Garden Isle Healthcare And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review, the facility failed to provide routine dental services for one of one resident (R)4 sampled for dental care. The deficient practice puts R4 at risk for developing cavities and other mouth infections. Findings Include: On 02/19/25 at 11:49 AM observed R4 in his bed. R4 had his mouth open and surveyor noted R4 had a thick orange-colored build up on his front teeth. Review of R4's Electronic Health Record (EHR) found he was admitted to the facility on [DATE] and his diagnoses include, but are not limited to, cerebral palsy (disorder that affects ability to move, balance and maintain posture), tracheostomy status, unspecified intellectual disabilities, functional quadriplegia, and unspecified lack of coordination, abnormal posture. Review of R4's Minimum Data Set (MDS) quarterly assessment dated [DATE] and and annual assessment dated [DATE] found he is dependent upon staff for all of his care. Review of R4's EHR did not find any consultation notes or progress…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and policy review, the facility failed to ensure the resident's right to a dignified existence and treat each resident with respect and dignity for (4) residents. Resident (R)35, R67, R30, R60 residents sampled. Findings include: 1) R60 was admitted to the facility on [DATE] with diagnosis which includes cancer, aphasia (the loss of the ability to understand or express speech), seizure disorder, and malnutrition. Review of R60's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/24, Section C. Cognitive Patterns, R60's Brief Interview for Mental Status (BIMS) was 4, indicating R60's cognition is severely impaired. Section GG. Functional Abilities and Goals documented R60 has functional limitation in range of motion for the upper and lower extremities on one side, uses a wheelchair, and requires substantial assistance (helper does more than half the effort) for toileting hygiene. A significant change MDS with an ARD of 01/01/24 documented,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for one of three (Resident (R)71) sampled for closed records. R71 was coded on the discharge Minimum Data Set (MDS) as discharged to a short-term general hospital. Staff confirmed R71 was discharged home on [DATE]. Findings include: On 02/21/23 at 03:10 PM, conducted a review of R71's Electronic Health Record (EHR). On 01/21/24 at 03:53 PM, Minimum Data Support Staff (MDSS)6 documented in a progress note, Resident remained on skilled services for rehab services until 1/17/24 and was discharge to home on 1/18/24. Review of R71's discharge MDS with an Assessment Reference Date (ARD) of 01/18/24 documented in Section A 2105. Discharge Status- 04. Short-Term General Hospital. On 02/22/24 at 03:28 PM, conducted a concurrent record review of R71's EHR and interview with MDSS6 and MDSS1. After reviewing R71's progress notes and discharge MDS (ARD 01/18/24), MDSS6 confirmed R71 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure there was an ongoing resident-centered activities program that met the resident's needs, for 1 of 3 residents (Resident 4) sampled for activities. Specifically, the facility failed to consistently act on the resident's need for social contact and sensory stimulation and failed to develop and/or implement a person-centered activities program that the resident found meaningful. As a result of this deficient practice, Resident (R)4 was placed at risk of experiencing a decline in his psychosocial well-being and comfort. This deficient practice has the potential to affect all residents at the facility. Findings include: R4 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care. His current diagnoses include, but are not limited to, cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), aphasia (loss of ability to understand or express speech), intellectual…

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, review of Facility Reported Incidents (ACTS #10723, 10743), review of Complaint (ACTS #10735), complainant interview, staff interview, and review of policy, the facility did not provide timely psychiatric assessment for one Resident (R)46, out of three residents sampled, to reduce the risk through multiple falls. R46 had an increasing number of falls with recent fracture needing surgery and hospitalization. Findings include: (Cross reference F689 Accidents) Review of Electronic Health Record (EHR) showed R46 was admitted to the facility on [DATE] with a diagnosis including the following: Stroke, Adjustment disorder, Atrial Fibrillation, Atherosclerotic heart disease, High blood pressure, Anxiety, Restlessness, Agitation, Frequent falls . Initial assessment for falls using the John Hopkins Fall Risk Assessment Tool found R46 as being high risk for falls. Further fall risk assessments showed R46 continued to be high risk for falls throughout the course of stay. Comprehensive Care Plan…

