Allure Of Moline

Based on Interview and Record Review, the facility failed to investigate an alleged incident of resident to resident verbal abuse for two of three residents (R44, R87) reviewed for Abuse in the sample of 35. Findings include: The facility's Abuse, Neglect and Exploitation policy (undated), documents It is the policy of this facility to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Instances of abuse of all residents, irrespectively of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. This same policy documents Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age,…

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 requiring dependence on staff for hygiene, was provided a shower weekly, for one of one resident (R79) reviewed for showers in the sample of 35. Findings include: The facility's Resident Showers policy (undated), documents It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. On 5/18/25 at 9:25 AM R79 was sitting in his room in a high-back wheelchair. R79 was pleasantly confused with conversation and his hair was slicked back and shiny with an oily appearance. On 5/19/25 at 9:30 AM V11 (R79's family) stated she is able to visit R79 three to four times a week. V11 stated (R79) is scheduled to get baths or showers twice a week and it is on Tuesday and Saturdays. I don't think his hair is getting washed. If I ask they will wash his hair or a lot 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, interview, and record review the facility failed to perform indwelling urinary catheter care per facility policy for one of one resident (R45) reviewed for urinary catheters in the sample of of 35. Findings include: The facility's Catheter Care, (not dated), documents, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Catheter care will be performed every shift and as needed by nursing personnel. Compliance guidelines, knock and gain permission to enter the resident's room, explain the procedure, provide privacy by closing the door, closing the blinds/curtains, pulling the room dividing curtain, etc. Gather supplies needed, assist resident to a lying position or the most comfortable position for the resident. Drape resident to expose only the perineal area, perform hand hygiene, don gloves. For a male, gently grasp penis, draw foreskin back if applicable, using circular motion, cleanse the meatus with a clean cloth…

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 a resident receiving hemodialysis was provided dialysis prescribed medication and received physician ordered daily weights for one of two residents (R82) reviewed for dialysis in the sample of 35. Findings include: The facility's Hemodialysis policy (undated), documents This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. This same policy documents The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility; Physician/treatment orders, laboratory values, and vital signs; Nutritional/fluid…

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

Based on observation, interview, and record review the facility failed to apply gloves during Insulin administration for one of three residents (R148) reviewed for Insulin administration in a sample of 35. Findings include: The facility policy, Infection Control Guidelines for All Nursing Procedures, dated August 2012 directs staff, To provide guidelines for general infection control while caring for residents. Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions and excretions regardless of whether or not they contain visible blood. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. R148's current Physician Order Sheet, dated May 2025 includes the following physician orders: Humalog Injection Solution 100 UNIT/ML (Insulin Lispro). Inject as per sliding scale subcutaneously before meals related to Type 2 Diabetes Mellitus.…

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 hot water at comfortable temperatures for 22 residents (R4-R25) who reside on D-Hall of 22 residents reviewed for water temperatures in the sample of 27. Findings include: On 5/6/25 at 10:15am V5, CNA (Certified Nurse Assistant) stated there is no hot or even warm water in any of the rooms on D-Hall It's been like this for about a month. V5 stated We have to go to the nurses station to get hot water to clean residents that we get up in the morning. On 5/6/25 at 10:25am R4 stated that the CNA's have to get hot water from the nurses station to clean him up. R4 stated there have been times they used the bathroom sink water from his bathroom and it was cold and uncomfortable. R4 stated all the CNA's know about No hot water, its been like this for at least a month. On 5/6/25 at 11:35am V5, Maintenance Director used a digital thermometer to check the hot water temperature in the bathroom sink in R4's room. After approximately three minutes the hot water reached a maximum of 76 degrees F (Fahrenheit). Water…

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 prevent resident to resident physical assault for one resident (R5) of four residents reviewed for abuse in the sample of 27. Findings include: Facility Policy/Abuse, Neglect and Exploitation dated 2025 documents: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Physical abuse includes, but is not limited to hitting, slapping, punching, biting and kicking. Final Incident Investigation Report dated 4/21/25 indicates R6 reached out and struck R5; residents separated immediately. R6 placed on 1:1…

