North Port Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and medical record review, the facility failed to notify the resident representative of significant changes for two (Resident #4 and Resident #6) of 4 residents reviewed for significant changes. The findings included: The facility policy issued 5/2017 and revised 6/2023 for Change in Resident Condition or Status - Resident Rights Standard states the facility shall notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. Resident #4 was admitted to the facility on [DATE] from the hospital for rehab after Urinary Tract Infection and Cerebrovascular Accident. Her BIMS (Brief Interview for Mental Status) was 99 which indicates resident not cognitively intact. A skin check dated 3/7/24 in Resident #4's medical record read…

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, review of facility's policy and procedure, resident representative and staff interview, the facility failed to implement their policies and procedures, and immediately address an allegation of staff to resident abuse for 1 (Resident #1) of 3 residents reviewed for abuse. The findings included: Review of the facility's policy, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and injury of unknown origin( ANEMMI) revision 10/2022 noted physical abuse included, Hitting, slapping, pinching, and kicking. The policy listed several criterias, including any resident or family complaint of physical harm, pain or mental anguish resulting from willful infliction from others, will be considered as possible ANEMMI. The policy specified any employee having either direct or indirect knowledge of any event that mighty consitute Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and injury of unknown origin must report the event promptly. Residents will be protected from harm…

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, review of facility's policy and procedure, resident and staff interview, the facility failed to ensure the reporting of an allegation of staff to resident abuse to the State Survey Agency, and Adult Protective Services within the specified timeframe for 1 resident (Resident #1) of 3 residents reviewed for abuse. The findings included: Review of the facility's policy, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and injury of unknown origin( ANEMMI) revision 10/2022 noted, with response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Ensure that all alleged violations involving abuse, neglect . are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse OR result in bodily injury . The facility procedure noted, any and all staff observing or hearing about such events must report the event immediately to the Administrator, immediate Supervisor AND one of the following: Director of Nursing, ANEMMI Prevention Coordinator, or Risk…

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, records review, review of policies and procedures, the facility failed to implement their policies and procedures and accommodate the preferences of 4 (Residents #2, #4, #6 and #7) of 4 residents reviewed for smoking. The findings included: Review of the undated facility's document titled, Resident smoking at North Port Rehab signed by each resident who smokes noted, 1. I agree to follow the smoking schedule set forth by the facility. The times are posted on the door to the door to the courtyard. 2. I agree to follow the policy and procedure on smoking, and I am only allowed to smoke with supervision. 3. I will not smoke outside by myself. 4. I agree to smoke only in the designated smoking area only. 5. I agree I will not smoke in my room. 6. I agree I will not smoke around oxygen. 7. I agree to turn in my cigarettes and lighter or any other smoking materials to the person that is supervising me smoking. 8. I agree not to keep my smoking materials in the room. I understand that if I do 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, staff interviews and facility policy review, the facility failed to prepare food in accordance with professional standards for food service safety. This failure is evidenced by staff having personal drinks, personal phones, and a bucket of sanitizing agent on the food preparation counter during meal preparation. The findings included: Review of facility policy titled Food Storage with an effective date of 1/15/2021 noted, To ensure that all food served by the facility is of excellent quality and safe for consumption, all food will be stored according to the current Federal and State Food Code . Do not use or store cleaning materials or other chemicals where they might contaminate foods . On 10/17/23 at 10:00 a.m., a tour of the meal preparation area of the kitchen was done with Dietary cook/ supervisor Staff B. Staff B said, Sorry about the mess, I am making lunches now. An uncovered container of steamed whole Brussel sprouts, an uncovered container of chopped meat, and utensils were observed on the meal preparation counter. Two personal cell phone, two…

