Clark Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide necessary services that are consistent with professional standards to prevent the development and worsening of pressure ulcers. The facility failed to a. follow the provider order in the prevention of pressure injury for one resident (R44), b. follow policy and manufacturer directions when adding multiple layers on low air loss mattresses for two residents (R212) and (R91) and c. provide adequate supervision for low air loss devices to prevent accidents for one resident (R158) out of a total sample of thirty-five residents. Finding include: On 05/14/24 10:00AM R91 observed in bed with a drive low air loss mattress head of bed elevated. R91 observed laying on one fitted sheet, two incontinent cloth pads and a folded flat sheet used for a draw sheet along with adult brief. On 05/16/24 11:00AM PM surveyor accompanied with V27 and V10 observed R158 lying in bed on air mattress g-tube infusing rate of 60ml/hr. Observed V27 and V10…

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 one (R221) resident had access to call light of six residents reviewed for call lights in a sample of 35 reviewed. Findings include: Minimum Data Set, 2/21/2024, Brief Interview for Mental Status score indicates R221 has moderate cognitive impairment; does not have behavioral concerns with inattention, disorganized thinking, altered level of consciousness. Nursing-Admission/readmission UDA, 2/14/2024, call light evaluation indicates R221 is cognitively able to use the call light and is able to call for assistance by pulling the call light string with the use of the right and left finger(s), hand or arm. On 5/14/24 at 12:29 PM, observed R221 lying in bed watching television. The call light was observed clipped to the upper right corner of R221's pillow that was behind R221's head. No part of the string draped to the front of the pillow. R221's call light system consists of a string that reaches from a toggle switch located on 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 observations, interviews and records review, the facility failed to protect one (R101) resident's personal and confidential information of 6 residents reviewed for patient information protection in a sample of 35. Findings include: On 5/14/2024 at 10:02am during inspection of the medication cart on the 5th floor with V28 (Licensed Practical Nurse-LPN), V28 was observed going to the medication room and leaving her computer on, with the computer screen displaying R101's picture, medical and personal information. The computer screen was observed facing the main hallway of the unit, and it was visible to staff members and residents passing by. V28 stated she should have closed or made sure the contents of the screen were hidden and not visible to anyone (public) because that's a HIPAA (Health Insurance Portability and Accountability Act) violation. V28 stated she should have closed the computer, but since she was not going far, she didn't think she needed to close the computer. On 5/14/2024 at 12:44pm, V4 (Assistant Director of Nursing-ADON) stated computer screen needs to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to initiate a new Level I screen for a resident with a known mental illness for one (R223) resident reviewed for Pre-admission Screening and Record Review (PASARR) in a sample of 35. Findings include: R223's Face sheet documents that R223 was admitted to the facility on [DATE] with diagnoses not limited to: Schizoaffective Disorder Bipolar Type. R223's Level II PASARR outcome letter documents that R223 has a short-term approval without special services dated [DATE] with an expiration date of [DATE]. R223's Level II PASARR outcome letter documents in part, This determination allows you a limited number of days in a Medicaid-certified nursing facility. The short-term approval will end on the Date Short Term Approval Ends listed on the Notice of PASRR Level II Outcome that came with this letter. If you or your care provider thinks you need to stay after that date, a nursing facility staff member must submit a new Level I screen. The new Level I screen must…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow physician order policy for prescribed gastrostomy tube feeding rate. This failure affected one (R4) resident reviewed for tube feeding in a sample of 35. Findings Include: On 05/14/24 at 01:26 PM, observed R4 lying in bed with HOB/head of bed elevated, and tube feeding infusing. Observed 1.2-liter (L) bottle of Jevity 1.2 hung with label listing date (05/14/24) and hang time (9:00 AM). Observed tube feeding infusing at 55 milliliters (ml) per hour (hr.). On 05/14/24 at 01:57 PM, V15 (Registered Nurse) stated V15 knows R4 well and has taken care of R4 before. V15 stated V15 follows R4's tube feeding orders listed in R4's electronic health record (EHR) ordered by R4's physician. V15 stated R4 is NPO (nothing by mouth) and receives Jevity 1.2 at 55 ml/hr via gastrostomy tube. V15 stated V15 hung R4's tube feeding bottle at 9:00 AM this morning and set the rate at 55 ml/hr. On 05/14/24 at 02:00 PM, surveyor went with V15 to view R4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records review, the facility failed to follow their policy on controlled drug count by failing to accurately count and reconcile controlled medication record/log for three (R220, R492, R211) of six residents in a sample of 35 reviewed. Findings include: R220 current face sheet documents R220 is a [AGE] year-old individual with medical diagnoses that include but not limited to: bipolar disorder, current episode mixed, severe, without psychotic features, attention-deficit hyperactivity disorder, unspecified type, generalized anxiety disorder, osteomyelitis, unspecified. R220's POS (Physician Order Sheet) documents Active 10/11/2023 - Lyrica Capsule 150 MG (Pregabalin) -Give 1 capsule by mouth two times a day for Nerve pain related to chronic pain syndrome Active 10/11/2023-clonazePAM Oral Tablet 0.5 MG (Clonazepam) -Give 1 tablet by mouth three times a day related to generalized anxiety disorder Active 04/17/2024-Adderall Oral Tablet 20 MG(Amphetamine-Dextroamphetamine) - Give…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and review of records, the facility failed to protect a resident's right (R15) to be free from physical abuse and failed to address continuing abusive behaviors of a resident (R4). These failures affected 2 residents (R4 and R15) out of 5 residents (R4, R9, R10, R11, and R15) reviewed for abuse. These failures resulted to R4 requiring hospitalization for psychiatric evaluation and R15 being transferred to local hospital after sustaining skin tear on left eyebrow. Findings include: R4 is [AGE] years old, initially admitted on [DATE]. R4 has diagnoses of seizure, and schizoaffective disorder bipolar type. R4's minimum data set assessment dated [DATE] shows R4 scored 15 indicating that R4's cognition is intact. On 10/31/2023 at 11:38 AM, R4 was seen sitting in his wheelchair talking to himself. R4 agreed to talk in his room and was able to answer questions within topic. R4 stated that he sometimes has disagreements with other residents but cannot remember who those other 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.

