PM. Staff C,…

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 properly store medications for one resident (Resident#122) out of seven residents sampled as evidenced by an observation of medication in the room Resident#122's room without staff present. There were 142 residents residing in the facility at the time of the survey. On 4/23/2024 at 9:09 AM. An observation was made of two small, white, circular tablets inside a transparent medicine cup, on top of side table next to Resident#122's. (photo evidence). Resident #122 stated the medication was given to her by the overnight nurse and kept due to not wanting to take it on an empty stomach. On 4/23/2024 at 9:14 AM, Staff C, Licensed Practical Nurse (LPN) was asked about the medications observed in Resident #122's room. Staff C, LPN stated: I did not administer any medication to Resident#122. Staff C stated: I did rounds at 7:15 AM this morning and visually assessed [Resident #122] and I did not see any medication. I am not aware of [Resident#122]…

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, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. As evidenced by failure to ensure cold food holding temperatures at 41 degrees Fahrenheit (F) or below, failure to ensure the proper cleaning of food preparation equipment, failure to ensure maintenance of light fixture, exhaust hoods, and vents to prevent food contamination, failure to handle silverware in a sanitary manor, failure to ensure leftover foods are dated, labeled and failure to ensure the maintenance of refrigeration units and shelving and failure to prevent contamination of potentially hazardous foods prepared and provided in bagged lunches for resident going out of the facility for dialysis. The findings included: 1) During the initial kitchen sanitation tour conducted on 12/12/22 at 9 AM accompanied with the Certified Dietary Manager (CDM), the following were noted: (a) Observation of the walk-in refrigerator it was noted that the outside exterior required repair repainting 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 and interview, it was determined that the facility failed to treat residents with respect and dignity in a manner that promoted enhancement of quality of life that included; not providing drinking cups for approximately 77 residents, failed to provide dessert plates for approximately 78 resident. Failure to provide dining knives for residents on dysphagia diets, failure to allow 1 (Resident #95)out of 1 resident sampled for dialysis to sit in lobby area while awaiting transportation, and failure of staff to sit during the feeding of Resident #64. The findings included: 1) During the observation of the lunch meal on 12/12/22, breakfast and lunch meal on 12/13/22, and breakfast meal on 12/14/22 it was noted that cartons of milk were served on the tray however a drinking cup was not provided to these residents. During routine meal observations it was noted that residents were required to drink milk directly out of the carton. Residents were noted to issue grasping the cartons or spilling when…

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, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 (200 Unit and 300 Unit) of 5 resident areas. The findings included: During the initial resident and room screenings conducted on 12/12/22 and the environment tour conducted on 12/13/22 at 1:00 PM accompanied by the Director of Maintenance, the following were noted: On the 200 Wing hallway floor outside of Rooms #201 to 204 it was noted that the wood laminate floor was buckling and curving upwards in 3 areas and was a potential fall/injury risk to residents. Observation of room [ROOM NUMBER] revealed three of the room walls were noted to be damaged and in disrepair, the bathroom walls were noted to have large black scuff areas, and the bathroom sink required recaulking. In room [ROOM NUMBER] the personal closet (1) was noted to have exterior damage, the over-bed table exterior was damaged and noted to have exposed…

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

Based on observation, interview, and record review, it was determined that the approved facility menu was not followed for a potential 103 residents (Regular and Therapeutic Diets) and 27 residents (includes sampled Resident #14, Resident #20, and Resident #28) with physician ordered pureed diet. The findings included: 1) During the review of the 12/12/22 approved lunch meal the following was noted: Italian Sausage (Regular and Therapeutic Diets) Dinner Roll with Margarine Pureed Dinner Roll with Margarine Thin Crust Pizza (Entree Substitute) Pureed Cheese Ravioli (Pureed Entree Substitute) Marinated [NAME] Bean Salad (Dysphagia Vegetable Substitute) Pureed Marinated [NAME] beans (Substitute vegetable) Tossed Salad with Dressing (Regular Entree Substitute) During the observation of the lunch tray in the main kitchen and interview with the Certified Dietary Manager (CDM) on 12/12/22 at 11:30 AM, it was revealed that, Shredded Roast Pork substituted for Italian Sausage. The CDM stated that the pork was not ordered in time or was not available for delivery. *The Dinner Roll 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, record review, and interview, it was determined that the facility failed to prepare food in a form designed to meet the needs of residents with physician ordered thickened liquids that included 26 facility residents and included sampled Resident #10, Resident #42, Resident #64, and Resident #70. The findings included: 1) Review of the approved menu for the breakfast meal of 12/13/22 noted documentation of 8 ounces of milk be served for regular and therapeutic diets. During the observation of the breakfast meal in the main kitchen on 12/13/22 at 7:30 AM, it was noted that residents on physician ordered thickened liquids tray cards that documented 8 ounces of thickened milk (Nectar and Honey Consistency) were not receiving an 8-ounce portion of thickened milk. Interviews with Staff A, B, C who were working on the tray line stated that the thickened milk has not been available for some time. Interview with the Certified Dietary Manager (CDM) at the time of the observation noted that the thickened milk (both Nectar and Honey) is purchased pre-thickened in 8-ounce…

