Pruitthealth - Brookhaven

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record reviews, and review of the facility's policy titled Care Plans, the facility failed to develop a baseline care plan that addressed care and management for a PICC (peripherally inserted central catheter) line within 48 hours of admission for one of four residents (R) R542 reviewed with PICC lines. This deficient practice had the potential to increase the resident's risk of adverse health outcomes related to PICC lines. Findings include: Review of the facility's policy titled Care Plan dated 12/31/1996 under the section titled, Procedure revealed, New admission Baseline Plan of Care 1. Upon a new admission, a baseline care plan will be developed by the attending nurse/nurses in conjunction with other Inter- Disciplinary Team (IDT), the patient, resident and or patient /resident representative. The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission. 2. The Baseline Care Plan will be updated to reflect changes 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 staff and resident interviews, record reviews, and review of the facility's policy titled Care Plans, the facility failed to develop a resident centered care plan for one of five residents (R) R68 reviewed for unnecessary medication use, that included problem, goals or interventions related to diuretic use, and one of six residents (R101) for enteral feedings received through a gastrostomy tube (G-tube). In addition, the facility failed to develop a comprehensive care plan for one of four residents (R6) with a seizure disorder that included necessary seizure precautions, to ensure the resident's optimal physical, mental, and psychosocial well-being. Findings include: Review of the policy titled Care Plans, with an effective date of 12/31/1996, under the Policy Statement revealed, It is the policy of the health care center for each resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following the completion of the [NAME] Data Set (MDS) and Care Area…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and record reviews, the facility failed to provide nail care for one of four residents (R) R101 reviewed for Activities of Daily Living (ADLs). Specifically, the facility failed to and trim R101's long fingernails on both hands and clean fingernails on his left hand. The deficient practice had to the potential to cause skin breakdown and infection to the palm of hands with contractures. Findings include: Review of the Electronic Medical Record (EMR) for R101, revealed that he was with diagnoses that included but were not limited to cerebral infarction and contractures of right upper arm. Review of the care plans for resident R101 revealed that he has Activities of Daily Living (ADL) decline related to cardiovascular accident (CNA) with right sided hemiplegia, right arm contracture, sepsis, protein calorie malnutrition. Review of the admission Minimum Data Set (MDS) dated [DATE] for R101, Section GG (Functional Abilities and Goals) revealed, he was dependent for personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review and review of the facility's policy titled Activities Program, the facility failed to provide an ongoing program of activities based on person-center activities for three of nine residents (R) (R92, R121, and R540) reviewed for activities whose primary language was non-English. Findings Include: Review of the facility's policy titled Activities Program, dated 9/28/2023 under the section titled Procedure revealed, 5. The programming should reflect cultural and ethnic interests of the resident. Review of records revealed the facility had nine residents whose primary language was non-English. 1. Review of the clinical records for R92 revealed she was admitted to the facility with diagnoses that included but not limited to cerebral infarction, emphysema, unspecified, unspecified asthma, uncomplicated, pneumothorax, unspecified, muscle weakness, acute respiratory failure with hypoxia, shortness of breath, chest pain, chronic obstructive pulmonary…

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, staff interviews, record review, and review of the facility's policy titled Medication Administration: Enteral Tubes, the facility failed to ensure that one of seven residents (R) R101 received enteral feedings, as ordered and to properly label and date the formula bottle, bags, and syringes used to provide the resident with needed nutrients. Findings include: Review of the facility's policy titled Medication Administration: Enteral Tubes dated 1/30/2020 under the Policy Statement revealed, The healthcare center provides safe and effective administration of enteral formula and medications. Enteral formulas will be administered via feeding tube by the physician order following nursing assessment of the resident's condition and in consultation with the dietitian and consultant pharmacist . Review of the Electronic Medical Record (EMR) for R101, revealed he was admitted to the facility with diagnoses that included but were not limited to cerebral infarction, enterocolitis due to Clostridium…

