Bennett Hills Rehabilitation and Care Center

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 resident's rights to be free from abuse were protected. This was true for 1 of 1 resident (Resident #36) reviewed for abuse. This failure placed all residents at risk for ongoing abuse and potential physical and psychosocial harm. Findings include: The facility's Abuse: Prevention of and Prohibition Against policy revision date December 2023, documented it was the policy of the facility that each resident had the right to be free from abuse, neglect, misappropriate of resident property, exploitation, and mistreatment. Resident #36 was admitted to the facility on [DATE], with the multiple diagnoses including dementia and cognitive communication deficit. A facility reported incident dated 12/20/24 documented the following: - CNA #3 heard CNA #2 verbally abusing Resident #36. - CNA #3 immediately told CNA #2 to leave Resident #36's room. - The Administrator was notified and CNA #2 was suspended pending…

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 review of the State Operations Manual, Appendix PP, policy review, employee record review, and staff interview, it was determined the facility failed to ensure policies were implemented to protect residents from potential physical and/or psychosocial harm. This was true for 1 of 6 facility staff (NA #1), whose personnel files were reviewed for pre-employment background checks. This had the potential to place each of the residents residing in the facility at increased risk for physical and/or psychosocial harm. Findings include: The State Operations Manual, Appendix PP revised 8/8/24, documented, a facility must have written procedures for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property. The facility's Abuse: Prevention of and Prohibition Against policy revised December 2023, documented prior to hire, the facility will screen potential employees for history of abuse, neglect, exploitation, or misappropriation of resident property. On 6/13/24, NA #1 was hired by the facility. On 3/19/25, a review of NA #1'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 review of the State Operations Manual-Appendix PP, the Resident Assessment Instrument (RAI), record review, and staff interview, it was determined the facility failed to ensure a resident's diagnosed medical condition was documented on the resident's comprehensive MDS assessment. This was true for 1 of 7 residents, (Resident #9) whose MDS assessments were reviewed. This failure created the potential for harm if care decisions were based upon inaccurate or lack of information. Findings include: The State Operations Manual, Appendix PP, revised 8/8/24, documented a facility must make a comprehensive assessment using the RAI specified by CMS and include active disease diagnoses and health conditions. The RAI, revised October 2024, documented diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back…

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 nurse staffing information was accurate and posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include: The State Operation Manual, Appendix PP revised on 8/8/24, documented the facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. On 3/20/25 at 11:47 AM, a review of the posted nursing staff hours dated October 2024 - March 2025 was conducted with the following results. - On 10/18/24, the posted nurse staff hours was blank. - On 1/9/25, the…

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

Based on observation and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and stored appropriately, this was true for 2 of 2 medication carts audited for labeling and storage of medication. This failure created the potential for residents to have missed doses of medication. Findings include: On 3/19/25 at 8:05 AM, the East Hall medication cart was audited with CMA #1 present. Observed on the bottom of the third drawer; 1 oval shaped white tablet, 1 small round white tablet, 1 large oblong white tablet. On 3/19/25 at 8:13 AM, CMA #1 stated the pills should not have been loose in the medication cart. On 3/19/25 at 9:34 AM, the Skilled Hall medication cart was audited with LPN #1 present. Observed on the bottom of the third drawer; 2 small, round white pills. On 3/19/25 at 9:42 AM, LPN #1 stated the pills should not have been loose in the medication cart and should have been destroyed. On 3/19/25 at 2:20 PM, the DON stated the nurses or medication aides should have destroyed the loose pills.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of the Idaho Food Code, the facility failed to appropriately store and label food products, and cover meal trays correctly. This failure had the potential to impact all residents in the facility. This placed residents at risk for use of spoiled foods, and potential contamination, and adverse health outcomes including food-borne illnesses. Findings include: The Idaho Food Code, revised February 2021, stated, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded . 1. The following were related to labeling and storage of food products: On 3/17/25 at 9:51 AM, the following was observed in the dry food storage area, with the DS present: - Dry pasta, open date 10/9/24, should have been disposed on 3/9/25. - Barley dry food, use by date of 12/24. - Ragu pasta sauce use 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe, clean, homelike environment. This failure had the potential to impact all residents, by placing them at risk for injury and infections. Findings include: On 3/19/25 at 11:17 AM, observed in room [ROOM NUMBER] with CMA #1 present, the sharps container was filled past the full line. On 3/19/25 at 11:28 AM, CMA #1 stated the sharps container should have been changed when it was full. On 3/19/25 at 1:48 PM, observed with the DON present, overfilled sharps container with multiple used razors poking out of the opening, in the south hall shower room and fuzzy black mold-like substance on the shower tiles. On 3/19/25 at 1:53 PM, observed with the DON present, overfilled sharps container with multiple used razors poking out of the opening, in the north skilled hall shower room and fuzzy black mold-like substance by ceiling vent. On 3/19/25 at 3:18 PM, the Maintenance Supervisor stated he felt the black stuff on and next to the shower ceiling vent…

