Timber Point Healthcare Center

Based on observation, interview, and record review the facility failed monitor and record cool down temperatures for prepared meats, label opened food items in the refrigerators, label opened dry foods, and failed to use correct dish machine sanitizing test strips. These failures have the potential to affect all 69 residents residing in the facility. Findings include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6-1-25 and signed by V1 (Administrator) documents 69 residents currently reside within the facility. The facility's two stage cool down process policy (not dated), documents, Potentially hazardous foods will be cooled properly to prevent food borne illness. Foods will be cooled to proper temperatures. The time and temperature of food cooling will be documented at two- and four-hour intervals. The facility's labeling and dating food policy (not dated), documents, Prepared and packaged foods will be labeled and rotated to decrease the risk of food borne illnesses, provide the highest quality of product for the residents and minimize waste.…

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 track infections of individuals who enter or live in the facility per CMS (Central Management Services) requirement. This failure had the potential to affect all 69 residents residing in the facility. Findings Include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6-1-25 and signed by V1 (Administrator) documents 69 residents currently reside within the facility. The facility's Infection Prevention and Control Manual Infection Prevention and Control Program (not dated) documents, A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to regulatory requirements and following accepted national standards. A system of surveillance that is designed to identify possible communicable diseases or infections before they can spread to other persons in the facility.…

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 designate or hire a full-time infection preventionist per CMS (Central Management Services) requirement. This failure had the potential to affect all 69 residents residing in the facility. Findings Include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6-1-25 and signed by V1 (Administrator) documents 69 residents currently reside within the facility. The facility's Infection Prevention and Control Manual Infection Prevention and Control Program (not dated) documents, The facility will designate one or more individual(s) as the infection preventionist(s)(IP)(s) who is responsible for the facility's IPCP (infection prevention control program). The infection preventionist will have primary professional training in nursing, medical technology, microbiology, epidemiology, or another related field. Is qualified by education, training, experience, or certification, works at least part time at the facility, has completed specialized training in infection prevention and control. The facility IP will…

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 ensure all Certified Nursing Assistants received 12 hours of annual in-service training. This failure has the potential to affect all 69 residents residing within the facility. Findings Include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6-1-25 and signed by V1 (Administrator) documents 69 residents currently reside within the facility. All CNA (Certified Nursing Assistant) trainings from 1/1/2024 through 6/2/2025 were reviewed and no CNAs received 12 hours of required annual in-service training. On 6/3/2025 at 1:30 PM, V2 (DON/Director of Nursing) confirmed all CNAs currently employed at the facility have not received 12 hours of annual in-service training required.

Based on interview, and record review the facility failed to resolve several repeated grievances for eight of eight residents (R5, R14, R23, R30, R31, R47, R50, R58) reviewed for grievances in a sample of 44. Finding Include: The facility's grievance policy dated/revised 1/2025, documents, To provide a process to assist residents, their representatives such as other interested family members or other resident advocates in filing grievances or complaints when such requests are made. Consistent with 483.12(c)(1), by anyone furnishing services on behalf of the provider, all alleged violations involving neglect, abuse, including injuries of unknown source and/or misappropriation of resident property will be immediately reported to the administrator of the provider as required by state law. Written grievance decisions will include the date the grievance was received, a summary statement of the resident grievance, steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the residents concern(s), a statement as to whether the grievance as…

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 ensure oxygen tubing was changed weekly as ordered and dated for five of five residents (R5, R12, R13, R38, and R39) reviewed for oxygen in the sample of 44. Findings include: The facility's Respiratory Therapy Prevention of Infection policy dated 8/2008 documents The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Steps in the Procedure - Infection Control Considerations Related to Oxygen Administration 7. Change the oxygen cannula and tubing every seven (7) days, or as needed. 8. Keep the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use. Documentation - The following information should be recorded in the resident's medical record: 1. The date and time the respirator therapy was performed. 1.) R38's current Physician Order Report documents, 04/22/25 Oxygen: Change tubing and mask weekly…

