Arcadia Retirement Residence

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, document review and medical record review (RR), the facility failed to promptly notify the ordering physician of significant radiology findings. One Resident's (R)2 repeat chest xray findings showed significant changes from the previous xray taken three days earlier, and were not communicated to the physician for approximately one hour after the radiologist recorded the interpretation. In addition, the facility does not have a policy/procedure or effective process in place to identify which imaging results should be called to provider. This deficient practice has the potential to affect all residents and may result in adverse outcomes. Findings include: 1) R2 was a [AGE] year old male with past pertinent medical history of hypertension, Parkinson's disease, Alzheimer's, Arteriosclerotic heart disease, diabetes, urinary retention, unsteady on feet and muscle weakness. He had advanced functional and activity of daily living dependence with on an off confusion. R2 had a fall on [DATE] while 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.

2) While conducting an interview with Resident (R)29 on 10/31/23 at 11:05 PM, the resident reported staff being very loud and waking up the resident, daily, when they come into the room at 04:30 AM to assist the resident's roommate to the bathroom. R29 confirmed she wants to sleep in and does not want to be awaken by staff at that hour. During an interview with the Director of Nursing (DON) and an Advising DON (AADON) on 11/03/23 at 10:19 AM, the DON confirmed staff should minimize the sound level to avoid disturbing resident's sleep. Based on observations and staff interview, the facility failed to maintain a safe, homelike environment as evidenced by two different areas of the building being in disrepair and staff not maintaining comfortable sound levels. Findings include: 1) Observation on 11/02/23 at 01:00 PM of the third floor Diamond Head Nursing Unit revealed two different areas of the building where there was broken corner protectors, cracked drywall and unfinished wall repair. This also created a risk for accident hazards. During staff interview on 11/03/23 at 07:40 AM,…

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 interviews, the facility failed to ensure the resident's right to a dignified existence for two residents sampled. As a result of this deficient practice, residents are at risk for more than minimal harm. Findings include: On 11/02/23 at 09:57 AM, observed Activity Staff (AS)4 standing next to Resident (R)25 looking out the window, in the activity room/dining room looking out the window. Observed R25 tap AS4's arm with the back of her right hand. AS4 responded to the incident by quickly hitting away the resident's hand and immediately moving away from the resident. AS4 initially appeared annoyed by R25 touching him/her and rubbed the area if his/her arm that R25 touched. At 10:12 AM, while conducting activities, another resident stood up from the chair, observed AS4 walk behind the resident, put both hands on her shoulders and applied some force to the resident's shoulders, prompting the resident to sit back into the chair, twice. The third time the resident stood from the chair, AS4 placed his/her right hands on the resident's left shoulder while standing…

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 review, the facility failed to ensure the resident representative's right to make decisions on behalf of the resident for one resident (Resident (R)70) sampled. As a result of this deficient practice, there is a potential risk of more than minimal harm. Findings include: R70 is an [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis which include but are not limited to peripheral vascular disease, Dementia, diabetes mellitus type 2. Review R70's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/24/23, documented in Section C. Cognitive Patterns a score of 9 on the Brief Interview for Mental Status (BIMS), indicating the resident has moderate cognitive impairment. Review of the resident's documents and consent forms documented R70 has a Power of Attorney (POA) for health care decision and the POA is actively involved in exercising his/her right to make decisions on behalf of R70. Review of six consent forms in R70 Electronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide reasonable accommodation of resident's needs to one out of 21 sampled residents (Resident (R) 21). This failed practice has the potential to affect all the residents in the facility. Findings Include: R21 is a [AGE] year-old male admitted to the facility on [DATE]. R21 is currently receiving hospice care in the facility. Concurrent observation and Interview were conducted on 11/01/23 at 10:17 AM in R21's room. R21 stated that he is constantly requesting for more water, and it takes telling two or three staff until someone finally provides him with more. The resident has two small cups on his bedside table. One cup was filled halfway with water and the other cup was filled with clear light brown liquid. Resident's water pitcher was located on top of the bedside dresser, which is located behind the resident. Due to the location, the resident is unable to reach the water pitcher. Observation was conducted on 11/01/23 at 12:10 PM in R21's room.…

