Moweaqua Rehab & Hcc

Based on interview and record review, the facility failed to resolve grievances for four (R31, R33, R48 and R49) of five residents reviewed for grievances from a total sample list of 34 residents. Findings include: The facility provided Resident Grievance Policy and Procedure, dated May 2018, documents it is the intent of the facility to encourage residents, their residents, or representatives to communicate any concerns, suggestions, complaints or opportunities for improvement in care or services. Each grievance will be investigated and addressed with a response. The Administrator/Executive Director will ensure grievances are addressed and resolved within a five-day time frame and final outcome communicated to the person originating the grievance. The resident council minutes, dated 1/3/24, document concerns including call lights taking too long and the food being cold. The facility resident council minutes, dated 11/4/24, document a grievance of late breakfast and late lunch was noted along with call lights not being address. The response to the grievance was that low staffing 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 provide fingernail care, bathing, and timely toileting/incontinence cares for three (R16, R21, R30) of 16 residents reviewed for Activities of Daily Living (ADLs) in the sample list of 34 residents. Findings include: 1. The facility grievance log (January-November 18, 2024) documents 19 formal resident complaints related to call light response times. Facility Grievance Forms document the following recent grievances made during Resident Council meetings: -8/7/24: 3rd shift not cleaning up residents letting the resident in urine and not cleaning up the resident and Call lights aren't being answered in a timely manner -9/23/24: Took 3 hours for call light to be answered when (urinary) catheter was leaking -9/26/24: staff member didn't provide timely care resulting in her to go in her pants -10/9/24: Call lights not being answered in a timely manner. -11/4/24: Call lights not being answered in a timely manner. R30's diagnosis list (printed 11/19/2024) documents R30's diagnoses include: Hemiplegia/Hemiparesis…

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 upon observation, interview, and record review, the facility failed to to ensure the resident's menus and/or the individual resident's food plan met her/his nutritional needs and preferences for four (R14, R16, R19, R43) of four residents reviewed from a total sample list of 34. 1.) R19's physician order, dated 2/5/24, documents diet order of regular diet mechanical soft texture with nectar thick fluids. On 11/17/24 at 1:10 PM, R19's plate of food includes carrots sliced, plain. [NAME] colored rice with brown orange cubes and green peas; fried breading piece mixed in; 1/2 cup red paste looking puree on side of plate. Side small plate has crumbled yellow cake substance with white frosting. Bowl contains plain macaroni noodles and brown lentil beans with clear liquid and thin red liquid as drink. V6, Resident family member, demonstrated carrots hard and unable to cut as well as cold when served. R19's Dietary slip, with meal dated 11/17/24 Lunch, documents diet as general, mechanical soft and nectar thick liquids. Meal to be served, pasta faggioli soup, white rice, grilled fried…

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 timely and palatable meals to residents. These failures affect seven residents (R18, R19, R21, R25, R30, R31, R43) of 15 reviewed for meals in the sample list of 34. Findings include: On 11/17/2024 at 8:39AM, V3 (Cook) reported facility meal times are 7:30AM, 12:00PM, and 5:30PM. On 11/19/2024 at 12:46PM, facility meal times were posted in the hallway outside of the dining room. The meals times posted were: breakfast at 7:30AM, lunch at 12:00PM, and supper at 5:30PM. The facility grievance log (January-November 18, 2024) documents 47 formal resident complaints related food. Facility Grievance Forms document the following recent grievances made during Resident Council meetings: --9/18/24: Cold food and Food is tasteless. --9/23/24: Food is cold and bad. Coffee is bad. --10/9/24: Cold food on hall trays and dining room. --10/9/24: Meals are not being served on time. --11/4/24: Breakfast on the hall 9:00/9:30AM Lunch on the hall 1:00/1:30PM. 1. On 11/17/2024 at 10:20AM, R30 reported supper meals have been…

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 follow physicians orders for treatment of a nonpressure wound for one resident (R54) of two residents reviewed for nonpressure wounds in a sample list of 34. Findings Include: R54's Minimum Data Set (MDS), dated [DATE], documents R54 is cognitively intact. R54's Treatment Administration Record (TAR) for November documents a current physician's order to Change wound vac dressing day shift every day shift every Monday, Wednesday,and Friday. R54's Hospital discharge orders, dated 10/10/24, document, Left Medial Calf- Negative pressure therapy to be changed three times per week. Vac (vacuum) is continuous at 125mmHg. R54's TAR for November documents that treatment was not completed Monday 11/4/24, Friday 11/8/24, Monday 11/11/24, or Friday 11/15/24. On 11/17/24 at 10:00AM, R54 stated, I fell here (at the facility) and my surgical incision busted open and I bled all over the floor. That was when I got the wound vacuum. The nurse don't bother to change 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 investigate, determine root cause, and implement resident centered fall interventions for one resident (R54) of one resident reviewed for falls in a sample list of 34. Findings Include: R54's Minimum Data Set (MDS), dated [DATE], documents R54 is cognitively intact. On 11/17/24 at 10:00AM, R54 stated, I fell here (at the facility) and my surgical incision busted open and I bled all over the floor. R54's hospital history and physical documents, (R54) presented to emergency room from Extended Care Facility where he had a mechanical fall in which his left lower extremity wound opened up and he was found to have bleeding. R54's progress Note, dated 10/1/24 at 2:45PM, documents, nurse was called to residents room due to resident falling. Resident's daughter was in his room with him when resident got up from his wheelchair to walk to his bed and fell. Resident was sitting on the floor next to his bed with his daughter sitting behind him holding him up. Noted…

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 administer oxygen as ordered, failed to correctly apply a nasal cannula, failed to provide oxygen humidification, and failed to maintain clean, dated, and labeled oxygen tubing for one (R160) of five residents reviewed for respiratory care from a total sample list of 34 residents reviewed. Findings include: The facility provided Oxygen Administration Policy, dated 1/2017, documents there must be an order for oxygen administration and that the nasal cannula tube should be placed approximately one-half inch into the resident's nose, held in place by an elastic band placed around the resident's head. Equipment and supplies include a nasal cannula and humidifier bottle that should be replaced weekly and as needed. R160's physician orders, dated 10/23/24, documents oxygen to be administered at two liters per nasal cannula continuously to keep R160's oxygen saturation above 92%. R160's physician orders, dated 10/23/24, documents oxygen tubing to be changed weekly on Wednesday nights. On 11/17/24 at 11:09AM, R160…

