Accolade Healthcare Of Peoria

Based on observation, interview, and record review, the facility failed to ensure medications were not left at a resident's bedside for one of 24 residents (R40) reviewed for medication storage in the sample of 59. Findings Include: The Facility's Administration of Medications policy dated 8/2023 documents Residents shall receive their medications on a timely basis in accordance with state and federal guidelines and within established facility policies. Self-administration of medications is permitted when approved by the interdisciplinary team, with a written order from the primary attending physician. On 9/6/24 at 9:30 AM, R40 was lying in bed with R40's bedside table over his bed. A clear medicine cup containing 11 pills was noted on R40's bedside table. The medication cup had been tipped over with approximately half of the pills spilled out onto the table. R40 stated, This is what some of the nurses do. R40 was not able to name his medicine or state which pill was what. R40's Medical Record did not contain any assessments or physician orders for self-administration 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 observation, record review and interview, it was determined the facility failed to ensure call lights were answered in a timely manner and responded to accommodate the residents needs for 2 of 2 residents (R3, R4) with mobility restrictions observed for call light accessibility. Findings include: On 4/24/24, R3 was admitted to the facility for rehabilitation services status post lumbar fusion surgery. On 4/24/24, R3's Care plan indicates limited physical mobility related to surgical aftercare and spinal stenosis. On 5/6/24 at 12:10 PM, R3 was observed sitting in a wheelchair with Spine brace on; R3 had a hand over forehead, head down and grimacing; pulling and moving brace around and complained of pain. R3 stated We (R3 and R5 (R3's roommate) put the call light on twice. They (Certified Nurse Aides/CNA) said they would be back. At 1:04 PM, R3 was sitting in wheelchair with a back brace on R5 stated I put on the call light. They had to go find a mechanical lift. At 3:08 PM, R3 stated I'm still waiting for the gals to come put me on my side. I've been on my back since I got…

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 call lights were available for resident use for 1 of 2 residents (R3) reviewed with mobility restrictions observed for call lights. Findings include: The Daily Care policy, dated 8/2/17, documented the guidelines and procedures for daily cares to all residents. The policy documented to Place call light within reach. On 4/24/24, R3 was admitted to the facility for rehabilitation services status post lumbar fusion surgery. On 4/24/24, R3's Care plan indicated limited physical mobility related to surgical aftercare and spinal stenosis. On 4/24/24, The Physical Therapy and Occupational Therapy Evaluation and Plan of Treatment documented Precaution Details: Spine Brace to be worn while patient is up doing transfers and/or ambulating. Does not need to be worn while in bed or chair. SPINAL PRECAUTIONS- NO BLT (NO BENDING, LIFTING more than 7 pounds), OR TWISTING. FALL RISK, 8/10 pain in right hip and bilateral knees. The evaluation documented R3 required substantial/maximal assistance with bed mobility,…

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 provide resident-centered care for one resident (R3) who required rehabilitation services status post-surgical fusion of the lumbar spine, as evidenced by lack of physician orders for spinal precautions; no care plan intervention related to spinal precautions or back brace use; improper use of mobility devices and inadequate assessment of medication management. Findings include: R3 was admitted on [DATE] post a lumber fusion surgery and a history of Gastro Esophageal Reflux Disease (Heartburn/Indigestion/GERD). On 4/23/24, the facility received R3's Hospital Transfer Papers which documented Up to chair 3 (three) times per day. Spine brace (back brace designed to give support to thoracic and lumbar spine by preventing twisting and flexion (bending forward) to be worn while up ambulating. Does not need to be worn while up in chair or bed. On 4/24/24, The Physical Therapy and Occupational Therapy Evaluation and Plan of Treatment documented…

