Cartersville Center For Nursing And Healing

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADLs), the facility failed to provide scheduled showers/baths for two residents (R) (R10 and R45) dependent on staff for ADLs. The facility census was 110 residents. Findings include: Review of the undated facility policy titled Activities of Daily Living revealed under Purpose: To attain or maintain the patient's highest practicable, physical, mental, and psychosocial wellbeing. The policy revealed under Practice Standards: 1. The Center must ensure that: 1.1 A patient is given the appropriate treatment and services to maintain or improve his/her ability to carry out ADLs; and 1.2 A patient who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Review of the electronic medical record (EMR) revealed R10 was admitted with diagnoses of but not limited to chronic obstructive pulmonary disease (COPD), hypertensive chronic kidney disease, and unspecified osteoarthritis.…

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 review of the facility's policy titled, Activities, the facility failed to develop and introduce an activities program for one of 63 sampled residents (R) (R 413). The deficient practice had the potential to place the resident at risk for a diminished quality of life. Findings include: A review of facility's policy titled Activities dated January 2024 revealed a Policy Statement: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designated to meet the interests of each resident, as well as support their physical, mental and psychosocial well-being. An interview and observation on 8/19/2024 at 10:30 am of R413 revealed he was awake and alert, lying in bed. He voiced concern around being moved into this room on 8/15/2024, that there was no television and that was his only entertainment. He was unaware 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 observations, staff and resident interviews, and record review, the facility failed to follow the physician's orders for ointment and compression stockings for one of 63 sampled residents (R) (R413). The deficient practice had the potential to place the resident at risk for medical complications, and a diminished quality of life. Findings included: A review of the electronic medical record (EMR) revealed R413 was admitted with diagnoses including, but not limited to, cellulitis of the right lower limb, lymphedema, venous insufficiency chronic, and heart failure. A review of R413's admission Minimum Data Set (MDS) assessment dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment). A review of R413's Physician Orders dated August 2024 revealed an order dated 8/2/2024 for skin assessment to be done on day shift every Friday. Further review revealed an order dated 8/15/2024 for wound care to bilateral…

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, and review of the facility policy titled, Oxygen (O2) Safety the facility failed to ensure O2 tanks were securely stored in a designated location to prevent accidents and hazards for one of eight residents (R) (R163) who use O2. Findings include: A review of the facility policy titled Oxygen Safety detailed 1. Safety is the responsibility of all staff, residents, visitors, and the general public. 4. Oxygen Storage- a. Oxygen storage location shall be in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors or gates that can be secured against unauthorized entry. c. Cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty. Observation on 8/19/2024 at 11:30 am revealed R163 sitting in a wheelchair in her room. Two O2 tanks (e-cylinder) were in the corner of R163's room between the bedside table and the bed. Both O2 tanks were in an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility's policies titled, Medication Administration, and Pain Management, the facility failed to ensure pain management was provided for one of two residents (R) (R68) reviewed for pain management. The deficient practice had the potential of unmet needs and a diminished quality of life. Findings include: A review of the facility's policy titled Medication Administration dated January 2023 revealed a Policy Statement as follows: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent infection or contamination. A review of the facility's policy titled Pain Management dated August 2023 revealed a Policy Statement as follows: The facility must ensure that pain medication is provided to residents who require such services, consistent with professional standards…

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, and review of the facility's policy titled, Medication Storage, the facility failed to lock the medication cart for one of two medication carts; and found expired, used and new items co-mingled in bags, sink, and storage box in one of two medication storage rooms. The deficient practice had the potential for residents, unauthorized staff, and visitors to have access to medications and biologicals stored on the medication cart and staff to use contaminated items. The facility census was 110 residents. Findings include: A review of the facility's policy titled Medication Storage dated [DATE] revealed under General Guidelines: a. all drugs and biologicals will be stored in locked compartments under proper temperature controls. b. During a mediation pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 8. Unused medications: the pharmacy and all medication rooms are routinely inspected by…

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 policy titled, Documentation in Medical Record, the facility failed to maintain accurate documentation of care and services provided for one of 63 sampled residents (R) (R413). Findings include: A review of the facility policy titled, Documentation in Medical Record, dated November 2023, revealed the Policy Statement stated, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the residents' progress through complete, accurate, and timely documentation. The section titled Principles of Documentation section three included a. Documentation shall be factual, objective, and resident centered. False information shall not be documented. A review of the clinical record revealed R413 was admitted on [DATE] with diagnoses including, but not limited to, cellulitis of the right lower limb, lymphedema, venous…

