Spencer Post Acute Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Medication Administration Record - Treatment Administration Record (MAR-TAR), Electronic Health Record (EHR) review, and staff interviews the facility failed to provide 2 of 31 medications as ordered resulting in a medication error rate of 6.45. The facility reported a census of 67 residents. Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview for Mental Status (BIMS) of 5 indicating severe cognitive impairment. The MDS documented Resident #5 had a diagnosis of type 2 diabetes mellitus without complications.Review of Resident #4's MAR-TAR documented a physician's order for insulin Lispro injection per sliding scale if blood glucose was 140-180 2 units at 7:30 AM and insulin Glargine inject 32 units subcutaneously one time a day at 7:00 AM.Review of Resident #4's EHR titled, Orders documented a physician's order for insulin Lispro injection per sliding scale if blood glucose was 140-180 2 units at 7:30 AM and insulin Glargine inject 32…

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, Medication Administration Records - Treatment Administration Records (MAR-TAR) and Electronic Health Records (EHR) review the facility failed to ensure the residents were free of significant medication errors to 2 of 6 residents reviewed (Resident #4 and #7). The facility reported a census of 67 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview for Mental Status (BIMS) of 5 indicating severe cognitive impairment. The MDS documented Resident #5 had a diagnosis of type 2 diabetes mellitus without complications. Review of Resident #4’s MAR-TAR documented a physician’s order for insulin Lispro injection per sliding scale if blood glucose was 140-180 2 units at 7:30 AM and insulin Glargine inject 32 units subcutaneously one time a day at 7:00 AM. Review of Resident #4’s EHR titled, Orders documented a physician’s order for insulin Lispro injection per sliding scale if blood glucose was 140-180 2 units at 7:30…

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, policy, Electronic Health Record (EHR) review and staff interview the facility failed to follow the menu and prepare food to meet the residents nutritional needs for 22 of 26 residents (all residents with a regular diet) reviewed. The facility reported a census of 67 residents.Findings include:A continuous observation on 8/12/25 at 11:40 AM revealed Staff A, Certified Dietary Manager (CDM) served the lunch meal. Staff A completed hand hygiene, completed temperature checks on the food, placed serving utensils in the steam table wells with the food, and began lunch service. Through the entire lunch service a 3 oz scoop was utilized to serve all regular diet peas.On 8/12/25 at 12:30 PM Staff A acknowledged the scoop utilized to serve the regular diets the peas was a 3 oz scoop and should have been a 4 oz scoop. Review of document dated 8/14/25 titled, Diet Type Report documented 22 regular diets served in that building for the lunch meal on 8/12/25.Review of document titled, Week 4 Tuesday Diet Spreadsheets the lunch menu revealed regular diets should have 4oz…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, resident family interviews, staff interview, electronic health records (EHR), document review and policy review the facility failed to maintain medical records on each resident that were complete and accurate by failing to accurately transcribe a physicians order into the EHR for 2 of 8 residents reviewed (Resident #9 and #73). The facility reported a census of 67 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #73 did not document a Brief Interview for Mental Status (BIMS) as Resident #73 was admitted on [DATE]. On 8/13/25 at 8:40 AM Staff C, Certified Medication Assistant / Certified Nurse Assistant (CMA/CNA) stated Resident #73’s MAR did not match the bubble pack for the potassium chloride ER tablet. Staff C stated MAR read potassium chloride ER give 20 mEq BID. Staff C stated Resident #73’s bubble pack for potassium chloride documented 20 mEq give 2 tablets daily. Review of Resident #73’s bubble pack for potassium chloride documented potassium…

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, staff interviews, Centers for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to screen for eligibility, offer, provide education and document vaccine consent or refusal for the pneumococcal immunization for 1 of 5 resident reviewed (Resident #8) for immunizations. The facility reported a census of 67 residents. Findings include: Resident #8 Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.Review of the clinical record revealed Resident #8 had received the Pneumococcal Conjugate Vaccine 13-valent (PCV13) on 05/19/20, and Pneumococcal Polysaccharide Vaccine 23-valent (PPSV23) on 10/14/98. The clinical record lacked documentation that Resident #8 was educated, offered a consent for or refusal of the Pneumococcal Conjugate Vaccine PCV20 or PVC21 vaccination. Review of the CDC recommendations dated October 2024 for adults 50 years or older who…

