St James Wellness Rehab Villas

Based on observation, interview, and record review the facility failed to maintain the kitchen dishwasher and sink in good repair. This applies to 80 residents in the facility receiving dietary services. Findings include: On 12/05/24 10:55 AM, V26 (Dietary Manager) stated 80 residents were served from dietary services on 12/3/24. On 12/03/24 at 10:33 AM, V26 was unable to run the dishwasher stating it is currently not working. The trough like sink near the dishwasher was filled with dirty water. Covered shelves containing neatly stacked dishware declared clean by V26 Dietary Manager and V27 Assistant Dietary Manager were caked with yellow crusts, dried food, and small dead black bugs. On 12/03/24 at 10:42 AM, V27 Assistant Dietary Manager stated the dishwasher and sink have been backing up and not working since June. A shop vac is used to remove the water from the sink when it backs up. Dishes are either washed in the three-compartment sink for resident use or we use paper / disposable plates. On 12/04/24 at 12:08 PM, V33 Dietary Aide states residents' meals are served on Styrofoam…

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 provide a resident and/or their family/POA (POA/Power of Attorney) in writing of the reason for transfer to the hospital. The facility also failed to notify the ombudsman of the transfer. This applies to 6 of 6 residents (R26, R35, R50, R68, R72, and R73) reviewed for discharge in a sample of 30. The findings include: 1. R26's Face Sheet showed R26 was admitted to the facility on [DATE]. R26 had multiple diagnoses which included multiple sclerosis, dementia, diabetes, emphysema, hypertension, and major depressive disorder. R26's MDS (Minimum Data Set) dated 11/04/24 showed R26 had severe cognitive impairment. R26's Progress Notes showed the following: 08/20/24 at 6:45 PM Writer called to resident room by CNA'S (Certified Nursing Assistant). Resident noted slow to respond to verbal stimuli, as her normal baseline is AOX4, ashen color to skin noted, skin diaphoretic warm to touch. Noted for bloody (dark red) stool or urine, unable to determine which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide in writing to the residents and/or their POA (POA/Power of Attorney) regarding bed hold and return at the time of discharge to the hospital. This applies to 6 of 6 residents (R26, R35, R50, R68, R72, and R73) reviewed for discharge in a sample of 30. The findings include: 1. R26's Face Sheet showed R26 was admitted to the facility on [DATE]. R26 had multiple diagnoses which included multiple sclerosis, dementia, diabetes, emphysema, hypertension, and major depressive disorder. R26's MDS (Minimum Data Set) dated 11/04/24 showed R26 had severe cognitive impairment. R26's Progress Notes showed the following: 08/20/24 at 6:45 PM Writer called to resident room by CNA'S (Certified Nursing Assistant). Resident noted slow to respond to verbal stimuli, as her normal baseline is AOX4, ashen color to skin noted, skin diaphoretic warm to touch. Noted for bloody (dark red) stool or urine, unable to determine which orifice blood is coming from.…

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 ADL care (Activities of Daily Living) for 5 residents (R20, R69, R10, R62, & R5) who are dependent on care for daily living in a sample of 30. The findings include: 1. On 12/3/24 at 10:51 am R10 was observed with long jagged nails, white flakes of skin on the right upper side of his gown next to his face and his face had dry flaking skin. R10's 11/12/24 MDS (minimum data set) section C showed that R10's cognition is severely impaired. R5's 11/12/24 MDS section GG showed that R10 is dependent on staff for personal hygiene. R10's 3/8/24 care plan showed that R10 is dependent on ADLs with approaches including provided assistance with ADLs as needed. On 12/05/24 11:02 AM V1 DON (Director of Nursing) said that nail care and skin care should be provided as needed. 2. On 12/03/24 at 10:10 AM R20 was observed with long jagged fingernails. R20's 11/24/24 MDS section GG showed that R2 needs partial/moderate assistance for hygiene from staff. On 12/05/24 at 10:15 AM V2 said R20 should not have long jagged nails…

