El Paso Rehabilitation and Health Care Center

Based on interview and record review the facility failed to complete a thorough abuse investigation for three (R22, R23, and R31) of 13 residents reviewed for abuse in the sample of 36. Findings include: The facility Abuse, Prevention, and Prohibition Policy, dated 12/2024, documents Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing statements if indicated. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will give a statement if indicated. 1. The Final Report to the State Agency, dated 1/1/2025, documents, Original Complaint: It was reported to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure continuous one-to-one supervision for one known physically aggressive resident (R22) of three residents reviewed for supervision in a sample of 36. Findings include: The facility's In-Service documentation titled, What Is 1:1 Supervision? dated 01/15/25, included the following bullet points: Resident should NEVER be out of sight; You should always be with the resident, resident should never be left unattended. R22's Physician/Practitioner Note, dated 02/12/25, documents Complaint: psychotic disorder in ETOH (Ethyl alcohol) induced dementia. HPI (History of Present Illness): [AGE] year-old male with ETOH induced Dementia with target behaviors of physical aggression towards others. He is not able to consent for his own meds and in the process of getting a State Guardian. He remains on 1:1 supervision due to his highly impulsive behaviors and mood swings. R22's clinical record documents the following diagnoses: Other Schizoaffective…

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's indwelling urinary catheter tubing was secured in place for one (R1) of three residents reviewed for indwelling urinary catheters in a sample of 36. Findings include: The facility's undated Catheter Care, Urinary policy documents Changing Catheters 2. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) R1's current Physician Order Sheet documents R1 has an indwelling urinary catheter. On 3/11/25, at 12:09pm, R1 sat in a wheelchair in her room. An indwelling urinary catheter tubing was hanging out of R1's incontinent brief with a clasp dangling on the tubing; tubing was not secured to R1's leg. At this time R1 stated This one is supposed to be strapped to my leg, but it isn't today. I am not okay with it because sometimes it gets yanked. On 3/11/25, at 3:21pm, R1 was lying in bed with an indwelling urinary catheter draining into a catheter bag. V14 Certified…

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 maintain the privacy of residents' health information for six of six residents (R5, R11, R40-R43) reviewed for confidentiality/privacy in a sample of 43. Findings include: The undated Residents' Rights for People in Long-Term Care Facilities documents Your rights to privacy and confidentiality - You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. The facility's undated Employee Handbook Acknowledgment Form includes but is not limited to the following: 507 - Non-Disclosure of Resident or Community Information: HIPAA (Health Insurance Portability and Accountability Act of 1996) grants significant privacy rights to our residents concerning the use or disclosure of their medical information. It is the policy of the Community to protect the privacy of Protected Health Information (PHI), and to ensure that such information is used and disclosed appropriately and in accordance with all applicable laws and regulations. PHI (Protected Health Information)…

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 2 residents (R11 and R31) were free from resident to resident physical abuse of seventeen residents reviewed for abuse in a total sample of 43. Findings Include: The Facility's Abuse, Prevention and Prohibition Policy dated 12/2024 documents Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or their agencies serving the resident, family members or legal guardians, friends or other individuals. The Facility's Abuse, Prevention and Prohibition policy dated 12/2024 documents the definition of abuse as means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 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…

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 a home-like environment including but not limited to chipped paint, holes, missing trim, loose cable cords and unpainted walls in resident rooms for eight (R10, R11, R17, R26, R46, R59, R66, and R86) of 18 residents reviewed for environment in a sample of 27. Findings include: The facility's undated Maintenance Supervisor Job Description documents the following: Position Description: Responsible for supervising and coordinating the activities of the maintenance department to ensure environmental center compliance in accordance to Federal, State and Local ordinance, regulations and building codes. Ensures center is maintained in a sanitary, attractive, and orderly condition; in good repair, free from hazards such as those caused by electrical, plumbing, ventilation, heating and cooling systems. Principal Responsibilities: Performs all routine maintenance and repair work for the center in accordance with Federal, State and Local ordinance, regulations and building codes. Picks up work order requests daily…

