Ironwood Rehabilitation and Care Center

Based on observation, record review and staff interview, it was determined the facility failed to ensure medications were stored securely. This was true for 1 of 3 medication carts observed (North Hall Med Cart). This failure created the potential for harm related to unmonitored use of medications. Findings include: On 4/30/26 at 8:59 AM, the medication cart on the North Hall was observed to be unlocked and unattended. On 4/30/26 at 9:03 AM, LPN #1 returned to the medication cart. LPN #1 stated the cart was locked and attempted to demonstrate by pulling on a drawer handle, the drawer opened. LPN #1 stated the cart locked on a timer and she thought the cart was locked when she stepped away. LPN #1 stated she did not know how long the timer on the cart took to lock when left unattended and added she should have double checked it. On 4/30/26 at 9:59 AM, the CRN stated medication carts must be locked when the staff leave it unattended.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined, the facility failed to ensure a residents medical record was complete and accurately documented. This was true for 1 of 6 residents (Resident #11) whose medication regimen were reviewed. This failure created the potential for poor continuity of care and medication error when Resident #11's medication administration record (MAR) did not record their medications were not administered due to a hospitalization. Findings include: Resident #11 was admitted to the facility on [DATE] with multiple diagnoses including emphysema, muscle weakness, and a need for assistance with personal care. Resident #11's MAR documented, on 4/16/26, their midday and bedtime medications were not administered and on 4/17/26, their early morning medications were not administered. Resident #11's MAR did not include documentation of a code recording why the medications were not administered and the spaces for documentation were left blank. On 4/30/26 at 4:52 PM, the DON stated…

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, review of CDC guidance, and interviews, it was determined the facility failed to ensure an infection control program was implemented. This was true for 1 of 1 resident (Resident #37) whose intravenous site was observed, and 1 of 1 staff (RN #2) who was observed while providing wound care to Resident #50. This deficient practice created the potential for Resident #37 to develop an infection to his IV site and the spread of infection due to cross contamination when RN #2 did not perform hand hygiene when changing gloves. Findings include: The CDC webpage titled Clinical Safety: Hand Hygiene for Healthcare Workers was accessed on 5/5/26, documented gloves were not a substitute for hand hygiene. The CDC recommended the following:-Perform hand hygiene before donning gloves and touching the patient or the patient's surroundings.-Always clean your hands after removing gloves.The facility's Infection Control policy revised 1/26, documented hand hygiene should be performed before donning sterile…

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, it was determined the facility failed to ensure residents were provided with the pneumococcal vaccine when requested. This was true for 1 of 5 residents (Resident #6) whose medical records were reviewed for pneumococcal immunization. This failure created the potential for Resident #6 to have an increased risk of pneumococcal pneumonia (a serious bacterial lung infection) and the potential for severe illness or death. Findings include: The facility's policy, titled Immunizations-Residents, dated 1/26 documented, It is the policy of this facility to offer and administer influenza, pneumococcal, and COVID-19 immunization to eligible residents after providing education on the risks and potential side effects of the vaccine(s) and obtaining consent. Resident #6 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including fracture of left tibia, stroke, unsteadiness on feet, need for assistance with personal care, and muscle weakness…

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 documentation and staff interview, it was determined that the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of food and nutrition services, including resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population. These deficiencies had the potential to affect all residents requiring medical nutrition therapy, nutritional assessments, and appropriate supplementation and dietary interventions. Findings include: The State Operations Manual, Appendix PP, revised 8/8/24, documented, if a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services. The director of food and nutrition services must at a minimum meet one of the following qualifications: - A certified dietary manager. - A certified food service manager, or - Has similar national certification for food service management and safety from a national…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, it was determined the facility failed to treat each resident with respect and dignity that promoted enhancement of his/her quality of life and dining experience. This deficiency created the potential for psychosocial harm if the residents felt excluded from the dining experience. This was true for 3 of 24 residents (#1, #17, and #28) who were observed eating in the dining room. The findings include: The facility posted the following meal times for the dining room: Breakfast: 7:30 AM Lunch: 12:00 PM Dinner: 5:30 PM The following residents did not receive their meal in a timely manner, or did not receive their meal at the same time as the other residents at the same table: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including GERD, multiple sclerosis, and depression. Resident #17 was admitted to the facility on [DATE] with multiple diagnoses including heart failure, hypertension, and end stage renal disease. Resident #28 was admitted to 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, policy review, and staff interview the facility failed to ensure staff provided meal service according to the facility's posted mealtime schedule. This failure created the potential for 69 residents to experience poor quality of life, potential nutritional issues, and complications with medications required to be taken with meals if waiting more than 45 minutes to receive their meals. Findings include: A posted dining schedule at the front entrance of the facility documented: - Breakfast at 7:30 AM - Lunch at 12:00 PM - Dinner at 5:30 PM On 9/22/24 at 12:30 PM, during the lunch dining room observation, residents were seated for the lunch meal at 12:00 PM. At 12:35 PM it was observed that the first tray of food was delivered to residents in the dining room. The last meal was delivered to dining room residents was at 12:53 PM. On 9/24/24 at 8:00 AM, the following was observed during the second kitchen inspection: - 7:30 PM - Residents are seated in the dining room for their breakfast meal. - 8:00 AM - Dining room service begins. - 8:07 AM - Meal service begins…

