Gateway Transitional Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders without errors for 1 of 6 residents (Resident #68) observed to receive medication during the survey. This had the potential to affect the resident's health if she did not receive the medications that were ordered. This resulted in a facility medication error rate of 6.9%. Resident #68 was admitted to the facility on [DATE], with multiple diagnoses including fractured left humerus (long bone in the upper arm) and diabetes.Resident #68's physician order dated 6/13/25, documented Cranberry Oral Tablet. Give 500 mg by mouth one time a day for supplement.Resident #68's physician order dated 6/13/25, documented Multivitamin Oral Tablet. Give 1 tablet by mouth one time a day for supplement.On 7/23/25 at 9:25 AM, observed LPN #6 administer Cranberry oral 450mg tablet and Multi-vit with minerals to Resident #68.On 7/23/25 at 9:36 AM, LPN #6 stated the Cranberry tablet 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, policy review, and staff interview, it was determined the facility failed to ensure stored medications had not passed their expiration date and ensure medication carts were kept locked when not attended by authorized staff in an area where residents could access it. These failed practices affected a) 1 of 3 medication storage rooms creating the potential for residents to receive expired medications with decreased efficacy and b) 1 of 4 medication carts which had the potential for residents to gain access and ingest medications that can cause significant adverse outcomes. Findings include:The facility’s Pharmacy Services Drug Storage policy dated 10/24, documented medication and treatment carts will be kept locked when unattended. On 7/21/25 at 11:00 AM, observed the Hall-B medication cart had been left unlocked and unattended. On 7/21/25 at 11:08 AM, LPN #1 stated the Hall-B medication cart had been left unlocked when unattended and should not have been. On 7/23/25 at 10:55 AM, the DON stated medication carts should not be left unlocked when unattended and had…

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, interview, policy review, and review of the Idaho Food Code, the facility failed to ensure food items were dated, labeled, and stored at a safe temperature. These deficient practices had the potential to impact all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include:The FDA Food Code Section 3-501.17 stated, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, states refrigerated, ready-to-eat, time/temperature control for safety food prepared and 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. Review of the facility's Foods Brought by Family or Visitor policy revision date January 2019, documented food items should be labeled with date it was prepared, if known, and 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, interview, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility. Findings include:U.S. Food and Drug Administration 2022 Food Code, 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled.On 7/21/25 at 8:18 AM, observed in the kitchen, next to the freezers a garbage can with a hole in the lid.On 7/21/25 at 8:21 AM, the DS #1 stated she was unaware the garbage can should have had a solid lid on it.On 7/23/25 at 3:05 PM, the ED stated the garbage can should have had a solid lid and did not.

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 and prevention practices were maintained to provide a safe and sanitary environment when staff did not store oxygen supplies in a sanitary manner. This was true for 4 of 9 Residents (#5, #47, #72, and #84). These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: 1. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including fracture right humerus (long bone in the upper arm) and COPD (a group of lung diseases that block airflow and make it difficult to breathe). On 7/21/25 at 9:07 AM, observed Resident #5's nasal cannula draped on bedside table without a cover. 2. Resident #47 was admitted to the facility on [DATE], with multiple diagnoses including spina bifida (a birth defect in which an area of the spinal column does not form properly, leaving a section 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.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure the kitchen was maintained in a sanitary manner when sanitizer solutions were had inadequate strength, rust was observed on the inside of the ice machine, and the dishwashing area contained caulking that was peeling off with food particles entrapped creating a surface that was uncleanable on the stainless counter. These deficiencies had the potential to affect all 76 residents residing in the facility 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: 1. The initial kitchen inspection was conducted on7/8/24 from 9:45 AM through 10:28 AM with the DS. The following was observed: a. The stainless-steel counter where the dish machine sprayer hose was located was observed with a brown and black rubbery substance (caulking) partially adhered to two pipes coming up through the stainless counter and was also partially adhered to the stainless counter…

