Hallmark Healthcare Of Pekin

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure nebulizer masks and nebulizer tubing were dated and stored in a bag between uses for two resident (R41 and R161), failed to ensure a resident had a physician order for oxygen for one resident (R2) and failed to ensure nasal cannula tubing were dated for two of six residents (R26 and R161) reviewed for respiratory care in a sample of 32. Findings include: 1. On 9/29/24 at 10:55 AM R26 was sitting in her wheelchair in her room wearing oxygen. There was no date on the oxygen tubing. R26 stated I don't know how often they change the tubing, but I know it is not once a week. On 9/29/24 at 10:56 AM V8/CNA/Certified Nursing Assistant verified there was no date on the oxygen tubing. On 10/1/24 at 1:34 PM, V2/Director of Nursing stated that oxygen tubing should be changed at least once a week and labeled with the date. R26's admission Record printed 9/29/24 at 10:32 AM documents that R26 was admitted to the facility 5/18/23 with diagnoses…

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 implement their Abuse Policy to report staff-to-resident abuse to the administrator immediately for one of one resident (R7) reviewed for abuse reporting in the sample of 32. Findings include: R7's MDS (Minimum Data Set) assessment dated [DATE] documents R7 is cognitively intact. On 9-29-24 at 9:20 AM V5 (Registered Nurse/RN) stated, (V6/CNA/Certified Nursing Assistant) reported to me on 9-28-24 around 12:30 PM that (R7) was saying that (V6) yanked on her arm (R7's arm) rough and hurt (R7's) shoulder. I have only worked here three weeks and was not trained on the abuse policy. I did not report (R7's) allegations to (V1/Administrator). I just thought it was a racist issue. On 9-29-24 at 9:30 AM V4 (CNA) stated on 9-28-24 around 12:15 PM R7 was refusing care from V6 (CNA). V4 stated R7 reported to her that V6 was rough during cares and was rude to R7. V4 stated she did not report R7's allegation to V1. On 9-29-24 at 9:18 AM V1 stated, (V5) should have…

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 physician ordered pressure relieving interventions for a resident identified as being a high risk for pressure ulcer development for one of three residents (R13) reviewed for pressure ulcers in the sample of 32. This failure resulted in R13 developing a painful, facility acquired stage four pressure ulcer to the left heel that became infected with MRSA (Methicillin Resistant Staphylococcus Aureus) and Proteus Mirabilis and required surgical debridement on multiple occasions. Findings include: R13's MDS (Minimum Data Set) Assessments dated 3-8-24 and 9-6-24 documents R13 is cognitively intact. R13's Braden Scale for Predicting Pressure Sore Risk dated 6-12-24 documents R13 is at high risk for developing pressure sores, is chairfast and her ability to walk is severely limited or non-existent, is completely immobile and does not make even slight changes in body or extremity position without assistance, has adequate nutrition, and requires moderate to maximum assistance in moving. R13's Current Care Plan…

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 physician ordered scheduled medication from the pharmacy for one of fifteen residents (R2) reviewed for pharmacy services in the sample of 32. Findings include: R2's Physician Orders, dated 9/29/24, documents Order date: 9/12/24: Cyclobenzaprine hydrochloride 10 mg (milligrams) one tablet by mouth three times a day for muscle spasms. On 9/29/24 at 8:23 AM V9/LPN (Licensed Practical Nurse) was administering R2's scheduled medications. R2's Cyclobenzaprine Hydrochloride 10 mg was not available in the medication cart. V9 stated, We (the facility) have been having trouble getting this medication in from pharmacy and I am not sure why. On 9/30/24 at 2:10 PM V9/LPN stated, R2 was still out of her Cyclobenzaprine 10 mg tab. V9 stated, I did not notify the (R2's) doctor yesterday or today that R2 was out of her Cyclobenzaprine. I did just call the pharmacy and it is something to do with insurance coverage for that medication. On 9/30/24 at 2:30 PM V2/DON verified R2's Cyclobenzaprine was not given yesterday 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to perform anti-psychotic drug assessments, failed to perform gradual dose reductions, and failed to document behaviors and diagnosis to justify the use of an anti-psychotic medication for one of five residents (R38) reviewed for the use of anti-psychotic medication with the diagnosis of Dementia in the sample of 32. Findings include: R38's current Physician's Order document R38 was admitted to the facility on [DATE]. R38's OBRA (Omnibus Budget Reconciliation Act) Initial Screen dated 1-16-22 documents R38 does not have a mental illness. R38's MDS (Minimum Data Set) Assessments dated 4-26-24 and 7-24-24 document R38 receives an anti-psychotic medication on a routine basis, has had no gradual dose reduction attempts, and has no physician documentation as to why a gradual dose reduction is clinically contraindicated. R38's Initial Psychiatric Evaluation dated 2-3-23 and signed by V22 (Psychiatric Nursing Practitioner) documents, Assessment:…

