Lake Mariam Health And Rehabilitation Center

Based on interviews and record review, the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program. The findings included: A review of the QAPI plan dated 2023 revealed the following: The plan provides a framework for a systematic, organization-wide improvement system specific to identifying aspects of quality needs and gaps in systems of care and management practices in our organization. Ensuring that all quality management initiatives regarding the delivery and management of care are clinically sound, promote consumer safety, and are based on current best practices. Which indicators of quality were evaluated during the quarter, and what were the results of the actions? What actions are planned and have been taken to improve quality and the results of those? Lessons learned from this process. Plan for sustained compliance. A record review of the previous Recertification survey dated 10/08/2021 revealed that the facility was found to be out of compliance under Physical Environment and cited at F925 and F921. The facility was found to be out…

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 3) On 01/22/24 at 7:30 AM, an initial tour was conducted of the residential rooms on the second floor. Resident #153 was observed in bed with the catheter bag on the floor (photographic evidence obtained). Resident #153 was admitted to the facility on [DATE] with a suprapubic catheter. 4) On 01/22/24 at 9:00 AM, Resident #155 was observed in bed being served breakfast. Staff L, a Licensed Practical Nurse, entered the room and gave Resident #155 an insulin injection into his left arm without wearing gloves. Based on observations, interviews and record review the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment for the laundry area, for 2 of 2 shower rooms located on the 1st floor; failed to ensure urinary catheter drainage bag was maintained off the floor for 1 sampled resident for catheter care (Resident #153); failed to utilize appropriate PPE (Personal Protective Equipment) during administration of an injectable for Resident #155; and failed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide documentation of offering/acceptance/declination of the pneumococcal vaccine for 4 out of 5 sampled residents reviewed for vaccines (Residents #9, #53, #69, and #94). The findings included: Review of the facility's policy titled, Pneumococcal Vaccine (Series) Policy with a reviewed/revised date of 01/31/22 included: It is our policy to offer our residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current CDC (Center for Disease Control) guidelines and recommendations. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. The type of pneumococcal vaccine (PCV15, PCV20, or PPSV23/PPSV) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to have an effective pest control program. The findings included: A review of the policy titled, Pest Control Program, revised on 01/06/23, revealed the following: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. The facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services regularly and regularly. The facility will maintain a reporting system of issues arising between scheduled visits with the external pest service and treat them as indicated. An observation conducted on 01/22/24 at 7:34 AM, in the main kitchen showed pests in all stages of life near the food production area. Continued observation showed pests in all stages of life in the dishwasher room on the floor. In this observation, the Certified Dietary Manager said that the pest control company comes into the kitchen…

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 treat residents in a dignified manner during dining observations for 3 of 7 sampled residents reviewed for dignity, Residents #79, #40, and #25; and failed to provide timely grooming to preserve dignity, for 1 of 7 sampled residents, Resident #15, also reviewed for dignity. The findings included: Review of the facility's policy, titled Promoting/Maintaining Resident Dignity, revised on 08/02/22, revealed the following: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Staff members provide care to residents to promote and maintain resident dignity during interactions with residents. 1. Record review revealed Resident #79 was admitted to the facility on [DATE] with diagnoses that included Dementia,…

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 policy review, the facility failed to ensure call lights remained in reach for 2 of 100 sampled residents observed during the initial screening process (Resident #58 and Resident #155). The findings included: The policy of the facility, titled, Call Lights: Accessibility and Timely Response implemented 11/2020 and revised 07/19/22, revealed Staff will ensure the call light is within reach of resident and secured, as needed; and The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 1. Review of the resident's Medicare A 5-day scheduled assessment with a target date of 01/06/24 documented: Section C: the resident is rarely/never understood. Section GG: the ability to safely come to a standing position from sitting in a chair or on the side of the bed is not applicable and picking up object is dependent. On 01/22/24 at 7:55 AM, Resident #58 was observed in his wheelchair. The call light was observed on 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 observations, interviews and record review, the facility failed to provide written notice to the resident or the resident's representative of a room change for 1 of 32 sampled residents reviewed for room changes (Resident #69). The findings included: Review of the facility's policy, titled, Change of Room or Roommate with a reviewed / revised date of 03/08/23 included: It is the policy of this facility to conduct changes to room and/or roommate assignments when considered necessary and/or when requested by the resident or resident representative. Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advance notice of such a change as is possible. The notice of change in room or roommate will be provided in writing, in a language and manner the resident and representative understand. Record review for Resident #69 revealed the resident was admitted to the facility on [DATE] with a diagnosis 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 observation, interview, and record review, the facility failed to develop and implement baseline care plans within 48 hours of a resident's admission for 1 of 1 sampled resident, reviewed for catheter care (Resident #153). The findings included: During an observation on 01/22/24 at 7:30 AM, Resident #153 was observed in bed. On the floor, next to his bed, a catheter bag containing urine was observed on the floor. Record review revealed Resident #153 was admitted to the facility on [DATE], in the late afternoon, with diagnoses that included Type 2 Diabetes Mellitus, Heart Failure and Urinary Retention. The resident was admitted with a suprapubic catheter. (A suprapubic catheter is a device that's inserted directly into the bladder to drain urine). Review of the Electronic Health Record (EHR) revealed no evidence of a baseline care plan for the catheter or for catheter care. Review of the comprehensive care plans revealed no care plan for a catheter or catheter care. On 01/22/24 at 11:13 AM, an interview…