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 interventions were implemented to prevent the development of pressure ulcers or worsening of wounds for 1 of 1 resident (R3) reviewed for wound and at high risk for a pressure ulcers. Findings include: On 4/18/24. R3 had a lumber fusion surgery and required Precaution Details: Spine Brace (back brace designed to give support to thoracic and lumbar spine by preventing twisting and flexion (bending forward) to be worn while patient is up doing transfers and/or ambulating. Does not need to be worn while in bed or chair. SPINAL PRECAUTIONS- NO BLT (NO BENDING, LIFTING more than 7 pounds), OR TWISTING. FALL RISK, 8/10 pain in right hip and bilateral knees. On 4/24/24 R3's Braden Scale for Predicting Pressure Sore Risk Assessment was documented as a 12 (twelve), high risk. On 4/24/24, R3's Minimum Data Set (MDS) section M documented R3 had a stage 2 pressure ulcer (resolved as of 5/6/24), a surgical wound and was at risk for a pressure ulcer. On 4/24/24, R3's Careplan documented R3 has limited 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure staff were competent to perform cares for a 1 of 1 resident (R3) reviewed for specialized equipment and spinal precautions. Findings include: R3 was admitted to the facility on [DATE] post a lumber fusion surgery and spinal stenosis. On 4/23/24, the facility received R3's Hospital Transfer Papers which documented Up to chair 3 (three) times per day. Spine brace (back brace designed to give support to thoracic and lumbar spine by preventing twisting and flexion (bending forward) to be worn while up ambulating. Does not need to be worn while up in chair or bed. On 4/24/24, The Physical Therapy and Occupational Therapy Evaluation and Plan of Treatment documented Precaution Details: Spine Brace to be worn while patient is up doing transfers and/or ambulating. Does not need to be worn while in bed or chair. SPINAL PRECAUTIONS- NO BLT (NO BENDING, LIFTING more than 7 pounds), OR TWISTING. FALL RISK, 8/10 pain in right hip and bilateral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure the right resident received IV (intravenous) access hydration, micronutrient therapy and failed to obtain a physician's order to administer IV hydration and micronutrient (vitamin and mineral therapy) for one of three residents (R1) reviewed for IV therapy in the sample of three. Findings include: R1's Incident Report dated 1-17-24 at 1:23 PM and signed by V2 (Director of Nursing) documents, Incident Description: (IV therapy company) inserted an IV on (R1's) right wrist. (R1) did not receive much, maybe 100 ml (milliliter). (R1) pulled IV out and was waving it around. No injuries noted. Witnesses: V9 (IV Hydration RN/Registered Nurse) statement: I (V9) got the A and B (resident) bed mixed up and when I asked (R1) her name, she said yes. V8 (IV Hydration RN) statement: I had a trainee (V9) and (V9) mixed up the A and B bed. R1's Order Summary Report and Physician's Orders dated 1-1-24 through 1-31-24 do not include an order for R1 to receive IV…

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 consistently offer/provide bedtime snacks to six residents (R8, R14, R27, R43, R63, R93) which include the Resident Council President (R8) of 16 residents reviewed for bedtime snacks in the sample of 45. Findings include: Facility policy/Bedtime Snacks dated 8/2017 documents: To ensure that residents are offered bedtime snacks daily. All residents within the facility shall be offered a snack at bedtime. Charge Nurse and Nursing Assistants will offer snacks to all residents every evening prior to bedtime. On 10/11/23 at 10am, Resident group meeting was held with 16 residents. Six residents (R8, R14, R27, R43, R63, R93) including the Resident Council President (R8) stated they were not consistently offered or provided with bedtime snacks. R8, R63 and R93 stated the kitchen puts out snacks at the nurse's station but the CNA's don't consistently offer or pass out. R63 stated there have been two residents who will take all of the snacks back to their room and the staff don't replace them. On 10/12/23 at 2:40pm, V19 CNA…

