Pruitthealth - Griffin

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews the facility failed to ensure residents' furniture was in good and functional condition related to one broken dresser drawer. The facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in three of 13 rooms related to missing base boards, a hole in a closet door, and dust buildup on the filters of two packaged terminal air conditioner (PTAC) units. Finding include: Initial environmental observation rounds on 2/23/2024 starting at 8:31 am revealed: room [ROOM NUMBER]-PTAC unit noted with dust buildup on the filter. A 3-inch hole near the base on A bed closet door. Missing base board behind B bed and loose base board by bathroom door. room [ROOM NUMBER]-PTAC unit noted with dust buildup on the filter. room [ROOM NUMBER] shared dresser was missing the 3rd drawer front. Observation on 2/24/2024 at 9:00 am revealed: room [ROOM NUMBER]-PTAC unit noted with dust buildup on the filter. A 3-inch hole near the base on A bed closet…

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 interview, and record review, the facility failed to ensure staff followed recipes for preparing pureed meals to avoid compromising the nutritive value of food items served to residents on a pureed diet when compared with items served to residents on a regular diet for seven of 55 residents receiving a pureed diet. Findings Include: Review of the lunch menu for 2/23/2024 revealed items which included baked lasagna, mashed potato Garlic bread and brownie. Observation on 2/23/2024 at 12:00 pm with the Dietary Manager (DM) of pureed food items revealed DM placing approximately 8oz (ounces) of lasagna and three slices of bread for seven residents into the food processor. The DM then placed an unmeasured amount of hot water she got from the sink into the food processor. She turned on the food processor. After approximately 30 seconds, the dietary manager checked the consistency of the bread/lasagna and added more unmeasured amount of water into the processor. She then turned on the food processor for approximately one minute and then placed the mixture in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of facility policies titled Influenza (Flu) Vaccinations for Health Care Center Residents, and Pneumococcal Vaccinations, the facility failed to provide evidence that two residents (R) (255 and 106) were offered the Influenza and Pneumococcal vaccine, and two residents (47 and 304) were administered the Influenza and Pneumococcal Vaccine after consenting to receive the vaccines. This deficient practice had the potential to put (R255), (R106), (R47), and (R304) at risk for contracting influenza and pneumococcal. Findings include: A review of the facility's policy titled Influenza (Flu) Vaccinations for Health Care Center Residents, with a revised date of [DATE]: All residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Timing of Vaccination 1. Current and newly admitted residents will be offered the influenza vaccine beginning…

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 interviews, and a review of the facility policy titled admission Policy for Healthcare Centers, the facility failed to ensure that one of 36 residents (R) (50) sampled with a mental illness had a Level I Pre-admission Screening and Record Review completed prior to admission to determine the need for specialized services. Findings include: A review of the facility policy 'admission Policy for Healthcare Centers' last revised 1/4/2021 revealed: 'Collection of Paperwork-Prior to admission, the Admissions Director will obtain the following information and upload it to (name of electronic medical records). The upload will include all verification and be available for the financial counselor to validate the secured payment source: Copy of state specific PASSAR FORM.' R50 was admitted to the facility on [DATE] with diagnoses including but not limited to moderate intellectual disabilities, anxiety disorder, and schizophrenia. A record review of the admission Minimum Data Set (MDS) 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 observation, staff interview, record review, and a review of the facility policy titled, Care Plans, the facility failed to follow a care plan for one of five residents (R) (28) reviewed for unnecessary medications. The deficient practice had the potential to cause R28 to not receive treatment and/or care according to their needs. Findings include: A review of the facility policy titled, Care Plan, with a revision date of 7/27/2023, revealed under admission Comprehensive Plan of Care: 4. The care plan approach serves as instructions for the patient/resident's care plan and provides continuity of care by all partners. Short and concise instructions, which can be understood by all partners, should be written and have a relationship to the problem and goal (s). Record review of the care plan for R28 revealed the resident had a plan of care developed for psychotropic drug use - resident receives antianxiety (Buspirone) medication due to a diagnosis of Anxiety. A review of the care plan interventions included attempting a gradual dose reduction if/as indicated. Record 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 staff interviews, record review, and review of the facility's policy titled Physician Orders, the facility failed to follow physician orders for one of 36 sampled Residents (R) (R154). Specifically, the facility failed to transcribe the correct doses of Eliquis (a medication to treat and prevent blood clots) into the Electronic Medical Record (EMR) system and administer the medication as ordered. Findings include: Review of the facility's policy titled, Physician Order dated 7/19/2023 under the Policy Statement revealed Physician orders must be completed and legible when written by the physician, physician extender or transcribed by the licensed professional. Written orders for medications may be transcribed by a licensed professional nurse or licensed pharmacist. Faxed orders are considered to be original physician's orders. Under the section titled, Written Orders revealed 3. Any dose or order that appears to be inappropriate due to patient/resident's age, condition, or diagnosis should be verified…

