Luxe At Jupiter Rehabilitation Center (the)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly administer oxygen therapy for 2 of 2 sampled residents, as evidenced by failure to ensure proper physician orders for oxygen use for Resident #302, and that the prescribed physician order for oxygen was followed for Resident #54. The findings included: Review of the Policy titled, Standards and Guidelines for Oxygen Administration revised 12/2023, documented, in part, Oxygen therapy is administered by way of an oxygen mask, cannula or other device per physicians' orders with the appropriate flow of oxygen. 1) Observations of Resident #302 from 03/31/25 to 04/03/25 revealed that the resident is on oxygen by nasal cannula. The setting of his oxygen is set at 4.5 LPM (liters per minute). A review of Resident #302's records revealed Resident #302 was admitted to the facility on [DATE] with diagnoses to include COPD (Chronic Obstructive Pulmonary Disease) with Acute Exacerbation, Chronic Respiratory Failure with Hypercapnia, Dependent…

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 an assessment and an order for side rails for 1 of 1 sampled resident reviewed for side rails (Resident #302). The findings included: Observations were made from 03/31/25 to 04/02/25 of Resident #302's bed. He has 2 metal side rails up on the right side and 1 metal side rail up on the left side. On 04/02/25-04/04/25 observations were made of a larger bed in Resident #302's room with 1 side rail up on each side of the bed by the head of the bed. A review of Resident #302's records revealed Resident #302 was admitted to the facility on [DATE] with diagnoses to include Visual Loss, Hypertension, Type II Diabetes Mellitus, Unspecified Delirium, and COPD (Chronic Obstructive Pulmonary Disease). A review of the admission Assessment for bed rails dated 03/18/25 documents that side rails are not needed. There was no Physician Orders or documentation on further assessing the resident for side rails. During an interview on 04/04/25 at 4:40 PM…

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, policy review and interview the facility failed to obtain an ordered laboratory result for a medication (Depakote) for 1 of 1 sampled Resident (Resident #61). The findings included: The facility policy titled, Standards and Guidelines: Physician's Orders, revised on 01/2024 documented in part: Physician orders should be followed as prescribed, and if not followed, this should be recorded in the resident's medical record during that shift. The physician should be notified and the responsible party if indicated. Resident #61 was admitted to the facility on [DATE] with diagnoses to include in part Hypertension, Major depressive disorder, Congestive heart failure, Atrial fibrillation, Anemia, Protein calorie malnutrition and a brief psychotic disorder. On 11/27/24 Resident #61 was ordered 750 mg Depakote Sprinkles by mouth two times a day for mood disorder. The order was changed on 02/13/25 to read Depakote 500 mg 1 tablet two times a day for mood disorder. The facility has a pharmacist…

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 honor food preferences for 5 of 10 sampled residents, Residents #27, #29, #44, #50, and #85, who had food complaints, as evidenced by the failure to follow the meal ticket and menu. The findings included: 1) Review of the record revealed Resident #27 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale. Review of a dietary progress note dated 02/04/25, documented in part, Resident #27 would like to update her food preferences, to include a chef garden salad with ranch dressing as an entree every Monday, Wednesday, and Friday. A subsequent progress note dated 02/18/25 documented the resident was happy with the updated food preferences. Review of a dietary assessment by the Registered Dietitian (RD) on 02/27/25 revealed the resident now had wounds and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses. This had the potential to affect 111 of 112 residents on PO (by mouth) diets. The findings included: A. During the initial tour of the Main Kitchen on 03/31/25 at 9:15 AM, accompanied by the Kitchen Manager and the Regional Manager of Dietary, the following was observed: 1. The [NAME] microwave had light and dark brown debris on all sides of the interior of the microwave. The kitchen managers agreed with this finding and said they will clean it up right away. 2. To the right of the coffee station, 2 recessed circular insets were dirty. One had brown liquid on the bottom. The Kitchen Manager wiped it out. The plastic utensil holder close to the round insets had brown residue on the top and spots of black powdery residue. 3. The 2 [NAME] double-door ovens had black…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and clinical record review, the facility failed to ensure that residents who are unable to carry out their activities of daily living to maintain personal hygiene, grooming, mobility are provided the necessary care and services in a timely manner. The facility also failed to maintain accurate documentation of the care and services that are provided. This failure affected 3 of 6 sampled residents (Resident #1, #5 and a confidential random resident). The findings included: 1) Review of the clinical record for Resident #5 revealed that the resident was admitted to the facility on [DATE] with diagnoses which included, Dysphasia following Cerebral Infarction, Pneumonitis following ingestion of other solids and liquids, Acute Respiratory Failure, Sepsis, Cardiac Arrest due to other underlying conditions, Gastrostomy, Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side and Metabolic Encephalopathy. Review of the 03/04/25 plan of care revealed that 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, policy review and interview, the facility staff failed to report an allegation of neglect for 1 of 2 sampled residents reviewed for neglect (Resident #2). The findings included: Review of the facility policy titled, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) revised on 01/2024 documented the following: Standard: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. Reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property and mistreatment, collectively known and referred to as ANEMMI and hereafter defined, will not be tolerated by anyone, including staff, residents, volunteers, family members, legal guardians, resident representatives, friends or any other individuals. The Health Center Administrator is responsible for assuring that Residents' Rights of personal privacy,…

