Goldwater Care Marseilles

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to update a resident's physician regarding a change in resident's pressure injury to 1 of 3 residents (R2) reviewed for pressure injury in the sample of 5. The findings include: R2's electronic face sheet accessed on 6/20/25 documents that R2 was admitted to the facility on [DATE] and was discharged on 5/8/25. R2's Physician Order Sheet dated 4/25 states, Cleanse area with NS(Normal Saline)/wound cleanser, pat dry. Apply medihoney and bordered foam every Tue, Thu, Sat. R2's facility assessment dated [DATE] under behaviors does not show R2 had any rejection of care. R2's admission assessment dated [DATE] show R2 was admitted to the facility with a stage 2 pressure injury to his coccyx/sacral area. A wound assessment dated [DATE] by V3 (Wound Nurse) documents, coccyx pressure ulceration present on admission, wound measurements of 0.90 centimeters (cm) x 0.50 cm x 0.10 cm with scant amount of serous drainage. A wound assessment details dated 4/28/25 by V3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident (R1) from sexual abuse by (R2). This applies to 1 of 3 residents reviewed for abuse in the sample of 4. The findings include: R1's electronic face sheet printed on 2/14/25 showed R1 has diagnoses including but not limited to Alzheimer's disease, anxiety disorder, and insomnia. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment. R1's care plan dated 1/24/25 showed, Problematic manner in which I act characterized by inappropriate sexual behavior (verbal or physical) related to need for affection, need for attention, resident touches other residents. I initiate contact with other residents resident given a baby doll for companionship, distract resident if possible . R2's electronic face sheet printed on 2/14/25 showed R2 has diagnoses including but not limited to dementia with agitation, congestive heart failure, pulmonary edema, and alcoholic cirrhosis of the liver. R2's facility assessment dated [DATE]…

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 potential allegations of theft to the Abuse Coordinator and local law enforcement for 12 (R1 through R10 and R12 through R13) of 12 residents reviewed for misappropriation of resident property in the sample of 13. Findings include: The facility Abuse Prevention policy and procedure, dated 10/24/22, documents the facility prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belonging or money without the resident's consent. This same policy documents Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. In addition to the administrator 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 ensure medications were administered per the physician's order and facility policy for two (R1 and R5) of nine residents reviewed during medication administration and two (R2 and R4) of four residents reviewed for medications in a sample of five. Findings include: The facility's undated Medication Administration General Guidelines policy documents Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration.) This policy continues to state, Administration: 2. Medications are administered in accordance with written orders of the prescriber. 3. When medications are administered by mobile cart and taken to the resident's location (room, dining area, etc.), medications are administered at the time they are prepared.…

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 transcribe and administer medication per physician order for one of three residents (R1) reviewed for medications in a sample of three. Findings include: The facility's Physician Orders-Entering and Processing, dated 8/22/17, documents to enter the order into the resident's chart under order tab and according to the instructions for the type of order that is received. Be sure to include a diagnosis or indication for use. If a diagnosis is not already in the resident's clinical record, ask the physician for a diagnosis. Medications orders should include: Route, Dose, Time, Frequency, If a treatment, be sure to put in the directions the specific area(s) to be treated. R1's admission Orders, dated 7/9/24, documents to take Carbidopa-Levodopa (Dopamine Precursor) Oral Tablet 25-100mg (Milligrams) two tablets by mouth six times daily, related to Parkinson's Disease with Dyskinesia, with Fluctuations. This form also documents to take Carbidopa-Levodopa ER (extended release) 50-200mg one tablet by mouth at bedtime. R1'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that staff knocked prior to entry to a resident room for one resident (R40) and failed to ensure call lights were responded to in a timely manner for four (R5, R34, R45, R48) of 16 residents reviewed for call light timeliness in a sample of 31. Findings Include: Facility's Resident Rights Policy dated 8/23/17 documents: Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. Facility's Residents' Rights for People in Long Term Care Facilities, Ombudsman Program revised 11/2018, documents: Your rights to dignity and respect; your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Facility staff must knock before entering your room. Your facility must provide services to keep your physical and mental health, at their highest…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff report a resident's change of condition to a medical doctor for one resident (R54-who was having chest pain) of 19 residents reviewed for medical doctor notification in a total sample 31. FINDINGS INCLUDE: Facility policy, entitled Physician-Family Notification-Change in Condition, dated 11/13/2018, documents: The facility will inform the resident, consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: (B) a significant change in the resident's physical, mental, or psychosocial status. R54's Electronic Medical Record (EMR) documents R54's diagnoses to include: Hypertensive Chronic Kidney Disease with Stage 5 Kidney Disease, Type II Diabetes Mellitus, Asthma, Anemia, Bipolar Disorder, Hypertension, and Dependence on Renal Dialysis. R54's Physician Orders, dated 11/30/2023, document R54 has an order for:…

