Loft Rehabilitation & Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to immediately report verbal abuse and report an injury of unknown origin to the abuse coordinator for two of three residents (R47, R315) reviewed for abuse in the sample of 39. Findings include: The facility's Abuse/Neglect/ and Exploitation Policy, dated 12/5/22, documents, 6. Identification of Abuse, Neglect, and Exploitation- The facility will consider factors indicating possible abuse, neglect, and or/exploitation of residents, including, but not limited to, the following possible indicators: b. Physical marks such as bruises or patterned appearances such as a handprint, belt, or ring mark on a resident's body. c. Physical injury of a resident, of unknown source. e.Verbal abuse of a resident overheard. 14. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and…

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 staff to resident verbal abuse for one of three residents (R47) reviewed for abuse in the sample of 39 Findings include: The facility's Abuse, Neglect and Exploitation policy, reviewed/revised dated 12/5/2023, documents Investigation of Alleged Abuse, Neglect and Exploitation- When suspicion of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include. Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. If there is no discernible response from the resident, or if the resident's response is incongruent with that of a reasonable person, interview the resident's family, responsible parties, or other individuals involved in the resident's life to gather how he/she believes the resident would react to the incident.…

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 care plan was updated for one of 24 residents (R17) in a sample of 39 reviewed for care plans. Findings Include: The facility policy, named Care Plan Revision Upon Status Change, revised 1/25/2024, documents the following, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1.) A comprehensive care plan will be reviewed, and revised as necessary, when the resident experiences a status change.) The care plan will be updated with the new or modified interventions. R17's Face Sheet, dated 7/7/2024, documents: Special Instructions: UNDER NO CIRCUMSTANCES IS V21- R17's Friend, ALLOWED TO TAKE R17 OFF THE PROPERTY. V21 is allowed to visit; V21 is allowed to go outside with resident as long as they DO NOT leave the property. V21 is NOT allowed to bring in outside food and beverages. The facility Resident/Family Complaint, dated 7/8/2024, documents the following: R17 left…

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

Based on observation, interview and record review, the facility failed to provide a resident with scheduled Physician ordered showers for one of one resident (R12) reviewed for hygiene in the sample of 39. Findings include: The facility's Activities of Daily Living (ADLs) policy, dated 12/5/23, documents Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming and oral care. Assisting with coordinating other care and physician services. This same policy documents A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. R12's current Care Plan, dated 6/1/24, documents (R12) has an ADL self-care performance deficit related to dementia, spinal stenosis, depression, altered mental status. Interventions/Tasks: Bathing/Showering; Requires staff supervision with showering. Prefers a bath at least one time weekly. This same care plan documents R12 is cognitively intact has diagnoses of Sciatica, Pain in Joints, Difficulty 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.

Based on record review and interview the facility failed to ensure that a mentally ill resident did not leave the building unsupervised for one (R17) of three residents reviewed for Safety in a sample of 39. Findings Include: The facility policy, Accidents and Supervision, dated 1/5/2023, documents, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and the facility will provide the adequate supervision. R17's Diagnosis Information documents the following diagnosis: Cerebral Infarction Frontal Lobe with Executive Function deficit, Alcohol Induced Dementia, Alcohol Dependence, Schizoaffective Disorder, Bipolar Type, Schizophrenia, Major Depressive Disorder, moderate, Anxiety Disorder, and Cognitive Social Deficit. On 7/29/2024 at 10:36 AM V1/Administrator in Training, stated, R17 left the faciity on 7/6/2024 with V21 (R17's Friend) to go out for lunch. V22 (R17's Family Member), informed staff later that day, that R17 should never leave the facility with V21. They both are alcoholics, and this is why I do…

