Islands Skilled Nursing & Rehabilitation

2) On 04/29/25 at 08:13 AM observed medication cart two near nurse's station with keys left unattended in a disposable cup on top of the medication cart. Inquired of Registered Nurse (RN) 7 if the medication cart keys are supposed to be left on the medication cart and she stated, they told us to put them there. Inquired of RN7 who she meant and she stated manager. Inquired if RN7 is supposed to keep the keys on herself and she stated no that they were told to put the keys near the cups on top of the medication cart or the side of the cart near the medication cups and hide them. Inquired if the set of keys includes the narcotic key and she confirmed it does. Inquired of RN7 if she knew what the facility policy states regarding medication cart keys and she stated she had not seen it. At this time reviewed the medication cart Narcotic Endorsement Log and found there were two blank slots for 04/13/25 when the oncoming nurse for 0700-1900 shift and off going nurse for 1900-0700 shift did not initial confirmation of reconciliation of narcotic count. Inquired of RN7 why this occurred 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 and interview, the facility failed to ensure the ice machine was kept in clean and sanitary condition in accordance with professional standards for food service safety. This deficient practice placed the residents at risk for foodborne illness. Findings include: On 04/27/25 at 09:10 AM, initial tour of the kitchen was conducted with Kitchen Manager (KM). Opened door to ice machine and observed a grayish-green buildup under the area where ice is dispensed. KM acknowledged that the ice dispenser had a buildup of a grayish-green residue. Used a dry paper towel to wipe the area and was able to remove some of the residue. KM said the ice machine was recently serviced on 03/31/25 by an outside vendor but did not notice the buildup under the dispenser. KM presented log where monthly inspection of the ice machine is documented, next service is scheduled on 04/30/25. KM said he will ask the staff to clean the dirty dispenser today and add this task on the weekly log.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to correctly fill out an accurate Physician Orders for Life Sustaining Treatment (POLST) for one of three residents reviewed for Advance Directives, Resident (R) 18. Findings Include: Record review of R18's Electronic Health Record (EHR) revealed he was admitted to the facility on [DATE] and his diagnoses include, but not limited to, dysphagia, oropharyngeal phase, type 2 diabetes mellitus with other skin complications, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and tracheostomy status. Continued record review revealed R18's EHR did not have an Advanced Health Care Directive appointing an agent as his Power of Attorney to make health care decisions should he become unable to. Review of R18's POLST, that was prepared on 06/18/24, revealed under section D Signatures and Summary of Medical Condition, the Legally Authorized Representative (LAR) box was marked with an X.…

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 5) On 04/27/25 at 11:10 AM observed R31 resting in his bed. At this time observed R31's indwelling urinary catheter tubing and urinary bag, which was covered with a privacy bag, resting on the floor next to R31's bed. Record review of R31's Electronic Health Record revealed he was admitted to the facility on [DATE] and his diagnoses include, but are not limited to, chronic pulmonary edema, persistent vegetative state and neuromuscular dysfunction of bladder, unspecified. Review of R31's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/25/25 revealed he was coded for having a urinary catheter and he is totally dependent upon staff for his care. On 04/30/25 at 02:18 PM a phone interview was conducted with the Interim Director of Nursing (DON). Inquired if it was okay for residents with a urinary indwelling catheter and the urinary bag to rest on the floor. Interim DON confirmed nothing of the Foley (urinary indwelling) catheter system should be resting on the floor. Based on observations,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record and document reviews, the facility violated federal regulations when they initiated a discharge that did not originate through the Resident's (R)1's Representative's verbal or written request, and was not in alignment with R1's goals for care and preferences. R1 was transferred to an acute care hospital for a medical condition requiring higher level of care. It was R1's Representative's intent to have him return to the facility post hospitalization. Although the facility had the capacity and capability to provide the respiratory specialty services needed, the facility inappropriately made the decision, to deny him the right to return. In addition, the medical record did not contain documentation of the required elements of this discharge. As a result of this deficient practice, R1's Representative was not given the appropriate notification of facility initiated discharge and was unable to appeal the appropriateness of discharge and R1 was denied the right to return to the facility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record and document reviews, the facility did not provide the required notification of transfer/discharge to one Resident's (R)1's representative out of a sample size of four. When R1 was transferred to the hospital for a higher level of care and admitted , it R1's Representatives expectation R1 would be returning to the facility when discharged . While R1 was hospitalized , the facility made the decision to not readmit. The facility failed to provide the Representative or Ombudsman written notice of the facility initiated discharge. As a result of this deficient practice R1's Representative did not have the information needed to exercise their rights to appeal the appropriateness of the facility initiated discharge. Findings include: 1) R1 is a [AGE] year old male with a history of hypertension, quadriplegia with tracheostomy and gastrostomy tube (tube placed through the abdomen in the stomach) for nutrition after a hemorrhagic stroke. He is nonverbal at baseline. R1 has had multiple…

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, document review and record review, the facility had an established transfer/discharge policy, but failed to follow and implement that policy and did not comply with regulations that apply to discharges. Specifically, R1 was sent to the Emergency Department (ED) and hospitalized for further care. His Representative had the expectation R1 would return to the facility, but when he was ready for discharge, the facility refused to let him return and resume residence. Findings include: 1) R1 had been a resident at the facility since 03/07/2024. On 05/31/2024, he was transferred to the Emergency Department for a higher level of care. When his condition was stable, the hospital Social Service department contacted the facility Admissions Director to arrange for R1 to return to the facility. The facility informed the hospital they would not let R1 return due to concerns they had with the mother's behavior. 2) On 07/17/2024 at 10:30 AM. during an interview with the Admissions Director (AD), she said…