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 for 4 of 8 sampled residents reviewed for Activities of Daily Living (ADL) care (Residents #53, #70, #79, and #76). The findings included: Review of the facility's policy, titled, Nail Care with a reviewed / revised date of 06/07/21 included: The purpose of this procedure is to provide guidelines for the provisions of care to a resident's nails for good grooming and health. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule and as the need arises. Principles of nail care: Nails should be kept smooth to avoid skin injury. Only licensed nurses shall trim or file fingernails of residents with diabetes. Procedure included: gently clean underneath nails with an orange stick. Document completion of task, any complications, or if resident refuses. 1. Record review revealed Resident #53…

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 toenail care for 1 of 32 sampled residents (Resident #53) reviewed for Foot Care. The findings included: Review of the facility's policy, titled, Nail Care with a reviewed / revised date of 06/07/21, included: The purpose of this procedure is to provide guidelines for the provisions of care to a resident's nails for good grooming and health. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule and as the need arises. Principles of nail care: Nails should be kept smooth to avoid skin injury. Toenails of residents with diabetes or circulation problems shall be filed only. Procedure included: gently clean underneath nails with an orange stick. Document completion of task, any complications, or if resident refuses. Review of the facility's policy, titled, Skin Integrity - Foot Care with a reviewed /…

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 identify and treat the resident with hand contractors for 1 of 1 sampled resident reviewed for range of motion (Resident #79). The findings included: A review of the facility's policy, titled, Use of Assistive Devices, revised on 2/2023, revealed the following: the purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and dignity. The facility will provide assistive devices for residents who need them. The nursing, dietary, social services, and therapy departments will work together to ensure the availability of devices, such as for ordering and replacement. Record review revealed Resident #79 was admitted to the facility on [DATE] with diagnoses that included Dementia, Anxiety, and Dysphagia. The care plan initiated on 06/28/23 revealed Resident #79 had impaired cognitive function and impaired thought process…

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 identify significant weight loss in a timely manner; and failed to provide nutritional intervention to prevent weight loss for 3 of 5 sampled residents reviewed for weight loss (Resident #55, Resident #57, and Resident #86). The findings included: Review of the facility's policy, titled, Weight Monitoring, revised on 11/30/23, revealed the following: It is the policy of the facility to minimize the risk of a resident's significant weight loss and for residents to maintain acceptable parameters of nutritional status. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes identifying and assessing each resident's nutritional status and risk factors and evaluating/ analyzing the assessment information. Developing and consistently implementing pertinent approaches, monitoring the effectiveness of interventions, and revising them as necessary. The newly recorded resident weight should…

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 physician orders for tube feedings, for 2 of 2 sampled residents reviewed for tube feedings (Resident #58 and Resident #34). The findings included: Review of the facility policy, titled, Care and Treatment of Feeding Tubes, revised on 11/27/23, revealed in part the following: 'Direction for staff regarding nutritional products and meeting the residents' nutritional needs will be provided, how to determine whether the tube feedings meet the resident's needs, and when to adjust them accordingly-ensuring that the selection and use of enteral nutrition is consistent with manufacturer's recommendations-ensuring that the administration of enteral nutrition is compatible with and follows the practitioner's orders. Feeding tubes will be utilized according to physician orders, which typically include the kind of feeding and its caloric value, volume, duration, mechanism of administration, and flush frequency. The facility will utilize 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, record and policy review, the facility failed to maintain respiratory equipment in a sanitary manner for 1 of 1 sampled resident reviewed for respiratory care (Resident #58). The findings included: The facility's policy, titled, Nebulizer Therapy revised 05/04/22, revealed, in part, Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag or plastic bag, change nebulizer tubing weekly or as needed. Review of the record revealed Resident #58's most recent readmission to the facility was on 01/16/24, with diagnoses that included Respiratory Failure, Obstructive Uropathy and Non-Alzheimer's Dementia. Record review revealed the resident receives Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (milligrams per milliliter) via nebulizer every 4 hours. A nebulizer is a drug delivery device used to administer medication in the form of a mist inhaled into the lungs. On 01/22/24 at 8:00 AM, an observation was made of a nebulizer device on a chair in Resident #58's room. Further observation revealed the nebulizer device that was placed…

