Sharon Health Care Willows

Based on interview, observation and record review, the facility failed to implement behavioral interventions to prevent episodes of physical abuse for seven residents (R1, R4, R5, R6, R9, R11 and R12) reviewed for abuse in the sample of 16. Findings include: The facility's Abuse Prevention Program Facility Procedures policy (updated 06/03/24) documents the following: As part of the resident social history evaluation and Minimum Data Set assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriation of resident property, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis. The facility's Behavior Monitoring policy (updated 06/05/24) documents the following: At any time the IDT (Interdisciplinary…

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 use of a safe sanitation solution, record sanitation solution checks, ensure kitchen trash bins were kept away from food preparation areas and covered, maintain clean floors in the kitchen, and ensure the ice machine scoop was handled and stored appropriately to avoid cross contamination in the facility's kitchen. This failure has the potential to affect all 115 residents living in the facility. Findings include: The facility's Sanitation Checks, dated October 2024, documents Take the designated bleach bucket and fill with luke warm water (70 degrees). Using dispenser add bleach water and mix. Test solution if it is not 100 ppm (parts per million), add more bleach, mix and test. Record results and initial. Procedures are to be done at least prior to the start of each meal. Buckets are changed more often if needed. On 10/15/24 at 10:00 AM, V9 (Dietary Manager) confirmed the facility's sanitizing bucket is used to wipe food preparation surfaces in the kitchen and the solution should be at least 100 ppm…

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 update a care plan to include targeted behaviors and non-pharmacological interventions for two (R7 & R51) of 23 residents reviewed for care plan revision in a sample of 30. Findings include: Facility policy Care Plan Policy, updated 6/5/24, documents Patients receive care and treatment based on an assessment of their needs. The data is used to determine and prioritize the patient's plan of care. 1. R7's medical record documented R7 was alert and oriented, admitted to the facility on [DATE], and had Schizophrenia. R7's current physician orders for October 2024 documents R7 takes the following: Lorazepam 1 MG (milligram) by mouth two times a day for anxiety started 2/17/24; Zoloft 200 mg by mouth at bedtime started 2/27/24; Risperidone (antipsychotic) 5 mg by mouth two times a day started 2/28/24; Olanzapine (antipsychotic) 20 mg by mouth at bedtime started 5/28/24; and Trazodone (antidepressant) 50 mg by mouth at bedtime started 2/16/24.…

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 range of motion program was in place for residents with functional limitations in range of motion for three of five residents (R8, R47, R90) reviewed for range of motion in the sample of 30. Findings include: The facility's Restorative Program Policy, dated 6/6/24, documents It is the policy of this facility that a resident is given the appropriate treatment and services to maintain or improve his or her abilities, as indicated by the individual's comprehensive assessment, to achieve and maintain the highest practicable outcome. Our goal is to promote each resident's ability to maintain or regain the highest degree of independence as safely possible, and to achieve and preserve their highest level of mental, physical and psychosocial functioning. Restorative nursing is available seven days a week and is provided for the residents with assessed needs according to program criteria. Purpose: The restorative nursing program is designed to Preserve function, Promote optimal improvement, Increase…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement non-pharmacological interventions, and failed to identify, document or track behaviors for one (R7) of six residents reviewed for psychotropic medications in a sample of 30. Findings include: Facility policy Psychotropic Medication, undated, documents Each psychotropic medication is tracked for behaviors, mood/depressions. Psychotropic medications are used when non-pharmacological approaches have previously failed. Identify target symptoms/behaviors. R7's medical record documents R7 was alert and oriented, admitted to the facility on [DATE], and has Schizophrenia. R7's current physician orders for October 2024 documents R7 takes the following: Lorazepam 1 MG (milligram) by mouth two times a day for anxiety started 2/17/24; Zoloft 200 mg by mouth at bedtime started 2/27/24; Risperidone (antipsychotic) 5 mg by mouth two times a day started 2/28/24; Olanzapine (antipsychotic) 20 mg by mouth at bedtime started 5/28/24; and Trazodone…