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 update one Resident's (R)1 care plan (CP) of a sample size of four. R1's representative had specific requests/preferences regarding his care, which were not included in the CP. As a result of this deficiency, the CP was not comprehensive or individualized to include agreed upon interventions. This deficient practice could affect all residents and be a barrier to meeting their highest practicable psychological and physical well-being Findings include: 1) R1 is a [AGE] year old male with a past medical history includes cerebral hemorrhage with quadriplegia, chronic respiratory failure with tracheostomy, hypertension, dysphasia (difficulty swallowing), and gastrostomy tube dependent for nutrition. At his baseline, he does not require oxygen and is alert and oriented 1x-2x (person and place). He requires extensive assistance for all activities of daily living, can only make some needs known with expression, nodding head and gestures, and totally dependant…

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, document review and medical record review, the facility failed to provide availability of physician services 24 hours a day. On 05/31/2024, the nursing staff was unable to reach a physician/provider to discuss a Resident's (R)1 condition. This deficient practice puts any resident requiring emergency physician services at risk of delay in care, which could result in harm or death. Findings include: 1) R1 is a [AGE] year old male with a past medical history of cerebral hemorrhage, chronic respiratory failure with tracheostomy, dysphasia (difficulty swallowing), gastrostomy tube for nutrition and is alert and oriented 1x-2x (person and place).He requires extensive assistance for all activities of daily living and totally dependant on staff. He was to the facility from an acute care hospital on [DATE]. On 05/31/2024, R1 had an increased heart rate (HR) and behavioral changes, and then developed a temperature. His condition required notification of a provider (Physician or Advanced Practice…

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 interview the facility failed to provide Nursing Staffing Information to include hours worked by Registered Nurses (RNs), Certified Nurse Aides (CNAs) and resident census each day. Findings Include: On 05/15/24 at 08:40 AM, observed facility's Daily Assignment sheet that was posted near the nurse's station on the treatment cart. The posting listed RN and CNA names and area they were assigned to work that day and the shift. No hours worked were posted for the RNs and CNAs and no resident census for the day was included on this posting. On 05/16/24 at 02:06 PM interviewed Director of Nursing (DON). During this interview shared requirements of F732. DON confirmed his posting was missing resident census and total numbers of hours worked by RNs and CNAs.

Based on review of the Facility Assesment (FA), the facility failed to conduct, document, and annually review its facility-wide assessment. The facility used a facility assessment tool as a template in place of an up to date and accurate assessment to identify the needs of its residents. The deficient practice placed all residents in the facility at an increased risk of harm. Findings include: On 05/16/24 at 03:43 PM, FA reviewed. Requirement. Nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents. The FA was missing accurate and up to date information regarding special treatments and conditions. Acuity 1.5; respiratory treatments, oxygen therapy 0-15, suctioning 0; tracheostomy care 0; ventilator or Respirator 0. Facility matrix reviewed. 24 Residents with tracheostomies; 15 residents on mechanical ventilators and require special respiratory treatments.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan (CP) for three of 34 residents sampled (Resident (R) 4, R12, and R29) with psychotropic and sedative medications. Non-pharmacological interventions and monitored behaviors were not included in the residents' CP. Findings include: Cross Reference to F758. The facility failed to specify and monitor behaviors related to the psychotropic medications administered. 1) R4 was admitted to the facility on [DATE] with diagnoses of, but not limited to, major depressive disorder, generalized anxiety disorder, and insomnia. Review of R4's physician orders included psychotropic medications, trazodone (antidepressant) 200 milligrams (mg) daily as needed (PRN) for insomnia, trazadone 50 mg PRN every eight hours for anxiety, and sertraline (antidepressant) 175 mg a day for depression. On 05/16/24 at 11:31 AM, concurrent record review and interview with Registered Nurse (RN) 23 was done. Review of R4's CP…

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 interview and record review the facility failed to update the care plan for one Resident (R) 27 with treatment plans and recommendations. R27 has a tracheostomy and wears a Passy Muir valve (PMV) to improve communication. R27's representative's decision to not have a tracheostomy cap (T-cap) trial were discussed at the interdisciplinary team (IDT) meeting but not included in the care plan. The deficient practice has the potential to dishonor R27 and her representative's rights. Findings include: Cross reference to F551 rights exercised by representative. On 05/16/24 at 08:30 AM, requested a copy of R27's care plan and IDT meeting minutes for the past six months. Received and reviewed a written copy of the IDT meeting dated: 09/11/23 at 09:00 AM from Director of Nursing (DON). Handwritten care plan summary with IDT. No documentation found on the report to include capping the trachea (trach) or to wean off of the trach. Reviewed the social services quarterly IDT meeting dated 03/20/24. Respiratory Summary: Reviewed and discussed current treatment. Verbalized understanding. 3.…

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, the facility failed to ensure a resident received treatment and care in accordance with professional standard of practice for one of 16 residents sampled (Resident (R) 29). The facility did not follow the physician ordered bowel instruction and as a result, R29 was placed at increased risk of avoidable skin breakdown, infection and discomfort. Findings include: R29 was admitted to the facility on [DATE] with diagnoses of, but not limited to, chronic kidney disease stage 4, gastrotomy status, tracheostomy status, muscle weakness, other abnormalities of gait and mobility, bed confinement status, long term use of antibiotics, unspecified Escherichia coli (E. coli) as the cause of diseases classified elsewhere, pneumonia, and abnormalities of gait and mobility. Review of R29's physician orders included Senna-Docusate (stool softener), give one tablet via G-Tube two times a day for constipation, hold for loose stool. Review of R29's Electronic Health Record (EHR) found R29 had…