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 its staff follow safety precautions to prevent hand injury and failed to provide timely medical care for one resident (R1) reviewed for injury in a sample of three. These failures resulted in R1 sustaining pain and swelling in his right hand and being transported to the Emergency Department/ED. Findings include: R1's Radiology Results Report, Reported 1/11/24, documents: Impression: 1. Suspicious for volar dislocation of the middle phalanx at the right long finger PIP/proximal interphalangeal joint. R1's Hospital Notes dated 1/11/24 documents: R1 was evaluated and treated in our Emergency Department on 1/11/24. X-ray Impression: No acute osseous abnormality. After Visit summary: No acute abnormalities seen on imaging. Recommend stabilization and symptom management. The Facility's Report Form-(State Department) Notification for R1, dated 1/10/24, documents: Statement: It was reported to (V3 Assistant Director of Nursing/ADON) that (R1) had a finger injury. Upon investigation, it was discovered that (V7…

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 identify and provide the sufficient staffing necessary to meet the needs of the residents. This failure has the potential to affect all 60 residents residing in the facility. Findings include: The facility's Facility Assessment revised 2018, does not include staffing requirements necessary to meet the needs of the residents based on the resident population and census. The facility's Resident Council Minutes dated 9/25/23 documents Resident stated not enough CNAs (Certified Nursing Assistant). The facility's Resident Council Minutes dated 11/27/23 documents Department Concern: g. Nursing: Would like to see more CNA help. On 12/6/23 at 7:40 AM, V10, Registered Nurse (RN) stated We only have the three CNAs here right now for 60 residents. We normally run with four, but there are days we only have three. On 12/6/23 at 7:50 AM, V7, Licensed Practical Nurse (LPN) stated With there only being three CNAs in the building, we do miss showers, but we…

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 food products during meal service. This failure has the potential to affect all 60 residents residing in the facility. Findings include: The facility's Proper Hand Washing and Glove Use policy dated 2020 documents 7. Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for break, or to another location in the building; after handling potentially hazardous raw food; or if the gloves become contaminated by touching the face, hair, uniform or other non-food contact surfaces such as door handles and equipment. On 12/7/23 at 7:15 AM, V4, Food Service Director (FSD), observed standing at the steam table preparing meal trays for breakfast meal. V4 picked up sausage and toast with her gloved hand and placed it on a plate, handed it to another kitchen staff worker who placed it in a food warmer. V4 then walked around the steam table to the kitchen entry, grabbed the door handle, opened the door, and assisted another staff member push the food…

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

Based on interview and record review the facility failed to complete their facility assessment to include the staffing requirements needed to care for the resident population and census. The facility also failed to review the facility assessments annually. This failure has the potential to affect all 60 residents residing in the facility. Findings include: The facility's Facility Assessment revised 2018, does not include staffing requirements necessary to meet the needs of the residents based on the resident population and census. On 12/6/23 at 3:15 PM, V1, Administrator, verified the Facility Assessment was last reviewed in 2018 and stated I wasn't aware the Facility Assessment needed to be reviewed every year. I didn't know it had to include what our staffing numbers had to be. Right now, I can't answer your questions on what our staffing ratios for our resident population should be. I'll have to talk to corporate and see if we can get the Facility Assessment updated. On 12/7/23 at 1:08 PM, V1, Administrator, stated I was told we won't have the updated Facility Assessment for you.…

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 protect a resident's right to have their call light answered in a timely manner for four residents (R1, R2, R4 and R5) reviewed for call lights in a sample of eight. Findings include: The facility's Call Light Guidance policy dated 9/22/20 documents Resident call light shall be responded to within a reasonable amount of time. R1's minimum data set (MDS) documents a brief interview of mental status (BIMS) of 14. R2, R4 and R5's MDS documents a BIMS of 15. A BIMS of 12-15 indicates an individual is cognitively intact. The facility's Resident Council Minutes dated 8/29/23 and 10/30/23 documents Resident stated call light wait times are long. On 12/6/23 at 8:48 AM, R1 stated It would take the CNAs (Certified Nursing Assistant) two hours to answer my call light. I got tired of waiting for my call light to be answered one night so I transferred myself to the wheelchair and went out in the hallway and found a CNA sleeping. That explains why they…

