Manor Court Of Peoria

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide oral care/personal care to four of four residents (R1, R2, R3, and R4) reviewed for ADL (Activities of Daily Living) Care in the sample of ten. Findings include: The facility's Personal Care of Residents policy dated 12/2002 documents, Purpose: To provide that residents of the facility receive adequate care. Each resident shall have proper daily personal attention and/or care including skin, nails, hair, and oral hygiene. 1. R1's Care Plan dated 1-6-23 documents R1 needs one assistance of staff for mouth care. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is moderately cognitively impaired and requires extensive assistance of one staff physical assist for personal hygiene. On 10-6-23 at 8:35 AM R1's natural teeth were yellow stained. R1 stated, The staff never help me brush my teeth. I do not think I have toothpaste. 2. R2's Care Plan dated 9-9-23 documents, Mouth Care: Perform oral care before breakfast and…

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

Based on observation, interview, and record review the facility failed to provide a resident with pureed meat as ordered by the physician for one of four residents (R2) reviewed for meals in the sample of ten. Findings include: The facility's Pureed to Liquid Consistency Diet Order Procedure dated 05/2020 documents, All foods pureed to liquid consistency should be smooth with no lumps or particles. All food on the pureed to liquid consistency diet should be prepared in the kitchen. R2's Physician's Order Report dated 9-6-23 through 10-6-23 documents R2's diet order as puree. On 10-6-23 at 9:30 AM R2 was sitting in a high back padded wheelchair in the dining room. R2 was feeding herself a bowl of mechanical soft (crumbled pieces) of a sausage patty with gravy on top. V7 (CNA/Certified Nursing Assistant) was sitting next to R2 and stated, (R2) is supposed to have a pureed diet. (R2) always gets mechanical soft sausage. On 10-6-23 at 9:40 AM V9 (CNA) stated (R2) is always served mechanical soft sausage. On 10-6-23 at 10:00 AM V12 (Dietary Manager) stated, (R2's) sausage is 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.

Based on observation, interview, and record review, the facility failed to ensure monitoring of high temperature sanitization of dishes. This failure has the potential to affect all 38 residents who receive meals from the kitchen. Findings include: Facility Policy/Dish Machine High Temperature Recording Procedure dated (Adopted 08/19) documents: Hot Water is used for sanitizing in High Temperature Dish Machines, not chemical sanitizer. Therefore, it is important to record wash temperatures and final rinse temperatures Three Times per Day. ABC: After all, three meals, before you wash meal dishes, Check and record dish machine wash and final rinse temperatures. Procedure: 1. Record temperatures on a High Temperature Dish Machine Temperature Log. 2. Goal temperatures are located on the metal plate located on the front of the dish machine. Appropriate temperatures are as follows: Wash Temperature: 150-160 degrees F. Final Rinse Temperature: 180 degrees or higher. 3. Do not wash dishes from meals until you have checked the dish machine temperatures. Staff will test the dish machine…

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 an Antibiotic Stewardship Program, this failure has the potential to affect all 39 residents who currently reside in the facility. Findings Include: The Facility's Antibiotic Stewardship Policy dated 12/18/19 documents It is the policy of the facility to follow an Antibiotic Stewardship Program, including the core elements as outlined by the CDC (Center for Disease Control). The Facility Antibiotic Stewardship policy documents Antibiotic use will be calculated on a monthly basis for QAPI (Quality Assurance and Performance Improvement). The CDC (Center for Disease Control) website documents As of November 2017 each (long term care) facility must have had an antibiotic stewardship program in place as part of their infection prevention and control program. The Antibiotic Stewardship program must include the use of antibiotic use protocols and a system to monitor antibiotic use. The Facility's unfinished Core Elements of Antibiotic Stewardship in Nursing Homes adopted 11/28/2017 documents Tracking Monitoring Antibiotic…