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 interview, the facility failed to ensure the attending physician documented in the residents' medical record that a review of the medication regimen review (MMR) recommendation from the pharmacist was reviewed and what, if any, action had been taken to address it for three of five residents sampled (Resident (R) 4, R12, and R29). Findings include: 1) Review of R4's physician orders included psychotropic medications, trazodone (antidepressant) 200 milligrams (mg) daily as needed (PRN) for insomnia and trazadone 50 mg PRN every eight hours for anxiety. Review of R4's monthly MRR found recommendations in August 2023, October 2023, and November 2023 with no documentation from the physician that the MRRs were reviewed. In August, October, and November the pharmacist recommended the physician to provide a specific stop date or time period and a clinical rationale to continue trazodone PRN psychotropic medications past 14 days. On 05/16/24 at 11:31 AM, concurrent record review and interview with Registered Nurse (RN) 23 was done. Concurrent record review found…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to specify and monitor behaviors related to psychotropic and sedative medications for three of five residents sampled (Resident (R) 4, R12, and R20); and failed to ensure a PRN (as needed) psychotropic medication was limited to 14 days or ensure the physician document their rationale to extend the 14 days in a residents medical record for one of five residents sampled (R4). Findings include: 1) R4 was admitted to the facility on [DATE] with diagnoses of, but not limited to, major depressive disorder, generalized anxiety disorder, and insomnia. Review of R4's physician orders included psychotropic medications, trazodone (antidepressant) 200 milligrams (mg) daily as needed (PRN) for insomnia, trazadone 50 mg PRN every eight hours for anxiety, and sertraline (antidepressant) 175 mg a day for depression. On 05/16/24 at 11:31 AM, concurrent record review and interview with Registered Nurse (RN) 23 was done. Review of R4's Treatment Administered Record (TAR)…

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 of two of four residents (Resident (R) 17 and R31), record review, one closed record review for R37 and interview the facility failed to ensure its medication error rate was not five percent or greater, an error rate of 38.36 percent (10 errors out of 26 opportunites). This deficient practice could put all residents at risk for medication errors which could include medications given the wrong route and receiving medication when it should be held which could put the residents at risk for harm. Findings Include: 1) On 05/15/24 at 08:50 AM observed Registered Nurse (RN) 80 prepare and pass medication to R17 on the third floor. Prior to medication pass the nurse reported R17's blood pressure was 116/65 and pulse was 67. R17 is a [AGE] year old resident who was admitted to the facility on [DATE] with diagnoses including, but are not limited to,cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and anoxic brain damage, not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and policy review, the facility failed to ensure it established and maintained an infection prevention control program to prevent the spread of infections evidenced by the following: Environmental cleaning of resident's rooms was not being routinely conducted; resident care equipment was not cleaned and left in resident rooms; disposable care equipment was reused; and an infection control and prevention policy was not complete for the provision of infection prevention and control based on recognized guidelines, facility assessment; environmental cleaning and disinfection for resident care areas and equipment; and the kitchen was found with areas where residents food could be contaminated. The deficient practice places all residents in the facility at an increased risk for illness. Findings include: 1) Random observations were conducted in R31's room on 05/13/24 and 05/14/24 of resident R31's suction canister, cross reference to F695. On 05/15/24 at 08:51 AM observation in 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 observations, record review, and interviews, the facility failed to ensure residents were provided privacy and dignity while receiving care in the facility for three of 16 residents (Resident (R) 4, R7 and R26). R4 and R7 had urinary catheter bags that were uncovered and visible to people in the hall. R26 was exposed staff and visitors in the room during personal care. This deficient practice disregarded the resident's right to dignity and respect. Findings include: 1) On 05/14/24 at 2:55 PM, observation in R26's room. R26 is a dependent male resident on a mechanical ventilator who's bed is next to the open door and in a room with three other residents. The privacy curtain was half closed and revealed R26 laying in his bed naked, while receiving personal care from Certified Nurse's Aide (CNA) 12 and CNA68. The surveyor pulled the curtain closed saying I'll close the curtain to give .[R26] .privacy, and noted the curtain was too short, leaving a large gap at the head of the bed. The CNAs said to the surveyor, it's too short. The privacy curtain was not large enough to drape…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the rights of a resident's representative in a medical treatment decision to insert a tracheostomy cap (T-cap) was exercised. The deficient practice dishonored the resident representative's right to make important decisions in the care and treatment for Resident (R) 27. Findings include: Electronic Health Record (EHR) reviewed. R27 is an [AGE] year-old female resident, admitted on [DATE] with a diagnosis that included respiratory failure with a tracheostomy (an artificial airway in the throat). R27 is dependent on staff for her care and Family Member (FM) 3 is her legal guardian and makes R27's healthcare and treatment decisions. 05/14/24 at 10:54 AM, observation and interview with FM3 who reported that two months ago a Speech Therapist (SLP) who no longer works here did something that really upset her. The SLP had the respiratory therapist (RT) apply a T-cap to R27's trach. FM3 stated that she was very upset because placing the cap…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure written copy of the Notice of Medicare Non-Coverage (NOMNC) form was provided and acknowledged by the beneficiary (resident) or the beneficiary's representative according to the NOMNC instructions for three of three residents sampled (Resident (R) 190, R191, and R192). Findings include: Review of R190's Electronic Health Record (EHR) found R190 was admitted to the facility on [DATE] and discharged home on [DATE]. R190's Minimum Data Set (MDS) at discharge with an Assessment Reference Date (ARD) of 03/16/24 documented R190's Brief Interview for Mental Status (BIMS) a 14 out of 15 (cognitively intact). Review of R191's EHR found R191 was admitted to the facility on [DATE] and discharged home on [DATE]. R191's MDS at discharge with an ARD of 03/23/24 documented R191's Brief Interview for Mental Status (BIMS) a 15 out of 15 (cognitively intact). Review of R192's EHR found R192 was admitted to the facility on [DATE] and discharged to a care home on…

