Tucker Park Crossing of Journey LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on family and staff interviews, and record reviews, the facility failed to notify the Power of Attorney (POA)/family of a change in condition of one resident (R) (R7) of eight residents reviewed for notification of change. Findings include:Review of the admission Record for R7 revealed he was admitted to the facility on [DATE] and diagnoses included, but were not limited to, asthma and end-stage renal disease. Further review of the admission Record revealed one person was listed as R7's POA and two people were listed as emergency contacts.Record review of R7's Minimum Data Set (MDS) Quarterly assessment, dated 8/21/2024, revealed that a Brief Interview for Mental Status (BIMS) was assessed at eleven (indicating moderate cognitive impairment).Review of a Nursing Skilled Note, dated 6/26/2025, revealed R7 was observed vomiting {sic} coffee ground- like emesis, in house nurse practitioner notified and assessed resident. Recommended that the resident be sent out to the hospital for further management.…

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 Grievance/Complaint Log and Lost and Found, the facility failed to make a prompt effort to file a grievance for two of eight sampled residents (R) (R7 and R8) who verbally reported grievances. This deficient practice had the potential to place residents at risk of not having their grievances resolved in a timely manner. Findings include:Review of the facility policy titled Grievance/Complaint Log, with a review date of 10/2024, revealed Policy Statement: The disposition of all resident grievances and/or complaints will be recorded on our facility's Resident Grievance/Complaint Log. Policy Interpretation and Implementation: 1. The disposition of all written grievances and/or complaints must be recorded on the Resident Grievance/Complaint Log.Review of the policy titled Lost and Found, with a review date of 10/2024, revealed Policy Statement: Our facility shall assist all personnel and residents in safeguarding their personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Confidentiality and Privacy Information, the facility failed to ensure the privacy for one of 30 residents (R) (R98) was maintained by displaying a sign on the bedroom wall disclosing protected personal information. Findings include: A review of the facility's policy titled Confidentiality and Privacy Information, effective date of 10/2023 under the Policy Statement revealed, Our facility shall treat all resident information confidentially. The resident has a right to personal privacy and confidentiality of his or her personal medical record. Review of R98's quarterly Minimum Data Set (MDS) dated [DATE] revealed, for Section B (Hearing, Speech, Vision), indicated the resident's vision was highly impaired; Section C (Cognitive Patterns), a Brief Interview of Mental Status (BIMS) of 15 which indicated little to no cognitive impairment. Observation on 10/27/2024 at 5:24 pm in the room of R98 revealed, 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 staff interviews, record review, and review of the facility's policy titled, F 625 Bed Hold, the facility failed to ensure a bed-hold policy upon transfer to the hospital for one of two residents (R) (R27) reviewed for hospitalizations. Findings include: Review of the facility policy titled F 625 Bed Hold revised May 2023 revealed, 1. Upon admission and when a resident is transferred for a non-emergency hospitalization or for therapeutic leave, a representative of the business office will provide information concerning our bed-hold policy. 2. When emergency transfers are necessary, the facility will provide the resident and the resident representative with information concerning our bed-hold policy per state law as applicable. Review of R27 clinical records revealed, the resident admitted to the facility with diagnoses that included but not limited to chronic kidney disease, acute on chronic systolic (congestive) heart failure, chronic obstructive pulmonary disease, unspecified, acute respiratory…