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 assess residents for bedrail use for 1 of 32 sampled residents (Resident #11) reviewed for bedrail use; and failed to follow recommendations of bedrail assessments for 2 of 32 sampled residents (Residents #58 and #153) reviewed for bedrail use. The findings included: Review of the facility's policy, titled, Proper Use of Bed Rails with a reviewed / revised date of 07/25/22, included: If bed rails are used, the facility ensures correct installation, use and maintenance of the rails. Under the Section: Ongoing Monitoring and Supervision included: As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms b. Size and weight c. Sleep habits d. Medication(s) e. Acute medical or surgical interventions f. Underlying medical conditions g.…

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 maintain the daily posted nurse staffing information, as observed during the survey week. The findings included: Upon entering the facility on 01/22/24 at 7:00 AM, the surveyors did not observe that the 'daily nurse staffing' was posted at the front desk. Throughout the first day of the survey on 01/22/24 from 7:00 AM until approximately 6:30 PM, the surveyors did not observe that the 'daily nurse staffing' in the facility was posted. Throughout the day on 01/23/24 and 01/24/24, the surveyors continued to not see the daily posted nurse staffing at the front desk or anywhere else in the facility. An interview was conducted on 01/24/24 at 2:37 PM with the facility's Nurse Staffing Development Coordinator. She stated the daily staffing numbers are to be posted daily at the front desk. The surveyor and the Nurse Staffing Development Coordinator walked to the front desk together and saw that the sign containing the daily staffing numbers was located behind the front desk, not visible to residents and visitors, and the paper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide physician ordered medications to one (Resident #3) of three residents sampled for pharmacy services. Findings included: A review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of dementia, cerebral infarction, cognitive communication deficit, seizures, and depression. A review of Resident #3's physician's orders summary revealed the following medication orders: - An order, dated 2/13/2024, for lacosamide 200 milligrams (mg), one tablet by gastric tube (GT) two times a day (9:00 AM and 5:00 PM) for seizures. The order remained active until 3/25/2024. - An order, dated 3/25/2024, for lacosamide 10 mg per milliliter (ml), give 10 ml GT two times (6:00 AM and 6:00 PM) a day for seizures. - An order, dated 2/13/2024, for phenobarbital 100 mg GT one time a day at bedtime (9:00 PM) for seizures. The order remained active until 4/1/2024. A review of Resident #3's Medication Administration…

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 preserve the nutritional value of food items in the puree diet. This had the potential to affect ten (10) of 10 residents who were on a puree diet. The findings included: Record review of the facility's meal tracker, week 3, showed the following menu items for Monday, 01/22/24: roast chicken, seasoned cornbread, stuffing, and collard greens. In an observation conducted on 01/22/24 at 7:30 AM, a full-size stainless steel 6-inch deep steam table pan was noted on top of the stove. Closer observation showed cooked collard greens. In this observation, the Certified Dietary Manager (CDM) said this was the cooked collard green vegetables on the pureed diet for today's lunch meal. In an observation conducted on 01/22/24 at 7:35 AM, Staff L, Dietary Cook, placed the already-cooked collard greens in the warmer. Staff L stated that she cooked the vegetables for the pureed diet a little earlier, and when she is done with the breakfast tray line, she will puree the cooked collard greens. When asked about the breakfast…

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 the appropriate orders for 3 of 32 sampled residents, for fluids, as prescribed by the attending physicians, Resident #74 and Resident #40; and failed to provide adequate hydration for Resident #53. The findings included: 1. Record review showed that Resident #74 was admitted to the facility on [DATE] with diagnoses of Diabetes, Anemia, and Hyperlipidemia. During the dining observation on 01/23/24 at 8:28 AM, Resident #74 was noted in his room with the breakfast tray. The breakfast meal ticket showed a regular, mechanical, soft diet with thick nectar liquids. Closer observation of the meal tray revealed a 12-ounce Styrofoam cup of water that was not thickened and placed near the breakfast tray. In this observation, Resident #74 was asked by the surveyor if he was aware that he was on a specific fluid consistency restriction, and Resident #74 could not answer. 2. Resident #40 was admitted to the facility on [DATE] with diagnoses…