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

Based on record review and interviews, the facility failed to report an allegation of abuse immediately but no later than two hours after the allegation was made or allegation of mistreatment and an injury of an unknown origin within 24 hours to the State Survey Agency (SA) for two of two residents sampled (Resident (R) 34 and R10). Findings include: Review of the facility's policy and procedure Abuse Investigation and Reporting with no effective, revision or review date documented All alleged violations involving abuse, neglect, exploitation, including injuries of an unknown source and misappropriation of poverty will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: .The State licensing/certification agency responsible for surveying/licensing the facility .will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violations does not involve abuse AND has not resulted in serious bodily injury. 1) On…

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

Based on record review and interviews, the facility failed to prevent further potential abuse or mistreatment while the investigation was in progress for Resident (R) 34. The facility did not remove Certified Nurse's Aide (CNA) 16 from the facility providing access to the resident and/or other vulnerable residents while the investigation was in process. Findings include: Cross reference to F609. The facility failed to report an allegation of abuse immediately but no later than two hours or allegation of mistreatment within 24 hours after the allegation was made to the State Survey Agency (SA) for R34. On 05/10/24 at 08:36 AM, the SA was informed by the Long-Term Care Ombudsman (LTCO), of an incident that occurred on 05/08/24 during the LTCO's resident visits at the facility. The LTCO reportedly informed the Director of Nursing (DON) and Administrator on 05/08/24 of possible resident to staff abuse between R34 and CNA16 and requested they send a report for an allegation of physical and verbal abuse to the SA and Adult Protective Services (APS). On 05/13/24 at 10:47 AM, an 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 interviews, the facility failed to ensure written notification of transfer/discharge was provided to the resident or resident's representative, as soon as practicable, before transferred or discharged and send a copy of that notice to a representative of the Office of the State Long-Term Care Ombudsman (LTCO) for one of three residents sampled (Resident (R) 29). Findings include: R29 was transferred and admitted to the hospital on three separate occasions, on 01/01/24 to 01/09/24 with diagnoses of tachycardia and recurrent aspiration pneumonia, on 02/01/24 to 02/06/24 with diagnosis of acute aspiration pneumonia, and on 03/26/24 to 04/01/24 with diagnosis of acute respiratory failure with hypoxia. A review of R29's Electronic Health Record (EHR) found no documentation that a written notification for transfer to the hospital was provided to R29 or his representative and LTCO for the three hospitalizations. On 05/15/24 at 01:02 PM, an interview with Social Services Director (SSD) was done. SSD reported the facility did not give written notification for…

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 interview the facility failed to re-assess Resident (R) 15 for falls quarterly. The deficient practice puts all residents who are at risk for falls or have had a change in their fall risk if the assessment is not completed and interventions added and implemented to the care plan. Findings include: On 05/14/24, during record review of R15's Electronic Health Record (EHR) found R15's last fall assessment was dated 12/12/23. The next quarterly fall assessment was due 3/12/24 and this was not done. On 05/14/24 at 03:15 PM interviewed Registered Nurse (RN) 79, nurse assigned to R15 and inquired when was the last fall assessment completed for R15 and how often are they due. RN79 stated she is new to facility and does not know but will find out and let me know. RN79 stated the computer will generate when the next assessment has to be done and will make it available for the nurses to fill out. On 05/15/24 at 03:52 PM, interviewed Director of Nursing (DON) and inquired when fall assessments are due and he stated quarterly. Inquired about R15's last fall assessment…