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 CNAs/Certified Nursing Assistants received twelve hours of required continuing competency training annually. This failure has the potential to affect all 39 residents residing in the facility. Findings include: The Administrator provided a binder that includes facility in-services that have been completed for 2023. None of these in-services document the 12 hours of required training for CNAs (Certified Nursing Assistants). There was no documentation for 2022 included in the binder. On 5/18/23 at 12:45 pm, V2 (Director of Nursing/DON) stated that she started working at the facility in the fall of 2022 and does not know if the required CNA training was completed in 2022 and has not yet completed the training for 2023. On 5/18/23 at 12:49 pm, V1 (Administrator) stated she only has in-service documentation for the CNAs that have been completed since she started working at the facility late last year and is unable to locate any of the required CNA training for 2022 and has just recently started the training for 2023. 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 the facility failed to develop care plans for multiple care areas and services for nine residents (R4, R6, R18, R20, R23, R28, R29, R35, R140) of 16 residents reviewed for care plans in the sample of 40. Findings include: 1. R6 Current Physician Orders for R6 include orders for: Ipratropium-albuterol solution for nebulization 0.5mg-3mg (milligram)/3ml (milliliter) inhalation, four times per day as needed for wheezing/shortness of breath. Albuterol sulfate solution for nebulization 2.5mg/3ml (0.083%) inhalation three times per day. Ipratropium-albuterol solution for nebulization 0.5mg-3mg/3ml, amount 1 vial inhalation as needed three times per day. Current Medication Administration Record (MAR) indicates R6 received albuterol sulfate 2.5mg/3ml three times per day via nebulizer from 5/1/23 through 5/18/23. On 5/16/23 at 11am, R6 was in her room and stated she uses the nebulizer sometimes. Nebulizer machine was on the bedside table and had the medication chamber, mouthpiece 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 record review the facility failed to administer vaccinations per CDC (Center for Disease Control) guidelines for five residents (R16, R18, R23, R24 and R29) of five residents reviewed for immunizations in a total sample of 39. Findings Include: The Facility's Immunizations policy dated 06/2017 documents It is the policy of the facility to provide immunizations in accordance with CDC (Center for Disease Control Control) recommendations, resident consent, and physician orders. Purpose: to reduce the overall incidence of influenza by offering immunizations to all residents and to reduce the overall incidence of pneumococcal pneumonia by providing the pneumonia vaccines to residents 65 years or older and to others at high risk. The Facility's Immunizations policy documents If a resident or responsible party refuses an immunization it should be documented in the permanent medical record on the Resident Immunization Record. The resident will be offered to receive the vaccine annually. R16's Medical Record documents Flu Immunization: 12/29/2021. R18's Medical Record did not…

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

Based on observation, interview, and record review the facility failed to assess one resident (R6) for self-administration of medications of 16 residents reviewed for medications in the sample of 40. Findings include: Facility Policy/Self-Administration of Medications dated/revised 12/02 documents: Self-administration preference shall be noted in the resident's record. If the resident chooses to self-medicate, the interdisciplinary team shall meet and assess the resident's ability to self-medicate. This includes the resident's cognitive, physical, and visual ability to carry out this responsibility. The storage and documentation of self-administered medications shall be the responsibility of the nursing staff. Facility staff, with the direction of the Director of Nursing, shall exercise program oversight with guidance of residents in self-administration of medication. All medications used by the resident shall be properly recorded by the facility staff at the time of use on self-administration record. The MAR will indicate self-administration. The clinical record shall record 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 ensure a thorough investigation of an allegation of employee to resident abuse for one resident (R23) and failed to ensure thorough investigations were completed for two residents (R29, R140) with injuries of unknown origin of three residents reviewed for abuse in the sample of 40. Findings include: 1) Nurse Progress Note for R29, dated 3/29/23 at 2:12pm indicates swelling noted to right wrist, painful to touch; X-ray ordered. Radiology Report dated 3/29/23 indicates R29 had a non-displaced fracture of distal right (fracture). Serious Injury Incident Report (initial and final) for R29, dated 3/31/23 indicates date of last fall was 2/3/23 with no injury. Report indicates R29 experiences tremors and muscle spasms due to disease processes, striking forearms and wrist(s) against hard surfaces. Report indicates Incident Category as Right Wrist Fracture not Injury of Unknown Origin. The Current Care Plan did not include interventions to protect…