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, policy review and interview, the nursing staff failed to implement the facility policy for the storage of nebulizer equipment. The failure affected 1 of 6 sampled residents (Resident #1). The findings included: Record review revealed the facility's policy titled, Respiratory Treatment Administration, last revised 12/2023 documented Nebulizers are administered per physician's orders and nebulizer tubing is stored in a hygienic manner (i.e. labeling bag with date tubing was change). Additional guidelines: Report other information in accordance with facility policy and professional standards of practice. Observation of care conducted on 01/22/25 starting at 9:10 AM revealed Resident #1 was lying in her bed. A nebulizer machine was observed on the nightstand, the nebulizer mask was dirty, stained with yellow substance, and it was inside a plastic bag from a grocery store with a bread label. The mask was connected to the nebulizer machine. The resident's spouse informed the surveyor that the staff does not change the mask and that he put it inside 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 notify 1 of 8 sampled resident representatives of a change in condition and treatment (Resident #5). The findings included: Review of the record revealed Resident #5 was admitted to the facility on [DATE]. Review of the profile page revealed the specified family member of Resident #5 was the resident's first emergency contact. Review of the current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had a Brief Interview of Mental Status (BIMS) score of 6, on a 0 to 15, indicating the resident was cognitively impaired. Further review of the record revealed a documented change in condition as of 09/09/24 of malaise (a vague feeling of discomfort) and poor appetite, with orders for laboratory work to include a urinalysis. The area on this change in condition form where the resident representative was to be notified was left blank. Review of the progress notes lacked any notification to the resident representative. Review of the urinalysis…

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 policy review, observation, and interview, the facility failed to ensure a safe and functional environment as evidenced by the failure to maintain 4 of 6 Soiled Utility/Holding (biohazard) rooms secured (1E, 1W, 3E and 3W); failure to maintain 1 of 6 housekeeping areas secured (1W); failure to ensure 1 of 6 (2W) emergency exits of the residential areas secured; failure to ensure 2 of 2 observed oxygen tanks were secured; and failure to provide documented evidence of timely repairs for 4 of 4 resident toilets. The findings included: Review of the policy Oxygen Storage revised 12/2023 documented, General Guidelines: . 3. Oxygen Tanks should no be left free standing, as per facility protocol. 1) During a facility tour on 09/30/24 beginning at 10:47 PM, the following was observed with photographic evidence obtained: a) At 11:00 PM the housekeeping door on 1W was propped open with a crushed water bottle. Inside the room was a mop bucket full of dark brown/black water and a gallon jar of cleaning solution labeled Danger Peligro. b) At 11:14 PM the Soiled Utility/Holding door 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 record review, incident review, and interview, the facility failed to ensure a complete and thorough investigation for 1 of 2 sampled residents with an allegation of neglect, as evidenced by a lack of written statements from all staff involved in the incident and contradictions during staff interviews regarding the incident with Resident #1 on 09/04/24. The findings included: Review of the record revealed Resident #1 was admitted to the facility on [DATE] and transferred out to the hospital on [DATE], after dislodgement of the resident's Peripherally Inserted Central Catheter (PICC/intravenous access through a vein in the arm and threaded into a large vein near the heart). A change in condition form and progress note, both dated 09/04/24 at 7:15 PM but created eight days after the event on 09/12/24 by the Assistant Director of Nursing (ADON), simply documented the PICC line was noted on the floor with a small quantity of blood on the floor, sheets and adjacent to the IV site on the resident's right arm.…

