Childrens Comprehensive Care Center INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and observation, the facility failed to provide enteral feedings per physicians' orders for 2 of 2 sampled residents, Resident #10 and Resident #2, reviewed for enteral feeding (tube feeding). This has the potential to affect 26 residents who had orders for enteral feedings. The findings included: Review of The American Society for Parenteral and Enteral Nutrition (ASPEN) Safe Practices for Enteral Nutrition Therapy (Journal of Parenteral and Enteral Nutrition, Volume 41, Number 1, January 2017 15-103. DOI: 10.1177/0148607116673053) was conducted. ASPEN recommends the inclusion of critical elements in tube feeding orders. The critical elements include the patient's name, the name of the formula, the delivery site, the administration method and rate, and the volume per feeding or total volume per day. The development of nurse-driven protocols for volume-based feeding was recommended.1. Record review revealed Resident #10 was admitted to the facility on [DATE], with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to obtain orders for respiratory care including suctioning and trach care for 2 of 2 sampled residents reviewed for respiratory, Residents #4, and #28. The findings included:According to the website: https://www.ncbi.nlm.nih.gov/books/NBK593189/#:~:text=In%20emergent%20situations%2C%20a%20provider,used%20for%20suctioning%20mouth%20secretions the following in part was included: In emergent situations, a provider order is not necessary for suctioning to maintain a patient's airway. However, routine suctioning does require a provider order. 1. Record review for Resident #4 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnoses that included in part the following: Cerebral Palsy, Dependence on Respirator (Ventilator) Status, Tracheostomy Status, Cleft Palate, Other Apnea of Newborns, and Myotonic Muscular Dystrophy. The Minimum Data Set (MDS) assessment dated [DATE] documented in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor for behaviors and side effects for residents receiving psychotropic medications for 3 of 28 sampled residents receiving psychotropic medications, Residents #25, #13, and #5. The finding included:1. Record review revealed Resident #25 was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Tracheostomy Status, Dependence on Respiratory (Ventilator) Status, and Other Epilepsy and Recurrent Seizures. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented in Section C a Brief Interview of Mental Status was not conducted due to the resident is rarely/never understood. Review of the physician's orders for Resident #25 revealed an order dated 03/23/26 for Diazepam (a psychotropic medication) oral solution 5 MG\/5ML Give 3 ml via J-Tube three times a day. Review of the record for Resident #25 for the month of April 2026, including the Medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow infection control protocol as evidenced by not properly wearing Personal Protection Equipment (PPE) during tracheotomy care for 1 of 2 sampled residents reviewed for tracheotomy, Resident #13; and failed to ensure that it practiced appropriate hand hygiene while dispensing medications for 1 of 6 sampled residents reviewed during medication administration observation, Resident #1. The findings included:1. Record review for Resident #13 revealed the resident was admitted to the facility on [DATE] with a re-admission on [DATE] with diagnoses that included: Anoxic Brain Damage, Dependence on Respirator [Ventilator], Tracheostomy Status, Gastrostomy Status, Sepsis due to Serratia (bacteria), Lobar Pneumonia, Unspecified Organism, and Pulmonary Mycobacterial Infection. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 is dependent on staff for all Activities of Daily Living (ADLs).During an afternoon tour of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to follow their own policy for labeling an insulin vial with an open date and administering insulin without an open date label for 1 of 3 sampled residents (Residents #3). Findings included:A record review of a facility's policy titled, Insulin Administration, dated 06/15/20, and reviewed on 07/20/25, it documented under procedure that opened insulin must be labeled with the date.Records review documented Resident # 3 was admitted to the facility on [DATE] with diagnoses which included Disseminated Intravascular Coagulation (Defibrination Syndrome), Personal History of Endocrine and Metabolic Diseases, Peritoneal Abscess and Chronic Obstructive Pulmonary Disease with Acute Exacerbation.A review of the most recent Minimum Data Set (MDS) assessment, dated 01/21/26, under Section C of the Brief Interview for Mental Status (BIMS), revealed the score was disabled. Section N documented yes responses to hypoglycemic and anticonvulsant…