Based on interviews and records reviewed, the facility failed to report and initiate an investigation of an injury of unknown source in the time frame required resulting in the delay of the investigation. This failure affected 1 resident (R3) out of 15 residents reviewed. Findings include: On 11/01/2023 at 1:15 pm V2 (Assistant Administrator -AADM) states R3 was sent to the hospital due to lethargy; it was the nurses and the CNAs and the supervisor who found out that she was lethargic, and R3 was sent to the hospital in the same day. On 11/01/23 at 1:17 pm V1 (Administrator) states when we were reviewing the hospital paperwork, we saw the diagnosis. The liaison updated us on the 9/8/23 about the hospital diagnosis based on the CT scan results. Based on this information received, we initiated the investigation. On 11/01/23 at 1:19 pm V2 (AADM) says Once we learned about the diagnosis on 9/8/23, we started interviewing staff to see if there was a fall. R3 was on 1:1 supervision after she came back from the hospital in April due to the fall incident. Staff said there was no fall…

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, interviews, and review of records, the facility failed to follow policy in discarding expired medications for 1 out of 3 residents (R4) for a total of 4 residents reviewed for insulin medication. This failure has the potential to affect 1 resident (R4) in receiving quality insulin. Findings include: R4 is [AGE] years old, initially admitted on [DATE]. R4 has medical diagnosis that include diabetes mellitus. R4's medication list includes injectable insulins and oral medication for diabetes. R4 currently has an order to check blood sugar four times every day. At the nurse's station on 8/22/2023 at 10:49 AM with V6 (Registered Nurse) medication cart was reviewed. R4's insulin (Lantus) vial was seen, and it was written as follows: Date Opened 7/23/2023 and Date Expired 8/19/2023. V6 said, Yes, that was expired. It should have been taken out of the medication cart and discarded. Expired insulin is not as effective as insulin that is not expired. The right thing to do is to take it out of the…

