Lacon Rehab And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Findings Include: B. On 05/20/25 at 10:30 AM R49 was lying in bed and talking on her cell phone. (R28/another wandering resident) entered resident room with shuffling gait and mumbling. R49 stated Hi (R28), this isn't your room, turn around. R49 kept talking on her phone. R28 continued into the room. R49 stated into the phone I am going to have to let you go, I have to get her out of here. R49 transferred herself to her wheelchair and put on slippers and said come on (R28), you walk in front of me. R28 grabbed R49's hand and was easily walked out the residents door and continued on down the hallway. On 5/20/25 at 10:35 AM R49 stated this happens all the time. (R28) doesn't really bother me because she will leave easily, she's just very confused. (R11) is the one who wanders in and won't get out. (R11) comes in and uses my bathroom gets the seat all gross, gets water everywhere when she is washing her hands, goes through my stuff and has tried to get into my bed with me. Just this morning around 6:30 AM (R11)…

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.

B. The facility's policy titled Hand Hygiene, reviewed/revised 4/24/24, documents, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. R57's admission record documents that R57's date of admission to the facility was 4/2/25 and her diagnoses include Encounter for other Orthopedic Care, Displaced Intertrochanteric Fracture of Left Femur, and Iron Deficiency Anemia. R57's current care plan documents R57 has alteration to her Integumentary (skin) System due to pressure ulcer to coccyx 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 2. R32's admission Record documents that R32's date of admission to the facility was 3/5/25 and his diagnoses on admission include Unspecified Dementia, Severe, with agitation, Anxiety Disorder, Depression, Hypertension, Altered Mental Status and Adult Failure to Thrive. R32's Minimum Data Set (MDS) dated [DATE] documents cognition as severely impaired and Section E documents physical behaviors, verbal behaviors, and behavioral symptoms directed toward others. R32's Physician Order dated 3/7/25 documents that R32 has an order for Quetiapine Fumarate/Seroquel (antipsychotic) 50mg (milligrams) by mouth twice a day for agitation related to Unspecified Dementia, Severe, with agitation and Ativan 1mg-Benadryl 25mg-Haldol 2mg (combination of antianxiety, antihistamine, antipsychotic) cream apply one milliliter (ml) topically every four hours as needed for aggression/anxiety. R32's current care plan documents R32 receives antipsychotic therapy and antianxiety therapy with no indication for use. R32's Medication…

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

Based on observation, record review, and interview, the facility failed to update/revise Care Plans, to include contact precautions, for one resident (R48), of one resident, reviewed for Care Plan revisions, in a total sample of 57 residents. FINDINGS INCLUDE: Facility policy, entitled Comprehensive Care Plan, Revised 6/25/2024, documents, 3. Each resident's comprehensive care plan has been designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect treatment goals and objectives in measurable outcomes; e. Identify the professional services that are responsible for each element of care f. Aid in preventing or reducing declines in the resident's functional status and/ functional levels; and g. Enhance the optimal functioning of the resident by focusing on a rehabilitative program. 4. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment. 5. Care plans are revised as changes in the resident'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to thoroughly document an instance of suicidal ideation and failed to monitor one resident after verbalization of suicidal ideation (R18) of five residents reviewed for mood and behavior in a total sample of fifty-seven. Findings Include: The Facility's Responding to Intent of Self-Harm policy dated 3/13/2023 documents the purpose of the policy is to establish a process to identify and respond to the risk of self-harmful thoughts, behaviors and action to ensure resident safety. Suicidal Ideation-verbal expressions of thoughts of harming oneself that may or may not lack specific intent or associated actions and which are generally vague, passing thoughts related to poorly defined, circumstantial issues. The Facility's Responding to Intent of Self-Harm policy documents any staff member who becomes aware of a resident's intent to inflict self-harm, including but not limited to suicidal ideation, suicidal attempt and/or parasuicidal behaviors/self-directed…

