Allure Of Knox County

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was dated, changed weekly, failed to provide a care for plan oxygen use, and failed to correctly identify oxygen use on MDS (medical data set) for one (R2) of one resident observed with oxygen therapy in the sample list of 33. Findings Include: The facility's Oxygen Administration policy, not dated, documents, Policy, oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and residents' goals and preferences. Policy explanation and compliance guidelines, 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the residents' assessment and orders, such as, but not limited to: a. The type of oxygen delivery system, b. When to administer, such as continuous or intermittent and/or when to discontinue, c. Equipment setting for prescribed flow rates, d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered e. Monitoring for complications…

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 documentation of communication and collaboration with the dialysis facility regarding dialysis care and services for one (R8) of one resident reviewed for dialysis care in a sample of 33. Findings Include:The facility's Hemodialysis policy, not dated, 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 residents goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. Purpose, the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatment received at a certified dialysis facility. Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Compliance Guidelines, 5. The licensed nurse will communicate to the dialysis facility via telephone communication or written format, such as a dialysis communication…

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 multi-dose injectable insulin pens were labeled with the date when opened for two of 15 residents (R5 and R56) reviewed for storage and labeling of medications in a sample of 33.Findings include:The facility's Labeling of Medications and Biologicals policy, undated, documents, All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. 8. Labels for multi-use vials must include: a. The date the vial was initially opened or accessed.On 6/8/26 at 9:30 AM V7 (LPN/Licensed Practical Nurse) was standing at the Back Hallway medication cart. V7 opened the top drawer of the medication cart where multi-dose insulin injector pens were stored. This drawer contained R5's opened 1/3 full Lispro Insulin100 u/ml (units/milliliter) injector pen that was not labeled with the date when opened. V7 stated, All insulin pens should be labeled with the date opened. V7 verified…

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 notify R2's Power of Attorney of R2's transfer to the hospital. This failure affects 1 of 1 resident reviewed for transfers. The facility policy, Notification of Changes, document: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. R2's EMR document R2's diagnosis included: Chronic Obstructive Pulmonary Disease, Chronic Bronchitis, Aphasia, Diabetes Mellitus Type II, Chronic Kidney Disease, Neurologic Neglect Syndrome, Hemiplegia Right Dominant Side, Atherosclerotic Heart Disease, Dependance on Supplemental Oxygen, Gastro-Esophageal Reflux Disease, Major Depressive Disorder, Anxiety Disorder, ST Elevation Myocardial Infarction, Hypertension, Hypercholesterolemia, Dysphagia, and Nicotine Dependence. R2's Progress noted document: [DATE] 9:28 p.m., Aide notified…

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 assess the pain of a resident who received scheduled medication to control pain for one resident (R4) of three residents reviewed for pain. 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. Monitoring, Reassessment and Care Plan Revision a. Facility staff will reassess resident's pain management at established intervals for effectiveness and/or adverse consequences such as: i. tolerance 11. Physical dependence iii. increased sensitivity to pains iv. constipation v. nausea, vomiting, and dry mouth vi. sleepiness, dizziness, and/or confusion vii. depression viii. itching and sweating; b. If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised…

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 complete post-fall documentation and implement appropriate fall interventions for four Residents (R1, R2, R3 and R4) and monitor for post fall injuries for three Residents (R2, R3 and R4) of four Residents reviewed for Falls in a sample of four. Findings include:The Facility Fall Prevention Policy, revised 1/2025, documents: each Resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls; a fall is an event in which an individual unintentionally comes to rest on the ground, floor or other level and may be witnessed, reported or presumed when a Resident is found on the floor or ground; the nurse will indicate on the Care Plan, the Resident's fall risk and initiate interventions on the Resident's baseline Care Plan; provide interventions that address unique risk factors measured by the risk assessment tool, medications, psychological, cognitive status…

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 obtain consent prior to the use of psychotropic medications for two of three residents (R1 and R2) reviewed for psychotropic medications in the sample of three. Findings include: The facility's undated Use of Psychotropic Medication(s) documents the following: 11. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care,the treatment alternatives or other options and the preferred option to accept or decline, in a format the facility deems to use (e.g.written consent form, narrative note, etc.). R1's medical record documents R1's diagnoses include: Major Depressive Disorder, Bipolar Disorder Depressive State and Anxiety disorder. R1's medical record includes a MD (Medical Doctor)/Nursing Communication form for R1, dated 02/14/25 by V8 (the facility's Medical Director), documents V8's facility visit with R1 and an order to discontinue R1's Venlafaxine Hydrochloride…