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 the facility failed to include Resident (R) 35's daily preferences to her baseline care plan which is to be developed within 48 hours of a resident's admission. Findings Include: On 05/13/24, record review of R35's Electronic Health Record (EHR) found she was admitted to the facility on [DATE]. R35 is a [AGE] year old resident with diagnoses that include, but are not limited to adjustment disorder, unspecified, functional quadriplegia who has a tracheostomy (breathing tube in neck) and uses a ventilator (machine) to help her breath. Review of R35's baseline care plan found it was filled out on 04/23/24. Section 1. General Information and Initial Goals D. Daily Preferences that Resident Prefers was left blank. Resident prefers the following (check all that apply) 1. Choosing clothes to wear. 2. Caring for personal belongings. 3. Receiving tub bath. 4. Receiving shower. 5. Family or significant other involvement in care decisions and 6. Other (specify). This section was 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 observation, interview and record review, the facility failed to ensure residents were provided with supplies necessary to maintain optimal nutrition, grooming, and personal and oral hygiene for seven residents in the sample (Resident (R) 1, R7, R26, R27, R31, R33, and R4). Six of the seven residents in the sample are receiving enteral nutrition (fed by tube) by gravity instead of a pump due to a shortage of the pump tubing, and R33 had significant weight loss; R27 frequently runs out of suction toothbrushes needed for her increased secretions; and R4 is provided briefs to small for him. The deficient practice places residents who require maximal/ dependent assistance in the facility at risk of achieving maximum physical health and well-being. Findings include: 1) Random observations conducted in residents' rooms on 05/13/24 at 10:55 AM, 11:00 AM; 02:15 PM and 05/14/24 at 09:35 AM; 02:00 PM; 04:30 PM. Observed R1, R7, R26, R27, R31, and R33 with tube feedings being provided by gravity drip with pumps that were not in use attached to the poles. Electronic Health Record (EHR)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to change a suction cannister half full of red-brown secretions and clots for one of three residents in the sample (Resident (R) 1). The deficient practice placed residents receiving tracheostomy care at an increased risk of illness. Findings include: Cross reference to F880. Electronic Health Record (EHR) reviewed. R1 is a dependent female resident admitted on [DATE] A sputum culture was obtained that resulted in a bacterial infection on 05/06/24, R1 was started on intravenous (IV) antibiotics. Random observations were conducted in R1's room on 05/13/24 at 11:16 AM, and 05/14/24 at 09:14 AM. R1's suction cannister noted with dark red brown fluid with clots, volume 50 percent full. The date on the cannister was smeared and not readable. On 05/14/24 at 01:45 PM, observed the cannister was replaced with a new cannister with the current date. On 05/14/24 at 02:09 PM interview with Respiratory Therapist (RT) 22 and the Respiratory Therapist…

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.

3) On 05/15/24 at 09:45 AM, inspected medication cart RN80 was using. While checking narcotics reviewed Narcotic Endorsement Log and found two blank spaces dated 05/03/24 0700-1900 ON and 1900-0700 OFF. Inquired of RN80 why these were left blank and RN80 stated someone forgot to sign the form. On 05/17/24 at 03:40 PM interviewed DON and inquired if nurses are expected to sign the Narcotic Endorsement Log after the narcotic count is done and he confirmed this. Showed DON the May 2024 Narcotic Endorsement Log and he stated staff forgot to sign the form. Based on observation, record review and interview, the facility failed to label medications in accordance with acceptable professional standards, including expiration date, and store medications in a locked compartment when left unattended by authorizing administering nursing staff for three residents sampled (Resident (R) 1, R4, and R14) .The facility also failed to assure the narcotic medication count was endorsed each shift by having the nurses sign the Narcotic Endorsement Log when coming on shift and going off shift. The deficient…

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 and interview, the facility failed to ensure nurses accurately documented in two sampled residents' record (Resident (R) 17 and R14). The nurse did not accurately document the route Resident (R) 17 received his medications and a cup full of medications left on R14's bedside table unattended was documented in the Medication Administration Record (MAR) as administered. This deficient practice could put all residents at risk for incorrect documentation of medications administered to them. Findings Include: 1) Cross reference to F759 . The facility failed to assure it was free of medication error rate of five percent or greater with a nurse incorrectly documenting medications given the wrong route resulting in medication administration errors and documentation errors for Resident (R) 17. On 05/15/24 at 08:50 AM, observed Registered Nurse (RN) 80 prepare and pass medication to R17. During medication preparation RN80 read each medication blister pack and popped out the medication into an individual medication cup which she labeled. Observed RN80 crushed…

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 ensure pneumococcal vaccination was offered to one of the six residents (R) 3 in the sample. This deficient practice placed the resident at risk for acquiring, transmitting and developing possible complications from pneumococcal disease. Findings Include: On 09/06/23 at 11:38 AM, review of R3's electronic health record (EHR) conducted. R3 is a [AGE] year-old resident admitted on [DATE]. Diagnoses include but not limited to amyotrophic lateral sclerosis (disease that affects nerve cells in the brain and spinal cord causing loss of muscle control), chronic respiratory failure, severe protein-calorie malnutrition, adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition and often accompanied by depressive symptoms and impaired immune function). R3 also had a tracheostomy (opening created at the front of the neck where a tube is inserted into the windpipe) and is ventilator (breathing machine) dependent. CDC guidance…

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 that one resident (R), R28, out of the six residents sampled, had the appropriate documentation for the administration or refusal of the COVID-19 vaccination. This deficient practice fails to ensure that residents and/or their representatives were educated about the COVID-19 vaccine and that the COVID-19 vaccination could be administered while in the facility. Findings Include: Record review of R28's electronic health record (EHR). The Medical Diagnosis tab revealed that R28 was admitted for a stroke on 08/15/23. The Immunization tab did not have an entry for the administration of the COVID-19 vaccine. An admission Summary progress note for 08/15/23 at 3:36 PM documented by a nurse stated, . COVID: NEGATIVE. COVID vaccine TBD [to be determined] by ID [Infectious Disease] RN [Registered Nurse]. On 09/06/23 at 12:38 PM, a concurrent observation of R28's EHR and interview with the Infection Preventionist (IP) nurse were conducted in the conference room. The IP's Health Status Note dated 08/15/23 at 4:28 PM 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 resident interviews and record reviews, the facility failed to ensure the resident's right to an environment that promotes enhancement of his or her quality of life, as evidenced by staff speaking a foreign language while providing care to residents was honored by staff members. Findings include: On 05/22/23 at 10:42 AM an interview was conducted with resident council representatives. During the interview R24 stated, they don't speak English sometimes. When asked how he felt about staff speaking a foreign language around him, he replied, you in America, talk English. On 05/24/23 at 11:00 AM R3 stated that staff still speak in Filipino around the residents, but it doesn't bother him. R3 added, but it might bother other residents. A review of the facility's Resident Council Minutes was conducted on 05/22/23 at 02:20 PM. According to the Resident Council Minutes dated 06/24/22,CNAS [Certified Nurse Aides] are talking loud in their language around residents, residents are bothered. Furthermore, Resident Council Minutes dated 04/26/23 stated, staff continues to speak to each…