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 observation, interview and record review, the facility failed to ensure an indwelling urinary catheter tubing was off the floor and an indwelling catheter urinary drainage bag was covered for one of two residents (R15) reviewed for indwelling catheters in the sample of 39. Findings include: The facility's Catheter Care Policy, dated 1/24/23, documents Policy: 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. Policy Explanation: 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. R15's Order Summary, dated 7/30/24, documents the following physician order: Maintain indwelling catheter with 16 french 20 cubic centimeter balloon. R15's current Care Plan, dated 5/1/24, documents I have an Indwelling (Urinary) Catheter related to obstructive uropathy and urinary strictures. On 7/29/24 at 9:51 AM R15 was sitting in her wheelchair in the middle of the memory care unit hallway. R15'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 and record review, the facility failed to ensure the medication error rate was less than five percent with two medication errors in a medication pass sample of 29, making the medication error rate 6.9% for one of five residents (R5) reviewed for medication administration in the sample of 39. Findings include: R5's current Medication Administration Record (MAR), dated 7/1/24-7/31/24, documents R5 has an order for blood glucose monitoring followed by a sliding scale Insulin Aspart Injection Solution 100 units/milliliter. Inject as per sliding scale: if 110 - 140 = 5; 141 - 169 = 6; 170 - 199 = 7; 200 - 229 = 8; 230 - 259 = 9; 260 - 289 = 10; 290 - 319 = 11; 320 - 349 = 12; 350 - 399 = 13 call provider for above 400, subcutaneously before meals related to Type Two Diabetes Mellitus This (MAR) documents administration times are 7:30 AM, 11:30 AM and 5:30 PM, before meals. R5's current Medication Administration Record (MAR), dated 7/1/24-7/31/24, documents, R5 has an order for Metformin Oral Tablet (medication to lower blood sugar) 500 milligrams. Give 500 mg 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to staff a sufficient number of nurses' aides on a consistent basis in order to provide services to meet the resident's needs safely and in a manner that promotes each resident's rights and well-being. This failure has the potential to affect all 62 residents in the facility. Findings Include: The facility's Activities of Daily Living (ADL) policy dated 12/5/22 documents the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. Care and services will be provided for resident bathing. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility's Safe Handling and Transfers policy dated 12/15/22 documents it is the policy of the facility to ensure that residents are handled and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide eight consecutive hours of Registered Nurse coverage per day. This failure has the potential to affect all 62 residents in the facility. Findings Include: The facility's Facility assessment dated [DATE] documents the facility will utilize licensed nursing staff including those of Registered Nurses (RN) in order to provide support and care for the residents. The May 2024 nurse schedule documents from the dates of 5/22/24 through 5/31/24, there were six days that the facility did not provide RN coverage. These days include 5/22/24, 5/23/24, 5/25/24, 5/26/24, 5/28/24, and 5/29/24. The Resident Census sheet from 6/1/24 documents a total census of 62 residents. On 6/1/24 at 4:20 PM V1 Administrator confirmed six of the last ten days the facility did not provide eight consecutive hours of Registered Nurse coverage per day. V1 also confirmed the current resident census was 62 residents.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide showers to dependent residents. This failure affected four of four residents (R1, R3, R6, R7) reviewed for showers on the sample list of eight. Findings Include: The facility's Activities of Daily Living (ADL) policy dated 12/5/22 documents the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for resident bathing. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. R1's Medical Diagnoses dated May 2024 documents R1 is diagnosed with Multiple Sclerosis and Right Side Hemiplegia. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact and requires substantial maximum assistance for bathing/showering. The undated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide safe mechanical lift transfers for dependent residents. This failure affected two of three residents (R1, R4) reviewed for mechanical lift transfers on the sample list of eight. Findings Include: The facility's Safe Handling and Transfers policy dated 12/15/22 documents it is the policy of the facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Mechanical lifts may include equipment such as full body/full mechanical lifts, sit to stand lifts, or ceiling track lifts. Two staff members must be utilized when transferring residents with a mechanical lift. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes 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.