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 interview the facility failed to develop a plan of care to address advanced directives for one of two residents (R44) reviewed for advanced directives in the sample of 44. Findings include: The facility's Advanced Directive and Advanced Care Planning/POLST (Physician Orders for Life Sustaining Treatment) Guideline dated [DATE] documents Purpose: It is the practice of the facility to establish, implement and maintain written guidelines for advanced directives and advanced care planning/POLST. The resident has the right and the facility will assist the resident to formulate an advance directive at their option. Procedure: G. During the quarterly RAI (Resident Assessment Instrument) process and with any significant changes of condition, facility staff will a. Identify, clarify, and review the existing care instructions and whether the resident wishes to change or continue instructions from the advance directive. e. Changes to the resident choices for advanced directives will be…

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

Based on observation, interview, and record review the facility failed to protect the resident's right to be free from misappropriation of intravenous medication for one of one resident (R319) reviewed for misappropriation of medications out of a sample list of 44. Findings include: The Abuse Prevention Policy undated documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful…

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 interview the facility failed to issue a bed hold notice for two of two residents (R25 and R28) reviewed for hospitalization in the sample of 44. Findings include: The facility's Bed Hold and readmission policy dated November 2016 documents Standards: 1. Residents, or their designated representative, shall be informed of this policy at the time of admission and at the time of transfer to a hospital, or for therapeutic leave which extends beyond 24 hours. The facility provides written notification at the time of transfer as included in the designated state form. The notice to the resident or the representative will specify the facility's policy, the duration of the state bed hold policy and the reserve bed payment policy. 2 In the event of an emergency hospitalization the resident or their representative shall be notified by telephone or in person of this policy, within 24 hours, and asked to provide the facility with their decision. The staff member making the call or explaining 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 and interview the facility failed to accurately code a MDS (Minimum Data Set) Assessment for one of 17 residents (R44) reviewed for MDS accuracy in the sample of 44. Findings include: The facility's Comprehensive Assessment/MDS Policy undated documents Policy: It is the policy of this facility to perform a comprehensive, accurate, standardized, reproducible assessment of each residence status following admission, quarterly thereafter and annually in order to obtain information vital to the development of the resident's plan of care. In addition to facility approved departmental assessment forms, the assessment shall be summarized using a standardized federally and state approved uniform data set. Standards: 11. All assigned disciplines shall participate in the completion of the MDS assessment form and shall verify accuracy and completion of each respective section by indicating the letter of the section, adding their signature and dating. The scope of each discipline's assessment is…

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 interview the facility failed to refer a resident to the PASRR (Preadmission Screening and Resident Review) State Agency to obtain a Level II PASRR after being diagnosed with a Mental Illness for one of one resident (R31) reviewed for Mental Illness in the sample of 44. Findings Include: The Pre-admission Screening and Resident review (PASRR) policy, undated documents It is the policy of this facility to 1. Comply with Federal, State and the appointed screening agency Maximus, in standards addressing the PASRR assessment/screening process. 2. Request full and complete PASRR materials (Level 1 and 2) from each referral source prior to or soon following admission. Procedure: 1. A facility representative shall request the complete screening from the referral source. 2. A copy of all the materials received will be placed in the residence business file and the EMR (electronic medical record) at the discretion of administration. R31's admission Record documents that R31 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the fingernails were kept trimmed for two of 17 residents (R29 and R37) reviewed for ADL (Activities of Daily Living) Assistance in the sample of 44. Findings include: The facility's Nail Care Guidelines dated 2/23 documents Guidelines: Nail care includes routine cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 1. R29's MDS (Minimum Data Set) assessment dated [DATE] documents R29 requires substantial/maximal assistance of staff for personal hygiene. R29's Shower Sheets dated 03/01/25 through 06/02/25 document R29's fingernails have not been trimmed during this timeframe. On 06/01/25 at 9:54 AM R29 was lying in bed. All of R29's fingernails were long, jagged, and extended past her fingertips. R29 stated she cannot remember the last time her nails were clipped. R29…

