Timbercreek Rehab and Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident (R2) from physical abuse by another resident (R1), reviewed for abuse, in a sample of seven.Based on interview and record review, the facility failed to protect a resident (R2) from physical abuse by another resident (R1), reviewed for abuse, in a sample of seven.FINDINGS INCLUDE:The facility policy, Abuse, Prevention and Prohibition Policy, dated 03/2025 directs staff, Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals.R1's facility form admission Record, documents that R1 was admitted to the facility on [DATE] with the following diagnoses, Schizophrenia, Mood Disorder, Anxiety, Depression, Schizoaffective Disorder and Mild Intellectual…

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 resident rooms were clean and free of urine odor, resident room windows had privacy blinds or curtains in good repair, resident heating units were properly attached to the wall, and failed to ensure all resident rooms had adequate cooling for five of 18 residents (R4, R7, R9, R38 and R68) reviewed for homelike environment in the sample list of 40. Findings include: The facility's Resident Rights policy dated 12/2024 documents it is the responsibility of the staff in the facility to provide services to the residents, and advocate for Resident Rights. 1.) 06/10/25 10:36 AM 06/09/25 11:17 AM R4 had two cardboard boxes taped to the window covering the windows with silver tape. On 6/10/25 at 12:10 PM, V20 (Certified Nursing Assistant) stated there are cardboard boxes that cover windows because the windows let in hot/cold air. 06/09/25 11:00 AM, V5 (Maintenance Director) stated the blinds do not block out the sun, so residents will often ask to have boxes over the windows. V5 further stated the facility plans…

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 abuse for one resident (R2) reviewed for abuse in a sample of six. Findings include: The Initial Incident Report sent to (State agency) for 4/1/25 incident between R1 and R2 documents, (R1) allegedly walked a crossed the hallway to (R2's) room and swatted at (R2) while (R2) was in bed. The Final Incident Report sent to (State agency) for 4/1/25 incident between R1 and R2 documents, (R2) was lying in bed yelling out, as he does sometimes when he forgets to use the call light, and resident (R1) with dementia came in (R2's) room and swatted at (R2), (R1) left .right after, then staff came in and made sure he (R2) was okay. On 4/23/25 at 11:59 AM, V1/Administrator stated, (R2) was in his room in bed yelling for staff and (R1) went to (R2's) room to tell (R2) hush and swatted at (R2). (R1) swatted at (R2) more than once. V1 was asked if physical contact was made and V1 stated, Yes. On 4/24/25 at 11:20 AM, R2 stated, I had my call light on, but staff…

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 residents consumed their medications for five residents (R1, R2, R3, R5 and R7) and the facility failed to have a physician's order for medication administered for one resident (R7) of 8 residents reviewed for medication administration. Findings Include: The Facility's Medication Administration policy dated 12/16/24 documents, Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a until dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. The Facility's Medication Administration policy documents, Observe the resident consume the medication to insure resident swallows medication. Never leave prepared…

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

Based on observation, interview and record review the facility failed to properly store medications for 2 residents (R6 and R8) of seven residents reviewed for medication pass in a total sample of 8. Findings Include: The Facility's Procurement and Storage of Medication policy reviewed 12/16/24 documents, All medications, except those requiring refrigeration, shall be kept in the locked medicine room or locked medication cart. On 4/2/25 at 10:05 AM there were two albuterol inhalers each with over 100 doses left on R6's bedside table. The inhalers did not have any label on them with name or date dispensed. There was no one in the room. On 4/2/25 at 10:10 AM V5 (Licensed Practical Nurse) confirmed there were two albuterol inhalers on R6's bedside table. V5 stated R6 did not have an order for the albuterol inhaler. V5 stated, (R6) used to have an order for the inhalers. I don't know why he has some in his room, he shouldn't. On 4/2/25 at 10:15 AM there was a Combivent Inhaler on R8's bedside table. There was no one in the room. The inhaler had R8's name and dispensing information from…

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 one resident (R1) was free from misappropriation of funds of three residents reviewed for abuse. Findings Include: The Facility's Abuse Prevention Program dated 11/28/2016 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. The Facility's Abuse Prevention Program also defines Misappropriation of resident property means the deliberate misplacement,…

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 complete physician ordered wound treatments daily for one of three residents (R1) reviewed for Wound Care in the sample of three. Finding Include: The facility's Health Care Decubitus Care/Pressure Areas policy, dated 1/2018, documents, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. Complete all areas of the Treatment Administration Record or Wound Documentation Record. Initiate physician order on the treatment sheet. Documentation of the pressure area must occur upon identification and at least once each week on the TAR (Treatment Administration Record) or Wound Documentation Form. On 11/4/2024, at 11:28 AM, R1 had a surgical wound to left stump that was red where sutures were, with minimal swelling. Wound was 3cm in length, 2cm in width, and was 1.2cm deep. Wound was bleeding and had blood dripping on the floor. R1 stated that the wound was sensitive to touch, and hurts when it is touched,…