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 revise a nutrition and wound Care Plan for one (R4) of 16 residents reviewed for Care Planning in the sample of 40. Findings include: On 5/17/23 at 11:00 am, R4 was sitting up in a wheelchair with pressure relieving boots to his bilateral lower extremities. On 5/17/23 at 1:30 pm and on 5/18/23 at 1:30 pm, R4 was lying in bed with pressure relieving boots to his bilateral lower extremities. The current Care Plan for R4, documents (R4) has pressure ulcer to left heel with osteomyelitis of both feet. The Interventions include: Administer antibiotics as ordered. Monitor for side effects. Educate (R4) and family/representative on precautions needed related to osteomyelitis and handwashing. Monitor labs and/or cultures as ordered. The Wound Management Detail Report for R4, dated 3/29/23, documents Wound to left heel Closed/Resurfaced and left heel 1.4 x 4.0 pink epithelial tissue with dry scattered scabbed areas, area dark purple ecchymosis (bruising) vs (versus) DTI (deep tissue injury). On 5/18/23 at 10:00 am, R4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to continue a restorative mobility program as recommended by Physical Therapy for one resident (R29) of 16 residents reviewed for mobility in the sample of 40. Findings include: Physical Therapy Discharge summary dated [DATE] indicates discharge recommendations for R29 include: Fitness Program - walk with staff when appropriate; restorative program established/trained. Summary Recommendations Prognosis is Current Level of Function - Excellent with strong family support, Excellent with consistent staff support. On 5/16/23 at 11:10am, V18 (Family) stated R29 had been walking with the walker but hasn't been for a while now. At that time, a walker with an arm tray on the right side of the walker was at R29's bedside. V18 stated the arm tray/support was put on the walker after R29 had the cast put on so he could still walk. On 5/18/23 at 12:55pm, V11 (Physical Therapy Assistant/ PTA) stated that R29 is on a Fitness Program now and V12 (Rehab…

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, record review, the facility failed to monitor the weight of a new admission for one resident (R18) of four residents reviewed for nutrition in a total sample of 40. This failure caused R18's significant weight loss to be undetected therefore not treated. Findings Include: R18's Medical Record documents she was admitted on [DATE] after a fall at home. R18's Medical Record documents on 3/17/23 R18 weighed 103 pounds. R18's medical record documents the next weight being done on 4/3/23 at 101 pounds. R18's medical record documents on 4/11/23, R18 was 102.4 pounds and on 4/17/23 R18 was 99.6 pounds. On 5/18/23 V4 (LPN/Infection Preventionist) stated R18 should have been weighed on 3/24/23 and 3/31/23. When R18 went from 102.4 pounds to 99.6 pounds in one week, we should have reweighed her. On 5/18/23, V16 (Registered Dietician) stated, I was not aware that (R18) had any weight loss or problems. I assessed her when she first came in on 3/29/23 but have not assessed her since then. I…

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 an appropriate indication for use, failed to monitor behaviors and failed to provide target behaviors on a consent for an antipsychotic medication for two residents (R23 and R140) with a diagnosis of Dementia receiving antipsychotic medications of five residents reviewed for unnecessary medications in the sample of 40. Findings include: 1. Psychotropic Medication Consent dated 4/15/23 indicates consent was signed for R140 to receive Seroquel (antipsychotic) 25mg (milligrams) daily for diagnosis of anxiety with agitation. Current Physician Order Report indicates R140 has orders to receive Seroquel (start date 4/13/23) 25mg (milligrams) each evening for Unspecified, Moderate Dementia with Anxiety. Current Care Plan/Behavioral Symptoms dated initiated 5/9/23 indicates R140 tends to scream and holler when cares a are being given. No care plan was developed and/or implemented to address psychotropic/antipsychotic medications (Seroquel) administered to R140. No behaviors were identified in R140's progress…