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, resident and staff interviews, and review of the facility's policy titled Oxygen Administration, the facility failed to follow physician orders for oxygen therapy for one of 19 residents (R) (R8) on oxygen therapy. In addition, the facility failed to change nebulizer equipment weekly and cover nebulizer masks when not in use for one of 19 residents (R539) on oxygen therapy. This deficient practice posed significant risks, including potential medical complications, unmet needs, and a diminished quality of life for the resident. Findings include: Review of the facility's policy titled Oxygen Administration dated 8/2/2023 under the section titled Policy Statement revealed, It is the policy of [Name of Facility] Hospice and Healthcare Centers/Veteran Homes to provide oxygen safely and accurately to appropriate patients/residents. Under the section titled Procedure: revealed, Oxygen will be administered by licensed personnel only when ordered by the physician, PA or NP. The physician order may…

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, staff interviews, record review, and review of the facility's policy titled Labeling, Dating, and Storage, the facility failed to label dry goods and discard on or before the expiration date. In addition, the facility failed to label and store frozen food items in the freezer to ensure proper food safety and to maintain proper ice machine cleaning. The facility had a census of 119 residents that received an oral diet from the kitchen. Findings include: Review of the facility's policy titled Labeling, Dating, and Storage, dated 11/11/2022 under the section titled Policy Statement revealed, It is the policy of [Name of Facility.] for all partners who assist in handling, preparing, serving, and storing food and beverage items to follow the proper procedures for labeling, dating, and storage to ensure proper food safety. Under the section titled, Scope revealed, This applies to all Dietary partners employed by [Name of Corporation.] Under the section titled Procedure revealed, 1. Food 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, record review, facility document review, and review of facility policies titled P.I.C.C. (peripherally inserted central catheter) Catheter Dressing Change, P.I.C.C. Infusion Access Device Maintenance, and Infection Prevention-Hand Hygiene policy, the facility failed to follow infection control practices for three of 14 residents (R) (R549, R543 and R16). Specifically, the facility failed to ensure proper hand hygiene and physicians orders for dressing change were followed when providing care of the P.I.C.C. for (R549 and R543) and failed to follow procedure for catheter care for (R16). Findings include: Review of facility's Policy titled P.I.C.C. (peripherally inserted central catheter) Catheter Dressing Change revised 10/23/2024 documented Policy Statement: [Facility name] pharmacy services requires that PICC infusion access device site care must be established in order to observe infection control policies and procedures. The procedure should be completed once a week and PRN…

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 staff interviews the facility failed to provide a safe and comfortable environment for the residents, staff and the public as evidenced by an unpleasant odor on one hall (South Wing) of three halls. This deficient practice had the potential to cause diminished quality of life. The facility census was 128 residents. Findings include: Observations from 11/3/2024 through 11/7/2024 during survey revealed an unpleasant odor was present on the South Wing of the facility. Review of facility's documents revealed there was no evidence of a facility's policy regarding environment - free from unpleasant odors. Interview on 11/7/2024 at 11:26 am with Floor Technician WW revealed, he sweeped and vacuumed the hallways daily. He also stated he would apply liquid disinfectant on the carpet only if there was a stain on the carpet. Interview on 11/7/2027 at 11:35 am with the Housekeeping Supervisor, confirmed the South Wing hallway had an odor which could be due to the area having heavy wetters. Interview on 11/7/2024 at 11:36 am with Administrator, she confirmed there had…

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, staff interviews, and review of the policies titled Infection Prevention and Control Program Surveillance Reporting and Hand Hygiene and Contact Precaution Compliance and review of the RN/LPN Annual Skills Fair 2023, the facility failed to ensure infection control practices were maintained to prevent the potential for infections and cross contamination. Specifically, the infection control data for August 2023 was not analyzed for trends in urinary tract infections that include appropriate corrective actions and staff failed to wash/sanitize hands after glove removal and prior to donning clean gloves during wound care for one resident (R) (R34). The census was 110. Findings include: 1. Review of the facility policy titled Infection Prevention and Control Program Surveillance Reporting revised 11/30/2023 revealed the policy is to establish and maintain an Infection Control Program that includes detection, prevention, and control of the transmission of disease and infections…