Based on interview and record review, the facility failed to ensure the services of a Registered Nurse (RN) a minimum of eight consecutive hours a day, seven days a week. This failure has the potential to affect all 67 residents residing in the facility. Findings include: The Nursing Schedule dated April 2024, documents no RN hours were scheduled or worked on the following dates: 4/13/24, 4/14/24, 4/27/24, and 4/28/24. On 4/30/24 at 1:30 p.m., V1 (Administrator) stated the facility did not have any RN services on 4/13/24, 4/14/24, 4/27/24, and 4/28/24. V1 stated the facility follows the federal regulation and should have a minimum of eight hours of RN services per day. V1 stated at this time, the facility only employs one full time RN that is only scheduled to work the floor. V1 stated the other RNs employed are administrative and are not regularly scheduled to work the weekend shifts. The Centers for Medicare and Medicaid Services (CMS) 802 form dated 4/29/24, provided by V1 (Administrator), documents there are 67 residents residing in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify a resident's representative of a new roommate assignment for one of three residents (R1) reviewed for notification of change in the sample of five. Findings include: The Facility's Change of Room or Roommate policy dated 11/24/20, states 4. Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advanced notice of such a change as is possible. 7. The Social Service designee or Licensed Nurse should inform the resident's sponsor/family in advance of a change in the resident's room or roommate. The Facility's room roster dated 4/29/24, documents R1 and R3 reside in the same room. On 4/29/24 at 10:10 a.m., R1 and R3 were not in their room. This room was observed to have R1 residing in the second bed, closest to the window, and R3 residing in the first bed, closest to the door. R1's electronic medical record documents R1 is an [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 resident hallway ceiling tiles and ceiling exhaust vents were kept clean and without debris. This deficiency has the potential to affect all 57 residents residing in the facility. Findings include: The facility's Maintenance Director job description, dated 6/2021, documents Position Purpose: Directs the day to day activities of the Maintenance department in accordance with current federal, state and local standards, guidelines and regulations governing the facility, and to assure the facility is maintained in a safe and comfortable manner. On 1/4/24 at 10:10 AM, the resident hall four was toured with V10 (Maintenance Director). Two separate areas towards the center of the hall contained six exhaust vents each that were surrounded by ceiling tiles. All of the vents contained large amounts of thick gray fuzzy debris and some light brown staining on the metal grids. Four of the drop ceiling tiles surrounding the metal vents contained areas of small speckles of dark gray and black spots that varied in size…

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's personal funds were not charged for service while receiving Medicaid benefits for one of three residents (R2) reviewed for billing in the sample of four. Findings include: The facility's Business Office Manager job description, dated 6/2021, documents Position purpose: Leads, guides and directs the financial operations of the healthcare facility in accordance with generally accepted accounting principles; local, state and federal regulations, standards and established facility policies and procedures to achieve facility financial goals. Major duties and Responsibilities: Performs daily accounting functions in accordance with current acceptable accounting and cost-reimbursement principles related to skilled and long-term care operations. Ensures facility's billing checks and balances are followed by all team members as required by the facility policy including but not limited to the balancing of the daily census, Medicare triple check prior to billing, etcetera. Maintains a working knowledge of the state…

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 report a resident's missing items as possible misappropriation to the abuse coordinator for one of three residents (R1) reviewed for misappropriation in the sample of four. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated 12/5/22, documents Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. The Abuse coordinator in the facility is the Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect or exploitation immediately to: Administrator 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 screen eight (R7, R11, R22, R24, R30, R39, R44, and R306) residents for trauma, PTSD (post-traumatic stress disorders), and/or cultural preferences in a sample of 26. Findings include: Facility Trauma Informed Care policy, dated 12/20/22, documents It is the policy of this facility to provide care and services which 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-traumatizations. The facility will use a multi-pronged approach to identifying a resident's history of trauma as well as his or her cultural preferences. Facility Social Services Designee job description, dated June 2021, documents Position Purpose: Assists in planning, organizing, implementing, and evaluating the overall operation of the facility's Social Services Department in accordance with current federal, state, and local standards, guidelines and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to change a pressure ulcer dressing as ordered by the physician for one resident (R10) out of three residents reviewed for pressure ulcers in a sample of 26. Findings include: The facility's Wound Treatment Management policy dated 8/24/22 documents Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. R10's wound assessment upon admission dated 4/12/23 documents Stage IV pressure ulcer to left lateral heel measuring 4.2 centimeters (cm) x 3.0 cm x 0.4 cm. R10's wound assessment dated [DATE] documents Stage IV pressure ulcer to left lateral heel measuring 3.7 cm x 2.3 cm x 0.4 cm. R10's Rreatment Administration Record (TAR) dated 5/1/23 through 5/31/23 documents treatments were not completed on 5/10/23 and 5/24/23. R10's physician order sheet dated 4/30/23 documents Cleanse left heel. Apply (biologic debridement agent), calcium alginate, cover…