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 and interviews, the facility failed to provide food to residents in a safe and sanitary method. This had the potential to affect 4 residents on oral diets. The facility had 4 residents on the date of the survey who ate food orally. The findings included:An initial tour of the kitchen was conducted at 9:25 AM accompanied by the cook.When asked how many people she cooked for, she said she cooked for 4 residents at the Children's Comprehensive Care Center.The following was observed inside the True brand reach-in refrigerator:1. The [NAME] Chicken Broth had no date written on the box to show the date that the broth was opened. When the cook was asked for how long the item was safe to serve, she showed the surveyor the expiration date on the box. She was not aware that there was printed information on the side of the box that stated the broth must be used within 14 days after the carton had been opened.2. The Fruit Salad and container of Turkey Bacon had spilled dark yellow liquid on top of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, interview, observation and record review, the facility failed to notify the resident's representative regarding a change in skin condition, for 1 of 3 sampled residents observed (Resident #1). The findings included: Review of the facility policy and procedure titled, Change in a Resident's Condition or Status, which was not dated, and provided by the Director of Nursing (DON), included: Our facility shall promptly notify the resident, his or her attending physician, and representative (or sponsor) of changes in the resident's condition and/or status. The nurse supervisor will record in the resident's medical record any changes in the resident's medical condition or status. Review of the facility policy and procedure titled, Trach Care, dated 02/2025, included: Prevention is the best medicine for the care of the skin around the trach and the neck. Meticulous care should be taken to assess the skin each shift and document findings. Skin care management plans should be…

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: -develop a care plan for activities of daily living (ADLs) for 2 of 4 residents reviewed for ADLs (Resident # 7, and #19) ; -develop a care plan related to skin impairment for 1 of 2 residents reviewed for pressure injury (Resident #19); and -follow the care plan for residents with seizure precautions and pad placement on the bed rails for 1 of 3 reviewed for bed rails (Resident #130). The findings included: 1) Review of Resident #7's clinical record documented an admission on [DATE] and most recent readmission on [DATE]. The resident diagnoses included Cerebral Palsy, Restlessness and Agitation, Seizures, Feeding Difficulties, Hypoxic Ischemic Encephalopathy, Tracheostomy Status, Acute Respiratory Failure with Hypoxia, Candidiasis of Skin and Nail, and Sepsis due to Methicillin Susceptible Staphylococcus Aureus. Review of Resident #7 Minimum Data Set (MDS) assessments documented a discharge-return anticipated assessment dated [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, observation, interview and record review, the facility failed to 1) ensure that it utilized and practiced appropriate Enhanced Barrier Precautions during high contact resident care activities for 6 of 29 sampled residents observed, (Residents #24, #28, #8, #4, and #10); And, 2) failed to ensure that it practiced appropriate hand hygiene while administering eye drops during a Medication Administration Observation for 1 of 5 residents (Resident #27). The findings included: 1) Record review of the un-dated facility policy and procedure titled Routine Practices and Transmission Based Precautions provided by the Director of Nursing (DON) reviewed documented in the Policy Statement: Introduction and purpose: There are two (2) tiers of recommended precautions to prevent the spread of infections in healthcare settings: Standard Precautions and Transmission-Based Precautions. 1. Routine Practices (RP) - Routine practices are based on the premise that all clients/patients/residents…

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 assist a resident with feeding in a manner to promote dignity for 1 of 3 residents that eat by mouth, Resident #17. The findings included: Resident #17 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, an Annual Minimum Data Set (MDS), dated [DATE], Resident #17 was not assessed for cognition due to 'Resident is rarely/never understood'. The MDS documented that Resident #17 was dependent upon staff for all Activities of Daily Living (ADLs), including eating. Resident #17's care plan for nutrition, initiated on 07/31/23, documented, Feeding tube present due to dysphagia with H20 flush only for hydration, patency of tube and medication administration. Additional risk factors include: chewing/swallowing difficulty, mechanically altered diet, decreased ability to feed self, abnormal labs. The goal of the care plan was documented as, Resident will have no further weight gain through next review date.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide fingernail grooming to 4 of 4 residents reviewed for Activities of Daily Living (ADL) (Resident #7, #8, #12 and #19). The findings included: Review of the facility's policy provided by the Director of Nursing (DON) titled ADLs/Hygiene reviewed on 01/2024 documented .every resident will receive a bath daily .according to their needs .personal hygiene: i.e. face and hands washing .nails cutting .will be done as needed . Review of the facility's Certified Nursing Assistant (CNA) job description revised on 08/22/19 provided by the Director of Nursing (DON) documented under essential functions .adheres to schedule and performs bathing .and hygiene of residents .ensure residents are ready for school, that they are neat and clean . Review of the facility's Registered Nurse job description revised on 09/21/20 provided by the Director of Nursing (DON) documented under essential functions .provides physical hygiene measures, assures…