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, record review, and staff interview, the facility failed to ensure the required nursing staff posting accurately reflected the actual staff hours to care for the 76 current residents and failed to ensure the posting included an updated census for each shift. This failure had the potential to inaccurately inform any resident, family member, or visitor to the facility of the available nursing staff caring for residents. Findings include: On 7/9/24 at 3:05 PM, a posted nurse staffing was not observed in the R and D/C hall Nurse's Stations. There were white boards located at or near the nurse's stations with staff assignments for the halls. On 7/9/24 at 3:15 PM, the DNS showed the nursing staff posting for 7/8/24 and 7/9/35 on the wall across from the A/B Nurse's Station. The postings included the date, the number of CNAs, RNs, and LPNs, and the anticipated hours to be worked. The nursing staff posting did not include the actual number of hours worked for each nursing staff category or the updated census to account for any admissions, discharges, 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 record review, policy 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 2 of 2 residents (#10 and #24) reviewed for transfers. 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 policy, dated 12/2023, states It is the policy of this facility to inform the resident or resident's representative in writing of the right to exercise the bed hold provision of 7 days upon admission and provide a second notice before transfer to a general acute care hospital or before the resident goes on therapeutic leave. In the event of an emergency transfer, the second notice will be provided within 24 hours. A copy of this notification shall become a part of the resident's health record at the time of transfer. 1.…

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, the facility failed to ensure residents' Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 19 residents (Resident #39) reviewed for accuracy of MDS assessments. This deficiency created the potential for residents to not have their care needs met due to inaccurate assessments. Findings include: Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, and hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a stroke. a. During an interview with Resident #39 on 7/8/24 at 11:15 AM, in response to the question if he had any issues with his teeth, gums, or dentures, Resident #39 stated he did not have teeth and wanted dentures. A Nutrition - admission Evaluation, dated 2/20/20, documented Resident #39 was edentulous (lacking teeth) of both the upper and lower jaws. Annal MDS assessments dated 7/20/23, and 4/20/24, and a significant change of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 4 residents (Resident #33) reviewed for quality of care. This created the potential for Resident #33 to have decreased caloric intake and weight loss when physician's orders were not followed to provide a specific dietary supplement. Findings include: Resident #33 was admitted to the facility on [DATE] with multiple diagnoses including dementia, adult failure to thrive, and dysphagia (impaired swallowing) after a stroke. A quarterly MDS assessment, dated 6/13/24, documented Resident #33 was 61 inches tall (5 feet, 1 inch) tall and weighed 85 pounds. The assessment documented Resident #33 experienced a significant unplanned weight loss. The assessment further documented Resident #33 was severely cognitively impaired. A Weight Summary, dated 9/30/22 - 7/9/24, documented on 7/2/24 Resident #33 weighed 83.6 pounds and had a body mass index (BMI) of 16.4…

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, facility fall reports, observation, and staff interview, the facility failed to ensure residents were adequately supervised and had interventions in place to prevent falls. This was true for 2 of 6 residents (#22 and #67) reviewed for falls. The failure to implement adequate supervision and interventions created the potential for Resident #22 and Resident #67 to sustain significant injuries from falls. Findings include: The facility's Fall Prevention/Investigation and Falling Star policy, dated January 2024, documented, it was the facility's policy to prevent falls and investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury. The policy documented if the resident sustained a fall, an Incident Report was completed by the nurse which included: - A brief description of the fall by staff and by the resident. - Identification of medications, environmental conditions, equipment…

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 a resident received oxygen therapy per physician's orders. This was true for 1 of 1 resident (Resident #39) reviewed for oxygen therapy. This failure created the potential for Resident #14 to experience hyperoxia (cells, tissues, and organs are exposed to an excess supply of oxygen. Findings include: The facility's policy, Oxygen Administration, revised 1/2024, stated it was the policy of the facility that oxygen therapy is administered as ordered by the physician or as an emergency measure until the order can be obtained. The policy documented the procedure as follows: - Oxygen per MD/NP [Medical Doctor/Nurse Practitioner] orders - Reassess oxygen flowmeter for correct liter flow. Instructions for Tubing and Humidifier Changes: - Oxygen tubing is to be replaced every seven (7) days. Oxygen masks or nasal prongs are to be replaced every seven (7) days. - Humidifiers are not required if flow of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, observation, and staff interview, it was determined the facility failed to ensure that prior to the placement of bed rails, alternatives to bed rails were attempted and individual residents were thoroughly assessed for the risk of entrapment. This was true for 1 of 2 residents (Resident #31) reviewed for bed rails. This failure created the potential for harm due to the risk for injury, entrapment and/or death 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: The facility's policy, Bed Rails, revised 1/2022, stated it was the policy of the facility to attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail was used, the facility must ensure correct installation, use, and maintenance of bed rails. The policy documented after the facility attempted alternatives to bed rails and determined the alternatives failed to meet 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, the facility failed to ensure the medical necessity of psychotropic medication administration. This was true for 1 of 6 residents (Resident #7) reviewed for psychotropic medication administration. This failure created the potential for Resident #7 to experience negative side effects related to receiving more psychotropic medication than necessary. Findings include: The facility's Psychotropic Medications Policy, revised 12/2023 stated, Residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contradicted, in an effort to discontinue these drugs. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including paraplegia (the inability to voluntarily move the lower parts of the body), anxiety disorder, insomnia, and depression. A quarterly MDS assessment, documented Resident #7 was cognitively intact. The assessment documented Resident #7 was receiving antipsychotic,…