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 the policies titled Resident Rights and Daily Occupied Resident Room Cleaning, the facility failed to ensure it was maintained in a safe, clean, and comfortable home-like environment in nine resident rooms on two of three halls, including the common areas and the shower rooms and equipment used for showers. The census was 110. Findings include: Review of Resident Rights revealed under Safe Environment section revealed that residents have the right to a safe, clean, comfortable, and homelike environment . Review of the policy titled Daily Occupied Resident Room Cleaning dated 10/23/2023, revealed that daily cleaning of resident's room should include sweeping the floors, damp mop floors, report any needed work orders for repair, and use disinfectant spray on surfaces. Observation on 4/30/24 at 9:50 am during initial tour of the facility revealed there was a strong malodorous odor upon entrance of building. Observation on 4/30/24 at 9:52 am, during 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 observations, record review, staff and resident interviews, and review of the policy titled Activities Program, the facility failed to ensure an ongoing program of activities based on preferences for three of three residents (R) (R8, R35, R19) reviewed for activities. These residents were not provided with person-centered activities that would meet their individual needs. Findings include: Review of the policy titled Activities Program revised 9/28/2023, the policy statement revealed the center provides an ongoing program of activities designed to meet the physical, mental, and psychosocial well-being of each resident while offering a rich array of activities to the residents of the center. Procedure: Number 3. There shall be at least one different structured recreational activity provided daily each week that shall accommodate resident's needs/interests/capabilities as indicated in the care plan. Number 4. The facility posts a monthly schedule of planned activities for easy review in the center. This…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and a review of the facility policies titled Influenza (Flu) Vaccinations for Health Care Center Residents and Pneumococcal Vaccinations, the facility failed to ensure that five residents (R) (R8, R15, R16, R40, and R45) reviewed for vaccination status, received education, were offered, consented to receive, and/or refused the pneumococcal vaccination, of 44 sampled residents. Findings include: A review of the policy titled Influenza (Flu) Vaccinations for Health Care Center Residents, with a revision date of [DATE] revealed the following: * Current and newly admitted residents will be offered the influenza vaccine beginning on [DATE] of each year and it will be offered for as long as the influenza viruses are circulating, and the unexpired vaccine is available. * Residents admitted during the flu season will be offered the vaccine within two weeks of the resident's admission to the facility, if not previously vaccinated during the season. A review of the policy titled…