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 notify and obtain a physician order prior to provide pressure injury care for 1 of 2 reviewed for pressure injury (Resident #19) and - failed to administer medications within the medications time frames identified during medication administration observation task (Resident #18, #24, #28 and #29). The findings included: Review of the facility's policy provided by the Director of Nursing (DON) titled Physician' Medication Orders dated on 03/20/24 documented .no drugs or biologicals shall be administered except upon the order of a person duly licensed .all drug and biological orders shall be written . Review of the facility's policy provided by the Director of Nursing (DON) titled Medication Administration and Documentation revised on 03/20/24 documented .medications must be administered in a timely manner and in accordance with the Attending Physician's written/verbal orders .medications .must be administered within one (1)hour of their…

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 and interviews, facility failed to ensure that the administration of enteral nutrition was consistent with the practitioner's orders for 2 of 3 sampled residents (Resident #7 and #15). The findings included: 1 ) Review of Resident #7's clinical record documented an admission on [DATE] with readmission on [DATE]. The resident diagnoses included Cerebral Palsy, Restlessness and Agitation, Seizures, Feeding Difficulties, Hypoxic Ischemic Encephalopathy, Tracheostomy Status, Acute Respiratory Failure with Hypoxia, Candidiasis of Skin and Nail, and Sepsis due to Methicillin Susceptible Staphylococcus Aureus. Review of Resident #7 Minimum Data Set (MDS) assessments documented a discharge-return anticipated assessment dated [DATE]. The assessment documented that the resident was dependent on the staff for all activities of daily living (ADLs). Review of Resident #7's care plan titled resident name .relies on enteral feeding for all nutrition and hydration needs due to Short Bowel…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to 1. Assess residents for the use of bed rails and 2. Obtain informed consent for the use of bed rails for 2 of 2 residents reviewed for bed rails, Residents #10 and 130. The findings included: The facility's policy, 'Safety Measures and Equipment in the Pediatric Unit' most recently revised February 2024, documented: An appropriate size bed or crib will be selected for each resident according to their age and needs. Side rails on all cribs/beds of all residents will be in the up position and securely fastened at all times, unless someone is actually with the resident. 1). Resident #10 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, an Annual Minimum Data Set (MDS), date 10/17/24, Resident #10 was not assessed for cognition due to 'Resident is rarely/never understood'. The MDS documented that the resident was dependent upon staff for activities of daily living (ADLs). Resident #10's…