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 preferred television programs were displayed on the unit television viewing area for one (R84) of 45 residents reviewed for dignity in the sample of 45. Findings include: Facility Policy/Resident Privacy and Dignity dated 8/2/17 documents: Provide all residents with a home-like environment that promotes dignity and respect to the residents of the facility. On 10/10/23 at 10:44am, R84 was sitting in the memory care television viewing area watching the television. The program on the television was a cartoon with violent and graphic content. At that time, R84 stated she did not like watching cartoons, and acknowledged the content was offensive. R84 also stated she would prefer to watch a program that didn't make her feel like a 4th grader. On 10/10/25 at 10:50am, V22 and V23 (R92's family members) entered the television viewing room with R92. At that time, V22 noted the cartoons on the television, looked over at R84, and asked her if she would rather watch a different program. R84 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a baseline care plan for a resident's anticoagulant and insulin medications (R359) and a resident's CPAP/continuous positive airway pressure machine (R309) for two of 25 residents (R309 and R359) reviewed for care plans in the sample of 45. Findings include: The facility's 24 Hour (Interim) Care Plan Policy revised 02/21 states, Purpose: To provide guidelines for completion of a 24-Hour (Interim) Plan of Care for newly admitted residents. A 24-Hour Care Plan guides provision of care from the time of the resident transfer/admission until the Interdisciplinary Care Plan is completed. Policy: Based on information obtained during the admission process an Interim care plan will be developed as soon as possible after admission. Responsibility: It is the responsibility of the Interdisciplinary Team (IDT) to develop the Interim Care Plan. It is the responsibility of the Charge Nurse/Care Plan Coordinator to complete an Interim 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 record review and interview the facility failed to maintain an accurate Care Plan for one resident (R12) of 25 reviewed for care plan accuracy in a total sample of 45. Findings Include: The Facility's Care Plan policy dated 6/23 documents 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 consonant with the physicians plan of care. On 10/10/23 at 10:30 AM, R12 stated (Staff) don't ever get me up. I would like to be out and about more. They say I refuse but I have never refused to get up. I have never refused anything. R12's Current Care Plan, dated 8/15/22, documents (R12) has a behavior of refusing to be turned and to get up from bed. R12's medical record does not contain any documentation regarding R12 ever refusing to get out of bed or refusing to be turned while in bed. R12's MDS (Minimum…

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 perform recommended exercises for one (R12) of four residents reviewed for mobility in a total sample of 45. Findings Include: The Facility's Range of Motion dated 9/2018 documents the purpose of the policy is to provide resident with limited range of motion appropriate treatment and services to increase or prevent further decrease range of motion. Policy: all residents will be assessed on admission and quarterly, or more often as a change of condition warrants, for risk factors for development of contractures. A program will be developed based on the resident's unique risk factors and involving formalized therapy as applicable. Any ROM will be reflected in the interdisciplinary care plan and will be systematically and consistently followed. It is the responsibility of the CNA (Certified Nurse Aide) to perform exercises as identified. R12's Therapy to Nursing Recommendations, dated 8/25/22, documents Passive Range of Motion to (Both) Lower Extremities 2-3 times per week to prevent contracture formation. Encourage Active…

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 Enhanced Barrier Precautions were maintained for a resident with a Gastrostomy Tube/G-Tube and the facility failed to wear gloves while administering medications through a G-Tube for one of three residents (R359) reviewed for gastrostomy tubes in the sample of 45. Findings include: The facility's Tube Feeding (Administration of Medication) Policy dated 8/2017 states, Procedure: 4. Wash hands. Apply gloves. The facility's Gloves (Use) Policy revised 8/20 states, Policy: Gloves will be used per Standard Precautions, isolation precautions, and according to the CDC/Centers for Disease Control and Prevention Guidelines. Gloves will be worn to prevent the spread of infection and disease to residents and employees, protect wounds from contamination, protect hands from potentially infectious materials, and to prevent exposure to the HIV/Human Immunodeficiency Virus (AIDS) acquired immunodeficiency syndrome and Hepatitis B viruses from blood or body fluids. Procedure: 4. Nonsterile gloves should be used…