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, interviews, and review of the facility's policy titled Medication Administration: General Guidelines, the facility failed to assess and determine if it was appropriate for one of eight sampled residents (R) (R36) to self-administer medications left at bedside. This failure placed the resident at risk for inappropriate and unsafe medication use. Findings include: Review of the facility's policy titled Medication Administration: General Guidelines, dated 5/31/2023, Procedure: Number 3. Patients/residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Number 9. Only the licensed or legally authorized personnel that prepare a medication may administer it. Review of R36's clinical record revealed she was admitted to the facility on [DATE] with diagnoses including anxiety disorder, muscle weakness, lack of coordination, pain, diabetes, and mild vascular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of facility policies titled Therapy Evaluations and Specialty Services: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health, the facility failed to accommodate the needs for three of five sampled residents (R) (R15, R39 and R42). Specifically, R15 had order for durable medical equipment (DME) lift chair to accommodate her mobility with transfers to decrease pain; and failed to ensure R39 and R42 had transportation arrangements for follow-up for post-surgical appointments, resulting in need for rescheduling missed appointments. Findings include: Review of the policy titled Therapy Evaluations dated 3/9/2023, revealed the policy is that all physician's orders for therapy evaluations be addressed in a timely manner by Physical, Occupational and/or Speech therapy as designated by the physician. The evaluation will include discipline-specific findings related to the patient/resident's functional status and underlying impairment 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 record review, interviews, and review of the facility policy titled Grievances: Healthcare Centers, the facility failed to ensure prompt resolutions for residents' grievances regarding missing items. The census was 110. Findings Include: Review of the policy titled Grievances: Healthcare Centers, revised 1/10/2024, documented the policy is to follow an established process whereby patients and/or other customers may have their grievances and complaints resolved in a prompt, reasonable and consistent manner. A grievance includes complaints with respect to care and treatment that has been furnished to a patient, as well as that which has not been furnished, the behavior of staff and of other patients, and other concerns regarding the patient's facility stay. Procedure: Number 1. If the grievance is associated with a missing item, refer to the Missing Item Policy and associated forms. Number 5. The grievance/complaint should be resolved within three business days. Number 8. The Administrator will present…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the facility's policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to provide a complete and thorough investigation of allegations of abuse for two of three residents (R) (R10 and R44) reviewed. Findings included: A review of the facility's policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, revealed that interviews should be conducted with all individuals who have relevant information, utilizing open-ended questions. Written signed statements from any involved parties should be obtained (and notarized. if necessary). Statements should be gathered from the following individuals: the suspect; the person(s) making accusation(s); the patient(s) involved; reliable patients who may have witnessed the incident; and any other persons who may have information. The policy continues to document that all investigative information…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and reviews of the policy titled Minimum Data Set (MDS) Assessment Accuracy, the facility failed to ensure that a Significant Change MDS assessment was completed for one resident (R) (R8) who had been placed on Hospice services. The sample size was 44. Findings include: Review of the policy titled Minimum Data Set (MDS) Assessment Accuracy reviewed on 1/11/2024 revealed the policy is that each Minimum Data Set (MDS) reflect the acuity and the medical status of each resident in accordance with acceptable professional standards and practices. Significant Change in Status Assessment (Comprehensive) ARD (Assessment Reference Date) must be no later than the 14th calendar day after the determination of a significant change has been made. Review of the quarterly MDS assessment dated [DATE] revealed that R8 had a Brief Interview for Mental Status (BIMS) of 15, indicating that the resident was cognitively intact. Review of the Physician's Orders for R8 indicated that resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the policy titled Minimum Data Set (MDS) Assessment Accuracy Policy, the facility failed to ensure that resident's ethnicity and language needs were properly assessed on the MDS for one of one resident (R) (R6) reviewed. Review of the Minimum Data Set (MDS) Assessment Accuracy Policy dated 12/6/2022 documented it is the policy of the healthcare center that each MDS reflect the acuity and the medical status of each patient/resident in accordance with acceptable professional standards and practices. The assessment will be scheduled to accurately account for the acuity and complexity of the patient/resident. Each Assessment Reference Date (ARD) will be chosen to capture services rendered and reflect an accurate clinical profile of each patient/resident. Review of the clinical record revealed R6 was admitted to the facility on [DATE] with diagnoses of bacterial infection, unspecified fracture of unspecified thoracic vertebra, cognitive communication deficit,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, interviews and review of Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, the facility failed to ensure that services were provided in accordance with professional standards of quality as evidenced by the failure to conduct weekly skin assessments to identify skin breakdown and provide treatments before pressure ulcer development for two of three sampled residents (R) (R26 and R20) reviewed for pressure ulcers. Findings include: Review of the Georgia Rule 410-10-.02 - Standards of Practice for Licensed Practical Nurses revealed that: (1) The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician practicing medicine, a dentist practicing dentistry, a podiatrist practicing podiatry, or a registered nurse practicing nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration 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, record review, staff and resident interviews, the facility failed to provide activities of daily living (ADL) care for three of 10 residents (R) (R8, R35 and R27) reviewed for ADLs. Specifically, the facility failed to provide showers as scheduled for R8, R35, and R27. Findings include: Review of East Shower Schedule revealed showers were provided for residents on Mondays, Wednesdays, and Fridays from 7:00 am to 7:00 pm or from 7:00 pm to 7:00 am; and on Tuesdays, Thursdays, and Saturdays from 7:00 am to 7:00 pm or from 7:00 pm to 7:00 am. 1. Review of R8's admission Record revealed the resident was admitted to the facility with diagnoses including rhabdomyolysis, type 2 diabetes mellitus with ketoacidosis with coma, hypotension, muscle weakness, cerebellar ataxia, unspecified fall, dysarthria and anarthria, degenerative disease of nervous system, and morbid (severe) obesity due to excess calories. Review of R8's care plan revealed the resident was not care planned for bathing preferences.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the policy titled Documentation of Skin and Wound Care, facility failed to perform weekly skin assessments to identify potential skin breakdown, and implement interventions in a timely manner to prevent unavoidable pressure ulcers, for two of three residents (R) (R26 and R20) reviewed for pressure ulcers. Findings include: Review of the policy titled Documentation of Skin and Wound Care dated [DATE] revealed the policy is to provide current and timely documentation of residents condition related to skin/wound care, accurate information on residents status as it pertains to skin and interventions in place and provide detailed history of the wound assessments that have occurred in the healthcare center. Procedure: Number 1. Documentation regarding wound observations should be completed on pressure ulcers Diabetic wounds and any chronic or complex wounds (weekly) on admission or re-admissions. 1. Review of the clinical record revealed R26 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of the policy titled Restorative Nursing Program and Therapy Evaluations, the facility failed to provide restorative therapy services to attain or maintain the highest practicable physical, mental, and psychosocial well- being for two of four residents (R) (R19 and R27) reviewed who were referred for Restorative Therapy Services. Findings include: Review of the policy titled Restorative Nursing Program dated 11/4/2021 revealed that it is the policy of the facility to provide restorative nursing to the residents to maintain optimal physical, mental, and psychological functioning and well-being. Restorative nursing services are provided by qualified staff that are been trained to do such services. The nurse will complete a restorative care screening tool, determine the appropriate restorative needs and develop a care plan for each restorative service and review the resident's progress to determine discharge from the program. Review of the facilities policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the policy titled Weight Monitoring Program, the facility failed to provide care and services to maintain an acceptable parameter for the nutritional status for one resident (R) (R26), resulting in a 7.82% weight loss in The sample size was 44 residents. Findings include: Review of the policy titled Weight Monitoring Program dated 6/2/2023 documented the weight frequency for new admissions will be weighed weekly times four weeks and/or until weight is stable. A significant weight change is defined as: 5 percent (%) weight Loss or gain in one month; a 7.5% weight Loss or gain in three months; and a 10% weight Loss or gain in six months. Patients/residents will be placed on the Weight Monitoring Program unless the weight loss is anticipated and/or planned. Patients/residents placed on the weight monitoring program will be weighed weekly. Patients/residents with a planned/anticipated weight loss will have documentation of awareness of weight loss and a notation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the policy titled Therapy Evaluations, the facility failed to evaluate a therapy recommendation per two different physician's order for one of three sampled residents (R) (R15) related to providing a Durable Medical Equipment (DME) lift chair. Findings include: Review of the policy titled Therapy Evaluations dated 3/9/2023, revealed the policy is that all physician's orders for therapy evaluations be addressed in a timely manner by Physical, Occupational and/or Speech therapy as designated by the physician. The evaluation will include discipline-specific findings related to the patient/resident's functional status and underlying impairment and prior functional level. Procedure: Number 11. All therapy recommendations will be reviewed with the patient, family/caregiver and the Nursing Department, and subsequent training will be documented and recorded indicating the training components and understanding and competence with the instructions provided. 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 staff interviews and a review of the facility's documents titled, Facility Assessment [name of facility] and Facility Assessment [name of facility] 2024, the facility failed to determine its capacity and capability of the clinical staff to provide the necessary care and services for one of 43 sampled residents (R) (R10). Specifically, R10 wore an external cardiac defibrillator, and facility did not have staff educated on how to care for a resident with an external defibrillator. Findings include: Review of the facility provided Facility Assessment [name of facility], revealed the facility assessment did not include a section addressing cardiac services. A review of the facility provided Facility Assessment [name of facility] 2024 revealed a sufficiency analysis category for heart/circulation. Review of the electronic medical record (EMR) revealed R10 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, dysphagia, anemia, acute myocardial infarction, atherosclerotic heart…