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 Monitoring of Antipsychotics, the facility failed to ensure one of five residents (R) (28) reviewed for unnecessary medications received medications as ordered. Specifically, the facility failed to decrease the dose of buspirone (an antianxiety medication) for R28 as ordered by the physician. Findings include: A review of facility policy titled Monitoring of Antipsychotics, revised 7/20/2020 revealed the Policy Statement: Patients/residents receive antipsychotic medications only when medically necessary. Every effort is made for patients/residents who use antipsychotics to receive the intended benefit of the medications and to minimize the unwanted effects of the antipsychotic medications. The Procedure section line numbered 6 stated: Gradual dose reduction is attempted with all patients/residents who receive antipsychotic medications. A review of R28's Face Sheet revealed the resident was admitted to the facility with a diagnosis including anxiety disorder and major depressive disorder. Record review…

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 a review of the facility policy titled COVID-19 Vaccination Clinics, the facility failed to offer and/or administer the COVID-19 vaccine to two of five residents (R) (255 and 106) reviewed for vaccines. Findings include: Review of facility's policy titled COVID-19 Vaccination Clinics, revision date [DATE]: All partners, residents, and patients who have no medical contraindications to the vaccine will be offered the updated COVID-19 vaccine per CDC recommendations to encourage and promote the benefits associated with the vaccinations against COVID-19. Administration 1. The patient or legal representative will sign the COVID-19 Vaccine Consent/Refusal Form indicating their wishes to receive or decline the vaccination. 2. All new admissions and new hires will be reviewed for consent or declination of vaccine to ensure previous doses of the vaccine have been documented, and new/next doses can be scheduled appropriately. 3. All residents and partners declining to be…

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

Based on Facility Assessment Review and interview, it was determined the facility did not complete a Facility Assessment, creating the potential that the facility would not adequately evaluate the characteristics of their resident population, community resources, and risks; develop a plan to address these factors, and deploy their resources in the most effective manner to maintain safety and security for all facility residents. This deficient practice had the potential to affect all 40 residents in the facility. Findings include: Review of the Facility Assessment, provided by the Administrator at the beginning of the survey on 04/25/22, revealed: Resident Population Profile data from 04/25/21 through 04/25/22 which was a compilation of data extracted from Minimum Data Set (MDS) assessments and included such information as the total number of admissions; average length of stay; functional abilities; diagnostic groups; residents receiving high-risk medications such as insulin and blood thinners; and basic demographic information such as race, gender, and age. Several areas which…

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, review of facility procedure and record review, the facility failed to ensure that four residents (R) (16, 20, 28 and 32) reviewed for assistance with Activities of Daily Living (ADL) in the sample of 20 residents, received assistance to maintain grooming and assistance with wearing the residents' personal clothing, shaving, and nail care. Findings include: A request for a policy and procedure for the provision of ADLs from the Administrator on 04/27/22 at 5:17 PM revealed the facility did not have a policy. Review of the facility's undated procedure titled, Hand Care - Clean, Cut, and File Fingernails revealed Allow the individual's fingers to soak for 5 to 10 minutes. Use soap if permitted by your organization and according to policy and Procedure . Softens thickened skin cells, fingernails, and debris beneath fingernails for easier cleaning .Clean beneath the fingernails (while the other hand is immersed) using the end of the plastic applicator stick; avoid using an orange…

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 document review, facility policy review and interview, the facility failed to provide evidence of Registered Nurse (RN) coverage in the facility at a minimum of eight hours a day, seven days a week for the period of February 5, 2022, through April 9, 2022. This absence of RN coverage could have a negative impact on all residents residing at the facility. Findings include: Review of the facility's policy titled Staffing dated 06/01/17 revealed .At least one Administrator, onsite Manager, or a designated responsible staff person at least [AGE] years of age will be on the premises twenty-four (24) hours per day. The policy does not indicate that the facility must have a RN onsite eight hours per day. Review of the facility's documents titled, DAILY ASSIGNMENT/STAFFING FORM dated from 01/01/22 to 04/27/22 revealed there was lack of documentation of an RN being in the Skilled Nursing Facility (SNF) unit on duty a minimum of eight hours a day on 02/05/22, 02/12/22, 02/13/22, 02/26/22, 02/27/22, 03/14/22, 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 observation, record review, policy review and interview, the facility failed to ensure that staff performed hand hygiene and disinfected resident equipment contaminated during and after providing a resident (R ) (13) fecal incontinence care. In addition, the facility failed to ensure that all staff were screened for COVID-19 prior to entrance into the facility to work, and that staff donned personal protective equipment (PPE) prior to entering the room of one of two residents (R197) sampled for transmission-based precautions (quarantined for COVID precautions). The facility census was 40. Findings include: Review of the facility's policy titled Handwashing dated 07/27/20 revealed partners will clean their hands by either using soap and water or antiseptic hand sanitizer. Cleaning your hands reduces the spread of germs and decreases the spread of infections .When to perform Hand Hygiene .After contact with blood body fluids, excretions, mucus membranes, non-intact skin, or wound dressings .If your hands…

