Thomasville Vistas of Journey LLC

Based on resident interviews, staff interviews, and record review, the facility failed to ensure two of 11 sampled residents (R) (R4 and R5) were not served identified food allergens. The deficient practice had the potential to place R4 and R5 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: 1. Review of R4's admission Record revealed diagnoses that included, but were not limited to, gastro-esophageal reflux disease and vitamin deficiency. The admission Record revealed shellfish products listed in the allergies section. Review of R4's quarterly Minimum Data Set (MDS) assessment, dated 3/6/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment). Review of R4's Order Summary Report active orders as of 12/1/2024 revealed an allergy to shellfish products. Review of R4's Progress Notes revealed an entry dated 12/10/2024 that the resident did not have any reactions or issues during this shift. An entry dated 12/11/2024 noted that R4 had no…

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, Enhanced Barrier Precautions, the facility failed to ensure staff followed infection control processes during wound care for one of one residents (R) (R3) observed for wound care from a sample of 11 residents. The deficient practice increased the risk of staff spreading infection to other residents in the facility. Findings include: Review of the facility policy titled, Enhanced Barrier Precautions, dated 4/1/2024, revealed the Policy section included, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. 3. Implementation of Enhanced Barrier Precautions: 3a. Make gowns and gloves available immediately near or outside of the resident's room. Noted: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). 3b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and my not need…

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 Payroll-Based Journal (PBJ) Staffing Data Report [NAME] Report 1705D Fiscal Year (FY) Quarter 2 2024 (January 1 - March 31), the facility failed to provide Registered Nurse (RN) coverage for 8 hours within a 24-hour period on 1/7/2024, 1/21/2024, 2/4/2024, 2/18/2024, 3/3/2024, 3/17/2024 and 3/31/2024. The facility census was 40 residents. Findings include: Review of the most recent PBJ Staffing Data Report CASPER Report 1705D FY Quarter 2 2024 (January 1 - March 31) revealed the facility triggered for No RN Hours which indicated four or more days within the Quarter with no RN hours for the following dates: 1/7/2024, 1/21/2024, 2/4/2024, 2/18/2024, 3/3/2024, 3/17/2024 and 3/31/2024. Review of the form titled, [Facility Name] Daily Nursing Sheet, dated 1/7/2024 revealed, there was not a registered nurse scheduled on the 1st, 2nd, or 3rd shifts. Further review revealed on 1/21/2024, 2/4/2024, 2/18/2024, 3/3/2024, 3/17/2024, and 3/31/2024 there was RN coverage eight hours on 1st shift. Review of the form titled, Daily Staffing…

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

Based on observation, staff interviews, and review of facility documents, the facility failed to ensure recipe for puree carrots and chicken were followed to preserve nutritional value of food for residents receiving a pureed diet. The facility also failed to ensure residents consuming a puree diet were served the recommended three ounces (oz) of protein during meal service. Findings: Review of the untiled document submitted by the Dietary Manager with scoop number, diameter capacity (in ounces) and color (color of scoop handle) revealed the number 16 scoop that was used to measure the puree foods had the following: Number 16 -Diameter 2 1/4 inches/5.72 cm (Centimeters), Capacity - 2 3/4 0z. The number 16 scoop did not provide the needed three ounces of protein per resident. Review of the document titled, Quantified Recipe (Recipe #220) for baked chicken revealed the following: portion size: number 8 scoop, serving utensil #8 scoop, baked chicken 30z SCR. 1. Prepare according to ground recipe. Stock Chicken/soup base for thinning. Recipe #249 Seasoned carrots, portion size #16 scoop…