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

Based on observation, record review and interview, the facility failed to develop a hand brace care plan for one resident (R20) of 19 residents reviewed for Care Plan in a sample of 31. Findings include: The facility's Comprehensive Care Plan Policy revised 11/17/17 documents: Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the 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 comprehensive assessment. The comprehensive care plan must describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. A comprehensive care plan must be…

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

Based on observation, interview, and record review the facility failed to provide activities of daily living for two (R73 and R12) of two residents reviewed for activities of daily living in the sample of 31. Findings include: The facility's Nail Care policy and procedure, revised 1/25/18, documents Observe condition of resident nails during each time of bathing. Note cleanliness, length, uneven edges, hypertrophied nails. Perform hand hygiene. After bathing, use orange stick, and clean debris from around and under finger and toes nails. This policy documents to trim resident fingernails in an oval fashion avoiding tissue after bathing or when needed. The facility's undated Shaving Male and Female Residents policy and procedure, documents Purpose: to provide cleanliness, comfort and improved morale. Male residents will be assessed for daily shaving need and assisted as his functional needs indicate. 1. The admission MDS (Minimum Data Set) Assessment for R73, dated 4/19/24, documents R73 is cognitively intact and requires staff assistance for activities of daily living and dependent…

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 was changed and dated weekly and ensure cylinder oxygen tanks were stored securely for one (R21) of one resident reviewed for oxygen use in the sample of 31. Findings include: The facility's Oxygen and Respiratory Equipment - Change/Cleaning policy and procedure, revised 1/17/19, documents Nasal Cannulas are to be changed once a week and PRN (as needed); Whenever possible, residents using a portable oxygen tank, will be switched to a room oxygen concentrator while in their room; and Oxygen humidifiers should be changed weekly or as needed and will be dated when changed. The facility was unable to provide a policy and procedure for storage of oxygen. On 6/11/24 at 10:30 am, R21 was lying in bed with eyes closed with undated oxygen cannula connected to an undated humidifier bottle. An oxygen cylinder tank, infusing oxygen at three liters, was secured to the back of R21's wheelchair with the oxygen tubing connected and dated 5/27/24. On 6/12/24 at 10:00 am, 6/13/24 at 9:06 am, and 6/14/24 at…

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 assure medications were not left at the bedside for one resident (R43) out of 27 residents reviewed for medication administration pass in a sample of 31. Findings include: The facility's Medication Administration General Guidelines Policy undated, documents: Administration: 2. Medications are administered in accordance with written orders of the prescriber. 12. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 16. The resident is always observed after administration to ensure that the does was completely ingested. On 6/12/24 at 11:35am, V13 Registered Nurse/RN took medication (Lanthanum and Midodrine) into R43's room; stated to R43, here is your meds. R43 indicated to V13 to leave the medication on her bedside table; V13 left the medication for R43 on R43's bedside table and walked out of R43's room. The facility's Electronic Health Records/EHR does not document a physician order…