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, document review and record review, it was determined the facility failed to provide a wheelchair for one of twenty sampled Residents (R) (R7). This failure created the potential that R7 would experience feelings of isolation and depression when she had no means to leave her room. Findings include: Review of R7's Face Sheet, located under the Face Sheet tab of her Electronic Medical Record (EMR) revealed she was admitted to the facility on [DATE] with diagnosis quadriplegia. Review of R7's annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/15/22 revealed she had a Brief Interview of Mental Status (BIMS) score of 15, indicating that she was cognitively intact; did not reject care; was dependent on two staff persons for assistance with transfers from bed; had only transferred from bed once or twice in the past seven days; and had not come out of her room onto the unit during the previous seven days. An observation and interview with R7 on 04/05/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review and facility policy review, the facility failed to ensure three of six residents sampled (Resident (R)194, R23 and R28) for advance directives, electronic medical records (EMR) included advance directives (code status) physician orders' consistent with resident's wishes/ desires regarding life-sustaining treatment (CPR). The deficient practice had potential for the facility to provide or withhold (CPR) treatment inconsistent with residents wishes/desires for life-sustaining treatment. Findings include: The Advance Directive policy was requested from the facility however, the facility-provided the document. titled; Advance Directive Checklist Form dated 01/20 revealing a form for resident/family to complete to document wishes/desires for life-sustaining treatment. Review of the facility's policy titled, Do Not Resuscitate [DNR]policy: Georgia, Advance Directives, dated [DATE] revealed, .If upon admission or any time thereafter a patient/resident .requests or consents to a DNR…

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, document review and interview, the facility failed to ensure the residents' environment was in good repair for two of twenty sampled Residents (R) (R7 and R18) . Findings include: 1. Observation of R7's room and interview with R7 on 04/25/22 at 11:37 AM revealed the built-in dresser along the wall across the room from her bed had gouges in the wooden faces of all three drawers, missing drawer pulls, and worn finishes at the corners of the drawers exposing particle board below. There was an area of damaged and mismatched tiles, two tiles wide by three tiles long on the floor, next to her bed. R7 stated that she had been moved out of this room several months ago on the pretense that the room needed to be remodeled. R7 stated, They came to me a couple of weeks ago and asked if I wanted to move back to this room. I agreed and was pretty excited because I knew it had been remodeled. When I got back here, I was very disappointed to see that it was in the same shape as when I left. I feel like they deceived me a little, but I don't know what can be done about it now.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide two of four Residents (R) (R26 and R30) and their representative information regarding bed holds when they were transferred to the hospital. Findings include: 1. Review of the Census tab of R26's Electronic Medical Record (EMR) revealed she was originally admitted to the facility on [DATE], then hospitalized from [DATE] through 03/10/22. 2. Review of the Census tab of R30's EMR revealed she was originally admitted to the facility on [DATE], then hospitalized from [DATE] through 02/01/22. An interview with the Administrator on 04/26/22 at 2:14 PM revealed that the facility had not presented any of these residents and their representatives with bed hold information when they were hospitalized . The Administrator confirmed that he knew of the requirement to present bed hold information at the time of transfer to the hospital. The Administrator stated that it was his expectation that the facility would provide the bed hold document. A 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 observation, record review, interviews, and review of facility policy, the facility failed to ensure the residents' care plan was revised for one residents (R) (13) in the sample of 20 residents. Specifically, R13's care plan did not accurately reflect the resident's lack of compliance with the use of a splint for right upper extremity (RUE) contractures. Findings include: Review of R13's Face Sheet located under the Face sheet tab in the electronic medical record (EMR) revealed that R13 was admitted on [DATE] and re-admitted on [DATE]. Review of R13's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/07/22 located under the RAI tab in the EMR revealed R13 had a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated the resident has severe cognitive impairment. The MDS documented that R13 had a functional limitation in range of motion (ROM) on an upper extremity on one side. Review of R13's Care Plan located in the RAI tab of the EMR revealed on 06/24/21…

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 interviews, the facility failed to ensure that one (Resident (R) 27) of 20 residents reviewed for quality of care received adequate bowel monitoring. Findings include: Review of R27's Face Sheet located under the Face sheet tab in the Electronic Medical Record (EMR) revealed that R27 was admitted on [DATE] and re-admitted on [DATE]. Review of R27's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/25/22 located under the RAI tab in the EMR revealed R27 had a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated the resident has sever cognitive impairment. The MDS documented R27 was always incontinent of bowel and bladder. Review of R27's Care Plan located in the RAI tab in the EMR dated 09/03/21, R27 was identified as dependent upon staff to maintain care needs related to weakness, impaired mobility/contractures, incontinent of bowel and bladder, and impaired cognition/communication due to health conditions that included diagnoses of CVA…