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, Comprehensive Care Plan, the facility failed to develop a care plan specific to the recommendations per the physician's order related to the pain scale for one resident (R) (R23), failed to develop a care plan for dialysis for R64, and failed to to follow and update the care plan for refusals on restorative care for R19. The sample size was 30 residents. Findings include: Review of the facility's policy titled, Comprehensive Care Plan dated August 2024 revealed, An individualized comprehensive person-centered care plan that includes measurable objective and time frames to meet the resident's medical, nursing, mental, cultural and psychological needs is developed for each resident. Further review of the policy revealed, (1) The facility's Care Planning/Interdisciplinary Team (IDT), in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, record review, and review of the facility's policy titled, Administering Medication the facility failed to follow the physician's orders as recommended for one of 30 residents (R)(R23). Findings include: Review of the facility's policy titled, Administering Medication dated October 2024 documented Medications shall be administered in a safe and timely manner, and as prescribed. (3) Medications must be administered in accordance with the orders, including required time frame. R23 was admitted to the facility on [DATE] with a diagnosis that includes fracture of left lower leg sequela, and displaced trimalleolar fracture of unspecified lower leg, initial encounter for closed fracture. Review of the most recent quarterly MDS dated [DATE] documented R23 had a Brief Minimum Data Set (BIMS) score of 14 indicating little to no cognitive impairment. Further review revealed R23 had no behavior exhibited and requires a four-person mechanical lift, and assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and review of the facility's policy titled Goals and Objectives, Restorative Services and Rehabilitative Nursing Care the facility failed to provide a right-hand grip splint for up to 4.5 hours for one of one Residents (R19) reviewed for rehab and restorative. Findings include: Review of the facility's policy titled Goals and Objectives, Restorative Services last reviewed 10/2024 revealed the policy was specialized rehabilitative service goals and objectives shall be developed for problems identified through resident assessments. Under the Policy's Guidelines section revealed, Rehabilitative goals and objectives are developed for each resident and are outlined in his/her plan of care relative to therapy services. 2. (b) Assisting the resident in developing and strengthening his/her physiological and psychological resources. 2. (c) Encouraging the residents to maintain his/her independence and self-esteem. Review of the facility's policy titled Rehabilitative…

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 Oxygen Administration, the facility failed to administer oxygen (O2) as ordered for one of two residents (R) (R9) reviewed for respiratory care. Findings include: Review of the facility's policy titled Oxygen Administration with effective date of 4/2024 under the section titled, Purpose revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration. Under the section Preparation revealed, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Under the section, Documentation revealed, After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record:1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. Review of R9'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.

2. During observation on 5/5/2024 at 1:15 pm in Room B-24 , it was revealed there was paint missing around the toilet paper holder in the bathroom. During observation on 5/5/2024 at 1:20 pm in Room B-30, the wall behind the bed had three holes in the sheet rock. 3. Observation on 5/05/2024 at 1:07 pm in Room A-19 revealed a bath basin and a urinal that were unlabeled and unbagged. There was a large amount of spider webs with leaves on the outside part of the window. The wall behind the B bed had a large number of dark scuff marks. The base board in the corner of the bathroom was found coming off the wall. The personal refrigerator in the room was dirty. Observation on 5/5/2024 at 1:22pm in Room A-20 revealed scuff marks on the inside of the bathroom door and on the wall in front of B bed. There was also a hole in the wall plaster behind the towel rack in the bathroom. Observation on 5/5/2024 at 1:26 pm in Room E-51 revealed there were three bath basins on the floor under the sink in the bathroom. They were not labeled and not in a bag. There was paint chipped off on the bathroom…

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 reviews, and review of the facility's policy titled Administering Medications F760, the facility failed to ensure the medication error rate was less than five percent (5%). Specifically, the facility failed to obtain physician orders to crush medications prior to administration for two of four residents (R) (R37 and R90). There were 29 opportunities observed resulting in two medication errors. The medication error rate was 6.9%. Findings include: Review of the facility's policy titled, Administering Medications F760, last revised 10/2023 under the section titled, Guidelines revealed, 3. Medications must be administered in accordance with the orders, including any required time frame. 1. Review of R37's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section C (Cognitive Pattern), a Brief Interview for Mental Status (BIMS) of six which indicated severe cognitive impairment; Section I (Active Diagnoses) revealed, acute kidney failure, altered mental status,…

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 policies titled, Indwelling Urinary Catheters F690 and Handwashing/Hand Hygiene F 880, the facility failed to follow standard infection control practices for one of four residents (R) (R15) during catheter care observation. The facility also failed to ensure hand hygiene was performed during meal tray distribution. The deficient practice had the potential to affect all residents. The facility census was 115 residents. Findings include: 1. Review of the facility policy titled Indwelling Urinary Catheters F690 with a revision date of 6/2022 revealed under Infection Control, 1. Use standard precautions when handling or manipulating the drainage system. 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. Review of the facility policy titled Handwashing/Hand Hygiene F 880 with a revision date of 10/2022 revealed under Guidelines, 5. Employees must wash their hands for at least twenty (20)…

