Lakeside Rehabilitation and Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review and staff interview, it was determined the facility failed to ensure medications were disposed properly. This was true for one of one staff (LPN #2) observed disposing the medications in the regular trash can. This deficient practice created the potential for harm if resident pick up and take the medication. Findings include: The facility's Destruction of Controlled Substance procedure, undated, documented under the section Disposal of Drugs - Drug Buster Drug Disposal System Remove discontinued, expired, contaminated or unusable medication from original prescription container or packaging and dispose of by placing into Drug Buster container. On [DATE], three pills were observed on top of LPN #2's medication cart and LPN #2 was looking at the computer. There was no barrier between the medication cart and the three pills. When LPN #2 saw the Surveyor, she immediately pick up the three pills and threw them in the trash can which was located on the side of her medication cart.…

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

Based on observation, interview, review of facility policy, and review of facility training document, the facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) for one of three residents (Resident #173) observed for enhanced barrier precautions (EBP) when providing care out of a total sample of 32 residents. This had the potential for the resident to have an increase for infection. Findings include: Review of Resident #173's admission Record in the Profile tab of the electronic medical record (EMR) revealed an admission date of 09/21/24. The admission Record revealed a diagnosis of malignant neoplasm (cancer) of endometrium (tissue of the uterus). Review of Resident #173's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/28/24, located in the EMR MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the resident was moderately cognitively impaired. During observation and interview 10/08/24 at 9:26 AM revealed Resident #173 had a STOP Enhanced Barrier Precautions (EBP)…

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 policy review, review of grievances, and staff interview, it was determined the facility failed to ensure resident grievances were investigated and resolutions were documented. This deficient practice placed all residents at risk of having unmet needs and poor quality of life when their concerns were not properly addressed. Findings include: The facility's grievance policy, revised 1/27/23, stated the Grievance Officer supervised and documented the details of the investigation and resolution of grievances. This policy was not followed. On 10/31/23 at 2:00 PM, residents at the resident council meeting stated they were unhappy with the facility's grievance process. They explained when they submitted a grievance, they did not know how the facility was addressing their concerns. Residents attending the meeting also stated they filed a grievance concerning staff training and did not receive a response. On 11/1/23 at 05:26 PM, the Administrator stated the facility was unable to produce documentation the grievance submitted by the resident council about staff training was…

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

Based on observation and staff interview, it was determined the facility failed to ensure licensed nurses were competent to administer insulin using a pen. This was true for 17 of 17 licensed nurses whose training records were reviewed for competencies. This had the potential to adversely affect residents who received insulin injections. Findings include: The facility's Insulin Injection policy, dated 12/22/22, documented Hold the insulin pen so you can read the name of the insulin. Looking at the dose window, dial to 2 units by turning the dosage selector forward. With the needle pointing up, press the injection button firmly with thumb and look for drops of insulin to come out of the tip of the needle. The Lippincott Manual of Medical-Surgical Nursing (10th edition, p. 579), documented insulin pen devices must be primed to ensure there is no obstruction and to clean any air in the needle. On 10/31/23 at 11:50, LPN #2 prepared a Lispro insulin pen for administration to Resident #25. LPN #2 did not prime the insulin pen prior to administering the insulin to Resident #25. A request…

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, review of the FDA Food Code, and resident and staff interview, it was determined the facility failed to ensure resident meals were palatable and maintained their correct temperature. This directly impacted 2 of 2 residents (#10 and #41) and had the potential to affect the other 72 residents who dined in the facility. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being. Findings include: The FDA Food Code 2022 states hot food will be maintained at 135 degrees F or above. On 10/30/23 at 10:45 AM, Resident #41 stated the meals were served in styrofoam containers and the food was usually cold and tasted bland. On 10/31/23 at 9:10 AM, Resident #10 stated the food was not tasty and most of time the food was served cold. On 10/31/23 at 3:34 PM, during the Resident Council meeting, residents complained about the food temperatures. During an observation of the lunch meal service on 11/2/23 beginning at 11:35 AM, the steam table food temperatures were over 140 degrees F as follows: Chicken stir fry 180…

