Beecher Manor Nrsg & Rehab Ctr

Based on observation, interview, and record review, the facility failed to provide an ambulatory resident with continuous oxygen (a portable oxygen tank holder). This applies to 1 of 1 residents (R76) reviewed for oxygen in a sample of 37. Findings include: On 8/27/24 at 10:52 AM, R76 was observed lying in bed wearing 4 liters of oxygen per nasal cannula. R76 said 4 liters was her baseline oxygen setting and what she was wearing at home before coming to facility. R76 said she is able to walk to the bathroom by herself, but she does not have a way to bring the oxygen with her to the bathroom. R76 said she has a portable oxygen tank holder on the back of her wheelchair, but her wheelchair is bariatric and is too wide to fit into the bathroom. R76 said when she has a bowel movement she requires staff assistance to help wipe and it can take them a long time to come and help her in the bathroom. R76 said she feels short of breath after a few minutes without her oxygen on while bearing down for a bowel movement, while waiting for staff assistance, and while pulling her pants up. 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.

Based on interview and record review the facility failed to maintain current and accurate advanced directives for 2 residents (R69, R115) in a sample of 37. Findings include: On 08/28/24 at 02:03 PM until 02:09 PM, the state surveyor and V2 DON (Director of Nursing) were conducting a record review for R69 and R115. 1. R69's electronic health record showed 6/21/24 Full Code Status POLST (Physician Orders for Life Sustaining Treatment) Declaration form, and the Advance Directive book at the nurses' station showed R69's 2/23/21 DNR (Do Not Resuscitate) form. 2. R115's electronic health record showed a 5/11/24 DNR form and in the Advance Directive book it showed R115's 2/16/24 Full Code form. On 08/28/24 02:13 PM V2 (DON) V2 said that both the Advance Directive book and the electronic health record should be the same because if they are not the facility may not give the right life sustaining measures that the person wants. The facility's Advance Directive policy dated November 2016 showed that copies of written advance directives documents will be filed uploaded in the residence…

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, and record review, the facility confined a resident to her bed by placing interconnected bed bolsters on both sides of the bed and two upper side rails up. This applies to 1 of 1 resident (R81) reviewed for physical restraint in a sample of 37. The findings include: R81 is a [AGE] year-old female with moderate cognitive impairment as per the Minimum Data Set, dated [DATE]. On 8/29/24 at 9:45 AM, during wound care with V3 (Assistant Director of Nursing) and V16 (wound care nurse), R81 was observed with a wedge to her right upper body with both upper side rails up and two Bolsters to the bottom of bed inter-connected with a strap. On 8/29/24 at 9:45 AM, V3 (Assistant Director of Nursing / ADON) stated, Those bolsters are inter-connected with a strap restricting her to get out of bed. It can be a restraint if we don't have a physician order. We put it there to prevent her fall. R81's care plan does not indicate any use of bed bolsters planned for resident care (falls). R81'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 record review and interview the facility failed to provide written notice of the facility's bed hold policy to 1 resident (R69) or representative before being transferred to the hospital in a sample of 37. Findings include: On 08/28/24 at 11:46 AM a review of R69's electronic health record showed that on 8/6/24 R69 was sent to the hospital for labored breathing, oxygen saturation at 86% while on 2 liters of oxygen, a blood pressure of 100/46, and a heart rate of 143. The record review did not show any documentation that R69, or his representative, received a copy of the facility's bed hold policy. On 8/29/24 02:14 PM, V2 DON (Director of Nursing) said that the facility did not have any documentation showing that the resident or representative received the facility's bed hold policy. On 8/29/24 at 4:06 PM, V2 DON said that it is her expectations that the facility staff provide the resident or the resident's representative, the facility's bed hold policy when they are being transferred to the hospital.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the physician's order to provide wound care. This applies to 1 of 3 residents (R1) reviewed for wound treatment and care in a sample of 37. The Findings include: R1 is an [AGE] year-old female with mild cognitive impairment as per the minimum data set (MDS) dated [DATE]. On 8/29/24 at 10:01 AM, V16 (Wound Care Nurse) and V3 (Assistant Director of Nursing) provided wound care to R1. V16 removed the old dressing from the right hip wound and observed no hydrofera blue (thick blue pad to absorb exudate/drainage from the wound). V16 then cleansed the right hip wound with saline, pat dry it, and applied Hydrofera blue with a gauze dressing. On 8/29/24 at 10:10 AM, V16 removed the old dressing from the right hip superior wound and observed no hydrofera blue (thick blue pad to absorb exudate/drainage from the wound). On 8/29/24 at 10:10 AM, in response to the surveyor's inquiry, V16 stated that she changed R1's wound dressing yesterday 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, interview and record review the facility failed to provide restorative care services. This applies to 2 of 2 residents (R65 and R74) reviewed for rehab services in a sample of 37. Findings include: 1. R65 admitted to the facility on [DATE] with diagnoses that includes cerebral infarction, dysarthria, weakness, aphasia, Alzheimer's, foot drop, basal cell carcinoma, and left artificial knee joint. R65 MDS (Minimum Data Set) dated 7/15/24 shows she is cognitively impaired and dependent on staff for all care needs. R65 current care plan includes nursing rehab PROM (Passive Range of Motion) to right hand with 3 sets 4 reps 6-7 days a week as tolerated. Restorative program to apply right wrist splint apply upon rising remove at night. Review of R65's restorative care documentation for August 2024 shows she received PROM 18 times August 1st through August 29th. R65's right hand splint was placed 17 times August 1st through August 29th. On 8/27/24 at 12:44 PM, R65 did not have a splint on her hand.…