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's medication was administered for 1 of 6 residents (R3) reviewed for medication administration in the sample of 6. The findings include: The 2/28/25 quarterly assessment documents R3 was admitted to the facility on [DATE], and is cognitively intact. The same assessment documents R3 to have multiple diagnoses including hypertension, anxiety, depression and respiratory failure. On 5/2/25 at 10:00 AM, R3 was lying in bed sleeping, and a cup of 5 pills was sitting on the bedside table, along with 3 large chewable tablets. R3 awoke and said she did not know her pills were there. She said the cup had her morning pills, but did not know how long they had been sitting there. R3 attempted to name her medications, but fell back to sleep. The medication cup contained 1 large white pill, 1 white capsule, 1/2 of a large white pill, a green capsule, and 1 small round white pill. The May 2025 Medication Administration Record (MAR) shows…

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

Based on interview, and record review, the facility failed to investigate an allegation of potential physical abuse and ensure the alleged victim was protected from further abuse for one of three residents (R4) reviewed for abuse in the sample of three. Findings include: The Facility's Abuse, Neglect and Exploitation, not dated, documents abuse, neglect or exploitation occur. Written procedures for investigations include Identifying staff responsible for the investigation, exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence), investigating different types of alleged violations, identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation. On 3/11/2025 at 10 AM, R4 stated, (V5 CNA/Certified Nursing…

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 toilets were clean and free of fecal matter and failed to remove and store soiled wash clothes in a safe manner to prevent potential cross contamination. The failure effected three of three residents (R1, R2, R3) reviewed for infection control in a sample of three. Findings include: The facility's Standard Precautions Infection Control Policy, not dated, documents All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection to residents, staff and visitors. Policies and procedures have been established for containing, transporting, and handling resident-care equipment and instruments/devices that may be contaminated with blood or body fluids. Personnel are trained in the use of these procedures. Policies and procedures have been established for routine and targeted cleaning of environmental…

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

Based on record review and interview, the facility failed to provide required nursing coverage of a Registered Nurse for July 8-17, 2024. This failure has the potential to affect all 91 residents residing in the facility. FINDINGS INCLUDE: The Centers for Medicare & Medicaid Service/CMS Form 671, entitled Long Term Care Facility Application for Medicare and Medicaid, dated 7/16/2024, documents 91 residents reside in the facility. The facility Nursing schedule (untitled), covering the dates July 8-21, 2024, document the facility does not have the services, of a Registered Nurse/RN, on July 8, 9, 10, 15, 16, and 17, of 2024. The schedule also document on 7/12/24 there is an RN for only 8 hours; and only 4 hours on 7/13-14/2024. On 7/17/2024, at 9:50 a.m., V2/Director of Nursing confirmed the lack of RN coverage on 7/8-17/2024 and stated, We just can't get RN's that want to apply and we have been cited for it.

Based on observation, interview, and record review, the facility failed to follow Enhanced Barrier Protection and Contact Isolation Precautions policy and procedures for five (R24, R36, R66, R88, and R295) of five residents reviewed for infection control in the sample of 29. Findings include: The facility's undated Enhanced Barrier Precautions policy and procedures documents, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. This policy documents Residents requiring enhanced barrier precautions include Residents with wounds and indwelling urinary catheters even if the resident is not known to be infected or colonized with a MDRO (multidrug-resistant organism). PPE (personal protective equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. Note: face protection may also be needed 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 record review and interview, the facility failed to ensure the resident's representative was notified of a change in condition for one resident (R19) of twenty four residents reviewed for a change in condition in a sample of 29 residents. Findings include: The Notification of Change policy, no date, documents, The facility must inform the resident, consult the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. 2. Significant change in the resident's physical condition. This may include: b. Clinical complications. 3. Circumstances that require a need to alter treatment. This may include: a. New Treatment. On 3/5/24, R19's Minimum Data Set section C documents a Brief Mental Assessment of four (Severe Cognitive Impairment). On 3/26/23, R19's medical record documents (R19) is Covid positive. Isolation precautions initiated. Director of Nursing and Administrator aware. Monitoring ongoing. On 3/28/24, R19's medical record documents, Call placed to family to inform that resident has tested…