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, incident review, and interview, the facility failed to ensure sufficient staffing, as evidenced by the lack of timely response to needed PICC (Peripherally Inserted Central Catheter) line dislodgment care for 1 of 2 sampled residents with an IV (intravenous) line (Resident #1); and as evidenced by numerous verbal and written complaints. The findings included: 1) Review of the record revealed Resident #1 was admitted to the facility on [DATE] and transferred out the hospital on [DATE], after dislodgement of the resident's Peripherally Inserted Central Catheter (PICC/intravenous access through a vein in the arm and threaded into a large vein near the heart). Review of the Medication Administration Record (MAR) revealed the IV antibiotic Invance 1 gram was started at 5:33 PM by Staff C, RN, who was the assigned direct care nurse for Resident #1 on 09/04/24 during the day shift. Review of the PPD Detail Report, that documented when staff clock in and out, revealed Staff C had clocked out 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 record review and interview the facility failed to ensure food preferences for 2 of 3 sampled residents (Residents #7 and #8). The findings included: 1) Review of the record revealed Resident #7 was admitted to the facility on [DATE]. During an interview on 10/02/24 at 11:09 AM, the resident stated some of the food is just about inedible and unable to recognize. When asked if she could get an alternate meal upon request, the resident stated, I eat the PB&J (peanut butter and jelly) and tuna sandwiches, but they haven't had any tuna now for the past couple of weeks. When asked how she knows what is on the menu for that day, Resident #7 stated I have to look at the menu on the wall. During an observation and interview on 10/02/24 at about 2:00 PM, when asked if there has been an issue providing tuna sandwiches over the past two weeks, the Kitchen Manager stated he had plenty of tuna and showed the surveyor a partial case of restaurant sized can tuna. When told Resident #7 was informed by direct care staff…

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 policy review, observation, and interview, the facility failed to maintain an infection control program as evidenced by the failure to initiate and maintain Enhanced Barrier Precautions (EBP) for 4 of 4 sampled residents (Resident #1, #6, #7 and #8) The findings included: Review of the policy titled,Enhanced Barrier Precautions, revised 05/28/24 documented, Procedure: 1. Enhanced Barrier Precautions (EBP) are used for resident with any of the following: . b. Wounds and/or indwelling medical devices even if the resident is not known to be colonized with MDRO (multidrug-resistant organisms). 9. Appropriate PPE for EBP would include: a. Gown. b. Gloves. 10. Employees should wear appropriate PPE when performing the following duties for residents requiring EBP: a. Dressing b. Bathing/Showering c. Transferring d. Providing hygiene e. Changing soiled linens f. Providing pericare such as changing briefs g. Toileting h. Device care i. Wound care 1) Review of the record revealed Resident #1 was admitted to the…