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, and record review, the facility failed to label, date, and discard old food and beverages from resident's personal refrigerators. This applies to 2 of 2 residents (R34 and R49) in the sample of 37. The findings include: 1. On 08/27/24 at 10:52 AM R34's personal refrigerator in her room had nine soft, and old individual ice cream sandwiches in the freezer. The ice cream sandwiches did not have an opened or expiration date. R34 said it's been a long time since I ate one. R34 stated the staff assists her with cleaning out the refrigerator. On 08/28/24 at 1:43 PM the individual ice cream sandwiches remained in the freezer. On 08/28/24 at 1:46 PM V13 (Housekeeper) stated she cleans the resident's refrigerators out. V13 said she did not know R34 had old ice cream sandwiches. V13 said old, soft ice cream should not be in the refrigerator. R34 could get sick if she eats it. On 08/29/24 at 9:37 AM V2 (Director of Nursing) said all residents food in the personal refrigerators should…

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 interview and record review, the facility failed to report an alleged accusation of misappropriation of resident narcotics. This applies to 10 of 10 residents (R1-R10) reviewed for misappropriation of property in the sample of 10. The findings include: R1-R10 were on narcotics and resided in zones that V3 RN (Registered Nurse) was scheduled to work per facility nursing assignment sheets. On 10/10/23 at 9:33 AM, and 1:40 PM, V2 (Director of Nursing) stated that during suspension of an employee (V6 Certified Nurses Assistant) related to an altercation that occurred involving her and two other Registered Nurses (V3 and V5). V6 stated V3 was taking narcotics from the carts. V2 stated that the altercation had occurred during overnight shift from 10/03/23 to 10/04/23 at 1:30 AM. V2 stated an investigation [for misappropriation of property] was initiated on 10/04/23 when the suspension occurred [for inappropriate staff behavior]. V2 added that a narcotic count of residents was done and residents on PM narcotics were interviewed and no issues were found. V2 stated documentation 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.

