Sunset Rehabilitation and Health Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to date oxygen tubing, place an oxygen sign on resident doors, and ensure a nebulizer facemask and tubing was changed weekly for three of three residents (R5, R34, R56) reviewed for oxygen therapy in the sample of 37. Findings include: The Oxygen Administration Policy revised 3/17/22, documents, To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues. Oxygen therapy will be administered to the resident upon the written order of a licensed physician or may be given in an emergent life-sustaining situation without an order, until an order may be obtained by a licensed physician. It will be administered by way of an oxygen mask, nasal cannula and/or a nasal catheter. Procedure: 5. Place the Oxygen in Use sign on the outside of the room entrance door. Tubing will be changed and dated weekly. 1. R5's admission Record documents R5 was admitted on [DATE] with diagnoses which included Morbid…

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 attempt a Gradual Dose Reduction (GDR) of Olanzapine (Antipsychotic medication) for one of three residents (R34) reviewed for antipsychotic medications in the sample of 37. Findings include: The facility's Psychotropic Medication Policy, dated 11/28/17, documents, It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drug is any drug used: For excessive duration. Residents who use antipsychotic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue the drugs. Any resident receiving psychotropic medications will be reviewed at a minimum of every quarter by the interdisciplinary team. Reductions shall be attempted at least twice in one year, unless the physician documents the need to maintain the resident regimen according to the regulatory guidelines for such. The facility's Reduction of Psychotropic Medications…

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 change gloves and perform hand hygiene while providing incontinent care and implement Enhanced Barrier Precautions (EBP) for a resident with an open wound, for two of 18 residents (R5, R56) reviewed for infection control in the sample of 37. Findings include: The Incontinence Care Policy, dated 7/1/23, documents, To provide guidelines to all nursing staff for providing proper incontinence care in order to clean skin clean, dry, free of irritation and odor. All incontinent residents will receive incontinence care in order to keep skin clean, dry and free of irritation and/or odor. Incontinence care will be provided as required. 8. Wash all soiled skin areas and dry very well, especially between skin folds; changing gloves and performing hand hygiene as required to prevent cross-contamination. The Enhanced Barrier Precautions, dated 7/13/23, documents, Purpose: To reduce transmission of multi-drug-resistant organisms/MDRO (Multi-Drug…

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 keep a urinary catheter insertion site clean every shift for one of one resident (R7) reviewed for urinary catheter care in the sample of 13. Findings include: The facility's Indwelling Catheter Care policy, dated 10-7-22, documents, Purpose: To provide guidance to facility staff on the care of residents with an indwelling foley catheter within the facility to prevent catheter-associated urinary tract infections. The facility shall maintain and care for foley catheters per the facility, following physician orders and adhering to facility infection control and best nursing practice standards. R7's Care Plan, dated 7-22-24, documents, Goal: The resident will show no signs and symptoms of urinary infection through the review dated 8-12-24. (Provide) catheter care every shift. R7's Treatment Administration Records (TARs), dated 5-16-24 through 7-31-24, document, Provide (indwelling urinary) catheter care every shift. These same TARs, dated 5-16-24 through 7-31-24, document R7 did not receive indwelling 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.

Based on record review and interview, the facility failed to obtain scheduled IV (Intravenous) antibiotics from the pharmacy for one of three residents (R8) reviewed for pharmacy services in the sample of 13. Findings include: R8's Physician's Order, dated 7-15-24, documents, Start Primaxin 500 mg (milligrams) IV (Intravenous) every six hours for the diagnosis of UTI (Urinary Tract Infection). R8's Medication Administration Records, dated 7-18-24 through 7-26-24, document R8's scheduled Primaxin 500 mg IV was not administered on 7-23-24 at 2:00 AM, 7-23-24 at 8:00 AM, or 7-23-24 at 2:00 PM. On 7-27-24 at 10:00 AM, R8 stated, I missed several doses of my IV antibiotic. I am not sure why. All I was told from the staff is they (facility) staff did not get the antibiotic delivered from the pharmacy. On 7-30-24 at 11:15 AM, V1 (Administrator) stated, The pharmacy messed up and did not send (R8's) IV antibiotics. I called (V17, Pharmacy Customer Service Representative) and let him know we did not have enough IV antibiotics to give (R8). (V17) told me the pharmacy had an internal issue…