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, document review and observation, the facility failed to ensure residents retained their personal items. This failure has the potential to affect all 54 residents residing in the facility. Findings include: 06/25/24 11:51 AM, Resident council meeting three residents (R2, R5, R144) complained of missing items and a slow response to return clothes because a washing machine part is broken and hasn't worked in a year. The Resident Council Monthly Meeting minutes dated October 2023 through June 2024 documents complaints of missing clothes and slow response return clothing/items. On 6/24/24 at 9:20 AM, V9 (Housekeeping Supervisor) stated Once a month V8 (Activity Director) fills out a form and gives it to me. I look for the missing items and write down what items I cannot find and give it back to her. It (Washing Machine) has been broken for over a year. They have been telling me the parts are going to be here for 6 months now. I can't keep up. We used to have two laundry people now it's just me and another person on second shift from 2:00 PM until 10:00 AM. We struggle…

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

Based on observation and interview, the facility failed to ensure prior survey investigations were available and signs were posted to notify residents/families of the availability of the survey investigations. These failures have the potential to affect all 54 residents residing in the facility. Findings include: On 6/25/24 at 11:00 AM, three (R2, R5, R144) Resident Council Members were all in agreement that they were unaware state investigations were available to read. Throughout the survey on 6/24/24, 6/25/24 and 6/26/24 a posted notice of availability of prior survey investigation findings was not observed. A State survey inspection binder was not observed during observational tours of the facility. On 6/25/24 at 1:42 PM, V8 (Activity Director) stated I'll have to go ask V1 (Administrator) where it is at (survey investigation binder). At 1:52 PM, V8 located the survey investigation binder at the entrance way and was behind the guest sign in book and a sign asking guest to sign in. The survey investigation binder was not visible and was located in a non-patient care area. On…

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

Based on observation, interview, and record review the facility failed to maintain a safe kitchen environment, failed to test the dishwasher sanitation system and failed to educate staff on the use of the dishwasher. This has the potential to affect all 54 residents residing in the facility. Findings include: The facility's Dish Machine Use policy, dated 4/23/21, documents that food service staff required to operate the dish machine will be trained in all steps of dish machine use by the supervisor or a designee in all aspects of proper use and sanitation. The dish machine hot water sanitation rinse temperatures may not be more than 194 degrees Fahrenheit or less than: 165 degrees Fahrenheit for stationary rack, single temperature machines. 180 degrees Fahrenheit for all other machines. The facility's (undated) Chemical Sanitizer policy documents to follow the directions precisely that are on the litmus paper vial and test the water on the surface of the bottom of the glasses. Concentration should be 50 ppm/parts per million to 100 ppm. On 6/24/24 at 9:30am, V4, Dietary Manager,…

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

Based on record review, observation and interview, the facility failed to ensure enhanced barrier precautions (EBP) were implemented as ordered for 1 of 5 (R19) residents who had an order for enhanced barrier precautions in a sample of 34 residents. Findings include: The Enhanced Barrier Precautions policy dated 3/27/24 documents EBP are used to prevent transmission of infectious organisms spread by direct or indirect contact with the patient or the patient's environment. EBP is used during high-contact care activities for residents with indwelling medical devices. On 4/16/24, R19's Physician's Order documents Infection precautions-enhanced barrier staff wear gown/gloves when in direct patient contact every shift every shift: signage on door. Gown and gloves required for the following high-contact care activities: dressing, bathing/showering, transfer, changing linens, providing hygiene, changing briefs/assist with toileting, device care/use and or wound care. On 4/16/23, R19's Care plan documents Enhanced Barrier Precautions (EBP), educate resident/power of attorney/responsible…