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 have fall interventions in place for 4 residents (R20, R51, R71, & R83) who are at risk for falls in a sample of 30. The findings include: 1. On 12/03/24 at 10:10 AM, R20 was standing up next to his bed, his wheelchair on the side of his bed, out of R20 reach. R20 was wearing only socks, and the socks were not non-skid or slip resistant. R20's electronic health record showed that R20 has a history of falls, 10/20/24 Fall report, and 12/12/23 Fall report, and 6/22/24 Quarterly fall report all show that R20 is a high risk for falls. R20's 10/21/24 care plan showed that R20 is at risk for falling related to nontraumatic intracranial hemorrhage, spastic hemiplegia with approaches including provide proper, well-maintained footwear. On 12/05/24 at 09:15 AM R20 was in his room sitting in his wheelchair, V2 (Director of Nursing) and the R20 without shoes and wearing socks that were not non-skid. V2 said that R20 should be wearing proper footwear.…

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 obtain physician orders for over-the-counter medications and to have medications stored in resident rooms. This applies to 6 of 6 residents (R13, R58, R66, R67, R72 and R73) reviewed for medications in the sample of 30. The findings include: 1. On 12/3/24 at 10:26 AM, R73 was observed in bed watching TV. R73 had a bottle of eye vitamin and mineral supplement on a dresser in his room. R73 said he has been using it for two years. On 12/4/24 at 9:42 AM, the bottle of eye vitamin and mineral supplement was still noted in R73's dresser. On 12/5/24 at 10:03 AM, the bottle of eye vitamin and mineral was still in R73's room. Review of R73's Electronic Medical Records (EMR) shows that R73 has the following diagnoses of glaucoma. R73's Minimum Data Set (MDS) of 9/18/24 shows that R73's cognition is intact. Review of R73's current physician order was done, R73 did not have an order for eye vitamin and mineral and did not have an order for 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.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene during provisions of bowel/bladder care and wound care, no signage for residents in EBP (Enhanced Barrier Precautions), improper disposal of PPE (Personal Protective Equipment), and improper practices for residents on transmission base precautions. This applies to 8 residents (R83, R54, R59, R62, R88, R13, R39, R73) reviewed for infection control in the sample of 30. The findings include: 1. On 12/3/24 at 11:21 am V8 (Certified Nurse's Assistant) was providing incontinence care for R83, V8 begins to attach a brief to R83 rolling him back and forth on the bed, then she removed his soiled gown, then V8 repositioned R83 in his bed, then she turns the volume down on his TV controller, returns to applying his brief, adjusts his sheet, adjust the bed height, then adjusts R83 again in his bed and touches the top of R83's bedside table. V8 did all of this without removing her gloves and cleaning her hands after removing the soiled gown. 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 properly position resident's indwelling catheter bag/drainage bag during wound care dressing change. The facility failed to provide incontinent care to residents in a timely manner. This applies of 6 of 6 residents (R14, R24, R29, R71, R73 and R83) reviewed for indwelling catheters and incontinent care in a sample of 30. The findings include: 1. On 12/4/24 at 9:54 AM, V13 (Registered Nurse/RN) was gathering supplies outside of R73's room for wound care dressing change. At 9:58 AM, V16 (Certified Nurse Aide/CNA) was already in R73's room providing care. R73's catheter drainage bag was on the right side of the bed, not below the bladder. V13 approached R73 and informed him of the wound dressing change, and instructed V16 to turn R73 on his left side so she could access the wounds on R73's back and sacral area. R73's catheter drainage bag was on the bed throughout the wound dressing change, backflow of urine was noted in the catheter tubing.…