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, Pre-admission Screening and Resident Review (PASARR) Program, the facility failed to ensure a Level II PASARR was conducted for one of five sampled residents (R) (R40) reviewed for PASARR. Findings include: Review of the facility's policy titled, Pre-admission Screening and Resident Review (PASARR) Program dated 9/2023 under the Policy Statement revealed, This community will coordinate assessments with the preadmission screening and resident review (PASARR) program. Under Policy Interpretation and Implementation revealed, 1. Upon admission, the Social Worker or designee will, within the context of the established assessment process, the recommendations of the PASARR level II and the PASARR evaluation report with be incorporated into the resident's assessment, care planning and transition of care . 8. The Interdisciplinary Assessment Team must use the MDS from currently mandated by Federal and State regulations to conduct 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 interviews, record reviews, and review of the facility policy titled, F656, F657, F658 Comprehensive Care Plans, the facility failed to implement the care plan for one of six residents (R) (R58). This failure had the potential for R58 to not receive treatment and/or care according to their needs. Findings include: A review of the facility policy titled, F656, F657, F658 Comprehensive Care Plans, last approved 9/2023, revealed the Policy stated, An individualized comprehensive person centered care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental, cultural, and psychological needs is developed for each resident. The section titled Guidelines stated, 8. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas, b. Incorporate risk factors associated with identified problems, c. Build on the resident's strengths, d. Reflect the resident's expressed wishes regarding care and treatment goals if…

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 facility policy titled, Quality of Life-Activities of Daily Living (ADL), the facility failed to provide ADL care for three of seven residents (R) (R23, R87, and R70). Specifically, the facility failed to provide nailcare for R23 and R87 and failed to provide showers as scheduled for R70. Findings included: Review of the facility policy titled Quality of Life-Activities of Daily Living with a last revised date of November 2017 revealed under Policy Statement Residents who are unable to carry out activities of daily living receive the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Review of the electronic medical record (EMR) for R23 revealed that he was admitted to the facility with the following diagnoses but not limited to hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, unspecified symbolic dysfunctions, psychosis, 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 a review of the facility policies titled, Range of Motion Exercises and Goals and Objectives, Restorative Services, the facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for one of nine Residents (R) (R22) receiving restorative care. This deficient practice had the probability to cause a further decline in range of motion for R22. Findings include: Review of the facility policy titled, Range of Motion Exercises last revision date 11/2016, revealed, Residents with limited range of motion will receive appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. Review of the policy titled, Goals and Objectives, Restorative Services last approved date 9/2023, revealed under Policy interpretation and implementation, Rehabilitative goals and objectives are developed for each resident and are outlined in his/her plan of care relative to therapy services. Review of the medical record for R22 revealed the Quarterly…

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 reviews, and a review of the facility policies titled Falls and Fall Risk, Managing F689 and Oxygen Administration, the facility failed to provide interventions to prevent falls for one of six residents (R) (R58) and failed to ensure an oxygen cylinder was stored and secured for one of 15 residents receiving oxygen (R15). Findings include: A review of the facility policy titled, Falls and Fall Risk, Managing F689, last approved 4/2024, revealed the Policy stated, 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. A review of the facility policy titled Oxygen Administration, last approved 4/2023, revealed the section titled Equipment and Supplies documented 1. Portable oxygen cylinders should be strapped to the stand. 1. A review of R58s' Quarterly Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and record review, the facility failed to properly check for Gastric tube (G-tube) (tube in the stomach for nutrition) placement for one of four Residents (R) (R33) receiving nutrition through a G-tube. Findings include: Review of the Electronic Medical Record (EMR) for R33, revealed that he was admitted with diagnoses that included, but were not limited to end stage renal disease, adult failure to thrive, and aphasia following other cerebrovascular disease. Review of the care plan for R33 dated [DATE] revealed that he requires tube feeding and is at risk for fluid balance fluctuation, alteration in nutrition and weight loss, and has a swallowing problem. An intervention that is in place for this problem is to check for tube placement and gastric contents/residual volume per facility protocol and record. Review of the Physician Orders dated [DATE] for R33 revealed that the resident was to have continuous feeding of Nepro at 78 milliliters (ml)/ hour via the G-tube: at 12…

