Axiom Healthcare Of Mount Vernon

Based on observation, interview, and record review the facility failed to provide food at palatable temperatures. This failure has the potential to affect all 50 residents residing in the facility. Findings include: On 3/4/25 at 1:17 PM, the kitchen was toured. The steam table in the kitchen was 3 compartments with no pan in the center compartment and the right compartment had a silver pan that did not appear to be the correct size for the compartment because it did not sit flush with the steam table. On 3/4/25 at 1:25 PM, V37 (Dietary Aide) said a couple months prior to this investigation the steam tables left compartment's water pan had rusted through and started to leak causing the middle compartment to no longer work. V37 said staff had put a large pan over the water pan in the left compartment and continued to use it. V37 said the water pan in the right compartment had fallen through a couple months prior to this investigation and staff had used an oversized pan over what was left of the water pan to be able to put food on the steam table. On 3/4/25 at 1:29 PM, V38 (Cook) said…

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 investigate and report a resident death to the Department, failed to seek emergency services for a resident experiencing a change of condition, failed to implement new fall interventions, failed to obtain orders for a resident receiving peritoneal dialysis (PD) along with training staff on emergency PD procedures, failed to maintain communications with facility medical director during off hours, failed to provide routine training to staff, and failed to provide an Administrator the training needed to direct the day to day functions at the facility. The failure has the potential to affect all 50 residents living in the facility. Findings include: The [DATE] Midnight Census Report documented 50 residents residing in the facility. 1. R2's admission Record documents as admission date of [DATE], includes diagnoses of Parkinson's Disease, Type 2 diabetes mellitus, morbid obesity, dementia, and hydrocephalus. R2's Progress Note dated [DATE] at 3:25AM, late…

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 conduct ongoing training in effective resident care communications for all staff. This failure has the potential to affect all 50 residents residing in the facility. Findings include: The facility's Facility assessment dated [DATE] documents under Staff Training/Education and Competencies to include effective communication training for direct care staff. The facility's in-services provided by V1 Administrator, was reviewed. There is no documentation effective communication training was conducted. On 2/20/25 at 3:07 PM, V7 (Regional Director of Operations) stated they did not complete effective communication training with the facility staff. The 2/12/25 Midnight Census Report documented 50 residents residing in the facility.

Based on interview and record review the facility failed to conduct ongoing training in Quality Assurance and Performance Improvement (QAPI) for all staff. This failure has the potential to affect all 50 residents residing in the facility. Findings include: The facility's in-services provided by V1 Administrator, was reviewed. There is no documentation QAPI training was conducted. On 2/20/25 at 3:07 PM, V7 (Regional Director of Operations) stated they did not complete QAPI training with the facility staff. The 2/12/25 Midnight Census Report documented 50 residents residing in the facility.

Based on interview and record review the facility failed to conduct ongoing training in Compliance and Ethics for all staff. This failure has the potential to affect all 50 residents residing in the facility. Findings include: The facility's in-services provided by V1 Administrator, was reviewed. There is no documentation Compliance and Ethics training was conducted. On 2/20/25 at 3:07 PM, V7 (Regional Director of Operations) stated they did not complete Compliance and Ethics training with the facility staff. The 2/12/25 Midnight Census Report documented 50 residents residing in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to conduct required in-service training and competencies for Certified Nursing Assistants (CNA). This failure has the potential to affect all 50 residents residing in the facility. Findings include: The facility's Facility assessment dated [DATE] documents under Staff Training/Education and Competencies to include annual in-service and competencies for all Certified Nursing Assistants. The facility's in-services provided by V1 Administrator, was reviewed. There is no documentation the required in-service training and competencies for CNA's was conducted. On 2/20/25 at 3:07 PM, V7 (Regional Director of Operations) stated the annual required CNA in-services and competencies were due in September 2024 and were not completed. The 2/12/25 Midnight Census Report documented 50 residents residing in the facility.

Based on interview and record review the facility failed to conduct ongoing training for all staff, to meet the resident's behavioral health care needs. This failure has the potential to affect all 50 residents residing in the facility. Findings include: The facility's in-services provided by V1 Administrator, was reviewed. There is no documentation of training to meet the resident's behavioral health care needs was conducted. On 2/20/25 at 3:07 PM, V7 (Regional Director of Operations) stated they did not complete training to meet the resident's behavioral health care needs with the facility staff. The 2/12/25 Midnight Census Report documented 50 residents residing in the facility.