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 review of the job description for the Certified Dietary Manager (CDM) and staff interview, it was determined the facility failed to ensure there was a qualified Dietary Manager with required competencies and skills. This had the potential to affect the meal/food satisfaction of all 52 residents residing in the facility who received food from the kitchen. Findings include: The Dietary Supervisor (Dietary Manager) Job Description provided by the facility documented the individual was responsible for directing the overall operation of the dietary department. The DM was to ensure that quality nutritional services were provided, and the dietary department was maintained in a clean, safe, and sanitary manner. Education and experience requirements include a minimum of two years' experience in a supervisory capacity in a hospital, skilled nursing care facility or other related medical facility. The Job Description stated if the DM was not a qualified Dietitian or Nutritional Professional, the individual must be a Certified Dietary Manager (CDM), Certified Food Service Manager 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.

Based on observation, record review, policy review, and staff interview, the facility failed to ensure the dish machine was monitored adequately in accordance with the manufacturer's specifications for temperature and sanitizer concentration; sanitizing solutions for wiping kitchen surfaces and for pot washing were adequate in sanitizer concentration; and foods in the residents' refrigerator on the nursing unit were labeled and dated in the facility's kitchen. These deficiencies placed the 52 residents residing in the facility who received meals from the kitchen at risk for food borne illness. Findings include: The facility provided the undated Idaho Food Code, [Chapter 4], Idaho Department of Health & Welfare, Division of Public Health when the request for their kitchen sanitation policy was made. Review of the Idaho Food Code stated under 4-501 Warewashing [process of cleaning and sanitizing kitchen items] Machines, Manufacturers' Operating Instructions, A warewashing machine [commercial dishwasher] and its auxiliary components shall be operated in accordance with the machine'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.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure waste was properly contained with lids or otherwise covered. This created the potential for insect and pest infestation of the facility's premises and had the potential to adversely affect all 52 residents residing in the facility. Findings include: Review of the facility's Garbage and Rubbish Disposal policy, dated 10/2017, documented All garbage and rubbish containing food wastes shall be kept in containers . All containers shall be provided with tight fitting lids or covers and such containers must be kept covered when store or not in continuous use .Garbage and rubbish containing food wastes shall be stored so as to be inaccessible to vermin . Outside dumpsters provided by garbage pickup service must be kept closed . 1. During an observation on 5/13/24 at 11:25 AM, with the DM, there was a large dumpster that had two plastic lids, each covering half of the top of the dumpster. Both lids to the dumpster were open; the contents in the dumpster were exposed. There were no staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a safe, homelike environment. This was true for 2 of 3 shower rooms observed in the facility. This deficient practice created the potential for harm if: a) residents were injured due to unsafe areas in the facility and b) residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, or undignified. Findings include: The facility's Safe, Homelike Environment policy, dated October 2007, documented the facility would provide a safe, clean, comfortable, and homelike environment. The following areas were observed: - On 5/14/24 at 8:41 AM, the skilled hall shower room was observed with 8 missing floor tiles. The air vent on the ceiling had a dry, light gray substance, in the vent slats. The ceiling around the vent had a black substance around the vent. - On 5/14/24 at 8:46 AM, the skilled hall hallway, outside room [ROOM NUMBER] was observed…

