Westminster Commons

Based on observation, record review, staff interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for two of 46 sampled residents (Resident (R) 9 and R18). Failure to code the MDS correctly regarding R18's feeding tube, and R9 for hospice care, could lead to inaccurate assessment and care planning of the resident. Findings include: Review of the RAI Manual, dated 10/01/19 indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment . 1. Review of R9's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 11/13/20 and a readmission date of 01/21/21, with medical diagnoses that included adult failure to thrive and unspecified dementia. Review of R9's Physician order,…

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

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure care plans were comprehensively developed for two of 46 sampled residents (Resident (R) 18 and R52) reviewed for care plans. This deficient practice placed the residents at risk for unmet care needs. Findings include: Review of the facility policy titled Care Plan-Comprehensive, dated 01/23, revealed A Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident. An Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a Comprehensive Care Plan for each resident. The Comprehensive Care Plan has been designed to: . identify the professional services that are responsible for each element of care; . Incorporate risk factors associated with identified problems. 1. Review of R18's admission Record located in the EMR under the Profile tab, revealed an admission date of 04/16/25 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 record review, resident and staff interviews, and facility policy review, the facility failed to ensure timely medication administration for one of seven residents (Resident (R) 286) reviewed for medication administration of 46 sample residents. The facility further failed to ensure physician orders were followed for the administration of medications using the gastrostomy (G-Tube) for one of six residents (Resident (R) 18). This had the potential for creating anxiety to the resident and possible medication administration errors or choking. Findings include: Review of the facility's policy titled, Administering Medications, dated 04/19, revealed Medications are administered within one (1) hour of their prescribed time, unless otherwise specified. 1.Review of R286's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] and had a discharge date of 01/18/25 with diagnoses which included chronic obstructive pulmonary disease,…

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 interview, record review, and facility policy review, the facility failed to ensure residents with a urinary catheter bag were properly positioned in a manner to prevent potential urinary tract infections due to contamination for one of three residents (Resident (R)10) reviewed for urinary catheters out of a total sample of 46 residents. The failure to ensure catheter bags were properly positioned placed the resident at risk of infection. Findings include: Review of the facility's undated policy titled, Indwelling Urinary Catheter Use, revealed It is the policy of the facility to ensure the appropriate use of indwelling urinary catheters in accordance with State and Federal Regulations, and national guidelines .Indwelling urinary catheters and drainage bags should not be changed at routine or fixed intervals. Indwelling urinary catheters and drainage bags are changed when there is indication of infection, obstruction, or as clinically indicated. Review of R10's admission Record,…

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

Based on observations, staff interviews, record review, and policy review, the facility failed to ensure a resident with side rails was assessed for entrapment, evaluated for need, informed of the risks/benefits, and failed to obtain a physician's order for side rail use for one of one residents (Resident (R) 20) reviewed for side rails out of a total sample of 46 residents in the sample. This had the potential for safety risks to the resident. Findings include: Review of the facility policy titled Bedrails, with no revision date, revealed, The facility shall provide adequate management of Bedrails to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. If a bed or side rail is used, the facility will ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. a. Assess the resident for risk of entrapment from bed rails prior to installation. b. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior 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 staff interviews, record review, and review of facility policy, the facility failed to ensure residents reviewed for verbal and physical abuse had accurate documentation of the abuse incidents in the resident record for one of nine residents (Resident (R) 189) reviewed for abuse out of a total of 46 resident in the sample. The deficient practice had the potential for facility residents to not be identified for potential incidents of abuse, which could affect physical and psychosocial well-being. Findings include: Review of the facility's policy titled, Medical Records, dated 08/2022, revealed It is the policy of the facility to maintain Medical Records in accordance with State and Federal Regulations .The facility will maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible, systematically organized. Review of R189's admission Record located in the EMR under the Profile tab revealed an admission date of 08/29/24. The resident discharged on 10/13/24. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the facility policy titled, Fall Prevention Protocol Policy, the facility failed to adequately supervise, accurately evaluate and identify risk, analyze recurrent falls, and implement new interventions for one of three residents (R) (R2) reviewed for falls. Specifically, the facility failed to ensure fall interventions were implemented for R2 after having two documented fall incidents. Findings include: Review of the facility policy titled Fall Prevention Protocol Policy revised 10/18/2021 revealed under step 1. All residents/patients are screened for fall risk on admission, significant change of condition, quarterly and annually. 4. After an incident of a fall: a. Complete the Post Falls Assessment. d. Complete pain assessment after the fall. g. Referrals, interventions, care plan updates completed in the clinical meeting. h. Review fall incident during the clinical meeting with a root cause analysis. Review of the electronic medical record (EMR) for R2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer or provide documentation of consent or refusal for three of five residents (Residents (R)3, R50, and R34) of 22 sample residents reviewed for pneumonia vaccinations and/or their representatives, the opportunity for the residents to be vaccinated in accordance with nationally recognized standards. Findings include: Review of CDC website titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html, last reviewed 9/22/2023, indicated . CDC recommends pneumococcal vaccination for all adults 65 years or older. The tables below provide detailed information . For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give one dose of PCV15 [pneumococcal conjugate vaccines] or PCV20 . If PCV15 is used, this should be followed by a dose of PPSV23…