Based on interview, and record review the facility failed to provide assistance with activities of daily living for 4 of 5 residents (R8, R18, R21, R28) reviewed for activities of daily living care in a sample of 29. Findings include: 1. R8's admission Record documented an admission date of 6/6/24 with diagnoses including: congestive heart failure, type 2 diabetes. R8's 2/14/24 Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of 13, indicating R8 was cognitively intact, and Section GG documented R8 dependent on staff for tub/shower transfer. On 3/5/25 at 3:40 PM, R8 said there had been times the facility was too short staff to assist her with showering. R8 said 2 to 3 weeks prior to this interview it was really bad and she had to go 7 to 9 days without a shower. R8 said about a week prior to this interview R8 needed to use the bathroom and had waited about 2 hours for staff to assist her. R8 stated (V40) was here that day and watched me have to wait. R8 said she was not sure if she had to wait for so long because the mechanical lift battery was dead…

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, observation, and record review the facility failed to notify the physician of intravenous medications being unavailable for administration. The facility also failed to notify the physician for residents change in condition for 2 of 3 residents (R1, R16) reviewed for physician notification in a sample of 29. Findings include: 1. R1's document titled admission Record documents an admission date of [DATE]. R1's Order Summary Sheet documents diagnoses of Peritoneal Abscess, Anal Abscess, other specified sepsis, colostomy, hypertension, severe protein-calorie malnutrition, and anemia. R1's Minimum Data (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. R1's Order Summary Report dated February 2025, documents orders for Vancomycin (antibiotic) intravenous (IV) 1 gm (gram) two times a day for abdominal abscess, order date [DATE], start date [DATE], until [DATE]; and Unasyn (antibiotic) 3gm IV four times a day for abdominal…

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, observation, and record review the facility failed to obtain and administer Intravenous medications as ordered by the physician to 1 of 3 residents (R1) in a sample of 29. Findings include: R1's document titled admission Record documents an admission date of 1/30/2025. Document titled Order Summary Sheet documents diagnoses of Peritoneal Abscess, Anal Abscess, other specified sepsis, colostomy, hypertension, severe protein-calorie malnutrition, and anemia. R1's Order Summary Report dated February 2025, documents orders for Vancomycin (antibiotic) Intravenous (IV) 1 gm (gram) two times a day for abdominal abscess, order date 1/31/2025, start date 1/31/2025, until 2/14/2025. Unasyn 3gm IV four times a day for abdominal abscess, order date 1/31/2025, start date 1/31/2025, until 2/14/2025. R1's MDS (Minimum Data Set) dated 2/6/2025 includes a BIMS (Brief Interview for Mental Status) score of 15 indicating cognition intact. On 2/13/2025 at 11:20AM, R1 stated he did miss some of his IV medications…

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, observation, and record review the facility failed to ensure physician's orders were followed for administering Intravenous medications and insulin to 2 of 3 residents (R1 and R21) reviewed for medications in a sample of 29. Findings include: 1. R1's document titled admission Record documents an admission date of 1/30/2025. Document titled Order Summary Sheet documents diagnoses of Peritoneal Abscess, Anal Abscess, other specified sepsis, colostomy, hypertension, severe protein-calorie malnutrition, and anemia. R1's Order Summary Report dated February 2025, documents orders for Vancomycin (antibiotic) intravenous (IV) 1 gm (gram) two times a day for abdominal abscess, order date 1/31/2025, start date 1/31/2025, until 2/14/2025. Unasyn (antibiotic) 3gm IV four times a day for abdominal abscess, order date 1/31/2025, start date 1/31/2025, until 2/14/2025. R1's MDS (Minimum Data Set) dated 2/6/2025 includes a BIMS (Brief Interview for Mental Status) score of 15 indicating cognition intact. 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 interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for 8 consecutive hours per day seven days a week. This failure has the potential to affect all 48 residents living in the facility. Findings Include: The Long-Term Care Facility Application for Medicare and Medicaid document dated 12/10/2024, documents 48 residents residing in the facility. Review of the nursing schedules document that no RN was on shift 4/6/2024, 5/4/2024, 5/12/2024, 6/1/2024, 6/29/2024, 6/30/24, 8/3/2024, 8/4/2024, 8/10/2024, 8/11/2024, 8/17/2024, 8/18/2024, 8/24/2024, 8/25/2024, 8/31/2024, 9/7/204, 9/8/2024, 9/21/2024, 9/22/2024, 9/23/2024, 9/25/2024, 9/26/2024, 9/27/2024, 9/29/2024, 10/1/2024, 11/3/2024, 11/17/2024. On 12/10/24 at 2:17 PM, V2 (Director of Nursing/DON) stated the facility had been having issues with having daily Registered Nurse (RN) coverage. V2 stated, work schedules dated April 1st, 2024 - December 1st, 2024, had multiple days with no 8 hours of daily RN coverage. On 12/10/2024 at 2:23 PM, V4 (Registered Nurse/RN) stated 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 prepare food according to planned menu/recipe. This has the potential to affect all 48 residents living in the facility Findings Include: The Week at a Glance menu documents Chicken Cordon Bleu Casserole for lunch on 12/12/24 and Sweet and Sour Pork for lunch on 12/13/24 On 12/12/24 at 12:30PM, V19 (Family Member) questioned what the standards for the food is in a long term care setting because it is poor quality here. V19 went on to state that that her concern is the food quality is low and that makes it hard for the residents to eat. On 12/12/24 at 12:42PM, V12 (Cook) stated that they did not have the chicken or the ham the recipe called for. V12 stated at this time that they used frozen luncheon style ham and just sliced it up to add to the casserole, and the chicken that was used was chunk chicken that was cooked down and not very visible in the casserole. V12 went on to state that she is unsure of how much protein was added, or if it was enough because the packages of frozen ham lunch meat did not have the…