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, review of Facility Reported Incidents (ACTS #10723, 10743), review of Complaint (ACTS #10735), complainant interview, staff interview, and review of policy, the facility did not provide enough supervision for one Resident (R)46, out of three residents sampled, to reduce the risk through multiple falls. R46 had an increasing number of falls with recent fracture needing surgery and hospitalization. Cross reference F684 Quality of Care Findings include: Review of Electronic Health Record (EHR) showed R46 was admitted to the facility on [DATE] with a diagnosis including the following: Stroke, Adjustment disorder, Atrial Fibrillation, Atherosclerotic heart disease, High blood pressure, Anxiety, Restlessness, Agitation, Frequent falls . Initial assessment for falls using the John Hopkins Fall Risk Assessment Tool found R46 as being high risk for falls. Further fall risk assessments showed R46 continued to be high risk for falls throughout the course of stay. Comprehensive Care Plan problem…

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 interview and record review, the facility failed to identify triggers which may cause re-traumatization, and consistently use trauma-informed approaches when caring for, and planning the care for, 1 of 1 resident (Resident (R)274) sampled for Trauma-Informed Care. As a result of this deficient practice, R274 did not have his needs met, was placed at risk of re-traumatization, and was hindered from attaining his highest practicable mental and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility with a history of trauma, post-traumatic stress disorder, and/or psychosocial adjustment difficulties. Findings include: R274 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care with diagnoses that include, but are not limited to, Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), chronic post-traumatic stress disorder (PTSD), depression, anxiety,…

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 interview and record review, the facility failed to provide or obtain from an outside resource, routine dental services to meet the needs of 1 of 1 resident sampled for dental concerns. This deficient practice has the potential to affect all residents currently residing in the facility. Findings include: Resident (R)48 is an [AGE] year-old male with no natural teeth, admitted to the facility on [DATE]. On 02/21/24 at 08:46 AM, an interview was done with R48 at his bedside. R48 complained of sore gums, and not being provided a textured diet that he could eat comfortably. R48 shared an example of being given dry cereal for breakfast with no milk to pour over it. R48 stated eating the dry cereal feels like it cuts into his gums, but he has no choice because he is hungry. R48 also reported that while he did have dentures, they no longer fit properly. When asked when the last time was that a dentist evaluated the state of his gums, and the fitting of his dentures, R48 replied that he had not seen a dentist…

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 an interview and record review, the facility failed to maintain an accurate medical record for two residents (Resident (R)24 and R225). An interview with the Director of Nursing (DON) confirmed a document for R225 was uploaded in R24's Electronic Health Record (EHR) erroneously and should not have been. Findings include: On 02/21/24 at 10:15 AM, conducted a record review of R24's EHR. A form titled, MD (physician) Response (attached on 10/12/23) for R225 filed in R24's EHR. The MD Response for documented the physician response to nursing staff regarding questionable orders for Acetaminophen, which would exceed the recommended daily dose of the medication and could potentially negatively impact R225's health status. Review of R225's EHR, Medication Administration Record (MAR), documented identified the orders nursing staff questions were present, the resident was not administered a dose which exceeded the recommended daily dose of Acetaminophen and was not impacted. On 02/22/24 at 12:42 PM, conducted a concurrent interview and review of R24's EHR with the Director of Nursing…

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 policy review, the facility failed to ensure that staff followed hand hygiene and contact precautions practices consistent with accepted standards of practice. Registered Nurses (RN)60 did not complete hand hygiene between glove changes during a dressing change for a Pressure Ulcer (PU) on R70's coccyx. Staff Member (SM)15 did not wear personal protective equipment while delivering lunch to R11's room, who was on contact precautions. This deficient practice places the residents in the facility at an increased risk for communicable disease. Findings include: During an observation on 02/22/24 at 2:00 PM in R70's room with RN60 and RN75 prepared to change R70's dressings. Dressing changes for R70 included the wound on his left lower leg; two PUs on the upper back, and one pressure ulcer on the coccyx. While changing the coccyx PU, RN60 removed the dressing, cleaned the site, and removed her dirty gloves. RN60 picked up the clean gloves and started to place her fingers in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, label, monitor, and discard food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure all perishable or refrigerated food items were labeled, dated, and monitored. Residents (R) risk serious complications from foodborne illness as a result of their compromised health status. Unsafe and/or unsanitary food handling practices represent a potential source of pathogen exposure for all residents at the facility. Findings include: On 02/07/23 at 10:14 AM, during a tour of the facility kitchen with the Food Service Manager (FSM), the following observations were done: An opened gallon of Caesar (cream-based) Dressing with no date opened indicated and/or facility label. An opened gallon of [NAME] Slaw (cream-based) Dressing with 1/23 written in sharpie on the lid and no facility label. An opened gallon of Ranch (cream-based) Dressing with 1/23 written in sharpie on the lid and 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 interview and record review, the facility failed to provide proper notification of discharge for three of the sample residents (Resident (R)169, R12 and R66) who were discharged home. The facility failed to provide written notification of the discharge to the resident or her representative, and/or failed to send notification of the discharge to the Office of the State LTC [long-term care] Ombudsman (LTCO). This deficient practice has the potential to affect all residents at the facility who are discharged or transferred. Findings include: Resident (R)169 is a [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation, and was discharged fifteen (15) days later on 11/09/22. During a review of her electronic health record (EHR) on 02/08/23 at 03:30 PM, it was noted that there was no discharge notification or LTCO notification found for the discharge. Discharge notification was requested from the facility. On 02/09/23 at 01:42 PM, an interview was done with the Administrator in…