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 interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans. This was true for 4 of 13 residents (#17, #24, #31, and #198) whose care plans were reviewed. These failures placed residents at risk of negative outcomes if services were not provided or provided incorrectly due to lack of information in their care plan. Findings include: The facility's Comprehensive Person-Centered Care Planning policy, revised 12/2023, documented the facility interdisciplinary team will develop and implement a comprehensive person-centered care plan for each resident and will include residents' needs identified in the comprehensive assessment and any specialized services. 1. Resident #17 was admitted to the facility on [DATE], with multiple diagnoses including amputation of her left leg above knee and spina bifida (a birth defect in which a developing baby ' s spinal cord fails to develop properly). A quarterly MDS…

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 1 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 and Reconciliation policy, revisied 12/2023, documented a reconciliation of all controlled medication is conducted by two licensed nurses and is documented on an audit record at each shift change. On 5/15/24 at 2:23 PM, during a medication cart audit, a narcotic accountability record was observed to have multiple blank…

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 staff interview, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 3 of 45 medications (6.67%) which affected 2 of 6 residents (#17 and #24) whose medication administration was observed. This failed practice placed residents at risk of not receiving their prescribed medication or dosage of their medication. Findings include: The facility's Administration of Medication policy, revised 1/2022, documented prior to administering the resident's medication, the nurse or medication technician should compare the drug and dosage schedule on the resident's MAR with the drug label. 1. Resident #17 was admitted to the facility on [DATE], with multiple diagnoses including amputation of her left leg above the knee and spina bifida (a birth defect in which a developing baby ' s spinal cord fails to develop properly). A physician order, dated 5/14/24, documented to administer to Resident #17 normal saline flush solution (a…

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

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents were provided nourishing, palatable, well-balanced meals that met their daily special dietary needs and specific preferences as documented on the residents' meal ticket. This was true for 5 of 14 residents (#2, #19, #25, #26, and #39) reviewed for food and nutrition services. This deficient practice created the potential for harm if residents experienced dissatisfaction, hunger and/or weight loss from not having complete meals served. Findings include: The facility's Food and Nutrition policy, dated 12/2023, documented, It is the policy of this facility to assure that menus are developed and prepared to meet the nutritional needs of the residents and resident choices . 'Reasonable effort' means assessing individual resident needs and preferences and demonstrating actions to meet those needs and preferences . a. The Resident Council meeting minutes, documented concerns with resident's meal selections as follows: - 8/11/24 meeting minutes -…

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

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to provide nutritionally comparable and sufficient alternate meals to residents. This was true for 5 of 14 residents (#2, #14, #19, #25 and #39) reviewed for food preferences. This created the potential for dissatisfaction, and decreased meal intake. Findings include: The facility's Food and Nutrition Menus policy, dated 12/2023, documented Menu alternatives aligned with individual needs and preferences should be available if the primary menu or immediate selections for a particular meal are not to the resident's liking . a. The Resident Council meeting minutes from 7/14/23 - 3/13/24, documented concerns with the provisions of alternate menu as follows: - 7/14/23 meeting minutes: one resident expressed a concern about dietary alternates. - 10/12/23 meeting minutes: wants to change around alternatives. - 2/14/24 meeting minutes: a request for salads to be included on the alternate list. - 3/13/24 documented: Several dietary preferences: concerns and several…