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 leg wounds were protected from cross contamination during scheduled dressing changes for one of four residents (R47) reviewed for skin conditions in the sample of 30. Findings include: The facility's Treatments policy (undated), documents The treatment will be carried out in accordance with physician orders, pharmacy recommendations and CDC (Centers for Disease Control) guidelines, using universal precautions. The facility's Skin Treatment Protocol, dated 6/5/24, documents The facility strives to ensure that each resident receives care and services necessary to attain and maintain the highest practicable overall well-being, in accordance with the comprehensive assessment and plan of care. This policy also documents when treating a wound: Sterile technique is not necessary, unless ordered by a physician. Clean technique is used for all other dressings and universal precautions are adhered to. If clean, un-sterile dressings are used, then measures must be taken to prevent contamination 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 protect a resident from physical abuse by another resident, for two of three residents (R1 and R4), reviewed for abuse, in a sample of eight. FINDINGS INCLUDE: 1. The (facility) Incident Investigation Report, dated 5/23/24 and completed by V3/Licensed Practical Nurse (LPN) documents, (R4) was yelling at (R3) in a wheelchair and approached (R3) while out on the patio area. (R3) kicked (R4), causing (R4) to lose his balance and fall unto (R4's) buttocks. Witnesses stated (R4) did not hit (R4's) head upon falling. The (facility) Witness Statements for R5, R6, R7 and R8, dated 5/23/24 and attached to the Incident Report between R3 and R4 all document that (R4) was yelling at (R3) and approached (R3) at which time (R3) kicked (R4) who fell to the ground. On 7/1/24 at 11:10 A.M., V1/Administrator confirmed the physical altercation between R3 and R4 resulted in R3 kicking R4, who fell to the ground. 2.) The Facility Incident Investigation Report, dated 6/12/2024, documents the following: On 6/5/24 at 7:10AM on south unit, (R1)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide periodic Diabetic vision exams for one (R1) resident reviewed for vision examination in a sample of three. Findings include: The facility's Diabetes Mellitus Residents Policy, Undated, documents: It is the policy of (Facility) to provide all (Insulin Dependent Diabetes Mellitus/IDDM) Residents with the best possible nursing care. In so doing, certain criteria will be done and is as follows: As Ordered: 1. Yearly eye exams as ordered by physician. The facility's Vision and Hearing Policy, Undated, documents: The comprehensive assessment and plan of care determines the amount of care needed by each individual resident to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities. The facility's (Vision) Contract for Ophthalmic Services, dated 3/31/21, documents (Vision) agrees to serve as the Ophthalmic Consultant on the facilities professional staff. (Internet definitions: Ophthalmic means 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 notify a resident's family of a hospitalization for 1 resident (R1) of 3 residents reviewed for policy and procedures in the sample of 6. Findings include: The (Facility) Change in Condition/Notification Policy dated 9/20/23 documents The facility will promptly notify the resident, his/her attending physician, and representative of changes in the resident's medical/mental condition and/or status. Unless otherwise instructed by the resident, the nurse will notify the resident's representative (within 24 hours unless medical emergency) when: d. It is necessary to transfer the resident to a hospital/treatment center. On 10/2/23 at 12:55 PM, V1 (Administrator) stated that V4 (R1's Power of Attorney) did complain that he came in to visit R1 and R1 was not in the facility. R1 had been sent to the hospital. The nurse did admit that she got busy and forgot to call V4. On 10/4/23 at 12:04 PM, V2 (Director of Nursing) stated that V13 (Licensed Practical Nurse) should have contacted V4 (R1's Power of Attorney) when R1 went to the…

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

Based on observation, interview, and record review, the facility failed to wear personal protective equipment per their policy and current Centers for Disease Control guidelines. These failures have the potential to affect all 112 residents residing in the facility. Findings include: Centers for Disease Control and Prevention online web address Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated May 8, 2023, documents Personal Protective Equipment for healthcare personnel who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). On 9/14/23 the facility front entrance had signage on the front door documenting the facility was in a COVID outbreak. On 9/14/23 at 10:40am, V1 Administrator stated We had COVID positive staff on 9/2/23, and a COVID…

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 conduct annual testing on opportunistic waterborne pathogens. This failure has the potential to affect all 111 residents who reside in the facility. Findings Include: The facility's Water Management Plan policy (undated) documents, The facility is actively involved in preventing the occurrence and spread of legionella bacteria. In the latter regard, a proactive system of water management has been implemented. While Legionella has never been a problem affecting residents it is recognized that vigilance must be ongoing both within and external to the site. Within facility itself, a buildup of scale and sediment, construction/renovation equipment changes/failure, system startup/shut down and alterations in water pressure are prime areas to be monitored. Mixing valves, heat loss and/or hot weather-related overheating of pipes containing cold water are less commonly observed bacterial sources but must be considered. Lack of use of a specific faucet or showerhead may also encourage biofilm growth merely because of stagnation.…