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 that 2 residents (R5 & R10) received oxygen as their physician ordered in a sample of 30. The findings include: 1. On 12/03/24 at 01:33 PM, R5 observed in bed with oxygen on at 2 liters per minute through a nasal canula. On 12/05/24 at 11:22 AM R5 observed in her bed with oxygen on at 2 liters per minute through a nasal cannula. V2 DON (Director of Nursing) was present at the time. On 12/05/24 at 11:12 AM V2 said while looking at R5 EHR (Electronic Health Records), that R5's records showed that she is to be on 4 liters of oxygen continuously. R5's 11/26/24 Physician's Order showed, Oxygen: Nasal Cannula. Rate 4 liters/Min. Humidity 100 %. Continuous. 2. On 12/03/24 at 10:51 AM R10 observed in his bed with his nasal canula not in his nostrils but around his neck. At 10:56 AM to 11:03 AM V6 was in R10 room adjusting his bed and repositioning him in his bed but did not put his oxygen cannula in his nostrils. V6 did not put R10's oxygen on him until the State Surveyor brought it to her attention that R10…

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 residents' call light system was functioning properly. This applies to 2 of 2 residents (R39 and R42) reviewed for functioning call lights in a sample of 30. The findings include: On 12/3/24 at 12:06 PM, R39 in bed. R39's sister was also at her bedside. R39 said her call light has not been working for a while. R39 said she either yells out for help or asks her roommate to use her call light when she needs help. R58 (R39's roommate) said she does use her call light to call for staff assistance when R39 needs help. R58 said they have told staff about the call light not working. At 12:07 PM, surveyor pushed R39's call light, the light did not come on in her room or outside her room. Review of R39's Electronic Medical Record shows that R39 has the following diagnoses of metabolic encephalopathy, dementia, convulsions, shortness of breath and delusional disorders. R39's Minimum Date Set of 9/25/24 shows that R39's cognition is moderately impaired and is dependent on staff for toileting hygiene,…

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 notify a Physician for a resident change in condition. This applies to 1 of 3 residents (R1) reviewed for change in condition in a sample of 3. The findings include: On 9/8/24 at 9:50 AM, R1 stated that on last Friday, 8/30/24, from around 6pm - 630 pm, he began vomiting and having diarrhea until 8:00 AM the next morning. On 9/7/24 at 10:20 AM, V9 CNA (Certified Nurse's Assistant) stated that last Friday, 8/30/2024 she was R1's CNA for 1st and 2nd shift. V9 stated that during 2nd shift, R1 had 2 episodes of vomiting where she and V3 (Nurse) each emptied a wash basin of emesis. V9 stated that she also changed R1's linen 5 to 6 times because R1 had 4-5 episodes of diarrhea during 2nd shift and the last episode was around 10 pm - 10:30 PM. V9 stated that she notified V3 of R1's episodes of vomiting and diarrhea and she recorded his bowel movements but the electronic charting only allows to chart bowel movement once per shift, so she recorded his bowel movements as large. On 9/7/24 at 3:17 PM, V3 (Nurse) stated that he did 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 observation, interview, and record review, the facility failed to follow its Covid-19 infection control policy and The State Agency guidelines on COVID-19 by having COVID-positive residents and asymptomatic/COVID-negative residents in the same room to prevent a potential outbreak. This applies to 4 of 8 residents (R1, R3, R5, and R7) reviewed in a sample of 9. The findings include: R1 was a [AGE] year-old female admitted on [DATE] with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. R2 (R1's roommate) is a [AGE] year-old female admitted on [DATE] with mild cognitive impairment as per MDS dated [DATE]. On 12/15/23 at 2:10 PM, R2 was observed in her wheelchair in her room and stated, I tested COVID-19 positive almost two weeks ago. I remain in my room with my roommate (R1). Record review on laboratory report dated 12/01/23 documented COVID-19 positive test result for R2. On 12/15/23 at 12:10 PM, V2 (Director of Nursing / DON) stated, R1 was exposed to COVID-19 as her roommate…