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 administer a resident's physician ordered IV (Intravenous) antibiotic for one of three residents (R8) reviewed for medication errors in the sample of 13. Findings include: The facility's Medication Error Policy/Procedure, dated 7-16-23, documents, Purpose: To provide guidelines to staff regarding procedure for reporting and recording medication errors. Policy: A medication error shall be defined as any variation in administration of medication from the physicians' orders and/or facility policy. It is the responsibility of the nursing personnel to report and record any and all medication/treatment errors. It is the responsibility of nursing and/or designee to assure MD (Medical Doctor) and POA (Power of Attorney) are notified of all med (medication) errors. A details account of the incident must be recorded. Such documentation must include the time and date of the incident, the name, strength, and dosage of medication administered, the condition of the resident, any treatment administered, and the date and time that 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, interview, and record review, the facility failed to prevent two residents with wandering behaviors (R8 and R38) from entering resident's room and infringing on resident's privacy for five of five residents (R3, R4, R9, R46, R47) reviewed for resident rights in the sample of 50. Findings include: The facility's Residents' Rights policy, dated 11/2018, documents, Your facility must be safe, clean, comfortable, and homelike. You have the right to privacy. R8's current Care Plan does not include a plan of care to address R8's wandering behaviors. R38's current Care Plan documents R38 has impaired cognition resulting in wandering behaviors related to Lewy Body Dementia. This same Care Plan documents R38's goal is to provide supervision, assistance, and redirection to prevent R38 from distracting others. On 7-10-24 at 9:40 AM, R3 was lying in bed with a cubicle curtain closed between him and his roommate (R9). R8 entered. R8 was in a wheelchair and self-propelled himself into R3 and R9's room, and then entered R3 and R9's bathroom. R8 was confused. R3 yelled at R3…

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 above the bed lighting was in working condition and room temperatures were kept at comfortable levels for two of three residents (R3 and R9) reviewed for a comfortable and homelike environment in the sample of 50. Findings include: The facility's Residents' Rights policy, dated 11/2018, documents, Your facility must be safe, clean, comfortable, and homelike. On 7-10-24 at 9:40 AM, R3 was lying in bed with a cubicle curtain closed between him and his roommate (R9). R9 was confused. R9's above the bed light was on and the light was missing the pull string that was used to turn the light on and off. R3's above the bed light was also missing a pull string. R3's and R9's window was unlocked and slid down approximately one foot from the top allowing outside air into R3 and R9's room. R3 stated, I have been here in this room since the first (7-1-24). There is no way to turn the lights above my bed or my roommate's bed off or on because the strings are missing. I have not been able to sleep at night with these…

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 meals to all the residents seated together at the same time, during meal time for one resident (R50), and failed to sit next to and allow a resident to eat independently for one resident (R48). This applies to 2 residents (R50 and R48) reviewed for meal service. Findings include: 1. The facility's Dining Room Procedures, revised 10/16, documents 6. Plates should be passed to all residents at one table at the same time. On 11/28/23 at 11:26 AM, R50 observed sitting at the dining room table when his tablemate received a meal tray. On 11/28/23 at 11:44 AM, V6, Certified Nursing Assistant (CNA), and V7, CNA, observed putting dirty trays back into the food warmers and closing the doors. R50 observed still sitting at the dining room table without a meal tray. This surveyor approached V7 and asked if they were done serving all the residents. V7 stated, Yes, all the trays have been passed. V7 was then asked why R50 did not receive a meal tray. V7 stated, Oh! (opened the food warmer) They didn't send one down…

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 give the appropriate notices for Medicare Part A for three (R23, R54 and R231) of three residents reviewed for Medical Part A Services in a sample of 34. Findings include: R54's Medical Part A skilled services start date was 10/4/23 and last covered day was 10/23/23. R54 was not given the Advanced Beneficiary Notice/ABN or the Notice of Medicare Non-coverage/NOMNC. R23's Medical Part A skilled services start date was 7/14/23 and last covered day was 8/4/23. R54 was not given the ABN or the NOMNC. R231's Medical Part A skilled services start date was 11/17/23 and last covered day was 11/21/23. R54 was not given the ABN or the NOMNC. On 12/01/23 at 10:00 AM, V1, Administrator, stated, We don't have the ABN or NOMNC notices for (R54, R23, or R231). Social Services is responsible for them, but he just started, and these were prior to him starting in that position. On 12/01/23 at 10:42 AM, V1 stated, (R231) went back to the other facility; (R23) met max potential; and (R54) refused visits. We did not send any notices to these…