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, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, clean, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 69 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The FDA (Food Drug Administration) Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, states marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded. The FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions, states cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to…

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

Based on observation and staff interview, it was determined the facility failed ensure Activity Room has adequate and comfortable lighting for the residents to enjoy their activity. This failure had the potential for residents to experienced psychosocial harm if they were unable to perform their independent functioning and task performance. Findings include: On 9/23/24 at 2:50 PM, Resident #40 asked the surveyor to visit the Activity Room. On 9/23/24 at 2:59 PM, the facility's Bistro which was being use by the facility as their Activity Room was observed to have dim lighting. There were missing light bulbs and multiple lights were out on the track lighting. On 9/24/24 at 2:26 PM, the Maintenance Director stated he was unable to replace the light tracks because it was no longer available in the area. The Maintenance Director stated he reported it to the previous administrator, and he was told it would be replaced during the remodeling of the facility. On 9/24/24 at 2:41 PM, the Activity Director (AD) stated residents expressed concerns about the lighting in the Activity Room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review, document review, and interviews, the facility failed to ensure allegations of sexual abuse were reported to the Administrator and, within two hours, to the State Agency. This was true for 1 of 8 residents (Resident #13) reviewed for abuse and neglect. This deficient practice created the potential for psychosocial harm to Resident #13 whose sexual abuse allegation was not reported and investigated thoroughly. Findings include: The facility's Abuse Prohibition policy and procedure, dated 7/1/20, documented the center prohibits the abuse, neglect, and exploitation of residents and misappropriation of resident property by anyone, including staff, resident representative/family, and friends. The policy also stated all alleged violations would be reported immediately, but not later than two hours after all allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause…

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 policy review, record review, and staff interviews, it was determined the facility failed to ensure an alleged allegation of sexual abuse was thoroughly investigated. This was true for 1 of 8 residents (Resident #13) reviewed for abuse and neglect. This deficient practice created the potential for Resident #13 to continue to be sexually abused and experience physical and/or psychosocial harm. Findings include: The facility's Abuse Prohibition policy and procedure, dated 7/1/20, documented a resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation, and to have all allegations thoroughly investigated. The policy also stated all documents would be retained to show all alleged violations were thoroughly investigated. Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including dementia and anxiety. A Quarterly MDS assessment, dated 7/28/24, documented Resident #13 was severely cognitively impaired. A progress note, dated 5/13/24…

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, it was determined the facility failed to ensure resident care plans were revised to reflect current needs and interventions. This was true for 2 of 18 residents (#32 and #42) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include: The facility's Care Planning Process policy, revised 5/19/23, documented care plans will be updated in regard to the needs, problems, strength, goals and interventions of the residents at least quarterly, annually, or with significant change. 1. Resident #42, was admitted to the facility on [DATE], with multiple diagnoses including diabetes, atrial fibrillation (irregular heartbeat), anemia, and obstructive sleep apnea. On 9/23/24 at 3:05 PM, Resident #42 stated, I'm supposed to be tested for a BiPAP. I only got a follow-up appointment today that said I need to go to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 18 residents (Resident #42) reviewed for standards of practice. Resident #42 was not evaluated for a skin condition. This deficient practice created a potential for harm if care and services were not provided. Findings include: Resident #42, was admitted to the facility on [DATE] with multiple diagnoses including diabetes, atrial fibrillation (irregular heart beat), anemia, and obstructive sleep apnea. On 9/24/24 at 11:39 AM, Resident #42 was observed scratching at scabbed sores on her upper right arm. Resident #42 stated she is a picker/scratcher and that she suspects some of her medication may be causing a problem. A review of progress notes from 9/15/24, documented that the physician provided a follow-up visit for a skin assessment in the bilateral groin area, but nothing related to itching arms. On 9/26/24 at 10:30 AM, RN #3 stated that the CNA's…