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, Used By Dating Guideline, the facility failed to ensure food items were properly labeled and dated, failed to discard expired foods by expiration date, and failed to ensure ice machine was kept clean and free of lime and calcium buildup. The deficient practice had the potential to affect 36 of 40 residents receiving an oral diet. Findings: Review of the facility policy titled, Used By Dating Guideline Dated 5/1/2011 revealed under Section 1: foods that have been mixed with other ingredients, prepared in any way, or portioned out include, but are not limited to juices, thickened beverages, canned fruit, unused portions, prepared salads, cut fruits/vegetables, roasted/sliced meats use by date-three days after preparation. Observation on 8/9/2024 at 7:50 am revealed in the reach in cooler located to the right of the main kitchen a small steamtable pan of tuna salad that was unlabeled and dated, a bag of cooked macaroni noodles that were not label or dated, 16 oz (ounce) bottle of opened Zesty Italian…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policy titled, Promoting/Maintaining Resident Dignity, the facility failed to promote, maintain, and protect residents' dignity for two of three residents (R11, R20) with an indwelling urinary catheter. Findings include: Review of the facility's undated policy titled, Promoting/Maintaining Resident Dignity under the section titled Policy revealed, It is the practice of this facility to protect and promote residents rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. 1. Review of R11's Face Sheet revealed diagnoses that included but not limited to, cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant, retention of urine, disorders of urinary system, and obstructive and reflux uropathy. Review of R11'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 record review and staff interviews, the facility failed to obtain a concurring Physician's signature on a Do Not Resuscitate (DNR) order for one resident (R) (R29) of two residents reviewed for DNR. Findings include: Record review of R29's medical record revealed the following diagnoses but not limited to Alzheimer 's Disease, paranoid schizophrenia, and hyperlipidemia. Record review revealed that R29's original admission date to the facility was 5/4/2022 and re-admission date was 11/22/2023. R29's face sheet and medical record revealed that resident did not have a Power of Attorney (POA) or Legal Guardian listed. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status Score (BIMS) of four which indicated severe cognitive impairment. The most recent Annual MDS assessment dated [DATE] indicated a BIMS score of two which also indicated severe cognitive impairment. Review of copy of Do Not Resuscitate Order (DNR) indicated the signature of an Authorized Person was 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 observations and staff interviews, the facility failed to ensure a consistent home-like environment free from missing floor tiles, peeling paint on walls, rust on resident equipment (raise toilet seats), and an odor-free environment in which odors were consistently present where residents resided on one of two halls (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and shower room on 300 hall) . Findings include: 1.Observation of room [ROOM NUMBER]'s bathroom on 8/9/2024 at 8:26 am and 2:00 pm and 8/10/2024 at 8:13 am and 2:00 pm revealed the frame of a raised toilet seat coated with dark brown substances. 2. Observation of room [ROOM NUMBER]'s bathroom on 8/9/2024 at 8:27 am and 8/10/2024 at 8:14 am revealed the frame of a raised toilet seat coated with dark brown substances. Continued observation revealed missing shower fixture (missing shower head) protruding from the wall with ragged edges, stained tiles covered with dark sticky brown substances on the tile around the commode. A strong…

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 policy titled, Hemodialysis, the facility failed to provide evidence of ongoing monitoring and care of a dialysis access site and failed to ensure ongoing communication and collaboration with the dialysis center for one of one resident (R) (R31) reviewed for dialysis services. This deficient practice had the potential to place R31 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: A review of the facility's policy titled Hemodialysis, dated 2/12/2022, under the section titled Policy revealed, This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental and psychosocial needs of residents receiving hemodialysis. Under the section titled Purpose revealed, The facility will assure that…

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 policies titled, Assessment Frequency/Timelines and Discharge Planning Process, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment was completed and transmitted within 14 days of discharge for one Resident (R) (R37). Review of the facility's undated policy titled, Assessment Frequency/Timelines revealed under Policy: The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI Manual. Under Policy Explanation and Compliance Guidelines: 6. A OBRA discharge assessment will be completed within 14 days of the discharge. Review of the undated facility policy titled Discharge Planning Process under Procedure: number 11. The evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis in the clinical record. Record review for R37 revealed the resident was admitted to the facility on [DATE] 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 observations, record review, staff interviews, and review of the facility's policy titled, Comprehensive Care Plans, the facility failed to follow the care plan for one of 26 sampled residents (R) (R31). Specifically, the facility failed to follow the care plan for R31's hemodialysis. Findings include: Review of the facility's undated policy titled Comprehensive Care Plans under the section titled, Policy revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objective and timeframes to meet a resident 's medical ,nursing , and mental and psychosocial needs that are identified in the resident 's comprehensive assessment. Under the section titled Policy Explanation and Compliance Guidelines revealed, (2). The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. (3) a. The services that are to be furnished to attain or maintain the resident 's highest practicable physical, mental, 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 observation, staff interviews, record review, and the facility policy titled, Oxygen Concentrator, the facility failed to ensure an environment free from potential accident hazard by failing to ensure an oxygen cylinder was secure in a cylinder holder for one resident (R), R20 out of ten residents receiving oxygen therapy. Findings include: Record review of the facility policy titled Oxygen Concentrator stated 2. Oxygen is administered under orders of the attending physicians, except in the case of an emergency. 6. Oxygen warning signs must be placed on the door of the resident 's room where oxygen is in use. 8. Storage of oxygen shall be in accordance with the facility Oxygen Safety Policy. Observation on 8/9/2024 at 9:33 am pm revealed an unsecured oxygen cylinder sitting on the floor of R20's room in front of an adjoining bathroom door. If the bathroom door was open the oxygen cylinder tank could have easily been tipped over. At the time of the observation, R20 was observed lying in bed in his room and receiving oxygen via a nasal cannula. Record review of R20's medical…