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 process medication orders timely to ensure medications were given per physician order for six of 18 residents (R26, R37, R66, R72, R80, R85) reviewed for physician orders in a sample of 27 residents. Findings include: The Medication Administration Policy for Senior Living, undated, documented all medication orders must be prescribed by a licensed healthcare professional and documented accurately in the resident's medical records. The Medication Administration Record (MAR) should be maintained for each resident and must be up-to-date and medications should be administered according to the five rights of medication use: right resident, right drug, right time, right dose, and right route. 1. R26's Face Sheet documents R26 with a diagnosis of paranoid schizophrenia. R26's MAR documents on 1/8/25 Aripiprazole (an antipsychotic medication used to treat schizophrenia) 15 milligrams/mg each evening was ordered by V6. R26's MAR noted Aripiprazole was not administered on 1/8/25 or 1/9/25. 2. R37's Face Sheet documents R37 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 observation, interview, and record review the facility failed to ensure a resident's privacy was maintained (R59) and failed to cover a resident's indwelling urinary catheter bag with a privacy covering (R52) for two of 18 residents reviewed for privacy and dignity in a sample of 27. Findings include: The facility's undated Resident Rights for People in Long-term Care Facilities documents You have the right to .Your facility must provide services to keep our physical and mental health, and sense of satisfaction. And Privacy - Your medical and personal care are private. 1. On 1/07/25, at 10:20am, R59 sat on the bed in her room. As this writer closed R59's door for a private conversation, R59's door to the hallway would not latch closed. At this time R59 confirmed that the door will not latch shut. R59 stated that if the door closed all the way it would block out noise and when I get dressed, I would like it closed all way. I stand behind it (the door) or dress in shower room. The facility's folder of Pending Work Orders includes but is not limited to a Maintenance Work Order…

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' activity calendar was able to be visualized for two of two residents (R46 and R60) reviewed for accommodation of needs in a sample of 27. Findings include: The facility's undated Resident Rights for People in Long-term Care Facilities documents You have the right to participate in your own care - Your facility must make reasonable arrangements to meet your needs and choices. 1. On 1/07/25 at 9:45am, R60 sat in a wheelchair in her room. R60 stated she is blind in her right eye. R60's activity calendar is taped on R60's bathroom door approximately five feet high. R60 stated that R60 cannot see it up there and R60 does not know what the activities are for today. R60 said I have torn it down and put it where I can see it. This writer took the calendar down and brought the calendar to R60. R60 stated I can't see that. I need bigger print. On 1/09/25, at 10:22am, R60 sat in a wheelchair in her room. R60 stated Sometimes I miss activities because I don't know what is going on. It makes me feel…

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

Based on observation, interview and record review, the facility failed to develop a Care plan for Hepatitis C and Blindness for one resident (R60) of 18 residents reviewed for Comprehensive Care plans in a sample of 27. Findings include: The facility's undated Care Planning policy documents Policy: Every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual. Purpose: 1. To assess each resident's strengths, weaknesses, and care needs. 2. To use this assessment data to develop a comprehensive Plan of Care (POC) for reach resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and wellbeing as possible. On 1/07/25 at 9:45am, R60 sat in a wheelchair in her room. R60's right eye appears cloudy and distorted. R60 stated she is blind in her right eye. R60's current Face sheet documents R60 has diagnoses including but not limited to Unspecified Viral Hepatitis C without hepatic coma and Blindness right eye. R60's…

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

Based on interview and record review, the facility failed to implement nonpharmacological interventions for one (R13) of eight residents reviewed for mood behavior monitoring in a sample of 27. Findings include: Facility Behavioral Assessment, Intervention, and Monitoring Policy, dated 12/2024, documents Staff will evaluate the resident's patterns of mood and behavior; the care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice; Interventions and approaches will be based on assessment; and nonpharmacological approaches will be utilized to the extent possible to manage behavioral symptoms. R13's medical record documents R13 has the following diagnoses: Depression and Anxiety. R13's current physician orders for January 2025 document the following: Mirtazapine Oral Tablet 45 MG/milligrams give 1 tablet by mouth at bedtime related to depression; Bupropion ER/extended release oral tablet 300 MG give 1 tablet by mouth one time a day related to depression; Venlafaxine ER 150 mg capsule give 1 caplet orally one time a day…

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 record reviews, the facility failed to maintain a bookkeeping system to adequately record individual resident accounts by not recording the date and amount of all financial transactions and failed to maintain the ongoing balance for any resident's account. This failure affected all 93 residents currently residing at the facility. Findings include: Facility daily census report for 11/07/2023 showed resident census of 93 in-house. On 11/07/2024 at 11:43 AM, V1 (Administrator) said he could not provide the current balance for any resident account because a few weeks ago, a discrepancy was found in that balances were not being carried over. V1 added that the last balance report available was from 09/30/2023. V1 then said that V4 (Payroll/Human Resources) and V8 (Medical Records) handled the banking days, and that V4 was supposed to be keeping track of resident account balances. V1 (Administrator) then said that all resident financial documents were turned over to the corporate office so that an audit could be conducted, and current balances obtained. 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 record review and interview the facility failed to prevent the physical abuse of one of three residents (R3)reviewed for abuse in the sample of eight. Findings Include: The Facility's Abuse, Prevention and Prohibition Policy dated 01/24 documents Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The policy documents Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also include the deprivation of 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 harm pain or mental anguish. It…

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 not base a residents involuntary discharge on the residents status at the time of transfer to an acute care facility and ensure a signed physician discharge order was in place when serving a notice of involuntary discharge for one of three residents (R1) reviewed for involuntary discharge in the sample of eight. Findings include: The facility's Facility Assessment, dated 8/16/24, documents the facility has an average daily census of 96 residents and the top three diseases and conditions among residents in the facility are Schizophrenia, Bipolar disorder and Schizoaffective disorder. This Facility Assessment also documents Services offered: Mental Health and Behavior. Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD (Post Traumatic Stress Disorder), other psychiatric…