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 resident and staff interviews, it was determined the facility failed to ensure podiatry (foot) services were provided as ordered for 2 of 2 residents (#13 and #61) reviewed for podiatry care. This deficient practice created the potential for residents to experience physical complications related to elongated and/or ingrown toenails and poor circulation. Findings include: 1. Resident #13 was admitted to the facility on [DATE] with a diagnosis of heart disease. A Quarterly MDS assessment, dated 7/28/24, documented Resident #13 was severely cognitively impaired. A physician's order, dated 7/12/24, documented an order for a podiatry referral. A physician's order, dated 7/31/24, documented a second order for a podiatry referral related to an ingrown right great toenail. A progress note, dated 7/18/24, documented, Received a referral for podiatry. When I talked to [POA] about upcoming appointments she specifically asked that [Resident #13] to not go out on appointments anymore…

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, it was determined the facility failed to ensure residents receiving PRN alprazolam (anti-anxiety medication) had clear indication for the use of the medication and clinical rationale supporting the continued use of the medication beyond 14 days. This was true for 1 of 6 (Resident #32) reviewed for unnecessary medications. This deficient practice had the potential for harm should residents received psychotropic medications that are unwarranted and used for excessive duration. Findings include: The State Operations Manual, Appendix PP, revised 8/8/24, documented PRN orders for anti-psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's record and indicate the duration for the PRN order. Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including anxiety. 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, policy review, I&A report review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed related to ensuring residents were free from significant medication errors, neurological checks were completed, and physician orders were followed. This was true for 4 of 13 residents (#2, #10, #38, and #41) reviewed for quality of care. Specifically: * Resident #2 was at risk for deteriorating effects of his severe PVD (Peripheral Vascular Disease - a circulatory problem in which narrowed arteries reduce blood flow to the limbs, leading to pain and the potential for non-healing wounds and tissue death) when he did not receive a referral to a vascular surgeon and a podiatrist as ordered by his physician. * Resident #41 and Resident #38 were at risk for undetected neurological impairment when the facility did not initiate neurological assessments in a timely manner or complete the neurological assessments after unwitnessed falls. * 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, policy review, and resident and staff interview, it was determined the facility failed to ensure infection control and prevention practices related to hand hygiene were followed. This was true for 7 of 7 residents (#10, #13, #22, #32, #33, #39, and #44) observed for hand hygiene prior to meals being served and after toileting. This failure placed residents, staff and visitors entering the facility at increased risk of infection due to cross-contamination. Findings include: The facility's Handwashing/Hand Hygiene policy, revised August 2019, directed staff to perform hand hygiene before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's skin, and before and after handling food. This policy was not followed. 1. During a meal service observation on 10/18/21 from 5:45 PM to 6:15 PM, the following was observed: - At 5:45 PM, the SSD was observed delivering a meal tray to Resident #32. 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, policy review, and resident family and staff interview, it was determined the facility failed to ensure a resident's physician, family, and/or representative were notified when the resident had a significant change in condition. This was true for 1 of 2 residents (Resident #41) whose records were reviewed for changes in condition. This failed practice had the potential to cause delayed care and treatment resulting from lack of notification to the physician and/or family of her significant weight loss and a fall. This deficient practice placed Resident #41 at risk of inadequate care due to the lack of physician involvement and resulted in the inability of her family to advocate and support her when her health declined. Findings include: The facility's policy for Physician Notification of Resident Change in Condition, undated, documented when there was a non-critical change in the resident's physical, mental or psychosocial status, the physician and resident's representative were notified…

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 policy review, record review, staff interview, and review of Incident and Accident (I&A) reports, it was determined the facility failed to ensure residents were free from abuse. This was true for 1 of 4 residents (Resident #13) reviewed for abuse. The facility failed to ensure Resident #13 was not abused by other residents. This failure resulted in the potential for residents to be subjected to ongoing abuse and potential harm. Findings include: The facility's policy, titled Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, undated, stated, A resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy defined physical abuse as including hitting, slapping, pinching, scratching, spitting, holding roughly, etc., by anyone. The policy stated the facility was to identify, assess, care plan interventions, and monitor residents whose behaviors might be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, policy review, and review of grievances, it was determined the facility failed to report allegations of potential abuse to the State Survey Agency within 2 hours. This affected 1 of 4 residents (Resident #50) who were reviewed for abuse/neglect. This deficient practice created the potential for harm if allegations were not acted upon in a timely manner and the abuse/neglect continued. Findings include: The facility's Prevention and Reporting: Resident Mistreatment, Neglect, Abuse Including Injuries of Unknown Source, and Misappropriation of Resident Property policy, undated, documented verbal abuse included using disparaging and derogatory terms toward residents or their families or within their hearing distance, regardless of their age, ability to comprehend or disability, that would demean or humiliate, resulting in pain or mental anguish. The policy documented alleged violations were to be reported immediately to the Administrator and State Survey Agency, but no later…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, grievance review, and policy review, it was determined the facility failed to ensure an allegation of potential verbal abuse was investigated. This was true for 1 of 4 residents (Resident #50) reviewed for abuse/neglect. This deficient practice placed Resident #50 at risk of further abuse and other residents in the facility at risk of abuse. Findings include: The facility's Prevention and Reporting: Resident Mistreatment, Neglect, Abuse Including Injuries of Unknown Source, and Misappropriation of Resident Property policy, undated, documented residents had the right to be free from abuse and neglect. The policy stated all alleged violations were thoroughly investigated and documents were retained showing a thorough investigation of all alleged violations. The policy also documented verbal abuse included using disparaging and derogatory terms to the resident. This policy was not followed. Resident #50 was admitted to the facility on [DATE], with multiple diagnoses…