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

Based on observation, interview and record review the facility failed to ensure the kitchen was clean and sanitary to prevent cross contamination. This has the potential to affect all 48 residents living in the facility. Findings Include: On 12/10/24 at 7:50AM, during the initial tour of the kitchen the following concerns were noted: The back door was propped open with no screen in place. The kitchen window was open. The window had a screen but the screen had holes in it allowing anything from the outside in. The refrigerator in the store room had a dried spilled puddle that was brown under a bottle of worcestershire sauce that only had loose plastic wrap as a lid and was laying on its side. Milk with a date of 11/10/24 was in the refrigerator crisper drawer in the store room refrigerator. Cups with a clear milky liquid were on the bottom shelf in the door not dated or labeled. Spilled pink puddles were dried on the bottom shelf of the refrigerator. Dried spilled splatters that were yellow in color were on various items inside the refrigerator door in the store room. Temperature…

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

Based on record review and interview, the facility failed to hold quarterly Quality Assurance and Performance Improvement (QAPI) meetings. This has the potential to affect all 48 residents residing in the facility. Findings Include: On 12/12/24 at 9:00 AM, V1 (Administrator) stated she is not able to provide any documentation of minutes or attendance sheets for the facility's quarterly QAPI meetings for January 2024 and April 2024. V1 further stated her employment in the administration role at this facility began in July 2024 and she is not aware if a meeting had been held. During the survey, a review of facility records revealed no documentation quarterly QAPI meetings were held in January 2024 and July 2024. No meeting minutes or attendance sheets were found. The facility was unable to provide reproducible evidence QAPI meetings had been scheduled or occurred. The facility's QAPI Plan revised on 10/24/2022, documents under Standards Committee shall meet at least quarterly to assure activities are performed and identified problems have correction actions taken or an appropriate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify resident representatives in writing of hospital transfers for 1 (R27) of 2 resident reviewed for hospitalizations in a sample of 24. Findings Include: R27's admission Record documented R27 is [AGE] years old with an Initial admission Date to the facility of 08/27/2021. R27's Nurse's Notes documented on 09/11/2024, that R27 was sent out to the local emergency department for an episode of choking. R27's Nurse's Notes documented on 11/11/2024, that R27 was admitted to the local hospital with a diagnosis of preseptal cellulitis. On 12/13/2024 at 10:09 A.M. V1 (Administrator) stated they do not have the bed hold / notice of discharge on R27 for dates 9/11/2024 and 11/11/2024. V1 stated typically the facility sends the notifications when a resident is sent to the hospital. V1 stated she is not sure why R27's representative was not notified.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify resident representatives in writing of the bed hold policy during resident transfers for 1 (R27) of 2 resident reviewed for hospitalization in the sample of 24. Findings Include: R27's admission Record documented R27 is [AGE] years old with an Initial admission Date to the facility of 08/27/2021. R27's Nurse's Notes documented on 09/11/2024, that R27 was sent out to the local emergency department for an episode of choking. R27's Nurse's Notes documented on 11/11/2024, that R27 was admitted to the local hospital with a diagnosis of preseptal cellulitis. On 12/13/2024 at 10:09 A.M. V1 (Administrator) stated they do not have the bed hold / notice of discharge on R27 for dates 9/11/2024 and 11/11/2024. V1 stated that she is not sure why R27's representative was not notified of the bed hold. V1 stated that it is her expectation for the facility to notify the resident / resident representative as per the regulation. The facility policy titled Bed Hold…