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

Based on observation, interview and record review the facility failed to follow facility dialysis policy and procedures for the care and monitoring of six (R1, R2, R3, R4, R5, and R6) of six residents reviewed for dialysis in the sample of six. Findings include: The facility's Dialysis Monitoring and Observation policy and procedure, revised 2/13/18, documents Purpose: To ensure residents receiving hemodialysis are monitored for complications. Monitoring: 1. Listen using a stethoscope for the bruit and thrill of the fistula once each shift. 2. Document the presence or absence of the bruit and thrill on the MAR (Medication Administration Record) or TAR (Treatment Administration Record) each shift. 3. While listening for the bruit and thrill, observe the skin condition for any increased redness or swelling and notify the physician and dialysis center if any present. Document abnormal findings. 4. If bleeding or oozing at the site is noted, apply pressure gauze dressing and notify the physician. 5. The physician and dialysis center will be notified if the bruit and thrill are not…

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 report an incident of resident to resident physical contact as potential abuse to the Administrator/Abuse Coordinator for one (R4) resident reviewed for abuse in a sample of five. Findings include: The facility's Abuse Prevention and Reporting Policy, Revised 10/24/22, documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Resident to Resident altercations that include any willful action that results in physical injury, mental anguish or pain must be reported in accordance with regulations. During orientation of new employees, the facility will cover at least the following topics: What constitutes abuse, neglect, exploitation, and misappropriation of resident property, an employee's obligation under the law for reporting a suspected crime to the facility, the state survey agency and local law enforcement, the time frames for reporting, and management's obligation to prohibit…

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 supervise one resident (R7) who requires supervision during meals of three residents reviewed for supervision during meals in a sample of 12. Findings include: R7 was re-admitted to the facility 2/17/24 with diagnoses that include Cerebral Infarct and Dysphagia. Current Physician Order Summary Order Report indicates R7 had orders for a Renal, Diabetic diet, puree texture. Order Special Instructions indicate May have mechanical soft textures, 1 teaspoon bite sizes with 1:1 supervision for pleasure related to End Stage Renal Disease. Order Report Summary dated 2/17/24 indicates R7 had Contact Precautions for C-difficile infection of stool. Current Care Plan indicates R7 has a swallowing problem related to holding food in mouth/cheeks (pocketing). Care Plan interventions dated 12/18/23 indicate Resident to eat only with supervision. On 2/28/24 and 2/29/24 R7 was located in a room with a Transmission Based Precaution sign on his door. On 2/29/24 at 1:15pm R7 stated sometimes staff sit with him when he eats, 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 provide showers to a resident dependent on assistance with showering for one of three residents (R1) reviewed for ADLs (Activities of Daily Living) in the sample of four. Findings include: The facility's Bathing-Shower and Tub Bath Policy revised 01/31/18 states, Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. Guidelines: A shower, tub bath, or bed/sponge bath will be offered according to a resident's preference two times per week or according to the resident's preferred frequency and as needed or requested. The facility's Certified Nursing Assistant (CNA) Job Description dated 5/2/17 documents Essential Duties and Responsibilities as providing resident hygiene assistance with shampoos, shaves, and helping with showers and baths. This same job description states to document actions by completing forms, reports, logs, and records. The Resident Shower Schedule documents R1 is to receive showers on Tuesday and Fridays. R1's current Care plan documents R1 is dependent on staff for…

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

Based on interview and record review, the facility failed to immediately have an experienced pest control service address a report of suspected bed bugs in the facility. This failure has the potential to affect all 75 residents residing in the facility. Findings include: The (State Agency)'s Prevention and Control: Bed Bugs in Health Care Facilities guidelines documents When bed bugs are suspected or confirmed, immediately and directly notify a designated authority for the facility. Reports passed up the chain may not get to a person with the authority to act, and the longer an infestation goes unchecked, the more costly it may become. An experienced pest management should inspect and treat as needed all areas where bed bugs areas suspected as wall as all rooms adjacent above and below. The facility's concern report dated 11/5/23 documents CNA (Certified Nursing Assistant) reports midnight shift found possible bed bugs in north dining room. Maintenance informed and is on his way to inspect facility. Beg bugs found on (R4)'s mattress. (Pest Control) contacted and came to inspect 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 monitor oxygen saturation levels according to physician orders and failed to ensure oxygen delivery equipment was properly set up to deliver humidified oxygen for three residents (R1, R2, R3) of three residents reviewed for oxygen therapy. Findings include: Facility Policy/Oxygen Concentrator dated 2013 documents: Procedure: Verify and understand the physician order Know the flow rate and duration of use If prescribed, attach the humidifier bottle to the oxygen outlet connection, and ensure there is water in the bottle. Adjust the flow meter control knob to the flow setting prescribed by the physician. Attach the oxygen tubing to the small port on the humidifier or nipple adapter and fit the nasal cannula. Listen for the intermittent sound, this indicates that it is functioning properly. Current Physician Order Summary Report indicates R1 has orders for Oxygen: May start O2 at 1-2 liters via NC (Nasal Cannula) to maintain O2 SATS above 90% every day and night shift for precaution (start date 2/11/22). Current…