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 obtain a new level II PASRR (Preadmision Screening and Resident Review) for a new diagnosis of serious mental illness for two residents (R27 and R50 ) out of four residents reviewed for PASRRs in a sample of 34. Findings include: 1. R50's medical record documents an admitting diagnosis of Dementia with behavioral disturbances, delusional disorder, and persistent mood affective disorder. R50s medical record, dated 11/13/23, documents a diagnosis of schizoaffective disorder. On 11/29/23 at 10:15 AM, V1, Administrator, verified R50 did not have a PASRR level II screening completed with the addition of his schizoaffective disorder, and stated, I don't know when the schizoaffective disorder was added. I know it was added after his admission because it's not on his admission paperwork. I didn't know they need to be re-screened for the the PASRR level II when they had a new diagnosis added. 2. The Face Sheet for R27 documents R27 was admitted to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level II (R22) and failed to obtain a new Level I Screening after expiration (R70) for two of four residents (R22 and R70) reviewed for PASARRs in the sample of 34. Findings include: 1. R22's Face Sheet documents R22's facility admission date as [DATE]. R22's Cumulative Diagnosis Log documents R22 with diagnoses to include but not limited to: Bipolar Disorder; Unspecified Psychosis; Depression; Panic Disorder; and Anxiety. R22's Omnibus Budget Reconciliation Act (OBRA) I-Initial Screen, dated [DATE], documents the following: There is a reasonable basis for suspecting developmental disability or mental illness with (R22); (R22) has a history of severe recurrent major depression with psychotic features; and (R22) has a history of a psychotic hospitalization. This same OBRA screening documents a Level II screening was needed, and it was not completed at the time, due to R22 discharging from 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 develop a Comprehensive Care Plan for one (R45) of 19 residents reviewed for Care planning in the sample of 34. Findings include: The facility's Comprehensive Care Planning policy and procedure, revised 7/20/22, documents, It is the policy of (The Facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of the Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each Resident that will described the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being. Care Plan - Plan of care describing a need/problem, and indicating the approaches/interventions to be instituted to assist the Resident in maintaining/receiving care in relation to the need/problem. Program 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 observation, interview, and record review, the facility failed to ensure a resident transferred out of bed for one (R9) of six residents reviewed for activities of daily living in a sample of 34. Findings include: The Facility Assessment, dated 4/18/23, states, The purpose of the assessment is to determine what resources are necessary to care for residents. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. The Reliant 600 RPL 600 User Manual, undated, documents, The weight limitation for the RPL600 is 600 pounds; troubleshooting- actuator fails to lift when button is pressed- boom actuator is in need of service, unit does not work properly and battery has been replaced and unit still does not work properly- check battery and replace if necessary, and contact mechanical lift facility for service. R9's MDS/Minimum Data Set, dated [DATE], documents…

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 resident had a device in place to prevent skin breakdown and prevent further contraction of a left hand contracture for one resident (R8) out of two resident reviewed for range of motion in a sample of 34. Findings include: The facility's Splint/Appliances policy revised 9/08 documents, A resident who has a contracture, or has a likelihood of developing a contracture, caused by a physical condition and requires further evaluation will be assessed by the Occupational Therapist for a splint/appliance as ordered by the resident's physician. 6. The Occupational Therapist will provide nursing with a schedule for the application and removal of the splint, subject to physician order. 7. The program will be identified on the resident's care plan including the problem, approaches and goals. R8's Occupational Therapy Plan of Care, dated 10/29/21, documents, Patient will utilize hand roll or palm protector for left upper extremity to prevent skin break down and for contracture prevention. R8's Occupational…