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

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for 1 resident (R1) out of 4 residents reviewed for call lights. Findings include: R1's diagnosis includes, but are not limited to, parkinson's disease, methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, hypotension, unspecified, fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, history of falling, dysphagia, oral phase, urinary tract infection, site not specified, vitamin d deficiency, gastro-esophageal reflux disease without esophagitis, generalized anxiety disorder, regular astigmatism, left eye, hypermetropia, bilateral, presbyopia, age-related nuclear cataract, bilateral, other hyperlipidemia, paranoid schizophrenia, other constipation, essential (primary) hypertension. R1 has a Brief Interview for Mental Status (BIMS) dated 7/20/2023 which documents that R1 has a BIMS score of 10, indicating R1 has some moderate cognitive impairments. On 8/15/2023 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 observations, interviews, and review of records the facility failed to follow multiple policies related to the following: Failed to maintain ice free from outside leaks coming from sanitary source or exposed to unsanitary surface. Failed to prepare food free of contact to object that sanitation was not maintained. Failed to store fruits inside walk in cooler fruits that are without molds and discolorations to prevent possible serving to residents. Failed to label food in dry storage that are opened. Failed to follow FIFO (first-in first-out) policy on canned fruits in dry storage room These failures have the potential to affect 229 residents who is taking food by mouth in receiving quality dietary services. Findings include: On 05/30/2023 at 10:09 AM. Surveyor observed V4 (Food Service Director) inside walk in cooler, a few inches under the condenser were a bag of fries, bags of cauliflower, peas and carrots not dated. V4 stated that food items when taken out of the box should be dated. Surveyor notes at the Dry Storage room ice machine on top of the ice compartment…

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 observations, interviews, and review of records the facility failed to remove garbage in a safe and efficient manner per policy to prevent garbage from overflowing with lids to contain garbage in order to not be exposed near food. These failures have the potential to affect 229 residents who is taking food by mouth in receiving quality dietary services. Findings include: On 05/30/2023 at 10:09 AM. Surveyor observed V4 (Food Service Director) at the stove area that food where being cooked and prepared garbage bin was full of garbage that lid cannot be closed. V4 stated I will notify the staff to empty the trash. V4 was asked for the schedule when to dispose garbage near food? V4 stated, The garbage needs to be discarded. On 05/31/2023 at 9:14 AM. V6 (Regional Director for Dietary) stated, There is a schedule for when garbage is to be discarded. V6 stated sometime when dietary staff are still doing food preparation they wait to be done and dispose garbage. V6 was asked if it is proper procedure to wait until garbage overflows to discard? V6 did not reply. On 06/01/2023 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 observations, interviews, and review of records the facility failed to place signs per policy for two residents (R168 and R176) who are in contact precautions for diagnosis of infectious disease. These failures have the potential to spread infection for all persons entering the room without taking proper precautions. This failure has the potential to affect all 234 residents. Findings include: On 05/30/2023 at 11:47 AM V12 (Registered Nurse) informed writer that there are two residents that are on contact isolation or on contact precautions. V12 stated, You need to use full PPE (Personal Protective Equipment) when entering rooms of R168 and R176. R168 has KPC (Klebsiella Pneumoniae) infection in his rectum and R176 has C. Diff (Clostridioides difficile) infection. At 12:20 PM, in the hallway at R168's room there was no posting or information that R168 was on contact isolation/precaution. Surveyor notes signage Enhanced Barrier Precautions that instruct Providers and Staff to use PPE. V12 was asked why the signage does not include other persons besides Providers and Staff.…

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

Based on observations, interviews, and review of records the facility failed to address maintenance issues with the ice machine that was exposed to leakage from an unclean source. These failures have the potential to affect 229 residents who is taking receiving ice use for daily consumption. Findings include: On 05/30/2023 at 10:09 AM. Surveyor observed V4 (Food Service Director) at Dry Storage room ice machine on top of the ice compartment dripping water was passing through the lid cover. Once lid open in a sliding upward motion, water from the machine on top dripped and entered ice storage where all the ice was located. V4 stated, Yes, this ice is being used by all residents. It should not be doing that. I will inform maintenance. On 05/31/2023 at 9:14 AM. Surveyor observed V6 (Regional Director for Dietary) inside the dry storage room where the ice maker is still dripping, when opened it dripped again inside the compartment full of ice. V6 stated, I will put a sign not to use ice maker. V6 stated I already notified V21 (Maintenance Director). They should have done this yesterday.…