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

Based on interview and record review the facility failed to provide medically related social services for one of three residents (R1) reviewed for involuntary discharge in the sample of eight. Findings include: The facility's Facility Assessment, dated 8/16/24, documents the facility has a total of 123 beds and the average of Mental Health/ Behavioral Health Needs in the resident population ranges between 100-123. This Facility Assessment also documents Services offered: Mental Health and Behavior. Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD (Post Traumatic Stress Disorder), other psychiatric diagnoses, intellectual or developmental disabilities. Provide person centered/directed care: Psycho/social/spiritual support: Provide opportunities for social activities/life enrichment (individual, small group, community). This assessment…

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 have a Certified Dietary Manager employed in the kitchen. This has the potential to affect all 95 residents living in the facility. Findings: The document, Dietary Supervisor, taken from the Job Description Manual, no date given, states, Responsible for the daily operations of nutrition service within the dietary department. Collects data and participates in the nutrition assessment process. Provides routine progress notes in the resident's medical records. Participates in the interdisciplinary team concerning resident's plan of care during care conferences and participates in the development of baseline care plans. Ensure care plan interventions, regarding nutrition/hydration, must be based upon the resident's assessment and disease processes. Reviews weight records routinely and communicates variances to the Dietitian and Disciplinary Team. Completes the assigned Minimum Data Set (MDS) section according to required timeline. Qualifications: Trained as a Certified Dietary Manager, Certified Food Protection Professional,…

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 have sufficient staff to serve the residents. This has the potential to affect all 95 residents living in the facility. Findings: The Facility Assessment, dated 5/31/24, states, Based on resident population and their needs, staffing ensures sufficient staff to meet the needs of the residents at any given time. Budgeted hours per payroll (2 weeks) is 900 - 945 hours. The electronic, Time Detail Report, for a two week period, 7/07/24 through 7/20/24, was provided. This report shows that the Dietary Department total hours worked in that department during that two week period were 301.25 hours. On 7/21/24 at 10:20 AM, there were three dietary employees working. V21 was on pots and pans, V20 was on cold food preparation and one, V15, Dietary Manager, was cooking. According to the schedule, the morning cook was not there. V15 stated, The cook called off. Someone is always calling off. We are always working short. On 7/22/24 at 10 AM, during the Resident Council Meeting, R21, R29, R46, R67, R83, agreed that often 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 maintain a clean kitchen including floors, walls, drawers, walk in cooler, reach in coolers, freezers, convection oven, range, grill and range grease trays, dishwasher area including the top of dishwasher, hand washing sink; label large food bins; label and date opened food items in the refrigerator; keep storage containers off of the floor; place eggs on the bottom shelf of refrigerator; maintain the correct chlorine level on the low temperature dish machine; keep a log of the dishwasher chlorine tests; check the sanitation buckets with the appropriate test strips and keep a log of the tests. This has the potential to affect all 95 residents who live in the facility. Findings: The document, Food Storage (Dry, Refrigerated, and Frozen), dated 2016, states, Food shall be stored on shelves in a clean, dry area. All food items will be labeled. The label must include the name of the food and the date by which it should be consumed or discarded. Store eggs separately. If they cannot be stored separately, place eggs…

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 keep the large outside garbage dumpster closed and the area surrounding the container free of debris. The is has the potential to affect all 95 residents living in the facility. Findings: The document, Garbage Disposal, no date, states, Storage areas will be kept clean at all times to discourage pests. Outdoor trash receptacles will be kept covered and the surrounding area kept free of litter. On 7/21/24 at 11:30 AM, V20 and V21, Dietary Aides, took the Dietary trash containers out to the large outside garbage dumpster. The lid on the dumpster was open. Several items had dropped form the dumpster onto the ground. Weeds surrounded the dumpster. V20, Dietary Aide, stated, This happens a lot. It's usually full to overflowing, especially on the weekend. The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7-21-24 documents 95 residents currently reside within the facility.

Based on observation, interview and record review, the facility failed to maintain a walk-in refrigerator at the correct temperature; repair/replace the gasket on the door to the walk-in refrigerator in order to seal the door when closed; failed to repair the condenser inside of the walk-in refrigerator; failed to correctly repair a rack on a shelf in the walk-in refrigerator. This has the potential to affect all 95 residents living in the facility. Findings: The document, Refrigerator and Freezer Temperature Checks, no date, states, In order to ensure all perishable food stuff stays fresh and palatable, temperatures will be recorded on all refrigerators in use. Dining Services will be responsible for taking temperatures on all kitchen refrigerators and recording temperatures on temperature report logs daily during each shift. Correct actions are taken as necessary to ensure only safely stored foods are served to residents. Each refrigeration unit in the main kitchen is checked at department opening and before any food product is used for the day. The employee ensures that all cold…