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 available for residents were labeled and had not expired. This was true for 2 of 5 insulin pends in a medication cart. This failure created the potential for insulin pens to be used for different residents presenting a risk for cross-contamination or to receive expired medications with decreased efficacy for blood glucose levels. Findings include: The facility's policy titled Labeling of Medications and Biologicals, revised 5/2020 stated t was the policy of the facility that medications and biologicals were labeled in accordance with facility requirements, state, and federal laws. The policy stated, Only the provider and pharmacy modifies or changes prescription labels. The policy stated the procedure was as follows: Each prescription medication label includes at the minimum: - Resident's name. - Medication name -Prescribed dose and strength of medication - Expiration date - Route of administration - Specific Directions or Instructions for use, as applicable - For…

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, observation, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was true for 3 of 19 residents (#10, #163, and #182) observed for infection control. These failures put residents at risk for cross contamination and infection. Findings include: 1. Resident #10 was admitted to the facility on [DATE], with multiple with diagnoses including Chronic Obstructive Pulmonary Disease (COPD - a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). A quarterly MDS assessment, dated 4/29/24, documented Resident #10 was moderately cognitively impaired. The assessment further documented he was receiving continuous oxygen therapy. A physician order, dated 4/10/24, documented Resident #10 was to receive Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg per 3ml via nebulizer every six hours for shortness of breath 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 observation, record review, policy review, and staff interview, it was determined the facility failed to ensure beds and bed rails were inspected and maintained as part of an ongoing program. This was true for 2 of 6 residents (#10 and #22) reviewed for bed rails. This failure created the potential for injury or harm if a resident was to become entrapped by unmonitored equipment. Findings include: The facility's Bed Rails policy, revised 1/2022, stated it is the policy of the facility to attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails. Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail. The policy stated when installing and using bed rails, the facility shall install bed rails using the manufacturer's instructions to ensure a proper fit and safe spacing. It further stated regardless of mattress…

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 a) date items in the freezer and refrigerator, b) ensure staff contained all hair with a hair net, c) ensure infection control practices were implemented when gathering ice to be used to keep foods cool and d) clean and maintain the kitchen floor. These deficient practices placed 18 of 18 sample residents (#1, #2, #11, #22, #23, #26, #27, #36, #42, #43, #44, #62, #65, #67, #71, #76, #228, and #229) who dined in the facility, and the other 61 residents who dined in the facility, at risk food borne illness or other disease-causing pathogens. Findings include: The facility's food labeling and dating policy, dated 2017, directed staff to date food upon receipt before being stored. The policy also documented food moved from the freezer to the refrigerator for thawing was to be labeled with the removal date and a use by date. The facility's Staff Attire policy, dated 9/2017, directed staff members to have their hair off the shoulders and confined in a hair net or cap. On 4/8/19 from 4:00 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 Resident Council meeting minutes, Resident Group interview, policy review, and staff interview, it was determined the facility failed to address Resident Council concerns. This was true for 8 of 8 residents (#3, #8, #17, #26, #36, #45, #60, and #64) who participated in the Resident Group interview. The deficient practice had the potential to cause psychosocial harm for residents frustrated by the perception their concerns were not valued or addressed by the facility. Findings include: The facility's Grievance policy, revised on 1/2018, documented the facility would make prompt efforts to resolve grievances, including Resident Council concerns, and to keep residents notified of progress toward resolution. Resident Council minutes, dated 2/28/19, documented complaints of cold meals and coffee, and long wait times for response to call lights. Resident Council minutes, dated 3/28/19, documented the residents wanted follow through with the issues they talked about in the meetings and still wanted hot coffee. The facility did not document what actions were taken to resolve 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, review of Resident Council minutes, resident interview, Resident Group interview, test tray evaluation, and staff interview, it was determined the facility failed to ensure palatable food was served. This was true for 15 of 18 residents (#1, #3, #8, #17, #20, #26, #27, #36, #38, #41, #45, #53, #54, #60, and #64) reviewed for food and nutrition. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being. Findings include: The facility's Food Quality and Palatability policy, revised 9/2017, documented food will be palatable and served at an appetizing temperature. Resident Council minutes, dated 2/28/19, documented complaints of cold meals and coffee. Resident Council minutes, dated 3/28/19, documented the residents wanted follow through with the issues they talked about in the meetings and still wanted hot coffee. The facility did not document what actions were taken to resolve the concerns identified at the 2/28/19 meeting. On 4/10/19 at 10:10 AM, during the Resident Group interview,…