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 Enhanced barrier precautions while performing wound care and follow hand hygiene for one of three residents (R1) reviewed for Wound Care, and Infection Control in a sample of three. Findings include: The Facility's Enhanced Barrier Precautions Policy, dated 7/13/23, documents, Enhance Barrier Precautions (EBP) should be used when contact precautions do not apply, for residents with any of the following: Open wounds that require a dressing change. Enhance Barrier Precautions require use of a gown and gloves during high-contact resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing. EBP is primarily intended to use for care that occurs within a resident's room, when high-contact resident care activities are bundled together. Outside of a resident's room, EBP should be followed when performing transfers in the shower/assisting with shower and when assisting a resident with toileting in common restrooms. High contact care activities include: Wound 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 observation, record review and interview the facility failed to ensure enhanced barrier precautions and/or contact precautions were in place for six (R5, R8, R13, R16, R38, R43) of six residents reviewed for Infection Control) in the sample of 37. This failure has the potential to affect all 90 residents who currently reside in the facility. Findings include: Facility Contact Precaution policy reviewed on 04/03/23 documents, In addition to Standard Precautions, use Contact Precautions or the equivalent for specified residents known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident (hand or skin to skin contact that occurs when performing resident care activities that require touching the residents dry skin) or indirect contact (touching with environmental surfaces or resident care items in the residents environment). This policy also documents gowns and gloves should be used when entering resident rooms. Enhanced Barrier Precautions policy dated 07/13/23 documents, Purpose: To…

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

Based on record review and interview the facility failed to monitor active infections in the facility and failed to implement their Antibiotic Stewardship Program. These failures have the potential to affect all 90 residents who currently reside in the facility. Findings include: Facility Antibiotic Stewardship Program dated 11/1/17 documents, Purpose: To improve the use of antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. Infection Control Surveillance and Monitoring policy last reviewed by the facility on 12/7/18 documents, It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with work practices and care of protective clothing and equipment is maintained. Procedure: Monitoring the effectiveness of the facility work practices and protective equipment will be conducted by the Administrator, ICP (Intervention Control…

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 issue a written Notification of Hospital Transfer upon Discharge for four (R38, R41, R51 and R61) of four Residents reviewed for hospitalization in the sample of 37. Findings include: 1.R51's Census List, dated 8/6/24, documents R51's Hospital Unpaid Leave dates of 4/13/24, 5/14/24, 5/18/24, 5/29/24 and 6/8/24. 2. The local hospital record for R38, document R38 was admitted to the local hospital on 6/4/24 through 6/8/24. The Dietary Progress Note for R38, dated 6/8/24, documents R38 returned to the facility after hospitalization. On 8/7/24 at 12:20 pm, V3 ADON (Assistant Director of Nursing) confirmed R38 had a hospital stay, however, there are no Nursing Progress Notes documenting R38 had a hospitalization. 3. On 8/5/24 at 8:25 am, R41 stated he has been in and out of the hospital since his admission to the facility, always comes back, and does not have any complaints. The medical record for R41, documents R41 was sent to the local hospital on 1/8/24, 1/12/24, 3/13/24, 3/30/24, 6/11/24, and 7/30/24. R41 came back and does…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop a comprehensive person-centered care plan for eight of 19 residents (R16, R17, R21, R28, R33, R41, R43, R63) reviewed for care plans in the sample of 36. Findings include: The facility's Comprehensive Care Planning policy, revised 7/20/22, documents, It is the policy of (Name of Facility Organization) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being .The following procedures shall be utilized in the development and maintenance of care plans: 3.) Components of the CPC (Comprehensive Plan of Care) may include:…

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 physician orders were obtained, oxygen tubing and humidifier bottles were changed routinely and dated, oxygen signs were posted, and oxygen cylinders were stored safely for seven (R17, R28, R33, R38, R41, R48, R51) of seven residents reviewed for oxygen in a sample of 37. Findings include: The facility's Oxygen Storage and Assembly policy, revised 01/02, documents, Policy: To properly store and assemble oxygen tanks and accessories in a safe and correct manner. This policy also states Safety and Storage of Oxygen Tanks: 1. Store tanks in a cool place away from a source of heat. 2. A chain, on a care or on a stand must secure tanks .5. Post oxygen safety warning sign outside the room where oxygen is stored or is in use. The facility's Oxygen Therapy policy, revised 8/03, documents, Note: Oxygen therapy may be used provided there is a written order by the physician. The order must state liter flow per minute, mask or cannula, time frame. On an emergency basis, oxygen may be administered until the…

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

Based on observation, interview and record review, the facility failed to ensure resident Minimum Data Set/MDS Resident Assessments were completed correctly for two (R16 and R17) of two residents in a sample of 37. Findings include: The facility's Comprehensive Care Planning policy, revised 7/20/22, documents, It is the policy of (named facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being. The Resident Assessment (RAI) shall be the guide utilized for all comprehensive assessments, care area assessments and care planning. 1. On 8/4/24, at 10:40am, R17 was in her room with oxygen infusing per nasal cannula. R17's Minimum Data Set/MDS assessments, dated…