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 Registered Nurse was scheduled to work eight consecutive hours, seven days a week. This failure has the potential to affect all 44 residents residing in the facility. Findings include: On 12/10/24, V1 (Administrator) provided copies of the facility's Daily Staffing Assignment Sheets (dated 11/26/24 - 12/10/24), which document which staff members worked, and the duration of the shift that was worked. Based on the facility's census for each day, the facility exceeded their minimum staffing requirements. On 12/10/24, V1 (Administrator) provided copies of the facility's daily staffing assignment sheets (dated 11/26/24 - 12/10/24), which document which staff members worked, and the duration of the shift that was worked. The facility did not have a Registered Nurse scheduled to work for eight consecutive hours on the following days: 11/26/24, 12/02/24, and 12/07/24. On 12/11/24 at 09:29 AM, V4 (Regional Nurse) verified the facility did not have eight consecutive hours of RN coverage on 11/26/24, 12/02/24 and 12/07/24.…

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 items in the kitchen were clean. This has the potential to affect all 44 residents residing in the facility. Findings include: The facility's Sanitation Inspection policy (undated) documents the following: All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. On 12/09/24 at 10:00 AM, the hot water dispenser on the coffee maker in the kitchen contained a large amount of white, crusty build-up around the dispensing spout. V5 (Dietary Manager) verified the presence of the build-up and stated, It needs to be cleaned with lime scale. On 12/06/24 at 10:08 AM, the facility's walk-in cooler had a large amount of dust and debris adhered to the fan covers, as well as the surrounding wall and ceiling. V5 confirmed the presence of dust and debris in the walk-in cooler, and stated, It needs to be cleaned. The facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS Form 671), dated 12/09/24 and signed by V1…

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 all components of their Infection Prevention Control Program. This failure has the potential to affect all 44 residents currently residing in the facility. Findings include: The facility's Infection Prevention and Control Program policy (undated) documents the following: A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. This same policy documents, Staff Referral to Treatment Centers: Our staff shall be referred to appropriate medical treatment center/service when she/he: Is feverish and appears to be in the infectious stages of an illness; Experiences occupational exposure to body/blood fluids; Has been exposed to a communicable disease; Exhibits infected skin lesions. This policy also documents, Our Infection Preventionist shall…

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 their antibiotic stewardship program. This failure has the potential to affect all 44 residents residing in the building. Findings include: The facility's Antibiotic Stewardship Program policy (undated) documents the following: It is the policy of the facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. This same policy documents, Director of Nursing- establish standards for nursing staff to assess, monitor, and communicate changes in a resident's condition that could impact the need for antibiotics, use their influence as nurse leaders to help ensure antibiotics are prescribed only when appropriate, and educate front line nursing staff about the importance of antibiotic stewardship and explain policies in place to improve antibiotic use. This policy also documents, Infection Preventionist- utilizes…