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

Based on observation and interview, it was determined the facility failed to ensure food containers were appropriately labeled and free of spillage; food processing equipment was cleaned after use; and containers for dish storage were free of debris. This had the potential to affect 74 of the 74 residents who resided in the facility and consumed food prepared from the facility's kitchen. Findings include: During the initial kitchen tour observation on 10/30/23 at 10:58 AM, one of three plastic bins had dried brown residue on the outside. The Robo Coup (a food processor) had dried beige-colored residue on it. During an additional tour of the facility's kitchen on 11/2/23 at 8:15 AM, the following concerns were identified: In the refrigerator, there were 1 of 5 containers of small curd cottage cheese that were previously opened without an opened date, and 2 jars of condiments (1 jar of tartar sauce and 1 jar of Dijon mustard) with spillage on the outside. The Robo Coup machine had dried beige-colored splatter on the front face plate. The metal cart that housed the warming pans was…

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

Based on observation, review of the Food and Drug Administration (FDA) Food Code, and staff interview, it was determined the facility failed to ensure trash was contained in the facility's dumpsters with closed lids for two of three outside trash dumpsters. This created the potential for insect and pest infestation. Findings include: The FDA Food Code 2022 states: 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered .with tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. 6-501.114 Maintaining Premises, Unnecessary Items and Litter. The PREMISES shall be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as EQUIPMENT that is nonfunctional or no longer used; and (B) Litter. These guidelines were not followed. On 11/2/23 at 11:45 AM, the facility's dumpster area was observed. Two of three dumpsters had the lids open. One of the dumpsters had trash overflowing onto the ground surrounding the dumpsters. On 11/2/23 at 2:30 PM, the Dietary Manager…

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 policy review, facility document review, and staff interview, it was determined the facility failed to ensure the Quality Assessment and Assurance (QAA) committee took actions to identify and resolve systemic problems. This failure affected 74 of 74 residents residing in the facility. The deficient practice resulted in insufficient monitoring and resolution of resident grievances which had the potential to cause residents psychosocial harm and/or decreased quality of life. Findings include: The facility's Quality Assurance and Performance Improvement (QAPI) Plan policy, revised May 2023, documented the QAPI plan would identify and use data to monitor their performance. The policy documented some of the sources for collecting data would be abuse, neglect, and maltreatment reports, resident or family grievances, and resident council meeting minutes. The policy documented the QAA committee would review data on a quarterly basis and the administrator had responsibility and was accountable for ensuring QAPI was implemented. The facility's Grievance policy, revised 1/27/2023,…

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 infection control and prevention practices were maintained to provide a safe and sanitary environment when hand hygiene was not performed during cares and food preparation. This directly impacted 1 of 4 residents (Resident #42) observed during resident care and had the potential to impact the other 70 residents residing in the facility. These failures had the potential to place residents at risk for cross contamination and infection. Findings include: The CDC website, updated on 3/15/16, accessed on 11/8/23 at 10:38 AM, stated hand hygiene should be during the following times: - Before preparing or eating food - Before touching your eyes, nose, or mouth - Before and after changing wound dressings or bandages - After using the restroom - After blowing your nose, coughing, or sneezing - After touching surfaces such as bed rails, bedside tables, doorknobs, remote controls, or the phone 1. Resident #42 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure a resident was assessed periodically to determine if they were safe to self-administer medications for 1 of 1 resident (Resident #40) reviewed for self-administration of medications. This failure created the potential for adverse effects if Resident #40 self-administered medications inappropriately. Findings include: The facility's Self-Medication Assessment and Management policy, undated, stated the facility used the Self-Medication Data Collection and Assessment form to evaluate a resident's ability to self-medicate safely. The policy stated the assessment was completed with changes in condition and quarterly This policy was not followed. Resident #40 was admitted to the facility on [DATE], with multiple diagnoses including history of traumatic brain injury (brain dysfunction caused by an outside force) and cerebral ischemia (an acute brain injury that results from impaired blood flow 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, and staff interview, it was determined the facility failed to ensure residents' call lights were within reach for 2 of 2 residents (Resident #37 and #268) reviewed for residents' rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention. Findings include: The facility's Resident Call System policy, dated September 2022, documented the call light communication system must be accessible to residents while in their bed or within reach while in their room. 1. Resident #37 was admitted to the facility on [DATE], with multiple diagnoses including respiratory failure. Resident #37's care plan, initiated 11/5/19, documented his call light was to be within reach and to encourage him to use it for assistance as needed. Resident #37 was observed in his room, sitting in his wheelchair on the following dates with his call light not within his reach: - On 1/8/24…