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 conduct water testing and monitoring to prevent waterborne pathogens, this applies to 71 of 71 residents that reside in the facility. The facility also failed to identify and properly store resident personal care items and perform hand hygiene during incontinence care. This applies to 7 of 7 residents (R1, R30, R40, R44, R52, R53, R169) reviewed for infection control in a sample size of 24. The findings include: 1. On 11/15/23 at 2:16 PM, V11 (Maintenance Director) stated the facility does not regularly test for legionella or other water borne pathogens. Water testing is only done if they have a suspicion there may be an issue. V11 did not provide any documentation for water testing conducted at the facility. V11 did not provide any water temperature logs or water system flushing records. On 11/16/23 at 1:01 PM, V14 (Infection Preventionist) stated the facility does not routinely test for legionella or other water borne pathogens. V14 did not know when water testing for pathogens was last completed. 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 provide personal hygiene assistance to meet the needs of residents. This applies to 8 residents (R49, R65, R19, R26, R46, R7, R51, and R20) reviewed for ADL's (Activities of Daily Living) in a sample of 24 residents. The findings include: 1. R49's Face sheet shows an admission date of 8/31/23. R49's MDS (Minimum Data Set) dated 9/6/23 showed R49's cognition is moderately impaired, and he requires one-person physical assist for shaving and moderate assistance for personal hygiene including bathing and washing hair. On 11/15/23 at 3:14 PM, R49 was noted to have unkempt and uneven facial hair, dry skin flakes all over his sweatshirt, shoulder length greasy hair covered with a hat, and a strong body odor. R49's mustache was noticeably longer on the right side of his lip than the left, and the hair on his face, chin, cheeks, and neck was all different lengths. R49 said he wanted his beard shaved and the staff does not offer to shave him. R49…

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 place a bed in a safe position. This applies to 1 of 1 resident (R170) reviewed for falls in a sample of 24. Findings include: On 11/14/23 at 11:55 AM, R170 was observed in her bed and her bed was in a high position. At 1:14PM V3 (Nurse) came into R170's room with the surveyor and observed R170's bed still in a high position. V3 lowered R170's bed to lowest position and said R170's bed should not be in that high position because she could fall, and that it is a fall risk. On 11/16/23 at 11:39 AM, V2 Director of Nurse's (DON) said that residents' beds should not be left in high positions when they are in it because they can fall out of the bed. R170's electronic health record showed that R170's mental status is severely impaired. R170's 11/2/23 fall risk observation showed a score of 11 making R170 a high risk for falls. R170's care plan showed R170 had a risk related to falling, related to impaired mobility, actual fall, and dementia, with approaches including, keep bed in lowest position with brakes…

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 provide proper incontinence care for 2 of 2 residents (R30 and R52) observed for incontinence care in a sample of 24. Findings include: On 11/14/23 at 1:02 PM, R30 was observed in his room in his wheelchair. R30 was calling for help and said he needed his brief changed. At 1:08 PM, R30 was again heard calling for help and V7 & V8 CNAs (Certified Nurses' Assistants) were in the hall near R30's room. At 1:11PM again R30 is heard calling out for help and again V7 and V8 are observed by R30's room. At 1:24 PM, V3 calls V7 and V8 to R30's room to provide incontinence care for R3. At 1:27 PM, V7 and V8 came to R30 room and assisted R30 to his bed and with gloved hands removed his soiled pants. R30's pant legs had a large amount of liquid stool in them. V7 and V8 then opened his soiled brief. V8 began wiping around R30's penis and not folding or changing the wipe as she cleaned the area. R30's perineal area was observed reddish in color. V8…

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 contain reusable nebulizer treatment masks, and BIPAP masks (bilevel positive airway pressure). This applies to 3 residents (R3, R20, & R45) reviewed for respiratory care in a sample of 24. Findings include: 1. On 11/14/23 at 12:31 PM, a BIPAP mask and a nebulizer mask was observed on R3's bedside drawer, not covered. R3's electronic health record showed that R3 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease. R3's care plan showed R3's has a risk for respiratory distress related to chronic obstructive pulmonary disease (COPD), with approaches including provide medication as ordered. R3's Physician Order Sheet showed an order dated 8/31/21 for CPAP/BIPAP at bedtime, on 8/31/23 order for Nebulizer with mask, and an order for Albuterol sulfate solution for nebulization every 4 hours. 2. On 11/14/23 at 10:45 AM, a nebulizer mask was observed not covered or…