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 and record review, the facility failed to immediately consult with the resident's physician after a resident fell and had the potential for requiring physician interventions for one resident (Resident (R)70) sampled. R70 fell and sustained multiple bruises and reported hitting her head, was on medications which inhibit the resident's blood clotting abilities (Aspirin and Xarelto) placing the resident at higher risk for internal bleeding, and the physician was not notified until 1 hour and 40-minutes after the resident fell. Facility staff reported R70's physician is regularly difficult to contact. As a result of this deficient practice, all residents under the same care of R70's primary physician is at risk for potential of harm. Findings include: On 10/31/23 at 01:05 PM, conducted a review of R70's Electronic Health Record (EHR). Review of the resident's progress notes documented on 10/08/23 at 08:20 AM, R70 had a witnessed, unassisted fall in the dining room and sustained bruising to the right forearm, abdomen, left breast, and a lump of the forehead. R70 was…

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

Based on interviews and record review, the facility failed to assure that two sampled residents (Resident (R)72 and R70 ) received an accurate assessment, reflective of the residents' status at the time of the assessment. This deficient practice places all the facility residents at risk for assessment inaccuracy. Findings Include: 1) A review was conducted of R72's Electronic Health Record (EHR). R72's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/28/23 indicated that R72 had three stage two pressure ulcers that were not present upon admission. Interview was conducted on 11/02/23 at 08:09 AM with R72 in the dining room. R72 stated that he had the pressure ulcer before admission to the facility. Interview was conducted with Director of Nursing (DON) on 11/03/23 at 10:26 AM. DON stated that R72's pressure ulcers were present during admission and was miscoded on the MDS. 2) Review of R70's quarterly MDS with an ARD of 10/18/23, Section C. Cognitive Patterns documented the resident's Brief Interview for Mental Status (BIMS) scored was documented as 15, indicating 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 record review (RR) and staff interview the facility failed to include R12's choices for her advanced healthcare directives in her baseline care plan. The deficient practice could affect any newly admitted resident at the facility. Findings Include: On 11/02/2023 at 01:21 PM RR did not find a signed Baseline Care Plan form for R12. On 11/02/2023 at 04:33 PM medical records was able to provide a copy of the baseline care plan for R12. Baseline care plan was signed by staff completing the baseline care plan on 09/29/2023 for R12 who was admitted that day. Noted the Advanced Directives/Code Status section was left blank. On 11/03/2023 at 11:41 AM reviewed R12's baseline care plan with Interim DON who stated the Advanced Directives/Code Status section is to be filled out, this area was left blank. Requested and received a copy of the Baseline Care Plan policy, from the Interim DON, which is dated from 05/2022. Policy states: Purpose: The facility must develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered…

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 (RR) and resident interview the facility failed to include use of a walker in Resident (R)35's comprehensive care plan and use of antidepressant in R12's comprehensive care plan. The deficient practice could affect any resident at the facility. Findings Include: 1. On 10/31/2023 at 09:29 AM met and spoke with R35 in her room. R35 asked surveyor if I saw her walker on the other side and she pointed towards the partition in her room. Looked on other side of partition but saw a walker that was in the living space of R35's roommate. R35 stated a facility staff, nurse, had told her she could not use her walker. Inquired if R35 had fallen and she denied falling in the facility. R35 stated she walked in the hallway yesterday with the therapist and she took the walker away. On 10/31/2023 at 10:00 AM spoke with R35's nurse and asked if she told resident she could not have her walker and nurse denied this. On 11/02/2023 at 09:14 AM went to interview R35 and found her sitting in her room with her walker next to her. R35 said she saw it on the other side near…

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 review, the facility failed to revise Resident (R)70's comprehensive care plan (CCP). R70 fell on [DATE] and sustained bruising to the right forearm, abdomen, left breast, and a lump on the forehead and is on daily scheduled medications which increases the resident's risk for bleeding and bruising. The resident's fall care plan was not revised after the fall and injuries sustained on 10/08/23 to include the risk for increased injury or additional monitoring related to the medication. As a result of this deficient practice, residents on anticoagulant/antiplatelet medication increases the severity of injury residents could sustain during a fall. Findings include: On 10/31/23 at 10:30 AM, initial observation of the resident documented the resident had bruising on the bridge of the nose. Inquired with nursing staff about the bruise on the resident's nose, staff stated they are unsure of how the resident got the bruise. On 10/31/23 at 01:05 PM, conducted a review of R70's Electronic…