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 Electronic Record Review (EHR), staff interviews, and policy review the facility failed to develop a comprehensive care plan that included problems, goals, or interventions for use of a diuretic or diagnosis of congestive heart failure, develop a comprehensive care plan that was personalized when a resident received hospice care, and did not follow a care plan for 4 of 18 residents reviewed (Resident #3, #20, #43, and #50). The facility reported a census of 53 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #50 entered the facility on 7/3/24. The MDS also documented a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS revealed diagnosis of essential (primary) hypertension and localized edema. The MDS documented use of diuretic. Review of Resident #50 ' s Physician Orders documented lasix oral tablet 40 mg (Furosemide), give 40 mg by mouth one time related to localized edema started 8/15/24 and lasix oral tablet 20 mg…

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 Electronic Health Records (EHR), policy review, resident interview, and observations the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 5 of 18 residents reviewed (Resident #1, #6, #17, #37, and #106). The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. Review of EHR documented Resident #1 resided in NN09-2. Observation on 8/20/24 at 1:05 PM of room NN09, Resident #1's room revealed the call light was on. Staff B, Certified Nursing Assistant (CNA) entered Resident #1 ' s room at 1:32 PM and answered the call light. Staff B told Resident #1 to let her find another CNA and would be right back. Staff B returned to Resident #1 ' s room at 1:34 PM with mechanical lift. On 8/20/24 at 1:40 PM Staff B stated Resident #1 ' s call light was on because she wanted to use…

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

Based on observation and staff interview, the facility failed to post the daily census sheet including the facility resident census and the actual working hours of nurses and nurse aides on duty for the current date. The facility reported a census of 53 residents. Findings include: On 8/21/24 at 10:52 am, the Longhouse portion of the facility, where the census posting is to be posted, had no census posting visible. Staff A, Licensed Practical Nurse (LPN) stated it had not been completed yet for the day. She stated the prior day's posting was probably in the medication room. On 8/21/24 at 10:55 am, Staff A, LPN obtained keys to the medication room and found census sheets dated 8/16/24 - 8/19/24. When asked if a census sheet had been completed for 8/20/24 she stated she was off work that day and did not know if one had been done. A census for 8/21/24 was filled out and hung on a board in the dining room. On 8/22/24 at 11:30 am, the Administrator stated the daily census posting is to be done by the charge nurse for each shift. She stated it should be initiated by the day shift at 6:00…

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 maintain sanitary practices by failing to keep the ice makers clean and by improperly handling food during meal service. The facility reported a census of 53 residents. Findings include: On 8/19/24 at 11:55 AM, a north building kitchen observation revealed black and pink substance on the internal plastic ice cube guard edge. At 12:05 PM, a south building kitchen observation revealed black and pink substance on the internal plastic ice cube guard edge. On 8/20/24 at 8:17 AM, Staff G, Dietary Aide (DA), transported a gallon of milk on a cart from kitchen without the lid on it. At 8:35 AM, the Dietary Manager opened a salt & pepper packet for a resident, sprinkled the salt and pepper on the resident's eggs then put the opened packets on the resident's plate. On 8/21/24 at 11:35 AM, Staff G, cook, put a glove on her left hand and used her right hand to adjust the glove fingers. She then put a glove on her right hand, placed her right hand on a non-food preparation counter, opened a drawer, and grabbed 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 observation, record review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices by not covering the clean linen cart when moving between buildings and in hallways at the facility, not disinfecting wheelchair after contaminated during personal cares for a resident with transmission based precautions, not completing hand hygiene and changing gloves in accordance with standards of practice and touched back of medication cards to cups used to distribute medications for 6 of 12 residents reviewed, (Resident #7, #20, #37, #14, #18 and #50). The facility reported a census of 53 residents. Findings included: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #50 entered the facility on 7/3/24. The MDS also documented a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS revealed indwelling catheter utilized by Resident #50. Observation on 8/21/24 at 8:35 AM Staff E cleansed the tip of catheter tubing…