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 a PASRR (Preadmission Screening and Resident Review) Level II screening for mental disorder was completed for one (R66) of one resident reviewed for PASRRs in a sample of 37. Findings include: R66's current Face sheet documents an admission date of 5/8/23. R66's Physician Order Sheet/POS, dated 5/8/23, documents diagnoses (including but not limited to) schizoaffective disorder. R66's Notice of PASRR (Preadmission Screening and Resident Review) Level I Screen Outcome, dated 5/1/23, documents PASRR Level I Determination: No Level II Required - Situational Symptoms and Your Level I screen shows low-level behavioral health symptoms which appear to be situational. The nursing facility will watch your symptoms/behaviors to see if they improve or resolve within 30-60 days of this screen. If they do not, a nursing facility staff member must submit another Level I screen to maximus. This is called a status change. The status change will decide if you need a PASRR Level II evaluation for serious mental illness. This screening…

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 resident Baseline Care plan includes oxygen for one (R28) of 19 residents reviewed for Care plans in a sample of 37. Findings include: The facility's Care Plan policy, revised 1/11/23, documents, Purpose: To provide guidance to the facility in developing, implementation and communicating the individualized plan of care of residents.' On 8/4/24, at 6:25 am, R28 was in her room with oxygen infusing per nasal cannula. R28's Nurse's Note, dated 6/26/24, documents R28 arrived at the facility for admission with nasal oxygen via concentrator. R28's current Baseline Care plan does not document oxygen or any cares for oxygen. On 8/07/24, at 1:30pm, V23 Care Plan Coordinator confirmed that R28's Baseline care plan does not have oxygen on it. V23 stated, There is no place to mark it on the sheet. It should have been written in. V23 confirmed at this time that R28 was admitted to the facility with oxygen.

Based on observation, interview, and record review the facility failed to revise resident Care Plans to reflect resident condition for three (R38, R41, and R43) of 19 residents reviewed for Care Planning in the sample of 37. Findings include: The facility's Comprehensive Care Planning policy and procedure, revised 7/20/22, documents It is the policy of (the facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The CCP (Comprehensive Care Plan) shall be reviewed after each Annual, Significant Change and Quarterly MDS (Minimum Data Set) and revised as necessary to reflect the resident's current medical, nursing, and mental and psychosocial needs as identified by the IDT (Interdisciplinary Team). The Care Plan shall be revised as necessary when the needs/problems and care and services specified in the plan of care no longer reflect those of the Resident. The facility's Resident Weight Monitoring policy and procedure, revised 3/19, documents Significant changes in weights are documented in the care plan with goals 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 assess and monitor pressure ulcers weekly and failed to perform hand hygiene in between glove changes for one (R16) of four residents reviewed for pressure ulcers in the sample of 37. Findings include: The facility's Decubitus Care/Pressure Areas policy and procedure, revised 1/18, documents, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. Documentation of the pressure area must occur upon identification and at least once each week on the TAR (treatment administration record) or Wound Documentation Form. The facility's Hand Hygiene policy and procedure, updated 8/14/23, documents, All staff will comply with current CDC (Centers for Disease Control and Prevention) hand hygiene guidelines to reduce the incidence of healthcare associated infections. This policy documents hand washing should occur when hands are visibly soiled or contaminated with blood or other body fluids. After contact with…

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

Based on observation, interview, and record review the facility failed to investigate a resident fall and conduct a root cause analysis for one (R48) of two residents reviewed for falls in the sample of 37. Findings include: The facility's Accidents and Incidents policy and procedure, revised 9/6/23, documents, All accidents/incidents involving a resident shall require an incident report. The interdisciplinary team (IDT) will complete an investigation to determine root cause and implement appropriate interventions. It is the responsibility of the DON (Director of Nursing)/Designee to investigate and ensure appropriate completion, notification, and follow-up on all accidents and incidents. The Fall Risk Assessment for R48, dated 6/11/24 and 7/3/24 document R48 with a total score of 21 indicating R48 is a High risk for fall. A Quality Care Reporting Form for R48, dated 7/11/24 at 4:10 am, documents a CNA reported R48 had an alleged fall. This Form does not include any other fall details for R48's alleged fall. The Physician Progress Notes for R48, dated 6/14/24 and 7/30/24 do not…

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

Based on observation, interview, and record review the facility failed to ensure Registered Dietician recommendations were communicated to the Physician and failed to document daily weights on the Medication Administration Records for two (R41 and R48) of five residents reviewed for nutrition in the sample of 37. Findings include: The facility's Resident Weight Monitoring policy and procedure, revised 3/19, documents, It is the policy of (the facility) that resident weights are recorded and monitored at least monthly. Monthly weights are obtained by CNA's (Certified Nursing Assistants) or designated staff by the 5th of the month. Monthly weights are entered in the computer in batch by the Dietary Manager, Care Plan Coordinator, or designee. The Food Service Manager and interdisciplinary team review the resident's weights and nutritional status and make recommendations for intervention. The Dietitian shall review and document all significant weight changes along with any recommended nutritional interventions in the dietary progress notes in the medical record monthly. Nursing…