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 policy review, record review, and staff interview, it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an Advance Directive. This was true for 1 of 21 residents (Resident #61) whose records were reviewed for advance directives. This deficient practice created the potential for harm or adverse outcomes if the residents' wishes were not followed or documented regarding their advance care planning. Findings include: The facility's Advance Directive policy, revised May 2023, documented the facility will determine upon admission whether the resident has an advance directive and review the advance directives annually, quarterly, with significant changes, and during care conferences with resident/representative. This policy was not followed. Resident #61 was admitted on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke with right sided weakness), and aphasia…

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, review of the State Survey Agency's Long-Term Care Reporting Portal, and staff interview, it was determined the facility failed to report the results of investigations of potential abuse to the State Survey Agency within 5 days for 2 of 2 residents (#16, and #42) whose records were reviewed for abuse and neglect. This failure placed all residents in the facility at risk for abuse. Findings include: The facility's Prevention and Reporting of Abuse, Neglect and Misappropriation policy, dated August 2022, stated the executive director or his designated representative will report investigation results to the State Survey Agency within 5 working days. This policy was not followed. The facility did not submit comprehensive investigation reports to the State Survey Agency within 5 working days, as follows: a. Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including chronic pain syndrome. A facility grievance, dated 5/25/23, documented Resident #16…

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 interview, it was determined the facility failed to ensure all pertinent health information was provided to the receiving hospital for 3 of 4 residents (#28, #43, and #368) reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if residents were not treated in a timely manner due to lack of information provided upon transfer. Findings include: The facility's Discharge policy, revised 5/18/23, stated the facility followed the federal guidelines as indicated by the Center for Medicare & Medicaid Services (CMS). 1. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and chronic respiratory failure with hypoxia (low oxygen level in the body tissues). A nurse's note, dated 7/14/23 at 3:54 AM, documented Resident #28 was transferred to the hospital due to abdominal pain and vomiting. A Nursing Home to Hospital Transfer Form, dated 7/14/23, documented Resident #28 was transferred 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents or their representatives upon transfer to the hospital. This was true for 1 of 3 residents (Resident #43) reviewed for transfer. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time. Findings include: The facility's Bed-Hold Notification policy, updated September 2022, stated at the time of transfer of a resident for hospitalization or therapeutic leave, the center must provide to the resident and the resident's representative written notice of the duration of a bed-hold. This policy was not followed. Resident #43 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke, and aphasia (an impairment of language…

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 refer 2 of 3 residents (#42 and #61), who were admitted with a Level I Preadmission Screening and Resident Review (PASARR), to the appropriate state-designated authority for review after the resident was identified with a Major Mental Illness (MMI). This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not provided due to lack of updated screening. Findings include: The CMS State Operation Manual, Appendix PP, revised 2/3/23, defines the PASARR process as follows: The PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders or intellectual disabilities and related conditions. This initial pre-screening is referred to as PASARR Level I, and is completed prior to admission to a nursing facility. A negative Level I screen permits admission to proceed and ends the PASARR process unless 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, and staff interview, it was determined the facility failed to ensure a baseline care plan was developed within 48 hours of resident's admission. This was true for 1 of 1 (Resident #370) reviewed for baseline care plan. This failure created the potential for harm when the care plan failed to provide direction for care. Findings include: The facility's Care Planning policy, revised 5/19/23, documented Initiate the Baseline CP [care plan] upon admission using the View Triggered Items button located in the care plan. Triggered items are generated from the initial admission assessment upon admission. Resident #370 was admitted to the facility on [DATE], with multiple diagnoses including COVID-19 and Rheumatoid arthritis (an inflammatory, autoimmune condition that can affect the joints and organs). Resident #370's Baseline Care Plan Summary, dated 1/6/24 at 7:58 AM, included the following section: Attendees: IDT (Interdisciplinary Team), 1. Nursing Department: resident had COVID.…

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 develop and implement comprehensive resident-centered care plans. This was true for 1 of 21 residents (Resident #61) whose care plans were reviewed. This failure created the potential for residents to receive inappropriate or inadequate care with a potential for subsequent decline in mental/physical overall health. Findings include: Resident #61 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) and aphasia (an impairment of language due to brain injury, affecting the production or comprehension of speech and the ability to read or write). a. An admission MDS assessment, dated 2/24/23, documented Resident #61 had an active diagnosis of paranoid schizophrenia and PTSD. Subsequent quarterly MDS assessments, dated 5/27/23 and 8/15/23, also documented Resident #61 had an active diagnosis of schizophrenia and PTSD.…

