Cherokee Specialty Care

Based on record review, interview, and facility policy the facility failed to have the Infection Preventionist at quarterly meetings for their quarterly Quality Assessment and Assurance (QAA) meetings. The facility reported a census of 53 residents. Findings include: The following Quality Assurance Committee Meeting Sign-In showed the Director of Nursing (DON) as the Infection Preventionist that attended the quarterly meetings for the following dates: a. 12/15/23 b. 3/8/24 c. 5/31/24 The Quality Assurance and Performance Improvement (QAPI) Program policy dated March 2020 identified the Infection Preventionist served on the committee. In an interview on 7/18/24 at 8:40 AM, Staff D, Registered Nurse (RN) reported she obtained certification as an infection preventionist. When asked if she attended QAPI meetings, Staff D replied, no. In an interview on 7/18/24 at 8:58 PM, the DON reported she completed the infection preventionist course but failed to realize the infection preventionist certification required succession completion of the infection preventionist certification test.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to immediately notify the physician and resident representative of a fall with an injury for 1 of 5 residents reviewed (Resident #32). The facility reported a census of 53 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #32 scored 13 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including diabetes and hypoglycemia. The Care Plan identified the resident had an actual fall related to unsteady gait initiated 10/16/2023. The Progress Notes documented the following: a. On 4/11/24 at 10:21 p.m. documented the resident received Hydrocodone (narcotic)-Acetaminophen 5-325 mg for pain in the right leg. b. On 4/12/24 at 10:06 a.m. the resident received Acetaminophen 325 mg for pain in her right ankle. She rated her pain a 6/10. c. On 4/12/24 at 5:16 p.m. the resident received Acetaminophen 325 mg for complaints of pain in her right ankle. 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 record review and staff interview, the facility failed to review and revise the comprehensive care plan for 1 of 18 residents reviewed (Resident #38). The facility reported a census of 53 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #38 scored 12 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident had frequent incontinence of bladder, and a urinary toileting program had not been attempted. The resident had diagnoses including a stroke, a seizure disorder, and chronic obsrtuctive pulmonary disease (COPD). The MDS history of the resident's urinary incontinence showed she had been frequently incontinent since 2/13/23, and no urinary toileting program had been attempted while in the facility. The Care Plan revised 6/3/22 identified the resident had occasional bladder incontinence. The interventions included assisting the resident to the bathroom or commode as needed, and assisting with perineal…

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 interview, the facility failed to provide adequate assessment and timely intervention for a resident with a change of condition for 1 of 5 residents reviewed (Resident #32). The facility reported a census of 53 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #32 scored 13 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including diabetes and hypoglycemia. The Care Plan identified the resident had an actual fall related to unsteady gait initiated 10/16/2023. The Progress Notes documented the following: a. On 4/11/24 at 10:21 p.m. the resident received Hydrocodone (narcotic)-Acetaminophen 5-325 mg for pain in the right leg. b. On 4/12/24 at 10:06 a.m. the resident received Acetaminophen 325 mg 2 tablets for pain in her right ankle. She rated her pain a 6/10. c. On 4/12/24 at 5:16 p.m. the resident received Acetaminophen 325 mg for complaints of pain in her right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to assure a resident who was incontinent of bladder received appropriate treatment and services to restore continence to the extent possible for 1 resident reviewed (Resident #38). The facility reported a census of 53 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #38 scored 12 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident had frequent incontinence of bladder, and a urinary toileting program had not been attempted. The resident had diagnoses including a stroke, a seizure disorder, and chronic obsrtuctive pulmonary disease (COPD). The MDS history of the resident's urinary incontinence showed she was occasionally incontinent of bladder on the admission MDS and she had been consistently, frequently incontinent since 2/13/23, and the MDS history of a toileting program documented no urinary toileting program had been attempted…