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

Based on observation, interview, and record review the facility failed to provide gastrostomy feeding per order and provide gastrostomy tube care for one (R43) of two residents reviewed for enteral feedings in the sample of 37. Findings include: The facility's Enteral Feeding policy and procedure, revised 2/08, documents, It is the policy of (the facility) to provide nutrition via Nasogastric or Gastrostomy tubes when ordered by physician. The resident may receive nutrition and hydration either by intermittent, continuous, or bolus feeding into the stomach by means of a tube when the oral route cannot be used. On 8/4/24 at 1:57 pm, An enteral feeding pump was resting in front of R43's bathroom door without a bottle hanging and not running. When writer asked R43 if she had a gastrostomy feeding tube, R43 raised her shirt to reveal a gastrostomy tube in her abdomen. The dressing covering R43's gastrostomy tube was undated and soiled a light tan at the split of the dressing. On this same date and time R43 stated she cannot remember when the dressing was changed last and stated 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 interview and record review, the facility failed to ensure medications were not left at residents' bedside for one (R17) of 19 residents reviewed for medication storage in a sample of 37. Findings include: The facility's Medication Administration policy, revised 11/18/17, documents, 14. Observe the resident consume the medication to insure resident swallows medication. Never leave prepared medications unattended. No medications should be left at bedside unless specifically ordered by the physician and then only in limited amounts as described by the physician. On 8/4/24, at 10:40 am, R17 was lying in bed with R17's pharmacy labeled Stiolto Inhaler and Ipratropium Nasal 0.06% spray resting on overbed table. At this time R17 stated, I can do my own inhalers. They just leave them here for me. R17's August 2024 POS/Physician Order Sheet documents orders for Ipratropium 0.06% Nasal for Atrovent Nasal Spray and Stiolto 2.5-2.5mcg/act (micrograms/activation) inhaler. R17's August 2024 POS/Physician Order Sheet does not include any order that allows R17 to keep any medications at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a comprehensive person-centered Care Plan for one (R1) of four residents reviewed for Care Plans in a sample of four. Findings include: Facility Elopement Prevention Policy, revised 10/2006, documents: the Interdisciplinary Team/IDT will initiate a plan of care for any Resident determined high risk for elopement and specific measures will be included in each high risk Resident's plan of care to minimize risk factors and communication of these interventions will be made to direct care staff through exposure to the Resident's plan of care and periodic review; the plan of care for minimizing elopement risks will be reviewed each time the Risk Assessment is completed with initials and dating of the care plan by any member of the IDT present for review. Facility Care Plan Policy, revised 7/20/22, documents: it is the policy of the Facility to comprehensively assess and periodically reassess each Resident admitted to the Facility; the results of the…

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

Based on record review and interview the facility failed to follow their Abuse Prevention policy to perform a health care worker background check and failed to obtain a fingerprint based criminal history check of an employed unlicensed dietary aide with two disqualifying criminal offenses. These failures have the potential to affect all 89 residents residing within the facility. Findings include: The facility's Resident Directory dated 4-5-24 documents the facility's resident census as 89 residents currently residing within the facility. The facility's Abuse Prevention Program policy dated 11-28-26 documents, Pre-Employment Screening of Potential Employees. This facility will not knowingly employ any staff convicted of any of the crimes listed in the Illinois Healthcare Worker Background Check Act (unless waivered under the provision of the act), or with findings of abuse listed on the Illinois Health Care Worker Registry. Prior to a new employee starting a work schedule the facility will under the Health Care Worker Background Check Act and facility Criminal Background Check…

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 that its medication cart was locked at all times when not in view, and failed to ensure Schedule II meds were double locked in the Medication Cart when the cart was not in view, per facility policy. This failure has the potential to affect five residents (R11, R12, R13, R14, and R15) of five residents reviewed for Pharmaceutical Services. Findings include: Procurement and Storage of Medications Policy darted 11/6/18, documents: 8. All medications, except those requiring refrigeration, shall be kept in the locked medicine room or locked medication cart. 10. Schedule II drugs are to be stored under double-lock subject to different key. Controlled Substances Policy dated 11/6/18 documents: Policy: It is the policy of the facility that all drugs listed as schedule II drugs are subject to specified handling, storage, disposal and record keeping. 1. Schedule II drugs are to be kept under two separate locks requiring two separate keys. A permanently affixed locked cabinet within the locked medication cart may…

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, record review, and interview the facility failed to ensure residents were showered twice weekly per their plan of care and their preferences for three of three residents (R1, R2, R3) reviewed for Activities of Daily Living in the sample of three residents. 1. R1's Baseline Care Plan documents R1 was admitted to the facility on [DATE], is dependent on two staff for bathing, and dependent on one staff for grooming. The facility's Shower Log and R1's Shower/Abnormal Skin Reports dated 11-10-23 (Admission) through 11-28-23 document R1 has only had two baths/showers since R1's admission on [DATE] and document R1 has had no bath or shower since 11-17-23. On 11-28-23 at 8:45 AM R1 was lying in bed. R1's face had a dried crusty substance around his mouth and R1's hair was unkempt. R1's beard and mustache were grown out approximately a half an inch long. R1 stated, I have only had one shower since I have been here. I like to have a bath or shower at least three times a week and I like to be clean…