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 showers to four residents (R1, R2, R4 and R5) out of five residents reviewed for showers in sample of eight. Findings include: The facility's Bath and Shower procedure undated documents The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition the resident's skin . Document procedure in the resident's electronic health record. The facility's AM shower schedule documents R1, R4 and R5 are to receive showers on Wednesday and Saturday and R2 on Tuesday and Friday. R1's medical record documents R1 was admitted to the facility on [DATE] and discharged on 11/16/23. R1's medical record does not document a shower was completed during this time frame. On 12/7/23 at 11:00 AM, V1, Administrator, stated they do not have a completed shower sheet or documentation showing R1 received a shower during her stay. R2's medical record and shower sheets does not document R2 received a bed bath or shower…

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 refrigerated foods were labeled with date opened, opened foods were stored in covered containers to prevent contamination, the kitchen floors were kept clean and free of debris, spills on the floor in the walk in cooler were cleaned, peeling paint was not hanging from the ceiling in food preparation areas, black spots were not covering the light fixture and ceiling above the ice machine, dust was not hanging from duct work over food preparation areas, and disinfectant used on the food preparation areas was the proper strength. These failures have the potential to affect all 56 residents in the facility. Findings include: A Food Storage policy dated 9/1/2021 states, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination, and All packaged and canned food items will be kept clean, dry, and properly sealed. In addition, this policy states, Storage areas will be neat, arranged for easy identification, and date marked 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to properly dispose of garbage which has the potential to affect all 56 residents in the facility. Findings include: A Housekeeper job description policy form (undated) states that housekeeping duties include, Empties, cleans and relines wastebaskets and places bags in receptacle to be transported to dumpster, and Cleans entrances and exits. A grievance log dated 7/31/23 documents that R10 complained to the facility about cleanliness. On 8/24/23 at 8:45a.m. R10 stated that he complained to the facility that there was always trash just outside the door near the dining room which leads to a [NAME] where residents like to sit with their visitors. R10 stated that the trash and cigarette butts are visible to residents as they come and go to the dining room for meals and activities. R10 stated that area is not pleasant to look at. R10 stated the window to his room faces the [NAME] and he can see the overflowing trash can from his bedroom window…

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

Based on interview and record review, the facility failed to conduct annual testing to rule out the presence of opportunistic waterborne pathogens in the facility's water system. This failure has the potential to affect all 56 residents currently residing in the facility. Findings Include: The facility's Legionella Water Management Program (revised July 2017) documents, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. A final report from a local water treatment company (dated 11/25/2020), documents the following result after the facility's water system was tested, Analytical Report, total Legionella- Not detected. On 8/24/2023 at 10:30 AM, V1 (Administrator) indicated the facility has not tested their water system for the presence of Legionella since 2020 and stated, I am unable to locate any other yearly testing. 2020 is the last year…

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 dining room ceiling tiles located directly over residents' dining tables were clean, free of dark stains and not bulging. This failure has the potential to affect all 56 residents in the facility. Findings include: A General Maintenance and Monitoring policy dated 9/15/19 gives as its purpose, To provide guidelines on maintenance rounds for facility upkeep to maintain a safe and hazard free environment. In addition, this policy states, The maintenance Director is responsible for upkeep and repair of facility equipment, and The Administrator will monitor that repairs are completed in a timely manner. On 8/21/23 at 12:21p.m. the ceiling in the center of the dining room, directly above where residents were eating their noon meal, had a brownish black discoloration in a ring pattern with two of the tiles severely bulging downward. These ceiling tiles remained in the same condition throughout the survey from 8/21/23 to 8/24/23. On 8/22/23 at11:45a.m. V4 (R37's family) stated, The dining room has some ceiling…

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 a wandering resident did not enter another resident's room without permission which affects two of 24 residents (R10, R29) reviewed for privacy in a sample of 24. Findings include: A Wandering/Elopement Policy dated 10/18/22 states, If identifies as at risk for wandering or elopement; the resident's care plan will include strategies and interventions that shall (be) implemented to maintain the resident's safety, including but not limited, to electronic monitoring device, room placement, frequent checks, etc. R29's Minimum Data Set assessment dated [DATE] documents R30 is severely cognitively impaired and requires supervision for locomotion on and off the unit and utilizes a wheelchair for mobility. R29's care plan dated 5/23/22 documents R29 is an elopement risk. This care plan instructs staff to, Provide re-direction and Diversion as needed. An additional intervention on R29's care plan dated 1/27/21 instructs staff to, keep within…