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 call lights were responded to in a timely manner for 8 of 8 residents (R4, R8, R11, R23, R30, R36, R39, and R42) who were in attendance for the Resident Council meeting. Findings include: On 12/10/24 from 09:30 AM - 10:30 AM, a group meeting with the following residents who regularly attend Resident Council Meetings at the facility was conducted: R4, R8, R11, R23, R30, R36, R39, and R42. All eight residents verbalized concerns with staff's response times to call lights. During this meeting, R30 stated the following, There have been a few times I have had to call the receptionist at the back desk to tell her to send someone to help me. I had a bowel movement, and needed changed. I pressed my call light and it was on for 20 minutes. I told the staff that came in to help me, who didn't seem to care. When I reported this, I was told that a call light audit had been completed, and my light was on for 15 minutes, not 20. That is still too long to sit with stool in your pants. R36 then stated, (State Agency) will not see…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital, for four of four residents (R6, R9, R29 and R52), reviewed for bed holds, in the sample of 28. Findings Include: The (undated) facility Bed Hold Notice Upon Transfer Policy, directs staff, At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or resident representative written notice which specifies the duration of the bed- hold policy and addresses information explaining the return of the resident to the next available bed. 1. R9's medical record documents that R9 was hospitalized on [DATE], 8/6/24, 8/19/24 and 10/18/24. R9's medical record does not contain documentation of written notice to R9 or R9's resident representative, of the facility bed hold policy. 2. R29's medical record documents that R29 was hospitalized on [DATE]. R29's medical record does not contain documentation of written notice to R29 or R29'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 develop a comprehensive care plan for Oxygen for one of one resident (R6) reviewed for Oxygen in the sample of 28. Findings include: The facility's Comprehensive Care Plan policy (undated) documents It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe, at a minimum the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. On 12/9/24 at 10:25 AM, R6 was sitting in the dining room with Oxygen on at two liters per nasal cannula. R6 was leaning forward 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 assess a resident's range of motion quarterly, failed to provide necessary equipment to maintain a resident's range of motion and failed to develop a plan of care for a resident's range of motion for one of three residents (R9) reviewed for range of motion in a sample of 28. FINDINGS INCLUDE: The (undated) facility policy, Prevention of Decline in Range of Motion directs staff, The facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant shall establish and utilize a systemic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventative care. Licensed nurses will assess resident's range of motion on admission/readmission, quarterly and upon a significant change. Residents who exhibit limitations in range of motion, initially and thereafter, will be referred to the therapy department for a focused assessment of range of motion. Based on the comprehensive assessment, the facility…

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 check placement with venous blood return prior to intravenous (IV) PICC (peripherally inserted central catheter) line medication administration for one of one resident (R47) reviewed for IV medication administration in the sample of 28. Findings include: The (undated) facility policy, Validation Checklist Flushing and Locking a Central Venous Access/Midline/PICC Catheter directs staff, Purpose: To determine if the individual performs flushing and locking of a central venous access catheter/midline/PICC in accordance with professional standards of practice. Attached 10mL (milliliter) normal saline syringe to connector maintaining sterility, Unclamped catheter, if clamp present, aspirated for blood return, slowly injected normal saline into the catheter, and Removed syringe and discarded in sharps container. On 12/10/2024, at 9:15 AM, V6/Registered Nurse (RN) attached a 10mL (milliliter) normal saline syringe to R47's PICC (peripherally inserted central catheter) connecter. Without aspirating for blood, V6…

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 address a resident's symptoms of depression and develop a care plan with interventions to recognize and treat symptoms of depression for one of two residents (R47) reviewed for mood in the sample of 28. Findings include: The Facility's Behavioral Health Services Policy (undated) states, It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental psychosocial functioning. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment difficulty, and trauma or post-trauma stress disorders. The facility will ensure that a resident who, upon admission was not assessed or diagnosed with a mental or psychosocial adjustment difficulty or a documented history of trauma and/or PTSD (post traumatic stress disorder) does not develop patterns of decreased…

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 employ a licensed Administrator. This failure has the potential to affect all 52 Residents residing in the Facility. Findings include: The Facility Resident Census Roster, dated [DATE], documents 52 Residents residing in the Facility. The Facility Department Head List, dated [DATE], documents that effective [DATE], V1 (Administrator in Training/AIT) is the Facility Administrator. The Facility Administrative Services Job Description, signed and dated [DATE] by V1 (AIT), documents: primary purpose of this position is to direct the day-to-day functions of the Facility in accordance with current Federal, State and Local standards, guidelines and regulations that govern nursing facilities to assure the highest degree of quality care can be provided to Residents at all times; and must possess a current encumbered nursing home administrator's license or meet the license requirement of the state. On [DATE], the Facility could not provide V1's (AIT)…

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 report an allegation of misappropriation of funds to the administrator, state agency, and the local police department for one of three residents (R1) reviewed for abuse in the sample of four. Findings include: The facility's Abuse, Neglect, and Exploitation policy dated 02/2023 documents, Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Reporting/Response 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other requires agencies (all enforcement) within all timeframes immediately, but not later than two hours after an allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in bodily injury. On 6-26-24 at 9:40 AM V4 (CNA/Certified Nursing Assistant) stated, When…