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, staff and resident representative interviews, the facility failed to ensure 1 (Resident #8) of 7 sampled residents was treated with dignity and respect in that the facility failed to ensure the resident was properly dressed when transported to an outside provider's appointment. The findings included: On 10/17/23 at 11:55 a.m., Resident #8 was observed in a reclining wheelchair in the lobby with her sister. She was partially covered with a blanket, and was wearing a long, short sleeved T-shirt. Resident #8's sister lifted the blanket which showed the resident was dressed in a T-shirt and incontinent brief. The shirt was not long enough to cover the brief. She was not wearing any bottoms, socks, or shoes. An orthopedic boot was observed on the resident's right lower leg. Resident #8's sister was visibly upset and speaking to the staff in a loud voice saying, I should call the police. My sister had plenty of warm clothing and you sent her out to the doctor's office with just 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 record review, review of the policies and procedures, observation, and staff interview, the facility failed to evaluate and modify interventions to prevent avoidable accidents for 1 resident (#358) of 1 resident reviewed who was identified as being at risk for falls and sustained multiple falls while at the facility, including a fall resulting in a transfer to the hospital. The findings included: The policy and procedure for managing falls and fall risk stated the staff would identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and minimize complications from falling. The staff will implement a resident-centered fall prevention plan to reduce the specific risk factors for each resident at risk of falls or with a history of falls. The resident-centered approaches to managing fall and fall risk state if a fall recurs despite initial interventions, staff will implement additional or different interventions or indicate why the 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 observation, review of facility policy and procedures and staff interviews, the facility failed to maintain an indwelling catheter in a safe and sanitary manner for 1 (Resident #84) of 1 resident sampled with an indwelling catheter. This has the potential to cause injury and urinary tract infection. The findings included: Facility policy Catheter Care Urinary documented The purpose of this policy is to prevent catheter-associated urinary tract infections. Be sure the catheter tubing and drainage bag are kept off the floor. Review of Resident #84's clinical record showed an admission date of 7/11/22 with diagnoses including obstructive and reflux uropathy (urine is unable to pass through the urinary tract). The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 2/22/23 documented Resident #84 was dependent on staff for toileting needs. The MDS noted Resident #84's cognitive skills for daily decision making were severely impaired. The care plan identified Resident #84 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review and facility policy review the facility failed to review the risk and benefits of bed rails, attempt alternative interventions prior to bedrail installation and failed to have a schedule for routine maintenance for 2 (Resident #68 and #308) of 7 residents reviewed for side rails. The findings included: Review of the facility policy titled Proper use of Side rails issued 09/2022 and last revised 09/2022 guidelines read: A side rail evaluation will be completed to determine the resident's need for using side rails; Alternative options may be trialed and documented prior to implementation of side rails; Side rails may be used if assessment and Interdisciplinary team review has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified; The resident care plan will address the use of side rails when applicable; Facility will follow…

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, clinical record review and staff interviews, the facility failed to administer medications according to physician's orders and manufacturer's specification for 4(Residents #9, #18, #41 and #509) of 5 residents observed for medication administration. Three licensed nurses on the morning shift with 26 opportunities were observed. Eleven medication errors were observed resulting in a 42.31% error rate. The findings included: 1. On 3/27/23 at 9:59 a.m., Registered Nurse (RN) Staff B was observed administering an enteric coated aspirin 81 milligrams (mg) to Resident #18. RN Staff B removed the medication from the bottle and placed it in a clear medication pouch and crushed the tablet. RN Staff B placed the crushed tablet in applesauce and administered the medication to Resident #18. Crushing enteric coated tablets may result in the drug being released too early, destroyed by stomach acid or irritating the stomach lining. 2. On 3/27/23 at 10:05 a.m., RN Staff B was observed administering 3 medications to Resident #41 including a tablet of Amantadine HCL 100 mg RN…

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 staff and family interview the facility failed to implement effective corrective actions to maintain compliance for deficiencies identified during the recertification survey completed on 3/31/23. The findings included: 1. On 5/15/23 at 12:38 p.m., quarter bed rails were observed in the up position for Resident #501, admitted [DATE]. At the time of the observation, Resident #501 said they have been on her bed since admission and said no one discussed the risks vs benefits of side rails with her and she said she did not sign a consent for use of bed rails. Record review revealed no evidence of discussion of risks vs benefits or signed consent. There was evidence of a side rail assessment completed on 5/5/23 that noted rails were not necessary at the time. 2. On 5/15/23 at 1:20 p.m., quarter bed rails were observed in the up position for Resident #502, admitted [DATE]. At the time of the observation, Resident #502's husband said the rails have been on the bed since admission…

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

Based on record review, review of facility policy and procedure, staff and resident interviews, the facility failed to accommodate the preference for morning showers for 1(Resident #4) of 26 residents sampled for activities of daily living (ADL'S). The findings included: The facility policy Activities of Daily Living, (revised 3/18) specified Residents will be provided with care, treatment and services as appropriate to maintain or improve good nutrition, grooming and personal hygiene . Interventions to improve or minimize a resident's functional abilities will be in accordance with the residents' assessed needs, preferences, stated goals and recognized standards of practice. Review of the clinical record revealed Resident #4 had an admission date of 7/22/22 with diagnoses including dementia, anxiety, major depressive disorder, and weakness. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 1/25/23 documented Resident #4 required extensive assistance with transfers, personal…