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 interview the facility failed to follow the Advanced Directive for one of two residents (R65) reviewed for Advanced Directive in the sample of 44. Findings include: The Advanced Directive and Advanced Care Planning/POLST (Physician Orders for Life Sustaining Treatment) Guideline dated [DATE] documents Purpose: It is the practice of the facility to establish, implement and maintain written guidelines for advanced directives and advanced care planning/POLST. The resident has the right and the facility will assist the resident to formulate an advance directive at their option. Procedure: G. During the quarterly RAI (Resident Assessment Instrument) process and with any significant changes of condition, facility staff will a. Identify, clarify, and review the existing care instructions and whether the resident wishes to change or continue instructions from the advance directive. e. Changes to the resident choices for advanced directives will be documented, included in the resident plan 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, interview, and record review the facility failed to ensure an indwelling urinary catheter bag was secured and off the floor for one (R64) of two residents reviewed for catheters in the sample list of 44. Findings include: The Urinary Catheter Care policy dated September 2005 documents The purpose of this procedure is to prevent infection of the resident's urinary tract. General Guidelines: 11. Be sure the catheter tubing and drainage bag are kept off the floor. R64's current Physician Orders document R64 was admitted to the facility on [DATE] with a 16 F (French) indwelling (urinary) catheter for urinary retention. On 06/01/25 at 11:02 AM, R64 was laying supine in bed with R64's indwelling urinary catheter bag laying on the floor next to R64's bed. On 06/03/25 at 10:00 AM, V5 (Licensed Practical Nurse) stated indwelling urinary catheter bags should be secured to the side of the bed and below the bladder. V5 further stated a urinary catheter bag should never be on the floor.

Based on record review and interview the facility failed to notify the physician of a resident not receiving a physician ordered enteral nutrition formula by gastrostomy tube for one of three residents (R1) reviewed for physician notification in the sample of three. Findings include: The facility's Gastric Tube Feeding via Continuous Pump policy dated 08/2008 documents, Purpose: The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. Verify compliance with physician's order, including the product volume and infusion rate. Report any complications promptly to the physician. 1. R1's Hospital Discharge Orders dated 11-21-24 document, Tube Feeding: Osmolite 1.5 at a goal rate of 45 ml (milliliter) per hour. R1's Medications Flowsheet dated 11-21-24 (R1's Admission) through 11-30-24 documents R1 did not receive her physician ordered Osmolite 1.5 calorie/ml (milliliter) at 45 ml per hour via gastrostomy tube on 11-21-24 through 11-25-24. R1's Medical Record does not include documentation of a physician being notified of R1 not…

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 interview the facility failed to follow their Admission's Contract to perform an inventory of a resident's personal belongings for one of three residents (R3) reviewed for personal belongings in the sample of three. Findings include: R3's admission Contract dated 8-20-24 documents, An inventory sheet will be provided for you and/or your family to fill out to identify all belongings upon admission. Please complete the inventory sheet in its entirety and sign/date. If you need assistance with filling out the inventory sheet, please contact a facility staff member and someone will be assigned to assist you. R3's MDS (Minimum Data Set) assessment dated [DATE] documents R3 is cognitively intact. R3's Medical Record does not include an Inventory Sheet of R3's personal belongings. On 12-13-24 at 12:40 PM R3 stated, When I came into the facility my caregiver brought in a tote of my belongings. The staff made me leave my things with them for three days. The staff said they clean everything…

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 interview the facility failed to administer a physician ordered enteral nutrition formula by gastrostomy tube for one of one resident (R1) reviewed for a gastrostomy feeding tube in the sample of three. Findings include: The facility's Gastric Tube Feeding via Continuous Pump policy dated 08/2008 documents, Purpose: The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. Verify compliance with physician's order, including the product volume and infusion rate. Documentation: 1. The date and time the procedure was performed. 2. The amount and type of enteral feeding. 1. R1's admission Record documents R1 was admitted to the facility from the hospital on [DATE] with the diagnoses of alcoholic cirrhosis of the liver, severe protein-calorie malnutrition, gastrostomy, ulcerative chronic pancolitis, gastrostomy, and hypocalcemia. R1's Hospital Discharge Orders dated 11-21-24 document, Tube Feeding: Osmolite 1.5 at a goal rate of 45…

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 interview the facility failed to provide readily available grievance forms and failed to post grievance/complaint procedures in a prominent location throughout the facility. This has the potential to affect all 70 residents residing in the facility. Findings include: The facilities CMS (Centers for Medicare and Medicaid services) Long Term Care Facility Application four Medicare and Medicaid Form 671 dated 7/8/24 and signed by V1/Administrator documents 70 residents currently reside within the facility. The facility's Grievance Policy dated 11-2016 documents, A copy of the facility's grievance/complaint procedures is posted in prominent locations throughout the facility. Grievance postings will include the contact information of the grievance official including name, business address, e-mail, and phone number. On 7/9/2024 at 2:00 PM during resident council meeting R25, R30, R53, R36, and R40 all stated that they do not know where or how to file a grievance. On 7/10/2024 at 10:30 AM, a wooden box was located to the left of the activity…