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 prevent the verbal abuse and neglect of one resident (R70) of 24 residents screened for abuse in a total sample of 29. Findings Include: The facility's Abuse, Neglect and Exploitation policy, dated 2/2023, documents, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Neglect means failure of the facility, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. On 7/16/24 at 2:00PM during a group meeting, R70 stated, I really don't like (V8/Certified Nurse Aide). She is hateful. She does not like to work that is for sure. She will flat out refuse to help people. She has…

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

Based on record review and interview, the facility failed to provide the resident and resident representative with a written notice of transfer, for three of six residents (R41, R74, R94) reviewed for transfer/discharge, in a sample of 29 residents. Findings Include: The Notification of Change policy, no date, documents, The facility must inform the resident, consult the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. 4. A transfer or discharge of the resident from the facility.1. Competent individuals: a. The facility must still contact the resident's physician and notify resident's representative. R41's medical record documents R41 was transferred to a local hospital on 5/4/24. The record lacked evidence the facility provided the resident and/or resident's representative with a written notice of transfer. R74's medical record documents R74 was transferred to a local hospital on 6/30/24. The record lacked evidence the facility provided the resident and/or resident's representative with a…

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

Based on record review and interview, the facility failed to prevent mental abuse for one resident (R3) reviewed for mental abuse in a sample of six. Findings Include: The facility policy named, Abuse, Neglect and Exploitation, not dated, documents the following: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definition: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Mental Abuse includes, but not limited to, humiliation, harassment, threats of punishment or deprivation. Mental abuse also includes abuse that is facilitated or caused by nursing home staff taking. Or using photographs or recording in any manner that would demean or humiliate a resident. R3's Reported…

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 prevent the verbal abuse of one resident (R2) of three residents reviewed for abuse. Findings Include: The facility's undated Abuse, Neglect and Exploitation policy documents, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedure that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility's Abuse, Neglect and Exploitation policy documents Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm,pain or mental anguish which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical…

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 staff responded to one resident (R4) request for assistance in a timely manner of three residents reviewed for call lights. Findings include: Facility Policy/Call Lights: Accessibility and Timely response, dated 2/1/23, documents: All staff members who see or hear an activated call light are responsible for responding. Current Physician Order Summary Report indicates R4 has diagnoses that include Colostomy, Cataracts and Glaucoma. On 4/9/24 at 2:55pm, two call lights were activated (lit) at the centralized call light board at the nurse's station. One of the activated call lights had been activated from R4's room. While walking down the hallway toward R4's room, which was located at the end of the hallway, R4's light was activated (lit) above his room door. On the same side of the hallway as R4's room, and two rooms before R4's room, V6/CNA (Certified Nurse Assistant) was sitting against the wall facing toward R4's room. On approach to where V6 was sitting, noted V6 with her head down looking at her…

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 correct dosage of Zonisamide(Anticonvulsant) medication for one of three (R2) residents reviewed for correct dosage of medication in a sample of 4. Findings Include: The facility policy named, Medication Errors, not dated, documents the following: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Policy Explanation and Compliance Guidelines: 1.) The facility shall ensure medications will be administered as follows: A.) According to physician's orders. R2's Discharge Orders, dated 3/1/2024, documents, give Zonisamide (anticonvulsant) 100MG(milligrams) Oral Nightly. R2's Order Summary Report, dated 3/2/2024, documents, Zonisamide Oral Capsule 100MG. Give 100MG(milligram) by mouth at bedtime, related to seizures. R2's Medication Administration Record, dated 3/1/2024 through 3/31/2024, documents,Zonisamide Oral Capsules 100MG Give 100MG(milligrams)…