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 regularly assess residents, obtain informed consent, identify or track specific managed behaviors, and provide therapy rationale. This failure affects for three residents (R262, R30, R41) taking psychotropic medication of five residents reviewed for medications in a sample list of 34. Findings Include: The facility's policy Psychotropic Medication Use ,dated 09/2022, states, Staff will complete Psychoactive Medication Review assessment on admission, when any new psychotropic medication is ordered, with a change in condition, and quarterly. This assessment will be completed for any medication prescribed to manage behaviors i.e. Depakote, Nudexa, etc. Prior to starting psychotropic medications, informed consent will be obtained from residents/representative per state guidelines. Residents who are admitted from the community or transferred from a hospital and are already receiving psychotropic medication will be evaluated for appropriateness 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 provide dental services for one (R16) of one residents reviewed for dental services from a total sample list of 34 residents. Findings include: R16's nutritional assessment, dated 8/8/24, documents R16 is edentulous and requires nutritional supplements in addition to a regular pureed diet with snacks. On 11/17/24 at 10:48AM, R16 was edentulous and stated she would like to have dentures. On 11/19/24 at 9:38AM, V12, Social Services Director (SSD), stated she does not recall asking R16 if she needs dentures, and the resident has never asked them about it. V12 stated the facility does not have a dentist who will provide dentures. On 11/19/24 at 3:31PM, V18, Family Member, stated they had never been asked about R16's dental issues, and she has been in need of dentures for some time, and would like her to be seen. On 11/20/24 at 10:03AM, V2, Director of Nursing, stated R16 is provided nutritional supplements because she isn't a good eater and needs the calories.

Based on observation, interview, and record review, the facility failed to provide the the correct food consistency for three residents (R263,R16, R19) of five residents reviewed for dietary consistency in a sample of 34 residents. Findings Include: 1. R263's Hospital History and physical, dated 11/8/24, documents, (R263) liquid/?pureed diet. This same history and Physical documents (R263) has been diagnosed with Advanced Amyotropic Lateral Sclerosis (AMS) for the past eight years. On 11/17/24 at 9:00AM, R263 was observed lying in bed leaning to the right side. R263 had severe contractures to all extremities and was unable to speak. R263 had a communication board and was able to express himself by pointing to letters or responses on the board. R263's full breakfast (ground consistency) was on the over the bed tray, untouched. When asked if R263 can feed self, R263 pointed to no. When asked if staff had offered to help, R263 pointed to no. There was a full cup of water on R263's over the bed tray. When asked if staff offer R263 drinks, R263 pointed to no. When asked if R263 refused…

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 repeatedly failed to maintain the dignity of four residents (R4, R7, R11, R3) out of four residents reviewed for dignity in a sample list of eleven residents. Findings include: 1. R11's Care Plan, dated 10/22/24, documents actual skin impairments to skin integrity related to incontinence and has areas of pressure to left hip, right Ischium, and right hip. This same Care Plan, with a date of 6/17/24, documents resident has bladder and bowel incontinence and to check and change every two hours and as needed. On 10/24/24 at 12:13 PM, R11 was lying in bed with the top sheet mostly covered with a light brown substance that has fading brown color towards the edges of the sheet. R11 was lying on a bed pad that is covered with a light brown substance that has fading brown color towards the edges of the pad. At this same time, R3, who is the roommate of R11, stated no one has been into change R11 at all this morning. R3 and R11's room has an odor of urine…

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 maintain a clean environment for four (R3, R4, R7, R9) residents out of five residents reviewed for cleanliness of environment in a sample of eleven residents. Findings include: The facility Resident Council report, dated 9/10/2024, documents, Description: Residents would like the rooms cleaned better. Wipe down room, sweep, mop. Summary/Findings: Some rooms needed more attention, but for the most part rooms have been cleaned. Action Taken: Housekeeping Supervisor will do spot checks to ensure cleanliness of rooms and hallways. The facility Resident Council Report, dated 10/9/12024, documents, Description: Would like rooms cleaned and wiped down, sweep and mop. Action Taken: Bedrooms should be cleaned daily and residents should assist us in keeping clutter down in their rooms by allowing staff to assist them in straightening. 1.) R3's Minimum Data Set (MDS), dated [DATE], documents R3 as cognitively intact. This same MDS documents R3…

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 planned showers for five residents (R2, R3, R4, R5 R6) out of seven residents reviewed for showers in a sample list of eleven residents. Findings include: 1.) R2's Minimum Data Set (MDS), dated [DATE], documents R2 is not cognitively intact. This same MDS documents R2 requires substantial/maximal assist with bathing. R2's Care Plan, dated 8/28/24, documents R2 has an Activities of Daily Living (ADL) self care deficit related to impaired mobility and right sided Hemiparesis. R2's documented bathing ADL log documents R2 received three showers/baths (on 8/19/24, 8/20/24, 8/29/24) out of eight monthly baths R2 should have received. This same type of log for R2's baths for September 2024, documents R2 received a shower/bath on 9/2/24. R2's Shower Sheets document R2's refusals on 9/5/24 and 9/18/24. There is no further documentation in R2's medical record stating if R2 was offered or given shower/baths on other days, and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement fall interventions for one (R4) resident out of three residents reviewed for falls in a sample list of eleven residents. Findings include: R4's undated Face Sheet documents R4's medical diagnoses as Right Femur Fracture, Hemiplegia and Hemiparesis following Cerebral Infarction, Diabetes Mellitus Type II, Acute Kidney Failure, Adult Failure to Thrive, Asthma, Atrial Fibrillation, Dysphagia, Repeated Falls, Metabolic Encephalopathy, Chronic Heart Failure, Muscle Weakness, and Age Related Physical Debility. R4's Minimum Data Set (MDS), dated [DATE], documents R4 as moderately cognitively impaired. This same MDS documents R4 requires moderate assistance with toileting, dressing, bathing, and supervision when moving from a sitting position to a standing position. R4's Fall Risk Assessment, dated 8/8/24, documents R4 as a high fall risk. R4's Care Plan intervention, dated 8/18/24, instructs staff to re-direct R4 to a common area 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.