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 the Minimum Data Set (MDS) assessment was accurately coded for 1 (R21) of 2 residents reviewed for accuracy of assessments in the sample of 24. Findings Include: R21's admission Record documented R21 is [AGE] years old with an Initial admission Date to the facility of 11/08/2024. Diagnoses listed on this document included Schizophrenia, depression, unspecified dementia, essential hypertension, anxiety disorder and hyperlipidemia. R21's (name of company) Notice of PASRR (Preadmission Screening and Resident Review) Level I Outcome dated 06/04/2024, documented PASRR Level I Determination: Refer for Level II onsite. R21's (name of company) Notice of PASRR Level II Outcome dated 06/06/2024, documented PASRR Determination: level II - excluded from PASRR - Primary Neurocognitive Disorder - No LOC (loss of consciousness). R21's MDS with an Assessment Reference Date of 11/15/2024 documented this MDS as being an admission assessment. Section…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide toileting assistance to dependent residents for 1 (R33) of 12 residents reviewed for activities of daily living in the sample of 24. Findings Include: R33's admission record documents an admission date of 7/17/22. This same document includes the following diagnoses: Parkinsonism, Diabetes Mellitus Type 2, Dementia, and other specified nutritional deficiencies. R33's Quarterly Minimum Data Set (MDS) dated [DATE] Section C0700 documents R33 has a short term and long term memory problem conducted by staff. This same MDS Section GG documents that R33 is dependent on staff for toileting, hygiene, and bed mobility. Section H, Bladder and Bowel, documents that R33 always has urinary and bowel incontinence. On 12/10/24, intermittent observations were made of R33 at: 8:30AM, 11:00 AM, 12:00 PM, 2:30 PM and 3:30PM in his wheelchair. On 12/11/24, intermittent observations were made of R33 at: 8:05 am in dining room eating breakfast in his…

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 implement treatment and services to a resident with limited range of motion to maintain or improve range of motion for 1 of 1 (R33) residents reviewed for positioning and mobility in the sample of 24. Findings Include: R33's admission record documents an admission date of 7/17/22. This same document includes the following diagnoses: Parkinsonism, Diabetes Mellitus Type 2, Dementia, and other specified nutritional deficiencies. R33's Quarterly Minimum Data Set (MDS) dated [DATE] Section C0700 documents R33 has a short term and long term memory problem conducted by staff. This same MDS documents in Section GG that R33 is dependent on staff for toileting, hygiene, showering, lower body dressing, oral hygiene, toilet transfer, chair/bed transfer, roll left and right and bed mobility. Section GG0115 is coded as having impairment on both sides for upper and lower extremities. Section M, Skin Conditions, documents R33 is at risk for developing…

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 communication and collaboration with an offsite dialysis center and failed to provide meals as ordered for a resident receiving dialysis for 1 (R8) of 1 residents reviewed for dialysis in the sample of 24. Findings Include: R8's admission record documents an admission date of 4/19/22. This same document includes the following diagnosis: muscle weakness, end stage renal disease, dependence on renal dialysis. R8's care plan documents a focus area revised on 10/22/24 that R8 needs dialysis related to ESRD (end stage renal disease). The goal for this focus area with the same revision date of 10/22/24 is for R8 to have no signs or symptoms of complications from dialysis through the review date. The interventions for this focus area are as follows: Check and change dressing daily at the access site and document, do not draw blood or take blood pressure in arm with graft, encourage R8 to go to scheduled dialysis appointments, midodrine 10 milligrams as needed, monitor bruit and thrill every shift, monitor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a gradual dose reductions (GDR) for 1 (R20) of 5 residents reviewed for unnecessary medications in the sample of 24. Findings Include: R20's admission Record documented R20 was [AGE] years old with an Initial admission Date to the facility of 04/28/2023. Diagnoses listed are chronic obstructive pulmonary disease, major depressive disorder, unspecified dementia, unspecified atrial fibrillation, essential hypertension, hyperlipidemia, chronic diastolic heart failure and generalized anxiety disorder. R20's Physician's Order with a date of December 2024 documented an order for lorazepam 0.5 mg (milligram) by mouth twice a day. Company Consultant Report dated 05/10/2024 documented under section titled comment, R20 has received Lorazepam 0.5 mg po BID from 10/2023. Please attempt a GDR (gradual dose reduction) to Lorazepam 0.5 mg at bedtime. Under section titled physician's response, a check mark is next to I accept the recommendation above, please…

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 that residents are free from significant medication errors for 1 (R20) of 4 residents reviewed for medication administration in the sample of 24. Findings Include: R20's admission Record documented R20 was [AGE] years old with an Initial admission Date to the facility of 04/28/2023. Diagnoses listed are: chronic obstructive pulmonary disease, major depressive disorder, unspecified dementia, unspecified atrial fibrillation, essential hypertension, hyperlipidemia, and chronic diastolic heart failure. R20's Nurse's Note dated 10/06/2024 authored by V2 (Director of Nursing) documented R20 returned to the facility from being in the hospital. R20 returned with orders to discontinue Eliquis due to R20 having a positive occult blood and anemia. R20's Nurse's Note dated 11/08/2024 authored by V4 (Registered Nurse/RN) documented messaged NP (Nurse Practitioner) related to Eliquis being given this month so far and it was discontinued on 10/06/2024.…

