Pittsfield Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to provide feeding assistance for 3 of 5 residents (R8, R41, and R52) reviewed for nutrition and feeding assistance in the sample of 33. The findings include: 1. R41's Face Sheet, undated, documents R41 was originally admitted to the facility on [DATE], with diagnoses of Generalized muscle weakness/wasting, falls, Lack of coordination, Hemiplegia/Hemiparesis affecting left side, Cerebral infarction, Trans Ischemic Attack (TIA), Anxiety disorder, Sacroiliitis, Right artificial shoulder joint, Hypertension (HTN), Anemia, Atrial Fibrillation, Chronic Kidney Disease (CKD) - stage 3, and prediabetes. R41's Care Plan, dated 11/15/24, documents R41 has had a 9% weight loss over 90 days. Interventions: Offer R41 house supplement with breakfast and lunch. It continues 9/18/24: Resident Care Information: Mobility: X1. Encourage ambulation to and from meals with staff assist. Regular diet/thin liquids Assistance for eating: set up; feeds self. R41's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to provide supplemental shakes as ordered for 1 of 5 residents (R41) reviewed for nutrition and feeding assistance in the sample of 33. The findings include: 1. R41's Face Sheet, undated, documents R41 was originally admitted to the facility on [DATE], with diagnoses of Generalized muscle weakness/wasting, falls, Lack of coordination, Hemiplegia/Hemiparesis affecting left side, Cerebral infarction, Trans Ischemic Attack (TIA), Anxiety disorder, Sacroiliitis, Right artificial shoulder joint, HTN, Anemia, GERD, Atrial Fibrillation, Chronic Kidney Disease (CKD) - stage 3, and prediabetes. R41's Care Plan, dated 11/15/24, documents R41 has had a 9% weight loss over 90 days. Interventions: Offer R41 house supplement with breakfast and lunch. It continues 9/18/24: Resident Care Information: Mobility: X1. Encourage ambulation to and from meals with staff assist. Regular diet/thin liquids Assistance for eating: set up; feeds self. R41's Minimum Data…

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 maintain communication with dialysis center and check patency of a dialysis shunt for 1 of 2 residents (R55) reviewed for dialysis in the sample of 33. Finidngs include: R55's Face Sheet, print date of 12/5/24, documents R55 was admitted on [DATE] and has a dependence on renal dialysis. R55's Minimum Data Set, dated [DATE], documents R55 is cognitively intact. R55's Care Plan, dated 9/9/24, documents, Problem (R55) has end stage renal disease that requires HD (hemodialysis). Approach: Monitor dialysis port / shunt for bleeding. If profuse or quick bleeding, apply direct pressure and contact EMS (Emergency Medical Services). On 12/2/24 at 1:11 PM, R55 stated the Dialysis Center does not use his right arm shunt. He stated it hurts too bad and they use his chest access. R55 stated the staff do not check his shunt. On 12/3/24 at 1:57 PM V28, Licensed Practical Nurse (LPN), stated, There is no written communication between the facility and the dialysis…