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 implement appropriate infection control practices when assisting residents during dining and after a Hoyer lift transfer of a resident on contact precautions. This was true for 2 of 6 residents (#33 and #42) observed in the assisted dining room and 1 of 4 residents (Resident #16) in contact precaution rooms. These deficient practices created the potential for harm by exposing residents to the risk of infection and cross contamination. Findings include: The facility's Infection Control policy, dated 9/29/17, directed staff to disinfect equipment after each use for residents in contact precaution rooms. 1. Resident #16 was admitted to the facility on [DATE]. Resident #16's record included a physician's order, dated 3/28/19, which documented she was to be on contact precautions due to a Vancomycin-resistant Enterococci (specific types of antimicrobial-resistant bacteria that are resistant to Vancomycin,…

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, resident, resident representative, and staff interview, it was determined the facility failed to document, investigate, and report complaints expressed by 1 of 19 residents (Resident #227) whose complaints were reviewed. This failure created the potential for harm if residents' verbal grievances were not acted upon and residents did not receive appropriate care or were at risk for abuse or neglect. Findings include: The facility's Grievance Policy, dated 1/2018, documented residents had the right to file a grievance orally or in writing and the right to obtain a review in writing; and when a grievance was voiced to a staff member a grievance form would be completed and the grievance would be evaluated and investigated. The facility's Grievance file did not include a grievance for Resident #227. On 4/10/19 at 9:56 AM, Resident #227 and his representative stated they reported incidents to the facility staff, as well as other concerns that were medical in nature, as follows: - A nurse answered the call light and said she could not help 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 record review, policy review, resident interview, and staff interview, it was determined the facility failed to ensure residents' care plans were revised as needed. This was true for 1 of 21 residents (Resident #67) whose care plans were reviewed. This failure had the potential for harm if cares and/or services were not provided due to inaccurate information. Findings include: The facility's Care Planning policy, undated, directed staff to develop a comprehensive care plan for each resident and care plans were to be updated quarterly and as needed. Resident #67 was readmitted to the facility on [DATE], with multiple diagnoses including depression, anxiety, generalized muscle weakness, and reduced mobility. a. Resident #67's quarterly MDS assessment, dated 3/21/19, documented she required the assistance of two staff with toilet use and transfers, and the assistance of one person with eating. Resident #67's care plan documented she required one-person assist with toilet use and transfers. The care plan…

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 and resident interview, it was determined the facility failed to ensure residents were offered the pneumococcal vaccine and information and education consistent with current Centers for Disease Control and Prevention recommendations. This was true for 1 of 7 residents (Resident #23) reviewed for pneumococcal immunizations. This failure created the potential for harm to residents should they acquire, transmit, or experience complications from pneumococcal pneumonia. Findings include: The Centers for Disease Control and Prevention (CDC) website, updated 11/22/16, documented recommendations for Pneumococcal vaccination (PCV 13 or Prevnar13®, and PPSV 23 or Pneumovax23®) for all adults 65 years or older: * Adults 65 years or older who have not previously received PCV 13, should receive a dose of PCV 13 first, followed 1 year later by a dose of PPSV 23. *If the patient already received one or more doses of PPSV 23, the dose of PCV 13 should be given at least 1 year…

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.