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 were protected from physical abuse for 13 of 13 residents (R1, R12, R18, R27, R28, R48, R50, R58, R93, R100, R102, R105, R106) reviewed for abuse in the sample of 37. Findings include: The facility's Abuse Prevention Program policy, dated 8/1/22, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. 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, Interview and Record Review the facility failed to ensure a range of motion program was in place for residents with functional limitations in range of motion for six of nine residents (R45, R55, R58, R67, R72, R83) reviewed for range of motion in the sample of 37. Findings include: The facility's Restorative Program Policy, dated 6/1/23, documents It is the policy of this facility that a resident is given the appropriate treatment and services to maintain or improve his or her abilities, as indicated by the individual's comprehensive assessment, to achieve and maintain the highest practicable outcome. Our goal is to promote each resident's ability to maintain or regain the highest degree of independence as safely possible, and to achieve and preserve their highest level of mental, physical and psychosocial functioning. Restorative nursing is available seven days a week and is provided for the residents with assessed needs according to program criteria. Purpose: The restorative 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 notify a patient representative of a room change for two of two residents (R100, R102) reviewed for notification of change in the sample of 37. Findings include: The facility's Room Change policy, dated 6/1/23, documents, As room changes occur, responsible parties will be notified of the changes. On 08/28/23 at 10:34 AM, R100 & R102 were aimlessly wandering back and forth in a closed hallway. 1. R100's Behavior/Incident Charting, dated 8/16/2023 at 10:51 p.m., document, R100 was transferred from north to South to room E10 bed 1 due to less residents with quieter environment to see if she would reduce pacing throughout the night. R100's Electronic Census, dated 8/31/23, documents that R100 changed rooms on 8/16/23. R100's current electronic record has no documentation of V15 (R100's family) being notified of R100's room change. On 08/29/23 at 11:44 AM, V15 (R100's family) stated, I was not aware that she was moved to another room let alone a hallway that's closed. 2. R02's Order Administration Note, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free form involuntary seclusion for two of two residents (R100, R102) reviewed for involuntary seclusion in the sample of 37. Findings include: The facility's Abuse Prevention Program policy, dated 8/1/22, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Involuntary Seclusion means separation of a resident from other residents, or from his/her room-or confinement 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 observation, interview, and record review, the facility failed to identify a physical restraint, obtain a physician's order for a restraint, obtain an informed restraint consent, perform restraint assessments, and have a plan of reduction for two of two residents (R100, R102) reviewed for restraints in the sample of 37. Findings include: The facility's Restraint policy, no date available, documents, Physical restraints is any manual method or physical or mechanical device that the individual cannot easily remove and which restricts free movement of normal functioning and access to one's body. On 08/29/23 at 08:35 AM, R100 and R102 were sitting behind the inner portion of a c-shaped table that was backed up to the wall. The table was flush with the wall with no gaps between the wall and the table. Both R100 and R102 would repeatedly stand up and sit down. At times, while standing both residents would attempt to push the table out of the way to walk, but the table would not move. On 8/29/23 at 12:35 p.m., R100 and R102 were standing behind the inner portion of a c-shaped…

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 care plan following significant weight loss for one of seven residents (R9) reviewed for weight loss in the sample of 37. Findings include: The facility's Weight Policy, dated 6/1/23, documents, The purpose of this policy is to monitor the residents' weights and track weight changes as they occur. Significant weight change is as follows: 1. if being weighed weekly 2% in one week; 5% or more in one month; 7.5 % or more in three months; 10% or more in six months. Within a week after weights have been received and reviewed by the Nursing Department and Dietary Manager, the weight committee will meet to discuss and recommend the need for any possible dietary interventions or diet order changes. If the dietician is present in the facility, the committee will consult with her. If not they will simply notify the physician for possibility of new orders. Order changes will be recorded in the clinical record as well as any needed care plan intervention changes. On 08/29/23 at 08:55 AM, R9 was sitting at 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 provide meaningful activities for residents residing on a closed unit for two of two residents (R100, R102) reviewed for activities in the sample of 37. Findings include: The facility's Activities policy, dated 6/1/23, documents, The facility has an on-going program of activities designed to meet in accordance with the comprehensive assessment, the interest and the physical mental and psychosocial well-being of each resident. A balance of recreational activities including physical, social, religious, arts and crafts, diversional and intellectual activities will be offered to meet the psychological well-being needs of the patients. On 08/28/23 at 10:24 AM, The E-hall way was dark with no lights on. Approximately 75 feet down the hallway, V22 (CNA-Certified Nursing Assistant) was sitting in a chair with two rolling bedside tables beside him blocking the hallway. R102 was pacing back and forth in the hallway and R100 was lying in bed. No activities were occurring. On 08/28/23 at 10:26 AM, V8 (CNA Supervisor)…