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

Based on interview and record review, the facility failed to provide the services of a registered nurse (RN) for eight hours in a 24-hour period, seven days a week. This failure has the potential to affect all 81 residents residing in the facility. Findings Include: Facility Facility Assessment Tool, revised 8/15/23 documents the average daily census is 70-80 residents. Staffing Plan: The facility's plan to ensure sufficient staff to meet the needs of the residents at any given time is based on the staffing calculator, which takes into consideration the facility census and acuity levels impacting staffing needs. Review expectations for minimum staffing requirements at the federal and state level. Federal law requires nursing homes to have sufficient staff to meet the needs of residents, to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. Facility Nurse Staffing undated documents, It is the policy to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical,…

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 employ a qualified Social Service Director. This has the potential to affect all 81 residents residing in the facility. Findings include: The Facility Assessment Tool dated 8/15/23 documents the facility is licensed for 202 residents and documents that the facility provides services to patients having a variety of mental health illnesses as well as medical needs. The facility's Social Service Director Job Summary, undated, states, Job Summary: Assist in planning, developing, organizing, implementing, and directing social service programs in accordance with current existing federal, state, and local standards as well as our established policies and procedures in order to ensure that the medically related emotional and social needs of the resident are met and maintained on an individual basis. This same Job Summary documents general job duties: f. Evaluate social and family information and assist in determining plan for social treatment; g. Work with emotional problems including assisting resident/family with anxieties and…

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

Based on interview and record review the Facility failed to ensure that the designated Medical Director, designated Director of Nursing and designated Infection Preventionist was present at the Facility's Quality Assurance Meetings. This failure has the potential to affect all 81 Resident's residing in the Facility. Findings include: Facility Quality Assurance/QA Plan, undated, documents to continually improve the way Residents are cared for, safety and operations within the facility through the Quality Assurance process, Quality Assurance activities are to be completed continuously and objectively to provide a comprehensive review of the facility's activities; that the Facility will conduct a quarterly meeting (at the minimum); the Quality Assurance Committee reviews all the activities of daily Quality Assurance Team; and the Quality Assurance Committee will review patterns or trends, areas identified for improvement and make recommendations as needed. Facility's Resident Census and Condition Report, dated 9/18/23, documents 81 Residents residing in the Facility. The Facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to thoroughly monitor active infections in the facility and failed to implement their Antibiotic Stewardship Program. These failures have the potential to affect all 81 residents who currently reside in the facility. Findings Include: The Facility's Antibiotic Stewardship Program dated 3/20/23 documents the purpose of the program is, To improve the use of Antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This will be accomplished utilizing the Core Elements. Tracking: Monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use. The Facility's Infection Control Surveillance and Monitoring Policy dated 12/7/18 documents the Director of Nursing updates the Infection Control Log on a daily basis in order to analyze data 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 develop a Comprehensive Care Plan for Hospice services for two residents (R36 and R52); Care Plan for PTSD (Post Traumatic Stress Disorder) for one resident (R64) and Care Plan for smoking, weight loss, and risk for urinary tract infection for one resident (R131) of 20 residents reviewed for care planning in the sample of 39. Findings include: The facility's Comprehensive Care Planning policy and procedure, revised 7/20/22, documents It is the policy of (the facility) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. The Comprehensive Care Plan (CCP) shall be developed within 7 days of…

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

Based on interview and record review the facility failed to revise resident care plans for five (R8, R36, R52, R54, R64) of 20 residents reviewed for care planning in the sample of 39. Findings include: The facility's Comprehensive Care Planning policy and procedure, revised 7/20/22, documents, It is the policy of (the facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. It is to be noted that the Care Plan is for planning care and services. The CCP (Comprehensive Care Plan) shall be reviewed after each Annual, Significant Change and Quarterly MDS (minimum data set) and revised as necessary to reflect the resident's current medical, nursing, and mental and psychosocial needs as identified by the IDT (Interdisciplinary Team). The Care Plan shall be revised as necessary when the needs/problems and care and services specified in the plan of care no longer reflect those of the Resident. On 9/20/23 at 8:50 am, V4 CPC (Care Plan Coordinator) stated the Nurses and Management staff are responsible to update the resident Care Plans for 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 record review and interview the facility failed to offer and/or administer Influenza and Pneumonia Vaccinations for four residents (R12, R44, R49 and R77) of five reviewed for immunizations in a total sample of 39. Findings Include: The Facility's Immunization of Residents dated 5/19/23 documents (This Facility) will offer immunizations and vaccinations that aid in the prevention of infectious diseases unless medically contraindicated or otherwise ordered by the resident's attending physician or the facility's medical director. Assess all newly admitted residents' pneumococcal and influenza vaccination status upon admission and record last known immunization on the resident's Immunization Record. Offer the Pneumococcal vaccination within 30 days of admission. Offer the influenza immunization annually from September 1st through March 31st. R12's Immunization Record has no information under Influenza or Pneumococcal Vaccination. R44's Immunization Record has no information under Influenza or Pneumococcal Vaccination. R49's Immunization Record has no information under…