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 review of the clinical record, review of facility policy and procedures and resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 1(Resident #96) of 26 residents reviewed for activities of daily living (ADL's). The findings included: The facility policy Activities of Daily Living, (revised 3/18) specified Residents will be provided with care, treatment and services as appropriate to maintain or improve good nutrition, grooming and personal hygiene. Review of the clinical record revealed Resident #96 had an admission date of 3/7/23 with diagnoses muscle weakness, need for assistance with personal care, chronic pain, falls, and atherosclerotic heart disease. The admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 3/7/23 documented Resident #96 was dependent on staff for bathing. The MDS noted Resident #96's cognitive skills for daily decision making was intact. The plan of care initiated on 3/8/23…

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, observations, staff and resident interviews, the facility failed to ensure 3 (Residents #14, #458 and #459) of 3 dependent residents reviewed for those residents who attend activities, maintained and/or improved their psychosocial well-being and independence. The findings included: On 3/27/23 review of the Director Recreational Therapy job duties stated they were required to plan, direct, and coordinate recreation-based treatment programs to help maintain or improve a patient's physical, social, and emotional well-being. They were required to oversee day-to-day activities of residents, initiate, and promote activities within the facility and stimulate patient interests and well-being, regulate programs in accordance with the patient capabilities, and maintain all activity related records of activity assessment, progress notes, and discharge summary. 1. Review of Resident #14's medical record revealed his original admission to the facility was 3/26/2019 with a readmission on [DATE]. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interview, the facility failed ensure 1 (Resident #75) of 2 sampled residents received prompt assistance to repair broken glasses to maintain vision ability. The findings included: Clinical record review revealed Resident #75 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] noted the resident used corrective lenses. On 3/28/23 at 1:49 p.m., Resident #75 said she uses bifocal corrective lenses. She said, I can't see without them. I need them to look at my phone. The resident explained a while ago, one arm broke after a staff member rolled her to her side. The staff person tried to glue it together. The arm broke again. The resident said she's been using the glasses with one arm. Resident #75 said a Certified Nursing Assistant (CNA) rolled her over yesterday afternoon. She did not take off her glasses quickly enough and the other arm broke completely. The CNA just took the broken glasses and placed them 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.

Based on observation, record review, resident and staff interview the facility failed to follow physician's orders for oxygen therapy for 3 (Resident #8, #17, and #23) of 4 residents reviewed for oxygen administration. Failure to follow prescribed oxygen therapy may result in inadequate oxygen treatment or an increased risk of side effects and complications. The findings included: 1. Review of the clinical record for Resident #8 revealed an admission date of 2/3/23. The admission Minimum Data Set (MDS) assessment with a target date of 2/7/23 revealed Resident #8 scored a 13 on the Brief Interview for Mental Status, indicative of intact cognition. Resident #8's diagnoses included lung disease, chronic obstructive pulmonary disease, and respiratory failure with hypoxia (low level of oxygen). The physician's orders included Oxygen at 2 liters per minute via nasal cannula every shift. On 3/27/23 at 11:10 a.m., Resident #8 was observed lying in bed, the oxygen (O2) was set at one and half liter (L) per minute via nasal cannula (n/c). Resident #8 stated she uses O2 at home at 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.

Based on record review, policy review and staff interviews, the facility failed to ensure medication irregularities and/or concerns were addressed in a timely manner when the consulting pharmacist identified irregularities and/or medication concerns, for 1 (Resident #14) of 5 resident's medication regimen reviewed. The findings included: On 3/30/23 review of Resident #14's medication regimen revealed he was receiving Gabapentin capsule 100 mg, 2 capsules, by mouth 3 times a day for neuropathy. Gabapentin was used to prevent and control seizures and relieve nerve pain. Some of the common side effects listed with the administration of Gabapentin were drowsiness, dizziness, fatigue, loss of coordination. Review of Resident #14's medical record revealed he had 2 unwitnessed falls on 11/15/22 and 11/17/22 and 1 witness fall on 11/6/22. On 12/12/22 the Consultant Pharmacist identified a potential medication concern stating Resident #14 was currently receiving Gabapentin which had the potential for dizziness and drowsiness and increased the risk of falls. Review of Resident #14's clinical…

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 staff and resident interview, the facility failed to ensure 1 (Resident #75) of 1 resident received timely dental treatment to maintain her ability to chew. The findings included: Resident #75 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Diabetes, Hypertension, Anemia, Congestive Heart Failure, and dependence on oxygen. Section B of the Quarterly Minimum Data Set, dated [DATE] indicated the resident had no dental problems. The Brief Interview of Mental Status (BIMS) was a level 6, which meant severely impaired cognition. The clinical record review noted Resident #75 had a dental consult ordered for right cheek pain on 3/2/23. She is a Medicaid recipient. On 3/28/23 at 9:21 a.m., Resident #75 stated she does not recall seeing the dentist but has mouth pain when chewing on the right side. She has been chewing on the left side. On 3/29/23 at 11:55 a.m., the Social Services Director (SSD) stated she contacted the dental provider 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.