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 an antibiotic stewardship program that included assessment and monitoring of residents for signs and symptoms of infections and failed to ensure that the antibiotic usage was appropriate and failed to the use of a recognized surveillance criteria to define the infections. This deficiency has the potential to affect all 54 residents that reside in the facility. Findings include: The facility policy named, Infection Control with Antibiotic Stewardship, dated 1/23/2024, documents the following: The policy establishes directives for Antibiotic Stewardship at this facility to develop antibiotic use protocols and a system to monitor antibiotic use. The Antibiotic Stewardship Committee will:2.) Develop and maintain a system to monitor antibiotic use. Which includes a review of antibiotics prescribed to the residents. Would also have written documentation of clinical justification for the antibiotic use. The facility Infection Control Log, dated April 2024, documents, Page 3 of 7, 4 of 7 and 7 of 7 does not document 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 follow their elopement policy, failed to document the testing of the elopement device and failed to ensure an elopement device was in place for three of five residents and reviewed for elopement (R14, R18, R32) and failed to provide supervision for high fall risk residents (R24, R40) residents for 5 of 5 residents reviewed for supervision, in a sample of 34. Findings include: 1. R18's current Physician Order Sheet, dated June 2024 documents R18's diagnoses as Alzheimer's Disease. R18's current Minimum Data Set Assessment, dated 5/8/24 indicates R18's Skills for Daily Decision Making are Severely Impaired (C1000) and Behavioral Symptoms E0200) of Daily Wandering. R18's current Wandering/Elopement Risk Assessment, dated 5/9/24 documents R18 as High Risk for Elopement. R18's current Care Plan, dated 4/19/21 includes the following Focus area: (R18) is at risk for wandering/elopement related to cognitive impairment. Also included are 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 record review, observation and interview, the facility failed to monitor refrigerator/freezer temperatures to ensure safe storage of resident's medications. This failure has the potential to affect 24 residents (R5, R7, R9, R10, R14, R17, R19, R20, R22, R26, R27, R30, R34, R35, R36, R46, R47, R48, R49, R53, R55, R56, R162, R212) who reside on the Saint [NAME] Wing and R15, R18, R21 on the Saint [NAME] Wing. Findings include: The Refrigerators and Freezers policy, dated 11/15/21, documents The facility will ensure safe refrigerator and freezer maintenance, temperature, and sanitation, and will observe food expiration guidelines. 1. Acceptable temperatures should be 35 degrees Fahrenheit to 40 degrees Fahrenheit for refrigerators and less than 0 degrees Fahrenheit for freezers. 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 3. Monthly tracking sheets will include time, temperature, and initials. 4. The food service supervisors or designated employees…

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 the resident and resident representative with a written notice of transfer, for one of one resident (R18) reviewed for hospitalizations, in a sample of 34. Findings Include: R18's medical record documents that R18 was transferred to a local hospital on 7/30/23. No evidence of a facility notification to R18 of a transfer/discharge was present on R18's chart. On 6/26/24 at 1:30 P.M., V1/Administrator verified that the facility did not provide R18 or his representative with a written notice of transfer.

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 one of one resident (R18), reviewed for bed holds, in the same of 34. Findings Include: R18's medical record documents that R26 was hospitalized on [DATE]. R18's medical record does not contain documentation of written notice to R18 or R18's resident representative, of the facility bed hold policy. On 6/26/24 at 1:30 P.M., V1/Administrator verified that the facility did not provide R18 or his representative with a Bed Hold Policy or a written Notice of Transfer.

Based on interview, and record review the facility failed to update the Care Plan to reflect the bilateral lower edema and daily weights for one of three residents (R212) in a sample of 34. Findings Include: The facility policy titled, Comprehensive Care Plan, revised June 25, 2020, documents the following: An individualized comprehensive care plan that includes measurable objectives and time able to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 3.) Each resident's comprehensive care plan has been designed to: a. Incorporate identified problem areas. 5.) Care plans are revised as changes in the resident's condition dictate. R212's Diagnosis Sheet, dated 5/9/2024, documents R212's admission date as 5/9/2024. The Order Summary Report, dated 6/26/2024, documents the following diagnoses: Chronic Obstructive Pulmonary Disease, Solitary Pulmonary Nodule, Non-Rheumatic Mitral Valve Insufficiency, Coronary Artery Disease, Acute Kidney failure Congestive Heart Failure, Presence of Heart Assist Device related to Left Ventricular…