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 the therapeutic diets as per physician's orders for 2 of the 32 sampled residents (Resident #86 and Resident #55). The findings included: A review of the facility's policy, titled, Meal Supervision and Assistant, revised on 11/29/22, showed, in part, that staff needs to check the tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow. 1 . Resident #86 was admitted to the facility on [DATE] with diagnoses of Parkinson's, Dementia, and Depression. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 04, indicating severe cognitive impairment. Review of the physician's orders, dated 12/04/23, revealed an order for regular texture, thin liquids, and fortified foods with meals. In an observation conducted on 01/24/24 at 8:40 AM, Resident #86 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.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety. The findings included: A tour of the main kitchen conducted on 01/22/24 at 7:14 AM and accompanied by the Certified Dietary Manager (CDM) showed the following: 1. No hairnets or facial hairnets were noted outside the main kitchen doorway. 2. A dirty rag was noted on the main production counter that was not in any buckets or solutions. 3. Four large rolls of pork loin were noted in the walk-in refrigerator and placed on a metal tray. The metal tray had a label of pork dated 01/18/24. In this observation, the CDM stated that the pork loin was placed in the walk-in refrigerator to thaw and that it is for the lunch meal tomorrow, 01/23/24. 4. Four large rolls of raw beef (approximately 10 pounds each) were placed in the walk-in refrigerator on a metal tray that needed to be labeled and dated. They did not have a sticker with a date indicating when they were placed in the walk-in refrigerator. 5. The walk-in freezer noted…

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 administer the facility in a manner that enables the effective and efficient use of its resources. The findings included: A review of the Administrator's job description revealed the following: 1. Lead and direct the facility's overall operations in accordance with customer needs, government regulations, and Company policies, focusing on maintaining excellent care for the residents while achieving the facility's business objectives. 2. Manage facility budgets and business practices to include labor costs, payables, and receivables. 3. Consult with department managers concerning the operation of their departments to assist in eliminating/ correcting problem areas and/or improving services. 4. Verify that the building and grounds are maintained appropriately, that equipment and work areas are clean, safe, and orderly, and that any hazardous conditions are addressed. 5. Monitor each department's activities, communicate policies, evaluate performance, provide feedback, and assist, observe, coach, and discipline as needed. 6.…

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 failed to communicate effectively between the Administrator and the Governing Body regarding the overall management and operation of the facility. The findings included: A review of the Quality Assurance and Performance Improvement Plan (QAPI) dated 2023 revealed that the QAPI Plan and program were reviewed and approved by The Committee of the Governing Body. The Governing Body of our facility has ultimate responsibility and leadership over our QAPI program, working with input from staff, residents, and resident representatives. The Governing Body designates a QAPI Steering Committee (Administrator, Director of Nursing, and Medical Director). The Governing Body ensures that the QAPI program has sufficient resources, facility-wide QAPI training occurs that policies are in place to sustain the program despite personnel changes, supports a culture of resident-centered rights and choices, holds staff accountable for quality in an environment free of retaliation; ensures staff is educated and proficient in their duties. A review 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 observations, interviews, and record review, the facility failed to have an integrative care plan and effective communication between the facility and the hospice provider for 1 of 1 resident reviewed for hospice (Resident #40). The findings included: A review of the facility policy titled, Coordination of Hospice Services, revised on 6/2023, revealed the following: when a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff to promote the resident's highest practicable physical, mental, and psychosocial well-being. The facility and hospice provider will coordinate a care plan and implement interventions per the resident's needs, goals, and recognized standards of practice in consultation with the resident's attending physician/ practitioner and resident's representative to the extent possible. The plan of care will identify the care and services that each entity will provide to meet the needs of the resident and 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.

Based on interviews and record review, the facility failed to monitor inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program. The findings included: Review of the facility's policy titled, Proper Use of Bed Rails with a reviewed/revised date of 07/25/22 included: If bed rails are used, the facility ensures correct installation, use and maintenance of the rails. Under the Section: Ongoing Monitoring and Supervision included: The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's records, including their care plan, including but not limited to, the following information: a. The type of specific direct monitoring and supervision provided during the use of the bed rails, including documentation of the monitoring. Responsibilities of ongoing monitoring and supervision are specified as follows: a. Direct care staff will be responsible for care and treatment in accordance with 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 observations, interviews, and record review, the facility failed to ensure resident room is equipped with a working toilet or located near an accessible toilet for 1 of 100 residents screened (Resident #53). The findings included: Review of the facility's policy titled, Safe and Homelike Environment with a reviewed/revised date of 04/11/23 included: In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Record review for Resident #53 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia, Muscle Weakness, Unspecified Abnormalities of Gait and Mobility, and Unspecified Hearing Loss Bilateral. Review of the Minimum Data Set 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 observations, interviews, and record reviews, the facility needed to ensure adequate lighting in designated resident dining and activities rooms. The findings included: A review of the facility's policy titled, Safe and Homelike Environment: revised on 04/11/23 revealed that in accordance with resident ' s rights, the facility will provide a safe, clean, comfortable, and homelike environment. It further showed providing adequate lighting, which means a level of illumination suitable to tasks the resident chooses to perform or the facility staff must perform. In a dining observation conducted on 01/22/24 at 7:50 AM, in the main dining room on the 2nd-floor, the following inadequate lighting was noted: The 4 round lights that are noted next to the main kitchen side had one light bulb working out of 4 light bulbs. The four lights noted near the outside window showed that only two bulbs were working out of 4 light bulbs. The dining room was noted to have 25 residents waiting for their breakfast meals. In this observation, Staff M, a Certified Nursing Assistant, was asked about…