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

Based on observation, interview and record review the facility failed to monitor unwitnessed fall injuries and initiate fall interventions (R64) and assess for Smoking Safety and Smoking assistance (R131) for two of six residents reviewed for accidents in a sample of 39. Findings include: 1. Facility Fall Prevention Policy, revised 11/10/18, documents: to provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility; immediately after any resident fall the Unit Nurse will assess the Resident and provide any care or treatment needed for the resident; a fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions; the Unit Nurse will place documentation of the circumstances of a fall in the Nurses Notes or on an AIM for Wellness form along with any new intervention deemed to be appropriate at the time. Facility Skin Condition Policy, revised 1/2018, documents: It is the policy of the Facility to provide proper…

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 perform hand hygiene and put on Personal Protective Equipment upon entering an Enhanced Barrier Precautions room of residents with suprapubic indwelling urinary catheters for two residents (R26 and R33) of six residents reviewed for indwelling urinary catheters in a sample of 39. Findings include: The Facility's Enhanced Barrier Precautions Policy dated 7/13/23 documents: the purpose is to reduce transmission of Multidrug-Resistant Organisms/MDRO. Enhance Barrier Precautions/EBP should be used when contact precautions do not apply, for residents with any of the following: Indwelling Medical Devices and Infection or Colonized with a MDRO; EBP requires the use of a gown and gloves during high-contact resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing; EBP is primarily intended to use for care that occur within a resident's room; this same Policy documents high-contact care activities that include caring for medical devices such as urinary catheters; the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow their Resident Weight Monitoring policy and procedure for two (R54 and R131) of seven residents reviewed for nutrition in the sample of 39. Findings include: The facility's Resident Weight Monitoring policy and procedure, revised 3/2019, documents It is the policy of (the facility) that resident weights are recorded and monitored at least monthly. Procedure: 1. New admission weight is obtained within 24 hours of admit and on the following two consecutive days after admission by CNA (Certified Nursing Assistant) as directed by nurse 3. Monthly weights are entered in the computer in batch by the Dietary Manager, Care Plan Coordinator, or designee . 5. If the monthly weight shows a significant change in 30 days (i.e 5. % +/-) the resident will be re-weighed. Re-weights are done by CNA or designated staff. Re-weights are again reviewed, and entered in the computer by the Dietary Manager, Care Plan coordinator or designee. 6. Monthly…

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 resident for Post Traumatic Stress disorder/PTSD for one of two residents (R50) reviewed for PTSD in a sample of 39. Findings Include: The Facility's Trauma Informed Care Policy dated 8/23/23 documents the purpose of the policy is to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Upon admission the Social Service Director will review hospital discharge records and interview the resident or the resident's representative to determine any history of trauma. The Social Service Director will complete a Trauma Informed Care Screen to evaluate for any history of a traumatic experience that a resident may have had. The Facility's Trauma Informed Care Policy dated 8/23/23 documents, Residents will be assessed for any history of trauma annually, quarterly and with a…

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

Based on observation, interview and record review the facility failed to administer medications to one resident at a time for three residents (R17, R36, R61) of 19 residents reviewed for medications in the sample of 39. The Facility's Medication Administration Policy dated 11/18/17 documents, Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an unauthorized person in accordance with all laws and regulations governing such acts. The complete act of administrations entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container) verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. On 9/19/23 at 12:30 PM V6 (Licensed Practical Nurse/LPN) was walking in the dining room with three clear medicine cups stacked on each other in one hand. None of the clear cups in V6's hand were labeled in any way as to which medicine cup belonged to which resident. V6 stated she…

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 address Medication Reconciliation Reports for two residents (R12 and R49) of five residents reviewed for medication review in a total sample of 39. Findings Include: The Facility's Consultant Reports policy dated 1/6/10 documents, It is the policy of (this facility) that any consultant reports with irregularities be reported to the resident's attending Physician and Director of Nursing and the report must be acted upon. The resident's attending Physician will review the consultant reports for acceptance or rejection and check the form accordingly. 1. R12's Consultation Report dated 6/8/23-6/9/223 documents, (R12) receives dual antiplatelet therapy with Aspirin Low Dose and Clopidogrel and does not have a CBC (Complete Blood Count) documented in the medical record within the previous 6 months. Recommendation: Please monitor a CBC on the next convenient lab day and every 6 months thereafter. Consider routine fecal occult blood tests, if clinical indicated (e.g., every 6 months for those at high risk for GI (Gastrointestinal)…

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 target behaviors for use of psychotropic medications for three residents (R12, R50 and R54) and failed to determine the origin of a psychosis diagnosis for one resident (R54) of five residents reviewed for mood and behavior in a total sample of 39. Findings Include: The Facility's Psychotropic Medication Policy documents It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drug is any drug used: 1. in an excessive dose, including in duplicative therapy 2. For excessive duration 3. Without adequate monitoring 4. Without adequate indications for its use 5. In the presence of adverse consequences that indicate the drugs should be reduced or discontinued. That these medications be withheld if the resident is lethargic and/or exhibiting signs of over sedation and the physician will be contacted if these conditions persist. These medications will not be given solely for staff convenience, This same policy also documents any resident receiving such medications shall have a…