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 obtain physician ordered daily weights for two of two residents (R18), reviewed for edema, and failed to ensure Hospice plans of care were available to staff and kept updated in the resident's record for one of two residents (R14 and R32) reviewed for Hospice in the sample of 34. FINDINGS INCLUDE: The facility's (undated) Hospice Nursing Facility Hospice Service Agreement documents, . (The) Hospice will furnish a copy of each Hospice patient's Plan of Care to the facility at the times of the resident's admission into the Hospice program. A Plan of Care is a written individualized plan of services necessary to meet the patient-specific needs for palliation or management of Hospice patient's terminal illness and related conditions necessary to meet the patient-specific needs which includes all patient care physician orders and planned interventions for problems identified during patient assessments; delineates the services to be provided by Hospice and Facility; is consistent with Hospice's philosophy; is based 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a person-centered dementia plan of care for one of one resident (R50) reviewed for dementia care, in the sample of 34. Findings Include: The facility policy, Care of resident with Dementia, dated November 5, 2019, directs staff, A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practical physical, mental and psychosocial well-being. The facility will provide dementia treatment and services which may include, but are not limited to the following: Ensuring that the necessary care and services are person-centered and reflect the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety and utilizing individualized non-pharmacological approaches to care. R50's current Physician Order Sheet dated June 2024 documents that R50 was admitted to the facility on [DATE] with the following…

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 safe resident transfer and fall intervention implementation for two (R2 and R3) of three residents reviewed for falls in a sample of five. Findings include: 1. R2's current Physician Order Sheet (POS) documents diagnoses including but not limited to: Lack of Coordination; Unsteadiness on Feet; Unspecified Tear of Unspecified Meniscus, Current Injury, Left and Right; Repeated Falls; Overactive Bladder; and Urge Incontinence. R2's Minimum Data Set/MDS assessment, dated 3/11/24, documents R2 is cognitively intact. R2's Fall Risk Assessments, dated 4/18/24 and 5/20/24, document R2 is a high fall risk. R2's current Care Plan Fall Interventions include but are not limited to Exchange single cord call light for double cord call light for additional access points in room to request assistance. R2's Care Plan also documents R2 has an alteration in her ability to care for self and needs assistance due to cognitive impairment, decreased strength and endurance, weakness. Interventions include R2 requires total…

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 kitchen equipment was free of dirt/grime buildup in that the tops of stationary equipment, and surrounding, cooking surfaces, were covered with buildup-including the overhead exhaust. This failure has the potential to affect all 51 residents residing in the facility. Findings include: Centers for Medicare and Medicaid Services Form 672 RESIDENT CENSUS AND CONDITIONS OF RESIDENTS, dated 3/21/23, document 51 residents reside in the facility. Facility policy, entitled Sanitation, revised 11-5-2019, document, 7. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. On 03/21/23, at 9:30 a.m., during the initial tour with V4/Dietary Manager, the exhaust hood [over the stove] had dirt/grime build up; and the top of stationary cooking equipment, surrounding the stove, were covered with dirt/grime. V4 confirmed the build-up and even stated, I will take care of that right away.

Based on observation, interview, and record review, the facility failed to ensure refuse receptacles [trash dumpster's] where food/trash is discarded outside are securely covered. This failure has the potential to affect all 51 residents residing in the facility. Findings include: Centers for Medicare and Medicaid Services Form 672 RESIDENT CENSUS AND CONDITIONS OF RESIDENTS, dated 3/21/23, document 51 residents reside in the facility. Facility policy, entitled Food Related Garbage & Rubbish Disposal, revised 11-5-2019, document, 2. All garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be covered when stored or not in continuous use; and 5. Garbage and rubbish containing feed wastes will be stored in a manner that is inaccessible to vermin; 7. Outside dumpster's provided by garbage pickup services will be kept closed and free of surrounding litter. On 3/21/23, at 9:30 a.m., during the initial tour with V4/Dietary Manager, the outside trash dumpsters were not securely covered. The lids were broken and subsequently open for access to vermin…

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 immediately notify a resident's physician of a new skin impairment, failed to implement treatment orders for new skin impairments, failed to measure, monitor, assess, and document residents' wounds and failed to follow physician orders for splints for four of 14 residents (R29, R32, R43, R51) reviewed for quality of care in the sample of 29. Findings Include: The facility's Skin Prevention, Assessment and Treatment Policy, revised 5/2/22, states, Purpose: To identify factors that place the residents at risk for the development of pressure ulcers. To implement appropriate interventions to prevent the development of clinically avoidable wounds. To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. Treatment Guidelines: 1. Any skin impairments, including pressure ulcers, non-pressure ulcer wounds; surgical wounds, skin tears, abrasions, etc.,…