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

Based on observations, interviews, and record review, the facility failed to equip corridors with securely affixed handrails on 1 of 2 floors of the facility (the First floor). The findings included: Review of the facility's policy titled, Handrails with a reviewed/revised date of 04/02/23 included: The facility will equip corridors with a handrail on each side of the hall. All handrails will be firmly secured. During an initial tour conducted on 01/22/24 from 7:45 AM to 11:30 AM, on the first floor (Memory Unit), the handrails were observed to be loose and not firmly secured to the wall. During an interview conducted on 01/25/24 at 1:45 PM with the Director of Plant Operations, the Director of Maintenance, and the Maintenance Assistant they acknowledged the handrails were loose. The Director of Plant Operations stated the handrails are secured to the wall, it is just the part of the handrail you hold onto that is loose.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review and policy review, the facility failed to follow their smoking policy for 2 of 9 residents identified as smokers (Resident #15 and #48). The findings included: The facility's policy titled, Smoking Policy revealed All smokers will be supervised during smoking without exception. Metal ashtrays with self-closing covers are to be used to hold and dispose of cigarettes in smoking areas. Resident #15 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Chronic Obstructive Pulmonary Disease and Cognitive Communication Deficit. Her Brief Interview for Mental Status (BIMS) score from the annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/01/23 was 13, which indicated the resident was cognitively intact. Section J of the MDS assessment revealed she was a current tobacco user. Review of the resident's care plan revealed the resident must smoke with supervision. Resident #48 was admitted to the facility 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 and interview with the Administrator and staff, and review of maintenance requests and submitted grievances, the facility failed to maintain a clean and comfortable environment for residents who lived on the first floor of the facility. Findings included: During a tour of the first floor of the facility, on 08/14/23 beginning at 9:30 a.m. upon stepping out of the elevator, a strong urine odor was apparent. Few wall decorations were evident through out the unit. In the Solarium, above the wall mounted television were three air vents that were discolored with black spots and lines of black that followed the louvers. Above the vents one of the ceiling tiles had an approximate 2 inch circle of black and gray with a encircling discoloration of a lighter tan. (Photographic evidence obtained) At 10:00 a.m. on 08/14/23, an observation of the first floor nourishment pantry was conducted. The cabinet in the pantry was noted to be constructed of particle board with many sides exposed, due to no…

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 resident, family member and staff interviews, review of logs, pest service reports, grievance logs, and observations of two dead and two live pests on the first floor of the facility, in resident rooms and in the nourishment pantry, the facility failed to ensure an effective pest control program. Findings included: During a tour of the first-floor resident rooms, common areas, and nourishment pantry, beginning at 9:30 a.m. on 08/14/2023, two dead bugs and one live bug were observed. (Photographic evidence obtained) Interviews with residents and one family member on 08/14/2023 from 9:30 a.m. until 12:30 p.m. confirmed they see bugs in their rooms and in the dining room. Resident # 10 was observed lying in bed with the television on. When asked about bug sightings she said yes, but mostly at night when you turn the lights on. She reported that she thought the bugs were why she felt so itchy. On 08/16/2023 at 11:00 a.m., Resident #11 was observed lying in her bed, on her left side facing the hall. As 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 observations, policy reviews, and interviews the facility failed to provide a safe, sanitary, and homelike environment on one unit (first secured floor) out of two units affecting eight resident rooms (room [ROOM NUMBER], #104, #106, #101, #111, #109, #108, #113, and #121) and three common areas (hallway, dining room and activity porch) for four of four days. Findings included. 1. During tours of the facility's secured unit located on the first floor the following observations were identified: - room [ROOM NUMBER]: On 10/5/21 at 10:01 a.m., an observation indicated the top of the wardrobe leaned towards the back with a television on top of it and below the towel dispenser next to the room's sink was an unpainted area with holes. (Photographic Evidence Obtained) - Hallway between room [ROOM NUMBER] and room [ROOM NUMBER]: The observation on 10/5/21 at 10:13 a.m., revealed a missing baseboard in the hallway between rooms [ROOM NUMBERS]. The area contained unprotected paper-backed wallboard. (Photographic…