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

Based on observation, interview, and record review, it was determined that 13 out of 13 facility residents that included Resident #10, Resident #14, Resident #20, and Resident #28, were not being served Fortified Foods (high calorie and high protein) with meals as per Dietitian assessment and attending physician orders. The findings included: Review of the facility's Fortified Food Program noted: The diet is important to ensure that calorie and protein needs are met by serving nutrient dense foods. The goal of the fortified food program is to be able to provide a higher calorie and higher protein food item to residents if the intake of regular foods or beverages are not able to meet estimated nutritional needs. A fortified food program may be used in the nutritional rehabilitation of individuals with poor nutritional status due to prolonged illness, burns, malnutrition, decreased intake of foods or fluids or significant weight loss . Fortified hot cereal at breakfast can be served in place of regular hot cereal or cold cereal .Fortified mashed potatoes can be served 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.

Based on record review and interview, the facility failed to ensure an effective Quality Assessment and Assurance (QAA) committee as evidenced by not implementing corrective plans of action for correcting repeated deficiencies related to labelling and storage of drugs and biologicals, infection control and sanitary food handling. Cross reference F761 Label/Store Drugs & Biologicals; Cross reference of F880 for Infection Prevention and Control and F812 for Sanitary Food Handling. The facility had deficient practice identified at 761 during the last recertification survey with exit date of 04/22/2021. The facility was cited F880 during an infection control survey conducted in 2020 and during the recertification survey with exit date of 4/22/2021. The facility was cited F812 during the recertification survey conducted in 2019 and during the last recertification survey with exit date of 04/22/2021. The facility was also QAA was cited during the last recertification with exit date of 04/22/2021. The findings included: During an interview conducted on 12/15/22 at 1:30 PM with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to have a facility-wide Infection Prevention and Control Program (IPCP) that is current and reviewed at least annually. The facility failed to use appropriate hand hygiene practices when providing catheter care for 1 resident sampled for catheter care (Resident #64) and failed to appropriately use Personal Protective Equipment (PPE) while providing feeding assistance to a resident on isolation precautions for 1 resident sampled for isolation precautions (Resident #50). The findings included: Review of the facility's policy titled Infection Prevention and Control Program with a revised date of October 2018 included the following: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections. The infection prevention and control program is developed to address the facility-specific…

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 1 of 1 resident with an opportunity to be out of bed per resident's preferences. The findings included: On 12/12/22 at 01:48 PM, Resident #50 was observed in bed. The Resident stated that activities had not been around since he has been quarantined. I would love to have a book, but someone would have to read it to me because I can't turn the page. Resident #50, when asked about his understanding of isolation precautions, Resident #50 replied, I don't think that I have COVID, but they won't re-test me. I've had the vaccines and 3 boosters. I haven't had any symptoms of it at all. Resident #50 further stated that he had a wheelchair that staff would put him in, and his personal belongings prior to being moved his current room. Resident #50 stated that the wheelchair was not brought to current room and that he had not been out of bed since being on precautions. Resident #50 clinical records revealed the resident was admitted 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.