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

Based on interview and record review, the facility failed to maintain sufficient working hot water heaters to produce hot water to three of the four facility showers in order to meet the needs of the resident showers for three residents (R2, R4, R5) out of four residents reviewed for showers in a sample of seven. Findings include: On 11/8/23 at 2:15pm R2 stated that it depends on whose working if she gets her shower. R2 stated Right now the water heater is broke, I got my last shower about a week ago. They gave me a bedbath last time instead. R2 stated that she was unaware there was a working shower on another unit. R2 stated they never offered to take her to take her to the other shower, only offered a bedbath. R2 stated she would have liked to have the option. R4's medical record documents R4 is scheduled to recieve two showers a week and received one shower the weeks of 10/30/23 and 11/5/23. R5's medical record documents R5 is scheduled to recieve two showers a week and recieved one shower the week of 10/30/23 and a bed bath on 11/2/23. On 11/8/23 at 11:29 AM, R4 stated I had 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 observation, interview, and record review, the facility failed to ensure resident call device was within reach for one (R1) resident reviewed for accessibility to call light system; and failed to transport residents in a timely manner from dialysis to their rooms for two (R1 and R2) residents reviewed for transport, in a sample of six. Findings include: Call Light Policy, Dated 2/2/18, documents, 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. The facility's Resident Rights Policy, Dated 1/4/19 documents: Guidelines: Notice of resident rights will be provided upon admission to the facility. These rights include the resident's right to: Exercise his or her rights. Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject…

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 staff were wearing name (identification) tags and were treating residents with respect. This has the potential to affect all 78 residents residing in the facility. Findings include: The facility's Dignity policy, revised 4-23-18, documents Guidelines: The facility shall promote care for residents in a manner and in an environment that maintains or enhances each residents' dignity and respect in full recognition of his or her individuality .Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. The facility's Incontinence Care policy, revised 4-20-21, documents Purpose: To prevent excoriation and skin breakdown, discomfort, and maintain dignity. R39's Minimum Data Set/MDS, dated [DATE], documents R39 is cognitively intact, frequently incontinent of bowel and bladder, and requires extensive assist with two person physical assistance for personal hygiene 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 ensure resident call devices were responded to in a timely and polite manner for two (R39 and R20) of 18 residents reviewed for call devices in a sample of 29. Findings include: The facility's Call Light policy, revised 2-2-18, documents Purpose: To respond to residents' requests an needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in timely manner .4. Requests shall be responded to in a courteous and professional manner .Procedure, Rationale/Amplifiation: 1. Answer light (signal) promptly. Knock on door, pause before entering. 2. Be courteous when entering room. Ask resident: 'May I help you?' .4. Listen to resident's request. Do not make him feel that you are too busy to help. 5. Respond to request. If item is not available, or request questionable, get assistance from charge nurse. Return to resident with prompt reply. Try to obtain item. Do not tell resident: 'We don't have it.' The facility'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 assess a resident prior to allowing the resident to self-administer medication for one resident (R7) out of eight residents reviewed for medication in a sample of 29. Findings include: The facility's Self-Administration of Medication procedure undated documents Residents who request to self-administer drugs will be assessed at the time of admission or thereafter, to determine if the practice is safe, based on the results of the Resident Assessment Self -Administration of Medications tool. R7's physician order sheet dated 5/17/23 documents Ketorolac Tromethamine Ophthalmic Solution 0.5%. Instill one drop in left eye four times a day for post cataract removal. Oflaxacin Ophthalmic Solution 0.3%. Instill one drop in left eye four times a day for post cataract removal. Prednisolone Acetate Ophthalmic Suspension 1%. Instill one drop in left eye four times a day for post cataract removal. On 06/20/23 at 9:51 AM, R7 observed lying in bed with Ketorolac Tromethamine Ophthalmic Solution 0.5%, Prednisolone Acetate…