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

Based on interview and record review the facility failed to ensure resident's complete/accurate medical records and thinned records were easily assessable for two (R26, R54) of two residents reviewed for medical records in the sample of 39. Findings include: The facility's undated Thinning Current Resident Records policy and procedure, documents, Information contained in the medical records of current residents will be thinned regularly. Once the information is removed, it will be filed chronologically in a 'thinned' folder or envelope. All information will be maintained in such a manner that it is easily accessible upon request from properly authorized persons such as nursing staff or surveyors. Information which must remain in the record and is never thinned. 1. admission record/admission transfer form. 2. Physician admission orders. 3. Original assessments by all disciplines. 4. Nursing admission assessment and nursing note. 5. History and physical examination. The facility's undated, Schedule for Thinning policy, documents, History and Physical is never removed, MD (Medical…

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 a written reason for residents' transfers to the hospital for evaluation and treatment to residents' representatives. This has the potential to affect all 82 residents who reside in the facility. Findings include: On 8/15/23 at 12:03 PM, V1 (Administrator in Training) stated written reasons for residents' transfers to the hospital are not provided to resident representatives. V1 stated resident representatives are only notified verbally. V1 stated, It is not a requirement that we do (notify resident representatives in writing). 1. R1's Profile Face Sheet documents V7 as R1's Family Member/Power of Attorney/POA. R1's current Power of Attorney for Health Care documents V7 as R1's POA. R1's Nursing Note on 6/18/23 (no time) documents R1 was sent to the local area hospital due to a change in condition. R1 is documented as not responding to questions, staring when questions are asked, jittery and lips quivering. R1's Nursing Note on 7/15/23 (no time) documents R1 was sent to the local area hospital due to altered mental…

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

Based on interview and record review the facility failed to provide the services of a registered nurse eight hours a day, seven days a week. This failure has the potential to affect all 82 residents residing in the facility. Findings include: The Facility's Facility Assessment Tool reviewed 8/15/23 documents the facility with an average daily census of 70-80 residents. This same Facility Assessment states, Federal law requires nursing homes to have sufficient staff to meet the needs of residents, to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week. The facility's Nurse Staffing Policy reviewed 12/7/17 documents the facility will provide sufficient licensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. The facility's Nurse's Daily Assignment Sheets document the facility did not have eight consecutive hours of registered nurse (RN) coverage in the building to provide services on the following dates: 7/1/23; 7/4/23; 7/8/23; 8/5/23;…

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 ensure contact isolation precautions were initiated for one of four residents (R4) reviewed for change in condition in the sample of four. This failure has the potential to affect all 82 residents who currently reside in the facility. Findings include: The facility's Contact Precautions Policy reviewed 4/3/23 states, In addition to Standard Precautions, use Contact Precautions, or the equivalent for specified residents known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident (hand or skin to skin contact that occurs when performing resident care activities that require touching the residents dry skin) or indirect contact (touching with environmental surfaces or resident care items in the residents environment). This same policy documents gown and gloves will be worn when entering the resident's room. The CDC (Centers for Disease Control and Prevention) Guideline for Isolation Precautions: Preventing Transmission of…

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

Based on interview and record review, the facility failed to follow facility policies to monitor antibiotic use to ensure proper antibiotic prescription and to identify antibiotic use trends to improve resident outcomes and reduce antibiotic resistance. This has the potential to affect all 82 residents in facility. Findings include: The facility's Assessment of Infections and Antimicrobial Usage Policy reviewed 3/20/23 states, Assessing antimicrobial use is essential for determining antimicrobial use trends. Antimicrobial use should be reviewed regularly to measure progress of antimicrobial stewardship activities. After completing the review, the facility should be able to describe who is getting antibiotics and why. Additionally, the results are useful to identify gaps in communication, inconsistencies in documentation, and compliance with facility policies and evidence-based recommendation for antimicrobial prescribing. The policy further documents, Assessment: 1. Obtain the list of antimicrobials monthly. 2. For the first antibiotic on the list note the resident name, date of the…

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

Based on interview and record review, the facility failed to designate a trained Infection Control Preventionist (ICP). This failure has the potential to affect all 82 residents who currently reside in the facility. Findings Include: The facility's Infection Control Surveillance and Monitoring Policy, revised 4/11/22, states, It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with infection control practices is maintained. The facility shall employ, at a minimum, a part time Infection Control Preventionist (ICP). These duties may be performed by the Director of Nursing (DON) with an approved Infection Control Certification. This same policy documents that the DON/ICP will: Investigate and implement controls to prevent infections in the facility; Direct the correct procedures to prevent the spread of infections; Follows up on documentation and reporting of infections to the physicians; Maintains programs that prohibits employees with communicable diseases from direct resident contact; Maintains and enforces hand…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a resident's Power of Attorney/Representative of a resident room change and of transfers to the hospital after a change in condition for two of four residents (R1 and R2) reviewed for notification of change in the sample of four. Findings include: The facility's Room Move Policy revised 9/17/18 states, It is the policy of (name of facility Corporation) to notify a resident, resident's roommate/s, and resident representative of any room move with as much advance notice as the situation allows. The residents, the resident's representative and the roommate/s have the right to know why the move is being made. The facility will take the residents preferences into account when those moves are made. Procedure: 1. With as much advanced notice as possible, notify the resident, resident representative, and the roommate of any impending room moves. 2. Fill out the Resident Notification of Room/Roommate Change form and have the resident/responsible party…