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 staff interviews, record review, and review of the facility policy titled, Facility Abuse Prevention, the facility failed to prevent resident to resident abuse on 7/04/2023, 9/03/2023, and 10/19/2023 for four of four residents (Resident (R) 43, R58, R22, and R24) of 22 sample residents from R50 resulting in a minor scratch injury to R43's face on 9/06/2023 and a skin tear to R58's right hand on 10/19/2023. Findings include: Review of the facility's policy titled, Facility Abuse Prevention, last reviewed on 11/15/2022, revealed Standard: The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. During a resident group meeting on 1/16/2024 at 3:00 PM, R54, R20, and R47 verbalized fear of R50's continued abusive behavior. 1. Review of R50's Face Sheet found under the Profile tab of the electronic medical record (EMR) revealed an admission date of 10/09/21 with diagnoses 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.

Based on staff interviews, record review, and review of the facility policy titled, Abuse Prevention Policy, the facility failed to report an allegation of abuse to the state agency for one of eight residents (Resident (R) 54) of 22 sample residents. Findings include: Review of the facility's policy titled, Abuse Prevention Policy, dated 11/15/2022, revealed .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made . Review of R54's undated admission Record under the Profile tab in the electronic medical record (EMR) revealed R54 admitted to the facility with diagnoses which included dementia, hypertensive heart disease with heart failure, and atrial fibrillation. Review of R54's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (AR) of 12/22/2023 coded the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R54 had intact…

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 staff interviews, record review, facility document review, and review of the facility policy titled, Abuse Prevention Policy, the facility failed to thoroughly investigate an allegation of abuse for one of eight residents (Resident (R) 54) reviewed for abuse of 22 sample residents. Findings include: Review of the facility's policy titled, Abuse Prevention Policy, dated 11/15/22, revealed .Components of an investigation may include a) interview with the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. b) interview all witnesses separately. include roommates, residents in adjoining rooms, staff members in the area and visitors in the area. Obtain witness statements, according to policy. All statements should be signed and dated by the person making the statement. c) Document the entire investigation chronologically. d) Notify the Local Ombudsman office to report the alleged abuse. e) Ensure that all alleged violations involving abuse, neglect, exploitation, or…

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 interview, record review, and review of the facility policy titled, Notice Before Discharge, and Transfer, the facility failed to notify the State Long-Term Care Ombudsman of the hospital transfers. for one of one resident (Resident (R) 81) of 22 sample residents. Findings include: Review of the facility's policy titled, Notice Before Discharge, and Transfer dated November 2022, revealed Standard of Practice .4. This facility shall send a copy of the notice to the representative to the Office of the State Long Team Care (LTC) Ombudsman for a facility-initiated transfers or discharge. Review of the undated admission Record located under the Profile tab of the electronic medical record (EMR) revealed R81 was admitted to the facility with diagnoses of calculus of gallbladder and hyperlipidemia. Review of the Progress Note located under the Prog [Progress] Note tab of the EMR, dated 12/02/2023, indicated Resident received in bed with labored breathing . writer was asked by DON [Director of Nursing] to transfer resident to the hospital, 911 was called, resident was transferred…