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 cover, label, and date pans filled with cooked chicken, cooked pork and cooked rice, and failed to maintain the temperature of milk below 41 degrees Fahrenheit. These failures had the potential to affect all 30 residents within the facility. Findings Include: The CMS (Centers for Medicare & Medicaid Services) Form 672 dated 6-7-22 documents 30 residents reside within the facility. The facility's Food Storage and Labeling Procedure dated 10/2021 documents, Objective: To provide staff with guidelines for food storage and labeling of foods. Food Storage: Keep all food covered in a resealable bag or container or the original container, if applicable. Labeling of Refrigerated Foods: The label should include: 1. Product Name: Even if you can see the product/leftover through the plastic wrap or lid, you must label the container or re-sealable bad with the product name. 2. Date: Document the date that the product is placed in the refrigerator. 3. Discard Date: Count seven days from the date you are placing the item…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly screen a resident prior to admission to determine safety needs, failed to administer, operate and implement policies and procedures in a manner that ensured the safety of residents identified as an elopement risk, and failed to have the ability to implement an effective Abatement Plan for Immediate Jeopardies identified during survey. These failures have the potential to affect all 30 residents residing in the facility. Findings include: The facility policy, titled, Job Description Administrator (revised 11/28/17), documents, Job Function: Responsible for directing the overall operation of the facility's activities with current applicable federal, state, local and corporate standards, guidelines and regulations ensuring the highest degree of quality resident care is provided at all times. Supervises: Department Heads and Office Staff. Reports To: Regional Manager. Primary Responsibilities: 1. Assure that the goals of the 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 interview and record review, the facility failed to develop and implement a plan of action to correct identified quality of care related deficiencies and follow up on resident care areas identified as a concern, through the Quality Assessment & Assurance Committee. This failure has the potential to affect all 30 residents living in the facility. Findings include: The facility's QAPI (Quality Assurance and Performance Improvement) Plan, effective 4/01/22, documents, (The facility) is committed to providing quality care to the customers it serves, in a home-like atmosphere. We attempt to deliver and maintain customers' functional status at the highest practicable physical, mental and psycho-social well-being; to promote human dignity; to provide person centered care that offers legitimate choices and control to customers to ensure quality of life; protect human dignity; and encourage staff engagement, competency and empowerment to better serve our customers and their families. We view QAPI as an integral role in management of our facility and board functions. Thou outcome 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 designate a qualified Infection Preventionist. This failure has the potential to affect all 30 residents residing in the facility. Findings include: The Resident Census and Conditions of Residents, CMS (Centers for Medicare & Medicaid Services) Form 672, dated 6-7-22 documents 30 residents reside within the facility. The facility's Infection Preventionist Job Description dated 04/2022 documents, Job Function: Responsible for the facility infection prevention and control program which is designed to help prevent the development and transmission of communicable diseases and infections. On 06/06/2022 at 1:00 PM, the facility could not provide documentation that any employee of the facility had completed an Infection Preventionist Nursing Home Training Course Infection Course between the dates of 11-16-21 through 6-6-22. The facility was unable to provide documentation on who the facility's Infection Preventionist was. On 06/06/22 02:19 PM, V2 (Director of Nursing/DON) stated, The facility has not had an Infection…