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

Based on observation, interview, and record review, the facility failed to administer correct dose of medication . There were 28 opportunities with 2 errors resulting in 7.14% medication error rate. The errors involved R41 in the sample of 3 observed during medication administration. Findings include: 1. On 12/3/2024 at 8:35AM, during medication administration, V4, Registered Nurse (RN), handed R4 nasal spray, and R4 was unable to administer. V4, RN, then sprayed one spray of fluticasone propionate nasal spray in each nostril. V4 then removed container of psyllium husk from medication cart. V4 then poured medication in medication cup measuring 30 Milliliters (ML). V4 then asked surveyor if correct dose. V4 then poured psyllium husk back in container and administered one teaspoon (tsp) in glass of water to R41. On 12/05/24 at 10:39 AM, V20, Licensed Practical Nurse (LPN), stated R41's nasal spray fluticasone proprionate is to be administered 2 sprays each nostril. V20, LPN, stated when administering Psyllium husks R41 is to receive 30 cc in med cup. R41's Physician Order (PO), with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to secure narcotics upon delivery from pharmacy for 4 of 4 residents (R3, R4, R5, R6) reviewed for pharmacy storage. Findings include: On 10/3/24 at 8:06 AM, V1, Administrator, stated, The pharmacy delivered medications and the nurse signed off they were delivered. In the morning, when the nurse went to load the medication into the STAT safe, the Tylenol with codeine was not there. We were unable to find the medications. I don't know if they were taken or if they were even in the order. The nurse was immediately put on suspension. I notified the police department and the DEA (Drug Enforcement Agency) was notified. At the end of investigation, I did terminate the nurse for not following our policy of accepting delivery of medications from the pharmacy. On 10/3/24 at 1:07 PM, V2, Director of Nurses, stated, It takes 2 nurses to load medication into the STAT safe. Pharmacy had delivered the medications between 12 and 1 AM. There where 2 nurses here, but one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to prevent abuse of 1 of 3 residents (R4) reviewed for abuse in the sample of 8. Findings include: R4's Face Sheet, undated, documents, R4 was admitted on [DATE], and has diagnoses of Spastic hemiplegic cerebral palsy, Major depressive disorder, Moderate intellectual disabilities, and Anxiety disorder. R4's Minimum Data Set, dated [DATE], documents R4 is severely cognitively impaired, requires substantial assistance from staff for transfers and toileting, and is always incontinent of bowel and bladder. R4's Abuse Initial and Final Report,dated 9/6/24, documents, It was stated that Shift Key CNA (Certified Nurses Aide) (V7) was yelling at resident (R4). (V4, CNA) was coming to clock in for her shift when she heard (R4) yelling. (V4) immediately went to (R4's) room, where she found the CNA (V7) being verbal with resident, and CNAs hands were on residents arm and shoulder, left side. According to the CNA (V7) the resident was refusing to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate a fall and provide a new progressive fall prevention intervention in place for 1 of 3 (R1) in the sample of 8. Findings include: R1's Face Sheet, 10/7/24, documents R1 was admitted on [DATE], and has diagnoses of Cerebral infarction due to embolism of right middle cerebral artery and Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R1's Minimum Data Set, dated [DATE], documents R1 is cognitively intact, requires supervision with dining, moderate assistance with bed mobility, and is dependent on staff for transfers. R1's Nurses Note, dated 09/20/2024 07:34 PM, documents, Resident found lying on left side in dining room by aide at 1905. Resident stated he was reaching for a napkin and slid out of his wheelchair. Resident assessed by nurse. Resident A&O (alert and orientated) x4. No injuries noted at time of fall. No c/o (complaint of) pain or discomfort at this time. ROM WNL (range of motion within…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to wear Personal Protective Equipment (PPE) for 2 of 3 residents (R2, R8) reviewed for COVID in the sample of 8. Findings include: 1. R2's Face Sheet, print date of 10/7/24, documents R2 was admitted on [DATE]. R2's Progress Note, dated 09/24/2024 09:57 AM, documents, Resident has cough with no production, nasal congestion, body aches, and overall fatigue. Res (resident) was covid-19 tested via rapid test and results were positive. POA (Power of Attorney) notified. Faxed MD (Medical Doctor) to notify and request Paxlovid per res request. Res placed in isolation at this time. On 10/3/24 at 12:19 PM, V8, Certified Nurse Aide (CNA), went to R2's and R7's room with 2 lunch plates. The door has signage documenting a N95 mask, gown, gloves, and eye protection must be worn. There is an isolation cart with supplies outside the door. V8 donned a N95 mask, gloves, and a gown. V7 entered the room without eye protection. On 10/3/24 at 1:25 PM, V8 was…

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 protect private health information by using cell phone to take pictures of a bruise for one 1 of 5 residents (R4) reviewed for resident rights in the sample of 10. Findings include: 1. R4's face sheet, dated 4/22/2024, documents in part a diagnosis of Unspecified dementia, unspecified severity, with agitation. R4's Minimum Data Set (MDS), dated [DATE], documents R4 has severe cognitive impairment. On 4/23/2024 at 10:29 AM, V1, Administrator, stated it was acceptable for pictures of R4's bruise to be taken with personal cell phone. V1 stated the picture was sent from a department head. V1 stated she needed to see pictures as R4 was leaving the facility. V1 stated she was three hours away in a meeting. V1 stated she needed the pictures to start an investigation. V1 stated the pictures were deleted. On 4/24/2024 at 10:59 AM, V13, Infection Control Nurse, stated it was brought to her attention R4 had bruises on his arm. V13 stated she took pictures of R4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent physical abuse to 1 of 5 residents (R4) reviewed for abuse in the sample of 10. Findings include: 1. R4's face sheet dated, 4/22/2024, documents R4 has a diagnosis of unspecified dementia , unspecified severity, with agitation. R4's Minimum Data Set (MDS), dated [DATE], documents R4 has severe cognitive impairment. R4's event report, dated 4/16/2024 at 9:19AM, documents a purplish-black bruise measuring 3 Centimeters (CM) x 3CM. R4's event report documents unknown activity during bruise. On 4/22/2024 at 3:02 PM, V14, Certified Nursing Assistant (CNA), stated he was assigned to R4 as 1:1 on 4/15/2024. V14 stated he was assigned to R4 for his whole shift.V14 stated R4 was pretty calm, but did get restless. V14 stated they made a couple of laps around the facility with R4 in transfer chair. V14 stated they remained outside in the court yard from 2 PM-5:30 PM because R4 was restless. V14 stated at one time he did try to stand up, but sat back down.…