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 post the results of the facility's most recent State survey, that is easily accessible to residents, legal representatives, and family members. Findings include: A resident council interview was conducted with resident representatives on 05/24/23 at 11:00 AM. Residents were asked if the result of the State inspection was available for the residents to read, Residents 3 and 26 both answered, no. A concurrent observation and interview with the Director of Nursing (DON) was conducted on 05/24/23 at 01:30 PM. When asked for the locations of the State survey report, DON pointed at the coffee table located on the first floor near the facility entrance. He then stated that there should also be a copy in the Medical Records Director's office on the fourth floor. Further asked if the residents had access to the State survey results on the units, DON answered, yes, both the units should have one. SA then requested for the DON to show the locations of the State survey report on both the second and third-floor units. DON and SA walked…

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 reviews and staff interviews, the facility failed to provide written notice of discharge to the resident or residents' representative for three residents (R) sampled, R6 and R38 who were discharged to an acute care hospital for a higher level of care, and R22, who was discharged home. The facility also failed to send a notice of discharge to the Office of the State Long-Term Care Ombudsman (LTCO). Findings include: Cross Reference to F625 - Notice of Bed Hold Policy Before/Upon Transfer (written notification of bed hold policy was not provided to residents or representatives). 1) R6 was admitted to the facility on [DATE]. On 05/23/22 at 10:45 AM review of the Electronic Health Record (EHR) revealed that R6 was admitted to an acute care hospital on [DATE] for scrotal abscess (accumulation of pus). Discharge notification and LTCO notification were not found in EHR. On 05/25/23 at 08:40 AM, a copy of the discharge notifications was requested from the Medical Records Director (MRD). At 09:36 AM, MRD…

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 reviews and staff interview, the facility failed to provide written notice of the facility's bed-hold policy for two residents (Residents 6 and 38) in the closed record sample. This deficient practice has the potential for miscommunication with residents that are discharged or transferred out of the facility. Findings include: Cross Reference to F623 - Notice Requirements Before Transfer/Discharge (written notice of discharge was not provided to residents or residents' representatives) 1) On 05/23/22 at 10:45 AM review of the Electronic Health Record (EHR) for R6 revealed that he was admitted to an acute care hospital on [DATE]. Discharge and bed-hold policy notifications were not found in EHR. During a concurrent interview and record review with the Director of Nursing (DON) on 05/23/23 at 01:00 PM, DON was not able to find or provide documentation that the resident or resident's family was notified of the facility bed-hold policy. 2) R38 was admitted to the facility on [DATE] and transferred to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews with staff, resident, and resident's representative, the facility failed to: 1) provide services for a resident that had a craniectomy (neurosurgical procedure that involves removing a portion of the skull to relieve pressure on the underlying brain) related to a motor vehicle accident, including scheduling of follow up appointments with the nuerosurgeon or development a care plan to address precauations while caring for this vulnerable resident; and 2) ensure nursing care provided for residents with gastrostomy tube (g-tube) met the needs of two residents in the sample (R19 and R189), and were in alignment with standards of good clinical practice and/or facility policy and procedure. as evidenced by nurses not verifying proper placement of the G-tube prior to use. Findings include: 1) Cross Reference to F689, Accidents. Resident (R)33 had a fall and based on a root cause analysis the facility did not revise the care plan to include interventions for fall…

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 interview and record review (RR), the facility failed to ensure there was enough staff to provide services and respond to each resident's needs in a timely manner, as evidenced by a complaint of long waits for call light response, and staffing ratios on both the second and third floor that were not in alignment with the Facility Assessment. As a result of this deficient practice, at least one resident experienced a decreased quality of life, was placed at risk of physical decline, and was unable to attain his highest practicable well-being. This deficient practice has the potential to affect all residents at the facility. Findings include: On 05/22/23 at 08:20 AM, an interview was done with Resident (R)17 at his bedside. When asked whether there was sufficient staff to meet his needs, R17 reported that he has waited ten (10) minutes on a good day, up to forty-five (45) minutes at times, for a response to his call light. R17 stated the only way to get help sometimes is to just keep on the call button. R17 continued on to state that even a 10-minute wait is too long when 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record reviews, the facility failed to ensure that the drug regimen of each resident was reviewed once a month by a licensed pharmacist, and that recommendations made by the licensed pharmacist were acted upon by the attending physician. The Medication Regimen Review (MRR) for the month of October 2022 was missing for four of the five residents (R) sampled for psychotropic medications (R26, R17, R21, and R20), and the physician failed to act upon recommendations for two of the five residents sampled (R26 and R17). As a result of this deficient practice, the residents were placed at risk of avoidable complications related to their medications. This deficient practice has the potential to affect all the residents in the facility taking psychotropic medications. Findings include: 1) On 05/23/23 at 09:33 AM, conducted a review of R20's Electronic Health Records (EHR). List of medications included Lorazepam (sedative) 1 milligram (mg) every 6 hours as needed for restlessness and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure all medications used in the facility were securely stored in locked compartments. Proper storage and labeling of medications is necessary to promote safe administration practices, and to decrease the risk of medication errors and diversion of resident medications. Findings include: 1) On 05/22/23 at 10:58 AM, an observation was done of Registered Nurse (RN)22 leaving the medication cart designated for the male residents on the second floor unlocked while he left the floor. When he returned to the second floor, RN22 was observed going directly into room [ROOM NUMBER]. Upon exit of room [ROOM NUMBER], RN22 was asked about the unlocked medication cart. RN22 stated I'm sorry, and explained that he does not usually leave it unlocked. Confirmed that the medication cart was solely assigned to him for the shift. On 05/22/23 at 01:46 PM, observed the same medication cart (designated for the male residents on the second floor) unlocked…