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 and staff interview the facility failed to assure a medication cart was locked when not being used by a nurse. The deficient practice could affect all residents, staff and visitors who could have access to the unlocked medication cart. Findings Include: On 11/02/2023 at 02:17 PM while standing in the hallway near the nurse's station on the second floor noticed a registered nurse (RN)5 walk away from the medication cart which she left unlocked. Surveyor remained with medication cart till RN5 returned. During this time the Interim DON came by and was shown the medication cart was left unlocked and unattended. On 11/02/2023 at 02:24 PM RN5 returned to unlocked medication cart. RN5 confirmed the med cart is supposed to be locked when it is left unattended. Inquired with RN5 if she had training regarding this matter when she attended orientation and she stated she had orientation and the locked cart is a known thing. RN5 denied getting separate training on this.

Based on record review (RR) and staff interview the facility failed to maintain an accurate medical record for R59 putting her at risk for a fall from a bed that was care planned to Do not not leave bed on lowest position. This deficient practice could affect all residents at the facility who have an impaired mobility. Findings Include: 1. During RR of R59's care plan noted under Impaired Mobility/Falls an intervention listed stated Maintain fall precautions. Adjust height of bed to comfortable height for easy in/out of bed. Do not leave bed on lowest position. On 11/02/2023 at 02:01 PM met with Interim DON and looked at R59's bed. R59 was sleeping in her bed and facility staff showed the bed was at it's lowest position. R59's bed was a regular hospital bed and not a low to the ground bed. Interim DON stated it appears to be an error in the care plan, regarding the height of the bed.

Based on observation and interview, the facility failed to ensure proper glove use procedures were followed by a staff member. This deficient practice places the residents at risk for the development and transmission of communicable diseases and infections. Findings Include: Concurrent observation and interview were conducted on 11/02/23 at 02:05 PM. Housekeeper (HK) 1 was observed entering the second floor through the stairwell access with gloves on. HK1 then entered the laundry room and immediately exited. Infection Control Coordinator (ICC) was present in the laundry room. When ICC was queried about HK1's glove use, ICC stated that HK1 should not have gloves on in the hallway.

Based on observations, review of the facility's policy and procedures, and interview with staff member, the facility failed to ensure that all foods were procured, stored, prepared, distributed, and served under sanitary conditions. Observations of a refrigerator found temperatures greater than 41 degrees Fahrenheit (F); and stored food items were not covered. Findings Include: During the initial kitchen tour observation with Head [NAME] on 12/19/22 at 08:15 AM, observed trays of raw chicken located in the walk in refrigerator on a tray cart uncovered. The plastic that was on top of the tray cart was not completely over the cart. Head [NAME] acknowledged it should be covered. Further concurrent observation with Head [NAME] during the initial kitchen tour on 12/19/22 at 08:21 AM, a refrigerator inside thermometer measured 46 degrees F and the exterior thermometer measured 51 degrees F. Interview with Head [NAME] confirmed the measurement and stated the refrigerator should be no higher than 41 degrees F. Second observation at 08:43 AM, found the inside thermometer measured at 46…

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 interview with staff member, the facility failed to ensure the dishwasher was maintained in safe operating condition. The facility did not ensure proper temperatures of the dishwasher was achieved. Findings Include: During the initial kitchen tour with Head [NAME] on 12/19/22 at 08:15 AM, Head [NAME] stated the facility's dishwasher used heat to sanitize the dishes and the final rinse thermometer should reach 180 degrees Fahrenheit (F). Observed a dish test tray going through the dishwasher. Observed the final rinse thermometer not reaching appropriate temperature. The thermometer for the rinse function did not reach 180 degrees F minimum as instructed on the dishwasher. Kitchen Aide (KA) 2 confirmed the rinse function did not reach 180 degrees F. A second observation of a test tray was done and the dishwasher final rinse thermometer reached 180 degrees F. Inquired with Head [NAME] how the facility ensured the thermometer was functioning properly, Head [NAME] stated they use test strips and the test strip would turn black to indicate the dishes were…