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, observation and record review the facility failed to follow infection control protocol per current standards of practice for 2 of 2 residents (R33 and R197) reviewed for infection control practices in the sample of 24. Findings Include: 1. R197's admission Record documented R197 is [AGE] years old with an Initial admission Date to the facility of 11/25/2024. Diagnoses listed on this document included presence of urogenital implants, colostomy status, neurogenic bowel, bladder - neck obstruction, paraplegia, pressure ulcer of sacral region, right hip, right buttock, left buttock, and personal history of transient ischemic attack. R197's Physician Orders with a date of December 2024 document an order for #16 Fr urinary catheter with 5 cc (cubic centimeters) bulb. There is also an order for coccyx pressure injury, loosely pack with gauze moistened with Dakins half strength solution. Cover with calcium alginate and dry dressing daily and as needed. Left hip pressure injury, cleanse wound with…

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

Based on observation, interview and record review the facility failed to provide a sufficient number of dietay staff to ensure meals are served at the facility designated meal times. This failure has the potential to affect all 29 residents living in the facility. Findings include: The facility policy revised 6/06 for mealtimes documents breakfast is to be served at 7:00am, Lunch 11:30am, and Supper at 5:00pm. On 08/01/24 the breakfast service was observed. Service began at 7:25am, there were two dietary workers, including the V3, Dietary Manager in kitchen. At 07:35am, there were still several residents without trays. Three residents were served on Styrofoam plates, all residents had Styrofoam bowls. On 08/01/24 the lunch service was observed. Service began at 11:50am, and the first lunch trays were served. At that time there were two dietary workers in the kitchen. At 12:30pm, trays were still coming out a few at a time and people were finished with their meals while other people were still waiting. On 08/05/2024 the first lunch trays were served at 11:42am, there were three…

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 serve meals at the facility's designated meal times. This failure has the potential to affect all 29 residents living in the facility. Findings include: The facility policy revised 6/06 for mealtimes documents breakfast is to be served at 7:00am, Lunch 11:30am, and Supper at 5:00pm. On 08/01/24 the breakfast service was observed. Service began at 7:25am, there were two dietary workers, including the V3, Dietary Manager in kitchen. At 07:35am, there were still several residents without trays. Three residents were served on Styrofoam plates, all residents had Styrofoam bowls. On 08/01/24 the lunch service began at 11:50am, and the first lunch trays were served. At that time there were two dietary workers in the kitchen. At 12:30pm, trays were still coming out a few at a time and people were finished with their meals while other people were still waiting. On 08/05/2024 the first lunch trays were served at 11:42am, there were three dietary workers in the kitchen including the V3, Dietary Manager. On 08/01/2024 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, interview, and record review, the facility failed to serve meals as per there designated schedule. This has the potential to affect all 27 residents living at the facility. Findings include: A Meal Time Policy dated June 2006 documented, Meal service begins at: Breakfast 7:00am, lunch 11:30am, Supper 5:00pm. On 5/28/24 at 11:30, lunch service was observed in the dining room. The first tray did not leave the service window until 11:55am. On 5/28/24 at 12:25pm, V5, Dietary Manager, stated breakfast is scheduled at 7:00am, lunch is scheduled at 11:30am, and supper is scheduled at 5:00pm. V5 stated, Meals are usually on time. We try not to be more than 15 minutes late. V5 stated the kitchen currently needs to hire three cross trained staff members, meaning staff who function as both Cooks and Dietary Aids. On 5/28/24 at 1:05pm,V12, Family Member of R9, stated he and his siblings visit R9 at nearly every meal. V12 stated he and his siblings have discussed the fact that all three meals are consistently served late on a daily basis. V12 stated he normally visits 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate and/or initiate investigations on allegations of resident to resident abuse and allegations of staff to resident abuse for three residents (R4, R6, R9) reviewed for abuse in a sample of 9. Findings Include: 1. R4's admission Record dated 03/24/2024 documents R4 was admitted to the facility on [DATE] with diagnoses that include Unspecified systolic (congestive) heart failure, chronic obstructive pulmonary disease, essential primary hypertension, type 2 diabetes mellitus, Urinary tract infections, anemia, acquired absence of left leg above the knee. R4's MDS (Minimum Data Set) dated 03/29/24 documents R4 has a BIMS (Brief Interview for Mental Status) score of 12, which indicates a moderate cognitive impairment. On 05/28/2024 at 01:53PM, R4 stated she had an incident on 05/26/2024 with R9. R4 stated after several times of asking R9 to move, he shoved his chair back into her. R4 was observed having a small area of discoloration 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 provide pressure ulcer treatment according to physicians orders for 1 of 1 resident (R5) reviewed for pressure ulcers in the sample of 9. Findings include: R5's Face Sheet documented an admission Date of 1/20/24 and listed diagnoses including Diabetes Type 2, Anxiety Disorder, Depression, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and Hypertension. R5's Minimum Data Set, dated [DATE] documented R5 has two Stage 2 pressure injuries which were present on admission to the facility. R5's May 2024 Physicians Order Sheet (POS) documented a 5/22/24 order to,Cleanse area to left buttock and sacrum. Pat dry well. Apply zinc barrier cream every (12 hour) shift and as needed. Cleanse right buttock, pat dry well, apply zinc barrier cream to periwound, apply calcium alginate to wound bed, and cover with dry dressing twice daily and as needed. R5's Treatment Administration Record (TAR) documented that from 5/22/24 to 5/28/24, the…