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 vital signs and a respiratory assessment, failed to ensure respiratory equipment was clean prior to use, and failed to monitor a resident during respiratory treatment for one (R306) of eight residents reviewed during medication administration in a sample of 26. Findings include: The facility's Nebulizer Therapy policy, reviewed 9/22/20, documents Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions .Policy Explanation and Compliance Guidelines: Care of the Resident .6. Obtain resident's vital signs and perform respiratory assessment to establish a baseline .14. Observe resident during the procedure for any change in condition .Care of the Equipment 1. Clean after each use. 2. Wash hands before handling equipment. 3. Disassemble parts after every treatment. 4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 5. Shake off excess water. 6. Air dry on an…

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 store personal items separate from resident food, throw away expired food, date foods after opening/delivery, and date health shakes. This has the potential to affect all 58 residents in the facility. Findings include: Facility Storage of Refrigerated Foods, revised 2017, documents Food in the refrigerator is covered, labeled, and dated with a use by date. Open products that have not been properly sealed and dated are discarded. Facility Storage of Dry Goods/Foods, revised 2017, documents Opened products are labeled, dated with the use by date and tightly covered to protect against contamination. Opened products that have not been properly sealed and dated are discarded. On 4/5/22 at 9am a tour was performed of the kitchen with V8 DM/Dietary Manager. Facility cooks cooler had a purse and 1/2 bottle of diet coke on the shelf. V12 [NAME] was in the kitchen and verified it was her purse and 1/2 bottle of diet coke that was in the cook's cooler and nothing should be stored in the cooler except food items for 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 store clean linen separately from soiled linen and trash. This has the potential to affect all 58 residents in the building. Findings include: Facility Handling Clean Linen, copyright 2020, documents It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. Clean linen shall be delivered to resident care units on covered linen carts with covers down. Nothing shall be kept on top of linen carts. Clean linen shall be kept separate from soiled linen. When clean linen carts are in use (i.e., in the hallway), keep at least one door length away from soiled linen collection containers. Facility Handling Soiled Linen, copyright 2020, documents It is the policy of this facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection. Linen should not be allowed 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, record review and interview the facility failed to designate a qualified Infection Preventionist. This failure has the potential to affect all 58 residents residing in the facility. Findings include: Facility Infection Preventionist Job Description, dated 6/2021, documents: a minimum requirement including a nursing degree from an accredited college or university or be a graduate of an approved Licensed Practical Nurse (LPN)/Registered Nurse (RN) program; three years' experience as an LPN or RN; and must have completed specialized training in infection prevention and control through an accredited continuing education. On 4/5/22 at 9:51 am, V1 (Administrator) stated, Our Infection Preventionist is (V4/Director of Business Development). On 4/5/22 at 12:45 pm, V4 (Director of Business Development) stated, (V2/Director of Nursing/DON) and myself share the Infection Preventionist duties. On 4/6/22 at 10:50 am, V4 (Director of Business Development) stated, (V2/Director of Nursing) has not completed the Infection Preventionist training, (V2) only has four modules…

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 the required in service training for nurse aides for dementia residents. This has the potential to affect all 58 residents in the building. Findings include: Documentation of Facility staff training was provided by V1 Administrator and V2 Director of Nursing/DON. The training documents they provided had no dementia training for the CNAs (Certified Nursing Assistants). On 4/8/22 at 11:42 am, V2 DON stated We have not done any dementia training, I cannot find any training on it, so it was not done. I went through all our training I gave you and you have it all. On 4/8/22 at 11:07 am, V22 VPO/Vice President Operations stated, We do not have a (learning management)system for tracking CNAs. Resident Census and Conditions form, dated 4/6/22, documents 58 residents reside in the facility.