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 two medication carts were free of expired medications. This failure has the potential to effect 25 residents receiving medications from the medication cart on the 1st floor and R22 receiving insulin from the medication cart on the 3rd floor. Findings include: On 5/30/23 at 10:15 AM, surveyor observed 1st floor medication cart with V12 (Registered Nurse). Surveyor notes Melatonin 1MG tablets with best by date of 4/23. On 5/31/23 at 9:45 AM, surveyor observed 3rd floor medication cart, 2nd side, with V19 (Registered Nurse). Surveyor notes Humalog Mix 50/50 KwikPen/Insulin Lispro Protamine and Insulin Lispro 3ML, opened date 5/30/23, Manufacturer Expiration date of 4/8/2023. Surveyor notes labeling documents in part that the medication was prescribed to R22. R22 has diagnosis that include but are not limited to Type 2 Diabetes Mellitus. On 5/30/23 at 10:25 AM, V12 (Registered Nurse) stated there should not be expired medications in the medication cart. V12 state the medication is not good after 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 observations, interviews and records review, the facility failed to ensure food served was palatable, attractive, and appetizing for four (R164, R145, R57, R155) residents reviewed for food quality in a sample of 35. Findings include: On 05/30/23 at 11:30 AM, V22 (Ombudsman) stated that the main issues she usually faces at this facility is the food. V22 stated the food quality is poor at this facility. On 05/30/23 01:10 PM, R145 was observed in her room with her lunch tray on the side table, with the food uneaten. Surveyor notes honey glazed ham, seasoned roasted cabbage, braised red cabbage, dinner roll, lemon pudding, hot tea/coffee, and margarine. R145 stated the food at the facility did not taste good and even if she requested a meal alternative, it was very rare to get it. R145 stated she relies on family members to bring her food from home for her to get the nutrition she needs. R145 stated she is losing weight because the food does not taste good and sometimes, they get served very little potions. R145 stated family brought her fruits, cereals and other refreshments…

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 menu and provide a nutritionally equivalent product (due to making a food substitution change) for residents on mechanically altered diets and 2-gram Na (sodium) diets. This failure has the potential to affect all 16 residents receiving pureed diets, 29 residents receiving mechanical soft diets, 2 residents receiving 2 gm Na diets and 7 residents receiving 2 gm Na/low fat/low cholesterol diets of those reviewed for food and nutrition services. Findings Include: On 09/18/22 at 11:58 AM, the following items were observed being served on the tray line for lunch service: 1 breaded chicken patty, # 8 scoop mashed potatoes, 4 oz. broccoli, 3 oz. ground breaded chicken, #10 scoop pureed breaded chicken, #8 scoop pureed broccoli, 2 oz. chicken gravy. On 09/18/22, during lunch tray line observation surveyor observed residents on mechanical soft diets receiving the following items for lunch: 3 oz. ground breaded chicken, 2 oz. chicken gravy, #8 scoop mashed potatoes, 4 oz. broccoli, 1 dinner roll, 1 slice 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 observations, interviews and record review the facility failed to ensure food was served in a sanitary manner for 5 residents (R7, R25, R36, R84, R176) receiving dessert served from the kitchen and beverages served on the second-floor unit. Findings include: On 9/18/22 at 12:17 PM during the second-floor dining observation, V8 (Certified Nursing Assistant) was observed passing residents' room trays that were placed on a 3-tier uncovered rolling cart. Food trays were observed with uncovered apple pie desserts and uncovered lemonades. From 12:17 PM to 12:35 PM, surveyor observed V8 serve R36, R7, R84, R176, and R25 with uncovered apple pies and uncovered lemonades on their lunch trays. At 12:36 PM, an interview conducted with V8. V8 stated that the desserts on the food tray should be covered because germs and bugs could get into the food. V8 stated that all foods and drinks should be covered. V8 stated that if food is not covered it could get contaminated and could cause the residents to get sick. V8 stated, Normally they cover the foods. I don't know why they're not covered…