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

Based on record review, policy review and interview, the facility staff failed to immediately report an allegation of abuse involving 1 of 2 sampled residents (Resident #1). The findings included: Review of the facility policy titled, Grievances, last revised 06/2023, documented The Grievance Officer will coordinate actions with the appropriate state and federal agencies depending on the nature of the allegations. all alleged violations of neglect, abuse and or misappropriation of property will be reported and investigated under guidelines for reporting abuse and neglect, as per state law. Review of the facility policy titled, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment and Injury of Unknown Origin (ANEMMI), last revised 10/2022 documented the following: Reporting and Response: All allegations of possible ANEMMI will be immediately reported to the abuse hotline by the Administrator or Designee and will be evaluated to determine the direction of the investigation Alleged violations are reported immediately, but not later than 2 hours after the allegation is made, if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a urinary catheter was secured to prevent excessive tension of the tubing; failed to provide catheter care following infection control practices to minimize complications; and failed to provide a privacy bag to promote the resident's privacy. The failure affected 1 of 2 sampled residents reviewed for urinary catheter care. (Resident #4) The findings included: Review of the facility policy titled, Catheter Care dated 01/2024 documented, The facility will maintain infection control guidelines related to catheter care use and catheter care to minimize catheter associated infections. Routine hygiene and care of the peri area is appropriate when providing incontinence care and bathing. Center of Disease Control (CDC) recommends maintenance and catheter care essentials: · Use appropriate hand hygiene and gloves · Properly secure catheters to prevent movement and urethral traction · Maintain a sterile closed drainage system · Maintain good hygiene at 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, it was determined, the clinical staff failed to complete an assessment after a resident sustained an injury; failed to obtain and report all pertinent information to the provider to ascertain the best course of treatment; failed to complete an incident report after the injury was reported by the resident; and failed to complete an investigation to determine if the resulting injury, a fractured wrist, met the criteria for an adverse event. These failures affected 1 of 3 sampled residents (Resident #1). The findings included: Clinical record review revealed Resident #1 was admitted to the facility for rehabilitation services on 02/10/24. Review of the Fall risk assessment dated [DATE] revealed the resident was assessed at high risk with a score of 12 (a score greater than 10 deems the individual as high risk). Review of the Minimum Data Set admission assessment with reference date 02/13/24 documented the resident was assessed as independent for skills of daily decision making;…

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 follow their grievance policy related to: 1) Medication concerns for 1 of 29 sampled residents (Resident #28); and 2) Food concerns for 17 out of 29 sampled residents (Resident #21, #289, #287, #31, #4, #67, #285, #59, #292, #186, #290, #69, #291, #294, #44, #15, and #11). The findings included: The facility's Grievances/Complaint, Filing Policy (2001 Med-Pass, Inc., Revised April 2017) states: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g. the State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Policy Interpretation and Implementation 3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such…

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 notify the Power of Attorney (POA) for 1 of 1 sampled resident reviewed for notification of change. The notification of change was related to Resident #28's change in medications. The findings included: Per Residents Rights [42 CFR 483.10], the facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law. The resident has the right to be informed of, and participate in, his or her treatment, including: The right to be informed, in advance, of changes to the plan of care. Record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's, Major Depressive Disorder, and Dementia. According to Minimum Data Set assessment completed on 09/29/23, Resident #28 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. Because 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the Facility failed to ensure the Power of Attorney for 1 of 11 sampled residents' was notified of and included in the Resident's Care Plan Meetings (Resident #28). The findings included: Per Residents Rights [42 CFR 483.10], the facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law. The resident has the right to be informed of, and participate in, his or her treatment, including: The right to be informed, in advance, of changes to the plan of care. Resident #28 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's, Major Depressive Disorder, and Dementia. According to Minimum Data Set assessment completed on 09/29/23, Resident #28 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. Because of Resident #28's cognitive issues, she was not able to make…

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 wound care dressing changes for 1 of 2 sampled residents reviewed for wound care, Resident #33. The findings included: The facility policy, titled, Steps for Clean Dressing Change, and undated, documented, in part: addresses step by step how to perform a dressing change. The final step is 19 which reads, 'document in chart as needed.' Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: Type 2 Diabetes Mellitus with Diabetic Neuropathy, Charcot's joint left ankle and foot, Peripheral Vascular Disease, Ankylosis left ankle, Hypertensive Heart Disease, Major Depressive Disorder, presence of other orthopedic joint implants and Cardiac Pacemaker. Review of the Minimum Data Set (MDS) assessment of 08/22/3 documented the resident to have a Brief Interview for Mental Status (BIMS) of 15, indicating cognition was intact. Review of the care plans documented the resident had cellulitis of left foot and 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 Based on observation, record review, interview, and policy review, it was determined, the facility staff failed to provide care and services to minimize complications for a resident with a gastronomy tube during medication administration. The failure affected 1 of 1 sampled resident (Resident #141). The findings included: Medication administration observation conducted on 12/05/23 starting at 10:22 AM revealed Staff A, a Registered Nurse, preparing medications for Resident #141. Staff A prepared two medications, Pepcid and Vimpat, crushed the medications separately and entered the room. The resident was sitting up in a chair and the tube feeding was off. Staff A then explained she needed to check for Gastronomy Tube (G Tube) placement and grabbed her stethoscope, listen to the resident's bowel sounds, then with her hands pressed down on the resident's abdomen. The staff then attached the syringe to the G Tube and poured thirty millimeters of tap water, then proceeded to administer the medications and flushed 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 policy review, record review and interview, the facility failed to ensure licensed nurses were able to demonstrate competency related to the acquisition and provision of medication administration. The failure affected 1 of 6 sampled residents (Resident #27). The findings included: Facility policy titled Medication Shortages/Unavailable Medications, not dated documents the following: When medications are not received or are unavailable for the customers, the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy provider. PROCEDURE If a medication shortage is noted at the time of medication administration (Med-pass), the licensed nurse or certified medication assistant must immediately initiate action to obtain the medication and not wait until the med pass is completed. B. If a medication shortage is noted during normal pharmacy hours: 1. A licensed nurse notifies the pharmacy and speaks to a registered pharmacist to determine the status of the order.…