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, Oxygen, Administration, the facility failed to obtain an order for oxygen therapy for one of 15 residents (R) (R32). Findings include: Review of the facility's policy titled, Oxygen Administration, dated April 2023 under the section titled, Purpose revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration. Under section titled, Preparation revealed, 1. Verify that there is a physician order for this procedure. Review the physician orders or facility protocol for oxygen administration. Review of the clinical record revealed R32 was admitted to the facility with the diagnoses of but not limited to chronic obstructive pulmonary disease, unspecified, acute respiratory failure, unspecified whether with hypoxia or hypercapnia. Review of R32's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Patterns) revealed a Brief Interview for Mental…

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 and staff interviews, the facility failed to ensure that privacy curtains provided full visual privacy for three (3) of 63 shared resident bedrooms: (B39, E 44, D5). Findings Include: Observation on 5/5/2024 at 2:15 pm revealed that room E44 privacy curtain was missing several hooks causing the curtain to hang leaving a large gap in the curtain, and not providing full privacy for the resident in the B bed. Observation on 5/6/2024 at 9:58 pm revealed room D5 privacy curtain had missing hooks and was unable to be drawn for full privacy while providing care for the resident. Observation on 5/6/2024 at 8:46 am revealed that there were hooks noted on the curtain track, but no privacy curtain observed for room B39-1 to provide privacy for the resident during care. Interview on 5/8/2024 at 2:19 pm with LPN DD revealed they do not keep maintenance work order books at any of the nursing stations. She stated there is a more manageable tracking system for the nursing staff to use electronically. Interview walking rounds on 5/8/2024 at 9:15 am with the Maintenance Director…

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 and staff interview, the facility failed to ensure trash was contained in dumpsters with closed lids for four of four outside trash dumpsters. Findings include: Upon arrival to the facility on 8/14/2023 at 9:00 a.m., two surveyors observed that the facilities four outside trash dumpsters were not covered by lids. Trash was observed in the dumpsters and on the ground around the four dumpsters. During the initial kitchen tour on 8/14/2023 at 9:53 a.m., accompanied by the Dietary Manager, an inspection of the four outside trash dumpsters was conducted. All four of the trash dumpsters were observed to have the lids open, with trash in the dumpsters, and on the ground outside of the dumpsters. The Dietary Manager confirmed the observations and promptly closed the lids. The facility did not have a policy related to the maintenance of the trash dumpsters.

Based on observations, staff interviews, record review, and review of facility policy titled, Oxygen Administration, the facility failed to provide safe oxygen (O2) administration for three of four residents (R) (R#11, R#14, and R#21) receiving O2 therapy from a total sample of 27 residents. The deficient practice had the potential of the residents receiving inadequate O2 therapy. Findings include: Review of the facility policy titled, Oxygen Administration, with a review date of April 2023, reads in part The purpose of this procedure is to provide guidelines for safe oxygen administration. Date the pieces of equipment as appropriate. Place the call light within easy reach of the resident . 1. Review of R#11's Face Sheet, located in the electronic medical records (EMR) section titled admission Records, revealed the resident was admitted to the facility with diagnoses that included acute respiratory failure and chronic obstructive pulmonary disease (COPD). Review of R#11's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 3/20/2023 located in the EMR section…

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, record review, staff interviews, review of the facility's policy Categories of Transmission-Based Precautions (aka Isolation), the facility failed to maintain an effective infection prevention and control program when one staff member failed to follow contact precautions for one of one Resident (R) (R#42) reviewed for transmission-based precautions (TBP) out of a total sample of 27 residents. The deficient practice had the potential of exposing residents to infections due to cross contamination. Findings include: Review of facility's policy Categories of Transmission-Based Precautions (aka Isolation), revised on March 2023 stated, (d) 1. In addition to wearing a gown [as outlined under Standard 2 Precautions], wear a gown (clean, nonsterile) for all interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. Review of the CDC's Prevent the spread of Clostridioides difficile (C. diff), updated on 7/20/2021, retrieved from https://www.cdc.gov/cdiff/prevent.html on 8/20/2023 stated, While caring for you…