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

Based on observation, interview, and record review, the facility failed to monitor the food intake for a resident with a history weight loss for 1 of 9 residents (R5) reviewed for weight loss in a sample of 9. Findings include: R5's Face Sheet documented an admission Date of 1/20/24 and listed Diagnoses including Diabetes Type 2, Anxiety Disorder, Depression, Hypertenstion, Chronic Obstructive Pulmonary Disease, and Chronic Kidney Disease. R5's Care Plan with an initiation date of 2/7/24 and a revision date of 5/30/24 documented a problem area, of Nutrition: (R5) Has a risk of weight loss related to sometimes preferring not to eat. At times, resident chooses to order foods on his own. R5's 2024 Weight Log documented the following weights: February: 272.5 lb (pounds), March 258lb, April 239.5lb, May 232.5lb. R5's Meal Intake Record for May 2024 contained no documentation on the following dates and times: 5/1/24 and 5/2/24, all three meals; 5/3/24 and 5/4/24, lunch; 5/6/24, breakfast; 5/8/24, supper; 5/10/24, breakfast and lunch; 5/17/24, breakfast and supper; 5/22/24, lunch; 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 8 hours of daily Registered Nurse (RN) coverage. This has the potential to affect all 27 residents residing in the facility. Findings Include: On 5/15/24 at 11:00am, V1 (Administrataor) said that they are short on Registered Nurses but it is getting better. V1 said she knows there is times when they did not have the 8 hours a day of coverage. On 5/14/24 at 11:30am, V2 (DON/Director of Nurses) said she is always trying to get more Registered Nurses, but it is better than it was. Review of the nursing staff schedules for March, April and May 2024 documents the facility did not have RN coverage on 3/2/24, 3/30/24, 4/6/24, 5/4/24, and 5/12/24. The facility Midnight Census Report Form dated 5/14/24 documents that 27 residents reside at the facility, with 1 resident in the hospital.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Physician visited and examined residents at least once every 30 days for the first 90 days after admission or at least once every 60 days thereafter for 3 of 3 residents (R1, R2 and R3) reviewed for physician services in a sample of 7. The findings include: 1. R1's admission record documents R1 was admitted to the facility on [DATE] and documents R1's primary physician as V3. The same document lists R1's diagnoses in part as unspecified systolic (congestive) heart failure, chronic obstructive pulmonary disease, Type 2 diabetes mellitus with unspecified complications, acquired absence of left leg above knee, peripheral vascular disease, and anxiety disorder. R1's MDS (Minimum Data Set) dated 4/25/24 documents that R1 has a BIMS (Brief Interview of Mental Status) of 12, indicating R1 has mild cognitive impairment. On 5/14/24 at 9:00am, V1(Administrator) said V3 (Medical Director) has not been coming to the facility to see residents for a…

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

Based on observation, interview, and record review, the facility failed to ensure the shower room was kept clean clean and sanitary condition for 13 of 17 (R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17) residents reviewed for environment in the sample of 17. Findings Include: On 3/3/24 at 9:44 AM, what is described as being the main shower room was inspected with V1 (Administrator). A black/brown/reddish substance was observed to the back wall of the shower stall extending from the floor to approximately 1 foot in height and 1 1/2 feet in width. The substance was wiped with a piece of toilet paper, with the substance wiping off on the toilet paper. V1 acknowledged the presence of the substance, and stated staff should be cleaning out the stall in between resident uses. R5 was observed in the shower room, waiting for his shower prior to this inspection. Due to a light malfunctioning, V1 instructed staff to close the shower room down and use the shower on the other hall. On 3/8/24 at 10:52 AM, V1 stated the residents who would potentially use the shower room in question…