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 screen and identify triggers for two of two residents (R45 and R62) reviewed for Trauma Informed Care in the sample of 34. Findings include: The facility's undated Trauma Informed Care policy and procedure documents the purpose, To ensure that all residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to climate or mitigate triggers that may cause re-traumatization of the resident. Procedure: 1. Upon admission the Social Service Director (SSD) will review hospital discharge records and interview the resident or the resident's representative to determine any history of trauma. 2. The SSD will complete a Trauma Informed Care Screen to evaluate for any history of a traumatic experience that a resident may have had. The facility's undated Social Service Director Job Summary documents: 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 interview and record review, the facility failed to obtain a Physician/Prescriber response to the Pharmacist's Medication Regimen Review/MRR for one of six residents (R22) reviewed for unnecessary medications in the sample of 34. Findings include: The facility's Medication Regimen Review Policy, dated January 2022, states, 6. The pharmacist will address copies of residents' MRRs to the Director of Nursing/DON and/or the attending physician and to the Medical Director. Facility staff should ensure that the attending physician, Medical Director, and Director of Nursing are provided with copies of the MRRs. 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the DON to act upon the recommendations contained in the MRR. 7.1 For those issues that require Physician/Prescriber intervention, facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation…

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 identify target behaviors and gain consent to warrant the use of antipsychotic medication for one resident (R50), and failed to attempt a gradual dose reduction for an antipsychotic medication for one resident (R22), out of five residents reviewed for unnecessary medications in a sample of 34. Findings include: 1. The facility's Psychotropic Medication policy, revised 11/28/17, documents, G. Use of Antipsychotic Drugs: 13. Antipsychotic's should not be used if one or more of the following is/are the only indication: a: Wandering. R50's medical record documents the following diagnosis: Dementia with agitation, delusional disorder, mood disorder and schizoaffective disorder. R50's Psychotropic Medication Consent -Antipsychotic, dated 8/13/20, documents, Medication: Seroquel. Medication dosage: 12.5 mg (milligrams) at bedtime. Medication used for these identified behaviors and diagnosis: Dementia and behavioral disturbances - exit seeking. R50's behavior tracking sheet, dated 11/2023, documents, Psychotropic 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 interview and record review, the facility failed to revise Care Plans for three residents (R9, R27, and R45) of 19 residents reviewed for Care Planning in the sample of 34. Findings include: The facility's Comprehensive Care Planning (CPC) policy and procedure, revised 7/20/22, documents, It is the policy of (The Facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Residents highest practicable physical, mental, and psychosocial well-being. The CPC shall be reviewed after each Annual, Significant Change and Quarterly MDS (Minimum Data Set) and revised as necessary to reflect the resident's current medical, nursing, and mental and psychosocial needs…

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 meet the nutritional needs by offering a menu balanced in protein and calories for a resident on a Vegetarian Diet. This has affected one (R9) of three residents in a sample of 32. Findings include: The document, Vegetarian Diet, dated 4/17, states, It is the policy of this facility to meet the nutritional needs and preferences of residents who do not eat meat or other animal products and provide a variety to the resident. The Facility Assessment, dated 4/18/23, states, The purpose of the assessment is to determine what resources are necessary to care for residents. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. Services offered by this facility (include) Individualized Dietary requirements, specialized diets, cultural or ethnic dietary needs. The Facility's Website states, Food and Nutrition Services - Our Facilities feature a Food and Nutrition…

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 complete a significant change in condition MDS (Minimum Data Set) Assessment within 14 days of a change in condition for one of three residents (R1) reviewed for a change in condition in the sample of three. Findings include: The facility's Comprehensive Assessment MDS policy, dated 11-1-2017, documents, The MDS shall be re-evaluated according to the following schedule. c. Significant Change in Status-The Interdisciplinary Team shall determine the presence or absence of significant change based on the resident's status during the previous assessment reference period compared with the current assessment reference period. Within 14 days of determination that a significant change in a resident's status: Is not self-limiting, impacts more than one area of the resident's health status and requires interdisciplinary review and/or care plan revision. R1's MDS Assessment, dated 9-5-23, documents R1 ambulated and transferred independently and had no pressure…