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 allow a resident to choose when to get out of bed for one resident (R20) out of 18 residents reviewed for choices in a sample of 29. Findings include: The facility's Dignity policy dated 4/23/18 documents The facility shall consider the resident's lifestyle and personal choices identified through the assessment process to obtain a picture of his or her individual needs and preferences. R20's current care plan documents Chair/Bed to chair transfer: Substantial/Max assist. R20's medical record documents Acquired abscesses of right leg below knee. R20's minimum data set (MDS) documents a BIMS (Brief Interview of Mental Status) of 15. BIMS of 13-15 indicates an individual is cognitively intact. On 06/20/23 at 09:24 AM R20 stated I'll push my call light because I want to get out of bed. The CNAs (Certified Nursing Assistant) will come in to find out what I want and I tell them I want to get out of bed. They'll shut my call light off and say they'll be back in a few to get me up, but they never return. I'll push my…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for a two residents (R19 and R71) out of 18 residents reviewed for care plans in a sample of 29. Findings include: Facility Comprehensive Care Plan, revised 11/17/17, documents To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. 1. R71's medical record documents R71 was admitted to the facility on [DATE] with a subclavian triple lumen catheter (Central Line). On 06/20/23 at 9:40 am, resident observed lying in bed with a left sided subclavain central line. R71's care plan does not include a central line. R71's physician order sheet dated 5/30/23 documents Change dressing to PICC (Peripherally Inserted Central Catheter line to left chest weekly and as needed for soil or dislodge. On 6/22/23 at 2:20 PM, V2, Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident Care Plans were revised for two (R39 and R70) of 18 residents reviewed for Care Plans in a sample of 29. Findings include: The facility's Comprehensive Care Plan policy, revised 11-17-17, documents Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Guidelines: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. On 6-23-23,…

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, facility staff failed to provide showers per facility policy for one (R27) of two residents reviewed for Activities of Daily Living in a sample of 29. Findings include: The facility's Bathing--Shower and Tub Bath Policy, Revised 1/31/18, documents: Purpose: To ensure residents cleanliness to maintain proper hygiene and dignity. Guidelines: A shower, tub or bed/sponge bath will be offered according to resident's preference two times per week or according to the resident's preferred frequency and as needed or requested. R27's Minimum Data Set (MDS) dated [DATE] documents R27 has a BIMS (Brief Interview of Mental Status) score of 15. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) R27's Bathing Schedules dated April, May and June 2023 document R27 was scheduled for showers on Wednesdays and Saturdays. R27's April 2023 Shower Log shows R27 was not showered or bathed on four scheduled…

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 have an order for hospice for one (R14) of one residents reviewed for hospice in a sample of 29. Findings include: R14's medical record documents R14 was admitted on [DATE]. R14's medical record has the following diagnosis effective 10/15/22 Encounter for palliative care. R14's nurses notes, dated 10/15/22 at 11:30pm, documents After arrival from (other nursing home, local) hospice notified. Hospice nurse came into the facility to speak with resident. R14's medical record and current orders for June 2023, has no documentation/orders indicating R14 was on hospice, and who the hospice provider was. On 6/23/23 at 2:00pm, V2 Director or Nursing/DON verified R14 had no orders for hospice and would get an order.