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 policy, observation, and staff interview the facility failed to provide a call light system within reach of a resident in contact precautions and accommodate the needs of a resident with closet door hanging unable to be opened for 2 of 18 residents reviewed, ( Resident #9 and #22). The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #22 documented a Brief Interview for Mental Status (BIMS) of 11 indicating moderate cognitive impairment. On 8/20/24 at 8:22 AM observation of Resident #22 lying in bed in his room with a call light not within reach lying on a recliner on the opposite side of the room as his bed . Resident #22 ' s door was closed related to transmission based precautions (TBP). On 8/20/24 at 8:22 AM Resident #22 stated he was unable to find his call light. Resident #22 stated he utilized the call light when in need of staff assistance. Review of Resident #22 ' s Care Plan documented contact and droplet isolation…

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, staff interviews, and policy review, the facility failed to include psychotropic medications in the baseline care plan for 1 of 18 residents reviewed (Resident #8). The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of Diabetes Mellitus, Cerebrovascular Accident (stroke), depression, and metabolic encephalopathy (brain dysfunction caused be chemical imbalance). It indicted he took an antidepressant within the 7-day look-back period. It also indicated he was admitted to the facility on [DATE]. On 8/20/24 at 2:52 PM, Resident #8 stated he took antidepressant medication and had been on it for a long time. The hospital Discharge Home Medication List directed Resident #8 to continue taking duloxetine (Cymbalta) 60 mg capsule, delayed release daily, by…

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, staff interview and facility policy review, the facility failed to revise a comprehensive care plan for 1 of 18 residents reviewed, (Resident #19). The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) of Resident #19 dated 6/7/24 documented diagnoses that included: non Alzheimer's dementia and depression. The MDS documented the resident received antidepressant medications during the assessment reference period. The current Care Plan of Resident #19 documented a Focus Area dated 5/7/24 of antidepressant medication use (mirtazapine and sertraline) related to depression. The Medication History of Resident #19 reflected that the resident's order for Mirtazapine (an anti depressant medication) was discontinued on 6/11/24. The Psychotropic Med Use Detail Report from the facility's pharmacy, dated July 2024, also reflected Mirtazapine to have been discontinued 6/11/24. The Nursing Note dated 6/11/24 at 1:50 pm documented Received signed medication review for Mirtazapine 'Stop Mirtazapine' . On 8/21/24 at 11:07 am,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and resident interview, the facility failed to follow physician orders to obtain a resident's weight following admission for 1 of 18 residents reviewed (Resident #106). The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS) Assessment of Resident #106 dated 8/15/24 documented the resident admitted to the facility on [DATE]. The MDS identified a Brief Interview of Mental Status (BIMS) score of 14 which indicated cognition intact. On 8/19/24 at 2:10 pm, Resident #106 reported she does not care for the food. She stated the food is cold and she has to supply her own seasonings. The Medication Administration Record (MAR) for August of 2024 for Resident #106 documented an order for Obtain weight upon admission, daily x 3 days, then weekly on Monday day shift x 4 weeks. The MAR reflected that Staff A, Licensed Practical Nurse (LPN) had documented the weight being done on August 10th, August 11th, August 12th, August 14th, and August…

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 staff interview, the facility failed to provide a Restorative Exercise Program to prevent a worsening of range of motion for 1 of 1 resident reviewed, (Resident #27). The facility reported a census of 53. Findings include: The Minimum Data Set (MDS) of Resident #27 dated 8/9/24 identified a Brief Interview of Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. The MDS documented the resident to have a functional limitation in range of motion affecting all 4 limbs. The MDS revealed the resident to be totally dependent upon staff for eating, bed mobility, dressing, toileting and transferring. The MDS documented the resident as unable to walk. The initial Care Plan for Resident #27 documented a Focus Area of Idiopathic Neuropathy/Radiculopathy, Lumbar Region, with a history of Cerebral Infarction. It indicated the resident used a mechanical lift to transfer and had an inability to ambulate, revision date 11/27/21. The Care Plan directed staff to follow a Restorative Exercise program for Functional Maintenance. 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 clinical record review, staff interview and facility policy review, the facility failed to attempt a Gradual Dose Reduction for 2 of 5 residents reviewed, (Residents #14 and #19). The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) of Resident #19 dated 6/7/24 documented diagnoses that included: non Alzheimer's dementia and depression. The MDS documented the resident received antidepressant medications during the assessment reference period. The MDS recorded the residents experienced no mood symptoms of feeling down, depressed or hopeless during the previous 2 weeks look back period. The MDS recorded the resident had no documented behaviors during the 7 day look back period. The Medication History of Resident #19 reflected the resident's order for Sertraline (an anti depressant medication) was decreased from 25 mg to 12.5 mg on 7/21/2023. The Psychotropic Med Use Detail Report from the facility's pharmacy, dated July 2024, also reflected Sertraline to have…