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 staff interviews, record review, and review of the facility policy titled, Care Plan Policy, the facility failed to develop a comprehensive person-centered care plan for two of two residents (Resident (R) 27 and R29) of 22 sample residents reviewed for care plans. Findings include: Review of the facility's policy titled, Care Plan Policy, approved November 2023, indicated Each resident will have a plan of care to identify problems, needs, strengths, that will identify how the facility staff will provide services to attain or maintain the residents highest practicable physical, mental, and psychosocial wellbeing. 1. Review of R27's undated admission Record found under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted to the facility with diagnoses of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the admission Minimum Data Set (MDS) found under the MDS tab of the EMR, revealed R27 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating he was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and review of the facility policy titled, Facility Care Plan Policy, the facility failed to review and revise care plan interventions for one of two residents (Resident (R) 60) reviewed for care plans of 22 sample residents. This failure had the potential to delay appropriate interventions for care needs and safety concerns. Findings include: Review of the facility's policy titled, Facility Care Plan Policy, with a review date of November 2023, revealed that the plan of care was to be reviewed and updated as necessary at the completion of every assessment by the interdisciplinary team and resident representative party if so desired. Review of R60's Face Sheet found under the Profile tab of the electronic medical record (EMR) revealed an admission with diagnoses of diabetes, pancreatic disease, iron deficiency anemia, dysphagia, pain, wrist drop, and repeated falls. Review of R60's Care Plan, dated 10/13/2023 and located under the Care Plan tab of the EMR,…

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 staff interviews, record review, and review of the facility policy titled, Administration of Medications, the facility failed to administer a physician ordered antibiotic medication for one of one resident (Resident (R) 79) of 22 sample residents. Findings include: Review of the facility's policy titled, Administration of Medications, dated 11/15/2022, revealed .Medications must be administered in accordance with the orders (physician orders) . Review of R79's undated admission Record located under the Profile tab in the electronic medical record (EMR) revealed the resident was admitted to the facility with diagnoses which included otitis media of the right ear, abscess of the external right ear, and mastoiditis of the right ear. Review of COMS-Clinical admission Evaluation V2 located under the Assessment tab in the EMR revealed the mental status of R79 was alert but experienced some forgetfulness. Review of the Physician Orders located under the Orders tab in the EMR, dated 12/20/2023, revealed Ampicillin-Sulbactam Sodium Injection Inject three grams intramuscularly every…

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 staff interviews, record review, facility document review, and review of the facility policy titled, Dialysis, Care of the Resident Receiving Dialysis Treatments, the facility failed to have ongoing communication and collaboration with the dialysis center for one of one resident (Resident (R) 3) reviewed for dialysis out of 22 sample residents. Findings include: Review of the Dialysis Contract, dated 6/21/2023 and provided by the facility, revealed .Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Nursing Facility and ESRD [End Stage Renal Disease] Dialysis Center . Review of the facility's policy titled, Dialysis, Care of the Resident Receiving Dialysis Treatments, dated 10/20/2022, revealed .Arrange for dialysis as ordered. Send Dialysis Information Transfer Form with resident . Post dialysis Assessment to be completed. Review of R3's undated admission Record under the Profile tab in the electronic medical record (EMR) revealed R3 was admitted to the facility with diagnoses which included end stage renal…

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 staff interview record review and, the facility failed to ensure the monthly review of drug regimens were completed by a licensed pharmacist for two of two residents (Resident (R) 29 and R50) reviewed for monthly regimen review of 22 sample residents. This failure has the potential to impact the residents' health and wellness. Findings include: 1.Review of R29's Face Sheet found under the Profile tab of the electronic medical record (EMR) revealed an initial admission date of 7/10/2021 with diagnoses of dementia, cerebral infarction, diabetes, hypertensive heart, end stage renal disease, hypoxemia, anemia, repeated falls, and insomnia. Review of R29's Consultant Pharmacist Note found under the Miscellaneous tab of the EMR revealed a documented pharmacy review dated 9/18/2023 recommending no changes. During an interview on 1/19/2023 at 3:30 PM the Director of Nursing (DON) stated that there were no additional monthly medication reviews found for R29. The DON further stated that she had been trying to develop a system for reviewing recommendations and documenting…

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

Based on observation, staff interviews, record review, and review of the facility policy titled, Administration of Medication, the facility failed to ensure the medication error rate was less than five percent for two of seven residents (Resident (R) 41 and (R)235) resulting from eight errors out of 29 opportunities for a medication error rate of 27.59 percent. Findings include: Review of the facility's policy titled, Administration of Medications dated 11/15/2022 revealed . Medications must be administered in accordance with the orders [physician orders] . Review of the facility's policy titled, Administration of Medication, dated 11/15/2022, revealed .Licensed Nurse/CMT [Certified Medication Tech] giving medication must follow the six rights to ensure safe medication administration. Each time you administer a medication, you need to be sure to have the: 1. Right individual; 2. Right medication; 3. Right dose; 4. Right time; 5. Right route; 6. Right documentation . 1. Review of R41's undated admission Record under the Profile tab located in the electronic medical record (EMR)…