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 the medication error rate was 14 percent. Four (4) medication errors were identified while observing a total of 28 opportunities, affecting Resident #27. The findings included: Review of the facility's policy provided by the Director of Nursing (DON) titled Medication Administration and Documentation revised on 03/20/24 documented .medications must be administered in a timely manner and in accordance with the Attending Physician's written/verbal orders .medications .must be administered within one (1)hour of their prescribed time .the individual administering the medication must initial the resident's MAR (Medication Administration Record) .after administering the next resident's medication . Review of Resident #27's clinical record documented an admission on [DATE] with a readmission on [DATE]. The resident Minimum Data Set (MDS) quarterly assessment dated [DATE] documented the resident was dependent on the staff for all the activities 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, interview and review of policy and procedure, the facility failed to: 1) ensure that it secured Medication cart #1 (south unit). 2) ensure that it secured the Respiratory Therapy Cart in the north unit. 3) ensure that expired biologicals were removed from the medication room and the crash cart located in the south unit. 4) ensure opened medications bottle were label properly . 5) ensure resident's medications temperature were keep at appropriate temperature. 6) ensure that resident's medications were properly disposed of in the south unit and in the nursery. The findings included: Review of the facility's provided Medication Storage and Labeling Centers For Medicare and Medicaid Services (CMS) form 20089 dated 06/2023 by the Director of Nursing (DON) documented medications and biologicals in medication rooms, carts .were maintained within: secured (locked) locations, accessible only to designated staff . Review of the facility's policy provided by the DON titled Destruction of Medications…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure that the day to day kitchen operations were overseen by a qualified nutrition professional. This has the potential to affect all residents that eat foods prepared in the kitchen. The census at the time of the survey was 29 residents, with 3 that eat from the kitchen. The findings included: The Facility Assessment, dated June 2024, documented: Additional References to the Facility Assessment: Food and Nutrition Services - Staffing. The facility must employ sufficient staff members with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Resident #17 was admitted to the facility on [DATE]. Resident #17's diet orders included: GIVE PUREED DIET WITH THIN LIQUIDS FOR BREAKFAST, LUNCH 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 record reviews, the facility failed to provide meals consistent with orders for pureed consistency for 1 of 3 residents observed for dining, Resident #17. The findings included: Resident #17 was admitted to the facility on [DATE]. Resident #17's diet orders included: GIVE PUREED DIET WITH THIN LIQUIDS FOR BREAKFAST, LUNCH AND DINNER. NURSING TO RECORD % CONSUMED - three times a day - 08/25/24. During an observation of lunch being served in the classroom, on 11/18/24 at 12:15 PM, Resident #17 was served pureed broccoli, pureed chicken and puree pasta. It was noted that all three food items pooled on the plate, all three food items were sitting in water from being pureed and the chicken and the broccoli were 'chunky' and not smooth. It was noted that all three pureed food items did not hold the shape of the scoop that was used to portion the food items. During an observation of Resident #17 having breakfast, on 11/20/24 at 8:46 AM, it was noted that Resident #17 received…

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 interviews and record reviews, the facility failed to ensure an accurate Facility Assessment. The findings included: Review of the Facility Assessment revealed the following: In Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies, the Facility Assessment, dated June 2024, it documented, for Food and Nutrition Services: Dietician, Cooks, Dietary Aides. In Section 3.2, Staffing Plan, under Other, it documented: Dietician: 1 Consultant approximately 12 hours per week Cooks: (1) Dietary Aides: (1) The Workforce Profile, documented the Education level/Professional requirement for a Dietician as 'High School Diploma'. There was no indication that there would be a Director of Food and Nutrition Services, or what are the qualifications. During an interview, on 11/21/24 at 4:24 PM with the Administrator, the Staff Coordinator, and the Medical Operations Director, when the inaccuracies in the Facility Assessment were brought to their attention, the Administrator acknowledged that Facility Assessment did…