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 keep flies and gnats out of the Kitchen, Dining Room and Resident Rooms. This has the potential to affect all 95 residents living in the facility. Findings: The document Infection Prevention and Control, dated 2019, states, Pest Control. The facility maintains an effective pest control program to remain free of pests. Facility-wide pest-control strategies are developed emphasizing kitchens, cafeterias, laundries, central sterile supply areas, loading docks, construction activities, and other regions prone to pest infestations. On-going measures are taken to prevent, contain and eradicate common household pests such as flies. On 7/21/24 at 10:20, the kitchen was entered for tour. Flies were observed during the three hours spent in the kitchen. Flies landed on food items being prepared, on the food items in the steam table, before and during service, on appliances, equipment, clean dishes glasses, plates and silverware. Flies were landing on V15, Dietary Manager, V20, V21, Dietary Aides. They were a constant…

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 protect facility residents from physical abuse by another resident (R32) for nine of nine residents (R2, R43, R55, R56, R57, R58, R67, R68, R89) reviewed for abuse, in a sample of 37. FINDINGS INCLUDE: The facility policy, Abuse, Prevention and Prohibition Policy, dated (revised) 01/24 directs staff, Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Resident-to-Resident Altercations: Resident to resident abuse includes the term willful. The word willful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. R32's current Physician Order Sheet, dated July…

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 the facility failed to provide accommodations for shaving preferences for one of 19 residents (R35) reviewed for accommodation of needs in a sample of 37. Findings include: On 7/22/24 from 1:00 PM through 1:15 PM, four of four resident shower rooms were observed and did not have mirrors. On 7/21/24 at 10:40 AM, R35 stated he could not shave because there were no mirrors in the shower rooms to facilitate shaving. On 7/22/24 at 12:45 PM, V18 (Certified Nurse Aide) stated The mirrors in the shower rooms were removed when they (facility) remodeled a few months ago. The residents could ask the staff (to shave) and we would have to take them a razor and stand with them in their room since there were mirrors. The shower room is where they (residents) usually shave though.

Based on record review and interview, the facility failed to acknowledge and comply with the resident's request to discard odorous urine at the bedside for 1 of 19 residents (R60) reviewed self-determination in a sample of 37. Findings include: The Residents' Rights policy, revised 11/2018, documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must be safe, clean and homelike. On 07/22/24 at 9:30 AM, R60 stated They (staff) do not empty my urinal at night. I call them to come empty my urinal, but they don't come. I have to sit in there (R60's room) and smell it (urine) all night long. That's gross. On 7/22/24 at 12:10 PM, V18 (CNA/Certified Nursing Assistant) stated Many times, the urinal is full when I get here. I see how (R60) might be wet and refuse to be changed at night, but the urinal should be emptied. I wouldn't like to smell my urine when I'm trying to sleep.

Based on record review and interview the facility failed to give a bed hold notification to a resident that was transferred to the hospital for one of three residents (R14) reviewed for hospitalization in a sample of 37. Findings Include: The facility policy named, Bed Hold Policy and Agreement, dated February 2024, documents, Policy: Bed Hold Policy of the Management Company that the facility will establish a system to notify the resident/responsible party/resident representative of the facility bed hold policy. The daily rate required holding a Resident's bed is specific to the room and payment program criteria of the resident. Procedure: The Bed Hold Agreement is to be obtained for each occurrence- hospital or therapeutic home leave. R14's Progress Notes dated 3/13/2024 documents the resident was sent out to the hospital and admitted . R14's Progress Notes dated 3/15/2024 at 2:01PM documents, (R14) returned to the facility per company transport. R14's vital signs within normal limits. New orders for antibiotic/urinary tract infection. On 7/23/2024 at 9:00 AM, V1/Administrator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to follow their elopement policy to update a resident's elopement risk care plan and failed to assess a resident's elopement risk quarterly for one of one (R20) resident reviewed for elopement in a sample of 37 residents. Findings include: The Elopements policy, reviewed 5/2023, documents All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified will have these issues addressed in their individualized care plans. 1. Residents who are at risk for elopement shall be provided at least one of the following safety precautions by the facility: 1. Door Alarms on facility exits; and/or A personal safety device that will alert facility staff when the resident has left the building without supervision; and/or Staff supervision. 1. Using the MDS (Minimum Data Set) resident assessment schedule, all residents shall be reviewed for safety concerns and precautions. Residents at risk for elopement shall be…

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

Based on record review, observation, and interview the facility failed to ensure dialysis (artificial kidney treatment) care was provided per policy, communicate with the dialysis facility before and after treatments, collaborate with the Interdisciplinary Team and ensure a resident's care plan documents detailed dialysis care and required services for a resident receiving renal hemodialysis for one of one resident (R12) reviewed for dialysis in the sample of thirty-seven. Findings include: The Dialysis Services Coordination Agreement, signed 8/24/21, documents E. Mutual Obligations 1. Collaboration of Care. Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Long-Term Care Facility and the End Stage Renal Disease Dialysis Unit. Documentation shall include, but not limited to, participation, as members of an interdisciplinary team. The Dialysis policy, revised 1/2002, documents If a resident has a fistula, contact the physician and/or the hemodialysis center for specific directions on care of the fistula. D. Fistula:…