Based on interview and record review, the facility failed to administer antibiotics as ordered by the physician for two of four residents (R2, R10) reviewed for antibiotic medication administration in the sample list of eleven. Findings include: 1. R2's August 2024 Electronic Medical Administration Record (e-MAR) documents an order for Doxycycline Monohydrate oral tablet 100 milligrams (mg) - give one tablet two times a day for Pneumonia until 8/30/24, start date 8/20/24. This same e-MAR documents the antibiotic Doxycycline Monohydrate was not given on 8/21/24 (AM dose), due to R2's refusal, and not given on 8/23/24 (PM dose) due to other-see progress note. Both 8/21/24 and 8/23/24 dates have no documentation of the physician being notified of R2 not receiving the antibiotic, or any reasoning for the refusal and just not being given in R2's medical record. 2. R10's e-MAR dated August 2024, documents an order for Augmentin 500-125 mg one twice a day by mouth. This same e-MAR documents the following: August 21, both AM and PM doses as 6; August 22, AM dose documents 5 and August 22 PM…

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 a resident had adequate storage for personal belongings and space to accommodate a resident bed for one of three residents residents (R7) reviewed for environment on the sample list of seven. Findings Include: R7's Current Care Plan states R7 is dependent on staff for activities, cognitive stimulation, and social interaction related to impaired mobility, and R7 prefers to not be around others in social settings, with an initiated of 06/02/2024. On 9/30/24 at 11:50 AM, two boxes of R7's personal belongings were in the hallway outside R7's room, with R7's personal pillow laying on top of the boxes, exposed to anyone walking in and out the adjacent entry/exit door. On 9/30/24 at 11:50 AM, R7 stated there is not enough room for her personal belongings in the room, and the staff put her belongings in the hallway. R7 stated anyone can steal her belongings, and R7 would never know. R7 stated this makes her upset that she cannot keep track of her belongings. On 9/30/24 at 11:50 AM, R7 stated staff have to move…

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 bath/showers on a regular basis for three residents (R2,R5,R7) of three residents reviewed for hygiene in a sample list of seven residents. Findings Include: 1. R5's Progress notes document R5 was admitted to the facility 8/29/24. R5's Minimum Data Set (MDS), dated [DATE], documents R5 is cognitively intact and totally dependent for shower or bath. R5's Plan of Care (POC) History for bathing, dated 9/1/24 to 10/1/24, does not document a bath or shower was provided for R5 during that time period. On 10/2/24 at 11:00AM, R5 was observed in a Bariatric bed receiving care. R5 stated, I have not gotten a full bath since I got here. I've not been out of bed. I didn't get up at home for a while either. I'd like to have my feet washed. On 10/1/24 at 2:00 PM, V3, Corporate Registered Nurse (RN), provided one hand written shower sheet that was dated 9/17/24, but stated, This is the only shower or bath I see documented since (R1's) admission.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide diabetic care for one resident (R1) of three residents reviewed for diabetic care in a sample list of seven residents. Findings Include: R1's face sheet documents R1 was admitted to the facility 8/14/24, with the diagnosis of Type II Diabetes Mellitus, Chronic Kidney Disease Stage III, Cardiomyopathy, and Cognitive Communication Deficit. R1's Progress note, dated 9/14/24 at 5:20PM, documents, (R1) noted diaphoretic, Altered Mental Status see current V/S (vital signs). Blood Glucose noted at 56. Nurse Practitioner on call for Patient Care Provider, gave new order Glucagon 1ml (milliliter), (IM) Intramuscular now. Recheck Blood sugar in 30 minutes. Resident noted [NAME] arms and legs. Writer phoned Wife she stated, 'I want him sent to emergency room at (hospital).' (nurse) phoned 911, 5:30PM first responders showed up (blood glucose) at this time 52. 6:30PM (Ambulance) here to transport resident, to (hospital). 6:30PM Report called to (hospital…

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 seek a prescription for an ordered controlled pain medication prior to depleting supply for one resident (R5) of three residents reviewed for pain in a sample list of seven residents. Findings Include: R5's current Physician's Orders include a Physician's Order, initiated 8/29/24, for Tramadol 50 Milligrams by mouth for moderate pain. R5's Medication Administration Record (MAR) documents R5 did not receive Tramadol 9/6/24, 9/7/24, 9/8/24, 9/9/24, 9/10/24, or 9/11/24. During that time, R1's pain on a scale of 1-10 ranged from a low of 0 to a high of 8. On 10/2/24 at 11:00AM, R5 stated, I have pain most of the time and they were out of my pain pill for about a week. I really hurt and it was so bad I had trouble sleeping. R5's Progress note, dated 9/9/24 at 11:00PM, by V10, Nurse Practitioner, documents, Per nurse, Still need this script Prescription (Script) sent ASAP (R1) is out of Tramadol and unable to pull from stat (emergency supply) due to needing script. On 10/2/24 at 2:00 PM, V3, Registered Nurse (RN) Corporate…

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 laboratory services for two of three residents (R2 and R5) reviewed for laboratory services on the sample list of seven. Findings Include: 1. R2's progress note, dated 9/9/24 at 11:00PM, written by V10, Nurse Practitioner, documents an order for a urinalysis. R2's progress note, dated 9/10/24 at 1:54PM, by V8, Licensed Practical Nurse, documents a physician order was received for a urinalysis. R2's clinical physician orders do not document an active order was entered for a urinalysis to be completed. On 9/30/24 at 11:50AM, R2 stated R2 has felt like R2 has a urinary tract infection and staff have not collected a urine sample. On 10/2/24 at 10:05AM, V4, Corporate Nurse, stated V10 did enter a progress note with an order for a urinalysis 9/9/24. V4 then stated V8 entered a progress note documenting an order was given by the physician to obtain a urinalysis on 9/10/24. V4 confirmed there is no active order in R2's clinical physician orders for a urinalysis to be performed. On 10/2/24 at 10:05AM, V4 confirmed R2's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provided showers to dependent residents. This failure affects four of four residents (R1, R2, R4, and R5) reviewed for showers and hygiene care on the sample list of five. Findings Include: 1. R1's Comprehensive Assessment, dated 8/12/24, documents R1 is severely cognitively impaired with one sided lower limb impairment, and requires moderate assistance from staff with showers. R1's Care Plan (current) documents R1 requires assistance by staff with bathing. The Facility Resident Shower Schedule documents R1 is to receive showers on Monday and Thursday on day shift. R1's Point of Care (POC) Bathing Record for August and September 2024 documents R1 has only received two showers in the month of August and none in the month of September. This same record documents R1's last shower/bed bath was on 8/7/24. On 8/30/24 at 10:45am, R2 stated R2's showers are supposed to be on Monday and Thursday, during the day. R2 stated R2 has been receiving…