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 a plan of care for a resident's Anticoagulant Use, Oxygen Use, and Enhanced Barrier Precautions for one of four residents (R1) reviewed for change in condition in the sample of four. Findings include: The facility's Comprehensive Care Planning policy, dated 7/20/22, documents It is the policy of (name of facility company) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining resident strengths, needs, goals, life history and preferences to develop a comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. Comprehensive Care Plans shall strive to describe: b. The resident's medical, nursing, physical, mental and psychosocial needs and preferences. c. Person centered measurable objectives and timeframe's for ease of evaluating resident…

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 revise a resident's care plan for one of four residents (R4) reviewed for change in condition in the sample of four. Findings include: The facility's Comprehensive Care Planning Policy, revised 7/20/22, documents the Comprehensive Care Plan shall be revised as necessary to reflect the resident's current medical, nursing, mental and psychosocial needs. R4's Current Care Plan documents R4 with altered elimination initiated on 11/21/22 with a goal to be free from infection for 90 days initiated on 2/19/23. R4's Urine Culture result reported on 7/28/23 documents a result of Escherichia coli ESBL (Extended Spectrum Beta-Lactamase). This same culture result states, Confirmed ESBL producing organism. R4's Physician Order Sheet/POS dated 7/01/23-7/31/23 documents orders on 7/30/23 to send R4 to the ER/emergency room for placement of a PICC/Peripherally Inserted Central Catheter Line related to urinalysis culture and sensitivity results and for a Urology Consult. R4's After Visit Summary/AVS from the local area hospital on 7/30/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to notify a resident's physician of a resident's continued complaints of pain with urination after completion of oral antibiotics for a urinary tract infection (R4), failed to ensure physician orders for a PICC (Peripherally Inserted Central Catheter) Line and Urology Consult were completed timely (R4) and failed to ensure enhanced barrier precautions were maintained for a resident with an indwelling urinary catheter during catheter care (R1) for two of four residents (R1 and R4) reviewed for change in condition in the sample of four. Findings include: 1. The facility's Notification for Change in Resident Condition or Status Policy, revised 12/7/17 documents the facility and/or facility staff shall promptly notify appropriate individuals, including the physician of changes in the resident's medical/mental condition and/or status. This same policy states, Procedure: The nurse supervisor/charge nurse will notify the resident's attending…

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

Based on interview and record review, the facility failed to ensure resident laboratory result values were reported to the physician in a timely manner for two of four residents (R1 and R3) reviewed for notification of change in laboratory results in the sample of four. Findings include: The facility's Notification for Change in Resident Condition or Status Policy revised 12/7/17 documents the facility and/or facility staff shall promptly notify appropriate individuals, including the physician of changes in the resident's medical/mental condition and/or status. This same policy states, Procedure: The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: m. Abnormal lab findings. 3. Except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status. The facility's Laboratory Tests Policy reviewed 9/27/17 states, Appropriate laboratory monitoring of disease processes and medications require consideration of many factors including…

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 perform a pressure ulcer wound treatment as ordered for one of two residents (R12) reviewed for pressure ulcers in a sample of 33. Findings Include: The facility policy titled Skin Condition Monitoring, dated 1/2018, documents It is the policy of this facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. On 10/4/2022 at 10:47 AM V7/LPN (Licensed Practical Nurse) performed wound care on (R12) coccyx area. Cleansed area with a wound cleanser, area was patted dry, and Alginate Calcium with Silver (topical wound dressing) with a secondary dressing of gauze island border was applied. Wound size measured approximately 1.5 cm x 0.5 cm (centimeters) with yellow - tannish dead tissue in the wound bed. Peri-wound is red. (R12) Wound Evaluation and Management Summary, dated 10/4/2022, documents, (R12) has a stage 4 pressure wound on coccyx for at least 53 days duration. There is moderate serosanguinous exudate. (R12) TAR (Treatment Administration Record), dated…

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 justify duplicative antipsychotic therapy of three antipsychotics, failed to obtain a physician ordered psychiatric evaluation and failed to document a clinically indicated diagnosis and adverse behaviors to warrant the use of an antipsychotic for two of three residents (R15, R27) reviewed for antipsychotic medications in the sample of 33. Findings include: 1. The facility's Psychotropic Medication policy, dated 6/17/22, documents, It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drug is any drug used: In an excessive dose, including duplicative therapy and without adequate indications for its use. These medications will not be given solely for staff convenience. Definition of duplicative drug therapy: Any drug therapy that duplicates a particular drug effect on the resident without any demonstrative therapeutic benefit. For example, any two or more drugs, whether from the same drug category or not, that have a sedative effect. This policy also documents 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.