Savannah Post Acute LLC

Based on observations, staff interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure that three of 11 sampled residents (R) (R24, R45, and R49) were administered oxygen (O2) therapy in accordance with the physician's orders. This failure had the potential to place R24, R45, and R49 at risk of respiratory complications and unmet needs. Findings include: Review of the facility policy titled Oxygen Administration, dated 2/1/2024, revealed the Preparation section included, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 1. Review of R24's Annual Minimum Data Set (MDS) assessment, dated 2/17/2025, revealed Section O (Special Treatments, Procedures, and Programs) documented that R24 received O2. Review of R24's Electronic Medical Record (EMR) revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) and acute respiratory failure with hypoxia. Review of R24 's Clinical Physician Orders revealed 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.

Based on observation, resident and staff interviews, and review of the facility policy titled Menus, the facility failed to ensure four of 49 sampled residents (R) (R90, R106, R103, and R72) were offered meal choices. In addition, the facility failed to ensure meal menus were followed for one of 49 sampled R (R72). Findings include: Review of the facility policy titled Menus, revised 10/2022, revealed the Procedures section included, . 6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. 8. Menus will be posted in the Dining Services department, dining rooms, and resident/patient care areas. 1. Review of R90's Quarterly Minimum Data Set (MDS) assessment, dated 3/18/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). In an interview on 5/13/2025 at 12:25 pm, R90 stated he was not given a choice of meals, and the only alternative food offered was a peanut butter and jelly sandwich. He…

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 policy titled, Person Centered Care Plans, the facility failed to develop a care plan for one of four sampled residents (R) (R1) with a history of wandering and exit-seeking behaviors. This failure increased the potential for R1 to not receive treatment and/or care according to their needs. Findings include: A review of the facility policy titled Person Centered Care Plans, dated 2/1/2024, revealed the Policy Statement was 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 Procedure section included . 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. g. Incorporate identified problem areas. H. Incorporate risk factors associated…

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 policy titled, Elopement Risk and Prevention Program, the facility failed to provide protective oversight and supervision to prevent elopement when one of four sampled residents (R) (R1) exited the facility and was unaccounted for by staff for over one hour. Findings include: A review of the facility policy titled, Elopement Risk and Prevention Program, dated 2/1/2024, revealed the Policy Statement of To identify those residents that have the potential to wander or are at risk for elopement. The Procedure section included 1. An elopement risk assessment will be completed by the admitting nurse/designee upon admission and readmission to the facility. The Elopement Prevention Program section included A. Residents identified at risk of elopement will have interventions placed. A review of R1's clinical record revealed diagnoses including, but not limited to, dementia, psychotic disturbance, mood disturbance, anxiety, depression, lack 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, a review of the Payroll-Based Journal (PBJ) Staffing Data Report, and a review of the facility document titled Facility Assessment Tool 2024, the facility failed to ensure adequate nursing staff for the first quarter of 2024. The deficient practice had the potential to adversely affect the care and services provided to the residents residing in the facility. The census was 109 residents. Findings include: A review of the PBJ Staffing Data Report Quarter 1 2024 (October 1, 2023, through December 31, 2023) revealed that based on the data submitted, the facility triggered for a One-Star Staffing Rating (Failure to submit PBJ data by the deadline, more than 4 days in the quarter without Registered Nurse (RN) Staffing hours, failure to respond to, submit documentation for, or failure to pass a Center for Medicare and Medicaid Services (CMS) audit designed to discover discrepancies in PBJ data). A review of The Facility Assessment Tool 2024 revealed the average daily census in the facility was 106 to 109 residents. Further review revealed the facility personnel…

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 and a review of the facility document titled Certified Medication Aide Bi-Annual Checklist, the facility failed to ensure that services provided by Certified Medication Aides (CMA) met professional standards of quality. Specifically, the facility failed to provide evidence that three of four CMAs completed a Medication Administration Competency Skills Checklist for CMAs before being allowed to administer medications to residents. This deficient practice had the potential to result in adverse outcomes for residents related to medication administration. The census was 109 residents. Findings: A review of the facility's document titled Certified Medication Aide Bi-Annual Checklist, dated 2/1/2024, documented that RN (Registered Nurse)/Pharmacist will conduct an Annual Competency for Medication Administration for a Certified Medication Aide in the state of Georgia. The CMA must either conduct the medication administration skill with proficiency or verbalize how to complete the medication administration based on various routes. The checklist will remain in the…