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 call lights were answered in a timely manner for three of three residents (R3, R5, R6) reviewed for call lights on the sample list of 6. Findings Include: 1. R3's admission Record, dated 02/17/2021, documents R3 is diagnosed with Muscle Weakness, Unsteadiness On Feet, and Limitation Of Activities Due To Disability. R3's care plan, dated 8/6/21, documents R3 is at risk for falls r/t (related to) impaired mobility. The care plan, dated 04/20/2022, documents R3 has bladder incontinence and R3 is able to utilize call light and let staff know when she has to use bedpan, which she uses for bowel and bladder. R3 has a Minimum Data Set (MDS) dated [DATE]. Section C of the MDS states a Brief Interview for Mental Status (BIMS) of 15, indicating R3 is cognitively intact. On 5/21/24 at 11:00 am, R3 stated it can take, and often does take, a long time for staff to answer the call light when activated for help. R3 stated CNA's (Certified Nursing Assistants)…

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 staff wear the required PPE (Personal Protective Equipment) when entering an isolation room, failed to don procedure/isolation face masks in resident care areas, and failed to correctly wear procedure/isolation face masks in resident care areas. These failures have the potential to affect all 53 residents residing in the facility. Findings include: The facility's Action Plan - COVID-19, updated on 5/22/23, documents, Source Control - refers to use of respirators, well-fitting face masks, or well-fitting cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Ensure everyone is aware of recommended IPC (Infection Prevention and Control) practices in the facility. When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of (a) resident for which a NIOSH Approved respirator…

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 notify a resident's representative of a new Physician's Order for a chest xray, and failed to notify the resident's representative of the results of that chest xray for one of three residents (R1) reviewed for notification in the sample list of eight. Findings include: The facility's Significant Condition Change & (and) Notification policy with a reviewed date of November, 2019 documents, Purpose: To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below: A significant change in the resident's physical, mental or psychosocial status. Sudden onset of shortness of breath Symptoms of an infectious process Change in level of consciousness such as agitation, lethargy, sudden lack of responsiveness or manic behavior Other abnormal assessment findings Calls will be made to the resident's representative until they are reached. R1's Progress Notes, dated 2/5/24, document diagnoses including Metabolic Encephalopathy, Dysphagia, Oropharyngeal Phase,…

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 protect the confidential health information for one of one resident (R1) reviewed for confidentiality in the sample list of eight. The findings include: R1's Healthcare Power of Attorney, dated 4/7/21, documents, I (R1) intend for the person named as my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records, including records or communications governed by the Mental Health and Developmental Disabilities Confidentiality Act. This release authority applies to any information governed by the Health Insurance Portability and Accountability act of 1996 (HIPAA) and regulation thereunder. I intend for the person named as my agent to serve as my personal representative as that term is defined under HIPAA and regulations thereunder. On 2/5/24 at 10:37 AM, V22, Licensed Practical Nurse/LPN confirmed she has notified V20, who is not R1's POA, for some issues. V22 stated V20 would call for updates on R1, and V22 would give…

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

Based on interview and record review, the facility failed to follow up with the physician to ensure timely care for one of three residents (R1) reviewed for COVID 19 infection in the sample list of eight. Findings include: The facility's Significant Condition Change & (and) Notification policy with a reviewed date of November/2019 documents, Purpose: To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below: A significant change in the resident's physical, mental or psychosocial status. The medical practitioner will be contacted immediately for any emergencies regardless of the time of evening or night shift. This applies to any day of the week including holidays. If the medical practitioner cannot immediately be reached in any emergency, the medical director will be called. If that medical practitioner cannot be reached, the director of nursing or the charge nurse can make arrangements for transportation to the emergency department. Each attempt will be charted as to the time the call was made,…

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 timely incontinence care for two (R1, R8) of four residents reviewed for incontinence in the sample list of eight. Findings include: 1.) R8's Minimum Data Set (MDS), dated [DATE],3 documents R8 has moderate cognitive impairment, is dependent on staff for toileting hygiene, and is always incontinent of bowel and bladder. R8's Care Plan, dated as revised 9/29/23, documents R8's incontinence, and includes an intervention to check R8 for incontinence every two hours and as required. On 12/18/23 at 10:11 AM, 10:50 AM, 11:35 AM and 1:22 PM, R8 was sitting in a geriatric chair near the nurse's station. At 1:36 PM, V7 and V10 Certified Nursing Assistants (CNAs), pushed R8 in the geriatric chair to R8's room, transferred R8 into bed using a full mechanical lift, and provided R8's incontinence care. R8's brief was wet with urine and contained a moderate amount of bowel movement. V7 stated R8 was last laid down after breakfast, just long…

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 fall interventions and thoroughly investigate falls for one (R1) of three residents reviewed for falls in the sample list of eight. Findings include: R1's undated Diagnoses List documents R1's admission diagnosis as traumatic subdural hemorrhage effective 7/28/23. R1's Minimum Data Set, dated [DATE], documents R1 has moderate cognitive impairment, is dependent on staff for toileting hygiene and transfers, and is always incontinent of bowel and bladder. R1's Care Plan, dated as revised 11/10/23, documents R1 is at high risk for falls, and includes interventions for Call Don't Fall signs next to bed and across room implemented on 8/12/23, nonskid socks implemented on 7/28/23, helmet to be worn as ordered and R1 is able to remove helmet, implemented on 8/20/23. R1's medical record does not document an order for this helmet, and there is no routine documentation of the application or refusal of this helmet. R1's Care Plan, dated as…