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

Based on observation, staff interview, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility reported a census of 47 residents. Findings include: During continuous observation on 7/16/24 from 12:15 PM to 12:45 PM Staff B dietary cook was observed wearing no gloves or hand hygiene completed when Staff B opened the freezer and obtained a box of frozen hamburger patties. Staff B then opened the box after cooking with a spatula and used the same hand to obtain a frozen hamburger patty. Staff B was observed to do this three times with no hand hygiene being completed. Staff B then proceeded to touch multiple items (lids for bowls, cabinet handles, spatulas, freezer door handles) in the kitchen with no hand hygiene being completed. In an interview on 7/16/24 at 12:57 PM with Staff C Dietary Service Manager revealed her expectations were for staff to wash hands at appropriate times while in the kitchen. In an interview on 7/16/24 at 1:12 PM with the Administrator revealed that her expectation would be 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 observation, clinical record review, resident interview, staff interview, and policy review the facility failed to use universal infection control measures and Enhanced Barrier Precautions (EBP) during PICC line (peripherally inserted central catheter) cares and medication administration for 1 of 3 residents reviewed for infection control (Resident #205). The facility reported a census of 53 residents. Findings include: Review of Resident #205's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 15 indicating intact cognition. The MDS further revealed diagnosis of cancer, heart failure, urinary tract infection, and MRSA (methicillin-resistant Staphylococcus aureus). Review of Resident #205's Electronic Health Record (EHR) profile page revealed that Resident #205 was on EBP. In an interview on 7/15/24 at 12:13 PM Resident #205 revealed she is receiving antibiotic treatment via PICC line for treatment of a UTI and that she had (MRSA). Observation on 7/17/24 at 7:43…

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

Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was stored and prepared under sanitary conditions. The facility identified a census of 53 residents. Findings include: 1. An initial kitchen tour conducted on 5/14/24 at 12:43 p.m., revealed the following observations: Observation of the kitchen fridge revealed the following items ready for service: a. bag of diced chicken open with no open date b. open container of cottage cheese lacked received date with a use by date of 4/20/24 c. open container of cottage cheese lacked received date with a use by date of 5/9/24 d. open package of deli ham with an open date of 5/3/24 with a use by date of 5/4/24 e. open container of tuna salad with an open date of 5/5/24 f. open container of smoked chicken salad with no open date g. open container of potato salad with no open date h. open container of coleslaw with no open date i. styrofoam container lacked a label or open date with a chef salad made inside j. 2- packages of frozen ready to cook soup- thawed and labeled keep frozen until ready…

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, facility policy and staff interview, the facility failed to complete proper hand hygiene with incontinence care with 2 of 3 residents (Resident #1 and #4). The facility reported a total census of 54 residents. Findings include: 1. Observation on 3/19/24 at 3:34 p.m. of Resident #1 being assisted by Staff A, Certified Nursing Assistant (CNA) and Staff C, CNA to lay down. After Resident #1was laying down Staff C performed hand hygiene and applied gloves, Staff C removed the soiled incontinence brief, performed perineal care. Staff C removed the soiled incontinence brief and with the same soiled gloves took barrier cream and applied to the buttocks area. Staff C removed gloves, performed hand hygiene and applied clean gloves and applied a new incontinence brief. Staff A and Staff C removed gloves when finished and performed hand hygiene. 2. Observation on 3/19/24 at 1:44 p.m., of Resident #4 being assisted by Staff A, CNA and Staff C, CNA to lay down and use the bedpan. After Resident #4 was completed Staff A performed hand hygiene and applied gloves, Staff A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and resident interview, the facility failed to assure a resident was free from exploitation for 1 of 24 residents reviewed (Resident #29). The facility reported a census of 49 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #29 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident required extensive assistance for transfer, toilet use, and personal hygiene. The resident had diagnoses including non-traumatic spinal cord dysfunction, non-Alzheimer's dementia, and acute cystitis (bladder infection). According to the MDS assessment dated [DATE] Resident #29 scored 15 on the BIMS indicating no cognitive impairment. The Care Plan identified the resident had impaired cognitive function/dementia or impaired thought process related to (alcohol induced dementia), with the goal to be able to communicate basic needs on a daily basis. The interventions included: a. Communicating with 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 Surveyor: [NAME]-[NAME], Lea Based on personnel file review and staff interview, the facility failed to obtain the Department of Human Services (DHS) approval to work for staff with a criminal record for 1 of 5 staff reviewed (Staff L). The facility reported a census of 49 residents. Findings include: A Staff List documented Staff L Activity Director hired on 1/26/22. A Single Contact License and Background Check (SING) completed 1/27/22 showed Staff L had a criminal record. Staff L's personnel record lacked DHS approval to work. On 11/9/23 at 9:50 a.m. the Administrator stated they could not find anything on a DHS evaluation for Staff L. She said they were told by corporate she was cleared (to work). The facility Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy revised April 2021 documented the facility would conduct employee background checks and not knowingly employ or otherwise engage any individual who had been found guilty of abuse, neglect, exploitation, misappropriation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person and had the daily rate filled in when residents transferred out of the facility for 4 of 5 residents reviewed (Residents #1, #7, #16, and #52). The facility reported a census of 49 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of anemia, heart failure and seizure disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of Resident #1 ' s Nrogress notes revealed the following information: On 11/3/23 at 2:20 a.m., sent the resident to the emergency room at 7:07 p.m On 11/3/23 at 1:26 p.m., resident returns to facility from local hospital. Review of the residents #1 ' s Census tab revealed the following information: 11/2/23 hospital unpaid leave 11/3/23 active Review of the clinical record revealed a…