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 care plans were revised as needed with changes in resident status for 1 of 21 residents (Resident #37) whose care plans were reviewed. This deficient practice placed residents at risk for adverse outcomes if care and services were not provided appropriately due to a lack of information in the care plan. Findings include: Resident #37 was admitted to the facility on [DATE], with multiple diagnoses including benign prostatic hyperplasia (enlargement of the prostate). The care plan, dated 5/20/21, documented Resident #37 had an alteration in urinary elimination related to bladder dysfunction and an indwelling catheter. A physician order, dated 9/18/23, documented to discontinue the catheter for Resident #37. On 10/31/23 at 1:40 PM, Resident #37 was observed without a catheter. On 10/31/23 at 1:44 PM, LPN #2 stated Resident #37's catheter was removed. On 11/2/23 at 12:50 PM, LPN #3 stated Resident #37's care plan should 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident and staff interview, it was determined the facility failed to ensure residents were provided with baths or showers consistent with their needs and preferences. This was true for 3 of 21 residents (#42, #51, and #64) who were reviewed for ADLs. This failure created the potential for residents to experience embarrassment, isolation, decreased sense of self-worth, and/or skin impairment and dental concerns due to a lack of personal hygiene. Findings include: 1. Resident #51 was admitted to the facility on [DATE], with multiple diagnoses including fracture of the lower back and dementia. On 10/30/23 at 11:57 AM, Resident #51 stated he did not get to bathe as often as he would like. He stated he may get one shower a week if he is lucky. Resident #51 stated he would like to get at least two showers a week, maybe three. Resident #51's care plan, dated 3/13/23, did not include documentation of Resident #51's preferences related to showers. A bathing report, dated 10/1/23 to 10/31/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of nursing practice were followed for bowel care and wound assessment. This was true for 2 of 21 residents (#43 and #56) whose records were reviewed. These failures created the potential for harm if residents experienced adverse effects with subsequent decline in health. Findings include: The facility's Bowel and Bladder policy, undated, stated standard bowel care to relieve constipation (in the absence of a bowel obstruction) with a provider order may include the following: - Milk of Magnesia (MOM - laxative) 30 ml by mouth HS (at bedtime) after eight shifts of no bowel movement - Bisacodyl Suppository rectally if no results from the MOM - Fleets enema rectally if no results from the Bisacodyl Suppository Resident #43 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the…

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

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 catheter care was provided. This was true for 1 of 2 residents (Resident #66) reviewed for urinary catheters. This failed practice created the potential for residents to experience urinary tract infections (UTIs) due to lack of proper care. Findings include: The facility's Catheter Care policy, undated, directed staff to perform peri care using a washcloth, soap and water or a plain disposable wipe to clean the site and document the procedure. This policy was not followed. Resident #66 was admitted to the facility on [DATE], with multiple diagnoses including urinary tract infection. Resident #66's care plan, dated 10/17/23, documented Resident #66 required extensive assistance with toileting. The care plan also documented to clean her peri-area from front to back and check catheter for patency and integrity every shift. Resident #66's record did not include documentation catheter care was provided. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure adequate care and treatment was provided to 1 of 2 residents (Resident #63) reviewed for feeding tube use. This created the potential for harm if complications developed from improper tube feeding practices. Findings include: The facility's Enteral Tube policy, dated 12/22/22, directed staff to change the feeding tube syringe every 24 hours and change the feeding bag every 24 hours. This was not followed. Resident #63 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia (low oxygen on the body tissues), and stroke with hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting the left side. A physician's order, dated 6/2/23, directed staff to replace Resident #63's feeding syringe and tubing every 24 hours and as needed. On 10/30/23 at 12:45 PM, Resident #63 was observed receiving…