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, policy review and record review the facility failed to ensure that one resident (Resident (R) 13) of three residents reviewed for limited range of motion in the sample of 20 residents was provided planned restorative nursing services to prevent a further decrease in range of motion. R13 entered the facility for rehabilitation therapy for a new onset of right sided hemiparesis (weakness and/or inability to move) and was not provided planned restorative nursing services. Findings include: Review of the facility's policy titled Restorative Nursing Program dated 11/04/21 revealed It is the policy of this healthcare center to provide restorative nursing which actively focuses on achieving and maintain optimal physical, mental, and psychological functioning and wellbeing of the patient/resident. Restorative nursing program is under the supervision of a Registered Nurse (RN), or a License Practical Nurse (LPN) and restorative nursing services are provided by Restorative Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review and facility policy review, the facility failed to assess for fall risk and implement fall prevention/interventions for two residents (R) (R193 and R26) sampled for accident hazards of 20 sampled residents. Findings include: Review of facility's policy titled Occurrence Reduction Program dated 11/21/17 revealed .healthcare center recognizes that due to the fragility of the patient/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident .In an effort to prevent occurrences, each patient/resident will be assessed for risk and appropriate and realistic interventions will be implemented upon identification of risk and after a fall. These interventions will be included in the care plan .Admission/readmission: .All patient/residents will have a scored Fall Risk Observation Form Completed .will be assessed utilizing the Fall Risk Observation Form upon admission .develop an individualized fall care plan with appropriate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to ensure one Resident (R) (R30) had appropriate indication for ongoing use of a indwelling urinary catheter out of a total of four residents reviewed for catheter usage. Findings include: Review of R30's Face Sheet, located under the Face Sheet tab of her Electronic Medical Record (EMR) revealed she was admitted to the facility on [DATE] and re-admitted from the hospital on [DATE] following a brief stay for a urinary tract infection (UTI) and dehydration. Review of R30's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/05/22, revealed she had a Brief Interview of Mental Status (BIMS) score of four, indicating severely impaired cognition; and had no indwelling catheter. Review of R30's physician's orders, located under the Orders tab of the EMR, revealed an order for an indwelling urinary catheter beginning on 03/15/22 for a diagnosis of urinary retention. Further 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 reviews and facility's policy review, the facility failed to ensure three residents reviewed for respiratory treatments (Resident (R)198, R195 and R28) in the sample of 20 had a physician's order for oxygen administration therapy (including flow rate, route of administration, monitoring, and oxygen equipment maintenance, changing oxygen tubing including labeling with date) prior to administration of oxygen administration therapy. Findings include: Review of facility's policy titled Oxygen Administration revised date of 11/01/19 revealed Oxygen will be administered by licensed personnel only when ordered by the physician, PA [physician assistant], NP [Nurse Practitioner] ., Regulate liter flow to ordered/desired flow rate .Change all oxygen tubing .The large external, black filter should be washed with soap and water once a week .clean exterior of concentrators weekly . 1. Review of R198's electronic medical record (EMR) under the tab Face Sheet, revealed R198 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 observations, interviews, record reviews, and review of facility policy, the facility failed to ensure two Residents (R) (R28 and R32) residents reviewed for siderails in the sample of 20, were accurately assessed for the use of the side rails, failed to obtain consents for the use of the side rails and failed to attempt alternative use of side rails prior to the use of side rails and failed to assess the resident for entrapment risks. Findings include: Review of the facility's policy titled Bed Rails dated 02/01/18, revealed prior to installing or using bed rails on a patient's bed, the patient should be assessed by the admitting nursing and/or interdisplinary team (IDT) .the patient and/or the patient's representative should be educated on the proper use of bed rails as well as the risks of using bed rails, which should include, but not limited to, the risk of entrapment. The nurse should complete the initial/annual observation for physical device form in determining whether the bedrails should be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer three (Resident (R) 13, R31, and 39) of five residents reviewed for flu/pneumonia vaccinations and/or their representatives, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to offer R13 and/or their representative the opportunity to be vaccinated with Pneumococcal 15-valent Conjugate Vaccine (PCV15) or Prevnar 20 (PCV20) in accordance with nationally recognized standards. The facility failed to offer R31 and/or their representative the opportunity to be vaccinated with influenza and pneumococcal vaccination of PPV13 prior to 10/21/21 and/or PVC15 or PCV20 after 10/21/21. The facility failed to offer R39 and/or their representative the opportunity to be vaccinated with one dose of PCV 15 or PCV20 after 10/21/21. The facility failed to update their most current policies 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.