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 facility's policies titled, Catheterization of a Male, Infection Prevention and Control Program, and Transmission-Based Precautions, the facility failed to maintain infection control protocol during indwelling urinary catheter insertion for one of seven residents (R) (R15) with an indwelling catheter, to perform hand hygiene during medication administration for one resident (R53), and to keep doors closed for contact isolation in two of four residents (R23 and R25) on contact isolation. The deficient practice had the potential to cause infection and adverse health outcomes. Findings include: Review of facility's policy titled Catheterization of a Male revised August 2024 revealed under Policy: Urinary catheterizations will be performed in accordance with current standards of practice to minimize risk for bacterial contamination or urethral trauma. Review of the facility's policy titled Infection Prevention and Control Program with a…

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

Based on observations, staff interviews, record review, and review of the facility policy titled, Handwashing and Hand Hygiene, the facility failed to follow proper infection control practices to prevent the spread of disease for one of seven sampled Residents (R) (R1). Specifically, staff entered R1's room, who was on contact isolation, without washing their hands or wearing gloves and a gown. Findings include: Review of the undated facility policy titled Handwashing and Hand Hygiene revealed under Policy Interpretation and Implementation 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents. and visitors. 1. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 7. Use an alcohol-based hand rub…

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, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent the potential spread of foodborne illness to all 104 facility residents. Concerns included improper dishwashing, inadequate sanitizer solutions, meat thawing, ice dispensing procedures, labeling, and food handling. Findings include: 1. The initial kitchen inspection was completed with the Dietary Manager on 07/12/22 from 9:43 AM to 10:07 AM. The following concerns were noted: a. The Dietary Manager (DM) stated she had been employed in her position for three weeks and was working on bringing the dietary department back up to acceptable standards. The DM stated, The dishwasher went down last night and indicated staff were using the three-sink method to wash dishware as well as pots and pan. The DM stated she called the company who serviced the dish machine to come and repair the machine, and in the meantime had started a deliming process. The DM stated staff used disposable dishware and silverware for serving breakfast. Coffee mugs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy, the facility failed to ensure three of eight residents (R) (R14, R97, and R43) were treated with dignity and respect in a manner to enhance quality of life and individuality. Specifically, residents were observed in clothing that was not their own and was too small, improperly dressed in view of other residents, and in soiled clothing. Findings include: Review of the facility's undated policy titled, ''Resident [NAME] of Rights,'' indicated, ''Be Treated with Respect: You have the right to be treated with dignity and respect.'' Review of the facility's undated policy titled, ''Quality of Life-Dignity,'' indicated, ''Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality'' 1. ''Resident shall be treated with dignity and respect at all times.'' 2. ''Treated with dignity'' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.''…

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 ensure a clean, comfortable, and homelike environment for 10 of 33 sampled residents (R) (R48, R17, R45, R33, R257, R9, R31, R24, R59) and one supplemental resident (R155). Specifically, the facility had multiple rooms with holes in the walls, pieces of wall paneling coming off the walls, dirty bathrooms, missing bath bars for washcloths, towels, missing tiles, dirty/torn resident equipment, dirty air conditioner ducts, wall paneling being held together with duct tape, TV cables hanging down, and excessive noise. Findings include: 1. During the initial tour conducted on 07/12/22 at 9:30 AM, observation of Resident (R) 48's room revealed there to be large chunks of rotting food particles in the air conditioning wall unit located next to R48's bed. At this time, there was a large silver bolt sitting on the window seal. During observation on 07/13/22 at 9:07 AM, R48's room revealed the same rotting food particles were observed in the air conditioning wall…

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 provide residents their showers as scheduled and nail care according to the Plan of Care ADL (Activities of Daily Living) for four of six residents (R) (R59, R14, R97, and R3) reviewed for ADL care in the sample of 33. Findings include: Record review of the undated ADL policy: Activities of daily living (ADLs) include Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the center must provide the necessary care and services to ensure that patient's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrates that such diminution was unavoidable. To include hygiene, bathing, dressing, grooming, and oral care, to attain or maintain the patient's highest practicable physical, mental, and psychosocial well-being. The Center must ensure a patient is given the appropriate treatment and services to maintain or improve his/her…