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 provide the resident/resident representatives with a written notice of transfer. This has the potential to affect all 70 resident's residing in the facility. Findings include: R43's medical record documents that R43 was transferred to a local hospital on 3/15/24. No evidence of a facility notification to R43 of a transfer/discharge was present in R43's chart. R56's medical record documents that R56 was transferred to a local hospital on 6/4/24. No evidence of a facility notification to R56 of a transfer/discharge was present in R56's chart. On 7/8/24 at 1:15 PM V2/DON verified the facility did not provide R43, R56, or their representatives with a written notice of transfer. V2/DON stated, I am not aware of a written notice of transfer form we (the facility) are supposed to give to the residents when they discharge to the Hospital. We (the facility) only send the continuity of care form that has the resident's current vitals and medications. The nurses would be the ones to give the resident the written notice of transfer,…

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 provide food items on the Always Available Menu to residents that requested substitution items from their meals. This has the potential to affect all 70 residents living in the facility. Findings: The document, Food Substitution, no date, states, Residents may be offered a substitute if desired. The Dietary List, Facility Always Available (Foods), no date, states, Chef's Salad; Cottage Cheese; Chicken Nuggets; Deli Sandwich; Cheeseburger; Chicken Salad Sandwich; Egg Salad Sandwich; Ham Salad Sandwich; Tuna Salad Sandwich; Grilled Cheese Sandwich; Peanut Butter and Jelly Sandwich; Lettuce and Tomato Salad; Fruit Plate; French Fries; Mashed Potatoes. On 7/09/24 at the 2:00 PM, Resident Council Meeting, the following residents, (R25, R30, R36, R40, R52), stated, We can get a peanut butter and jelly sandwich and maybe a fruit plate, but that is all that we can get. The Certified Nursing Assistants will ask the [NAME] to make us a grilled cheese, or a cheeseburger with lettuce and tomato or something like that and they tell us…

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 use Cool Down Temperature Logs for potentially hazardous food. This has the potential to affect all 70 residents living in the facility. Findings: The document, Two Stage Cool Down Process, dated 2015, states, Potentially hazardous foods will be cooled properly to prevent food borne illness. Foods will be cooled to proper temperatures. A two stage cooling process will be followed: Stage I: Cool foods from 135 degrees Fahrenheit (F) to 70 degrees F within two (2) hours. Stage II: Cool foods from 70 degrees F to 41 degrees F within four (4) hours. (Total of Six (6) hours.) If prepared from ingredients at room temperature: Cool foods from 70 degrees F to 41 degrees F within four (4) hours. The document, Hazard Analysis Critical Control Point (HACCP) Cooling Log, dated 2024, states, Record temperatures every hour during the cooling cycle. The supervisor of food operation will verify proper cooling procedures by routinely monitoring work activity and reviewing this log. Cooling temperatures will be documented. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a personalized Care Plan for 1 resident (R67) of 24 residents reviewed for personalized Care Plans in the sample of 34. Findings Include: The Care Planning policy dated August 2006, documents Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. R67's current computerized medical record, documents R67 was admitted to the facility on [DATE] with a diagnosis of Venous Insufficiency (Chronic) (Peripheral), Sciatica, Left Side (Primary), Major Depressive Disorder, Anxiety Disorder, Hypertensive Heart Disease Without Heart Failure, and Localized Edema. R67's MDS (Minimum Data Set) dated 6/10/24 documents a BIMS (Brief Interview for Mental Status) Score of 13/15, indicating cognition intact. On 07/08/24 at 10:47 AM, R67 was sitting in her room in her wheelchair. R67 stated her legs have been swelling a lot and R67 needs to wear compression…

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 provide physician ordered Ketoconazole cream (anti-fungal topical cream) timely to a resident with known topical yeast growth for one of one resident (R38) reviewed for skin conditions in the sample of 34. Findings include: The facility's Drug Order Policy (undated), documents It is the policy of this facility to obtain a physician's order for all medications and treatments and to process medication orders to ensure the resident's medical plan of care is implemented, on a timely basis. This same policy documents All orders from a licensed practitioner for resident drugs are processed by a licensed nurse and entered in the resident's medical record. The medication orders are processed timely, i.e. (that is) called/faxed to the selected pharmacy, is indicated on the resident identification. Drug order shall be transcribed onto the medication record by the licensed nurse who received them as soon as practical after the physician's order is received. R38's current care plan, dated 6/26/24, documents (R38) is 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.