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, policy review and interview, the facility staff failed to ensure antibiotic prescribing criteria includes clinical signs and symptoms, laboratory reports and appropriate monitoring to protect residents from harm caused by unnecessary antibiotic use, and to combat antibiotic resistance. The failure affected 1 of 6 sampled residents (Resident #27). The findings included: Clinical record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including Leukemia and Malnutrition. Review of the Minimum Data Set, admission assessment with reference date of 11/18/23 documented the resident was assessed as moderately impaired for skills of daily decision making; exhibited no behaviors, has an urinary catheter and is receiving oxygen therapy. Review of the Care Plan dated 11/17/23, titled revealed, The resident has a risk for injury/infection related to the presence of supra pubic catheter secondary to a diagnosis of neurogenic bladder, obstructive uropathy and prostate…

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 accurate documentation of medication removal and administration between the medication administration records (MARs) and the medication monitoring control record for 3 of 4 residents Residents #196, #200 & #147. The findings included: On 08/11/22 at 11:38 AM during the medication storage review process on the second floor, two residents were selected for narcotic medication reconciliation. The August 2022 MARs were compared against the medication monitoring control record for Resident #196. There were discrepancies between the records. It was revealed Resident #196 was on Alprazolam 0.50 mg once daily as needed. The medication monitoring control record documented for the removal of the medication on 8/1 at 9:47 PM, but this removal was not documented in the August 2022 MARs. Furthermore, the August 2022 MARs documented the administration of this medication on 8/2 at 12 AM, but the medication monitoring control record was not documented to reflect this removal. In addition, the medication monitoring control record…

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 maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. Staff J, a Certified Nursing Assistant (CNA) failed to ensure hand hygiene between residents, during the lunch meal tray delivery on 08/08/22 for 1 of 4 units (second floor west), affecting Residents #22, #198, #199, #91, #150, #92, #151, and #152. Staff K, a CNA, failed to don a gown and or ensure hand hygiene during COVID-19 testing for 2 of 5 residents (Resident #196 and Resident #149, also affecting Resident #22). The record lacked evidence of the prompt provision of Transmission Based Precautions (TBPs) and prompt monitoring for signs and symptoms of worsening COVID-19 for 1 of 3 sampled residents reviewed with the Sars-CoV-2 (COVID-19) virus (Resident #144). Staff L, a Licensed Practical Nurse (LPN) failed to maintain infection prevention and control processes for 1 of 2…