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 properly store the ice scoop and wash the portable ice coolers for the residents residing on floors 2 through 5. This deficient practice has the potential to affect all 55 residents on 2nd floor, all 49 residents on the 3rd floor, all 57 residents on the 4th floor and all 56 residents on the 5th floor that receive ice from portable coolers on the unit of those reviewed for infection control. Findings include: On 09/18/22 at 1:41 PM, surveyor observed metal ice scoop sitting on top of a portable plastic cooler containing ice in the 4th floor unit utility room. No storage bag or separate storage container observed for the ice scoop. On 09/18/22 at 1:55 PM, surveyor observed plastic ice scoop sitting on top of a portable plastic cooler containing ice in the 5th floor unit utility room. No storage bag or separate storage container observed for ice scoop. On 09/18/22 at 1:57 PM, surveyor observed plastic ice scoop sitting on top of a portable plastic cooler containing ice in the 3rd floor unit utility room. 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 observations, interviews and record reviews, the facility failed to maintain accurate code status orders that follow a resident's (R87) POLST (Physician Orders for Life-Sustaining Treatment) form and failed to remove a resident's (R108) hospital bracelet that was not consistent with the resident's code status for 2 of 35 residents reviewed for Advanced Directives. Findings include: On [DATE] at 10:49 AM, R87 oriented to person, city and year. R87 stated [R87] would like to be resuscitated if anything happens to [R87]. At 11:45 AM, surveyor reviewed R87's POS (Physician Order Sheet) and comprehensive care plan. POS documents in part a DNR (Do Not Resuscitate) code status dated [DATE] created by V5 (Nurse). R87's comprehensive care plan initiated [DATE] documents in part that R87 is a DNR. At 11:55 AM, surveyor reviewed R87's POLST in the EMR (Electronic Medical Records). POLST signed by R87 on [DATE] documents in part that R87 wants staff to Attempt Resuscitation/CPR (Cardiopulmonary Resuscitation),…

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 observations, interviews and record reviews, the facility failed to (a) assess the removal of a resident's (R219) urinary catheter as soon as possible, (b) provide a dignity bag for a resident (R219) and (c) keep a resident's (R108) urinary catheter bag off the floor for 2 of 3 residents reviewed for catheters. Findings include: On 09/18/2022 at 10:43 AM, surveyor observed R108's urinary catheter bag laying on the floor. At 11:10 AM, surveyor proceeded to R219's room. From the hallway, surveyor could see R219's urinary catheter bag hanging from the bed frame. Urinary catheter bag was not in a privacy bag. At 4:50 PM, surveyor reviewed R219's discharge hospital records from a recent readmission. Hospital records printed 9/11/2022 4:28 PM document in part on page 7 of 7: Please evaluate for [urinary catheter] removal at NH [nursing home]. On 09/19/2022 at 2:45 PM, V14 (Nurse) stated R219 went to the bathroom and voided independently prior to recent hospitalization. At 2:57 PM, V13 (Certified Nurse Aide) stated R219 went to the bathroom and voided independently prior to recent…

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 properly label an opened insulin vial for 1 (R166) out of 1 residents reviewed for insulin in a sample of 35 residents. Findings Include: On [DATE] at 11:10 AM, the 5th floor medication cart 2 was inspected with V21 (Licensed Practical Nurse). A 10ml vial of 70/30 insulin for R166 was stored in medication cart with no open date on the vial. On [DATE] at 11:10 AM, V21 (Licensed Practical Nurse) stated, insulin should have an open date written on the vial when it is opened. The open date lets you know when to discard the insulin. Insulin is only good for 28 days. Whoever opened this insulin must have forgot to put an open date on it. On [DATE] 11:25 AM, V3 (Director of Nursing) stated, insulin should be dated with an open date, so you know when to dispose of it. Insulin should be discarded 28 days after it is open. After 28 days 70/30 insulin is expired. R166 was admitted to the facility on [DATE], with diagnosis, not limited to, diabetes…

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, interviews and records review, the facility failed to provide dental services for one resident (R171) reviewed for dental care, in a sample of 35 residents. Findings include: R171 is a [AGE] year-old individual admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) dated [DATE], document R171 scored 13/15, indicating R171 has slight cognitive disability. 09/18/22 12:35 PM, R171 was observed laying down. R171 was alert and oriented to person, place, and day. R171 stated that because R171 has only two teeth remaining, R171 found it difficult to chew food, and R171 stated swallowing was hard because R171 was not able to chew food completely because of missing teeth. R171 opened R171's mouth to show R171 had only two upper teeth remaining. R171 stated that R171 would like partial or complete dentures. R171 stated having partials or full dentures would help R171 eat better and feel better. R171 stated that no one at the facility has ever offered to assist R171 with a dental…

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.