Based on interview and record review the facility failed to answer resident call lights timely for six (R7, R13, R28, R36, R43 and R48) residents of nineteen reviewed for call lights in a sample of 41. Findings include: Facility Call Light/Accessibility and Timely Response Policy, dated 8/1/2019, documents the purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet and bathing facility to allow residents to call for assistance; call lights will directly relay to a staff member or centralized location to ensure appropriate response; and all staff members who see or hear an activated call light are responsible to responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. Facility Resident Council Minutes, dated 3/29/22, document call light concerns were discussed, regarding being answered in a timely manner. Facility Resident Council Minutes, dated 2/15/22, document residents had concerns about call light answering.: Facility Resident Council Minutes dated…

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 revise a plan of care for five (R35, R40, R45, R50, and R53) of 19 residents reviewed for care planning in the sample of 41. Findings include: The facility's undated, Comprehensive Care Plans policy, documents 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment . 6. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed . Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 1. On 4/06/22 at 2:42 pm, R45 pulled up her shirt to reveal a gastrostomy feeding tube and stated she has a feeding tube, but it isn't being used anymore because she can eat regular food and take her medications by mouth. R45's current Care Plan documents Glucerna 1.5 via (gastrostomy feeding) tube at 55…

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

Based on record review and interview the facility failed to obtain and record resident weights, as ordered by a physician and failed to notify a resident's physician and/or representative of significant weight changes for five (R13, R40, R49, R50 and R53) of 19 residents reviewed for weight loss in a sample of 41. Findings include: Facility Weight Monitoring Policy, dated 1/1/2020, documents: based on the resident's comprehensive assessment, the facility will ensure that all resident's maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; weight can be a useful indicator of nutritional status, significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem; the facility will utilize a systemic approach to optimize a resident's nutritional status and risk factors;…

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 oxygen tubing, nebulizer tubing and humidity bottles were dated, changed and stored according to facility policy, failed to ensure oxygen flow rates were administered per physician order and failed to ensure oxygen tanks were filled for six of six residents (R7, R40, R45, R50, R51, and R53) reviewed for oxygen in the sample of 41. Findings include: The facility's Oxygen Administration policy, revised 9/24/20, states, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans and the residents' goals and preferences. 1. Oxygen is administered under orders of a physician, except in the case of an emergency. 5. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include: b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. c. Change humidification bottle when empty, every 72…

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 issue the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS (Centers for Medicare and Medicaid Services)-10055 to three (R13, R37, R38) of three residents reviewed for Beneficiary Protection Notification in a sample of 41. Findings include: 1. R13's SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form provided by V1 (Administrator) documents R13's Medicare Part A Skilled Services Episode Start Date as 1/25/22 and last covered day of Part A Service as 3/9/22. This form documents the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted and the SNF ABN Form CMS-10055 was not provided to R13 or R13's Representative. The handwritten explanation by V1 documents No information at this time. R13's Census Report documents R13 remained in the facility after R13's discharge from Medicare (Med) Part A Skilled Services on 3/9/22. 2. R37's SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form…

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 an order for leg braces and a hand brace for two (R35 and R40) of three residents reviewed for mobility in a sample of 41. Findings include: Facility Residents' Rights, revised 11/2018, documents Your facility must provide services to keep your physical and mental health at their highest practical levels. 1. R35's current diagnoses include Abnormal posture. R35's current care plan initiated on 3/17/22 documents (R35) has an ADL (activity of daily living) self-care deficit as evidenced by decreased mobility, severe morbid obesity, and lack of coordination. (R35) will receive assistance necessary to meet ADL needs. Dressing: (R35) requires extensive assist of two staff for completion of task. R35's current orders for April 2022 has no orders for R35's bilateral leg braces. On 4/5/22 at 9:30 am, R35 was in bed in his room, alert and oriented, bilateral leg braces lying on a three-drawer cart and stated, I wear (bilateral) leg braces and get them put on every day I get out of bed. At that same time, V10 and…

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 pressure ulcer treatments per order and failed to document skin concerns/pressure ulcers for two (R35 and R53) of four residents reviewed for pressure ulcers in a sample of 41. Findings include: Facility Registered Nurse, dated June 2021, documents Performs wound treatments as per physicians' orders. Facility Licensed Practical Nurse, dated June 2021, documents Responsible for providing optimum resident care by performing nursing procedures. Facility Wound Treatment Management, dated 8/1/19, documents 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. Wound treatments will be provided in accordance with physician orders. In the absence of treatments orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned nurse in the absence of the treatment nurse. Dressing changes may be provided…