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 employ a Certified Dietary Manager. This failure has the potential to affect all 81 residents currently residing in the facility. Findings include: The facility's Certified Dietary Manager Job Description dated (revised) October 2020 documents the following, The primary purpose of this position is to plan, organize, develop and direct the operations of the food and nutrition services department in accordance with current federal, state and local guidelines and regulations and as directed by the Administrator. Major Duties and Responsibilities: Oversees the budget and purchasing of food and supplies, and food preparation, services, and storage. Ensure that residents are provided a nourishing snack at bedtime. Maintains a clean and sanitary environment. This policy also documents, Minimum requirements include: Certification as a dietary manager. Must also meet State requirements for food service managers or dietary managers. V5's Certified Dietary Manager Credentialing Exam Application, dated 5/1/23 and signed 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 and record review the facility failed to make snacks readily available at bedtime for all residents. This failure has the potential to affect all 81 facility residents. The facility policy, Snacks (Between Meal and Mealtime) dated September 2010 directs staff, The purpose of this procedure is to provide the resident with adequate nutrition. Place the snack on the overbed table. Be sure the overbed table is adjusted to a comfortable position and height for the resident. Arrange the supplies so that they can be easily reached by the resident. Remove the snack tray when the resident has finished his or her snack. The person performing this procedure should record the information in the resident's medical record. The Certified Nursing Assistant Job Description documents, Role Responsibilities: Serves between meal and bedtime snacks. On 6/27/23 at 11:20 A.M., during the survey group meeting, R37 stated, We don't get any bedtime snacks offered to us. No one comes to you with a snack. Someone said there is a bowl of snacks at the nurses' station, but usually the door is…

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

Based on interview, observation and record review, the facility failed to ensure opened food items were sealed and dated; failed to ensure stored cracked eggs were disposed of; failed to ensure Food Temperature Logs of cooked food were completed and failed to ensure a milk refrigerator's temperature was continuously monitored. This failure has the potential to affect all 81 residents currently residing in the facility. Findings include: The facility policy, Food Receiving and Storage, dated (revised) October 2017 directs staff, Food shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Other opened containers must be dated and sealed or covered during storage. Refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines. The facility policy, Food Preparation and Service, dated (revised) April 2019 directs staff, Food and nutrition services employees prepare and serve food in a manner that…

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 the required dementia-specific in-service training for the past year. This failure has the potential to affect all 81 residents currently residing in the facility. Findings include: On 06/28/23, V1 (Administrator) provided copies of the facility's CNA (Certified Nursing Assistant) In-Service Training Records for V8, V9, V10 and V11/Certified Nursing Assistants (CNAs). No Dementia/Behavior Training was marked to signify completion on any of the four records. V1/Administrator verified she was unable to provide any Dementia In-Service Training for any staff, for the past year. The facility's Resident Census and Condition of Residents dated 06/26/23 and signed by V4/Minimum Data Set Coordinator, documents that 81 residents currently reside in the facility.

Based on observation, interview and record review, the facility failed to ensure the rights of its residents by providing meals to all residents seated at a table at meal time, at the same time; failed to offer needed assistance to residents during meal time and failed to ensure fluids were offered and served during meal time as requested by residents. This failure affected R47, R31 and other residents sitting in the dining area, reviewed for meal service. The facility policy, Serving A Meal, dated October 2022 directs staff, It is the policy to serve meals that meet the nutritional needs of residents. Remove domed lid from the tray and check to be sure everything is included on the meal tray that is required by the diet card, and the resident's preferences. Offer additional fluids with the meal when there are no dietary restrictions. The facility policy Hydration dated 9/1/21, directs staff, The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Sufficient fluid…

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 Psychosocial Programming and Psychological Services for seven (R12, R17, R45, R47, R65, R71 and R78) of eight residents reviewed for Behavior Health Services in the sample of 36. Findings include: The Behavioral Health Services policy and procedure, dated 1/9/23, documents, It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. 1. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment difficulty, and trauma or post-traumatic stress disorders. 2. The facility will consider the acuity of the resident population. This includes residents with mental disorders, psychosocial disorders, or substance use disorders (SUD's), and those…

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 a new PASARR (Preadmission Screening and Resident Review) for one (R78) of four residents reviewed for PASARR screenings in the sample of 36. Findings include: The facility's Resident Assessment - Coordination with PASARR Program, dated 09/01/21, documents: Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs . 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority . 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability…

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 perform a PASARR (Pre-admission Screening and Resident Review) level I or II screening for three of four residents (R45, R56, R65) reviewed for PASARR screening in the sample of 36. Findings include: The facility policy, named, Resident Assessment-Coordination with PASARR program, dated 9/01/2021 documents, This facility coordinates assessments with the preadmission and the resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines:1.) All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the States Medicaid rules for screening. a PASARR Level I-initial prescreening that is completed prior to admission. I. Negative Level screen-permits…