Based on observation, interview and record review, the facility failed to provide physician ordered yogurt with all meals, obtain physician ordered daily weights, provide lunch meals when out of the facility at scheduled hemodialysis, communicate with the dialysis center before and after treatments, monitor a central venous catheter dialysis port and ensure a resident's care plan documents detailed dialysis care and required services for a resident receiving renal hemodialysis for one of one resident (R38) reviewed for dialysis in the sample of 34. Findings include: The facility's Dialysis Transfer Agreement, dated 7/19/10, documents Facility shall ensure that all appropriate medical, social, administrative and other information accompany all designated residents at the time of transfer to (dialysis) Center. This information shall include, but is not limited to, where appropriate, the following: Appropriate medical records, including history of the designated resident's illness, including laboratory and x-ray findings; Treatment presently being provided to the designated resident,…

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

Based on observation, interview and record review, the facility failed to identify and monitor targeted psychotic behaviors to warrant the use of Abilify (antipsychotic medication) and attempt a gradual dose reduction of the medication in the past year for one of three residents (R25) reviewed for antipsychotic medications in the sample of 34. Findings include: The facility's Antipsychotic Medication Use policy dated/revised August 2008 documents, The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, symptoms, and risks. Nursing staff will document an individual's target symptom(s). The Attending Physician will identify, evaluate, and document with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications. Based on assessing the resident's symptoms and overall…

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 implement Enhanced Barrier Precautions for a resident with a Central Venous Catheter dialysis port for one of one resident (R38) reviewed for Dialysis in the sample of 34. Findings include: The facility's Enhanced Barrier Precautions policy, dated 2023, documents It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multi-drug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO. High-Contact resident care activities include: Dressing, Bathing/Showering, Transferring, Provide Hygiene, Changing Linens, Changing Briefs or toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing. Procedure: Post clear signage on the door/wall outside…

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 notify the physician and a resident's representative immediately once prescribed opioid medications were not obtained or administered as ordered for two of three residents (R1 and R2) reviewed for notification of changes in the sample of three. Findings include: 1. R1's Physician's Orders dated 10-5-23 through 3-8-24 document, Fentanyl 100 mcg per hour one patch transdermal once a day every three days at 9:00 PM for the diagnoses of Multiple Myeloma not having achieved remission. R1's Medication Flow Sheets dated 1-1-24 through 2-31-24 document R1's Fentanyl Patch 100 mcg/hour transdermal placed at 9:00 PM was not administered as scheduled on 1-25-24, 1-28-24, 1-31-24, or 2-3-24. These same Medication Flow Sheets document R1 did not have a Fentanyl 100 mcg/hour patch applied until 2-6-24. R1's Progress Notes dated 1-29-24 at 5:49 AM and signed by V5 (RN/Registered Nurse) document, At 5:45 am (R1) heard yelling (female's name) and had fallen in room. Fall was witnessed by roommate who states (R1) was having a nightmare 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 record review and interview the facility failed to ensure the residents' representatives were invited and attended care plan conferences for two of three residents (R1 and R3) reviewed for care planning in the sample of three. Findings include: The facility's Care Planning-Interdisciplinary Team policy dated 08/06 documents, The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. 1. R1's Medical Record dated 8-24-23 through 3-8-24 does not include any documentation of V8 (R1's Power of Attorney/POA) being invited or attending R1's care plan meetings except on one occasion (2-14-24). On 3-8-24 at 12:25 PM V8 (R1's Power of Attorney) stated, I have not been invited to a care plan meeting since (R1) was admitted until 2-14-24. I need to be involved with (R1's) care plan meetings to ensure the facility is taking appropriate care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess a newly identified pressure ulcer, and obtain a physician ordered treatment for two of three residents (R1, R3) reviewed for pressure ulcers in the sample of three. Findings include: The facility's Prevention of Pressure Wounds policy, dated 1/17, documents, Once a pressure injury develops, it can be extremely difficult to heal. Pressure injuries are a serious skin condition for the resident. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of developing pressure injury. 1. R1's Braden Scale Assessment, dated 10/25/23, documents a score of 13 putting R1 at a moderate risk 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.