Based on observation, interview, and record review, the facility failed to change gloves and perform hand hygiene during incontinence care for one (R39) of one residents reviewed for incontinence in a sample of 29. Findings include: The facility's Hand Hygiene/Handwashing, revised 1-10-18, documents Definition: Hand Hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, or antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel) .Examples of when to perform hand hygiene (either alcohol based hand sanitizer or handwashing): If hands will be moving from a contaminated-body site to a clean-body site during patient care. After glove removal. The facility's Incontinence Care policy, revised 4-20-21, documents Purpose: To prevent excoriation and skin breakdown, discomfort, and maintain dignity .Procedure: 2. Perform hand hygiene and put on non-sterile gloves. This policy continues to state the procedure to cleanse with soap, rinse and dry areas; continues with 12. Remove gloves and perform hand hygiene.…

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

Based on observation, interview and record review, the facility failed to label IV (intravenous) tubing and medication solution with a start date and time and failed administer medications as ordered by the physician for one resident (R71) out of eight residents reviewed for medication administration in sample or 29. Findings include: The facility's Medication Administration General Guidelines policy undated documents Medications are administered as prescribed in accordance with good nursing principles and only by persons legally authorized to do so. The facility's IV-Peripheral Insertion and Maintenance policy dated 11/28/12 documents 13. IV tubing shall be changed every 24 hours. A tape/label shall be placed on the tubing of each individual IV fluid indicating date, time changed and nurses initials. 14. Each solution bag shall be labeled with contents, dated/time when hung and expiration period of any medications. No IV fluid shall hang beyond 24 hours form start time/dated. 1. R71's physician order sheet dated 5/27/23 documents TPN (Total parenteral nutrition) Therapy per…

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 act on a pharmacists medication regimen review for one (R14) of five residents reviewed for pharmacist Medication Regimen Review (MRR) in a sample of 29. Findings include: Facility Pharmacist Medication Regimen Review, dated 11/28/17, documents The consultant pharmacist will report any irregularities in writing to the attending physician, the medical director/MD and the director of nursing/DON for follow up. The written documentation will include the residents name, the relevant drug, and the identified irregularity. The DON or designee with notify the attending physician of the recommendations within 3 business days of receiving the report from the Consultant Pharmacist. The MRR documentation of completed consultation will be maintained in the residents clinical record. R14's MRR, dated 5/15/23, documents See Report for any noted irregularities and/or recommendations. R14's Medical record has no documentation on what the reported irregularities or recommendations are. On 6/23/23 at 12:59 PM, V4 [NAME] President of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete psychotropic assessments, failed to complete the required Abnormal Involuntary Movement Scales (AIMS), failed to complete consents, failed to identify an appropriate indication for use, failed to identify and monitor specific target behaviors, and failed to attempt gradual dose reductions, to warrant the use of psychotropic medications for two (R68 and R229) of four residents reviewed for psychotropic medications in a sample of 29. Findings include: The facility's Psychotropic Medication - Gradual Dosage Reduction, revised 2-1-18, documents Purpose: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions. Guidelines: Informed consent shall be obtained a follows: a) Pychotropic medication shall not be administered without 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 interview and record review, the facility failed to obtain and have on hand a pain medication (Hydrocodone) for one (R10) of one residents reviewed for pain medication in a sample of 29. Findings include: Facility Resident and Family Handbook, dated 10/2013, documents The facility must provide services to keep your physical and mental health, and sense of satisfaction with yourself at their highest practical levels. Website https://www.icppharm.com, dated 2023, documents Significant medication error means one which causes the resident discomfort or jeopardizes his or her health and safety. Significance may be subjective or relative depending on the individual situation and duration. Facility Pain Management Program, revised 7/6/18, documents To establish a program which can effectively manage pain in order to remove adverse physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness. The purpose of this…

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 answer call lights in a timely manner for two residents (R26 and R125) of 18 reviewed for call lights in a sample of 36. Findings include: The facility Call Light policy, revised 1/5/22, documents to respond to residents' requests and needs in a time and courteous manner. All staff should assist in answering call lights. Nursing staff members shall go to resident room to respond to call system and promptly call call light when the room is entered. Bathroom light should be viewed as emergencies and immediate attention given. 1. 04/27/22 03:01 PM R125's call light was on from 12:00pm to 12:19pm without being answered. At 12:15pm, R125 stated that she has had her call light on for about 30 minutes, and needs her inhaler. R125 appeared short of breath at the time of the interview. V9, Social Service Director, answered the call light, and stated that she would get the V6, Registered Nurse for her. At 1:00pm R125 stated that she finally did get her inhaler after about 45 minutes. 2. On 04/25/22 at 01:16 PM, R26 was…