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 orders for a CPAP (Continuous Positive Airway Pressure) use for one (R309) of one residents reviewed for oxygen use in a sample of 45. Findings include: Facility Oxygen Administration, revised 2/21, documents Oxygen therapy will be administered to the resident only upon the written order of a licensed physician. R309's facility record documents an admission date of 10/2/23, and R309 has the diagnosis of Obstructive Sleep Apnea. R309's Inventory of Personal Effects, undated, documents CPAP. R309's Medication Review Report dated 10/11/23 has no documented orders for R309's CPAP. On 10/10/23 at 11:10am and 10/12/23 at 9:19am, R309's room had an oxygen sign on door, and R309's CPAP was on the right side of her bed. On 10/10/23 at 11:10am, R309 stated I take care of my own CPAP and wear it at night, I have had it since I got here. On 10/12/23 at 9:40am, V11 Licensed Practical Nurse/LPN stated I don't work midnights so I would not sign off on the CPAP. There is no order for (R309's) CPAP. On 10/12/23 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 observation, interview, and record review, the facility failed to ensure a physician ordered narcotic medication for pain control was available on admission for one (R260) of three residents reviewed for pain in a sample of 45. Findings include: The facility's Management of Pain policy, revised 8/19, documents Policy: Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve these goals through: Promptly and accurately assessing and diagnosing pain. Increasing comfort and reducing depression and anxiety in residents. On 10/10/23, at 10:15am, R260 is lying in bed with a cast noted to his right leg. R260 stated the following: (On admission) I had to wait for pain medication (Oxycodone) to get here. It is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an appropriate indication for use of an antipsychotic medication for one resident (R25) with a diagnosis of Dementia and failed to ensure prn (as needed) physician orders for an anti-anxiety medication did not exceed 90 days for one resident (R92) of five residents reviewed for unnecessary medications in the sample of 45. Findings include: Facility Policy/Antipsychotic Drugs dated 8/2017 documents: Residents will not receive antipsychotic medications unless they have one or more of the following specific conditions: Schizophrenia Schizo-Affective Disorder Delusional Disorder Psychotic Mood Disorders (including Mania and Depression with Psychotic features) Acute Psychotic Episodes Brief Reactive Psychosis Schizophreniform Disorder Atypical Psychosis Tourette's Syndrome Huntington's Disease Organic Mental Syndromes (Delirium, Dementia, Amnestic) with associated psychotic and/or agitated behaviors which: Have been qualitatively 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 obtain physician ordered laboratory results for one of 25 residents (R359) reviewed for physician orders in the sample of 45. Findings include: The facilities Anticoagulant Therapy Policy dated 08/02/2017, states, Policy; All residents on anticoagulant therapy shall have their medications monitored monthly, unless otherwise ordered by a physician. Procedure: 1. All residents on Coumadin should have an order for a monthly prothrombin time (unless ordered sooner by MD/Medical Doctor.) R359's current admission Record documents R359's diagnoses to included but not limited to: Permanent Atrial Fibrillation, Heart Failure, and Peripheral Vascular Disease. R359's Medication Review Report, dated 9/04/2023 to 10/31/2023, documents R359 is currently prescribed the blood thinning medication Warfarin Sodium daily for DVT (Deep Vein Thrombosis) prevention. This same report documents an order for an INR (International Normalized Ratio) to be obtained on 10/10/23. As of 10/11/2023 at 12:45PM, R359's PT (Prothrombin Time)/INR/Coumadin…

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 facility policy, and ensure that a resident had a physician order for medications that were stored at the bedside along with an assessment for self-administration of medications for two of four residents (R2 and R3) reviewed for self-administration of medication in a sample of four. Findings include: The facility's Self-Administration of Medication Policy dated 8/2017 documents it is the responsibility of the Interdisciplinary Team/IDT to assess and determine if those residents who request to self-medicate can do so. This same policy states, Procedure: A resident may not be permitted to administer or retain any medication in his/her room unless so ordered by the physician. 2. Should the resident's attending physician permit the resident to administer his/her medications, the following conditions will apply: A. The IDT will evaluate the resident's cognitive, physical, and visual ability to self-medicate using the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and obtain initial wound measurements, obtain physician orders for treatment of a skin impairment and to ensure a wound was monitored for one of three residents (R1) reviewed for wounds in the sample of four. Findings include: The facility's Skin and Wound Management Guidelines dated 4/2023 states, The facility will initiate aggressive wound management for those residents who have pressure injuries, vascular or diabetic wounds, surgical wounds, etc. This same policy documents for residents who have a wound on admission, the staff/licensed nurse will ensure there is a treatment order in place to include: wound site, how the area will be cleansed, type of treatment, frequency of treatment/dressing change, and periwound orders if needed. This same policy states, Wound Care Nurse: Review new admissions and readmissions and assess, measure, photograph, and document in Wound Rounds on any wound identified. This includes Stage I, significant…