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, the facility failed to have a Physician's order for one resident (R,) R20, of eight residents with indwelling catheters. In addition, the facility failed to ensure that R20's catheter tubing was not coiled and correctly position to prevent obstruction of urinary flow. Findings include: Record review of R20's medical record revealed the following diagnoses but not limited to retention of urine unspecified and chronic kidney disease. Record review revealed that resident has a history of urinary tract infections and sepsis. Record review did not reveal an active order for an indwelling catheter. Record review of Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status Score (BIMS) that indicated severe cognitive impairment. Section H revealed an assessment for catheter use. Observation on 8/9/2024 at 8:10 am revealed R20 lying in bed with catheter attachment and tubing touching the floor. During a secondary observation 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.

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, Oxygen Concentrator, the facility failed to ensure oxygen (O2) was administered in accordance with the physician order for one of eight residents (R) R20 receiving oxygen therapy. In addition, the facility failed to ensure that oxygen signage was placed on the resident 's door. The deficient practice had the potential for respiratory difficulty for R20. Findings include: Record review of the facility policy titled Oxygen Concentrator stated 2. Oxygen is administered under orders of the attending physicians, except in the case of an emergency. 4. Use of the Concentrator (a). The nurse shall verify physician 's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula). 6. Oxygen warning signs must be placed on the door of the resident 's room where oxygen is in use. 8. Storage of oxygen shall be in accordance with the facility Oxygen Safety Policy. Record review of R20'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.

Based on record review and staff interview the facility failed to ensure that one of 10 sampled residents (R1) was free from chemical restraints, related to not using other interventions to manage behaviors prior to using Haloperidol. Findings include Review of the medical record revealed R1 was admitted to the facility with the following diagnoses that include but not limited to chronic obstructive pulmonary disease, hypertension, gastro-esophageal reflux disease, deaf nonspeaking, mood disorder, post-traumatic stress disorder, type 2 diabetes mellitus, and anxiety disorder. Review of the Electronic Medication Administration Record (MAR) for February 2024 R1 was administered a one-time dose of Haldol injection solution 5 MG/ML on 2/8/2024 and a one-time dose of Haloperidol Lactate Injection Solution 1 mg intramuscularly one time only on 2/13/2024. Haloperidol Lactate Injection Solution inject 5 mg intramuscularly every 6 hours as needed for agitation on 2/20/2024 and Haloperidol Lactate Injection Solution inject 5 mg intramuscularly every 6 hours as needed on 6/28/2024. 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 record review, staff interviews and the facility policy Abuse, Mistreatment, Neglect, Exploitation, Misappropriation of Resident Property Policy, the facility failed to ensure that staff reported an allegation of restraining one resident (R1) of 10 sampled residents. Finding include Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation, Misappropriation of Resident Property Policy, dated 9/2012, revised 11/2022. D. Protect the Resident. 1. Assess the Involved Resident (s). a. Staff should report all incidents/allegations immediately to the Administrator or designee. Review of the medical record revealed R1 was admitted to the facility with the following diagnoses that include but not limited to chronic obstructive pulmonary disease, hypertension, gastro-esophageal reflux disease, deaf, nonspeaking, mood disorder, post-traumatic stress disorder, type 2 diabetes mellitus, and anxiety disorder. Review of the progress notes (nursing) revealed on 2/13/2024 that R1 appears agitated at this time. Resident threw the trash can, slammed door, and yelled…