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 ensure resident to resident physical abuse did not occur for two residents (R6, R7) of four residents reviewed for abuse in a sample of four. Findings include: Facility's Abuse Prevention and Prohibition Policy Revised 1/2024, documents: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Facility's Initial and Final Reports to (State Department of Public Health) for R6 and R7 document: After investigation of the incident between residents (R6) and (R7) it has been determined that that R6 made physical contact with R7. R6 has been education on appropriate communication with fellow residents and to keep hands to himself. R6 and R7 have been sitting in…

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 interviews and record review, the facility failed to follow its abuse policy for a thorough investigation for two residents (R6, R9) of four residents reviewed for allegation of resident to resident abuse in a sample of four. Findings include: The facility's Abuse Prevention and Prohibition Policy Revised 1/2024, documents: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will…

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

Based on interviews and record review, the facility failed to report allegations of abuse to the State Agency for two residents (R6, R9) of four residents reviewed for allegation of resident to resident physical abuse in a sample of four. Findings include: The facility's Abuse Prevention and Prohibition Policy Revised 1/2024, documents: The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing statements if indicated. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. The facility Administrator, employee, or agent who is made aware of any allegation of abuse or neglect shall report or cause a report to be made to the mandated stated agency per reporting criteria. R6 and R9's AIM/Assess, Intercommunication,…

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 record review, the facility failed to do a thorough investigation for an allegation of resident to resident abuse for two residents (R6, R9) of four residents reviewed for abuse in a sample of four. Findings include: The facility's Abuse Prevention and Prohibition Policy Revised 1/2024, also documents: The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing statements if indicated. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. The facility Administrator, employee, or agent who is made aware of any allegation of abuse or neglect shall report or cause a report to be made to the mandated stated agency per reporting criteria. R6 and R9's AIM/Assess, Intercommunication, Manage for…

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

Based on interview and record review the facility failed to provide evidence of facility's refusal to readmit a resident was not based on the resident's status at the time of transfer and failed to provide documentation by a physician regarding the basis of a resident's involuntary transfer/discharge with indications for why a resident should not return to the facility or what resident needs could not be met at the facility for one (R2) of three residents reviewed for Involuntary Discharge in a sample of three. Findings include: Facility Resident Rights for People in Long Term Care Facilities, revised 11/2018, documents You must be allowed to return to your facility after you are hospitalized as long as you still need that level of care. If you get Medicaid and are hospitalized for ten or fewer days, your facility must let you return when you leave the hospital even if the facility has given you a written discharge notice. If you are hospitalized for more than ten days, your facility must let you return if it has a bed available and you still need that level of care. If your…

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 permit resident (R2) to be readmitted to the facility from the hospital after inpatient psychiatric hospitalization for psychiatric assessment and treatment and failed to develop and implement a policy for Transfer/Discharge that addresses permitting residents to return to the facility after a hospital or therapeutic leave for one (R2) of three residents reviewed for facility-initiated transfers in a sample of three. This resulted in the resident (R2) remaining in the hospital for more than 30 days while waiting for nursing home placement. Findings include: Facility Resident Rights for People in Long Term Care Facilities, revised 11/2018, documents You must be allowed to return to your facility after you are hospitalized as long as you still need that level of care. If you get Medicaid and are hospitalized for ten or fewer days, your facility must let you return when you leave the hospital even if the facility has given you a written…

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

Based on interview and record review the facility failed to provide mail delivery on Saturdays. This failure has the potential to affect all 114 residents in the facility. Findings include: Resident Rights policy and procedure, dated 11/2018 documents The facility must deliver and send your mail promptly. On 2/5/24 at 10:45am during a resident group meeting, R52 stated mail is held on weekends and delivered on Mondays. On 2/7/24 at 1:30pm V17, Activities Director stated The mail has to go to the Main Office first. Activities delivers the mail after the business office sorts through the mail. There is no one here on the weekend from the Main Office to go through the mail on the weekends. The Long Term Care Facility Application for Medicare and Medicaid, CMS (Central Management Services) Form 671, signed and dated on 2/4/24 by V2 DON (Director of Nursing), documents there are 114 residents currently residing in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review the facility failed to provide a safe, clean and homelike environment at the facility. This failure has the potential to affect all 114 residents who currently reside in the facility. Findings Include: The Facility's Maintenance Person job description (undated) documents The Maintenance Person maintains all building, equipment, systems and grounds in good, safe and presentable conditions. He/She conducts a preventative maintenance program for all mechanical, signal and fire alarm and suppression and other systems. The solicitation of repair/replace construction and other bids from contractor for presentation to the Administrator and Corporate Maintenance Director is expected. The Facility's Environmental Supervisor job description (undated documents) The Environmental Supervisor is responsible for maintaining the facility and ground in a clean, safe, comfortable, sanitary condition. He/she insures that furnishings, fixtures, equipment, buildings and grounds are…