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, menu review, clinical record review, staff interviews, and policy review, the facility failed to serve the correct therapeutic diet for one of one resident who was ordered a renal diet, (Resident #15). The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #15 dated 6/14/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of anemia, Coronary Artery Disease (CAD - heart disease), Heart Failure (HF), hypertension, renal (kidney) disease, and Diabetes Mellitus. It indicated the resident received a therapeutic diet within the 7-day look-back period. The Electronic Health Record (EHR) included a Physician Order for a renal diet dated 10/05/22. On 8/21/24 at 12:15 PM, Staff G, cook, placed a small steam pan of carrots on the steam table. At 12:20 PM, lunch meal service began and Staff G was observed serving Resident #15 regular diet menu items. At 12:58 PM, Staff G stated she did not know why the carrots were sent…

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 for resident ' s dignity during dining when staff engaged in conversation that was not resident focused. The facility reported a census of 54 residents. Findings include: Observation on 3/13/24 at 12:32 p.m., Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA were seated at a table of 6 residents that were being assisted with meals. Staff A and Staff B were conversing between each other regarding personal issues and not interacting with the residents as they were being assisted with eating their meals. Interview on 3/14/24 at 12:53 p.m., with the Administrator revealed the staff should have been focused on the residents and involving them in the conversations. The Administrator revealed this topic is discussed quite often at staff meetings and discussed the focus should be on the residents when the staff is assisting them. In an electronic mail communication from the Administrator on 3/14/23 at 2:29 p.m., revealed the facility has staff do a course online on orientation and then yearly on 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 clinical record review, resident interview, staff interview and facility policy review the facility failed to provide bathing assistance twice weekly for 3 of 3 residents reviewed for bathing (Resident #1, #3 and #5). The facility reported a census of 54 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of obesity, rheumatoid arthritis and respiratory failure. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS revealed Resident #1 required substantial or maximal assistance with shower or bathe self including washing, rinsing and drying self and revealed Resident #1 was dependent on staff for transfers in and out of the shower or tub. Review of Resident #1 ' s Care Plan with a revision date of 3/4/24 revealed shower twice per week and assist with bathing. Review of Resident #1 ' s Task List revealed bathing as needed and Wednesday and Saturday. Review of report titled…

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, infection control policy and staff interview, the facility failed to provide proper hand hygiene with incontinence care with 2 of 3 residents (Resident #3 and #6) observed. The facility reported a total census of 54 residents. Findings include: 1. Observation on 3/13/24 at 10:11 a.m., of Resident #3 being assisted by Staff C, CNA and Staff D, CNA to lay down after breakfast. Staff C and Staff D performed hand hygiene upon entering Resident #3 ' s room. Staff C and Staff D applied gloves and assisted Resident #3 onto the bed with the mechanical lift to lay down. Staff C and Staff D assisted Resident #3 with removing soiled lift sheet, pants and underwear as Resident #3 was incontinent of urine and feces. Staff C and Staff D removed soiled gloves and reapplied gloves without performing hand hygiene. Staff C picked up clean wipes and perineal cream off the nightstand and laid them on Resident #3 ' s bed. Staff C picked up a clean dry wipe and applied perineal cream and performed appropriate perineal care. Repeating this on the front of the genitals and the hips,…