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 behavioral health interventions to ensure the safety of one resident (R33) and other residents R33 has access to in the facility. This failure has the potential to affect all residents who reside at the facility. Finding Include: The Resident Census and Condition of Residents Report, dated 10/16/23, documents the census is 41 residents. R33's Diagnoses list reviewed on 10/18/23 includes the following diagnoses: Alcohol Abuse, Seizures, Wernicke's Encephalopathy, Anxiety Disorder, Unspecified Dementia, and Atherosclerotic Heart Disease. R33's Minimum Data Set (MDS),, dated 8/1/23 documents R33 exhibits Disorganized Thinking, Inattention, and wandering. This MDS also documents R33 is completely independent with all Activities of Daily Living (ADLs) and only requires supervision with eating. R33's Progress Note 8/29/2023 at 2:00 AM, (R33) was found in a females resident's bed. CNA had woke (R33) up and (R33) began to start yelling and cussing and saying F* (Expletive) you! Writer had done many…

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 prevent cross-contamination of ice and sherbet, and failed to maintain a sanitary ice scoop. These failures have the potential to affect all 41 residents residing in the facility. Findings include: 1. On 10/16/2023 at 9:44AM, the dietary service ice machine was heavily soiled with accumulations of mineral deposits along all sides of the attached ice bin. The evaporator/condenser unit located immediately above the ice bin was actively leaking condensation water along all edges and down onto the exterior of the ice bin, and also leaking directly inside of the attached ice bin, cross-contaminating the ice stored inside of the bin. The bin had a hinged plastic door opening where staff access the ice and several pieces of plastic were missing from the hinge area of the door located directly above the stored ice. V15 (Dietary Manager) was present, and reported being unaware of the location of the missing pieces of plastic. On 10/17/2023 at 2:58PM, the ice machine remained as above. 2. On 10/16/2023 at 9:45AM, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain psychotropic medication assessments for five (R1, R4, R12, R20, R21) of five residents reviewed for psychotropic medications in the sample list of 20. Findings include: The facility's Psychotropic Medication Policy, dated September 2022, documents residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective. Staff will complete the Psychoactive Medication Review Assessment on admission, when any new psychotropic medication is ordered, with a change of condition, and quarterly. 1.) R4's physician order sheet, dated 9/16/22, documents Zoloft (antidepressant) 12.5 milligrams (mg) 6 days a week, with one day off. R4's physician order, dated 8/18/23, documents a Zoloft decrease to 12.5mg 5 days a week, with two days off for Depression. No assessments for Zoloft were documented in R4's medical record. On 10/16/23 at 9:46AM, R4 was crying in R4's room. 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 interview and record review, the facility failed to prevent misappropriation of property for one (R12) of one residents reviewed for misappropriation of property from a total sample list of 20 residents. Findings include: The facility Abuse Prevention and Prohibition Policy, dated October 2022, documents residents have the right to be free from abuse including misappropriation of resident property. Misappropriation of resident property will be prevented by Social Services assisting the resident/family to identify and mark personal possessions upon admission. An inventory will be completed and maintained in the resident's clinical record. The Social Services designee in collaboration with the Administrator will investigate all reports or complaints of missing resident property following the policy and procedure. The facility admission Agreement, dated February 2019, documents the resident or authorized representative will be responsible to complete a personal item inventory sheet and update the inventory…

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 a nicotine transdermal patch as ordered for one (R19) of two residents reviewed for smoking from a total sample list of 20. Findings include: The facility provided Administration of Medications Policy, dated April 2021, documents, If for any reason a physician's order cannot be followed, the physician shall be notified as soon as is reasonable. A notation shall be made on the nurse's progress notes in the patient's clinical record. The Center's for Disease Control Quit Smoking program documentation, dated 11/28/22, documents three strengths of Nicotine patches; 7 milligram, 14 milligram and 21 milligram. R19's diagnosis sheet, dated 9/23/23, documents a diagnosis of Nicotine Dependence. R19's physician orders, dated 10/11/23, document an order for a Nicotine patch 21 milligrams per 24 hours to be applied daily. R19's October 2023 medication administration record documents a patch was most recently placed on R19 on October 14,…

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

Based on observation, interview, and record review, the facility failed to obtain a wound care treatment order or complete a wound assessment for one of one resident (R30) reviewed for Moisture Associated Skin Damage (MASD) in a sample list of 20. Findings Include: On 10/16/23 at 10:10 AM, V6, Hospice Certified Nurse's Aide, stated (R30) developed excoriation as a result of moisture. (R30) has been experiencing diarrhea as a possible side effect from a recently completed antibiotic. V6 and V7, Certified Nurse's Aides (CNAs), were observed completing incontinence care for R30. R30 had an area approximately 1 inch in diameter on R30's left buttock which was beefy red, with a small amount of red drainage. V6 applied a white cream to the open area following cleaning. V6 stated V6 was applying zinc oxide because that is what hospice does for open areas caused by moisture. R30's current physician's order sheet (POS) for October 1, 2023 through October 31, 2023 does not include an order for zinc oxide or any other treatment to R30's MASD. R30's electronic medical record does not include 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to secure a resident's indwelling urinary catheter tubing to one (R4) of three residents reviewed for indwelling urinary catheters from a total sample list of 20 residents. Findings include: The facility provided Catheter Care, Urinary Policy, dated January 2017, documents the purpose of the policy is to prevent catheter-associated urinary tract infections by ensuring the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. The catheter tubing should be strapped to the resident's inner thigh. R4's physician orders, dated 6/20/23, documents an order for an indwelling urinary catheter, with a securement device to be placed and the catheter to be changed as needed for Neurogenic Bladder. R4's physician orders, dated 10/12/23, documents to give Cefipime (antibiotic) 1 gram per 50 milliliters, intravenously, every 24 hours for 6 days for a urinary tract infection. R4's Minimum Data Set, 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 interview and record review, the facility failed to ensure all licensed nurses were competent in medication administration to ensure residents take medication as ordered. This failure affects one of 20 residents (R3) reviewed for medication safety in a sample list of 20. Findings include: R3's Nurse's Progress note, dated 9/22/23 at 9:54PM, documents (V16), Licensed Practical Nurse (LPN) in (R3's) room to assure (R3) takes meds (medications) but (R3) stated (R3) will take them when (R3) gets done cleaning all the stuff out of (R3's) bed. (V16) took meds back and told (R3) (V16) would bring them back when (R3) is ready. (V16) back in room to give meds and (R3) (showed) (V6) meds that (R3) has had for days hoarded in room and also (wanted to) take with tonight's meds. (V6) did take out meds that (were) hoarded in room and explained to (R3) that (R3) cannot take all the meds at the same time because (they are) the same meds. (R3) did allow (V6) to take meds out and throw away. There is no documentation in R3's electronic medical record to indicate the physician was ever…