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 complete a new/updated PASARR (Preadmission Screening and Resident Review) Level II for one resident (R49) of one resident reviewed for PASARR screenings in a sample of 29. Findings include: On 3/24/23, at 9:30 am 10:00 am and 11:00 am, V1 (Administrator) stated, We do not have a PASARR Policy and the facility could not provide one. R49's Psychiatric Evaluation and Consultation, dated 3/15/23, documents that R49 has a diagnoses including Schizophrenia. R49's Local Area Emergency System Form, date of call 2/1/23, documents a history of Schizophrenia. R49's Psychotropic Medication Consent, dated 8/9/22, documents that R49 has a medication ordered (Quetiapine) and indication for use of Schizophrenia. R49's current Care Plan documents that R49 has a behavior problem related to Alcohol Induced Dementia and Schizophrenia. R49's Notice of PASRR Level I Screen Outcome, dated 4/29/22, documents a Level I Review, and Determination and no Level II required. The PASRR Outcome Explanation Notice of PASRR Level II, dated 4/29/22,…

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 revise a resident's plan of care to include mechanical lift transfers and splints for foot drop for one of 14 residents (R51) reviewed for care plans in the sample of 28. Findings include: The facility's Comprehensive Care Plan, revised 6/25/20, Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation: 1. Our facility's care planning/interdisciplinary team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 5. Care Plans are revised as changes in the resident's condition dictate. Care Plans are reviewed at least quarterly. R51's Face sheet documents R51 admitted…

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 transfer a resident using a mechanical lift with two staff members for one of five residents (R51) reviewed for accidents in the sample of 29. Findings include: The facility's Using a Mechanical Lift Policy, revised 9/2/2020, states, Purpose: To help lift residents who are too heavy to lift manually, to promote comfort and maintain good body alignment while the resident is being moved. Procedure: 4. The portable lift should be used by two nursing assistants to perform the procedure. R51's Face sheet documents R51 admitted to the facility on [DATE] with diagnoses to include but not limited to: Nontraumatic Intracerebral Hemorrhage in Hemisphere ; Hemiplegia; and Epilepsy. R51's Fall Risk Assessment, dated 2/23/23, documents R51 at medium risk for falls. R51's Minimum Data Set/MDS Assessment, dated 2/10/23, documents R51 with total dependence of two plus person physical assist for transfers (how a resident moved between surfaces including 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 follow the Facility Policy to obtain four weeks of admission weights for three Residents (R29, R43, 51) of 24 Residents reviewed for weight monitoring in a sample of 29. Findings include: Facility Weight Assessment and Interventions Policy, revised 1/19/22, documents: it is the policy of the Facility to prevent significant unplanned or unavoidable weight loss for our Residents; the nursing staff will measure weights on admission and then weekly for four weeks; if no weight concerns are noted at this point, weights will be measured monthly thereafter; and weights will be recorded in the resident's Medical Record. R29's Medication Administration Record/MAR, dated 3/1/23 through 3/22/23, documents that R29 admitted to the facility on [DATE]. The MAR, dated 3/1/23 through 3/22/23, does not document a weight on the dates of 3/1/23 through 3/22/23. R29's Weight and Vitals Summary Report, dated 3/22/23, does not document initiation of R29's weekly weights. On…

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

Based on observation, interview, and record review the facility failed to follow the facility infection control policy and procedure during medication pass for two (R16 and R53) of 24 residents observed for infection control in the sample of 29. Findings include: The facility's Administering Medication policy and procedure, Revised 3/19/2020, documents 12. Adherence to established facility infection control procedures shall be followed during the administration of medications. 1. Hand hygiene shall be required between residents. 2. Medications shall not be handled but dispensed in a clean manner using the lids of multi-dose bottles or medication cups. The facility's Hand Washing policy and procedure, revised 11/5/2019, documents Hand washing is an integral part of an effective infection control program. Its purpose is to reduce the risk of blood borne illness and prevent cross contamination. Hands should be washed before resident care, after resident care, after breaks, after using the restroom, after smoking or eating, after blowing nose, after disposing of trash, after handling…

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.