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 provide a clean area to prepare food for the residents. This deficient practice has the potential to affect all residents, visitors and staff who have meals served by the facility with food-borne illnesses. Findings include: On 05/22/23 at 08:03 AM, initial tour and observation was done in the kitchen area with the Director of Dietary Services (DDS). Noted pipes for the sprinkler system that ran across the ceiling immediately above the food preparation area was covered with dust. On 05/24/23 at 08:13 AM, concurrent interview and observation conducted with DDS in the kitchen area. Noted the pipes for the sprinkler system above the food preparation area were now free of dust. Asked DDS when the pipes were cleaned and how often they did it. DDS said the kitchen staff clean the sprinkler pipes once a month or as needed. Asked DDS if they have a log for when the task is completed, he said that they have a log they use daily to document tasks the kitchen staff completed at the end of the day, but it does not include 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, the facility failed to maintain accurate medical records for seven residents, physician progress notes were documented in the wrong record. This deficient practice has the potential to affect the medical care residents receive at the facility. Findings include: 1) On 05/25/23 at 08:59 AM, while reviewing the EHR for R17, three (3) physician progress notes in the last month had contained documented medical information for three different residents other than R17. One on 05/23/23 for R190. A second on 05/16/23 for R28. A third progress note on 04/28/23 for R9. 2) On 05/24/23 at 11:13 AM, conducted a review of R20's EHR. Under Progress Notes, noted an entry from the attending physician done on 05/23/23 at 07:55 AM. Entry contained the name and medical information for R190. Further review revealed that the attending physician also made entries on 05/16/23 at 08:53 AM and on 05/12/23 at 08:11 AM that contained the name and medical information for R16. Notified Registered Nurse (RN)11 of attending physician's entry in R20's progress notes that contained other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and record reviews, the facility failed to prevent the possible spread of infectious illnesses to other residents. The facility failed to follow airborne precautions put in place for one resident (R) 189. This deficient practice has the potential to spread infectious illnesses to other residents in the facility. Findings Include: On 05/22/23 at 09:18 AM, initial observation conducted on the second-floor unit. room [ROOM NUMBER] is occupied by four residents, including R189. A sign outside of the room indicated that R189 was on droplet precautions and the following personal protective equipment were required when providing care: mask, gown and gloves. Registered Nurse (RN) 22 was observed entering room [ROOM NUMBER] wearing only a mask holding a medicine cup filled with liquid and an empty cup. RN22 then placed the items on the bedside table, performed hand hygiene, and donned gloves. RN22 proceeded to administer the medication to R189 through his gastrostomy tube without…

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 identify and support one resident's (R)17 preference to not be placed in a yellow gown. As a result of this deficient practice, R17 did not have his needs met and was placed at risk of not attaining his highest practicable well-being. Findings include: An observation was done on 05/22/23 at 08:20 AM of Resident (R)17 in bed with a bright yellow facility gown on. When asked about the yellow gown, R17 stated I don't like it, I prefer the other gown, the blue one. On 05/23/23 at 07:29 AM, an interview was done with R17 in his room. R17 stated that he has told the CNAs [certified nurse aides] his preference to wear blue, but he still is put in whatever is available. On 05/25/23 at 08:00 AM, observed R17 in bed wearing another yellow gown. When asked about it, R17 shrugged and stated, I have no choice in the matter . they [staff] don't seem to think so, they keep putting me in this.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, the facility failed to provide safe, clean, and homelike environment for the residents. The facility failed to repair damaged linoleum floor, and ripped privacy curtain for one of the residents (Resident (R) 20) sampled and in two additional rooms. Findings include: On 05/22/23 at 08:33 AM, initial observation was done on the third-floor unit. Observed drawn privacy curtain for R20 in room [ROOM NUMBER] with two holes on the lower portion of it. The linoleum flooring on the foot of the bed was also in disrepair exposing the old, darker colored flooring under the existing one. R20's bed was located closest to the door making the damaged floor and ripped privacy curtain visible from the hallway of the unit. Observed the rest of the rooms on the third floor and noted rooms [ROOM NUMBERS] also had cracks in the linoleum by the foot of the beds. On 05/25/23 at 10:11 am, concurrent observation and interview was done with the Director of Maintenance and Environment Services…