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 non-pharmacologic interventions were offered or provided prior to administering as needed opioid pain medication. This was true for 1 of 1 (Resident #28) reviewed for pain management. This failure placed Resident #28 at risk of ADL decline related to unrelieved pain, and not being offered effective pain management. Findings include: The facility's Pain Management Procedure, undated, directed staff to utilize non-pharmacologic interventions as applicable including, but not limited to: acupuncture, massage, music therapy, physical therapy, relaxation therapy, superficial heat or cold therapy, TENS (Transcutaneous electrical nerve stimulation), vibration therapy and visualization therapy. This was not followed. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and chronic respiratory failure with hypoxia (low oxygen level in the body tissues) and low back pain. Resident #28'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 policy review, record review, and staff interview, it was determined the facility failed to ensure a resident with mental disorders and history of trauma received appropriate treatment and services. This was true for 1 of 1 resident (Resident #61) reviewed for trauma-informed care. This failure created the potential for the resident to experience compromised physical and psychosocial well-being. Findings include: A facility policy Trauma Informed Care and Screening, revised 4/13/23, documented The center strives to identify residents who have had or been witness to traumatic experiences so they may receive culturally competent, trauma-informed care. This policy was not followed. Resident #61 was admitted to the facility on [DATE], with multiple diagnoses including paranoid schizophrenia (mental disorder causing a person to experience paranoia that feeds into delusions and hallucinations) and post-traumatic stress disorder (PTSD). A social service admission evaluation, dated 2/20/23, documented 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.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include: Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency Schedules II-V), and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. The facility's Controlled Medication Storage policy, dated January 2023, documented at each shift change a physical inventory was conducted by 2 licensed nurses or per state regulation and documented on the controlled substances accountability record. This policy was not followed. 1. On 11/1/23 at 12:05 PM, during a medication cart audit a substance accountability…

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 interview, it was determined the facility failed to ensure actions were taken to address drug regimen reviews and recommendations identified by the consulting pharmacist were acted upon for 1 of 5 residents (Resident #7) reviewed for medication administration. This failure put Resident #7 at risk to experience adverse effects from medications that were not administered as recommended. Findings include: The facility's Medication Regimen Review and Reporting policy, dated September 2018, documented a pharmacy will do a review to prevent, identify, report, and resolve medication-related problems. The findings are communicated to the director of nursing and medical director to ensure findings are reviewed and documented in the resident's chart. This policy was not followed. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including dementia and gastro-esophageal reflux disease (GERD - stomach acid or bile flows into the food pipe and…

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

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications were dated when opened and not expired. This was true for 2 of 2 medication storage rooms inspected. This failure created the potential for residents to receive expired medications with decreased efficacy. Findings include: On 11/1/23 at 11:57 AM, a vial of Tubersol (a clear, colorless solution used in the detection of infection with tuberculosis) was observed in the medication storage room on hall 200. The vial was not labeled with the date it was opened. LPN #1 stated there was no date of when it was opened on the vial or the box. She stated it should have been dated when it was opened, and it was good for 30 days after opening. On 11/3/23 at 12:17 PM, a bottle of Nepro feeding supplement (therapeutic nutrition to help meet the nutritional needs of people on dialysis) was observed in the medication storage room on hall 600 with an expiration date of 11/1/23. LPN #6 stated the Nepro was expired and should have been discarded.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure employees received training on abuse and neglect. This was true for 2 of 5 employees whose personnel records were reviewed. This failure had the potential for harm to all residents in the facility if an employee did not identify abuse and report accordingly. Findings include: The facility's Prevention and Reporting of Mistreatment, Abuse, Neglect policy, dated August 2022, stated training will be provided during orientation for newly hired employees and annually for all other employees. This policy was not followed. On 11/3/23 at 10:31 AM, during an employee record review it was identified LPN #1's record had no documentation of training on abuse and neglect. It was also identified CNA #4's record did not include documentation of training on abuse and neglect. On 11/3/23 at 11:45 AM, the ADON stated employees were trained prior to providing direct care and annually. She stated she was unaware CNA #4 had not received training on abuse and neglect since her hire date on 6/1/22.…

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

Based on record review and staff interview it was determined the facility failed to have an RN on duty for at least 8 consecutive hours a day. This was true for 11 of 28 days reviewed for RN coverage. This created the potential for harm if routine and/or emergency nursing services went unmet and had the potential to affect the 66 residents residing at the facility. Findings include: The facility provided the daily posted staffing hours for 9/18/23 to 10/16/23. The daily staffing hours documented there were no RNs on duty for 9/19/23, 9/22/23, 9/23/23, 9/24/23, 9/30/23, 10/1/23, 10/13/23, 10/14/23, 10/15/23, 10/16/23 and 5 hours on 10/7/23. On 10/17/23 at 9:24AM, the Administrator stated he was aware there were multiple days with no RN coverage in the facility. On 10/17/23 at 9:45AM, the Regional Director of Clinical Operations stated that there were 3 days per week that an RN was not scheduled, and the facility only had 1 RN staff nurse. The facility failed to ensure an RN was on duty 8 hours a day, seven days a week.