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 incontinence care, failed to perform catheter care and failed to use a catheter securing device for two (R35 and R40) of six residents reviewed for catheters and incontinence care in a sample of 41. Findings include: Facility Certified Nursing Assistant Policy, dated June 2021, documents under job functions Report all accidents and incidents you observe on the shift that they occur, under personnel functions cooperate with inter-departmental personnel, as well as other facility personnel to ensure that nursing services can be adequately maintained to meet the needs of the residents, under personal nursing care functions assist residents with bath functions (i.e., bed bath, tub or shower bath, etc.) as directed, keep residents dry (i.e., change gown, clothing, linen, etc., when it becomes wet or soiled), assist resident with bowel and bladder functions, maintain intake and output records as instructed, keep incontinent residents clean and dry, weigh and measure residents as instructed, check each…

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 colostomy care to one (R35) of one resident reviewed for colostomies in a sample of 41. Findings include: Facility Ostomy Care- Colostomy, Urostomy, and Ileostomy, copyright 2020, documents It is the policy of this facility to ensure that residents who require colostomy services receive care consistent with professional standards of practice, the comprehensive person-centered care plan. Ostomy care will be provided by licensed nurses under the orders of the attending physician. R35's current diagnosis: DIVERTICULITIS OF SMALL INTESTINE WITH PERFORATION AND ABSCESS WITHOUT BLEEDING. R35's MDS/Minimum Data Set, dated [DATE], documents under section C Cognitive Patterns R35 is cognitively intact. R35's current care plan documents a colostomy with a start date of 11/3/20. (R35) has an alteration in gastrointestinal status related to disease process-Change colostomy as ordered and prn/as needed. Check and empty colostomy bag each shift…

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 gastrostomy tube care was completed for one (R45) of one resident reviewed for gastrostomy tubes in the sample of 41. Findings include: The facility Gastrostomy Site Care policy and procedure, dated 01/01/20, documents It is the policy of this facility to perform gastrostomy site care as ordered. The facility Flushing a Feeding Tube policy, revised 9/24/20, documents It is the policy of this facility to ensure that staff providing care and services to the resident via a feeding tube are aware of, competent in and utilize the facility protocols regarding feeding nutrition and care. Feeding tube care and services will be provided in accordance with resident needs and professional standards of practice. R45's admission MDS (Minimum Data Set) assessment, dated 3/18/22, documents R45 has a gastrostomy tube and receives 51% or more of total calories through parenteral or tube feeding and Average fluid intake per day by tube feeding 500cc/day (centimeters per day) or less. The current Care Plan for R45,…

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 physician ordered pain medication was readily available for two (R50 and R106) of three residents reviewed for pain in the sample of 41. Findings include: The facility's undated Pain Management policy documents The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences . Manage or prevent pain and use Non-pharmacological interventions. The facility's Unavailable Medications policy, dated 01/01/20, documents The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn (as needed), and emergency medications. A STAT (with no delay) supply of commonly used medications is maintained in-house for timely initiation of medications. The facility shall follow established procedures for ensuring residents have a sufficient supply of medications . Staff shall take immediate action when it is known 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 observation, interview, and record review the facility failed to communicate with the dialysis center before and after resident dialysis treatments, failed to provide a lunch meal on resident dialysis days and failed to monitor and assess dialysis access sites/grafts for two (R7 and R23) of two residents reviewed for dialysis in the sample of 41. Findings include: The facility's Hemodialysis policy, dated 01/01/20, 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. The facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This will include: 1. The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received…

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 store medications safe and securely for two of 20 residents (R35 and R40) reviewed for medications in a sample of 41. Findings include: Facility Resident Self-Administration of Medication, dated 7/1/21, documents It is the policy of this facility to support each resident's rights to self-administer medication. A resident may only self-administer medications after the facility's team has determined which medications may be self-administered safely. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other residents' rooms. Facility Storage of Medications, dated 5/1/18, documents Medications and biologicals are stored safely, securely, and properly. The medication supply is accessible by license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 1. On 4/05/22 at 9:30am, In R35's room there was a prescription acetic acid solution 0.25%/percent from (pharmacy), dated 8/16/21, with 50ml/milliliter…

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.