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, record review and staff and resident interviews, the facility failed to maintain and promote resident dignity for six residents (#150, #19, #94, #32, #33 and #28) related to: 1. Resident #150 was left with a large wrist band on his wrist that read, FALL RISK, 2. Staff ( A, D, and F) were observed talking on their electronic phone devices while providing care and services to four residents (#19, #94, #150, and #37), and 3. The facility failed to assist two residents (#33 and #28) timely during meal service for lunch, of a total of forty-four sampled residents during four of four days observed (10/5/2021, 10/6/2021, 10/7/2021, and 10/8/2021). Findings included: 1. On 10/5/2021 at 10:00 a.m. Resident #150 was observed in his room grimacing with a wash basin lined with paper towels at his side. The resident said he didn't feel well and that he was sick. He said he was admitted to the facility for about five days now. Resident #150 was observed with a yellow wrist band on his right wrist 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 observations, record reviews, and interviews the facility failed to implement the care plan for one (#43) out of twenty-two sampled residents that resided on the secured unit related to assessing the skin condition on a weekly basis. Findings included: Resident #43 was observed on 10/6/21 at 8:51 a.m. in the facility's secured unit's dining room. The resident was sitting in a wheelchair with a dirty surgical mask hanging from its handle. Resident #43 was observed on 10/8/21 at 8:20 a.m., sitting in the secured unit's dining room. The resident's hair was bushy and the resident's general appearance was unkept. The Resident Face Sheet for Resident #43 indicated the resident was admitted on [DATE] and included diagnoses not limited to Type 2 diabetes mellitus with ketoacidosis without coma, age-related cognitive decline, and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side. The care plan, initiated on 9/18/19, for Resident #43 indicated 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, record reviews, and interviews the facility failed to provide adequate supervision of three residents (#21, #29 and #45) with a mechanically-altered diet and who have behavioral and/or cognition issues out of 22 residents residing a secured unit. Findings included: 1. An observation was conducted, at 8:32 a.m. on 10/8/21, of Resident #21 sitting next to her bed with an over-the-bed table near the door, on the table was a meal tray with a covered cup of orange-colored liquid and a covered plate. Staff I, Certified Nursing Assistant (CAN) entered the room next to Resident #21's, and removed Resident #29 from the room, and placed the resident in the hallway. Resident #29 propelled himself to the doorway of Resident #21's room and moments later was observed drinking a cup of orange-colored liquid, which was not observed in his possession when the staff member removed him from the other room. The cup, previously observed on Resident #21's tray, was not on the tray and the lid was lying next to the covered plate. Staff I removed Resident #29 from the doorway, into…

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 a medication error rate of less than 5% related to four errors in twenty five opportunities for one resident (#17) out of seven residents sampled, resulting in a 16% medication error rate. Findings included: On 10/07/21 at 10:42 a.m. during a medication administration observation with Staff Q, Registered Nurse (RN) the following medication Resident #17 was given at 10:42 a.m., but due at 8:00 a.m.: Midodrine 5 mg (milligram) In addition the following medications were given at 10:42 a.m., but due at 9:00 a.m.: Memantine 10 mg and Iron 325 mg. The following medication on the Resident #17's Medication Administration Record (MAR) for October 2021 was due at 9:00 a.m., but not given to the resident: MVI with MIN (Multivitamin with Minerals). Review of Resident #17's medical record revealed no documentation in the resident's progress notes about the medications being late. The only notation documented was found in the October 2021 MAR…