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 inform residents of the facility's grievance procedure. This failure has the potential to affect all 114 residents in the facility. Findings include: Facility Policy/Resident Grievances/Complaints dated 11/1/17 documents: Grievances and/or complaints may be reported to the Administrator, any staff member, Resident Council and to State Agencies. The facility shall provide contact information including: grievance official name, business address, business phone; a reasonable expected timeframe for completing the review of the grievance and the right to contact outside agencies through required postings. Once a concern or grievance has been reported and is not easily resolved, a Grievance/Complaint Report form will be initiated. On 2/5/24 at 10:45am during a resident group meeting with the following residents (R7, R21, R39, R43, R57, R62, R95, R100), all eight residents did not know how to file a grievance and did not know there was a form to address and document grievances. On 2/6/24 at 12:50pm V14, Social Service Assistant…

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 sufficient staff to provide care and supervision for dependent residents. This had the potential to affect all 114 residents residing in the facility. Findings include: The facility's Nurse Staffing policy, no date available, documents, It is the policy of the facility to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychosocial well being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the State Agency. On 02/05/24 at 09:57 AM, R78 stated, It's crazy in here and they don't have enough staff to take care of all of us. On 02/05/24 at 10:00 AM, R70 stated, They don't have enough staff around here for all of these people, and us residents just have to deal with it. On 2/7/24 at 11:00 am, V11 (CNA-Certified Nursing Assistant) stated, We should have six CNAs if we are fully staffed. That doesn't happen often. It's hard to…

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 clean and maintain kitchen equipment. These failures have the potential to affect all 114 Residents residing in the Facility. Finding include: Facility Food Service Manager Job Description, revised 10/2016, documents V18's (Dietary Manager) job summary: to manage all aspects of the Food Service Department in the Facility including but not limited to Food Service personnel, supplies and equipment; take necessary measures to ensure that all food served to Residents has been prepared in a safe, sanitary manner while maintaining the highest quality; check all equipment for proper functioning and safety, responsible for overall sanitation of the department; responsible for overall sanitation of the department; and responsible for knowing Local, State and Federal regulations and policies and procedures which pertain to the Department. The Long Term Care Facility Application for Medicare and Medicaid, CMS (Central Management Services) Form 671, signed and dated on 2/4/24 by V2 DON (Director of Nursing), documents…

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

Based on observation, interview and record review the facility failed to remain in COVID-19 Outbreak Status for ten days after the last person tested positive for COVID-19. This failure has the potential to affect all 114 residents who currently reside in the facility. Findings Include: The Facility's COVID-19 Infection Control Measures Policy dated 5/19/23 documents A COVID outbreak is defined by one staff member or resident testing positive for COVID-19. The policy documents that during Outbreak Status all staff will wear well fitted surgical masks everywhere in the building that residents have access to and that residents would be encouraged to wear masks when out of their rooms. The Facility's COVID-19 Infection Control Measures Policy dated 5/19/23 documents that signs announcing a COVID outbreak status would be placed in visible areas of the facility for residents,staff and visitors information. The Policy documents that all visitors would be encouraged to wear masks at all times. The Facility's COVID-19 Control Measures Policy dated 5/19/23 documents HCP (Health Care…

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

Based on interview and record review the facility failed to maintain an Antibiotic Stewardship Program. This failure has the potential to affect all 115 residents who currently reside in the facility Findings Include: The Facility's Antibiotic Stewardship Program dated 11/01/2017 documents the purpose is to improve the use of Antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This will be accomplished by utilizing the Core Elements. This Policy did not list what the Core Elements of Antibiotic Stewardship in Long Term Care are. The CDC (Center for Disease Control) website lists the Core Elements of Antibiotic Stewardship in Long Term care as enhancing infection prevention and control, controlling source control, prescribing antibiotic when they are truly needed, prescribing appropriate antibiotics with adequate dosages, reassessing treatment when culture results available, using the shortest…