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

Based on observations, interviews, and record reviews, the facility failed to appropriately store medications and biologicals safely for 2 residents (R34, R173) in a sample of 24. Findings include: 1. On 11/15/23 at 11:00 AM, one 3-ounce bottle of antifungal powder with miconazole Nitrate 2% was observed on R34's dresser. R34's electronic health record did not show an order for self-medication or to have medications at bedside. R34's 8/18/23 order showed an order for miconazole nitrate powder 2% to be applied under skin folds twice daily 8am and 4pm. 2. On 11/14/23 at 12:53 PM, one prescription bottle of antifungal powder with R34's name on it (R34 stays in a different room), and one prescription tube of Menthol-zinc oxide ointment with R173's name on it, was observed on R173's dresser. R173's 11/17/23 physician order sheets did not show any orders for self-medication, to have medications at bedside, or orders for Antifungal powder 2% or Menthol-zinc oxide ointment. On 11/16/23 at 11:22 AM, V2 Director of Nurses said that residents should not have medications at their bedside if…

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 provide a safe environment for 1 of 1 resident (R20) in a sample of 24. Findings include: On 11/14/23 at 10:45 AM, R20's bedroom window frame was observed with about a six-inch sharp, jagged, pointed, broken piece of wood and outside light could be seen coming through. R20 said that he can see outside and that it was cold in his room last night because the air was coming through the broken window. On 11/16/23 at 9:27 AM, R20's window was observed with caulking around the window and a piece of foam around the broken jagged wood. R20 said that about 2-3 weeks ago he reported the window and the heat to V1 (Administrator). R20 said V1 told him he was going to send the maintenance man to his room, or he would put R20 in another room. R20 said that nobody came to fix it until about a week ago. R20 said he call the maintenance man to his room and told him about the window and the heat, and V11 said he was going to do something about it. On 11/16/23 at 2:48 PM, V1 (Administrator) said that about a week ago R20…

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 standard nursing practices with regards to hand hygiene and glove changing during provisions of incontinence care. This applies to 4 of 4 residents (R14, R15, R61 and R22) reviewed for improper nursing in a sample of 20. Findings include: 1. On 3/14/23 01:15 PM, V8 (Certified Nursing Assistant/CNA) rendered incontinence care to R14 who had a bowel movement. V8 cleaned R14's rectal and buttocks area, then she proceeded to apply a clean incontinence brief, assist with repositioning R14, and touched R14's beddings while wearing same soiled gloves. 2. On 3/14/23 at 1:35 PM, V8 (CNA) provided incontinence care to R15 who was wet with urine and had a bowel movement. V8 cleaned R15 from front to back of R15's perineum, then she proceeded to apply clean incontinence brief and applied barrier cream while wearing same soiled gloves. 3. On 3/14/23 at 2:15 PM, V8 (CNA) rendered incontinence care to R61 who was wet with urine and had a bowel movement. V8 wiped R62 from front to back. V8 removed her gloves and left…

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 nutrition supplements and fluid restriction as ordered by the Physician. This applies to 4 of 4 residents (R3, R8, R36, R41) observed for dining in the sample of 20. Findings include: 1. R3's diet order on POS (Physician Order Sheet) included General Regular diet, thin liquids, health shakes with lunch and dinner daily (start date 01/11/2023). On 03/13/23 at 12:29 PM, R3 received a Regular diet consistency room tray, along with 2% milk and lemonade. R3's diet card showed Nutrition Shake and R3 stated that she only receives a shake once in a while. On 03/13/23 at 12:49, this information was relayed information to V13 (Registered Nurse), who stated that R3 likes strawberry shakes and will get the same for her. 2. R8's diet order on POS included NAS (no added salt), Puree, Honey Thick Liquid, Vegetarian (start date 01/25/2023). On 03/13/23 at 12:12 PM, R8 was seen eating in the dining room and R8's diet card showed NAS pureed, vegetarian meals only, honey thick liquids. R8 received a 4 ounce cup of nectar…