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, and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse by another resident by failing to report an allegation of verbal and physical abuse to the State agency between two of 27 sampled Residents (R) (R#11 and R#161) reviewed for abuse. Findings include: 1. Review of R#11's Face Sheet, located in the resident's electronic medical records (EMR) section titled admission Record, revealed R#11 was admitted to the facility with diagnoses that included chronic renal disease with dialysis, non-Alzheimer's dementia, acute respiratory failure, and acute pulmonary edema. Review of R#11's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/26/2023 located in the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R#11 was cognitively intact and able to make her own decisions. The MDS documented R#11 did not exhibit any behavior during the assessment period. 2. Review of R#161's Face Sheet, located in the EMR section titled admission…

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 ensure the accuracy of a significant change Minimum Data Set (MDS) for one of 27 sampled residents (R) (R#42). This failure had the potential to affect the quality-of-care for R#42. Findings include: Review of R#42's Face Sheet, located in the electronic medical record (EMR) section titled admission Record, revealed the resident was admitted to the facility with diagnoses that included morbid obesity, kidney disease stage four, sepsis Escherichia coli, adult failure to thrive, sepsis shock, and dorsalgia (back pain). Review of R#42's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/28/2023 located in the EMR section titled MDS revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R#42's cognition was intact. A significant change MDS was completed since the resident had developed several pressure ulcers (stages II, III, and IV) and loss of appetite. A review of the assessment of Behaviors revealed no documented behaviors during the assessment period…

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, Comprehensive Care Plans, the facility failed to develop a comprehensive care plan for resisting care and wound care for one of 27 sampled residents (R) (R#42). Findings include: Review of the provider's, titled Comprehensive Care Plans, last revised August 2022 revealed: An individualized comprehensive person-centered care plan that includes measurable objectives and time frames to meet the resident's medical, mental, cultural and psychological needs is developed for each resident. 7. The care plan should describe the resident's nursing, medical, physical, mental and psychosocial preferences. They should include person specific, measurable objectives and time frames with a goal to measure their progress towards meeting such. 8. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build of resident's strengths; d. Reflect the resident's expressed wishes regarding care and treatment goals…

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 record review, the facility failed to ensure that one of five residents (R) (R#21) reviewed for Activities of Daily Living (ADL) received incontinent care. Sample size was 27 residents. The deficient practice had the potential for R#42 to develop pressure sores, and/or worsen ongoing pressure sores. Findings include: Review of R#21's Face Sheet, located in the electronic medical records (EMR) section titled admission Records, revealed R#21 was admitted to the facility with diagnoses that included major depressive disorder, unspecified psychosis, and cerebral infarct (stroke). Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/29/2023 located in the EMR section titled MDS revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R#21's cognition was intact. R#21 was totally dependent on staff for all areas of ADLs with two plus persons for physical assistance. R#21 was incontinent of bowel and bladder. Review of R#21's care plan with revision date of 8/04/2023 and located 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.

Based on staff interviews, record review, and review of the facility policy titled, Accidents-Elopement, the facility failed to prevent elopement out of the building and into the parking lot of one of one resident (R) (R#311) reviewed for elopement out of a total sample of 27 residents. Findings include: Review of the facility's policy titled, Accidents-Elopement, dated August 2023, revealed Staff shall evaluate, investigate and report all cases of missing residents. Definitions-Wandering: Random or repetitive locomotion, which may be goal directed (e.g., the resident is searching for something) or non-goal oriented or aimless. Elopement: A situation in which a resident leaves the premises or a safe area without the facility's knowledge or supervision if necessary and this situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration and/or other medical complications, drowning or being struck by a motor vehicle. Review of R#311's undated admission Record, located in R#311's electronic medical record (EMR),…