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 obtain wound treatment for a known wound for one (R40) of two residents reviewed for wounds in the sample of 36. Findings include: The facility's Wound Treatment Management policy and procedure, dated 11/23/22, documents, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. R40's Face Sheet includes the following diagnoses: Lymphedema, Morbid (Severe) Obesity, Post-Polio Syndrome, Fibromyalgia, Restless Leg Syndrome, Type 2 DM with Diabetic Neuropathy,…

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 notify the physician of the development of a pressure ulcer, obtain a physician ordered treatment, and perform hand hygiene/glove change during pressure ulcer care for one of one resident (R12) reviewed for pressure ulcers in the sample of 36. Findings include: The facility's Pressure Injury and Skin Condition, dated 1/17/18, documents, At the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes. The facility's Clean Dressing Change policy, dated 5/1/23, documents, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Loosen the tape and remove the existing dressing. Remove gloves, pulling inside out over the dressing. Wash hands and put on clean gloves. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other…

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 indwelling urinary catheter care in manner to prevent contamination and ensure indwelling urinary catheter bag was in dignity bag for one (R7) of one resident reviewed for urinary catheter care in the sample of 36. Findings include: The facility's Catheter Care policy and procedure, Revised 02/17/22, documents: Policy Explanation: . 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use . Compliance Guidelines: 7. Perform hand hygiene. 8. [NAME] (apply) gloves . Female: 12. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter . 23. Perform hand hygiene. On 6/26/23 at 12:30 pm, 6/27/23 at 8:45 am, 12:02 pm, and 3:53 pm, R7's indwelling urinary catheter bag was not placed in a dignity bag with urine visible in the tubing. On 6/28/23 at 1:42 pm, V15 and V16 CNA's (Certified Nursing Assistants) entered R7's room, applied gloves without hand 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 observation, interview, and record review, the facility failed to elevate the head of the bed during a gastrostomy tube (g-tube) flush and follow the plan of care to ensure an abdominal binder was worn at all times for one of one resident (R74) reviewed for g-tubes in the sample of 36. Findings include: The facility's Care and Treatment of Feeding Tubes policy dated 3/10/23, documents, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. The resident's plan of care will address the use of feeding tube, including strategies to prevent complications. The resident's plan of care will direct staff regarding proper positioning of the resident consistent with the resident's individual needs. The facility's Medication Administration via Enteral Tube policy, dated 9/1/21, documents, Procedure: Elevate the bed to a comfortable working height and place the patient in Fowler's (Head of bed elevated 45-60 degrees) position. Flush enteral tube with at least…

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

Based on observation, interview and record review the facility failed to identify PTSD (Post Traumatic Stress Disorder) triggers for one (R47) of one resident reviewed for Trauma Informed Care in the sample of 36. Findings include: The facility's Trauma Informed Care policy and procedure, dated 3/8/23, documents It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Definitions: Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. Common sources of trauma may include, but are not limited to: d. Physical, sexual, mental, and/or emotional abuse (past or present), e. Rape . Trauma -Informed…

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 and interview facility staff failed to wear gloves while handling medications for one of six residents (R4) observed during medication pass, in a total sample of 36. Findings Include: The (undated) facility policy, Medication Administration General Guidelines directs staff, Medications are administered as prescribed in accordance with good nursing principles and practices. The person administering medications adheres to good hand hygiene. On 6/27/23 at 7:59 A.M., V14/Licensed Practical Nurse prepared to administer medications for R4. Without performing hand hygiene, V14/LPN reached into the top drawer of the medication cart, withdrew a bottle of Acetaminophen 500 MG (Milligrams), poured one tablet into her ungloved hand and placed the tablet into a small, plastic medication cup. V14/LPN then reached into the top drawer of the medication cart, withdrew a bottle of Colace 100 MG, poured one tablet into her ungloved hand and placed the tablet into the same small, plastic medication cup. Again, V14/LPN reached into the top drawer of the medication cart, withdrew a…

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