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

Based on observation, interview and record review, the facility failed to implement fall interventions and report/investigate a resident reported fall for 2 of 7 resident (R102, R410) reviewed for falls in a sample of 37. Findings include: 1. The facility's Fall Prevention Policy, no date, documents, It is the policy of this facility to prevent falls and serious injury outcomes by recognizing multi-factorial risks and causes, and institute recommendations for falls prevention and management consistent with clinical practice guidelines and standards of care. R102's Care plan, dated 1/31/23, documents, has a history of Depression and catatonic schizophrenia. The care plan also documents the following interventions: R102 will be encouraged to attend group skills to build his social skills when around his peers and staff that he is unfamiliar with. R102's Care plan, dated 2/1/23, documents, (R102) is up and out of his room daily mostly walking around the facility, having a snack, or in the T.V. room sitting watching television. (R102) does not participate in group activities but will…

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 implement nutritional interventions to prevent further weight loss and failed to notify the physician after weight loss occurred for one of three residents (R70) reviewed for weight loss in a sample of 37. Findings include: The facility's Weight Policy (dated June 2023) documents, Significant weight change is as follows: 5% or more in one month, 7.5% or more in 3 months, and 10% or more in 6 months. Within a week after weights have been received and reviewed by the Nursing Department and Dietary Manager, Weight Committee will meet to discuss and recommend the need for any possible dietary interventions or diet order changes. If the dietician is present in the facility, the committee will consult her. If not, they will simply notify the physician for the possibility of new orders. At any time when the dietician is in the facility, any recommendations she makes will be referred to the physician for approval. On 8/29/2023 at 12:30 PM, R70 ate less than 50% of his lunch. R70 did not receive any staff assistance…

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/treat the residents pain, manage effectiveness of interventions implemented for 2 of 2 residents (R48, R410) reviewed for pain in the sample of 37. Findings include: The facility's Medication Administration policy, no date, noted the Medication Administration Record should be initialed immediately after administrating medication. The facility's Pain Management Protocol, no date, noted pain is assessed each shift, describe pain and document accordingly. 1. R48's physician's order for Tylenol 325 mg (milligram) 2 tablets by mouth every 4 hours as needed for headache and pain was initiated 5/2/17. R48's Pain Level Summary dated 8/29/23 at 8:46 AM noted a pain level of 8. R48's Medication Administration Record dated 8/23 lacked documentation that pain medication was administered on 8/29/23 following her assessment of pain at 8:46 a.m. On 8/30/23 at 1:00 PM, R48 stated pain medication was not given until later in the afternoon (8/29/23) around shift change (2:45 PM-3:15 PM). R48 stated in regards to nursing pain…

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 an informed consent when increasing an antipsychotic and failed to document justification to warrant the increase of an antipsychotic for one of five residents (R100) reviewed for antipsychotics in the sample of 37. Findings include: The facility's Psychotropic Medication policy, no date, documents, The facility follows the state and federal regulations related to the use of psychotropic medications in the long term care facility's to ensure the absolutely best care for the resident. Psychotropic medications will never be used for the purpose of disciplinary action or inappropriate usage. Psychotropic medications are used when non-pharmacological approaches have previously failed. Track and record each psychotropic medication is being documented with triggers and behaviors. Consent must be signed by the resident or responsible party such as a guardian. On 08/28/23 at 10:24 AM, R100 was lying in bed. On 08/28/23 at 10:34 AM, R100 was aimlessly wandering back and forth in the hallway. On 8/29/23 at 12:40…

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 four (R41, R70, R84, and R101) of 45 residents reviewed for homelike environment in the sample of 45. Findings include: The facility Resident Council Minutes, dated 5/27/22, documents there were twenty residents in attendance and documents: Old Business: Any unresolved issues from last month: WheelChairs stopped getting washed after a few times. On 7/20/22 at 12:09 pm, V2 ADON (Assistant Director of Nursing) stated the resident wheelchairs are cleaned following the undated resident Shower Schedule three times a week and as needed. V2 stated the third shift CNAs (Certified Nursing Assistants) are responsible to wash the residents wheelchairs during the third shift prior to the resident scheduled shower three times a week. On 7/20/22 at 9:59 am, V9 CNA (Certified Nursing Assistant) Scheduler provided the undated resident Shower Schedule the facility uses to also clean resident wheelchairs. This Shower Schedule lists each resident room number and the three days a week…