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 interviews, the facility failed to ensure that the call light communication system was functioning adequately to allow residents to call for staff assistance for five of 27 sampled residents (R) (R28, R30, R31, R35, R38). Findings include: 1. Review of the clinical record for R28 revealed the resident was admitted to the facility on [DATE], with diagnoses including hypergammaglobulinemia, shortness of breath, depression, hypertension, muscle weakness, and glaucoma. Review of the admission Minimum Set Data (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The resident had impairment to upper and lower extremities and required maximum assistance with ADL's. R28 was always incontinent of bowel and bladder. Observation on 5/2/2024 at 3:30 pm, revealed R28's call light was noted to be unplugged from the wall. The call light was pushed by the surveyor, and it did not come on. Observation 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 record review and staff interviews, the facility failed to ensure that clinical staff were educated related to the use of a wearable cardioverter defibrillator (WCD) for one of 43 sampled residents (R)(R10). This failure had the potential to place R10 at risk of not receiving necessary care and monitoring for cardiac instability. Findings include: Review of the electronic medical record (EMR) revealed that R10 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, acute myocardial infarction, atherosclerotic heart disease, chronic atrial fibrillation, atrial flutter, ischemic cardiomyopathy, and end-stage renal disease. Resident was admitted with a WCD. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R10 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of the Physician's Order revealed an order dated 7/18/2023 to change battery daily for resident's wearable cardioverter…