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 facility policy the facility failed to ensure five residents out six (R) (R307, R88, R308, R46 and R153) reviewed for advance directives had their code status consistently documented throughout their electronic medical record (EMR) for easy access to the clinical staff. Findings include: Review of facility-provided policy with no date, titled ''Code Status Orders'' reveled ''Code status communicates to the clinical staff whether the patient, desires cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest . code status will be easily accessible to the clinical staff for all patients. All patients require a code status order as soon as possible upon admission '' Review of facility-provided policy, with no date titled ''Cardiac and/or Respiratory Arrest'' revealed ''.The Center will perform CPR on all patients, except in limited circumstances, unless there is a written physician's order . not to resuscitate (DNR) . Purpose To ensure patient's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to have a system in place to ensure respiratory equipment was bagged when not in use, date/label oxygen tubing and humidifiers when changed out, and clean respiratory filters. The facility also failed to ensure respiratory care consistent with professional standards of practice was provided for four of four residents (R) (R43, R48, R84, and R46,) reviewed for respiratory care/oxygen therapy. Findings include: Review of the facility's policy titled, ''Oxygen Administration,'' revised on 12/12/20, indicated, ''Oxygen will be administered as per MD [medical doctor] order to aid in breathing . Date and initial tubing and humidifiers when started each week. Pre-billed humidifier bottle need only to be changed weekly or when empty if this is before week has been completed.'' 1. Observation and interview on 07/12/22 at 12:07 PM, revealed R43 to be sitting in a wheelchair wearing oxygen via nasal cannula. At this time, R43…

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, interview, record review, and policy review, the facility failed to ensure palatable food was served to nine out of 33 sampled (R) (R59, R47, R31, R97, R71, R43, R38, R30, R46) and residents who attended the resident council. Food was burnt, lacking in flavor, poorly prepared, cold, and condiments were not provided. Findings include: Review of the undated Resident Nutrition Services policy provided by the facility revealed, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. 1. Residents expressed concerns regarding the palatability of food as follows: a. During an interview on 07/12/22 at 12:25 PM, R59 was observed with her lunch meal consisting of chicken/dumplings, beige beans, ice cream and iced tea. R59 stated she did not like the meal and it did not taste good. R59 covered the plate with a lid, indicating she would not eat it and would skip lunch. Review of the Minimum Data Set (MDS) with an assessment…

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, record review and policy review the facility failed to ensure nine out of 104 total residents (R) (R59, R47, R31, R24, R97, R71 R43, R46, R102) and residents who attended the resident council were provided with choices about food and beverages. Findings include: Review of the undated Promoting/Maintaining Resident Self-determination policy provided by the facility revealed, It is the practice of the facility to protect and promote resident rights by promoting and facilitating resident self-determination through support of resident choice .The facility will accommodate the resident preferences to the extent possible . 1. Choices regarding food and beverages Residents expressed concerns regarding a lack of choices regarding food, food portions and beverages during the survey as follows: a. During an interview on 07/12/22 at 12:25 PM, R59 was observed a lunch meal consisting of chicken/dumplings, lima beans, ice cream, and iced tea. R59 stated she did not like the meal, covered the plate with a lid having eaten minimal food, indicating she would not eat…

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, facility policy review, and Pest Elimination Service Reports, the facility failed to ensure an effective pest control system was in place for six of 33 sampled residents (R) (R33, R38, R71, R47, R31, and R34). Specifically, the facility had sightings of live and dead roaches in resident rooms, staff bathrooms, and multiple complaints from residents. Findings include: Review of the facility's undated policy titled, ''Pest Control Program,'' indicated, ''It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.'' Definition: ''Effective pest control program'' is defined as measures to eradicate and contain common household pests (e.g., .roaches .).'' During an interview on 07/12/22 at 9:50 AM, R33 stated, ''The bugs. They are our friends.'' When R33 was asked if he has seen cockroaches in his room before and if he has told anyone, R33 stated, ''Yes, they know about it.'' One large dead black…

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 facility policies, the facility failed to ensure one of one resident (R) (R308) reviewed for self-administration of medication had a physician's order to safely perform self-administration of medication. The facility's deficient practice had potential for medication errors to occur for R308. Findings include: Review of facility-provided policy titled ''Medication: Self Administration'' dated December 2021 revealed ''. A physician/mid-level provider order is required .To provide a safe, effective process for patient self-administration.'' Review of facility-provided undated policy titled ''Nebulizer Therapy'' revealed ''.Observe resident during the procedure for changes in condition.'' Review of R308's electronic medical record (EMR) under her ''Profile'' tab revealed she was admitted to the facility on [DATE]. Review of R308's ''Med Diag'' tab revealed multiple diagnoses to include renal failure and diabetes. Review of R308's physician's orders under…