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, record reviews, and review of facility policy, the facility failed to implement an effective Quality Assurance/Performance Improvement plan of action to correct a deficiency cited during the annual recertification survey on 10/08/2021. The facility failed to ensure a medication administration error rate below 5%. A total of 12 administration opportunities were observed with 2 errors for 2 (Resident #4 and Resident #5) of 4 residents observed for medication administration, resulting in a medications administration error rate of 16.7%. Findings included: A review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program - Analysis and Action, dated March 2020, revealed under the section titled Policy Interpretation and Implementation that the QAPI committee is responsible for analyzing identified problems, establishing corrective actions, measuring progress against the established goals and benchmarks, communicating information to staff 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 and interviews the facility failed to maintain and effective pest control program control pests for one unit (secured) of two units where vulnerable residents resided. Findings included: A tour of the secured unit of the facility was conducted, on 10/5/21 at 11:14 a.m., a small legged insect was observed scurrying along the baseboard in room [ROOM NUMBER]. The insect was able to disappear in a space between the baseboard and the tiled floor. (Photographic Evidence was Obtained) On 10/5/21 at 12:30 p.m., a flying insect was observed crawling on a sock of a resident in room [ROOM NUMBER]. During a tour of the facility's secured unit with the Director of Nursing (DON) and Risk Manager (RM), which began at 9:41 a.m. on 10/7/21, a large legged insect lying on its back with legs waving in the air was observed next to a decayed wardrobe in room [ROOM NUMBER]. Resident #84 stated, while lying in the bed closest to the wardrobe, Oh we have roaches in here. The management staff acknowledged 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 resident and staff interviews, review of facility policies and procedures, and review of Resident Council Meeting minutes the facility failed to act on grievances related to outside activities. Findings included: On 11/13/19 at 10:30 a.m., a meeting was conducted with regular members of the Resident Council. During the meeting Resident #8 reported that residents had not been on an outside trip for almost a year. Resident #8 stated that some residents wanted to visit the local bingo hall or go out in the community to look at Christmas lights. Resident #53 reported that the facility's van was broken for over a year but was recently registered and tagged. A review of the previous Resident Council meeting minutes revealed the following: - 1/11/18: Discussion of New Business - Van broken when will it be fixed. The Administration response, dated 1/15/18, indicated the van was not repairable and the facility was waiting to determine the cost of installing an upgraded generator mandated by the state agency before making a decision on repairing the van. - 8/8/19: Request to go 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews with staff, and record review the facility failed to ensure that 1 of 2 residential floors was maintained in a safe and clean manner for residents related to soiled dining room vents, a patio doorway in ill repair, loose molding/baseboards, exposed strand board, sharp jagged edges on dining tables, rusted dining table with uncapped legs, miscellaneous items stored in the dining room, cable hanging from the ceiling and hole in the baseboard in room [ROOM NUMBER], and pillows with no coverings on top of a wardrobe closet in room [ROOM NUMBER]. Findings included: 1. On 11/12/19 at 11:30 a.m., on 11/13/19 at 1 p.m., and on 11/14/19 at 3:15 p.m., the following observations were made: A) 1st floor dining room vents. Three vents were observed with black bio growth specks all over them (photographic evidence obtained). Several residents were observed in the dining room during meal times. B) 1st floor doorway to patio used for Activities. A piece of loose metal in the doorframe 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, observation, and record review the facility failed to ensure that the effectiveness of the medication as well as behavior and side effects monitoring which are all essential for evaluating the use of psychotropic medications, was accurately recorded for four (# 10, # 14, # 52, and # 84,) of five sampled residents who were reviewed for unnecessary medications. Findings included: 1. Resident # 52 was originally admitted to the facility on [DATE] after a short stay at an acute care facility with the primary diagnosis of Huntington's Disease. Other pertinent diagnoses included but were not limited to chronic pain, migraine, major depressive disorder, unspecified convulsions, and anxiety disorder. A review of the minimum data set (MDS) dated [DATE] reflected that Resident # 52 was mildly impaired with a brief interview for mental status (BIMS) of 12 and had no behaviors of delirium; mood was documented as depressed and tired/little energy at a severity of 2, the behaviors section documented…

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 review of maintenance records, the facility did not ensure that a preventative maintenance schedule was in place to maintain the call light system for 1 of 2 floors in the building. Seven resident rooms and/or bathrooms (105, 107, 111, 113, 115, 124 and 125) out of 31 total resident rooms on the first floor of the building had call lights that were not functional and needed repair. Findings Included: Direct observation of call light function on 11/12/19 at 11 a.m. and 11/13/19 at 1 p.m. confirmed that the call lights for room [ROOM NUMBER] were not functioning. An observation was conducted on 11/12/19 at 1:30 p.m. The resident was observed sitting in her wheelchair in the hall, and she was observed going into room [ROOM NUMBER]. She pressed the call bell laying on the bed near the door. The call light did not light up (activate). The resident left the room and went down the hall. She called out to one of the nursing assistants at the end of the hall and expressed her need…