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

Based on observation and interview, the facility failed to assure a dignified existence for one of three sampled residents (R)56. Findings include: During an interview and concurrent observation on 02/07/23 at 12:30 PM, R56 stated to this surveyor that I don't like that I had to do it in my pants. I don't do this at home. R56 had his call light on and upon entering the room, he stated he needed to go. R56 stated that rehab had told him that he needed to walk and go to the bathroom. R56's call light was on and nursing station over 100 feet away. At 12:35 PM, surveyor walked to nursing station and asked who answers call lights? Registered nurse (RN) stated we all do Nurse's aide stated I am. Meanwhile, nurse manager (NM) walked past the conversation and towards the room and nurse's aide followed. Upon reaching R56's room, R56 stated he went already. R56 asked staff to close the curtain or cover him up when they change him. On 02/07/23 at 01:30 PM, interview with R56 who stated, I'm embarrassed because I don't wet my pants at home.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review (RR), the facility failed to ensure an Advance Directive and/or discussions regarding Advance Directives was documented in one resident's (Resident 16) medical record. As a result of this deficient practice, Resident (R)16 was placed at risk of not having her wishes honored for future health care decisions, should she become incapacitated. This deficient practice has the potential to affect all residents who wish to have end of life plans at the facility. Findings include: On 02/08/23 at 10:51 AM, a review of Resident (R)16's electronic health record (EHR) noted no advance health care directive (AD) found, and no documentation that it had been discussed. AD documentation was requested from the Director of Nursing (DON). On 02/08/23 at 03:14 PM, a copy of R16's AD was provided by the facility. On 02/09/23 at 01:31 PM, during further review of R16's EHR, it was noted that the facility had discussed the AD with R16 and obtained a copy of it from the acute care hospital 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 interview and record review, the facility failed to implement a process to address grievances for one resident (R) as evidenced by the facility failing to acknowledge, document, investigate, and resolve verbal complaints filed by a resident's family representative as grievances. This deficient practice has the potential to affect all residents/representatives verbalizing complaints. Findings include: On 12/05/22, a complaint was received by the State Agency (SA) from Resident (R)169's son regarding her care, with one of the allegations being an inappropriate discharge. R169 is a [AGE] year-old female admitted on [DATE] for short-term rehabilitation (rehab) following a stroke with diagnoses that include chronic kidney disease, high blood pressure, osteoarthritis, and osteoporosis. Per the complaint, R169 was discharged on 11/09/22 because showed no progress [in rehab], despite a request by R169's son that she remain a bit longer because her house is not ready to comply with her needs. On 02/09/23 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.

Based on record review and interview with staff members, the facility failed to report an allegation of physical abuse to Adult Protective Services. Findings include: Cross Reference to F610. The facility submitted a report of abuse to the State Agency. Resident (R)168 alleged. staff shoved dirty gloves in his mouth when he yells; they beat me when they change or turn me, or during shower; staff will push him hard to the wall and it hurts his hands and arms during change of incontinence brief. Interview with social services staff, inquired whether this allegation was reported to Adult Protective Services (APS). It was reported that a phone call was made to report the allegation. Requested documentation of the contact with APS. The facility did not provide documentation of a referral to APS.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff members, the facility failed to complete a thorough investigation and maintain documentation that an allegation of physical abuse was thoroughly investigated. There was no documentation of the resident interviews that were reportedly conducted. The facility did not thoroughly investigate the allegation, the facility failed to investigate the root cause of the bruises on the resident's arms (injuries of unknown origin) which was not documented in their report, the private caregiver was not interviewed, and the facility did not follow up on staff member's witness of certified nurse aides asking resident about the resident about the allegation. Findings include: On 06/02/22 at 05:21 PM the facility transmitted an initial report regarding an allegation of abuse related to Resident (R)168. R168 reportedly informed Physical Therapist (PT) of foot pain. The Charge Nurse (CN)12 was informed and followed up with resident. R168 informed CN12, They beat me when they change me…