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

Based on observations, staff interviews, and review of the facility's policies titled Equipment and Environment, the facility failed to ensure that the kitchen walls, floors, and equipment were clean and free of rust, debris, and grease buildup and failed to use un-expired quaternary test strips in the three-compartment sink. The deficient practices had the potential to place all residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. The census was 109 residents. Findings include: A review of the facility's policy titled Equipment, revised 9/2017, revealed the Policy Statementof All foodservice equipment will be clean, sanitary, and in proper working order. The Procedures section stated: 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. 4. All non-food contact equipment will be cleaned and sanitized after every use. 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. A 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.

Based on observations, staff interviews, and a review of the facility's policies titled Dispose of Garbage and Refuse and Environment, the facility failed to ensure the outdoor garbage and refuse area was free of litter and maintained in a sanitary manner for two of two dumpsters. The deficient practice had the potential to promote the harboring of pests, insects, and other organisms and create the potential for disease transmission by pests and rodents. The census was 109 residents. Findings include: A review of the facility policy titled Dispose of Garbage and Refuse, dated 8/2017, revealed the Policy Statement of All garbage and refuse will be collected and disposed of in a safe and effective manner. The Procedures section stated: 1. The Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris. A review of the facility's policy titled Environment, dated 9/2017, revealed the Procedures section stated: 7. All trash will be properly disposed of in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility's policies titled Infection Control and Prevention Policy and COVID-19 Employee and Resident Prevention and Control Practices, the facility failed to ensure infection control practices were followed to prevent transmission and spread of COVID-19. Specifically, the facility failed to ensure staff changed their masks when entering and exiting COVID-19 Transmission-Based Precaution (TBP) rooms and failed to ensure staff closed the doors of two COVID-19 TBP rooms during care. The facility was in an outbreak, with 31 residents and 11 staff tested positive for COVID-19. This deficient practice had the potential to spread COVID-19 to other residents, staff, and visitors. The census was 109 residents. Findings include: A review of the facility's policy titled Infection Prevention and Control Policy, dated 2/1/2024, revealed the Policy Statement included: The facility strives to prevent transmission of infections and communicable diseases, development 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 record review, staff interviews, and review of the facility's policy titled Antibiotic Stewardship, the facility failed to provide evidence of a process for periodic review of antibiotic prescribing practices and failed to document follow-up measures in response to the data for 12 of 12 months of infection control data reviewed. This deficient practice had the potential to adversely affect any resident who was prescribed an antibiotic. The facility census was 109 residents. Findings include: A review of the facility's policy titled Antibiotic Stewardship, dated 2/1/2024, revealed a Policy Statement of Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The Procedure section stated, 1. The purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics to the residents. A review of the facility's Antibiotic Stewardship Log revealed no documentation in the log book for July 2023 and January 2024 through March 2024. Further review revealed only a facility map labeled 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.

Based on record review, staff interviews, and review of the facility document titled Healthcare Center Infection Preventionist, the facility failed to designate a qualified staff member to the role of Infection Control Preventionist (ICP) for two of the last 12 months and failed to ensure staff assigned to the role of ICP had enough time to perform the ICP responsibilities for six of the last 12 months. These deficient practices had the potential to create an ineffective Infection Prevention program that may contribute to the spread of infectious diseases among all residents in the facility. The census was 109 residents. Findings include: A review of the facility document titled Healthcare Center Infection Preventionist, with an effective date of 2/1/2024, revealed the Job Purpose of: The Healthcare Center Infection Preventionist is responsible for the development, direction, implementation, management and operation of the infection prevention in the healthcare center. The Key Responsibilities section and the subtitle Infection Prevention documented: j. Develops, implements 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.