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 facility policy review, the facility failed to store physician ordered medications in a locked compartment for one of one resident (Resident (R)234), failed to discard medications that were not administrated for one of one resident (R10), and failed to discard expired medications located in the refrigerator on the Memory Care Unit. Findings include: Review of the facility's policy titled, Storage of Medications and Biologicals, dated 11/29/22, revealed . Facility should ensure that all medications and biologicals, including treatment items, are securely stored in locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. All Medication, Treatment carts must be secured/locked when not attended by licensed staff. 1. Review of the undated admission Record under the Profile tab in the electronic medical record (EMR) revealed R234 was admitted to the facility with diagnoses of diabetes mellitus, dementia, myocardial infarction, and hypertension. During the Medication Administration Observation on 1/17/2024 at 9:14 AM,…

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, record review, and facility's document review, the facility failed to implement the communication process, including how the communication would be documented between the facility and the hospice provider to ensure one of one resident (Resident (R) 49) needs were met and addressed of 22 sample residents. Findings include: Review of the undated Agreement for Hospice Care for Skilled Nursing Facility and Nursing Facility Residents, provided by the facility, revealed Section 1.6 Coordination of Services indicated, .d. Provide for an and ensure the ongoing sharing of information between all disciplines providing care and services in all setting, whether the care and services are provided directly or under arrangement. e. Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions Review of R49's admission Record located under the Profile tab of electronic medical record (EMR) revealed…

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

Based on record review, staff interview, and review of facility policy titled, Infection Prevention and Control Program Overview, the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infection. The facility census was 72 residents. Findings include: A review of the facility policy titled Infection Prevention and Control Program Overview Issued November 28,2016 and last reviewed October 2021 revealed the following (not all inclusive) Goals The goals of the infection prevention program are to: A. Decrease the risk of infection to residents and personnel. B. Monitor for occurrence of infection and implement appropriate control measures C. Identify and correct problems relating to the infection prevention practices. D. Maintain compliance with state and federal regulations relating to infection prevention. Scope of The Infection Prevention and Control Program The infection prevention program is comp A. Surveillance of 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 record review and staff interview, and review of the facility policy titled, Antibiotic Stewardship, the facility failed to ensure it developed and implemented an Antibiotic Stewardship Program to include antibiotic use protocols and a system to monitor antibiotic use. This had the potential to affect all 72 residents who reside in the facility. Findings include: During a review of the facility policy titled Antibiotic Stewardship Issued November 2016 and last reviewed November 2019 revealed a policy statement: Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. Standards of Practice: 1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. The policy explains the orientation, training and education, prescriber information to be provided, and other pertinent information related to monitoring antibiotics. During the entrance conference on 5/31/22, the team leader requested all…

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, record reviews, and facility policy titled, Facility Testing requirements for Staff and Residents. The facility failed to produce evidence of testing of residents and staff for the COVID-19 virus based on recommendations from the Centers of Disease Control (CDC), the Centers for Medicare and Medicaid (CMS) and the level of community transmission rates. The facility did not maintain testing logs or line listing forms for the residents or staff. The facility census was 72 residents. Findings include: A review of facility policy titled Facility Testing Requirements for Staff and Residents revised CMS: QSO -20-38-NH Testing of Staff and Residents Regulations issued September 4, 2020, revised September 24,2021 revealed the following: Policy statement: To enhance efforts to keep Coronavirus COVID-19 from spreading throughout this facility, the facility shall provide on-site testing. Staff and residents will be tested in adherence to Centers of Medicare and Medicaid Services guidance. Outbreak Trigger testing: Test all staff and residents in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews and reviews of the facility policy titled Documentation Policy the facility failed to ensure licensed nursing staff accurately documented daily wound care for two (2) of six (6) residents (R) (R#50 and R#58) reviewed for pressure related wounds. Findings include: Review of the policy titled Documentation Policy reviewed 10/2018, indicated: A designated staff member will chart on all residents to maintain a complete and accurate medical record. 1. R#50's was admitted to the facility on [DATE] with diagnoses that included but not limited to fractured ribs, falls, dementia, osteoporosis, and hypertension. Review of R#50's significant change Minimum Data Set (MDS) dated [DATE] revealed Section G-Functional Status: resident required extensive assistance with bed mobility, dressing, was total dependent for transfers, locomotion, eating, toileting, and personal hygiene; Section M-Skin: resident had one (1) pressure ulcer not present on admission and 2 unstageable deep…

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.