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's bathroom was clean for two of 24 residents (R10, R26) reviewed for a clean, homelike environment in a sample of 24. Findings include: A Deep Clean Procedures policy (undated) states, Starting in a clockwise rotation from the resident room door: clean, polish, scrub, scrape, dust, disinfect, sweep, wipe, and mop everything in the room, including dust mop and damp mop the entire room, and check all corners, ceiling and floor for cobwebs. A grievance log dated 7/31/23 documents that R10 complained to the facility about cleanliness. On 8/22/23 at 1:09 pm, R10 stated he had concerns with the cleanliness of the floor in his bathroom. R10 stated there is a build-up of dirt and grime at the baseboards and in the corners, and it has been that way for a while now. R10 stated he is going to have his family member clean it for him, because it wasn't getting taken care of by the facility. On 8/23/23 at 11:00a.m. R10 was in his room seated in a wheelchair. R10 stated he shares his room with R26. R10…

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

Based on observation, interview and record review the facility failed to ensure oxygen tubing and nebulizer tubing was dated and stored in a bag between uses for one of one resident (R40) reviewed for respiratory care in a sample of 24. Findings include: An Oxygen Administration policy dated 3/17/22 states, When Oxygen cannula/Mask is not in use it should be stored in a (plastic) or like bag attached to the oxygen concentrator. An Oral Inhalation Administration policy dated 9/2018 states, When equipment is completely dry, store in a plastic bag marked with the resident's name and the date. On 8/22/23 at 9:01a.m. R40 was lying in bed resting. R40's oxygen concentrator was located at the head of the bed between the bed and the window. R40's oxygen tubing was rolled up, laying on top of the concentrator and was undated and not placed in a plastic bag. R40's nebulizer machine was laying on R40's recliner with the tubing and mouthpiece laying on the linens in the recliner without being dated or placed in a plastic bag. On 8/22/23 at 9:09a.m. V13 (Licensed Practical Nurse) was preparing…

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 identify target behaviors, document consistent adverse behaviors, attempt a gradual dose reduction, provide justification for duplicative therapy and justification for a dosage increase to warrant the continued use of an antipsychotic medication for three of four residents (R16, R30 and R55) reviewed for antipsychotic medications in the sample of 56. Findings include: The facility policy, titled Psychotropic Medications Policy Chemical Restraints (revised 5/25/23) documents Purpose: To provide guidelines to ensure that residents who receive antipsychotic/psychoactive medications are maintained at the safest and lowest dosage necessary to control the resident's condition. Policy: In accordance with federal and state regulations, it is this facility's policy that residents will not be given unnecessary medications. Psychotropic/Psychoactive medication will not be prescribed without the informed consent of the resident, the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a binding arbitration agreement was thoroughly explained and residents understood its meaning prior to obtaining a signature for two of three residents (R58, R59) reviewed for binding arbitration in a sample of 24. An Arbitration Tracking Log dated 6/2/23 to 8/22/23 documents that R58 and R59 were admitted to the facility on [DATE], and both accepted the binding arbitration agreement. R58 and R59's Electronic Agreement to Arbitrate Health Care Negligence Claims Notice to Patients forms dated 7/8/23, with electronic check marks in the acceptance box, documents both R58 and R59 signed the facility's arbitration agreement 7/8/23 which states, This agreement provides that any claims which may arise out of your health care will be submitted to a panel of arbitrators, rather than to a court for determination. This agreement requires all parties signing it to abide by the decision of the arbitration panel. These same agreements document…

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

Based on observation, record review and interview the facility failed to develop a comprehensive care plan for two (R 27 and R 54) of 15 residents reviewed for care plans in a total sample of 24. Findings Include: Facility Care Planning policy, revised 7/14/22, documents To utilize the results of the comprehensive assessment to develop, revise, and review resident's care plan. To provide a method for all staff to have needed information in caring for the residents. Each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. The resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate, and planned to meet the individual needs of the resident. It is the responsibility of the staff to ensure that when providing care, the care plan information is utilized. Concerns and problems sources are, but not limited to: relating to diagnoses, physician's orders, and problems related to preventive care. Approach/Plan: List care to be…

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

Based on observation, interview, and record review, the facility failed to update a care plan to include current pressure ulcers and interventions for one (R25) of 15 residents reviewed for care plan revision in a sample of 24. Findings include: Facility Care Planning policy, revised 7/14/22, documents To utilize the results of the comprehensive assessment to develop, revise, and review resident's care plan. To provide a method for all staff to have needed information in caring for the residents. Each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. The resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate, and planned to meet the individual needs of the resident. It is the responsibility of the staff to ensure that when providing care, the care plan information is utilized. Concerns and problems sources are, but not limited to relating to diagnoses, physician's orders, and problems related to preventive care.…