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 staff interviews, the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner and failed to ensure the areas surrounding the dumpsters were free of trash debris for two of two dumpsters. Findings include: Observation of the dumpster area on 6/13/21 at 10:55 a.m., revealed several large clear bags of garbage on the top of both dumpsters. The dumpster on the left side closest to the fence had two visible large clear bags filled with trash on the pavement directly in front of the dumpster. Observation of the dumpster area on 6/15/22 at 10:05 a.m., with the Maintenance Director and Administrator, revealed there were several bags of garbage laying on the top of both dumpsters. Further observation revealed two large clear bags of trash on the ground directly placed in front of the dumpster on the left. During a follow up interview on 6/15/22 at 10:06 a.m. with the Administrator and the Maintenance Director confirmed the trash dumpsters were overflowing, and there should not be trash laying on the ground. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations and interviews, the facility failed to develop the appropriate interventions to treat and prevent the development of additional pressures ulcers for one resident (R) (R#104) out of 36 sampled residents. Findings Include: Review of the clinical record revealed that R#104 was admitted to the facility on [DATE] with diagnoses including but not limited to diabetes mellitus, dementia, thrombocytopenia, dysphagia, gastrostomy, and gastroesophageal reflux disease. Review of R#104's care plan revealed a care plan that stated, At risk for skin breakdown r/t (related to) bowel obstruction, atrial fibrillation, acute kidney failure, fecal impaction, dementia history of urinary tract infections, dysphagia, vitamin D deficiency, Alzheimer's, major depression, insomnia actual breakdown sacrum. The care plan did not reveal evidence of preventative wound care approaches or goals such as check for incontinence on rounds and provide perineal care as needed, turn, and reposition, or a pressure…

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, staff interview, and review of facility policies titled, Controlled Substances for Healthcare Centers, Automated Drug Cabinet, and Ordering Medications from the Pharmacy, the facility failed to follow the physician orders for two residents (R) (R#65 and R#724) related to the administration of scheduled medication for two out of two residents The sample size was 36. Review of a procedure titled Medication Administration undated, revealed 17. Ensure medications are given within one hour prior to or after time ordered. 22. Demonstrate proper action to take if medication not taken or given either by refusal/unavailable medication or other contraindications. Review of a policy titled Controlled Substances for Healthcare Centers revised 4/28/21, revealed 3. Prescriptions for medication in controlled substances schedules III-V (Lyrica is scheduled V) may be verbally authorized by the physician contacting the pharmacist directly. The pharmacist will reduce the oral authorization to writing 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.