Based on observation, record review, and staff interview, the facility failed to conduct regular inspection of all bed frames, mattresses, and side bed rails, as part of a regular maintenance program to identify areas of possible entrapment. The findings included: On 8/26/21 at 10:00 a.m., the Director of Nursing (DON) said the facility staff conducted a facility wide side rail audit to determine how many facility beds had side rails attached, how many residents had side rails on the bed, and which resident had orders for the use of the side rails. She said they currently had a resident census of 80, with 41 facility beds with side rails attached and 38 residents evaluated for the use of the side rails which was confirmed via a tour of the facility. On 8/26/21 review of the facility's Bed Maintenance and Inspection policy dated 11/2017, #5 stated, bed frame, mattress, and bed rail inspections will be conducted upon each item entering the facility and then place on a regularly scheduled inspection and maintenance cycle according to the manufacture's recommendations, to include…

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, resident and staff interview, and record review, the facility failed to provide a safe, sanitary, and homelike environment as evidenced by dry wall damage in resident's rooms, broken and missing floor tiles, discolored floor tiles, dusty bathroom vents, missing and/or discolored caulking around the base of the toilets in the resident's room. Failure to identify and complete needed repairs could cause safety and sanitary hazards to vulnerable residents. The findings included: On 8/23/21 an environmental tour was conducted at approximately 9:00 a.m., and the following resident's room and facility damages were noted: 1. Rooms 150 to 170, the floor tiles were discolored with a thick wax build up on the bathroom tiles. The vent in the bathrooms had a thick layer of dust. 2. rooms [ROOM NUMBERS] had missing floor tiles. 3. room [ROOM NUMBER], the drywall behind the window bed was damaged and part of the caulking around the base of the toilet was missing and discolored. 4. room [ROOM NUMBER], the…

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

Based on observation, interview, and record review, the facility failed to ensure 1 (Resident #55) of 2 residents reviewed for activities of daily living for grooming had nail care completed in a timely manner. The lack of routine grooming could affect a resident's psychosocial well-being and the prevention of infection. The findings included: On 8/24/21 at 10:04 a.m., observed Resident #55 in bed with her feet exposed. This observation revealed, all of Resident #55's toenails were long, discolored, and thick. The right foot big toenail and 4th toenail extended approximately ½ inch from the base. The left foot big toenail extended ½ inch and curved at a 90-degree angle to the toe. On 8/26/21 review of the facility policy titled, Care of Fingernails/Toenails version 1.2, stated the purpose of this procedure was to clean the nail bed, to keep nails trimmed, and to prevent infections. Under the General Guidelines it stated nail care included daily cleaning and regular trimming. The staff were to report any changes in color of the skin around the nail bed, blueness of the nails, any…

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, staff interviews, and facility policy review, the facility failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 2 residents (Resident #4 and #17) of 3 residents reviewed for bed rails. The findings included: 1. Review of facility policy titled, Proper Use of Side Rails revised December 2016 which stated, The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. And The use of side rails as an assistive device will be addressed in the resident care plan. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. On 8/23/21 at 10:00 a.m., Resident #4 was observed in bed asleep, with elevated side rails in use on both sides of his bed. On 8/24/21 at 10:47 a.m., Resident #4 bed observed with side rails elevated. On 8/25/21 at 8:41 a.m., Resident #4 observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and procedure and staff interviews, the facility failed to assure the facility's medication cart was locked and under direct observation of authorized staff in an area where residents and staff could access it for 1 of 2 medication carts reviewed. The findings included: Review of facility policy titled, Medication Storage in the Facility, dated April 2018, stated in policy section, Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. On 8/24/21 at 3:17 p.m., medication cart C was observed unlocked and unattended with drawers facing hallway by resident room [ROOM NUMBER]. Two residents were observed independently moving via wheelchairs in hallway near cart while unattended. On 8/24/21 at 3:23 p.m., observed Licensed Practical…

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.