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 document circumstances requiring a discharge to the hospital and monitoring upon readmission for one resident (R14) of 3 residents reviewed for change of condition in a total sample of 24. Findings Include: The Facility's admission Procedure policy dated 5/17/22 documents It is the responsibility of all staff to ensure the needs of a new admission into the facility are met and the documentation is in place addressing the interventions utilized with in the time frame defined by CMS (Center for Medicaid and Medicare Services). The Facility's admission Procedure Policy documents When a resident is admitted to the nursing unit the admitting nurse must document the following information in the nurses' notes, admission form, or other appropriate place as designated by the facility. a) The date and the time of the resident's admission, b) The resident's age, sex, race and marital status, c) From where the resident was admitted (i.e., hospital, home, other facility) d) reason for the admission, e) The admitting diagnosis, f) 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 follow occupational therapy's treatment plan to utilize an orthotic device to help prevent further contraction of the left hand for one resident (R54) of three residents reviewed for range of motion out of a sample of Findings Include: The facility's Restorative Program/Range of Motion policy revised 2/3/22 documents Purpose: To provide residents with limited range of motion appropriate treatment and services to increase or prevent further decrease in range of motion. R54's medical record documents R54 has a left-hand contracture. On 09/06/22 at 10:20 AM, observation of R54's left hand contracture. Resident can slightly open left hand. Upon R54 opening her left hand, it's observed that there's no device preventing R54's fingernails from coming in contact with her palm or to prevent further contracture. R54 stated I'm supposed to have a carrot in my left hand to help prevent this, but they lost my carrot. It's been a few days since I've used it. They call it a carrot because it looks like a carrot. It's a soft…

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 hang oxygen (O2) in use signage, document O2 titration, tubing and humidification bottle changes and failed to date O2 tubing for one (R155) of one resident reviewed for oxygen therapy in a sample of 15. Findings include: Facility Oxygen Administration Policy, revised 3/17/22, documents: to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues; oxygen therapy will be administered to the resident upon the written order of a licensed physician; it is the responsibility of the Charge Nurse to ensure that residents, who have an order for oxygen or will be obtaining an order for oxygen are receiving the proper amount via the proper way; required equipment includes a No Smoking/Oxygen in Use sign; check the order and place the oxygen in use sign on the outside of the room entrance door; observe the resident to be sure oxygen is being tolerated; prefilled disposable humidifiers will be changed when necessary; and label humidifier with date opened and tubing will be…

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

Based on record review and interview, the facility failed to identify and document specific behaviors necessitating the need for psychotropic medications for one resident (R41) of three residents reviewed for psychotropic medications in a total sample of 24. Findings Include: The Facility's Psychotropic Medications Policy dated 5/26/2022 documents In accordance with federal and state regulations, it is this facility's policy that residents will not be given unnecessary medications. The Facility's Psychotropic Medications Policy documents A behavior tracking record is used to keep record of resident's behaviors as required by federal regulations. The care plan will include objectives for gradual dose reduction as well as alternative interventions to assist in gradual dose reduction in accordance with Federal Regulations. R41's Physician Order Sheet for September 2022 documents R41's psychotropic medications as: Zolpidem 10 mg (milligrams) every night, Duloxetine 30 mg every day for Depression, Sertraline Hydrochloride 100 mg every day for Depression, Lorazepam 0.5 mg twice daily for…

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

Based on observation, interview and record review, the facility failed to maintain transmission-based precautions for two residents (R31, R41) of five residents reviewed for infection control in a total sample of 24. Findings include: The facility's Isolation for Transmission Based Precautions policy revised 6/20/22 documents Contact Precautions: 4. Staff will wear gloves (clean, non-sterile) when entering the room. 5. Staff and visitors will wear disposable gown upon entering the room and remove before leaving the room and will avoid touching potentially contaminated surfaces with clothing after gown is removed. Droplet Precautions: 4. Gloves, gown, and goggles should be worn if there is a risk of spraying respiratory secretions. The facility's Personal Protective Equipment (PPE) policy dated 5/31/22 documents 5. Provide the right supplies to ensure easy and correct use of PPE. a. Post signs on the door or wall outside of the resident's room to advise staff to take precautions. Signage on affected rooms will include the type of precautions to be utilized and instructions to use…

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.