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

Based on record review, and interview, the facility failed to provide/have quarterly Quality Assurance & Performance Improvement (QAPI) meetings. This failure has the potential to effect all 53 residents residing in the facility. FINDINGS INCLUDE: Facility policy, entitled 2023 Quality Assurance & Performance Improvement (QAPI) Plan, Copyright 2022, document, Committee meetings are held on a quarterly basis at a minimum. The committee shall maintain written meeting agendas, minutes, attendance records, and QAPI program progress notes. QAPI sign-in sheets provided only include one sheet/one quarter. No other documentation for QAPI meetings was able to be found/provided. On 2/15/2024, V14/Regional Nurse Consultant confirmed the facility does not have QAPI meeting sign-in sheets for three of the four quarters in 2023. V14 also confirmed sign-in sheets should have been completed and maintained in the facility. The Centers for Medicare and Medicaid Services/CMS form 671-Long-Term Care Facilities Application for Medicare and Medicaid, dated 2/14/2024, document 53 residents reside in 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 incontinent supplies were available for one of three residents reviewed for dignity (R42) in the sample of 25. Findings include: An undated policy titled Resident Rights in a section titled Respect and dignity documents, 4. c. The resident has a right to be treated with respect and dignity, including the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. R42's MDS/Minimum Data Set assessment dated [DATE] documents R42's BIMS/Brief Interview for Mental Status as 15 out of 15, indicating no cognitive impairment. R42's MDS dated [DATE] documents R42 is frequently incontinent of bowel and bladder. R42's Nutritional assessment dated [DATE] documents R42 is 62.5 inches tall. R42's weight documented on 02/04/24 is 226.5 pounds. On 02/13/24 at 11:26 AM, R42 stated, The facility does not have size 2XL (two extra-large) (incontinence briefs) or (cleansing) wipes. They always…

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 a resident was free of physical abuse for one (R14) of four residents reviewed for abuse in a sample of 25. Findings include: An undated Abuse, Neglect and Exploitation policy documents, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The definition of abuse is documented as, The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. R14's BIMS/Brief Interview of Mental Status, dated 1/30/24, documents R14's BIMS score is 14 out of 15, indicating R14 is cognitively intact. R27's BIMS, dated 12/20/23, documents R27's BIMS score is 11 out of 15, indicating moderate cognitive impairment. Facility Reported Incident, dated 02/08/24,…

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 follow their abuse policy for one (R47) of three residents reviewed for abuse in a sample of 25. Findings include: Facility Abuse, Neglect, and Exploitation policy, copywrite 2023, documents It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Investigation of Alleged Abuse, Neglect and Exploitation written procedures for investigations include: Investigating different types of alleged violations. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Providing complete and thorough documentation of the investigation. V1's email to state, dated 1/8/24 at 3:03 PM, documents On 1/5/24 (V9/R47's friend) reported (R47) was missing money from his wallet. Investigation initiated. Upon interview with…

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 report the misappropriation of money to the local State Agency for one of four residents reviewed for abuse (R42) in a sample of 25. Findings include: An undated Abuse, Neglect and Exploitation policy documents, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Misappropriation of Resident Property is defined as, the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. A section of this policy titled Reporting/Response documents, The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (law enforcement when applicable) within specified timeframe's: a. Immediately, but not later…

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 conduct a thorough investigation into an allegation of misappropriation of property for two (R47 and R42) of three residents reviewed for abuse in a sample of 25. Findings include: Facility Abuse, Neglect, and Exploitation policy, copywrite 2023, documents Investigation of Alleged Abuse, Neglect and Exploitation written procedures for investigations include: Investigating different types of alleged violations. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Providing complete and thorough documentation of the investigation. Misappropriation of Resident Property is defined as, the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. 1. V1 Administrators email to state, dated 1/5/24 at 8:02 PM, documents (R47) was in the hospital and his friend reports missing money. Investigation started, final to follow. V1'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 develop a smoking careplan for one (R47) of 24 residents reviewed for careplan development in a sample of 25. Findings include: Facility Comprehensive Care Plans, Copyright 2023, documents It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident to meet the residents medical, nursing, and mental and psychosocial needs that are identified in the residents comprehensive assessment. On 2/13/24 at 11:32 AM, R47 stated I am a smoker for 40 years, they keep my smoking materials locked up, and I have to ask for them. During this survey from 2/13-2/16/24 from 9 AM-PM, multiple observations were made of R47 smoking outside. On 2/14/24 at 9:33 AM, R47 was outside on the smoking patio smoking and holding smoking materials. R47's MDS/Minimum Data Set documents R47 is a smoker. Facility Smokers paper, no date, has R47 listed. R47's current care plan does not have smoking careplanned. On 02/16/24 at 11:27 AM, V14 Regional Nurse stated I don't see smoking on the…