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 interview and record review, the facility failed to meet the requirements for a facility-initiated discharge for one resident (R) in the sample (R169) as evidenced by the lack of provider orders for discharge, a medical clearance for discharge, and/or a discharge summary completed by the provider documenting the reason(s) for discharge. As a result of this deficient practice, R169 was placed at an increased risk of injury and/or readmission to an acute care facility. This deficient practice has the potential to affect all facility-initiated discharges. Findings include: On 12/05/22, a complaint was received by the State Agency (SA) from Resident (R)169's son regarding her care, with one of the allegations being an inappropriate discharge. R169 is a [AGE] year-old female admitted on [DATE] for short-term rehabilitation (rehab) following a stroke, with diagnoses that include pancytopenia (a condition in which there is a lower-than-normal number of red and white blood cells and platelets in the blood),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately record the discharge home status in the RAI, Minimum Data Set (MDS) for one Resident (R)66 of three residents sampled. As a result of this deficiency, the facility put R66 at risk for further RAI, MDS inaccuracy. Findings include: During review of R66's most recent MDS, Assessment Reference Date 01/13/23, Section A2100 was inaccurately marked as Acute Hospital which meant that R66 was discharged to acute hospital. Review of R66's progress notes showed that R66 was actually discharged home on [DATE]. During staff interview on 02/09/23 at 08:40 AM, MDS Coordinator (MDS Coord) acknowledged that R66 was inaccurately marked as being discharged to acute hospital. MDS Coord stated that they would do the necessary correction. Review of the Long-Term Care Facility RAI 3.0 User's Manual read the following: The RAI process has multiple regulatory…

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 member, the facility failed to develop a baseline care plan which included minimum information necessary to properly care for the immediate needs of a resident admitted with a Foley catheter. Findings include: On 02/07/23 at 11:20 AM observed Resident (R)118 lying in bed and there was a covered catheter bag hanging from the side of the bed. The catheter tubing was observed to be touching the floor. R118 was admitted to the facility on [DATE] from an acute facility with hospice services. R118 was admitted with hospice services. A review of R118's care plan found the facility did not develop a baseline care plan to include Foley catheter care. Also noted there were no physician orders for the use of a Foley catheter and care related to the catheter. On 02/09/23 at 11:07 AM an interview and concurrent record review was conducted with Nurse Manager (NM)1. NM1 reported the order for use of a Foley catheter was not in the facility's physician orders, it is…

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 facilitate the ongoing program of activities designed to meet the resident's psychosocial and physical needs. Activities were not carried out for one of four sampled residents (R)4. R4 was not observed out of room and up in wheelchair for stimulation to maintain R4's physical and psychosocial well-being and independence. Findings include: R4's admission date was 01/12/11 according to the assessment reference date (ARD) on the minimum data set (MDS). Diagnoses include but is not limited to cerebral palsy. Observation on 02/07/23 at 10:58 AM shows resident in room in bed. Observation on 02/07/23 at 02:00 PM shows resident in room in bed. Record review (RR) of care plan(CP) done on 02/08/23 at 0900 AM indicates to include R4 in small group activities to be with groups of people, include in all types of stimulating activities to observe. CP activity dated 06/03/21 indicates Turn on R4's TV to all types of TV shows when awake, he likes watching all kinds of TV show or children's shows per his mother. RR of interdisciplinary care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to manage critical lab [laboratory] values for one Resident (R) in the sample (R169), and failed to identify, care plan, and manage constipation for another resident (R16) in the sample. As a result of this deficient practice, R169 was discharged with an increased risk of injury and/or readmission to an acute care facility, and R16 developed potentially avoidable hemorrhoids. This deficient practice has the potential to affect all the residents at the facility admitted from an acute care facility or at risk of constipation. Findings include: 1) On 12/05/22, a complaint was received by the State Agency (SA) from Resident (R)169's son regarding her care, with one of the allegations being an inappropriate discharge. R169 is a [AGE] year-old female admitted on [DATE] for short-term rehabilitation (rehab) following a stroke, with diagnoses that include pancytopenia (a condition in which there is a lower-than-normal number of red and white blood cells 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, interviews and record reviews, the facility failed to ensure for three of six sampled residents (R)4, R16 and R169 received range of motion (ROM) exercises to prevent decline and reduction in mobility. Findings include: Observation on 02/07/23 at 10:58 AM shows resident in room in bed. Splints were not applied to BUE. Observation on 02/08/23 of R4 at 09:03 AM was done in his room. Has soft wraps on both arms. Record review (RR) of interdisciplinary care plan (ICP) was done on 02/08/23 at 09:05 AM. ICP provided and dated 01/31/21 indicates certified nurse's aide (CNA) will perform passive range of motion to bilateral lower extremities and did not address BUE or splints. RR of orders on 02/08/23 indicates ROM and up in chair three times a day. Observation on 02/08/23 of R4 at 01:48 PM was done in his room. R4 did not have his splints on. Splints were noted on bedside table. Splints looked over-worn and looked soiled. Registered nurse (RN)1 agreed and stated we need to order new splints from physical therapy (PT) It's dirty. RN1 attempted to put splints on and 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 observation, record review and interview with staff member, the facility failed to assure drug records are in order and that an account of all controlled drugs are maintained to ensure no diversion. Findings include: On 02/09/23 at 08:20 AM observation of medication cart was done with Registered Nurse (RN)8. Inquired what is the facility's process for ensuring accurate counts of controlled medications are done. RN8 explained two nurses will sign to attest to an accurate count of controlled drugs at the change of shift (oncoming and leaving). The nurse leaving and the nurse coming onto the shift. Requested to review their record. A review of the form titled, Emergency/Controlled Substance Inventory & Kit Verification for 02/01/23 to 02/08/23 was done. Review found missing signatures for the following days/shifts: 02/02/23, day shift of the oncoming nurse; 02/02/23, evening shift of the off-duty nurse; 02/06/23, evening shift of the on duty nurse; and 02/06/23, night shift of the off duty nurse. RN8 confirmed the missing nurse signatures. The facility provided a copy of the…