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 make efforts to correct deficiencies that were cited during the most recent annual recertification survey, with an exit date of 11/22/24 and a correction date of 12/31/24. The findings included: 1.) During the annual recertification survey, with an exit date of 11/22/24, the facility was cited for not developing a care plan for Activities of Daily Living for Resident #7 and Resident #19, and for not implementing interventions to care plans related to Seizure precautions for Resident #130. During the revisit to the recertification survey, on 01/09/25, it was determined by the Survey team that the deficiencies had not been corrected. During an interview, on 01/09/25 at 2:28 PM, with the Case Manager, Administrator, and Nurse Practitioner/Operations Manager (NP), when asked about the care plans not being initiated, the Case Manager confirmed that she was responsible for developing the care plans and that the care plans had not been developed. When asked about not having the care plans developed, the Case…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide evidence an event was thoroughly investigated in a timely manner, when oxygen tubing was found dislodged from the resident, for 1 of 1 resident investigated for respiratory care (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE]. He was discharged from the facility to the hospital on [DATE]. Resident #1 had a medical history significant for Respiratory Failure, Tracheostomy and Ventilator Dependent, Spina Bifida, Scoliosis, and Failure to Thrive. A Discharge Return Anticipated Minimum Data Set (MDS) was completed on 10/17/23. A Quarterly MDS was done on 07/31/23. This MDS documented Resident #1 had a Brief Interview of Mental Status score of 15, which indicates he was cognitively intact. This MDS documented Resident #1 was verbal and able to make himself understood. This MDS documented he was totally dependent on staff for his activities of daily living. Review of Care Plans revealed a care plan 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 interviews and record review, the facility failed to accurately complete a discharge Minimum Data Set (MDS) in a timely manner for 2 of 2 sampled residents reviewed for assessments (Resident #12 and Resident #31). The findings included: A review of the facility's policy titled MDS, Electronic Transmission, revised on 05/2023, showed that all MDS assessment and discharge and reentry records will be completed and electronically encoded in the facility's computer MDS informational system. It will further be transmitted to the state database in accordance with regulations. 1. Resident #31 was admitted to the facility on [DATE] and was discharged on 05/18/23. An entry MDS was done on 03/28/23, and an admission MDS was completed on 04/10/23. No discharge MDS was noted on Resident #31. A review of the Social Services Discharge summary dated [DATE], showed that Resident #31 transitioned home with the mother. 2. Resident #12 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide Range of Motion (ROM) devices and therapy to prevent deformities for 1 of 2 sampled residents for ROM (Resident #19). The findings included: Resident #19 was readmitted on [DATE] with diagnoses of Brain Damage, Respiratory Failure, and Drowning. The care plan initiated on 05/30/20 showed that he will maintain the current range of motion in all extremity stimulation. He will be provided with 2-4 times a week for physical management, and all his positioning needs will be addressed. It further showed that the physical therapy will follow the prescribed plan. In an observation conducted on 09/06/23 at 7:20 AM, Resident #19 was noted in bed. Closer observation showed no ankle foot orthosis (AFO) in place. In an observation conducted on 09/06/23 at 8:30 AM, Resident #19 was noted in bed. Closer observation showed no ankle foot orthosis (AFO) in place. In an observation conducted on 09/06/23 at 9:00 AM, Resident #19 was noted in bed.…

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 nutritional interventions in a timely manner for 1 of 2 sampled residents for nutrition (Resident #19). The findings included: A review of the facility ' s policy titled Weights, Heights, and Head Circumference, revised on 01/2021, showed that it is the policy of the facility to obtain and monitor weights. In an observation conducted on 09/05/23 at 10:37 AM, Resident #19 was noted in his bed. Closer observation showed a tube feeding with formulary (Pediasure Peptide) running at 45 milliliters (ml) an hour. Resident #19 was readmitted on [DATE] with diagnoses of Brain Damage, Respiratory Failure, and Drowning. The care plan initiated on 05/27/20 showed that Resident #19 requires tube feeding to maintain nutritional status. This was related to brain injury and tracheostomy dependence. The doctor's orders showed an order for weekly weights for a weight loss plan dated 07/05/23. Another order was noted for Pediasure Peptide 1.0 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, observations and interviews, facility failed to: (1) ensure that the administration of enteral nutrition was consistent with the practitioner's orders for 5 of 8 sampled reisdents (Resident #5, #18, #23, #137 and #237); (2) ensure that water ordered for flushes was administered per orders for 3 of 8 sampled residents; and (3) ensure the use of mixed enteral nutrition was consistent with the facility's policy for 1 of 8 sampled residents (Resident #23). The findings included: Review of the facility's policy titled Nasogastric/Gastrostomy Tube Feeding reviewed on 03/2022 documents .administration bag and tubing must be marked with the date and changed every twenty-four (24) hours .feeding preparations which involve blending, reconstitution .may hang for up to eight (8) hours .prepared feeding solutions must be refrigerated if held before used . 1.) Review of Resident #5's clinical record documented an admission on [DATE] and latest readmission on [DATE]. The resident diagnoses included…