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

Based on resident and staff interviews, record review, and review of the facility's policy titled, Dialysis, Care for a Resident, the facility failed to be in communication and collaboration with the dialysis facility regarding dialysis care and services for one of 27 sampled residents (R) (R#211). Findings include: Review of facility's policy titled, Dialysis, Care for a Resident, revised May 2021, revealed Residents with end-stage renal disease (ESRD) [kidney failure requiring dialysis] will be cared for according to currently recognized standards of care. 1. The type of assessment data that is to be gathered about the resident's condition on a daily basis . 2. Signs and symptoms of worsening condition and/or complications of ESRD . Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed . 1. How information will be exchanged between the facility. Review of R#211's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R#211 was admitted to the facility with 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.

Based on staff interviews, record review, and review of the facility's policy titled, Psychotropic Drug Use, the facility failed to ensure staff monitored for side effects and/or behaviors while administering antipsychotic medication for two of five residents (R) (R#4 and R#46) reviewed for unnecessary medications out of a total of 27 sampled residents. Findings include: Review of the facility's policy titled, Psychotropic Drug Use, dated January 2023, revealed through the on-going assessment process, monitoring should include a. potential side effects such as sedation, lethargy, agitation, mental status changes, or behavioral changes . 1. Review of R#4's undated admission Record, located in R#4's electronic medical record (EMR) under the Profile tab, indicated R#4 was admitted to the facility with diagnoses including Alzheimer's disease, major depressive disorder, and anxiety disorder. Review of R#4's Physician Orders, dated 6/01/2023, located in the EMR under the Orders tab, revealed an order for Seroquel 50 milligrams (mg) every morning and at bedtime. 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 observation, staff interviews, record review, and review of facility policy titled, Administering Medication, the facility failed to ensure a medication error rate below five percent. During medication administration five medication errors for resident (R) (R#71) were made from 30 opportunities. The medication error rate was 16.66 percent. Finding include: Review of a facility policy titled Administering Medication, with a review date May 2022, reads in part .Medications may not be prepared in advance and must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders . Observation on 08/17/2023 at 10:48 a.m. revealed Licensed Practical Nurse (LPN) 2 setting up the following nine medications for R#71: Zyprexa (antipsychotic)10 milligram (mg) one tablet Seroquel (antipsychotic)100 mg one tablet valproic acid (anticonvulsant) 20 cubic centimeters (cc) ferrous sulfate (FeSO4) (iron supplement) 325 mg one tablet metoprolol…

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 Physicians Orders for Life Sustaining Treatment (POLST), Guidance for Completing the POLST Form, the facility failed to ensure resident medical records were complete for two of seven residents (R) (R#7 and R#39) related to POLST forms not signed by the resident/resident representative and/or the physician resulting in the POLST forms not being completed. Findings include: Review of the Guidance for Completing the POLST Form stated .5. If a patient lacks decision making capacity, The POLST form may be signed by an authorized person, which includes, the following order priority: a. the agent name on the patients durable power of attorney for health care or health care agent name on the patients advance directive for health care, b. a spouse c. a court-appointed guardian d. son or daughter (age 18 or older) e. parent f. brother or sister (age 18 or older). The POLST does not list facility staff as an authorized person to sign. Record review revealed R#7's POLST form, found in the Electronic Medical Record (EMR) under 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 interview, and review of the facility's policy titled, Inspection of Heat/Air-conditioning Systems, the facility failed to ensure that heat/air-conditioning systems located on one of four nursing units were in good repair. The deficient practice had the potential to affect the safety, functional, and sanitary conditions for residents on a secured unit. Findings include: Review of the facility's policy titled, Inspection of Heat/Air-conditioning Systems, dated May 2022, revealed The facility's heating and air-conditioning system shall be inspected at lease[sic] semi-annually. 1. Prior to the beginning of each heating/cooling season our facility's heating and air-conditioning systems shall be inspected for possible gas leaks, lines that have bust, etc. 2. The Maintenance Department shall be responsible for such inspections and shall have the authority to use local gas and/or approved repairmen to assist in making inspections when assistance is necessary. During the initial tour conducted on 8/14/2023 at 11:45 a.m., observations were conducted 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.