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

Based on observation and interview with staff member, the facility did not assure medications were stored under proper temperatures. Findings include: On 02/08/23 at 09:20 AM observation of the medication storage room was done with Nurse Manager (NM)1. The refrigerator contained medication for the residents and an opened box of flu vaccine vials. A review of the temperature log (Medication Refrigerator Temperature Record) for January 2023 found no documentation temperatures were checked on the 03:00 PM to 11:00 AM shift on 01/08/23, 01/28/23, and 01/29/23. NM1 confirmed there was missing documentation and reported medication refrigerator temperatures are to be taken twice a day. On 02/08/23 at 10:40 AM, the facility provided the temperature record for December 2022. Review noted no documentation for the 03:00 PM to 11:00 AM shift on 12/02/22, 12/03/22, 12/14/22, and 12/18/22. A review of the policy Medication Storage - Storage of Medication provided by the facility on 02/08/23 at 10:40 AM notes in the procedure for medications requiring refrigeration a temperature log or tracking…

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 appropriate protective and preventive measures for COVID-19 and other communicable diseases and infections for three of six sampled residents (Resident (R)35, R45 and R33). This is evidenced by the facility failing to ensure staff followed transmission-based precautions (TBP) by wearing the proper personal protective equipment (PPE) and facility failing to follow their Mitigation Plan and isolating (R)45. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility. Findings include: 1) On 02/07/23 the State Agency (SA) was notified at Entrance that the facility had a current COVID-19 (COVID) outbreak, and as a result all staff on the affected floor (second floor) were required to wear at a minimum, eye protection and an N-95 respirator (N95) when in patient care areas. On 02/08/23 at 08:33 AM, observed Certified Nurse Aide (CNA)1 and CNA2 in…

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

Based on observations, staff interview and review of policy, the facility failed to properly transport two oxygen cylinders (O2 tanks) in a safe manner. As a result of this deficient practice, the facility put the safety and well-being of the residents, staff, as well as the public at risk for accident hazards. Findings include: During an observation on 02/07/23 at 10:30 AM, Maintenance Staff (Maint1) transported two O2 tanks in an unsafe manner. The two O2 tanks were laying sideways on a hand-truck cart, rolling back and forth hitting one another. Also, the head valve of the O2 tanks were sticking out the side of the cart having the potential of being knocked off during transport. During staff interview on 02/07/23 at 10:40 AM, the Housekeeping Manager (Hskpg Mgr) acknowledged that the O2 tanks were being transported in an unsafe manner. Hskpg Mgr further stated that the facility was working on obtaining portable oxygen cylinder holders for safe transporting of the O2 tanks. Review of facility policy on Oxygen Cylinder Storage read the following: Procedure, All freestanding…

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.