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 administer bolus enteral feedings as ordered by the physician for 1 of 1 residents (R1) reviewed for enteral feedings in a sample of 3. Findings include: R1's New admission Information sheet documents R1 was admitted to the facility on [DATE]. R1's January 2024 Physician's Order Sheet documents diagnoses including Parkinson's, weakness, diabetes mellitus (DM), dysphagia, altered mental status, and Percutaneous Endoscopic Gastrostomy (PEG) tube. R1's January 2024 Physician Order Sheet documented an order, dated 11/20/23, for enteral feeding of Jevity 1.5 Bolus PEG tube, 240 mL (milliliters) bolus 5x(times)/daily, 75 mL H2O (water) before and after. R1's Care Plan, dated 10/10/2022, documents under Nutrition R1 is at risk for alteration in nutrition related to dementia and Parkinson's and may impact resident ability to swallow or feed self. R1's Care Plan documents interventions including follow recommendations of Registered Dietician/ Licensed Dietician…

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 properly date, label, and cover food/drink items once opened; failed to throw out expired supplements; failed to maintain equipment and food contact surfaces in a safe and sanitary manner; and failed keep door closed to prevent potential pest contamination. This has the potential to affect all 32 residents residing in the facility. The Findings Include: On 11/14/23 at 9:45AM during the initial tour of the kitchen, the following items were found: 1. freezer base was dirty with food debris and papers 2. cheese in plastic bag was not sealed 3. a pitcher of a purple colored liquid was not labeled or dated 4. shredded cheese and ham and a bottle of thousand island dressing was not labeled and dated after being opened 5. mighty shakes best by used day 11/9/23 6. lemonade and water were in the refrigerator not covered or dated 7. two bowls of canned blushing pears were not covered or labeled 8. the back door leading to the outside was left open from 11:10 AM until 11:23AM 9. butter was open on the counter at 9:45 AM…

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, observation, and record review, the facility failed to implement interventions to prevent falls for one resident (R25) of three residents reviewed for falls in the sample of 35. Findings include: R25's Face Sheet documented an admission Date of 7/17/22, and listed diagnoses including Parkinson's Disease, Weakness, and Anemia. R25's Care Plan dated 10/4/23 documented a problem area, Under skilled therapy services for repeated falls, poor safety awareness, and abnormal gait. R25's Fall Risk Assessments, dated 1/9/23, 7/27/23, and 9/2/23 all documented R25 is at high risk for falls. R25's Minimum Data Set, dated [DATE] and 9/26/23, both documented R25 requires extensive assistance from at least one staff member for transfers. On 11/14/23 at 12:07pm, R25 was alert and oriented to self only. Nurses Notes documented the following: 6/4/23: Reported fall by CNA (Certified Nursing Assistant). Resident was trying to attempt to self transfer off toilet to wheelchair. He fell on his bottom. He did 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 ensure residents were free from unnecessary psychotropic medications for 1 of 5 (R16) residents reviewed for unnecessary medications in a sample of 35. The Findings Include: R16's new admission information sheet document an admission date of 4/28/23. A cumulative diagnosis log includes the following diagnosis: anxiety and depression with non date identified, and dementia with behaviors, with a date identified as 4/25/23 and updated 11/16/23. R16's current physician order sheet as of 11/17/23 has an order for Seroquel 25milligram (mg) twice daily. On 11/17/23 at 1:30 am, V1 (Administrator) confirmed the dementia diagnosis for R16 was not on the cumulative diagnosis sheet on 11/16/23, but she sent a request to the physician to add the diagnosis to R16's chart. V1 said she went ahead and added it before the physician responded. V1 stated when the physician responded, he discontinued the medication and did not add any diagnosis, including the dementia with behaviors. R16's current care plan was reviewed, and there was no…

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, observation, and record review, the facility failed to provide nutritional supplements according to Physicians Orders for one residents (R20) of seven residents reviewed for therapeutic diets in the sample of 35. Findings include: R20's Face Sheet documented an admission Date of 11/30/22, and documented diagnoses including Diabetes and Aortic Stenosis. R20's November 2023 Physicians Order Sheet documented an order for liquid nutritional supplement shakes twice daily. A Registered Dietician Note, dated 9/29/23, documented,noted fortified shake twice daily is ordered. Recommend changing to (trade name liquid nutritional supplement)twice daily due to availability. On 11/14/23 at 12:20pm, R20 was observed eating lunch in the facility's dining room. R20 was alert only to himself. R20's diet card listed, Lunch-(trade name) liquid nutritional supplement. There was no supplement on R20's tray. On 11/16/23 at 9:01am, V3, Dietary Manager, stated when a supplement is ordered twice daily, the supplement is to be given at the meals at which the resident has the best intake.…