Based on resident and staff interviews, record review, and review of the facility's policy titled Grievance Policy, the facility failed to thoroughly complete resident grievance forms to provide evidence that resident grievances were resolved in a timely manner and to ensure that residents were satisfied with the final resolutions for 42 of 101 resident grievance forms reviewed. This deficient practice had the potential to have an adverse effect on any resident who filed a grievance. Findings include: A review of the facility's policy titled Grievance Policy, revised 2/1/2024, documented the Policy Statement of It is the policy for healthcare centers to have and follow an established process whereby residents and/or other customers may have their grievances and complaints resolved in a prompt, reasonable and consistent manner. The Procedure section stated: 2. The Social Services or Administrator will be responsible for tracking all grievances: * The Social Services Director/Administrator will track the grievance on the Grievance Log Form. This will provide a central place for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Self-Administration of Medications by Patients/Residents, the facility failed to ensure three of 54 sampled residents (R) (R30, R32, and R71) did not have unsecured and unauthorized medication or medicated treatment products at the bedside. This deficient practice had the potential to cause adverse effects for R30, R32, and R71 and allow unauthorized medication access to other residents and visitors. Findings include: A review of the facility's policy titled Self-Administration of Medications by Patients/Residents, effective date of 2/1/2024, documented the Policy Statement of Each resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse/Registered Nurse and physician have determined that the practice would be safe for the resident and other residents of the healthcare center. Medication self-administer also applies to family members who wish 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 and staff interviews, the facility failed to post a complete listing of how to report abuse and the types of abuse, including a mailing address, email address, and information on how to report to the State Agency in a manner accessible to residents and visitors. The facility census was 109 residents. Findings include: During the initial tour on 4/8/2024 at 10:15 am and during daily walks throughout the building during the survey week of 4/8/2024 through 4/12/2024, observations revealed a posted white paper, measuring 8 x 10 inches, with bold black print stating Georgia Department of Community Services [PHONE NUMBER]. During the Resident Council Meeting held on 4/9/2024 at 1:45 pm, residents were educated on Resident Rights and Abuse. Eight of the 11 residents in attendance did not know what information to report to the State Agency or how to report it. None of the 11 residents could identify the location of the posting of the Georgia Department of Community Services telephone number. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, and review of the facility's policy titled Abuse, Neglect, and Misappropriation of Property, the facility failed to develop and implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. Specifically, the facility failed to report the misappropriation of property to the State Survey Agency (SSA) for two of four residents (R) (R41 and R45) who were investigated for abuse. This failure had the potential to have a negative impact on the quality of life for R65 and R41. The sample size was 54 residents. A review of the facility's policy titled Abuse, Neglect, and Misappropriation of Property, revised 9/15/2023, revealed the Policy Statement stated: It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal {sic}or State…

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 2. A review of R41's quarterly MDS dated [DATE] revealed a BIMS score of 10, indicating moderate cognitive impairment. The assessment documented that R41 had not exhibited behaviors. A review of a Grievance/Concern Form documented that R41 filed a grievance on 3/22/2024 stating that he was missing six hundred dollars. This grievance was documented by the Social Service Assistant (SSA). Findings from the grievance investigation indicated that the facility's safe was checked, and the money or wallet was not found. Further review of the grievance form revealed that the SSA and resident signed the form on 3/22/2024. The form was not signed or dated by the Administrator. In an interview on 4/11/2024 at 10:07 am, R41 revealed that he had recently reported that 600 dollars had been taken from him. R41 further stated that a report was taken and that he had filed a grievance in the past related to the issue, but no one had followed up with him about his money. A further interview revealed he signed the form but was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of the facility's policy titled Minimum Data Set (MDS)/Care Plan, the facility failed to develop or implement a comprehensive, person-centered care plan for three of 54 sampled residents (R) (R11, R60, and R49). Specifically, the facility failed to develop a care plan for contracture management for R11, implement a care plan for oxygen therapy for R11, dialysis care and treatment for R60, and oxygen therapy for R49. The deficient practice had the potential to place R49, R11, and R60 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: A review of the facility's policy titled Minimum Data Set (MDS)/Care Plan, dated 2/1/2024, revealed the Policy Statement of Each resident will have an individualized interdisciplinary plan of care in place. The Comprehensive Care Plan will be resident-centered, having the individual resident as the focus of control. The Procedure section stated: 2. The Interdisciplinary Team 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 resident and staff interviews, record review, and review of the facility's policy titled Bathing-Shower, the facility failed to provide assistance with activities of daily living (ADL), specifically baths or showers, for one resident (R) (R5) of 54 sampled residents. This failure placed R5 at risk for unmet needs and a diminished quality of life. Findings include: A review of the facility's policy titled Bathing-Shower, effective 2/1/2024, revealed the Purpose section stated: To clean the skin and shampoo hair (as needed). To increase circulation. To exercise body parts. To reduce tension. To promote comfort while maintaining safety and dignity. The Procedure section stated: 29. Provide the resident with the opportunity to bathe according to preference and facility procedure. 31. Review and revise resident/patient bathing plan, as indicated. A review of the clinical record revealed R5 had diagnoses including, but not limited to, muscle weakness, type 2 diabetes mellitus with moderate nonproliferative…