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 and policy review, the facility failed to follow up with pharmacy recommendations for 3 of 5 residents sampled for unnecessary medications (Resident #1, #6 and #30). The findings included: The facility's policy titled Consultant Pharmacists Monthly Drug Regimen Review dated 9/2018 and reviewed 4/2020 revealed Physicians/prescribers are to act on recommendations by their NEXT visit date to the facility. If they do not act on recommendations by their next visit, the D.O.N. will promptly forward those recommendations to the Medical Director for follow up .The D.O.N. will be responsible to ensure that documentation is completed to verify the Consultant Pharmacist Recommendations are acted on with a target completion timeframe of TWO weeks from the report date. D.O.N. is Director of Nursing. 1. Resident #1 was admitted to the facility on [DATE]. Diagnoses included Dependence on Respirator, Arthrogryposis Multiplex Congenita and Epilepsy. Arthrogryposis Multiplex Congenita is 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 observations, interviews, and record review, the facility failed to ensure that an antipsychotic medication to treat specific conditions is documented in the clinical record. It failed to provide a clinically written reason for the refusal of a gradual dose reduction (GDR) for 1 of 5 sampled residents reviewed for unnecessary medication (Resident #15). The findings included: A review of the facility policy titled Tapering Medications, revised on 03/20, showed the following: Medications will be reviewed by pharmacy and attending physician/subspecialists monthly for consideration of gradual dosage reductions. Tapering a medication is to find an optimal dose or determine whether continued use of the medication benefits the resident. Reductions are titrated slowly unless clinically contraindicated with the goal of drug discontinuation. Dosages are then monitored regularly with consideration of adverse reactions while examining the resident's response and level of functioning. Resident #15 was admitted to…

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 interviews, the facility failed to ensure that garbage was disposed of properly. The findings included: In an observation conducted on 09/06/23 at 7:00 AM, the main dumpster outside the facility was noted to be uncovered with large bags of garbage on the bottom of the dumpster. The area around the dumpster was noted with debris and dirty gloves. In an interview conducted on 09/07/23 at 1:00 PM, the Administrator stated that everyone is responsible for taking out the garbage when needed. The city will come twice a week to empty the primary dumpster outside. The dumpster is supposed to be covered with a lid, and the fenced area around the dumpster is closed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to follow physician orders for 1 of 5 residents reviewed for unnecessary medication (Resident #1). The findings included: The facility's policy titled Physicians' Medication Orders dated 04/2009, reviewed 02/10/19 and revised 05/21 revealed Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medication in this state. Resident #1 was admitted to the facility on [DATE]. Diagnoses included Dependence on Respirator, Arthrogryposis Multiplex Congenita and Epilepsy. Arthrogryposis Multiplex Congenita is a term used to describe a variety of conditions involving multiple joint contractures. On February 14, 2023 the consultant pharmacist made a recommendation under the category Administration error, Priority High. Resident has order to give Atenolol 25mg (milligrams) Q 24 HR PRN (every 24 hours as needed) for SBP (systolic blood pressure)>140 or HR(heart rate) >100; Hold for…

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

Based on interviews and record review, the facility needed to monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained for 2 of 2 repeated deficiencies from prior surveys. The findings included: A review of the facility ' s Quality Improvement Plan for 2023 to 2024 showed the following: identify indicators that reflect the quality of care for residents when monitored. Identified from the review and established priorities. Monitor areas of concern and develop a plan of action as indicated. A plan of action is needed to reduce, modify, or resolve the concern and plan of action by repeated monitoring as needed. A review of the [NAME] report showed that the facility had multiple repeated deficiencies at F692 (Quality of Care) and F814 (Food and Nutrition) from previous surveys. In an interview conducted on 09/07/23 at 3:20 PM with the facility ' s new Administrator, she reported that before she came, they were doing QAPI and safety meetings combined. QAPI was not done monthly but on a quarterly basis. She decided to start 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.

Based on interviews and record reviews, the facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) meetings were composed of the required committee members in their quarterly meetings. The findings included: A review of the facility ' s Quality Improvement Plan for 2023 to 2024 showed the following: The quality improvement team meets monthly to address quality improvement activities and consists of the Administrator, Medical Director, Director of Medical Operations, Director of Nursing, Resident Care Manager, Risk Manager, Dietary Consultant, Pharmacy Consultant, and the Maintenance Director. A record review of the Quarterly QAPI/Safety Meeting, conducted on April 18, 2023 (3rd quarter), did not show that the facility ' s Administrator participated in the meeting. A record review of the Quarterly QAPI/Safety Meeting, conducted on January 25, 2023 (2nd quarter), did not show that the facility ' s Administrator participated in the meeting. In an interview conducted on 09/07/23 at 3:20 PM, the facility ' s Administrator stated that she only started working…

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.