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 ensure the Nursing Aides were provided with annual Dementia management training. This failure has the potential to affect all 30 residents within the facility. Findings include: The Resident Census and Conditions of Residents, CMS (Centers for Medicare & Medicaid Services), Form 672, dated 6-7-22 documents 30 residents reside within the facility. The Facility's current CNA (Certified Nursing Assistant) Listing documents the following CNAs (V4, V5, V9, V26, V27, V28, V29) have worked for the facility for over one year. These same CNAs employee files did not contain evidence that these CNAs had the required annual Dementia management training. On 6-10-22 at 9:30 AM, V1 (Administrator) stated that V4, V5, V9, V26, V27, V28, and V29 have not received the annual Dementia management training.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a resident centered comprehensive plan of care related to elopement risk, respiratory care, discharge, psychotropic medication use, impaired/limited range of motion and hospice services, for six of 15 residents (R4, R13, R27, R31, R40, R89) reviewed for care planning, in a sample of 27. Findings include; The facility policy, titled Care Plan Policy (revised 11/28/19), documents It is the policy of this facility to develop and implement a Base Line Care Plan, a Comprehensive Person-Centered Care Plan and conduct Care Plan Meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy further documents, 7. The comprehensive Care Plan will describe, at a minimum, the following: a. The services that are to be furnished 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 interview and record review, the facility failed to ensure bedtime snacks were given to seven of eight residents (R2, R7, R18, R26, R29, R31, & R90) reviewed for receiving an evening snack, in a sample of 27. Findings include: The facility policy, titled Snack Procedure (10/2021), documents, Objective: To provide residents snacks of nourishing quality. Procedure: Snacks of nourishing quality will be available in the kitchen, satellite pantries, nourishment rooms and/or on a snack cart or nursing ice water pass cart throughout the day. All residents should be offered a bedtime snack. The Dining Services staff will supply snacks to each nurses' station for nursing to pass. Appropriate snacks for residents on mechanical diet will be sent. Snacks that require refrigeration will be placed in the satellite pantry or nourishment room. Nursing will be informed of the location of the bedtime snacks. On 6/07/22 at 10:00 am, during the group meeting with residents, R2, R26 and R7 all stated that they are not offered a snack before bedtime. On 6/06/22 at 2:10 pm, R31 stated staff do…

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

Based on interview and record review, the facility failed to notify the Physician and resident representative of an elopement for one of three residents (R27) reviewed for wandering in the sample of 27. Findings include: The facility's Accidents and Incidents policy dated 8/2014, documents, All accidents and incidents should be documented, by creating an event and attaching progress notes. When completing event documentation, the Notifications needs to be done at the time of the event, waiting until the next shift cannot be done. R27's Nurses Note dated 5/31/22 at 12:01 p.m., documents, Spoke with V25(R27's family member) that R27 had wandered out of the facility on 5/30/22 at approximately (7:20 p.m.) and found by (an apartment building) and brought back by V20 (Dietary Aide) and V21(Cook). No injury noted. R27 placed on frequent checks by shift nurse and (wander management device) placed. On 6/8/22 at 11:48 a.m., V20 stated on 5/30/22 at approximately 7:45 p.m., V20 found R27 outside unattended, in the back parking lot area of the complex, walking through the grass back towards…

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 keep a resident's fingernails trimmed and clean for one of one resident (R2) reviewed for Activities of Daily Living in the sample of 27. Findings include: The facility's Personal Care of Residents policy dated 12/2002, documents, It is a policy of the facility to provide a plan of personal care for residents. 1. Each resident shall have proper daily personal attention and/or care, including skin, nails, hair and oral hygiene, in addition to treatments ordered by the Physician. R2's Minimum Data Set assessment dated [DATE], documents R2 requires extensive assistance of staff for toilet use and personal hygiene. R2's Care Plan dated 1/28/22, documents the following: R2 requires moderate assistance of one staff for dressing and grooming; R2 has a colostomy and staff are to assist with the colostomy as needed to ensure hygiene. On 6/6/22 at 12:02 p.m. and 6/7/22 at 10:15 a.m., R2's fingernails on both hands were long and had a brown matter…