Based on observations and record review, the facility failed to implement an accurate care plan for blood pressure management for 1 (Resident #23) out of 21 sampled residents. The findings included: Review of the facility policy titled Medication Holds, dated April 2007 revealed the following: The attending Physician must provide an explicit order as to when to restart a medication that has been held, either at the time the order is given to hold the medication or subsequently. 1) During a medication administration observation opportunity and interview conducted on 12/13/22 for Resident #23's morning medication at approximately 9:40 AM. The Registered Nurse stated that the resident's vital signs had been taken prior to the observation and that the BP (Blood Pressure) was 93/50 and the Registered Nurse gave the ordered Lisinopril for a history of hypertension (high blood pressure). A review of Resident #23's physician orders revealed the order for the Lisinopril had no hold parameters from the physician in regard to low blood pressure. A review of Resident #23's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Record review, interviews, and observations the facility failed to provide an ongoing activities program for 3 (Resident # 259, Resident # 105, and Resident # 50) of 3 residents reviewed for activities, out of the 9 residents that were on isolation precautions. The findings included: The facility's policy, titled Coronavirus (COVID-19) - Resident Visitation, Dining, Activities with Effective date 07/07/20 and most recently revised on 08/26/22, did not address providing activities to residents in their rooms. During an interview, on 12/12/22 at 10:52 AM, Staff O, ADON (Assistant Director of Nursing) /Infection Preventionist when asked about residents that were on precautions, Staff O replied, when they come in from the hospital, we put them on droplet and contact precautions for 10 days, we do the COVID test on day 1 and day 3 and day 5. If they don't have any s/s of COVID after 7 days, we removed them from isolation. We do that because they are not fully vaccinated. During an interview, on 12/12/22 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, the facility failed to prevent new and worsening of pressure ulcers for 1 Resident #309 of 3 residents reviewed for pressure ulcers. The findings included: 1) Resident #309 was investigated as part of complaint investigation #2022017052. In this complaint, it is stated by Resident #309's daughter that she was admitted to the facility with no pressure ulcers and left with multiple pressure ulcers. Resident #309 was admitted to the facility on [DATE] from a different facility. Resident #309 had a medical history significant for dementia, peripheral vascular disease, heart disease, anemia, diabetes. During the initial record review, it was documented in the discharge paperwork from the original facility that Resident #309 was receiving wound care three times per week for bilateral wounds to heels. Resident #309 was discharged from this facility to a different facility on 08/04/22. The admission Minimum Data Set documented that Resident #309 was dependent on staff for all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide appropriate care, properly assess, document, and notify physician of a change in condition in a timely manner for 1 (Resident #64) of 1 resident sampled for catheter care. The findings included: Review of the facility's undated policy titled Notification of Changes included: This facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychosocial status. Review of the facility's undated policy titled Protocol - When to Call the Doctor included the following: A guideline for types of situations which frequently require physician notification are as follows: Bleeding. It is the responsibility of the nursing staff to observe the situation, make an assignment, collect information, and notify the physician when indicated in accord with this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure tube feeding was administered as ordered for 2 (Resident #62, and Resident #94) out of 4 sampled residents reviewed for tube feeding. There were 10 residents residing in the facility with orders for tube feeding at the time of the survey. The findings included: 1. During an observation conducted on 12/12/22 at 10:00 AM, Resident #62 was observed lying in her bed. Upon closer observation, it was revealed that the resident had Jevity 1.5 (formulary type) tube feeding that was started on 12/12/22 at 3:00 AM and was to be infused at 50 milliliters (mls) per hour (hr.) via feeding pump. The tube feeding was at the 950 mark out of a 1,000-milliliter capacity bottle (Photographic Evidence Provided). The tube feeding was not infusing. Record review for Resident #62 revealed that the resident was admitted to the facility on [DATE] with a recent readmission on [DATE], diagnoses included: Dysphagia Following Cerebral Infarction, Other Speech…

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 secure medications at the bedside for Resident #86 and failed to refrigerate medications per facility policy. The findings included: Review of the facility policy titled Medication Storage, dated 03/28/18 revealed the following: Medications and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. Medications shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubical, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Medications requiring refrigeration must be stored in a refrigerator located in the medication room at the nurses' station or other secured location. Review of the pharmacy list titled Medications with Shortened Expiration Dates, undated revealed the following: Latanoprost Ophthalmic Solution-store unopened in refrigerator: Yes; refrigerate once opened: No. 1) During 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, it was determined that the facility failed to provide a nourishing, palatable, well-balanced diet to meet the special needs of 1 (Resident #95) of 1 sampled dialysis resident. The findings included: On 12/13/22 at 9:00 AM, the surveyor was approached by Resident #95 while at the 200/300 Nurses Station. The resident who was alert and oriented times 3 asked if the surveyor would help with his issue with dialysis and his renal diet. Resident #95 stated to the surveyor that he has resided at the facility for the past 7 months and has had continued problems with diet and meals. The resident further stated that he leaves the facility on dialysis days (Mondays, Wednesdays, and Fridays) around 11:00 AM for the dialysis center which is approximately a 1.5-to-2-hour drive in the transport van. The resident was asked by the surveyor if he is given a bagged lunch to take to the dialysis center. The resident he only has been given a bagged lunch once or twice. and the few…

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.