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 a urinary drainage bag was placed in a privacy cover to maintain resident dignity for two of five residents (R18) and (R21) in a sample of 39. Findings Include: (R18's) Order Summary Report, dated 9/8/2022, documents Supra pubic catheter 16 French 10cc(Cubic Centimeters). (R21's) Order Summary Report, dated 9/8/2022, documents 16 French/10ml (Milliliter) Foley/catheter. On 9/6/2022, 9/7/2022 and 9/8/2022 (R18) and (R21's) urinary drainage bags were observed not to have a privacy cover over the urinary drainage bags. On 9/8/2022 at 10:30AM V10/LPN (Licensed Practical Nurse) stated, Yes, (R21's) urinary drainage bag should have a privacy cover on it. On 9/8/2022 at 10:40AM V11 (R21's) brother stated, I am here every day to visit, and I have never seen any kind of cover over (R21's) foley drainage bag. On 9/8/2022 at 11:00AM V3/ADON (Assistant Director of Nursing) stated, (R18's) urinary drainage bag should have a cover over it. On 9/8/2022 at 11:15AM (R18) stated, There has never been a cover over my…

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

Based on observation, interview, and record review, the facility failed to ensure resident wheelchairs were clean for one (R13) of 39 residents reviewed for homelike environment in the sample of 39. Findings include: The Cleaning of Equipment (wheelchairs) policy dated 7/1/22, documents non-removable covers and fabrics on your wheelchair can be vacuumed and then wiped down with disinfectant wipes or a damp cloth and left to dry. In the case of accidental spills and stains, cleaning with disinfectant wipes or a damp cloth may help until a more thorough wash can be completed. There is shared accountability between Environmental Services (EVS) and nursing home-based unit staff to ensure that wheelchairs are appropriately and consistently cleaned. The Resident Council Minutes dated 6/27/22 at 1:30 PM, documents Housekeeping/Laundry - Residents stated concerns with cleanliness. On 9/6/22 at 10:45 AM, R13 was sitting in her room in her (reclining, high back) wheelchair. The front wheel on the resident's right side had a large amount of hair wrapped around the wheel where the wheel…

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

Based on interview, observation and record review, the facility failed to ensure a resident with limited range of motion was provided appropriate treatment and services to maintain and/or prevent a further decrease for two of five residents (R36 and R106) reviewed for limited range of motion in the sample of 39. Findings include: 1. R36's Minimum Data Set Assessment (dated 06/15/22) Section G, Functional Status, documents R36 has impairment on one side of both her upper and lower extremities. R36's Contracture Risk Evaluation (dated 07/02/22) documents a score of 7, indicating R36 is a high risk for contracture development. R36's current medical record has no documentation of any type of restorative/range of motion program in place. On 09/07/22 at 1:15 PM, V2 (Director of Nursing) confirmed that R36 does not have any type of restorative/range of motion program in place and stated, We don't have a restorative program here. If a resident exhibits a decline, then therapy will pick them up. 2. On 09/06/22 at 1:15 PM, R106 was sitting in a wheelchair near his bed. R106 had a mechanical…

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 recognize a severe weight loss, develop a care plan, implement new interventions and notify a registered dietician or physician of a severe weight loss for one of three residents (R96) reviewed for weight loss in the sample of 39. Findings include: The facility's Weights policy, dated 7/2021, documents It is the responsibility of the Director of Nursing/ Designee to ensure that weights are obtained on a monthly basis, and to review weights for weight variances, and proper notification of physician and registered dietician if required. When a resident is noted to have a weight loss, there should be immediate intervention by Dietary. A house supplement of fortified foods can be offered to the residents who are receiving a Regular Diet, regardless of consistency, without obtaining a physician's order. This residents who are receiving a Therapeutic Diet (such as): Low Sodium, Low Fat, ADA (American Diabetes Association), Calorie Count, etcetera, require 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.