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 interviews the facility failed to ensure antipsychotic medications were not ordered as needed (PRN) beyond 14 days, failed to document the rationale in the resident's medical record and indicate the duration for the PRN order for one of ten sampled residents (R) R1. Findings include: The policy related to antipsychotic drug usage was requested but the facility was unable to provide the policy prior to exit. Review of the medical records revealed that R1 was sent to the emergency room (ER) on 2/14/2025 and returned on 2/16/2024. He return from the hospital to the facility with medications orders that included the prn Haldol. The prn Haldol was entered into the electronic medical record on 2/16/2024 as indefinitely. This order would have an end date of 3/2/2024. However, on 2/26/2024, Licensed Practical Nurse (LPN) DD entered a new order for the prn Haldol with an end date of 3/10/2024. Thus, a face-to-face re-evaluation and rationale for use was required by the physician in order to continue the prn Haldol till 3/10/2024. The medical records revealed that…

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 provide restorative services for one Resident (R1) of 10 sampled residents. Findings include: Policy related to restorative services were requested but not received by the time of exit. Review of the medical record revealed R1 was admitted to the facility with the following diagnoses that include but not limited to chronic obstructive pulmonary disease, hypertension, gastro-esophageal reflux disease, deaf nonspeaking, mood disorder, post-traumatic stress disorder, type 2 diabetes mellitus, and anxiety disorder. Review of Physical Therapy PT Discharge Summary dated 2/19/2024 through 3/15/2024 revealed R1 was discharged from skilled physical therapy with recommendation for Restorative Program. R1 had restorative for ambulation on the parallel bar; range of motion (ROM) seated bilateral lower extremity times two; transfer to wheelchair; and bed mobility up in chair in the morning. R1 was discharged from skilled physical therapy with recommendation for restorative service. The facility census is 38 residents. 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 record review and staff interview the facility failed to ensure evidence that a qualified Infection Preventionist (IP) was serving in the position at the facility. This deficient practice had the potential for creating an ineffective infection prevention program that may contribute to the spread of COVID-19 for all residents in the facility. The census was 38 residents. Findings include: Interview on 8/7/22 at 11:25 a.m. with Director of Nursing (DON) revealed she is the IP for the facility. DON stated that she used to have her infection control certificate hanging on her wall prior to leaving the facility to work elsewhere for about six weeks. DON stated that she does not know where her certificate is and she reported that she has been unable to get access to another copy. DON acknowledged that she is unable to provide proof of a certificate confirming completion of specialized training as an Infection Preventionist.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to maintain a surety bond sufficient to cover the current total funds in the resident trust account. This deficient practice had the potential to affect all residents with a trust fund account managed by the facility. The facility census was 38 residents. Findings include: Review of the facility's Surety Bond Continuation Certificate revealed a bond in the amount of $60,000.00 issued by the Ohio Insurance Company. Further review of the Surety Bond Continuation Certificate certifies that the Bond is continued in full force and effect until the 1st day of [DATE], subject to all covenant and conditions of said Bond. During an interview on [DATE] at 10:58 a.m. with the Business Office Manager (BOM) it was confirmed the surety bond amount for the current policy expired on [DATE]. BOM explained that when she discovered that the Bond was expired, she immediately notified the corporate office and informed them of this matter. The BOM then revealed that 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 resident and staff interview, observation, record review, and review of policy titled Comprehensive Resident Centered Care Plans the facility failed to develop the care plan related to caring for one resident (R) R#19) related to contractures of left hand of 23 residents sampled for care plans. Findings include: Review of the facility policy titled Comprehensive Resident Centered Care Plans (undated) indicated that it is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service, and intervention. It is the purpose to ensure that each resident is provided with individualized, goal directed care, which is reasonable, measurable, and based on resident needs. A resident's care should be the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity in resident care. 1.Observation 8/6/22 at 1:10 p.m. revealed R#19 lying in the bed with left…