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 review, interviews, and facility policy review, the facility failed to ensure basic accommodation of needs for one of one sampled residents (R) (R257) reviewed for accommodation of needs were provided. Specifically, the facility failed to ensure R257's call light was within reach, and also failed to ensure the residents bed was in good working condition. The foot board to R257's bed was observed to be broken and hanging off the bed. Findings include: Review of the facility's undated policy titled, ''Quality of Life-Dignity,'' indicated, ''Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.'' Review of the facility's undated policy titled, ''Answering the Call Light,'' indicated, ''When the resident is in bed . be sure the call light is within easy reach of the resident.'' Observation on 07/12/22 at 11:00 AM, revealed R257 lying in bed asleep. At this time, the resident's foot board of the bed was observed hanging off the bed while the resident was sleeping. At this time, the call…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to ensure an allegation of neglect was reported to the State Survey Agency for one of three residents (R) (R47) investigated for abuse. R47 reported having her call light taken away and placed out of her reach and her incontinence/toileting needs not being addressed for five hours. The incident was not reported to the State Survey Agency. Findings include: Review of the Abuse, Neglect and Exploitation policy dated 01/01/22 and provided by the facility revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property . Neglect means a failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . 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, interview, record review and policy review, the facility failed to ensure an allegation of neglect was thoroughly investigated for one of three residents (R) (R47) investigated for abuse. R47 reported having her call light taken away and put out of her reach and her incontinence/toileting needs not being addressed for five hours. Findings include: Review of the Abuse, Neglect and Exploitation policy dated 01/01/22 and provided by the facility revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, . Neglect means a failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure two of 33 sampled residents (R) (R256 and R52) had baseline care plans developed and implemented to address the resident's immediate needs within 48 hours of admission to the facility. R256 did not have a baseline care plan implemented. R52's baseline care plan did not address R52's dementia diagnoses. Findings include: Review of the facility's undated policy titled, ''Care Plans-Baseline,'' indicated ''A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services .the baseline care…

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 policy review, the facility failed to ensure each resident had a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for two of 33 sampled residents (R) (R3 and R41). Findings include: Review of the paper ''Care Plans Comprehensive Person-Centered'' undated policy, provided by the facility, revealed ''A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care planning process will reflect the resident's expressed wishes regarding care and treatment goals; The interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition.'' Review of the facility-provided policy titled Dementia Care no date revealed It is the policy of 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 observation, interviews, record review, and facility policy review, the facility failed to ensure one of 33 sampled residents (R) (R38) was being invited to regular care plan meetings. The facility also failed to have documentation to show the resident care plan meetings were being held regularly or with input from the resident. By not involving residents in their care, they are unaware of changes that may be made, or decisions made. Findings include: Review of the facility's undated policy titled, ''Care Plans, Comprehensive Person-Centered,'' Indicated, ''The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family . develops and implements a comprehensive, person-centered care plan for each resident . Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate . request meetings, request revisions to the plan of care, participate in establishing the expected goals and outcomes of care . The care planning process will:…

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 policy review, the facility failed to ensure resident's received care in accordance with nursing standards, specifically clarifying an order for an antibiotic without an end date and taking appropriate action when prescribed medications were not in stock, two out of 33 total sampled residents (R) (R59 and R46). R59 missed doses of an antibiotic prescribed by the physician and received the antibiotic for longer than the provider intended. R46 missed doses of a pain medication. Findings include: Review of facility-provided policy titled ''Unavailable Medication'' with no date revealed ''. If a resident misses a dose of medication staff shall follow procedures for medication errors, including physician/family notification . monitoring the resident for adverse reactions to omission of the medication.'' Review of the undated Medication Administration provided by the facility revealed, If medications(s) is not available, the nurse will: 5.1.1 Coordinate with pharmacy to procure…

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 services to one of four residents (R) (R64) reviewed for limitations in range of motion (ROM). The facility failed to ensure residents with ROM impairments were provided services to maintain function or prevent declines. In addition, the facility failed to implement established restorative programs for residents with programs in place. Findings include: Review of R64's undated Face Sheet located in the electronic medical record (EMR) Profile tab, revealed R64 was originally admitted to the facility on [DATE] and his most recent readmission was on 01/25/06 from the hospital. R64 had diagnoses including quadriplegia, multiple sclerosis, contracture unspecified hand, and a contracture to right elbow. Review of the EMR under the tab ''Orders for July 2022 revealed R64 was to have range of motion (ROM) to bilateral upper extremities (BUE) with splinting and to place elbow splints to right elbow for four hours daily. 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, record review, and facility policies the facility failed to provide nutrition management for one of one resident (R) (R308) reviewed for dialysis to meet her nutritional needs. Specially, the facility did not adjust meal schedule to provide nutrition prior to or during dialysis clinic appointments three days a week. The facility's deficient practice had potential to affect R308's nutritional intake and blood sugar values (low blood sugar). Findings include: Review of the undated ''Resident Nutrition Services'' policy provided by the facility revealed, ''Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.'' Review of R308's electronic medical record (EMR) under her ''Profile'' tab revealed she was admitted to the facility on [DATE]. Review of R308's EMR ''Med Diag'' tab revealed multiple diagnoses to include renal failure 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.