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 notify the Facility Ombudsman and the Residents/Resident Representatives, in writing, of Hospital Transfers/Discharges for four of four Residents (R64, R85, R108 and R110) reviewed for Bed Hold Transfer in a sample of 51. Findings include: Facility Transfer and Discharge Policy and Procedure Policy, undated, documents: it is the policy of the Facility not to transfer or discharge a resident unless the transfer or discharge is necessary to meet the Resident's welfare, and the Resident's welfare cannot be met in the Facility; the documentation in the Resident's clinical record shall be required; and the Facility shall notify the Resident ad the Resident's family member, surrogate or representative of the transfer and the reasons for the transfer as stated in the clinical record. Facility Resident Rights for People in Long Term Care Facilities, revised 11/2018, documents: before the Facility can transfer or discharge you, it must prepare you to be sure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the Facility failed to issue a Bed Hold Policy upon Discharge/Transfer to the Hospital for four of four Residents (R64, R85, R108 and R110) reviewed for Bed Hold Transfer in a sample of 51. Findings include: Facility Transfer and Discharge Policy and Procedure Policy, undated, documents: it is the policy of the Facility not to transfer or discharge a resident unless the transfer or discharge is necessary to meet the Resident's welfare, and the Resident's welfare cannot be met in the Facility; the documentation in the Resident's clinical record shall be required; and the Facility shall notify the Resident ad the Resident's family member, surrogate or representative of the transfer and the reasons for the transfer as stated in the clinical record. Facility Resident Rights for People in Long Term Care Facilities, revised 11/2018, documents: before the Facility can transfer or discharge you, it must prepare you to be sure that your discharge is safe and appropriate; and you 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 develop a person centered comprehensive plan of care for Mental illness/Psychtoropic medication use, limitation of range of motion, smoking, for 7 of 25 residents (R4, R22, R41, R45, R82, R104, R110) reviewed for care plans in the sample of 51. Findings include: The facility's Comprehensive Care Planning policy dated 11/1/17, states It is the policy of (the facility) to comprehensively assess and periodically reassess each resident admitted to the facility. The results of this Resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being. The Resident Assessment Instrument (RAI) shall be the guide utilized for all comprehensive…

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 2. R67's current computerized medical record, documents R63 has a diagnosis of Post Traumatic Stress Disorder (PTSD). R67's Care Plan dated 12/19/23, documents R63 is known to display fluctuations in mood related to his mental illness diagnosis of PTSD. R67's Care Plan does not document R67's trauma induced triggers for his diagnosis of PTSD or individualized interventions to reduce possible re-traumatization of R67. 3. R93's current computerized medical record, documents R93 has a diagnosis of Post Traumatic Stress Disorder (PTSD). On 2/7/23 at 1:38 p.m., R93 stated he had PTSD from his dad dying unexpectedly while in a car that R93 was driving. R93 stated I haven't been the same since that happened. I had to have an ambulance take me away when it happened because I lost it. R93's Care Plan dated 11/28/23, documents R93 is known to display fluctuations in mood related to his mental illness diagnosis of PTSD. R93's Care Plan does not document R93's trauma induced triggers for his diagnosis of PTSD 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to have a clinical indication for use and failed to identify and monitor target behaviors for the use of psychotropics for eight (R10, R45, R56, R60, R85, R92, R110, and R113) of eight residents reviewed for unnecessary medications in a total sample of 51. Findings Include: The Facility's Psychotropic Medication Policy dated 11/28/2017 documents It is the policy of this facility that resident shall not be have unnecessary drugs. Unnecessary drug is any drug used: 1. In an excessive dose, including in duplicative therapy 2. For excessive duration 3. Without adequate monitoring 4. Without adequate indications for its use 5. In the presence of adverse consequences that indicate the drugs should be reduced or discontinued. The Psychotropic Medication Policy documents that a psychotropic medication is defined as a medication that is used for or listed as used for antipsychotic, antidepressant, antibiotic, antianxiety, behavior modification, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the PASARR (Pre-admission Screening and Resident Review) Level II recommendations for one of three residents (R70) reviewed for PASARR screenings in the sample of 51. Findings include: R70's PASARR Level II Notice of Determination, dated 1/23/20, documents that R70 is eligible to be admitted to the nursing facility level of care. However, the following Special services are recommended for R70 to receive while residing in the facility: Instrumental Activities of Daily Living training/reinforcement; Mental Health Rehabilitation activities; Illness self management; Community re-integration activities. R70's Psychiatric Physician/Practitioner note, dated 11/9/2023 at 02:55 a.m., documents, History of Present Illness: Follow up visit of R70 a [AGE] year-old admitted to facility for Long Term Care from status post hospitalization. patient has past medical history consisting of depression, schizophrenia, and antisocial personality disorder. R70's…