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

Based on observation, record review, and resident and staff interview, it was determined the facility failed to ensure to respect and maintain residents' dignity. This was true for 8 of 8 residents (#20, #27, #35, #36, #40, #41, #45 and #99) reviewed for respect and dignity who required assistance with their meals. This deficient practice created the potential for psychosocial harm if residents experienced embarrassment or lack of self-esteem. Findings include: The facility's admission Packet included the Resident Rights which stated, You have the right to be with respect and dignity. On 5/13/24 at 11:01 AM, the Dietary Manager (DM) stated lunch was served in the main dining room at 11:30 AM. The DM stated the feeders sitting at the horseshoe shaped table were served last. 1a. On 5/15/24 the following observations were made during breakfast in the dining room: - At 7:23 AM, four residents (Resident #35, Resident #45, Resident #40, and Resident #99) were brought into the dining room by staff and seated at the two horseshoe shaped tables in the dining room for residents who required…

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 facility grievances, and staff and resident interview, it was determined the facility failed to ensure grievances were responded to and investigated, and prompt corrective action was taken to resolve them. This was true for 1 of 1 resident (Resident #37) reviewed for grievances. This failure created the potential for psychological harm if residents' grievances were not acted upon. Findings include: The facility's Grievances policy and procedure, revised December 2023, documented the Grievance Official would evaluate and investigate the concern and takes immediate action to resolve the concern and prevent further potential violations of any resident's rights while the alleged violation was being investigated. The policy also documented the Grievance Official or designee would respond to the individual expressing the concern within 3 working days of the initial concern to acknowledge receipt and describe steps taken toward resolution. Resident #37 was admitted 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, policy review, record review, and staff interview, it was determined the facility failed to ensure a seatbelt used for a resident was assessed as a potential restraint. This was true for 1 of 1 resident (Resident #29) reviewed for restraints. This deficient practice had the potential for adverse outcomes if the seatbelt was improperly used and if the resident experienced physical deterioration due to lack of movement. Findings include: The facility's Physical Restraint Assessment policy, revised 8/2007, defined physical restraint as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body, that the resident cannot remove easily, and restricts freedom of movement or normal access to one's body site. The policy also documented residents would not have restraints applied until the IDT had made and documented an accurate and thorough assessment of the need for the restraint. Resident #29 was admitted to the facility on [DATE] and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review. and staff interview, it was determined the facility failed to ensure information was provided to the receiving hospital for 1 of 1 resident (Resident #9) reviewed for transfers. This deficient practice had the potential to cause harm if the resident was not treated in a timely manner due to lack of information. Findings include: The facility's Criteria for Transfer and Discharge policy and procedure, revised 12/2023 documented when the facility transferred or discharged a resident, the facility should ensure the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider. Information provided to the receiving provider must include a minimum of the following: - Contact information of the practitioner responsible for the care of the resident. -Resident's representative information including contact information. -Advance Directive information - All special instructions…

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 transfer notices were provided to the ombudsman. This was true for 1 of 1 resident (Resident #9) reviewed for transfers to the hospital. This deficient practice had the potential for harm if residents were not aware of or able to exercise their rights related to transfers. Findings include: Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including depression, congestive heart failure (weakness of the heart leading to a buildup of fluid in the body) and dysphagia (difficulty swallowing). A nursing note, dated 3/10/24 at 1:47 PM, documented the physician and Resident #9's representative were notified that she was in pain and her pulse rate was greater than 100 beats /minute. An order was received to continue her pain management and blood pressure. A nursing note, dated 3/11/24 at 6:13 PM, documented Resident #9's condition continued to decline and the provider was notified. Resident #9'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, policy review, and resident and staff interview, it was determined the facility failed to ensure professional standards of nursing practice were followed for 3 of 13 residents (#31, #37, and #43) reviewed for quality of care. Resident # 31 was at risk of wound infection when his wound dressing was not dated. Resident #37 was at risk for adverse outcomes when his physician was not notified of Resident #37's refusal of medication. Resident #43 was at risk of adverse outcomes when his physician was not notified of hyperglycemic (low blood sugar) episodes. Findings include: The Lippincott Nursing Procedures textbook, dated 2018, section for Medication Administration - Dressing a Wound, documented dressings were to be labeled with the date, time, and initials. 1. Resident #31 was admitted to the facility on [DATE], with multiple diagnosis including subdural hemorrhage (a pool of blood between the brain and its outermost covering) and Type 2 diabetes. A physician's order, dated…