Based on interview and record review, the facility failed to have evidence of a thorough investigation regarding allegation of misappropriation of resident narcotics. This applies to 10 of 10 residents (R1-R10) reviewed for misappropriation of property in the sample of 10. The findings include: R1-R10 were on narcotics and resided in Zones that V3 RN (Registered Nurse) was scheduled to work per facility nursing assignment sheets. On 10/10/23 at 9:33 AM, and 1:40 PM V2 (Director of Nursing) stated that during suspension of an employee (V6 Certified Nurses Assistant) related to an altercation that occurred involving her and two other Registered Nurses (V3 and V5), V6 stated that V3 was taking narcotics from the carts. V2 stated that the altercation had occurred during overnight shift from 10/03/23 to 10/04/23 at 1:30 AM. V2 stated that an investigation [for misappropriation of property] was initiated that same morning when the suspension occurred [for inappropriate staff behavior]. V2 added that a narcotic count of residents was done and residents on PM narcotics were interviewed 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, interview, and record review, the facility failed to ensure a wound dressing was in place for a resident with a stage 4 pressure ulcer. This applies to 1 out of 3 residents (R2) reviewed for pressure wounds in a sample of 3. Findings include: On 9/29/23 at 2:28 PM, surveyor observed R2's sacral pressure wound with V3 (Wound Nurse). V3 stated R2's sacral wound is a stage 4 wound. When V3 opened R2's incontinence brief to visualize the dressing, the brief was soaked with urine and feces. No dressing was in place on her sacral wound. On 9/29/23 at 2:30 PM, V3 verified the dressing had come off and stated no one notified her to replace it. In R2's 9/27/23 Wound Evaluation and Management Summary, the Site 1 Focused Wound Exam showed a full thickness stage 4 pressure wound of the sacrum with duration of more than 207 days, with an objective to manage the moderate serous exudate. The Summary lists wound size in cm (centimeters) as 4 cm long x 3.5 cm wide x 1 cm deep. The Summary also lists wound undermining of 2.5 cm.at 9 o'clock. Primary dressing Alginate calcium…

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 interview and record review, the facility failed to ensure the Infection Preventionist (IP) has the required professional training to perform the role. This failure has the potential to affect all 114 residents residing in the facility. Findings include: Resident Census and Condition of Residents report dated 7/17/23 documents a total of 114 residents residing in the facility. On 7/18/23 at 12:41 PM, V6 (Infection Preventionist) stated, I do not have a degree. I took the class through the CDC (Centers for Disease Control and Prevention). On 7/18/23 at 2:16 PM, V1 (Administrator) stated corporate told her (V1) the IP did not need a degree as long as the training was completed. V1 affirmed V6 does not have any training in nursing or any health-related fields. V1 also added V6 did have a degree. On 7/19/23 at 10:17 AM, V6's personnel file showed V6 does not have any professional training and/or degrees other than a certificate from a Nursing Home Infection Preventionist Training Course dated 7/18/22 among other basic training certificates. The file showed V6 was previously…

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 and record review, the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 7 of 7 residents (R3, R23, R40, R50, R57, R89, R110) reviewed for ADL (activities of daily living) in the sample of 24. The findings include: 1. R50 had multiple diagnoses which included dementia, functional quadriplegia, acquired absence of right hand, cognitive communication deficit, and weakness, based on the face sheet. R50's quarterly MDS (minimum data set) dated 5/8/23 showed that R50 was severely impaired with cognition. The same MDS showed that R50 required extensive assistance from staff with personal hygiene. On 7/17/23 at 11:41 AM, R50 was sitting in his wheelchair across the unit nursing station. R50 had right below elbow amputation. R50's left hand fingernails were long, jagged, with black substances underneath. R50 had an accumulation of facial hair. R50 stated that he wanted to be shaven, and his fingernail trimmed and cleaned. V7…