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 fingernail care and facial hair grooming for one of three residents (R1) reviewed for ADL (Activities of Daily Living) dependence in the sample of three. Findings include: The facility's Preventative Skin Care policy, dated 01/2018, documents, Keep the resident's fingernails and toenails short and smooth to prevent them from accidentally scratching themselves. R1's Care Plan dated 6-8-23 documents, Provide bathing, hygiene, dressing, and grooming per resident's preference as able. Keep facial hair trimmed-shaved per resident's usual style. Fingernail care on shower day and as needed. On 10-27-23 at 8:25 AM, R1 was sitting in a wheelchair in the hallway. All ten of R1's fingernails were long, jagged, and had brown debris under them. R1's mustache and beard were approximately a half an inch long. R1 stated, I want my fingernails to be trimmed and clean. They need it. They are dirty. I am not sure when they were cut last. I also do not like having hair on my face. I need to be shaved. On 10-27-23 at 8:30…

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 follow their Fall Prevention policy to immediately assess a resident after a fall, document a fall in the resident record, and develop fall interventions immediately after a fall for one of three residents (R1) reviewed for falls with injury in the sample of three. Findings include: The facility's Fall Prevention policy, dated 11-10-18, documents, Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. 5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will place documentation of the circumstances of a fall in the nurses notes and, on an AIM, (Acute Illness Management) for Wellness form along with any new intervention deemed to be appropriate at the time. R1'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 interview and record review, the Facility failed to report a sexual allegation of abuse for one (R6) of three Residents reviewed for abuse in the sample of three. This failure has the potential to affect all Residents 67 residing in the facility. Findings include: Facility Resident Census Roster, dated 8/28/23, documents 67 Residents residing in the Facility. Facility Abuse Prevention Program Policy, revised 11/28/16, documents: the Facility affirms the right of our Residents to be free from abuse as defined below; this Facility therefore prohibits mistreatment or abuse of its Residents, and has attempted to establish a Resident sensitive and resident secure environment; the purpose of this policy is assure that the Facility is doing all within its control to prevent occurrences of abuse of our Residents; implementing systems to investigate all reports and allegations of mistreatment and abuse, promptly and aggressively making the necessary changes to prevent future occurrences; reporting of potential incidents of abuse; this Facility if committed to protecting our…

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 Certified Nursing Assistants received a minimum of 12 hours of in-service training over the past year, and dementia-specific training was administered. These failures have the potential to affect all 60 residents residing in the facility. Findings include: The Facility Assessment (dated 09/21/21) documents the following: Staff training and competencies are required for all departments upon hire and annually. At the time of orientation the Swat program covers many of the required and necessary education needed to begin employment. General training Topics: Care/Management for persons with dementia, Dementia and behavioral de-escalations/redirecting techniques. On 10/19/22 at 09:30 AM, V1 (Administrator) provided In-service Attendance Sheets, which document all training administered to Certified Nursing Assistants (CNAs) that has been conducted since the facility's last annual survey (09/2021). These forms document the following training was administered: Elopement/Wandering; Quality Assurance Reports/Survey Prep;…

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 conduct quarterly Quality Assurance meetings. This failure has the potential to affect all 60 residents within the facility. Findings include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 672 Resident Census and Conditions of Residents dated 10/17/22 and signed by V4 (Minimum Data Set Coordinator), documents 60 residents reside within the facility. The Facility's Quality Assurance (QA) Plan policy (undated), states, The purpose of the Quality Assurance Plan is: to help identify problems and potential problems; To provide information upon which corrective action can be planned; to help analyze the need for policy or procedural changes or in-service training; to act as a record that, when analyzed, will prevent similar mishaps or injuries; and to improve quality of resident care and overall safety in the facility. The Quality Assurance Committee will conduct Quarterly meeting (at a minimum). Quarterly Assurance Committee reviews all the activities of the daily Quality Assurance Team. The Quarterly…