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

Based on observation, interview, and record review, the facility failed to evaluate residents for smoking safety for one (R47) of two residents reviewed for safe smoking in a sample of 25. Findings include: Facility Resident and Visitor Smoking Policy Notification, undated, documents Residents who pose a hazard with smoking materials will have supervised smoking times, and placed in a supervised program for safe smoking. Facility Smokers paper, undated, has R47 listed. On 2/13/24 at 11:32 AM, R47 stated I am a smoker for 40 years, they keep my smoking materials locked up, and I have to ask for them. During this survey from 2/13-2/16/24 from 9 AM-PM, multiple observations were made of R47 smoking outside. On 2/14/24 at 9:33 AM, R47 was outside on the smoking patio smoking and holding smoking materials. R47's medical record has no smoking assessment as part of the chart. On 2/16/24 at 11:27 AM, V14 Regional Nurse stated I don't see a smoking assessment for (R47). (V5) Social Services Director/SSD does the smoking assessments. On 2/16/24 at 11:28 AM, V5 SSD stated I am supposed to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the Facility failed to ensure Resident grievances were promptly responded and resolved for three of four Residents (R1, R2 and R3) reviewed for Grievances in a sample of four. Findings include: Facility Resident and Family Grievances Policy, undated, documents: Facility will have prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance; 4. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC (Long Term Care) stay; 8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Official; 10. b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the Facility failed to develop a Care Plan for one (R1) of four Residents reviewed for Care Plans in a sample of four. Findings include: Facility Comprehensive Care Plan Policy, undated, documents: it is the Policy of the Facility to develop and implement a comprehensive person-centered Plan for each Resident, consistent with resident rights, that includes measurable objectives and timeframes to meet Resident's medical, nursing and mental/psychosocial needs that are identified in the Resident's comprehensive assessment; and the comprehensive Care Plan will include measurable objectives and timeframe's to meet the Resident's needs as identified in the Resident's comprehensive assessment, the objectives will be utilized to monitor the Resident's progress and alternative interventions will be documented, as needed. R1's Physician Order Sheet/POS, dated 12/27/23, documents that R1 admitted to the facility on [DATE], with diagnoses including: Fracture of Body of Sternum, Closed…

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 prevent a Pressure Ulcer for one (R1) of four Residents reviewed for skin issues in a sample of four. Findings include: Facility Pressure Ulcer Prevention and Management Policy, dated 2023, documents: the Facility is committed to prevention of avoidable pressure injuries and to provide treatment and services to heal the pressure ulcer/injury; the Facility will establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors, monitoring of the interventions and modifying the interventions as appropriate. Facility Pressure Ulcer/Skin Log, dated 11/15/23 through 12/8/23, does not document any skin issues for R1. R1's admission Nursing Note, dated 11/24/23, documents that R1 admitted to the Facility. The Nursing Note documents that R1 has bilateral upper extremity bruising (dark purple/blue from intravenous catheter/IV 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, record review and interviews the facility failed to implement interventions to reduce the risk of falls for one of three residents (R1) reviewed for falls in a sample of 3. Findings include: The facility policy named, Fall Prevention Program, dated 2023, documents the following, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: The facility utilizes a standardized risk assessment for determining a residents fall risk. The nurse will indicate the residents fall risk and initiate interventions in accordance with the resident's level of risk.5.) Low/Moderate Risk Protocols: Implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to I.) A clear pathway to the bathroom. ii.) bed is locked and lowered to a level that allows the residents feet to be flat on the floor when resident is sitting at the edge of the bed. iii.) Call light 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.