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 record review, the facility failed to serve sauce over mechanically ground chicken as shown on menu spreadsheet. This applies to 5 of 5 residents (R67, R88, R92, R99, R110) observed for dining in the sample of 24. The findings include: On 7/17/23 starting at 12:25 PM, during lunch meal service, R67 and R99 received very dry ground chicken without any sauce over it or ranch dressing on the side. R88 also received a room tray without any sauces on the dry ground meat or ranch dressing on the side. R92 and R110 received the dry ground chicken and received one packet of ranch sauce on the side. R92 took only a few bites and stated she does not want the rest. R92 stated she cannot open the ranch dressing packet. R110 was attempting to pick up the dry flaky ground chicken with her fork with some spillage and stated she is unable to open the ranch dressing packet. V1 (Administrator) who was in the vicinity, was notified about R92 and R110. On 7/17/23 at 12:31 PM, when V19 (Cook), who was at the tray line, was asked why the residents on mechanical soft…

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 and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and gloving during provisions of care, and use of PPE (Personal Protective Equipment) when entering an isolation room. The facility also failed to ensure a resident had a physician's order for isolation, and the indwelling urinary catheter bag was not touching the floor. This applies to 6 of the 24 residents (R24, R40, R48, R57, R60, R67) reviewed for infection control in the sample of 24. The findings include: Face sheet shows that R57 is 83 years-old who has multiple medical diagnoses which include hemiplegia and hemiparesis affecting left non-dominant side, lack of coordination and weakness. Minimum Data Set (MDS) dated [DATE] shows R57 requires extensive assistance for personal hygiene. 1. On 7/18/23 at 4:39 PM, V30 (Certified Nursing Assistant/CNA) rendered incontinence care to R57 who was wet with urine. V30 cleaned R57 from front to back of the perineum,…

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 interview and record review, the facility failed to adequately monitor and track the status of influenza (flu) and pneumococcal (pneumonia) vaccinations to ensure eligible residents were offered a vaccine or residents who consented to receive a vaccine actually received it. This failure affected 5 out of 5 (R2, R48, R60, R66, R90) residents reviewed for influenza and pneumococcal vaccinations in the total sample of 24 residents. Findings include: On 7/19/23 at approximately 10:30 AM, the influenza and pneumococcal vaccine consents were compared to the spreadsheet V6 (Infection Preventionist) provided for tracking of the flu and pneumonia vaccines. The following concerns were identified: 1. For R2, the tracking sheet was noted blank for both the flu and pneumonia. R2's Informed Consent for Vaccinations shows a verbal consent for the Influenza Vaccine was obtained on 10/16/20 from R2's POA. The pneumococcal immunization section was left blank. A second Informed Consent for Vaccinations was provided 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.

Based on observation, interview and record review, the facility failed to apply a splint and provide treatment plan as recommended and ordered to prevent contractures. This applies to 1 of 3 residents (R24) reviewed for range of motion in the sample of 24. The findings include: R24's diagnoses on the face sheet included Multiple sclerosis, Weakness, Dysarthria and Anarthria, Aphasia. R24's POS (Physician Order Sheet) included Restorative Programming PROM (Passive Range of Motion) to bilateral upper/lower extremities 10 reps [repetition] times one set, daily 6 to 7 days a week start date 5/17/23. The POS also included for R24 to get up in the [mechanical] chair on Monday, Wednesday and Friday from 1:00 PM-4:00 PM. R24's Annual MDS (Minimum Data Set) dated 5/17/23 showed R24 requires total dependence of two-person physical assistance for transfer and has impairment on both sides for functional range of motion. On 7/17/23 at 10:53 AM, on 7/18/23 at 11:14 AM and 1:38 PM, and on 7/19/23 at 11:25 AM, R24 was seen lying in bed and noted to have no hand splint on. R24 was nonverbal and 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 observation, interview, and record review, the facility failed to provide incontinence and catheter care in a manner that would prevent potential urinary tract infection and reduce friction at the catheter insertion site. This applies to 4 of 7 residents (R40, R57, R60, R67) reviewed for incontinence and catheter care in the sample of 24. The findings include: 1. Face sheet shows that R57 is 83 years-old who has multiple medical diagnoses which include hemiplegia and hemiparesis affecting left non-dominant side, lack of coordination and weakness. Minimum Data Set (MDS) dated [DATE] shows that R57 requires extensive assistance for personal hygiene. On 7/18/23 at 4:39 PM, V30 (Certified Nursing Assistant/CNA) rendered incontinence care to R57 who was wet with urine. V30 used wet wipes to clean R57 from front to back of her peri-area. V30 wiped R57 in a downward stroke from the pubic area down to the groin, and from pubic area down to outer labia. However, V30 did not separate the labia to clean inner area…