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 and record review, the facility failed to transcribe an antibiotic medication order and administer it as ordered by the physician, resulting in a delay in treatment for one resident (R) (R49) of seven residents receiving antibiotics. This failure had the potential for R49 to not receive medical treatment according to their needs and placed R49 at risk for adverse consequences. Findings Include: A review of the electronic medical record (EMR) Face Sheet revealed that R49 was re-admitted to the facility from an acute care hospital on 4/5/2024. A review of the facility-provided document titled Internal Medicine Discharge Summary, dated 4/6/2024, revealed that R49 had a current diagnosis of multifocal pneumonia. The discharge medication list included, but was not limited to, Levaquin (a medication used to treat bacterial infections) 750 milligrams (mg) by mouth daily for five days, starting 4/5/2024. R49 was discharged back to the facility on 4/5/2024. A review of theProgress Notes revealed an entry dated 4/7/2024 of Resident returned to the facility on…

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

Based on observations, staff and resident interviews, record review, and a review of the facility's policy titled Contracture Management, the facility failed to ensure one of 54 sampled residents (R) (R11) reviewed for limited range of motion (ROM) received passive range of motion (PROM) exercises and splint application as needed to address limited ROM in her right upper extremity. This failure created a potential for worsening contracture (fixed resistance to passive stretch), pain, or skin breakdown for R11. Findings include: A review of the facility's policy titled Contracture Management, dated 02/01/2024, revealed the Policy Statement of Assisting a resident to attain and/or maintain joint mobility promotes independence, prevents, or reduces contractures, preserves range of motion for use of prothesis, stimulates circulation and enhances muscle strengthening. A resident requiring passive range of motion, active range of motion and/or splint/brace application and removal are considered for the restorative program. Restorative programs including range of motion and splint/brace…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policies titled Oxygen Administration and Tracheostomy Care-Adults, the facility failed to provide respiratory care consistent with professional standards of practice for four of seven residents (R) (R11, R39, R22, and R49) receiving respiratory services. Specifically, the facility failed to ensure there was a current physician's order for oxygen therapy and oxygen saturation checks before administering oxygen, to ensure the oxygen concentrator and concentrator filters were clean, and to provide humidification for oxygen therapy for R11. In addition, the facility failed to document daily tracheostomy inner cannula change for R39. Additionally, the facility failed to ensure the oxygen concentrator filter was clean and to clarify a physician's order for oxygen for R22, failed to follow the physician's orders for oxygen, to ensure the oxygen concentrator had a filter, and to label and store respiratory equipment in a sanitary…

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 Dialysis Care, the facility failed to ensure ongoing communication and collaboration with the dialysis center for one of one resident (R) (R60) reviewed for dialysis services. This deficient practice had the potential to place R60 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: A review of the facility's policy titled Dialysis Care, effective 2/1/2024, documented the Policy Statement of Pre and Post care will be provided for dialysis residents. Communication to the dialysis will be completed and return documentation from the dialysis center will ensure the dialysis resident receives necessary interventions and shunt /end-stage renal disease (ESRD) management holistically. The Documentation section stated: 3. Complete the Pre and Post Dialysis assessment and send with the resident to dialysis. When a resident returns, upload document into the electronic health record and note…

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 and staff interview, the facility failed to develop a pneumococcal vaccine policy and procedure for the residents; and failed to provide documentation that three of five sampled residents (R) (#77, #24, and # 79) were offered and/or received the pneumococcal vaccine. Findings include: Review of the medical records revealed the following: R#77 had no documentation in his medical record and no documentation could be provided indicating that he was offered the education and had the opportunity to consent or refuse the pneumococcal vaccine. R#24 had no documentation in her medical record and no documentation could be provided indicating that she was offered the education and had the opportunity to consent or refuse the pneumococcal vaccine. R#79 had no documentation in his medical record and no documentation could be provided indicating that he was offered the education and had the opportunity to consent or refuse the pneumococcal vaccine. The facility provided no evidence of pneumococcal vaccine policies. During an interview with the Infection Control Prevention…