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 failed failed to promote the right to dignity for one (R1) of three residents reviewed for dignity on the sample list of 4. Findings include: R1's care plan, dated 7/28/23, documents R1 has a self care deficit and requires one person to assist him with dressing. On 8/16/23 at 9:41 AM, R1 was lying in bed. When asked if the facility takes good care of him, R1 shook his hand back forth giving the so so sign. When asked if he would like to wear clothes, R1 stated yes. On 8/16/23 at 12:00 PM, R1 was sitting in the dining room in a surgical gown in a reclining geriatric chair. The chair was reclined, and R1 was lifting R1's legs. The bottom of R1's surgical gown was sitting at the top of R1's legs. R1 was not wearing socks. R1's feet, legs, and incontinence brief were not covered and easily visible. R1's chair was at the back wall of the dining room and was facing out towards the entrance to the dining room. The dining room was full of residents and staff 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 ensure they employed an Infection Preventionist that has completed mandatory training in Infection Control and Prevention per the Centers of Disease Control (CDC). This failure has the potential to affect all 45 residents residing in facility. Findings include: The facility's Resident List Report, dated 8/1/23, documents 45 residents reside in facility. On 8/1/23 at 10:53 AM, V1, Administrator, stated the Director of Nursing (DON) nor the Assistant Director of Nursing (ADON), have the Infection Preventionist training certificate. On 8/2/23 at 10:23 AM, V2, DON, stated V2 has done modules 1-4 (observed) for the infection prevention training, and the current ADON has not started the infection prevention training. Throughout the survey days 8/1/23, 8/2/23, 8/3/23, 8/4/23, no designated Infection Preventionist was observed in the facility. The facility's Action Plan-COVID 19, dated Updated 5/22/23, documents, assign one or more individuals with training in IPC (Infection Prevention Control) to provide on-site…

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 one resident (R2) of four residents was not subjected to abuse from another resident (R1). This failure affects three of four(R1, R2, R8) residents reviewed for abuse on the sample list of 14. This past non-compliance occurred on 7/17/23. Findings Include: The facility's Abuse, Prevention and Prohibition Policy, dated Revised 10/22, documents each resident has the right to be free from abuse, residents must not be subjected to abuse by anyone, and this facility prohibits abuse of residents. The facility's Final Report, dated 7/21/23, documents R8 witnessed R1 hit R2 on R2's head with a shoe (on 7/17/23). This report also documents on 7/18/23, R2 was noted to have an area of discoloration on R2's left side by R2's hairline. R1's Electronic Medical Record (EMAR) documents R1's diagnosis as Alzheimer's Disease with late onset. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is severely cognitively impaired. R1's Care Plan, dated 7/17/23,…

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.

Based on observation, interview, and record review, the facility failed to provide a continued sufficient level of staff to care for resident's needs for seven (R20, R197, R198, R36, R38, R18, and R2) of 24 residents reviewed for sufficient staffing on the sample list of 37. This failure also has the potential to affect all 50 residents in the facility. Findings include: 1. On 9/26/22 at 1:05 PM, R20 (Resident Council President) stated, The call light response time is not good; we have to wait forever for help. We have to wait for food to be served at meal times for long periods of time, and showers are not being given twice a week. It has been a problem for months now. Resident Council Minutes, dated 4/11/22, documents a Nursing concern that: sometimes call lights are being ignored. Resident Council Minutes, dated 7/6/22, documents, a Nursing concern that: call lights are still not being answered. Resident Council Minutes, dated 8/5/22, documents, a Nursing concern that: Certified Nursing Assistants (CNAs) need to start answering call lights. Resident Council Minutes, dated 9/6/22,…

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 observation, interview, and record, review the facility failed to employ sufficient dietary staff to serve resident meals on standard tableware. This failure has the potential to affect all 50 residents residing in the facility. Findings include: On 9/25/2022 during the breakfast meal service, residents were served their meals on foam instead of standard ceramic tableware. On 9/25/2022 at 9:06 AM, V8 (Dietary Manager) was preparing resident meals in the facility kitchen, and reported the kitchen currently has low staffing, so V8 is currently working as the only cook to get meals served to the residents; today is V8's fourth double shift worked in a row. V8 reported the kitchen normally has three cooks including V8. V8 reported the facility gave permission for the kitchen to serve the resident breakfast meals on foam due to low staffing. On 9/25/2022 at 12:50 PM, V8 was working in the kitchen and stated, they (the facility) need to do something, I'm tired already. On 9/28/22 at 11:10 AM, R20 reported the facility doesn't have enough dietary staff, and the residents have been…

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 serve resident meals at a palatable temperature for three (R2, R7, and R37) of 24 residents reviewed for dining on the sample list of 37. This failure has the potential to affect all 50 residents in the facility. Findings include: On 9/25/2022 at 9:40 AM, R2 reported the meals in the facility are always cold and R2 is used to cold lunch and that makes R2 feel not that good. Resident Council meeting minutes document the following food complaints: 4/11/2022 - kitchen - nothing has changed still the same 4/11/2022 - food being cold 5/6/2022 - late meals, cold food. 6/3/2022 - still mixed feelings about food. Getting better but still needs improvement especially with the food being cold. 7/6/2022 - food still being cold 8/5/2022 - food is still being delivered cold 9/6/2022 - food terrible The facility Grievance Log document the following food complaints: R7 complained on 4/11/2022 of food served late and cold. R37 complained on 5/23/2022 of food being served cold on an ongoing basis. The facility Resident Census 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 and interview, the facility failed to prevent the potential for cross-contamination of stored food. This failure has the potential to affect all 50 residents residing in the facility. Findings include: On 9/25/2022 at 9:06 AM, the kitchen reach-in freezer evaporator was partially covered in frozen waste water that had leaked from the condenser onto the contents of the freezer. Six cardboard boxes containing individual servings of ice cream and nutritional supplements were stored beneath the leak on multiple shelves, and were partially covered with the frozen waste water. The waste water leak had partially destroyed the box stored on the top freezer shelf, covering many of the individual servings of ice cream and supplements before exiting the bottom of the box and covering part of the five additional boxes of food stored below. V8 (Dietary Manager) was present and reported the food in the kitchen was available for all residents to eat. On 9/26/2022 at 11:51 AM, the freezer and contents remained as above. On 9/27/2022 at 12:17 PM, the freezer remained as above,…