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 interview and record review the facility failed to ensure that accurate documentation of controlled drugs was maintained. This applies 6 of 6 residents (R2, R5, R12, R29, R66, R99) reviewed for controlled medications. The findings include: On 7/19/23 9:30 AM, the zone 2 medication cart was reviewed with the nurse on duty, V12 (Licensed Practical Nurse). V2 (Director of Nursing/DON) was present. During the review of controlled substances on the medication cart it was noted that quantities of resident medication on hand did not match the quantity documented for 4 residents as follows: R99's prescribed Lacosamide 100 MG (milligrams) tablet, was to be administered one tablet by mouth every 12 hours. The actual quantity on hand in the blister-pack medication package showed there were 20 tablets remaining, and R99's-controlled drug receipt documented there were 21 tablets remaining. R5's prescribed Phenobarbital 64.8 MG tablet, was to be administered one tablet by mouth every morning and two tablets by mouth at bedtime. The actual quantity on hand in R5's blister-pack medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to have a facility wide IPCP (Infection Prevention Control Plan) and failed to provide an Infection surveillance plan. The facility also failed to follow standard infection control practices during provisions of care related to hand hygiene and gloving for R20, R48, R55 and R77. This applies to all 94 residents residing at the facility. The findings include: 1. On April 20, 2022, V1 (Administrator) said she has never seen the facility's IPCP and has been looking for it since February 2022. She said that she has no knowledge of the facility's infection control policies having been reviewed after the dates shown on the policies. V1 said that the facility should have an IPCP, and the infection control policies should be updated at least annually. On April 20, 2022, V2 (Director of Nursing/Infection Preventionist) said she could not find the facility's IPCP, and she has worked at the facility for a year and in that time the facility'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 interviews and record reviews the facility failed to have an ongoing antibiotic stewardship program. This applies to all 94 residents residing in the facility. The findings include: On April 20, 2022, V2 (Infection Preventionist/Director of Nursing) said that the facility does not have an antibiotic stewardship program or plan. V2 said she tracks antibiotics on a spreadsheet, but she doesn't put the results or the effects of the antibiotics, on the tracking sheet. V2 said that the facility does not have protocols for prescribing antibiotics. On April 21, 2022, V1 (Administrator) said that the facility should have an antibiotic stewardship program, but she could not find it and does not recall seeing it. V1 said that the facility should have the program so the facility can provide good care and to meet regulations. A review of the form CMS-672 (Resident Census and Condition of Residence) dated April 18, 2022 shows that the facility had a total of 94 residents. On April 20, 2022, a review of V2's antibiotic spreadsheet did not show results or effects of the prescribed…

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 3. R62 was admitted to the facility on [DATE] with multiple diagnoses which included resistance to Vancomycin-VRE (Vancomycin-resistant Enterococcus), unspecified and neuromuscular dysfunction of the bladder, based on the face sheet. R62's admission MDS (minimum data set) dated March 13, 2022 shows that the resident is cognitively intact and would require limited assistance from the staff with most of his ADL (activities of daily living). R62 is on contact precaution due to diagnosis of CRE (carbapenem-resistant enterobacterales) of the wound. On April 19, 2022 at 11:29 AM, R62 was in bed alert, oriented and verbally responsive. R62's urinary catheter tubing was observed with scattered white sediments. After providing pressure injury treatment to R62's coccyx area, V3 (Nurse) and V7 (CNA/Certified Nursing Assistant) turned and repositioned R62. Prior to turning and repositioning the resident, V7 unhooked R62's urinary catheter bag from the left side of the bedframe and handed (over the bed) the said urinary…