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

Based on observation, interview and record review the facility failed to provide incontinent care for one resident (R104) incontinent of bowel of 24 residents reviewed for ADL's (Activities Of Daily Living) in the sample of 51. Findings include: Facility Policy/Preventative Skin Care dated 3/16/23 documents: Keep incontinent resident's clean and dry. Facility Policy/Perineal Cleansing dated 9/21/10 documents: To eliminate odor, prevent irritation or infection and to enhance resident's self-esteem. Current Physician Report Summary indicates R104 has diagnoses that include Diabetes Mellitus, Diarrhea. Report indicates GI (Gastrointestinal) consult was ordered for R104 on 8/20/23 due to chronic loose stools. On 2/4/24 at 8:10am R104 was seen in bed with soiled sheets (top and bottom). Linens had brown stains smeared and scattered on bed linens; foul odor noted in area of 104's bed. At that time R104 stated no one (staff) had been in the room to check on him during the night. On 2/4/24 at 8:15am V15, CNA (Certified Nurse Assistant) stated R104 often has loose stools and the stains 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 services to maintain or prevent further limitation in range of motion for one of two residents (R22) reviewed for range of motion in the sample of 51. Findings include: The facility's Splints/Appliances policy dated 9/2008, states A resident who has a contracture, or has a likelihood of developing a contracture, caused by physical condition and requires further evaluation will be assessed by the Occupational Therapist for a splint/appliance as ordered by the resident's physician. The program will be identified on the resident's care plan including the problem, approaches and goals. On 2/04/24 10:26 a.m. and 2/7/24 at 2:00 p.m., R22 was sitting in her wheelchair with her left hand curled into itself with her fingers also curled into the palm of her hand. R22 did not have any type of splint, brace, or washcloth on her left hand or under her fingers. R22's bedside dresser had a splint lying on top of it. R22 stated she cannot…

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 prevent repeated falls for one of eight Residents (R110) reviewed for Accidents in a sample of 51. Findings include: Facility Safe Smoking and Vaping Policy, revised 10/27/22, documents: the Facility works to provide appropriate care for residents keeping safety and comfort in mind; Residents may have the desire to smoke/vape and accommodations will be provided as the Facility deems appropriate; the implementation of the Smoking Safety Risk Assessment will be conducted once the resident indicate they may want to smoke; development of the Resident Smoking Contract will be completed by the Social Service Designee and the Resident; and must be dressed appropriately for weather. QAPI (Quality Assurance and Performance Improvement) Plan Policy, undated, documents: the Facility is committed to providing specialized assistance and wide-ranging services that enable our Residents to attain optimal well being and create an environment where people are loved, valued, at peace and feel safe; strive to achieve…

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 urinary drainage collection bags and urinary catheter tubing were kept off the floor for two residents (R64 and R104) of three residents reviewed for catheters in the sample of 51. Findings include: Facility Policy/Suprapubic Catheter Care dated 3/15/23 documents: To provide daily and as needed catheter care to resident's with suprapubic catheters to reduce the incidence of infection. On 2/7/24 at 2:10pm V2, DON (Director of Nursing) acknowledged catheter drainage bags should be kept off of the floor. 1. On 2/4/24 at 8:10am R104 was seen in bed with a suprapubic catheter and was attached to tubing. The lower portion of the catheter tubing and the drainage collection bag was on the floor next to the bed. There was also a urinary drainage collection bag and tubing on the floor underneath the bottom of R104's bed that was not attached to R104. At that time R104 stated no one (staff) had been in the room to check on him during the night. On 2/4/24 at 8:15am V15, CNA (Certified Nurse Assistant) stated R104…

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 interviews and record review, the facility failed to protect residents' right to be free from physical abuse for two residents (R1, R2) reviewed for abuse in a sample of four. Findings include: The facility's Abuse Prevention Program Policy, Dated 11/28/16 documents, The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility, staff, other residents, consultants, volunteers and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The facility's State Long Term Care Ombudsman Program Residents' Rights Brochure Dated 11/2018, documents:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to prevent an injury for one resident (R3) reviewed for accident/injury of unknown origin in a sample of four. Findings include: The facility's Injuries of Unknown Origin Policy, Dated 4/18/16 documents: All injuries of Unknown Origin will be investigated to determine the potential cause of the injury. Upon identification of the cause, interventions will be established to prevent any further injury by the (Interdisciplinary Team/IDT) or Administration. Upon identifying an Injury of Unknown Origin, the following will be completed: Implement the Abuse Prevention Program. The facility's State Long Term Care Ombudsman Program Residents' Rights Brochure Dated 11/2018, documents: Your rights to safety: Your facility must provide services to keep your physical and mental health, at their highest practical levels. R3's Final (State) Department of Public Health Report for Incident Dated 11/19/23 documents: It was reported to the abuse coordinator (V3…

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 administer the proper insulin dose as ordered by the physician and report hyperglycemia results to the physician for one resident (R1) and failed to properly administer insulin to two residents (R1 and R2) out of three residents reviewed for diabetes in a sample of three. Findings include: The facility's Emergency Care policy dated 12/22/17 documents Hyperglycemia / Hypoglycemia: It is the policy of this Health Care facility to provide the necessary care and services of those residents with a diagnosis of Diabetes Mellitus. This is achieved through proper diet, monitoring of blood glucose levels, monitoring of symptoms related to abnormal blood glucose levels, and the administration of medications per the physicians order, in accordance with Residents Rights. The procedures that follow shall be initiated in the event that a resident's blood glucose level extends out of the normal accepted ranges. Hyperglycemia: Blood Glucose levels that exceed 300 shall be considered to be hyperglycemia and may warrant prompt…

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.