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 and staff interviews, the facility failed to obtain a concurring Physician's signature for a Physician Orders for Life Sustaining Treatment (POLST) for Do Not Resuscitate (DNR) consents for one residents (R) (#111). The sample size was 34 residents. Findings include: Review of medical record for R#111 revealed a POLST with a choice to Allow Natural Death/DNR that was signed by one Physician on 4/12/22 and resident's daughter, that was not the residents Power of Attorney, on 4/6/22 there was no concurring Physician's signature. Further review of the Medical Record for R#111 also revealed that there was not a Health Care Agent for R#111 on file at facility. Interview with the Director of Nursing (DON) on 5/19/22 at 7:58 a.m. revealed DON stated per the facility's policy you do not need two physician's signatures on the POLST form. Interview with the Administrator on 5/19/22 at 8:45 a.m. revealed he did not have an answer as to why there was not a concurring physician's signature on the POLST form. Interview with Social Services Director (SSD) BB on 5/19/22 at…

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 staff interviews the facility failed to ensure that it was maintained in a safe clean and comfortable environment. Specifically, the facility failed to maintain clean privacy curtains in three rooms (102, 107, and 111), and failed to ensure that bathroom walls were in good repair in three resident rooms (106, 107, and 110). The facility census was 109. Findings Include: Initial facility tour conducted on 5/17/22 at 9:00 a.m. revealed observations of room [ROOM NUMBER] privacy curtain by the window of bed B had dark brown stain by the hem of the curtain. Observation of room [ROOM NUMBER] revealed bathroom wall has chipped paint under towel rack with sheet rock cracked and exposed and also black markings. Observation of room [ROOM NUMBER] privacy curtain between bed B and C had brown debris noted on the curtain. There was scuff markings on the bathroom wall with sheet rock exposed surrounded by black markings on the wall. Observation of room [ROOM NUMBER] revealed an unlabeled urinal…

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, and staff interviews the facility failed to ensure that treatment orders for one resident (R) (#71) were transcribed and implemented as ordered by the physician, of 10 residents with pressure ulcers. Findings include: Wound care observation on 5/19/22 at 9:15 a.m. for R#71 revealed Treatment Nurse gathered supplies from treatment cart which included dry gauze, Mesalt dressing, wound cleanser, gloves, and hand sanitizer. After nurse gathered supplies, nurse entered the residents' room and asked permission to complete dressing change. Resident was repositioned to her right side. An undated dressing was removed and placed on residents' bed on blue chuck that was resting underneath resident. Observation of R#71 wound revealed area to the top right of sacrum wound bed was beefy red with small amount of bloody drainage noted, wound edges where flat, no maceration was noted. Area was measured by wound doctor which included the following, wound was classified as a cluster wound with a surface area that measured 5.3 centimeters (cm) X 7.1cm X 1.2 cm,…

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

Based on observation, interviews, and record review, the facility failed to follow Physician's Order for one resident (R) (R#68) of five residents who received nutrition via gastric feeding tube. Findings include: Observation on 5/18/22 at 2:20 p.m. revealed R#68 out of bed sitting in Geri-chair in day area on unit. Feeding pump was connected to G-tube, and tube feeding formula Jevity 1.2 Cal was infusing at 40 milliliters (ml)/ hour (hr). Review of the Physician's Order revealed to turn Jevity 1.2 Cal off at 6:00 a.m., and turn feeding tube Jevity 1.2 Cal on at 6:00 p.m. Interview with Unit Manager (UM) Licensed Practical Nurse (LPN) CC on 5/18/22 at 2:50 p.m. revealed R#68 tube feeding order is that her tube feeding is turned off at 6 a.m. and it is turned back on at 6 p.m. LPN CC stated the nurse put it on too early. Interview with Registered Nurse (RN) II on 5/18/22 at 3:15 p.m. revealed she misread the order. She stated she is not a new nurse or new to the facility. RN II stated she was called into work today because of a nurse calling out. She stated most of the tube feedings…

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.