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, facility staff failed to follow the facility's infection control prevention protocols while the facility was in an outbreak status by failing to wear a surgical mask and eye protection. This failure has the potential to affect all 50 residents in the facility. Findings include: The facility's census and condition report, dated 9/25/22, documents there are 50 residents residing in the facility. On 9/25/22 through 9/28/22, there was a sign located at the front entrance of the facility that stated all staff and visitors are the wear a N95 (respirator mask) and eye protection while in the facility. On 9/25/22 at 2:30 PM, V28, Certified Nursing Assistant (CNA), was in the hall talking with family members. V28 was not wearing a mask or eye protection. V28 then went in and out of resident rooms on the 100 hall. On 9/26/22 at 10:00 AM, V2, Director of Nursing, stated We are currently on outbreak status because we have a staff member who tested positive. Our County transmissibility rate is high. There is no reason any staff member would 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide shaving, incontinence care, and assistance with eating for residents. This failure affects seven (R44, R18, R246, R198, R36, R2, and R38) of 24 residents reviewed for assistance with activities of daily living on the sample list of 37. Findings include: 1. R44 care plan, dated 9/7/22, documents R44 requires one assist with personal hygiene and oral care. On 9/25/22 at 8:50 AM, R44 had multiple whiskers on her chin. On 9/28/22 at 9:44 AM, R44 continued to have whiskers on her chin. R44 started to cry when asked if she would like them removed from her chin. R44 stated she can not do it herself, and would like them shaved off. 2. R18's care plan, with a revision date of 3/25/22, documents R18 requires assistance with activities of daily living due to spinal cord injury On 9/25/22 at 11:00 AM, R18 stated she waited 3 hours to get assistance with getting changed. On 9/26/22 at 4:02 PM, V2, Director of Nursing, stated call lights aren't…

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 the ability to self administer medications for two of two residents (R43, R245) reviewed for self administration of medications on the sample list of 37. Findings include: 1. R245's admission Assessment, dated 9/3/22, documents R245 was admitted to the facility with a diagnosis of Cellulitis, Chronic Obstruction Pulmonary Disease, Weakness, and a Decline in Mental Status. This admission Assessment documents under the section, Self Administration of Medications, R245 does not wish to self administer medications. R245's medical record did not contain an assessment for the self administration of medications, or an order for R245 to self administer medications. On 9/27/22 at 1:10 PM, V5, Licensed Practical Nurse, put a vial of Ipratropium Bromide and Albuterol Sulfate 0.5/3 milligram per 3 milliliter into R245's nebulizer and turned on the nebulizer machine. V5 then handed R245 the nebulizer mask and began to walk out of the room. R245 was talking and moving mask away from her face to talk as V5 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 honor a resident's dining location preference. This failure affects one (R2) of 24 residents reviewed for dining choices in the sample of 37. Findings include: R2's Care Plan (8/16/2022) documents R2 does not like to eat in the facility dining room, and likes to eat all meals in R2's room. The same record documents R2's dietary preferences will be honored by the facility. R2's Nutrition Assessment (5/18/2022) documents R2 prefers to eat all meals in R2's room. On 9/25/2022 at 9:40 AM, R2 reported eating meals in R2's room. On 9/26/2022 at 12:00 PM, R2 was eating lunch in the facility dining room. On 9/27/2022 at 12:30 PM, R2 reported eating lunch in R2's room every day, except the last two days because staff requested he eat in the facility dining room during those lunch times. R2 reported wanting to eat in R2's room.

Based on interview and record review, the facility failed to prevent the physical abuse of one resident (R40) by another resident (R41) for two of two residents (R40, R41) reviewed for resident to resident altercations on the sample list of 37. Findings include: R41's nurse's note, dated 9/19/22 at 11:39 AM, written by V2, Director of Nursing, documents, (R41)) was propelling self in hallway in wheelchair. (R41) passed by another resident (R40) and struck (R40's) arm with her hand and kept propelling self in wheelchair. (R41) didn't say anything to the other resident (R40) and denies hitting her when asked why she struck her. Skin assessment completed of both residents and residents were immediately separated. On 9/29/22 at 9:27 AM, V2, Director of Nursing, stated On 9/19/22 at 11:30 AM, (V5, Licensed Practical Nurse) came to me and stated (R41) hit (R40) in the hallway and seen it happen so she intervened. She separated the residents. (R40) was up by the bathroom facing towards the nurse's station and (R41) wheeled by (R40) and kind of just swung her arm back on the way by and hit…

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 secure urinary catheters and failed to prevent back flow of urine during cares for two of three residents (R26 and R42) reviewed for urinary catheters on the total sample list of 37. Findings include: The facility's policy, with a revision dated of January 2017, titled Urinary Catheter Care, documents, Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Maintaining Unobstructed Urine Flow: 3- The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Changing catheters: 2- Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. 1. On 9/26/22 at 1:45 PM, R26's urinary catheter tubing was not secured with a leg band or securement device. R26's urinary catheter tubing was draped over top of R26's left thigh, with the tubing attached to the urinary drainage bag chamber system on the right…

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

Based on observation, interview, and record review, the facility failed to develop written resident care policy and procedures for aerosol drug delivery system storage in residents rooms, and failed to ensure personal aerosol drug delivery system equipment was stored properly to prevent cross-contamination for one of two residents (R245) reviewed for respiratory therapy on the total sample list of 37. Findings include: R245's progress notes document 9/23/2022 at 12:48 PM, Bilateral lung sounds congested in all lung fields. (as needed) breathing treatments administered without effectiveness. Resident complains of shortness of breath and coughing. R245's progress noted document 9/25/2022 at 10:05 PM, Lung sounds remain coarse all lobes with productive cough. On 9/25/22 at 9:15 AM and 9/26/22 at 8:20 AM, R245 had an aerosol generating delivery system (mask and tubing) on R245's nightstand beside R245's bed. On 9/26/22 at 8:20 AM, R245 grabbed the nebulizer mask and tubing and was turning the machine on and off stating, I need a breathing treatment. On 9/27/22 at 1:10 PM, V5, Licensed…