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 and record review the facility failed to monitor and assess the IV (intravenous) antibiotic administration and failed to disconnect and flush the midline catheter after completion of the IV antibiotic administration. This applies to 1 of 5 residents (R72) reviewed for IV medication administration in the sample of 20. The findings include: R72 was admitted to the facility on [DATE], with multiple diagnoses which included UTI (urinary tract infection) based on the face sheet. R72's admission MDS (minimum data set) dated March 23, 2022, shows that the resident is cognitively intact and would require extensive assistance from the staff with most of her ADL (activities of daily living). On April 19, 2022, at 12:05 PM, V8 (RN/Registered Nurse) started the IV antibiotic for R72 via midline catheter on the resident's left arm. The IV antibiotic bag label indicated that the IV medication was a reconstituted Meropenem 500 mg with 50 ml Normal saline. The same IV antibiotic bag label shows…

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, and record review, the facility failed to perform treatment for pressure ulcers that would prevent potential development of infection. This applies to 2 of 8 residents (R55 and R62) reviewed for pressure ulcers in a total sample of 20 residents. The findings include: 1. R55's EHR (Electronic Health Record) showed R55 had diagnoses including atrial fibrillation, chronic kidney disease, diabetes, congestive heart failure, pemphigus vulgaris, and urinary tract infection. The EHR continued to show R55 was on contact isolation for and MRSA (Methicillin-resistant Staphylococcus aureus) of the blood. R55's MDS (Minimum Data Set) dated April 1, 2022, showed R55 had moderate cognitive impairment. The MDS continued to show R55 required the assistance of two staff members for bed mobility, transfers, and dressing. R55's Physician Order Report showed an order dated April 1 2022, to swab the left heel with betadine and wrap with gauze to protect. A Progress Note dated April 12, 2022, by V18…

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 interview, the facility failed to ensure that assessment, monitoring, and targeted behavior is being documented for a resident who is receiving psychotropic medications. This applies to 1 of 3 residents (R45) reviewed for psychotropic medications in the sample of 20. The findings include: Face sheet documents that R45 is [AGE] years old who has multiple medical diagnoses which include Altered Mental Status, Unspecified Dementia without Behavioral Disturbance, Major Depressive Disorder, Anxiety Disorder. On 4/18/22 and 4/19/22 between 11:00 AM to 1:00 PM, R45 was randomly observed in her bedroom. She was sitting on her wheelchair with flat affect. When state representative approached R45 to greet her and asked questions, R45 just stared without expression on her face. Physician Order Sheet (POS) showed multiple medication prescriptions which include Zyprexa (olanzapine) tablet 5 mg given at bedtime (8:00 PM) and Effexor XR (venlafaxine) capsule 150 mg given orally once 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 record review, the facility failed to ensure all staff were fully vaccinated for COVID-19. This has the potential to affect all 94 residents in the facility. Findings include: According to the COVID-19 Staff Vaccination Status for Providers list, the facility had a total of 345 staff members. There are two staff members partially vaccinated. The Staff Formulas calculations showed the facility has a 99.4 percent staff vaccination rate. The COVID-19 Staff Vaccination Status for Providers list showed V11 (CNA/Certified Nursing Assistant) and V17 (housekeeper) only received one vaccination of a multi-dose vaccine for COVID-19. On April 20, 2022, at 11:15 AM, V11 performed incontinence care on R48. On April 19, 2022, at 12:10 PM, V17 was wheeling his housekeeping cart out of the resident care area, wearing a surgical mask. V17 said he was unvaccinated when he applied for the job and received his first vaccination the day he started. On April, 20, 2022, at 10:55 AM, V17 was cleaning R19 and R56's room wearing a surgical mask. On April 20, 2022, at…

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.