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 resident and staff interview, it was determined the facility failed to ensure residents received oxygen therapy per physician's orders. This was true for 1 of 14 residents (Resident #16) reviewed for oxygen therapy. This failure created the potential for Resident #16 to experience respiratory distress for not receiving the sufficient amount of oxygen to maintain oxygen levels. Findings include: The facility's Oxygen Administration policy, dated 9/2023, documented It is the policy of this facility that oxygen therapy is administered, as ordered by the physician . The purpose of the oxygen therapy is to provide sufficient oxygen via wall outlet or oxygen concentrator . Oxygen per MD [Medical Doctor]/NP [Nurse Practitioner] orders . Reassess oxygen flowmeter for correct liter flow . Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (COPD - progressive lung disease characterized 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled and had not expired. This was true for 2 of 2 medication storage rooms inspected. This failure created the potential for residents to receive medication used for another resident presenting a risk for cross-contamination or to receive expired medications with decreased efficacy. Findings include: 1. On 5/15/24 at 1:43 PM, during a medication cart audit of the Skilled Hall medication cart, a bottle of Top Care eye drops (Lubricating eye drops) with an expiration date of 3/2024, was observed. On 5/15/24, RN #1 stated the eye drops were expired and should have been removed from the medication cart. 2. On 5/15/24 at 2:33 PM, during a medication cart audit of the East Hall medication cart, the following was observed: - A package of Loperamide (anti-diarrheal) 2 mg, 34 capsules, with an expiration date of 2/23/23. - An Albuterol Sulfate inhaler (medication used to help relax…

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, the facility failed to ensure 1 of 2 residents (Resident #6) reviewed for dialysis had an accurate medical record to include documentation of the dates she failed to attend dialysis. This deficient practice created the potential for her healthcare provider to be unaware of the extent of her non-compliance. Findings include: The facility's Content of Medical Record policy, dated 8/2020, stated All physicians, nursing staff and other health care professionals involved in the resident's care will be responsible for making prompt, appropriate entries in the record . Resident #6 was admitted to the facility on [DATE], with diagnosis of end stage renal disease with dependence on renal dialysis. A physician order, dated 8/8/23, documented Resident #6 had hemodialysis 3 times a week every Tuesday, Thursday and Saturday. Resident #6's Dialysis Flow Sheets from 3/1/24 through 5/15/24, showed 12 Dialysis Flow Sheets were missing during this period, on 3/2/24,…

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, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all 52 residents residing in the facility by placing them at risk for cross contamination and infection. Findings include: The facility's Standard and Transmission-Based Precautions policy, revised 4/2024, documented it was the policy of the facility to implement infection control measures to prevent the spread of communicable diseases and conditions. The policy further stated: - Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE [personal protective equipment] through the use of gown and glove during high-contact resident care activities that provide opportunities for indirect transfer of MDROs [Multidrug Resistant Organisms] to staff hands and clothing then indirectly transferred to residents or from…

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 who were offered and consented to the pneumococcal vaccine, received the vaccine. This was true for 1 of 5 residents (Resident #17) whose records were reviewed for pneumococcal vaccinations. This failure created the potential for residents to have an increased risk of pneumococcal (bacterial) pneumonia and the potential for severe illness or death. Findings include: The facility's Immunization - Residents policy, revised 12/2023, documented each resident was offered the pneumococcal immunization based on current CDC guidelines, unless the immunization was medically contraindicated, or the resident had already been immunized. There were two types of Pneumococcal vaccines available for adults: Pneumococcal conjugate vaccines (PCV15 and PCV20) and Pneumococcal Polyssacharide Vaccine (PPSV23). The Centers for Disease Control and Prevention (CDC) website, dated 3/15/23, and accessed on 5/21/24,…

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.