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, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with baths or showers consistent with their needs. This was true for 2 of 13 residents (#13, and #42) reviewed for activities of daily living. This failure created the potential for residents to experience embarrassment, isolation, decreased sense of self-worth, and/or skin impairment, due to lack of personal hygiene. Findings include: The facility's Resident Hygiene policy documented every resident should be assisted in maintaining healthy hygiene. The policy stated residents should receive routine daily care and regular baths or showers. Refusals of care were to be documented. This policy was not followed. 1. Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including unspecified dementia and aphasia (loss of ability to understand or express speech). Resident #13's quarterly MDS assessment, dated 8/10/21, documented she was severely cognitively impaired.…

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, policy review, I&A report review, and staff interview, it was determined the facility failed to ensure residents were provided sufficient supervision to prevent falls. This was true for 1 of 13 residents (#38) reviewed for falls. This deficient practice placed Resident #38 at risk of serious injuries and hospitalization when he sustained five falls within less than a month, including one fall a day for three consecutive days, resulting in multiple skin injuries. Findings include: The facility's policy for Accident and Incident Report, Investigation, Review, and Analysis, direct the staff to evaluate the factors leading to a resident fall and provide appropriate interventions to prevent future occurrences. The proper action following a fall included the following: * Ascertaining whether there were injuries and providing treatment as necessary. * Deterring what may have caused or contributed to the fall. * Addressing the contributing factors of the fall. * Revising the care plan and/or…

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, it was determined the facility failed to ensure a resident's urinary catheter needs were met in accordance with professional standards of nursing practice. This was true for 1 of 7 residents (Resident #20) reviewed for urinary catheters. This failed practice created the potential for harm and development of urinary tract infections due to improper handling of the urinary catheter. Findings include: Resident #20 was admitted to the facility on [DATE], with multiple diagnoses including neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord, or nerve problems) and paraplegia (paralysis of the legs and lower body). A quarterly MDS assessment, dated 10/8/21, documented Resident #20 had an indwelling catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) for urinary incontinence and required extensive assistance from two staff members for his ADLs except for eating. An…

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, it was determined the facility failed to ensure a alternatives to bed rails were attempted, and consent was obtained from the resident or the resident's legal representative prior to placing bed rails on a resident's bed. This was true for 1 of 5 residents (Resident #10) reviewed for bed rails. This failure created the potential for harm due to the risk of entrapment and due to lack of opportunity for the resident and/or their representative to make an informed decision regarding the use of bed rails. Findings include: Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, hypertension and muscle weakness. An admission MDS assessment, dated 8/9/21, documented Resident #10 was severely cognitively impaired. A physician's order, dated 10/19/21, documented for Resident #10 to have bilateral 1/4 bed rails on her bed to increase independence with bed mobility. A Safety Device care plan, revised 10/19/21,…

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, policy review, and staff interview, it was determined the facility failed to ensure residents' records documented residents were offered, provided education regarding benefits and potential side effects, consented to, and received or refused pneumococcal vaccines. This was true for 2 of 5 residents (#10 and #19) reviewed for immunizations. This failure placed residents at risk of severe illness or death, should they contract pneumococcal (bacterial) pneumonia. Findings include: The CDC website, accessed on 10/22/21, documented the current recommendations for pneumococcal vaccinations (PPSV23 and PCV 13) for all adults 65 years or older as follows: *Administer one dose of PPSV 23 to all adults 65 years or older, and to adults less than 64 years with certain medical conditions and adults less than [AGE] years old who smoke. *Administer one dose of PCV 13 for all adults with certain medical conditions. Healthy adults may receive PCV 13 based on discussions between the patient and health 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.