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 activities were provided to residents as scheduled. The facility census was 38 residents. Findings include: Review of the activity calendar revealed that there were activities scheduled on 8/6/22 and 8/7/22 at 10:30 a.m. Observation on 8/6/22 at 11:00 a.m., revealed 9 residents sitting in wheelchairs around the entrance of the dining room awaiting someone to arrive and perform an activity which was scheduled to begin at 10:30 a.m. There were no staff observed providing activities to residents. Observation on 8/7/22 at 11:00 a.m., revealed 12 residents sitting in wheelchairs around the entrance of the dining room awaiting someone to arrive and perform the religious activity which was scheduled to begin at 10:30 a.m. There were no staff observed providing activities to residents. Observation on 8/7/22 at 11:30 a.m., revealed 12 residents sitting in wheelchairs around the entrance of the dining room awaiting someone to arrive and perform the religious activity which was scheduled to begin 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 observation, record review, and staff interview, the facility failed to follow an Occupational Therapy (OT) Restorative Nursing Program (RNP) recommendation for range of motion (ROM) and orthotic application for two residents (R) (R#19) and (R) (R#24) reviewed for ROM and mobility. The sample size was 23 residents. Findings include: 1. Observation on 8/6/22 at 8:24 a.m., revealed R#19 sitting up in the bed eating breakfast using her right hand. R#19's left hand is positioned in body alignment, fingers on left hand are clinched closed into a fist. R#19 informed surveyor that no one has performed range of motion exercises on her left hand today or yesterday. Observation on 8/6/22 at 1:10 p.m. revealed R#19 lying in the bed with her left hand clinched closed. R#19 stated that no one has been in the room to perform Range of Motion exercised or apply the splint to her left hand. R#19 pointed to a blue and white hand splint on a shelf in her room and stated, there it is, they don't put it on. I don' think…

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 interviews, record review and review of the facility policy titled Falls and Fall Risk, Managing the facility failed to re-evaluate the effectiveness of current fall measures and failed to put new measures in place to prevent additional falls for one Resident (R) (R#4) of 23 sampled residents. Findings include: Review of the facility's policy titled Falls and Fall Risk, Managing (revised December 2007) states based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Observation on 8/6/22 at 3:11 p.m. revealed R#4 lying in bed. The bed is in the lowest position and the fall mat is not along the right side of the bed but is observed folded alongside of the wall. Record review revealed R#4 was admitted to the facility with diagnoses including, but not limited to dementia without behavioral disturbances, restlessness and agitation and anxiety disorder due to known physiological condition. A Brief Interview…

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 an order to receive dialysis services for one resident (R) R#29) of two residents receiving dialysis. Findings: Review of medical record for R#29 revealed diagnoses that included but not limited to bacterial infection of unspecified site, Diabetes due to underlying condition, and chronic kidney disease. Review of Physician Orders revealed orders for Levemir 100 Unit/ milliliter (ml) 35 units SQ daily, Humulin R 100Unit/ml sliding scale, and monitor dialysis access for signs of infection. However, there were no orders found for dialysis treatment. Review of care plan for R#29 dated 2/26/19 revealed problems/needs: 1. Problem: I require renal dialysis with dialysis on Monday, Wednesday, and Friday. An interview was conducted on 8/5/22 at 11:41 a.m. with R#29 who confirmed that she receives dialysis services three days per week. During an interview on 8/7/22 at 10:11 a.m. with the DON it was revealed that it is her expectation that orders be obtained for any and all treatments provided to the residents 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 record review, staff interview, review of facility policy titled Medication Monitoring the facility failed to document the intended duration of therapy for one resident (R) (#4), that had an as needed order (PRN) for PRN antianxiety and antipsychotic medications beyond 14 days, of five residents reviewed for unnecessary medications. Findings include: Review of the policy titled Medication Monitoring, revealed that PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN. PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for appropriateness of that medication. CMS 483.45(e)(4) regulations state that a PRN orders for psychotropic drugs are limited to 14…

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 and record reviews the facility failed to ensure that one resident (R#39) of five sampled residents was offered, received, and had documentation related to the COVID-19 vaccine. Findings include: Resident (R#39) was admitted to the facility on [DATE]. Record review revealed there is no documentation of COVID-19 vaccines or COVID-19 vaccination status. Interview with the Director of Nursing (DON) on 8/7/22 at 9:25 a.m. revealed she was not aware that R#39 had not received COVID-19 vaccines. DON stated that she is the Infection Preventionist (IP) for the facility, and she stated that she is responsible for the infection control program. DON stated that the Social Services Director (SSD) is responsible for getting the permissions from family or guardian for consent. DON stated the SSD gives her the consent forms. DON stated after she receives the consent forms, she screens the residents and then she administers the vaccine. DON confirmed that it's been almost a year and R#39 have no documented…

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.