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, and record reviews, the facility failed to develop and implement person-centered Comprehensive Care Plans (CPs) for 2 of 12 residents in the sample (Residents 19 and 21). As a result of this deficient practice, both Resident (R)19 and R21 were placed at risk for avoidable injury and/or declines in their quality of life and were prevented from attaining their highest practicable well-being. Findings include: 1) Cross-reference to F684 QOC. Despite two visits to the emergency room for malpositioning of his gastrostomy tube (G-tube), the facility failed to develop and implement a care plan to verify proper placement of the G-tube prior to use for R19. As a result of this deficient practice, the facility placed R19 at risk for avoidable pain and injury. 2) R21 was admitted to the facility on [DATE] with admitting diagnoses that include retention of urine, gross hematuria (blood in his urine), and benign prostatic hyperplasia (an enlarged prostate gland that causes problems 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 record reviews and interviews with staff members, the facility failed to revise the care plan for 2 (Residents 33 and 13) of 12 residents in the sample. Findings include: 1) Cross Reference to F689. Resident (R)33 fell on [DATE], a post fall risk assessment was completed. There was no documentation that R33's current care plan interventions were effective, therefore revisions were not indicated to prevent falls. Also, there was no documentation that based on post fall evaluation, the care plan was revised for fall prevention. 2) Cross Reference to F689. R13 had a history of falls and had an actual fall on 04/16/23. There was no documentation of care plan revisions to prevent further falls or there was no documentation of a need for revisions were needed, the current interventions are effective for fall prevention.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, residents, and resident representatives, the facility failed to ensure residents remained free from accidents for 2 (Residents 33 and 13) of 3 residents in the sample. The facility did not complete an initial fall risk assessment to develop interventions for fall prevention and did not assure monitoring for effectiveness and modifying interventions were done as necessary. Findings include: A review of the Fall Risk Assessment policy and procedure provided by the facility documented the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. A review of the Falls and Fall Risk, Managing policy and procedure noted in section titled Resident-Centered Approaches to Managing Falls and Fall Risk, 5. If falling recurs despite initial interventions, staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with resident and staff member, the facility failed to assure a resident who is incontinent of bladder received appropriate treatment and services to restore continence to the extent possible for 1 (Resident 13) of 2 residents in the sample. Findings include: Resident (R)13 was admitted to the facility on [DATE]. Diagnoses include but not limited to hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side; epilepsy; and protein-calorie malnutrition. On 05/22/23 at 02:00 PM, interviewed R13. R13 was asked if she is continent of bowel and bladder. R13 responded that she is told to use her diaper for toileting. R13 stated she can recognize the urge for voiding. R13 also reported that she has had some falls and has been told to stay in bed, so she complies. A review of a significant change Minimum Data Set with an assessment reference date of 03/24/23 noted R13 coded as always incontinent of urine and bowel. R13 was coded as 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review, the facility failed to provide nutritional care and services to address significant weight loss for one of two residents sampled, Resident (R)32. The attending physician and facility dietitian was not notified when R32 had a 9.24% weight loss within one month of admission to the facility. As a result of this deficient practice, the resident was placed at risk for potential complications due to impaired nutrition. Findings include: On 05/22/23 at 12:08 PM, observed R32 lying in bed with eyes closed and her lunch tray on the bedside table. Asked Registered Nurse (RN)21 if R32 was able to feed herself. RN21 replied that R23's family member (FM)1 was on her way to assist her with lunch since she did not eat breakfast that morning. RN21 also stated that FM1 works close to the facility and comes in everyday to assist R32 for meals. At 12:37 PM, observed FM1 at R32's bedside assisting her with lunch. Review of Electronic Health Record (EHR) was conducted 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, record review, and interview with staff member, the facility failed to use infection control precautions to ensure syringe used for gastrostomy tube (G-tube) was discarded according to the facility's practice and sanitarily stored to prevent infections. This deficient practice has the potential to expose the resident to infections. Findings include: On [DATE] at 08:11 AM a feeding tube set was hanging on a pole for Resident (R)33 was observed. Also observed a clear plastic bag containing a syringe. The syringe was not capped. There was pink fluid at the bottom of the plastic bag. The tip of the syringe was stored in the fluid and the cap was immersed in the fluid. Also observed black substance around the interior diameter of the hub. There was a label affixed to the plastic bag with a date of [DATE]. Record review noted physician order for: enteral feed every shift for gastrostomy intermittent feed, before each intermittent feeding and PRN check for residual; and flush feeding tube 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 staff interviews and record reviews, the facility failed to ensure two (Residents 20 and 17) of five residents sampled for medication review were free from unnecessary medications. The PRN (as needed) order for a psychotropic medication (drugs affecting behavior, mood, thoughts or perception) for R20 was not limited to 14 days and reordered indefinitely without a rationale for continuance. Also, the facility failed to assure a gradual dose reduction for R17 as recommended by the pharmacist was done. Findings include: 1) On 05/23/23 at 11:13 AM, conducted a review of R20's Electronic Health Records (EHR). R20 was admitted to the facility on [DATE]. Diagnoses include history of psychoactive substance abuse, intracerebral hemorrhage (bleeding in the brain), anxiety, severe depression, and restlessness and agitation. List of medications included Lorazepam (sedative) 1 milligram (mg) every 6 hours as needed for restlessness and agitation. Review of current orders revealed that R20 had a PRN order for…

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, interviews and record reviews, the facility failed to provide food that accommodates a resident's food allergies. Resident (R)190 was served food that contained an ingredient that she was allergic to placing her at risk for an adverse health condition. Findings include: On 05/24/23 at 08:06 AM while making observations on the third-floor unit, R190 waved at surveyor and made a hand gesture to enter the room. R190 stated that after she was done with her breakfast earlier that morning, she saw Honey Nut Cheerios documented on the meal ticket. R190 said she was concerned because she is allergic to almonds and peanuts and wanted to make sure the kitchen knows about her allergies. R190 also said that she was not having any allergic reactions at the moment and already notified the nurse on duty. Review of R190's Electronic Health Records (EHR) revealed that her allergies included lisinopril, almonds, peanuts, salmon, shellfish, mold, dust mites, grass pollen blade and weeds. Care plan also documented that R190 has a rash on her back related to allergies. On 05/24/23…

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.