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

Based on interview and record review, the facility failed to ensure that consents containing risk information for the use of psychotropic medications were obtained prior to administration. This applies to 1 of 3 residents (R35) reviewed for psychotropic medications in the sample of 20 residents. Findings include: Face sheet shows that R35 is 79 years-old with multiple medical diagnoses which include vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, bipolar disorder, and anxiety. Physician Order Sheet (POS) shows that R35 was prescribed multiple psychotropic medications which include, Aripiprazole 15 milligrams (mg) tablet once daily, Depakote 250 mg tablet twice daily, Duloxetine capsule extended release (ER) 60 mg capsule twice daily, Haloperidol lactate solution; 5 mg/ml (milliliter), to give 1 ml per injection for agitation every 6 hours as needed, Ativan 1 mg tablet to give 1 tablet every 8 hours as needed for increase aggression and anxiety, and Trazodone 50 mg tablet to give 1 tablet at bedtime as needed. 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 assist residents identified as needing assistance with personal hygiene. This applies to 3 of 3 residents (R36, R61, R129) reviewed for activities of daily living in the sample of 20. Findings include: 1. R36's EMR (Electronic Medical Records) included diagnoses of Asperger's syndrome, severe intellectual disabilities, other seizures, hydrocephalus, repeated falls, weakness. R36's quarterly MDS (Minimum Data Set) dated 02/08/23 showed that R36 requires extensive assistance of one person for personal hygiene. On 3/13/23 at 12:35 PM, R36 was lying in bed and calling Help, help. R36 was in hospital gown and noted to have long hair that was uncombed and beard that appeared overgrown to about 3-4 inches long. R36 stated that he needs to be changed and although he was alert and able to make needs known, parts of his speech was unclear. R36's request was relayed to V14 (Certified Nursing Assistant) who also added that R36 mostly stays in bed. On…

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

Based on observation, interview and record review the facility failed to assess and provide adaptive equipment to a resident, to prevent further reduction in mobility and ROM (Range of Motion). This applies to 1 of 2 residents (R65) reviewed for limited range of motion in the sample of 20. Findings include: R65 has multiple diagnoses which include cerebral infarction with left sided neglect/weakness, based on the face sheet. R65's quarterly MDS (Minimum Data Set) dated February 3, 2023 showed that the resident is cognitively intact. The MDS showed that R65 required extensive assistance from the staff with most of her ADLs (Activities of Daily Living). The same MDS showed that R65 had functional limitation in range of motion to one side of both her upper and lower extremities. On March 13, 2023 at 11:23 AM, R65 was in bed, alert, oriented and verbally responsive. R65 had contracture noted on her left hand. R65 was able to open her left hand slightly with pain. No adaptive device/equipment was in place. On March 14, 2023 at 1:11 PM, R65 was in bed, alert, oriented and verbally…

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 provide incontinence care in a manner that would prevent potential urinary tract infection (UTI). This applies to 3 of 4 residents (R14, R15, R61) reviewed for incontinence care in the sample of 20. Findings include: 1. On 3/14/23 01:15 PM, V8 (Certified Nursing Assistant/CNA) rendered incontinence care to R14 who had a bowel movement. V8 cleaned R14's rectal and buttocks area, then she proceeded to apply clean incontinence brief without cleaning R14's frontal peri-area. 2. On 3/14/23 at 1:35 PM, V8 (CNA) provided incontinence care to R15 who was wet with urine and had a bowel movement. V8 cleaned R15's frontal area with wet wipes from the pubic area down to the mid-perineum. Right after wiping R15's frontal perineum, V8 proceeded to clean R15's rectum and buttocks. However, V8 did not clean R15's groins and did not open the labia to clean the inner folds. 3. On 3/14/23 at 2:15 PM, V8 (CNA) rendered incontinence care to R61 who was wet with urine and had a bowel movement. V8 wiped R62 from pubic area down 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.