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 reviews, and interviews, the facility failed to appropriately manage inappropriate temperatures for two of its two medication refrigerators. This deficient practice has the potential to risk spoilage of necessary medications for residents, such as insulin and vaccines, and could result in serious and harmful outcomes. Findings include: On 12/21/22 at 08:41 AM, a medication refrigerator was observed in a nursing unit. Insulin, suppositories, and eye drops were kept in this refrigerator. An ACTION LOG FOR REFRIGERATOR AND FREEZER document was located on the refrigerator. There were two temperature ranges on the document, one read: STANDARD RANGES: Refrigerator: (33) - (41) degrees F [Fahrenheit] Freezer: (-25) - (10) degrees F. Another temperature range was handwritten and stated, [nursing unit] MED-ROOM REFRIGERATOR TEMP 36 - 46°F. Documented on the log for 12/04/22 at 01:30 AM, the temperature reading was 46.7° in the column next to the temperature, the heading stated, Out of Range reading: Inspect refrigerator/Provide Action Taken (i.e. Close door,…

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 interview with staff members, the facility did not assure Resident (R) 26's advance health care directive (AHCD) was documented and filed in the resident's medical record. The facility failed to ensure R26 was periodically given opportunities to formulate an AHCD. This deficient practice has the potential to cause harm to residents when they are provided medical care that is not in accordance with their wishes. Findings Include: R26 was admitted to the facility on [DATE]. Record review found a checklist documenting R26 formulated an AHCD but no AHCD was found on file in the resident's medical record. On 12/20/22 at 10:35 AM interview with Social Worker (SW) was done. SW confirmed the facility does not have R26's AHCD on file. SW stated R26's family members reported R26 has an AHCD but has not provided a copy to the facility. Inquired if SW has documentation of periodic follow-ups with resident and/or family members to ensure R26 exercises his right to formulate an AHCD or request a…

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

Based on observation, staff interview, record review and review of policy, the facility failed to provide a safe, clean environment for one Resident (R)32 of eight residents sampled. As a result of this failure, R32 had a prolonged exposure to mold and was put at risk for developing adverse reactions. Findings include: During an observation of R32 ' s room on 12/20/22 @ 11:30 AM, a small section of the ceiling, approximately 1foot x 1foot, was noted to have brown &/or black irregularly shaped stains and appeared moist and mold like. Maintenance Supervisor (Maint) was queried on 12/20/22 @ 11:45 AM and said there was a water leak and that a remediation company did testing and was scheduled to do clean-up/ repairs. Review of the remediation company ' s test results dated 11/3/22 read the following: This is regarding the mold and asbestos sampling and analysis, conducted on 10/24/22 . The purpose of this project was to collect and analyze air samples for mold and certain suspect asbestos containing building materials . Mold, the tape lift sample . The laboratory results indicated…

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, and interview with staff members, the facility failed to ensure Resident (R) 47 was free from physical restraints imposed for the purpose of convenience and not required to treat the resident's medical symptoms, as evidenced by R47's posey belt, used for safety, placed behind her where she is unable to reach and remove herself. The deficient practice has the potential to affect all residents at the facility from ensuring they are free from physical restraints not required to treat medical symptoms. Findings Include: R47 was admitted to the facility on [DATE] with diagnoses not limited to age-related osteoporosis, anemia, cognitive communication deficit, depression, history of falling, abnormalities of gait and mobility, and dementia. Review of R47's quarterly Minimum Data Set (MDS) with an assessment reference date of 11/22/22, R47's Brief Interview Mental Status (BIMS) scored her at a 3 (severe cognitive impact). In Section P0100. Physical Restraints used in chair or out of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff members, the facility failed to immediately report an injury of unknown source to the adult protective services (APS) in accordance with State Law for Resident (R) 44 after fracture results of R44's right foot. Findings Include: R44 was admitted to the facility on [DATE] with diagnoses not limited to dementia, Parkinson's disease, rheumatoid arthritis, and age-related osteoporosis. Review of R44's quarterly Minimum Data Set (MDS) with an assessment reference date of 10/04/22, R44's Brief Interview Mental Status (BIMS) scored him at a 3 (severe cognitive impact). In Section G. Functional Status, under Transfers (how resident moves between surface including to and from bed, chair, wheelchair, standing position), R44 requires extensive assistance with two-person physical assist. Review of R44's Electronic Health Record (EHR) clinical notes documented on 11/24/22 0110 staff reported swelling and discoloration to R [right] foot prior to changing resident. Assessed,…