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 time/temperature controlled foods at proper holding temperatures. This has the potential to affect all 38 residents residing in the facility. The Findings Include: On 10/11/22 at 9:30 AM during the initial walk through of the kitchen, an external refrigerator temperature gauge was showing a temperature of 52 degrees Fahrenheit. No internal thermometer was found inside the unit by V3 (Dietary Supervisor). V3 stated she would place a thermometer inside now to be checked at a later time to determine internal temperature accurately. V3 went on to state there has not been any known issues to refrigerator, and the current month log all showed temperatures up to date within acceptable range. V3 stated, The staff is finishing breakfast and starting lunch preparation, so it may be a little warmer due to being in and out of the unit a lot. On 10/11/22 at 11:30 AM, the refrigerator was found to have a thermometer placed inside it, and was showing a temperature of 58 degrees Fahrenheit. The contents of 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 and interview, the facility failed to ensure quarterly assessments were completed timely for 5 of 27 residents (R10, R4, R7, R3) reviewed for timely quarterly assessments in a sample of 27. The Findings Include: 1. R10's facility undated New admission Information documents R10 was admitted to the facility on [DATE]. R10's most recent quarterly MDS (Minimum Data Set) found in R10's clinical record was dated 5/14/22. On 10/12/22 at 2:30 PM, V4 (RN/Clinical Reimbursement Specialist) confirmed the most recent quarterly MDS completed for R10 was on 5/14/22. The computer system is showing an MDS was started, but not completed on 8/10/22, when it was due. 2. R4's facility undated New admission Information documents R4 was admitted to the facility on [DATE]. R4's most recent quarterly MDS (Minimum Data Set) found in R4's clinical record was dated 4/21/22. On 10/12/22 at 2:30 PM, V4 (RN/Clinical Reimbursement Specialist) confirmed the most recent quarterly MDS (Minimum Data Set) completed for R4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure annual assessments were completed timely for 1 of 27 residents (R1) reviewed for timely annual assessments in a sample of 27. The Findings Include: 1. R1's facility undated New admission Information documents R1 was admitted to the facility on [DATE]. The most recent MDS (Minimum Data Set) found in R1's Clinical Record was a quarterly assessment, dated 4/18/22. On 10/12/22 at 2:30 PM, V4 (RN/Clinical Reimbursement Specialist) confirmed the most recent quarterly MDS completed for R1 was on 4/18/22, and was due for an annual on 7/14/22, and was not completed.

Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS) for 1 of 8 (R22) residents reviewed for significant change in condition in a sample of 27 . Findings include: 1. R22's Face Sheet documented her admission date of 1/27/2022 for right hip fracture. R22's August 2022 Weekly Wound Tracking log documented a stage IV pressure area was present on the sacrum. Date of onset was 1/27/2022. R22's Minimum Data Set (MDS) documented type of assessment was quarterly, dated on 8/5/2022. On section M. skin assessment in part, there was 1 stage 2 pressure ulcer present on admission. The 8/5/2022 MDS did not code a stage IV pressure ulcer was present. There was no significant change MDS assessment documented after 8/5/2022. R22's Physician Orders Sheet (POS) documented, Admit to Hospice. R22's document entitled, Hospice/LTC Coordinated Task Plan of Care Date admitted to Hospice: 9/7/2022. Hospice Diagnosis: Lung Cancer. On 10/14/2022 at 12:53PM, V4, MDS nurse, stated, V3, previous MDS nurse, was out due to illness, and she was covering…

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 implement proper hand hygiene during wound care procedures for 1 of 8 (R22) residents reviewed for infection control in a sample of 27. Findings include: 1. R22's Face Sheet documented her admission date of 1/27/2022 for right hip fracture. R22's Physician Orders Sheet (POS), dated on 9/7/2022, documented in part, .wound care to left lateral ankle and sacrum. Cleanse with Normal Saline pat dry with 4 x 4 gauze and cover with foam every 3 days and as needed . R22's POS, dated on 10/3/2022, documented, Cleanse wound to coccyx with normal saline. Pat dry with 4x4 gauze. Apply a nickel thick layer of Thera honey to wound bed. Cover with foam dressing and change ever 2 days or as needed if loose, soiled or saturated with draining. On 10/13/22 at 1:55 PM, V5, Licensed Practical Nurse (LPN), put on gloves to remove R22's left ankle wound dressing. V4 discarded the dressing in the trash. (No hand hygiene performed). V5 then used the same gloved hands to cleanse and reapply the new dressing. (No 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.