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 procedures the facility failed to investigate the grievance for one (#94) of one resident reviewed for personal property in regards to a set of missing dental implants. Findings included: During an interview, on 11/13/19 at 8:43 a.m., Resident #94 and a family member reported the resident was missing a set of dental implants, and another resident had been observed in Resident #94's bed. The resident and family member stated that they had requested a velcro stop sign for the doorway. Observation of Resident #94 at the time of the interview revealed the resident was edentulous on the front bottom of oral cavity with two (2) metal poles on either side of the edentulous area. The observation indicated no stop sign banner was present in the doorway of Resident #94's room. The family member reported they had not heard anything from the facility regarding the grievance. Follow-up interview with Resident #94 on 11/14/19 at 9:29 a.m. revealed the resident did 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that the Minimum Data Set (MDS) Assessment was coded accurately for one resident (#296) of two residents reviewed for Communication-Sensory Deficits. Resident #296's MDS did not accurately reflect his vision status. Findings Included: Review of Resident #296's Minimum Data Set (MDS) dated [DATE] revealed the section for vision: ability to see in adequate light was marked 0 as adequate. Review of Resident #296's admission Record revealed diagnoses that included: Open angle Glaucoma. His physician orders included Latanoprost eye drops; 1 drop each eye in the evening. Azopt eye drops: 1 drop twice a day in both eyes. Initiate fall prevention program (started 11/4/19). Review of Resident #296's Care plan, dated 10/14/19, revealed: Falls: at risk for falls related to impaired vision, impaired cognition, and poor safety awareness. Approach: start 11/4/19: assist/guide to chair when observing resident sitting in chair. No additional…

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 a care plan for impaired vision was developed and implemented for one resident (#296) of two residents reviewed for care plan interventions applicable for Communication-Sensory Deficits. Findings Included: Review of Resident #296's admission Record revealed that he was re-admitted on [DATE] with diagnoses that included: Type 2 Diabetes Mellitus, Open angle Glaucoma, and Cognitive Communication Deficit. His physician orders included Latanoprost eye drops; 1 drop each eye in the evening. Azopt eye drops: 1 drop twice a day in both eyes. Initiate fall prevention program (started 11/4/19). Review of Resident #296's Minimum Data Set (MDS) dated [DATE] revealed: Brief Interview for Mental Status: Score 99 unable to complete. Hearing/Speech/Vision: vision: ability to see in adequate light (marked 0 = adequate). Functional status: Limited to extensive assist most activities of daily living. (Walking/transfers: limited one person…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that pharmacy recommendations were reviewed and acted upon in a timely manner for 2 (#10, and #14) of 4 residents reviewed for unnecessary psychotropic medications. Findings Included: 1. Review of Resident #10's admission Record revealed that she was admitted to the facility on [DATE] with diagnoses that included: psychotic disorder with delusions, dementia, major depressive disorder, and anxiety disorder. Her physician's orders included: Do Not Resuscitate, Buspirone tablet 7.5 milligrams (mg); oral; one tab twice a day for anxiety. Celexa tablet 10 mg; oral, give 10 mg tab every day for depression. Review of Resident #10's care plan revealed: 5/4/2019: Psychotropic Drug Use: anti-anxiety medication related to anxiety. Approach: monitor for drug use and effectiveness and adverse consequences. Pharmacy consultant review every month. Resident receives anti-depressant medication related to depression. Approach: Monitor mood and response 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 observation, interviews, and record review, the facility failed to maintain drugs and biologicals in accordance with accepted professional standards in 1 of 2 medication storage rooms. Findings included: On 11/14/19 at 12:42 p.m., an observation of the medication room located on the 1st floor was conducted. On the far-left corner of the room, against the wall, was a blue toolbox. Staff M, a Licensed Practical Nurse, identified the toolbox as an EDK (Emergency Drug Kit). There were no red or green tags on the outside of the box. A label on the top of the box provided the following information: item description, units of measure, quantity, product identification, expiration date, and tray description. The item description indicated that antibiotics were stored inside. Staff M was able to freely open the box, and inside, several drawers of antibiotics were observed. There was no pharmacy reconciliation slip inside to indicate if any medications had been removed. On the far-right corner of the room, on an open shelf, was a plastic see-through drawer, containing antibiotic…

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.

2. An observation was made on 11/12/19 at 11:58 a.m., of one of two metal tray carts on the secured unit of the facility. The tray cart contained meal trays for the residents eating in their rooms. The meal trays contained a covered plate and an uncovered tart-sized cheesecake. Photographic evidence obtained. At 12:07 p.m. on 11/12/19, Staff Member J, CNA, confirmed the cheesecakes were not covered and stated the kitchen sent them to the unit uncovered. On 11/14/19 at 12:44 p.m., the Dietary Manager stated dessert on the meal trays are to be covered. He stated even though the carts are covered, the food should also be covered and felt the kitchen staff was trying to preserve the presentation. Based on dining observations, interviews and record review the facility failed to serve food in a safe and sanitary manner related to 1) food being prepared in close proximity to a hand hygiene sink/soap; 2) uncovered desserts transported to unit and 3) lack of hand hygiene between residents in one of four dining observations. Findings included: 1. On 11/12/19 at 11:47 a.m., an observation 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.