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 develop personalized Care Plans for seven residents (R7, R31, R40, R78, R95, R99 and R109) of 45 residents reviewed for personalized Care Plans in the sample of 45. Findings include: Facility Care Plan Policy, updated 7/8/22, documents: Residents admitted to the facility will have a Care Plan initiated within 48 hours of admission and completed no later than 21 days after admission; Care Plan revised at least quarterly, whenever there is a significant change in the patient's condition and on an as needed basis; Patients receive care and treatment based on an assessment of their needs, the severity of their disease, condition, impairment or disability; the date obtained from the assessment is used to determine and prioritize the patient's plan of care; and modifications should be made following any incident/change of condition as indicated. The facility undated Smoking Safety Policy and Procedure, documents, Level I (Fully Independent): Full Independent smokers will be allowed to keep one pack of cigarettes on…

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 supervise residents requiring smoking supervision and failed to ensure safe smoking practices were implemented for four (R8, R76, R99 and R101) of 12 residents reviewed for smoking in the sample of 45. Findings include: The facility undated Smoking Safety Policy and Procedure, documents, Level I (Fully Independent): Full Independent smokers will be allowed to keep one pack of cigarettes on his/her person during a 'probationary' period. Those individuals that have demonstrated the capacity and willingness to use tobacco products safely, follow all rules/regulations concerning tobacco use, and are able to manage/budget these products effectively will be allowed to keep and carry their own smoking materials. Level III (Supervised): These individuals have demonstrated that they are incapable or unwilling to use tobacco products safely due to physical or cognitive limitations, and/or have had significant or repeated violations of the rules/regulations concerning tobacco use. These individuals will be given 1…

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 keep a blind resident's pathway clear of obstacles for one (R62) of three residents reviewed for incidents/accidents in a sample of 45. Findings include: On 7-1-22, at 7:25am, R62 sat in a wheelchair in the dining room. R62 stated that she had an accident and hit her nose. R62 stated, They put the (mechanical lift) on the wrong side (of the hall). They are not to put things on a certain side of the hall. R62's Progress Note, dated 8-4-22, documents, (R62) reported to this nurse that (R62) ran in to the (mechanical lift) and (R62's) peer told (R62) that (R62) had a bruise under (R62's) left eye. R62's current Physician Order Statement/POS, includes diagnoses of Blindness of left and right eyes. On 7-18-22, at 10:40am, R62 sat in a wheelchair in R62's room. At that time, V12 Certified Nursing Assistant/CNA, exited R62's room and verified there was a mechanical lift just outside of R62's room in the hall along the railing and a wheeled walker a few doors down along the same side. V12 stated that R62 has bumped…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain timely pressure ulcer/wound treatment orders from a Physician, perform weekly wound checks, and implement pressure relieving interventions for one of one resident (R78) reviewed for pressure ulcers in a sample of 45. Findings include: The facility's Skin Treatment Protocol (undated) documents, Decubitus ulcers are commonly referred to as bedsores or pressure sores. Pressure sores are usually formed when the skin breaks down because the resident remains in the same position for an extended period of time. When a resident remains in the same position for an extended period of time, there is a loss of circulation to that area, which destroys the tissues. The most common site of a pressure sore is where the bone is near the surface of the body. These include the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, toes, and under the breasts. The comprehensive assessment and plan of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure range of motion services were provided for three residents (R7, R13 and R31) of four residents reviewed for limited mobility and range of motion in a sample of 45. Findings include: Facility Restorative Program Policy, updated 5/24/21, documents: It is the policy of this facility that a resident is given the appropriate treatment and services to maintain or improve his or her abilities, as indicated by the individual's comprehensive assessment, to achieve and maintain the highest practicable outcome; Goal is to promote each resident's ability to maintain or regain the highest degree of independence as safely possible and to achieve and preserve their highest level of mental, physical and psychosocial functioning; that restorative nursing is available seven days a week; Restorative nursing program and documentation of the interventions and resident response will be completed with each implementation. Facility Description for 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 obtain a Physician order for oxygen use for one of two residents (R66) reviewed for oxygen in the sample of 45. Findings include: The facility's Oxygen Administration policy, undated, states, Documentation: In the progress notes, record: date and time of oxygen administration, type of delivery device, oxygen flow rate, resident's vital signs, skin color, respiratory effort, and lung sounds, and resident's response before and after initiation of therapy. The facility's Oxygen Concentrator policy, undated, states, Setting up the Concentrator: 2. Turn to the proper flow rate as ordered by the Physician. R66's Facesheet documents R66 with a diagnosis of malignant neoplasm of upper lobe, left bronchus of lung. On 7/17/22 at 6:52 AM, R66 was sitting up in the wheelchair in R66's room. At this time R66 stated, I wear it (oxygen) when I sleep which is basically all the time. An O2 (Oxygen) concentrator was noted in R66's room at the foot of R66's bed. Nasal cannula tubing was connected to the concentrator laying on…

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.