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 timely pain control for one resident (R198) of two residents reviewed for pain in a sample list of 37. Findings include: R198's admission Record, printed 9/28/22, includes the following diagnoses: Repeated falls, Muscle Weakness, Lack of Coordination, Unsteadiness on feet, Breast Cancer, Anemia, Anxiety, and Major Depression. R198's Care Plan, initiated on 9/15/22, documents, (R198) has pain (R198) will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Monitor/record/report to Nurse. (R198's) complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from (R198's) past experience of pain. Monitor/record pain characteristics (each shift) and PRN (as needed): Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors. monitor/record/report to Nurse…

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 assess a dialysis site for one of one (R31) resident reviewed for dialysis in a sample list of 37. Findings Include: R31's admission Record, printed 9/28/22, includes the following diagnoses: End Stage Renal Disease and Dependence on Renal Dialysis. R31's Care Plan, dated 8/17/22, documents, (R31) needs dialysis hemodialysis related to renal failure · (R31) will have immediate intervention should signs/symptoms of complications from dialysis occur through the review date. (R31) will have no signs/symptoms of complications from dialysis through the review date. Do not draw blood or take B/P (Blood Pressure in arm with graft. (R31) receives dialysis at (local dialysis center) (R31) has a chair time at 11:45 am. Our facility to provide transportation to and from dialysis. (R31) is to eat lunch prior to dialysis. (R31) has labs done at (Dialysis Center) and weights done Monday, Wednesday and Fridays at her dialysis appointments. Monitor for dry skin and apply lotion as needed. Monitor/document/report to MD PRN any…

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 R21 for bed side rail use, including an evaluation of alternatives prior to bed rail use, risk of entrapment, and benefits of use. This failure affects one resident (R21) reviewed for side rail use in the sample list of 37. Findings include: R21's Minimum Data Set (8/1/2022) documents R21 has severe cognitive impairment. On 9/25/2022 at 11:33AM, R21's right side bed rail was loose, and appeared to be an entrapment hazard, easily moving outward away from the mattress when grasped. The top of the rail had a large gap between the rail and R21's headboard. On 9/26/2022 at 3:09PM, R21's bed side rail was in the elevated position, and had a seven inch gap between the top of the rail and the headboard attached to the bed frame. On 9/27/2022 at 11:16AM, V4 (Licensed Practical Nurse) reported R21 is not cognitively intact, does move while in bed, but R21 does not use the bed side rail ever. V4 reported R21's family wanted the bed side rail, and that is the reason why the facility began using the rail for R21.…

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 initiate resident centered Dementia care interventions for one of one resident (R197) reviewed for Unsafe wandering in a sample list of 37. Findings Include: R197's admission record, printed 9/29/22, lists the following diagnoses: Dementia with Behavioral Disturbance, Type II Diabetes with Neuropathy, Cognitive Communication Deficit, Muscle Weakness, Unsteadiness on Feet, Chronic Kidney Disease, Altered Mental Status, and Parkinson's Disease. R197's Minimum Data Set (MDS), dated [DATE], documents R197 is severely cognitively impaired, experiences hallucinations and Delusions, displays physical, verbal, and other behavioral symptoms directed at others, and wanders. R197's progress note, dated 9/24/2022 at 4:15 PM, documents, (R197) was wandering in the hallways and staff found him exiting through the Assisted Living Facility doorway. CNA (Certified Nurse's Assistant) noticed his face was bleeding and he stated he had stubbed his toe and fell to 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 justify the use of psychotropic medications by failing to complete quarterly psychotropic assessments and identifying targeted behaviors, failing to limit the use of an as needed antianxiety medication to 14 days for two (R36, R197) of five residents reviewed for psychotropic medications in a sample list of 37. Findings include: 1. R36's admission Record, dated 9/28/22, includes the following diagnoses: Repeated Falls, Type II Diabetes, Anxiety, Unsteady on Feet, Muscle Weakness, and Major Depression. R36's Medication Administration Record for 9/1/22 through 9/30/22, documents R36 has physician's orders for the following psychotropic medications: 1. Lexapro (antidepressant) 20 MG Give 1 tablet by mouth one time a day. 2. Melatonin (sleep inducing) Give 5 mg by mouth at bedtime 3. Seroquel (antipsychotic) 50 Milligrams twice daily 4. Vistaril (Antihistamine) 25 MG Give 1 tablet by mouth every 6 hours. There is no assessment or identified targeted…

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

Based on observation and record review, the facility failed to administer eye drops per manufacturer's directions for one (R36) of five residents reviewed for medication administration on the sample list of 37. These failures resulted in two medication errors out of 25 opportunities resulting in a 8.0% error rate. Findings include: The Manufacturer's Instructions for Ipratropium Bromide eye drops, printed by V2, Director of Nursing, documents instructions to, Separate administration of other ophthalmic agents by at least 5 minutes. On 9/26/22 at 8:15 AM, V5, Licensed Practical Nurse, administered eye drops to R36. V5 administered one drop of Alphagan eye drops into both of R36's eyes, then immediately administered one drop of Sodium Chloride into both of R36's eyes. V5 did not wait 5 minutes between the administration of the eye drops.

Based on observation and interview, the facility failed to maintain a resident bed side rail in a safe condition. This failure affects one resident (R21) reviewed for side rails in the sample list of 37. Findings include: On 9/25/2022 at 11:33 AM, R21's right side bed rail was in the elevated position, and appeared to be leaning outward. When grasped, the rail easily moved both towards and away from the mattress four inches or more in each direction. The top of the rail was seven inches in distance from the headboard attached to the bed frame. On 9/26/2022 at 3:09 PM, R21's bed side rail remained as above. On 9/27/2022 at 11:16 AM, V4 (Licensed Practical Nurse) viewed R21's loose and improperly fitting bed side rail, and reported the rail was probably not safe. On 9/27/2022 at 11:30 AM, V19 (Certified Nurse Aide) reported R21 is transferred to R21's bed after each meal, and facility staff place R21's bed side rail in the elevated position.