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 test water temperatures regularly thus failing to ensure hot water temperature for resident showers/bathing for two (R8 and R53) of two residents reviewed for Activities of Daily Living/ADLs in a sample of 36. Findings include: The facility's Hot Water Temperature Monitoring in Resident Areas policy, undated, documents A. Policy: Building Manager will check hot water temperatures every scheduled workday in areas accessible to residents. If constant compliant temperatures are consistently demonstrated the Building Manager may develop a schedule for less frequent testing as approved by the Administrator. B. Procedure: 1) Record the water temperature gauge reading at the mixing valve on the hot water tank serving resident areas. 2) Using a thermometer accurate to within +/- 3 degrees F. check the water temperature in at least one (1) resident bathing room and one (1) resident rooms on each hallway or nursing unit. Vary the times and rooms each day for even representation. 3) Record date, room, temperature, 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 include psychotropic medication monitoring on a resident Care Plan for one resident (R33) of 20 residents reviewed for Care Plans in a sample of 36. Findings include: The facility's policy Psychotropic Medication - Gradual Dose Reduction, revised 2-1-18, documents Purpose: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions .The plan to alternatives to psychotropic medication and/or use of psychotropic shall be incorporated into the care plan with suitable goals and approaches. This will be initiated by the resident's needs/problems, goals and approaches as it relates to the use of psychotropic drug use. R33's current Physician Order Sheet/POS documents orders for the following psychotropic medications: Haldol, Depakote, Quetiapine Fumarate, and Ativan. R33's current Care Plan does not include any focus, goals, 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.

F684 Based on observation, interview and record review, facility staff failed to failed to ensure policies and procedures regarding hand hygiene were followed during wound care, for one of one residents (R29), reviewed for skin treatments, in a sample of 36. The facility policy, Hand Hygiene/Handwashing, dated (revised) 1/5/22 directs staff, Hand hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand rub. Perform hand hygiene after glove removal. R29's current Physician Order Sheet, dated April 2022 documents the following diagnoses: Type 2 Diabetes Mellitus, Cellulitis of Left Lower Limb. This same document includes the following physician orders: Left Lower Extremities, cleanse area with Normal Saline, cover wound bed with collagen matrix, cover with an foam dressing and secure with tape, every day shift. On 04/25/22 at 1:03 P.M., V3/LPN prepared to perform wound care for R29. V3/LPN cleansed her hands with soap and water, applied gloves, removed scissors from her uniform pocket and cut off (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 interview and record review the facility failed to provide rationale for continued use of as needed (PRN) psychotropic medications for one (R33) of eight residents reviewed for psychotropic medications in a sample of 36. Findings include: The facility's policy Psychotropic Medication - Gradual Dosage Reduction, revised 2-1-18, documents Purpose: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions .PRN (as needed) Psychotropics: PRN hypnotic, antianxiety or antidepressant medications shall not be used beyond 14 days unless the prescribing practitioner indicates the clinical rationale for extended use and the expected duration for PRN use of the medication. The duration of use should not extend beyond 6 months unless re-evaluated by the attending physician or prescribing practitioner and clinical rationale is provided. R33's Physician Order Sheet/POS, dated 2-1-22,…

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.

Based on interview and record review, the facility failed to limit as needed (PRN) psychotropic medication orders to 14 days and failed to document a medical indication and consistent behaviors that warrant the use of antipsychotic medications for three of eight residents (R11, R33, and R46) reviewed for psychotropic medications in the sample of 36. Findings include: The facility's policy Psychotropic Medication - Gradual Dosage Reduction, revised 2-1-18, documents Purpose: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions .PRN (as needed) Psychotropics: PRN hypnotic, antianxiety or antidepressant medications shall not be used beyond 14 days unless the prescribing practitioner indicates the clinical rationale for extended use and the expected duration for PRN use of the medication. The duration of use should not extend beyond 6 months unless re-evaluated by the attending…

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.