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 reviews and interviews, the facility failed to ensure that one resident's (R) comprehensive care plan goals were communicated to the receiving health care provider to ensure a safe and effective transition of care. R22 needed to be transferred to a hospital for higher level of care and could potentially be sub optimally cared for because her individualized care plan and goals were not communicated to the receiving facility. This deficient practice has the potential to affect all residents. Findings include: On 12/19/22 at 10:30 AM, on initial screening of residents, Registered Nurse (RN)9 stated that R22 was sent to the hospital that morning due to the need for higher level of care. On 12/20/22 at 11:58 AM, a record review of R22's electronic health record (EHR) was done. According to the progress notes, R22 needed a higher level of care to treat possible gastrointestinal (GI) bleeding and was sent to the hospital. No other documentation about her transfer was found in the EHR. On 12/21/22 at 12:13 PM, Quality Assurance Nurse (QAN)11 was interviewed. QAN11 was asked…

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 reviews and interviews, the facility did not provide written information about their bed hold policy to one resident (R), R22, who needed a higher level of care and was transferred to a hospital. The facility does not have a current bed-hold policy for residents who are hospitalized which leaves the resident with no possible bed to return to when their acute medical condition has resolved. This has the potential to affect all residents in the facility. Findings include: On 12/19/22 at 10:30 AM, on initial screening of residents, Registered Nurse (RN)9 stated that R22 was sent to the hospital that morning. On 12/20/22 at 11:58 AM, a record review of R22's electronic health record (EHR) was done. According to the progress notes, R22 needed a higher level of care to treat possible gastrointestinal (GI) bleeding and was sent to the hospital. No other transfer documentation was found in the EHR. On 12/21/22 at 12:13 PM, the Quality Assurance Nurse (QAN)11 was interviewed. QAN11 stated that she was not sure if the facility gave out written information about their bed hold…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview with staff members, the facility failed to implement one of 18 sampled residents Resident (R) 47 person-centered comprehensive care plan. An intervention to prevent injury for R47 with a history of falls was not implemented. Findings Include: R47 was admitted to the facility on [DATE] with diagnoses not limited to age-related osteoporosis, anemia, cognitive communication deficit, depression, history of falling, abnormalities of gait and mobility, and dementia. While admitted to the facility R47 had a total of four falls, on 06/25/22, 07/10/22, 08/04/22 and 11/01/22. Review of R47's clinical notes documents R47 had an unwitnessed fall in her room on 11/01/22 and had a X-Ray to right elbow on 11/02/22 with impression of acute displaced fracture of the olecranon (a long bone in the forearm that projects behind the elbow). The clinical notes document on 11/01/22, Per CNA staff, residents .bed alarm triggered, she went to check and she found resident on the floor…

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 interview the facility failed to update the nurse staffing data daily and at the beginning of each shift for one of four units. Findings Include: On 12/19/22 at 10:45 AM on the third floor, observed the daily nurse staffing data posted at the front of the nurse's station dated 12/19/22 with the total number of licensed and unlicensed nursing staff and hours worked for night shift. Day shift and evening shift were observed to be blank. On 12/19/22 at 11:00 AM concurrent observation and interview with Infection Preventionist (IP) and Registered Nurse (RN) 12 was done. IP confirmed the daily nurse staffing data for day shift was not filled out and day shift starts at 08:00 AM. RN12 stated day shift did not start until 10:00 AM today because she did not come in until 10:00 AM. IP and RN12 confirmed the time this observation and interview took place was 11:00 AM. RN12 took the posted nurse staffing data and began updating the day shift total working licensed and unlicensed staff and hours.

Based on observation, interviews, and record review, the facility failed to adhere to COVID-19 infection control protocol by not appropriately disinfecting and changing personal protective equipment (PPE) after exiting from one resident's (R), R25's COVID-19 isolation room, out of a sample of one resident. This deficient practice encourages the transmission of the COVID-19 virus which has the potential to affect all residents, staff, and visitors in the facility. Findings include: On 12/19/22 at 08:27 AM, in an interview with the Director of Nursing (DON), R25 was identified as having an active COVID-19 infection and was currently in isolation. On 12/20/22 at 11:09 AM, Registered Nurse (RN)9 was observed to be entering and exiting R25's room that had Airborne Precautions, Contact Precautions, and Droplet Precautions signage posted on R25's room door. An additional sign posted on R25's closed door was, Discard N95 [respirator] and DISINFECT FACE SHIELD at every exit from the room. RN9 exited from R25's room and did not disinfect her face shield and change her N95 mask before going 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.