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 ensure residents with Dementia were engaged in therapeutic activities to meet their individual cognitive abilities and provide staff with the appropriate training to meet the needs of residents with Dementia. These failures have the potential to affect all 14 residents (R48, R111, R12, R28, R24, R34, R18, R17, R13, R45, R36, R21 and R57) residing on the facility's Special Care Unit. Findings include: The facility policy titled, Special Care Unit Cognitive/Functional Evaluation (no date), documents, It is the policy of the Special Care Unit to evaluate all residents' cognitive and functional abilities in order to most effectively design and implement therapeutic activities to meet each resident's individual needs. The facility policy titled, Alzheimer's Specific Unit Training Requirements (no date), documents The facility will provide appropriate training to individuals working with residents diagnosed with Alzheimer's and/or Dementia to help meet the residents needs, taking into consideration the severity 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 observation, record review, and interview, the facility failed to ensure privacy during toileting for one of 15 residents reviewed (R57) for privacy in a sample of 44. Findings include: The facility policy titled, Alzheimer's Specific Unit Training Requirements (no date), documents, The facility will provide appropriate training to individuals working with residents diagnosed with Alzheimer's and/or Dementia to help meet the residents needs, taking into consideration the severity of the Alzheimer's/Dementia, the resident's physical abilities, behavior patterns and social and medical needs. The policy indicates training topics are to include, Promoting resident dignity, independence, individuality, privacy and choice. On 10/18/22 at 10:46 AM, upon entering the locked unit (B Wing), which is designated for cognitively impaired residents with Dementia/Alzheimer's Disease, R57 was observed in the unit's common bathroom located in the main hallway. R57 was sitting on the toilet urinating, with the door and privacy curtain open to the hallway. At that time, two male residents…

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 a resident with a known diagnosis of Dementia with Aggression and Behavioral Disturbances was supervised by staff and prevent resident to resident physical abuse, for one of one residents (R18) reviewed for abuse in a sample of 44. Findings include: An Abuse Prevention Program policy, dated 11/26/2016, states, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This policy also states, This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its resident, and 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 mistreatment, exploitation, neglect or abuse of our residents. A Physician's Order Sheet, dated 9/16/22, documents R18 was admitted on [DATE], with…

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 revise a plan of care and develop recommendations for interventions related to weight loss and falls for one of 15 residents (R21) reviewed for Care Plan Revision, in a sample of 44. Findings include: The Facility Policy, titled Resident Weight Monitoring (revised 3/19), documents 7. If there is an actual significant weight change (i.e. +/-5% x 1 month, +/- 7.5% x 3 months, +/- 10% x 6 months), the resident, family/guardian, physician and dietitian are notified. The physician shall be notified using the (physician) notification of weight change form. 8. The Food Service Manager and interdisciplinary team review the resident' weights and nutritional status and make recommendations for intervention. The policy further documents, 11. Significant weight changes are reviewed in the weekly Weight Committee Meeting. The Weight Committee will also identify any trends of gradual weight loss or gain. Significant changes in weights are documented in the care plan with goals and approaches/interventions listed. Monthly Weight…

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 develop and implement services to maintain and/or improve range of motion limitations for two of three residents (R43, R44) reviewed for limitations in range of motion in the sample of 44. Findings include: The facility's Range of Motion Protocol, dated 09/2008, documents, Policy: It is the policy of (the facility) to provide range of motion exercises for residents who through assessment demonstrate the need for exercise to prevent functional decline in range of motion. Procedure: The interdisciplinary team will identify those residents in need and consider the resident's age, diagnosis, prognosis, current joint condition, functional ability, and any mobility restrictions. Parts of the body on which range of motion exercises can be performed include all body joints or only those affected by disease process and may include the fingers, wrist, forearm, elbow, shoulder, toes, foot, ankle, knee, hip, and trunk. Range of motion exercises will be conducted as scheduled by nursing staff based on need determined by…

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

Based on interview, observation, and record review, the facility failed to document a rationale for a decline of a gradual dose reduction suggestion, monitor for behaviors that warrant the use of an antipsychotic medication, document consistent adverse behaviors to justify the continued use of an antipsychotic medication, and conduct a psychotropic medication evaluation as directed by the facility's policy, for two of three residents (R2 and R45) reviewed for antipsychotic medications in the sample of 44. Findings include: The facility's Psychotropic Medication Policy (revised 06/17/22) documents the following: It is the policy that residents shall not be given unnecessary drugs. Unnecessary drug is any drug used: In an excessive dose, including in duplicative therapy; For excessive duration; Without adequate monitoring; Without adequate indications for its use; In the presence of adverse consequences that indicate the drugs should be reduced or discontinued. This same policy documents, Any resident receiving such medications shall have a psychiatric diagnosis or documented evidence…

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.