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

Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was stored and prepared under sanitary conditions. The facility identified a census of 49 residents. Findings include: An initial kitchen tour conduct on 11/06/23 at 11:09 a.m., revealed the following observations: a. 1 cup of thickened juice uncovered and no label in refrigerator ready for service. b. 1 cup of thickened milk uncovered and no label in refrigerator ready for service. c. Open container of thickened water with no open date in the refrigerator ready for service. Container reads only good for 7 days after opening. d. Open container of thickened juice with no open date in the refrigerator ready for service. Container reads only good for 10 days after opening. e. Refrigerator noted to have a red liquid pooled in the bottom of the refrigerator f. 2 cups of ice cream with topping uncovered and no label in the freezer. g. Milk cooler ice buildup on left side, right side and back of cooler. h. Peanut butter container lid was on but there was peanut butter under and around…

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, facility policy review and staff interviews, the facility failed to perform proper hand hygiene during routine cares for 1 of 3 residents reviewed (Resident #16) and failed to pass personal linens in a sanitary manner through the facility. The facility reported a total census of 49 residents. Findings include: 1. The The Minimum Data Set (MDS) assessment dated [DATE] for Resident #16 documented diagnoses hypertension, diabetes mellitus and paraplegia. The MDS included a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Observation on 11/07/23 at 2:32 p.m., with Staff C, Licensed Practical Nurse (LPN), Assistant Director of Nursing (ADON) and Staff D, Registered Nurse (RN), MDS Nurse perform wound care for Resident #16. Staff C laid a barrier under Resident #16 ' s legs and laid ankles on top of the barrier. Noted Staff C to have 5 small round stickers stuck to her right inner arm. Staff C took a pair of dressing scissors off of the bedside table 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 record review, staff and resident interview, the facility failed to assure each resident received care in a manner that promoted maintenance or enhancement of his/her quality of life for 2 of 15 sampled residents (Resident #29 and #38). The facility reported a census of 49 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #29 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident required extensive assistance for transfer, toilet use, and personal hygiene. The resident had diagnoses including non-traumatic spinal cord dysfunction, non-Alzheimer's dementia, and acute cystitis (bladder infection). The Care Plan dated 6/21/23 identified the resident at risk for falls. The interventions included encouraging her to use her call light for assistance. The Care Plan identified the resident unable to transfer independently. The interventions included the resident required 1-2 person assistance with 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 clinical record review and staff interview the facility failed to notify the Long Term Care (LTC) Ombudsman for 1 of 4 residents reviewed who transferred to the hospital (Resident #52). The facility reported a census of 49 residents. Findings include: Resident #52 ' s clinical records revealed diagnoses of diabetes mellitus, atrial flutter and fibrillation and acute kidney failure. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15 indicating no cognitive impairment. Review of Resident #52 ' s Progress Notes revealed the following information: On 9/24/23 at 3:42 p.m., send to emergency room to be assessed. On 9/25/23 at 7:31 a.m., admitted to local hospital. Review of Resident #52 ' s Census tab revealed the following: 9/18/23 active 9/24/23 hospital paid leave 10/5/23 discharge paid 10/6/23 stop billing Review of MDS listing revealed the following: 9/18/23 entry 9/24/23 discharge return not anticipated Review of the facility document titled Notice of Transfer Form to Long Term Care Ombudsman dated August, September, and October lacked Resident…