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 manufacturer's instructions, Staff K, a Certified Nursing Assistant (CNA) failed to follow instructions for the COVID-19 antigen tests for 4 of 4 sampled residents (Resident #196, #149, #22, and #199). The findings included: Review of the [NAME] BinaxNOW COVID-19 Ag Procedure Card documented after obtaining the nasal sample and placing the swab in the test card, Close and securely seal the card. Read result in the window 15 minutes after closing the card. IN order to ensure proper test performance, it important to read the result promptly at 15 minutes, and not before. An observation of resident COVID-19 testing of residents was made on 08/10/22 beginning at 8:55 AM. Staff K, a CNA, obtained a nasal sample from Resident #196, placed the swab in the testing card, and at 9:04 AM she read the results as negative and threw away the sample in the red bag. On 08/10/22 at 9:04 AM, Staff K obtained a nasal sample from Resident #149. At 9:06 AM the CNA put the swab into the card 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, interview, record review and policy review, the facility failed to ensure resident choices are honored for 2 of 4 sampled residents. Resident #93 was not transferred back into bed in a timely manner, per her request, on two different occasions (08/06/22 and 08/10/22). Resident #93 was not offered and did not receive showers as per the facility schedule or as per her choice. Resident #94 was placed on contact precautions unnecessarily. The findings included: 1) During an interview on 08/09/22 at 9:26 AM, Resident #93 and her adult daughter explained Resident #93 was recently paralyzed from the waist down because of blood clots that were found on her spine. They explained the resident was at the facility for therapy and then long-term placement as she can no longer care for herself. They explained the resident could no longer walk and that the staff had to use a Hoyer lift (a mechanical device requiring two persons to safely lift a resident from one surface to another) for transfers. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure dressing changes for non-pressure ulcers were done as per physician order for 1 of 3 residents reviewed for skin condition (Resident #142). The findings included: During an interview on 08/08/22 at 2:55 PM, with Resident #142, she stated that no one has changed her bandage on her left leg since 08/04/22, it is weeping through the bandage. She stated that she told someone last week and they said the wound care person was coming in. I saw him across the hall, but he did not stop to see me and change it. The date of the bandage is 08/04/22. (Pphotographic evidence obtained.) Record review for Resident #142 revealed she was admitted to the facility on [DATE] with a diagnosis to include cellulitis of left lower limb. Her MDS (Minimum Data Set, dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of a 15, which means her cognition is intact. Further review of the MDS documents under skin condition applications 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the facility failed to ensure proper Foley catheter (indwelling urinary drainage device) care and services for 2 of 3 sampled residents. Staff failed to ensure proper catheter care for Resident #93. The tubing for the urinary catheters for both Residents #93 and #98 lacked anchoring, used to prevent urinary infections. The findings included: Review of the policy Catheter Care, Urinary dated January 2022 documented, Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Changing Catheters: . 2. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) This policy further describes the steps in providing catheter care to include cleaning of the resident with soap and water, then using a clean washcloth with warm water and soap to cleanse and rinse the catheter from the insertion…

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 proper respiratory care and services for 2 of 2 sampled residents (Residents #91 and #96). The nurse failed to stay with and monitor Resident #91 during a respiratory treatment via nebulizer, then failed to properly clean the nebulizer equipment after use. The oxygen tubing for the concentrator and nebulizer for Resident #96 was not changed for two weeks as per physician order. The findings included: Review of the policy Administering Medication through a Small Volume (Handheld) Nebulizer, revised January 2022 documented, Purpose: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Steps in the Procedure: . (after setting up of the medication) . 15. Remain with the resident for the treatment. 16. Monitor for medication side effects, including rapid pulse, restlessness and nervousness throughout the treatment. 17. Encourage the resident…

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

Based on observations, the facility failed to ensure garbage and refuse were disposed of properly. The findings included: During a kitchen tour on 08/08/22 at 7:55 AM, with the Dietary Manager, it was observed around the outside of the cardboard dumpster, boxes, dirty masks, plastic containers, wood strip, plastic strip, and debris on side of dumpster. By the second dumpster, a dirty glove was observed laying in the street by the sidewalk. On 08/11/22 at 6:50 AM, a secondary tour of the dumpster was completed with the Regional Certified Dietary Manager (CDM), two dirty gloves observed laying on the ground by the dumpster. Photographic evidence obtained.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure accurate documentation related to self/family administration of medications for Resident #31, 1 of 6 sampled residents reviewed for medications. The findings included: During an interview on 08/08/22 at 10:50 AM, with the spouse of Resident #31, she stated she had concerns that the facility was not giving her husband his medications in a timely manner and because of that she is having to administer them herself. A review of Resident #31's electronic records revealed the resident was admitted to the facility on [DATE] with a readmission from hospital on [DATE] with a diagnosis to include Parkinson's Disease, Orthostatic Hypotension, Spondylosis, Spinal Stenosis, Respiratory Failure, Benign Prostatic Hyperplasia, Nonrheumatic Aortic Stenosis, Muscle Weakness and Difficulty Walking. Review of his MDS dated [DATE] reveals he has a BIMS of 15, which means he is cognitively intact. A review of his Care Plans dated 08/08/22 reveals that he has a 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.