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 document a thorough assessment was completed after a resident elopement for one of three residents (R27) reviewed for wandering in the sample of 27. Findings include: The facility's Missing Resident policy dated 2/25/19, documents under the section, Response to Resident leaving the building: When resident returns to facility, a thorough exam should be completed, to assess for injuries. R27's Nurses Notes dated 5/31/22 at 12:01 p.m., document Spoke with V25 (R27's family member) that R27 had wandered out of the facility on 5/30/22 at approximately 7:20 p.m. and found by (an apartment building) and brought back by V20 (Dietary Aide and V21 (Cook). No injury noted. R27 placed on frequent checks by shift nurse and (wander management device) placed. R27's Nurses Note dated 5/30/22, does not document any information about R27's elopement from the facility, including a thorough head to toe assessment to ensure R27 had no injuries. On 6/8/22 at 11:48 a.m., V20 (Dietary Aide) stated V20 was sitting outside of the service door (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 provide treatment/services for residents with limitations of range of motion or document rationale for the services to not be provided for two of two residents (R4, R13) reviewed for range of motion in the sample of 27. Findings include: The facility's Range of Motion (Passive and Active) dated 3/2009, states, Range of motion may be defined as the extent of movement within a given joint, which is normally achieved through the action of muscles or groups of muscles. Purpose: 1. To prevent contractures; 2. To maintain normal range of motion; 3. To increase joint motion to the maximum possible range; 4. To maintain and build muscle strength; 5. To stimulate circulation; 6. To prevent deformities; 7. To prevent contractures from becoming worse if they are already present. The facility's Active Range of Motion Program policy dated 4/2014, states, 1. MDS (Minimum Data Set) Coordinator or nurse designee completes the Contracture Risk 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 observation, interview and record review, the facility failed to ensure oxygen was delivered according to the Physician's order, for one of one resident (R31) reviewed with oxygen, in a sample of 27. Findings include: The facility policy, titled, Oxygen Therapy (revised 3/16/17), documents, Objective: 1. To provide a source of oxygen to persons experiencing an insufficient supply of same. The policy further documents, Procedure: 1. M.D. (Medical Doctor) order will provide: when to use, how often, liter flow, and whether to use a cannula or mask. A Physician's Order Sheet, dated 5/08/22, documents R31 was admitted to the facility on [DATE] with the diagnoses of Chronic Obstructive Pulmonary Disease and Centrilobular Emphysema, and orders for Oxygen to be administered at 3 - 6 Liters via nasal cannula continuously for shortness of breath, with, Special instructions: baseline 3 (Liters per minute) and with activity 6 (Liters per minute) continuous. On 6/06/22 at 11:46 am, R31 was in his room resting in bed…

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 attempt non-pharmacological interventions and obtain consent prior to initiating an antipsychotic medication, monitor targeted behaviors and complete psychotropic assessments for two of four residents (R10, R27) reviewed for psychotropic medications in the sample of 27. Findings include: The facility's Psychopharmacologic Drug Usage Procedure policy, dated 10/18/17, documents, Purpose: To provide appropriate assessment and monitoring of residents receiving these medications. To ensure residents receive gradual dosage reductions and behavioral interventions in an effort to discontinue these medications and minimize adverse consequences. Psychopharmacological medication usage must be reassessed at least every 90 days and include rationale for continuing the medication. Consent for use of Psychopharmacologic medications must be given in writing by the resident and/ or the resident's representative. This consent form will also include 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 a resident's call light was in working order at all times for one of twelve residents (R24) reviewed for call lights in the sample of 27. Findings include: The facility's Call Light policy, dated 1/2004, documents, If the call light is defective, report immediately to maintenance. Check room frequently until call light is repaired. Fill out a maintenance work request form stating room number and take to maintenance immediately. The facility's Maintenance policy, dated 2/25/19, documents, It is the facility's policy to provide its' residents with an adequate maintenance service within the facility and maintaining Public Health rules and regulations. Any items that directly affects resident care will be given top priority and will be attended to as quickly as possible by appropriate maintenance worker. On 6/7/22 at 10:30 AM, R24 attended the Resident Council group meeting and stated that his call light in his room does not work. R24 stated that R24 has told staff and, They come down and wiggle it and say…

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.