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 and chart review the facility failed to accurately document a resident's specific need for 1 of 15 residents reviewed (Resident #24). The facility reported a census of 49 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #24 documented diagnosis of depression, and respiratory failure. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the MDS dated [DATE] revealed the facility failed to code insulin injections for 7 out of 7 days in the lookback period. Review of the August Medication Administration Record (MAR), indicated that Resident #24 administered insulin daily in the 7 day lookback period. Interview on 11/8/23 at 1:24 PM, with the MDS Coordinator agreed that it was coded inaccuratley. She voiced that she coded the 7 day insulin in section N300 on the MDS under the Injections of any type. She voiced that she should have coded it under N350 Insulin Injections also. She…

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 interviews, and policy review the facility failed to resubmit Preadmission Screening and Resident Review (PASRR) after a 180 day short stay approval expired on [DATE] for 1 of 1 residents reviewed (Resident #7) and failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 residents (Resident #42) reviewed for PASRR requirements. The facility reported a census of 49 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented diagnoses of depression, anxiety disorder, psychotic disorder, auditory hallucinations and visual hallucinations. The MDS showed a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive…

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 clinical record review and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch for and update care plan after high risk medication was discontinued in 1 out of 5 sampled residents (Resident #7) and update care plans with interventions to prevent further falls in 1 out of 15 residents reviewed for comprehensive care plans (Resident #48). The facility reported a census of 49 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented diagnoses of depression, anxiety disorder, psychotic disorder, auditory hallucinations and visual hallucinations. The MDS showed a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment. Review of the October 2023 Medication Administration Record (MAR) revealed the following orders: Hydrocodone-acetaminophen (opioid medication) with a start date of 8/29/23 and discontinue date of 10/31/23. Oxycodone…

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 interviews and observation the facility failed to provide professional standards of care by administering medications for 2 of 12 residents reviewed (Resident # 11 and Resident # 36). The facility reported a census of 49 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 11 documented diagnosis of hypertension, depression, chronic obstructive pulmonary disease. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Observation on 11/7/23 at 11:38 AM observed Staff A administer the Albuterol solution into the nebulizer device, Resident #11 stated that he would do the nebulizer after lunch, Staff A replied okay and left the room and the Albuterol solution in the nebulizer. 2. The MDS assessment dated for 8/10/23 for Resident #36 documented diagnosis of malnutrition, depression, chronic obstructive pulmonary disease. The BIMS dated 11/2/23 shows a score of 13, indicating no cognitive…

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 clinical record review, policy and procedures and staff interviews, the facility failed to implement measures as instructed in the Care Plan to ensure the bed remained in the lowest position on the floor to prevent falls for 1 out of 13 residents reviewed (Resident #48). The facility reported a census of 50. Findings included: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #48 documented diagnoses of stroke, traumatic brain injury and psychotic disorder. The MDS showed a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. The facility Incident Reports indicated Resident #48 fell in her room on the following dates: a. 9/14/23 b. 9/19/23 c. 9/21/23 d. 10/15/23 e. 10/16/23 f. 10/24/23 The Incident Report dated 10/16/23 showed Resident #48 suffered a skin tear to the right shoulder as a result of a fall that occurred that day. The Care Plan History dated 10/16/23 showed staff instructed to place the bed to the floor while the resident is 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, clinical record, facility policy, and staff interview, the facility failed to maintain an accurate clinical record 1 for out of 13 residents reviewed (Resident #48). The facility reported a census of 49 residents. Findings Included: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #48 documented diagnoses of stroke, traumatic brain injury and psychotic disorder. The MDS showed a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. The facility Incident Reports indicated Resident #48 fell in her room on the following dates: a. 9/14/23 b. 9/19/23 c. 9/21/23 d. 10/15/23 e. 10/16/23 f. 10/24/23 The Progress Notes for Resident #48 showed the facility failed to document the following falls: a. 9/19/23 b. 9/21/23 c. 10/24/23 The Falls - Clinical Protocol policy dated March 2018 identified: Assessment and Recognition 1. The physician will help identify individuals with a history of falls and risk factors for falling. a. Staff will ask 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.