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 document review, record review, resident interview and staff interviews the facility failed to provide a comprehensive care plan related to catheterization to a resident with placement of indwelling catheter, a resident with chronic obstructive pulmonary disease / respiratory compromise and a resident with pain to 3 of 5 residents reviewed (Resident #3, #45 and #13). The facility reported a census of 55 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #3 documented a Brief Interview of Mental Status (BIMS) not completed. The MDS revealed short and long term memory problems. MDS also revealed cognitive skills for daily decision making severely impaired. Review of Electronic Health Records (EHR) revealed Resident #3 returned from the hospital 9/20/23 with an indwelling catheter in place. Review of Resident #3 ' s medication administration records (MAR) revealed an order to change 16 French catheter as needed if leaking. During an observation on 10/25/23 of catheter cares…

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 document review, electronic health records review, observation, policy review, and staff interviews the facility failed to provide a professional standard of quality by not following physician orders for 3 of 4 residents reviewed (Resident #18, #47, and #207). The facility reported a census of 55 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #18 had a Brief Interview of Mental Status (BIMS) of 3 indicating severe cognitive impairment. An observation of medication administration on 10/24/23 at 7:56 AM revealed Staff D obtained medications from medication cart for Resident #18. Staff D obtained a liquid Potassium bottle with syringe rubber banded to the side of the bottle for Resident #18. Staff D poured liquid Potassium from the bottle into the medication cup. Potassium measured over 5 mL and under 7.5 mL. No measurement on the side of the medication cup for 6 mL. Staff D administered liquid medication to Resident #18. Review of medication administration…

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 resident's received baths as planned for 4 of 15 resident's reviewed (Resident #4, #13, #51 and #47 ). The facility reported a census of 55 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #4 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident required extensive assistance with bathing. The resident had diagnoses including cerebral palsy, aphasia (loss of ability to understand or express speech), stroke, non-Alzheimer's dementia, and hemiplegia or hemiparesis (paralysis or weakness of 1 side of the body). The Care Plan revised 1/19/23 identified the resident had impaired ability to perform activities of daily living (ADL's) related to cognitive impairment and disease process. The interventions included whirlpools or shower twice per week, and assist with bathing. The Care Plan identified dated 1/19/23 identified 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 assure functional maintenance programs were completed as planned for 3 of 3 residents reviewed (Resident #4, #13, and #8). The facility reported a census of 55 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #4 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident required extensive assistance with activities of daily living (ADL's) including bed mobility, transfer, dressing, toilet use, and personal hygiene. The resident had limitation in range of motion (ROM) of the upper and lower extremities on both sides. The resident had diagnoses including cerebral palsy, aphasia (loss of ability to understand or express speech), stroke, non-Alzheimer's dementia, and hemiplegia or hemiparesis (paralysis or weakness of 1 side of the body). The Care Plan identified the resident had mobility impaired related to a chronic and advancing neuromuscular…

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 document review, electronic health records review, observation, policy review, and staff interviews the facility failed to ensure medication error rates are not 5 percent or greater by having a medication error rate of 14.29 percent. The facility reported a census of 55 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #18 had a Brief Interview of Mental Status (BIMS) of 3 indicating severe cognitive impairment. An observation of medication administration on 10/24/23 at 7:56 AM revealed Staff D obtained medications from medication cart for Resident #18. Staff D obtained a liquid Potassium bottle with syringe rubber banded to the side of the bottle for Resident #18. Staff D poured liquid Potassium from the bottle into the medication cup. Potassium measured over 5 mL and under 7.5 mL. No measurement on the side of the medication cup for 6 mL. Staff D administered liquid medication to Resident #18. Review of medication administration record (MAR) revealed an order…

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 review, resident interview and staff interview, the facility failed to secure medications in a locked compartment, label with open dates and remove medication after expiration date. The facility reported a census of 55 residents. Findings include: 1. An observation on [DATE] at 9:45 AM Staff E pushed the medication cart down the hall. Staff E opened the drawer on the medication cart. Staff E removed the bubble pack from the medication cart. Staff E removed residents medications from the bubble pack. Staff E returned the bubble pack to the medication cart drawer. Staff E entered the residents room and did not lock the medication cart. Staff E then closed the door to the residents room. Staff E gave the medications to the resident. The resident took medication on her own with water wash down. Staff E walked out into the hall during the medication administration still able to observe the resident and locked the medication cart. Staff E walked back into the room and stated 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.

Based on observation, menu review and staff interview, the facility failed to serve food in accordance with professional standards for food safety. The facility reported a census of 55 residents. Findings include: The menu for the evening meal 10/24/23 included 1/2 a grilled tuna melt. On 10/24/23 at 5:47 p.m. Staff C [NAME] washed her hands and put on gloves. She touched multiple surfaces including the counter, the steam table, the diet cards, and the refrigerator to get something out of it. She then dumped out scrambled eggs squares on to a plate and touched both of them to turn them over, wearing the same gloves. During the meal service, she picked up some of the sandwiches with a pair of tongs and put the sandwich directly on the plate. Other times she picked the sandwich up with the tongs and then used her gloved hand to put it on the plate. Sometimes she just picked the sandwich up with her gloved hand and placed it on the plate. There were a minimum of 9 times when she touched the sandwiches that she was sending out to serve. She did not change her gloves throughout 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, record review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing personal care for 1 of 1 residents, during medication administration, and failed to review the infection control policy annually with appropriate staff. The facility reported a census of 55 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #33 documented a Brief Interview of Mental Status (BIMS) of 3 indicating severe cognitive impairment. MDS also revealed diagnosis of monoplegia of upper limb following cerebral infarction affecting left nondominant side and contracture of right and left knee. An observation on 10/24/23 at 8:56 AM of peri care on resident #33 revealed Staff H and Staff F completed peri cares. Staff H and Staff F completed hand hygiene and donned gloves. Staff H removed Resident #33 ' s pants. Staff F removed Resident #33 ' s briefs. Staff H completed peri care on groin and penis using single swipes…

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, observations, staff interviews, and facility policy review, the facility failed to protect resident from the use of physical restraint that the resident could not remove on their own (Resident #18 and #27). The facility reported a census of 55 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #18 documented diagnoses of non-Alzheimer ' s Dementia, repeated falls and anxiety disorder. The MDS showed a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Observation on 10/23/23 at 1:59 p.m., revealed a pillow under the fitted sheet on Resident #18 ' s left side of her back under the fitted sheet. 2) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #27 had long and short term memory problems and moderately impaired skills for daily decision making. The resident required extensive assistance with bed mobility, transfer, eating, and personal hygiene. The resident did 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 clinical record review and staff interview, the facility 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 #10) reviewed for PASRR requirements. The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #10 documented diagnoses anxiety disorder, depression and psychotic disorder. The MDS included a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. The MDS revealed an active diagnosis of anxiety disorder, depression and psychotic disorder. Review of Resident #1 ' s active diagnosis in her medical chart revealed delusional disorders, hallucinations unspecified, 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 record review and staff interview, the facility failed to review and revise the care plan to reflect the resident's current status for 2 of 15 residents reviewed (Resident #13 and #33). The facility reported a census of 55 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #13 scored 5 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident required extensive assistance with activities of daily living (ADL's) including bed mobility, transfer, personal hygiene and bathing. The resident had diagnoses including diabetes, non-Alzheimer's dementia, and Parkinson's disease. The MDS documented the resident received antipsychotic, antidepressant, antianxiety, and hypnotic medication. The October 2023 Medication Administration Record (MAR) showed the resident received the following medications: a. Clonazepam 0.5 mg at bedtime for sleep with a start date 4/7/23. b. Escitalopram 20 mg in the morning related to 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 document review, Electronic Health Records (EHR), and staff interviews the facility failed to provide dialysis services consistent with professional standards by not completing a post dialysis assessment to 1 of 1 residents reviewed (Resident #20). The facility reported a census of 55 residents. Finding include: The Minimum Data Set (MDS) dated [DATE] for Resident #20 documented a Brief Interview of Mental Status (BIMS) of 14 indicating no cognitive impairment. The MDS documented diagnosis of end stage renal disease. Review of a document titled Dialysis Flow Record for Resident #20 revealed no documentation of dressing conditions. Review of EHR for Resident #20 revealed no documentation of dressing conditions. Review of Resident #20 ' s Care Plan revealed an intervention to monitor, document, and report as needed any signs or symptoms of infection to the access site: redness, swelling, warmth, or drainage. Review of undated document titled Care Plan Approach for Dialysis Patients for Resident #20…

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