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 report an allegation of abuse in a timely manner for 1of 5 residents (R4) reviewed for abuse in the sample of 10. Findings include: 1. R4's face sheet, dated 4/22/2024, documents R4 has a diagnosis of unspecified dementia , unspecified severity, with agitation. R4's Minimum Data Set (MDS), dated [DATE], documents R4 has severe cognitive impairment. R4's event report, dated 4/16/2024 at 9:19AM, documents a purplish-black bruise measuring 3 Centimeters (CM) x 3CM. R4's event report documents unknown activity during bruise. On 4/22/2024 at 3:02 PM, V14, Certified Nursing Assistant (CNA), stated he was assigned to R4 as 1:1 on 4/15/2024. V14 stated he was assigned to R4 for his whole shift. V14 stated R4)was pretty calm, but did get restless. V14 stated they made a couple of laps around the facility with R4 in a transfer chair. V14 stated they remained outside in the court yard from 2 PM-5:30 PM because R4 was restless. V14 stated at one time, he did try…

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 initiate a timely and thorough investigation in response to allegations of abuse concerning residents for 1of 5 residents (R4) reviewed for abuse in the sample of 10. Findings include: 1. On 4/22/2024 12:56 PM, V1, Administrator, stated the undated, unsigned white sheet of paper in the abuse folder for R4 titled (staff) interview was her notes/timeline of her interview with V14. The white sheet has no times on it. On the piece of paper it is documented an employee from shift key had provided 1:1 to R4; there is no statement in the packet, nor was that employee interviewed. V1 was asked by surveyor how she could do a complete investigation without the alleged abuser written statement. V1 stated she does not have written statement yet. V1 stated V13, Infection Control Nurse did send her pictures from phone. R4's abuse investigation packet does not have a written statement or interview from V13. R4's abuse investigation packet failed to document any type of interviews with any staff or residents except for V14, CNA. V1 stated…

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 allow residents to receive mail on Saturdays. This failure has the potential to affect all 58 residents living in the facility. Findings include: During the Resident Council Meeting on 12/19/23 from 1:00 PM until 2:00 PM, R22, R28, and R7 stated they do not receive mail on Saturdays. 1. R28's Face Sheet, print date of 12/26/23, documents R28 was admitted on [DATE], and has a diagnosis of Type 2 Diabetes. R28's Minimum Data Set, (MDS), dated [DATE], documents R28 is cognitively intact. 2. R22's Face Sheet, print date of 12/27/23, documents R22 was admitted on [DATE], and has a diagnosis of hypertension. R22's MDS, dated [DATE], documents R22 is cognitively intact. 3.R7's Face Sheet, print date of 12/26/23, documents R7 was admitted on [DATE], and has a diagnosis of Alzheimer's Disease. R7's MDS, dated [DATE], documents R7 is cognitively intact. On 12/26/23 at 11:10 AM, V3, Social Service Director, stated the mail is not delivered on Saturday because…

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 have a procedure in place for filing Grievances, understanding what a Grievance is, and implementing a system to track resolutions of a Grievance. These failures have the potential to affect all 58 residents living in the facility. Findings include: 1. On 12/18/23 at 2:07 PM, V4 (R18's wife), stated, His (R18's) cell phone came up missing. The facility knew that it was missing. Someone from the facility called me and told me that they found it in the washer and it no longer worked. No one offered to replace the phone. On 12/18/23 at 2:54 PM, V3, Social Service Director/SSD, stated she has not had any Grievance filed through resident council or any formal Grievances filed. She stated if a small problem arises, she will handle it. We will make a progress note in the chart to document the issue. V3 stated she was unaware of any phone being lost or any laundry missing. V1, Administrator, was present for the conversation, and she agreed the facility just handles things as they come up. V1 stated thatshe was unaware of R18's…

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

Based on interview and record review, the facility failed to provide consecutive 8 hour Registered Nurse (RN) coverage in the facility. This has the potential to affect all 58 residents residing in the facility. Findings include: On 12/22/23 at 11:30 AM, the Nursing Working staffing schedule from October 2023 through December 2023 was reviewed with V2, Director of Nursing. The facility did not have consecutive 8-hour RN coverage for the following days: 10/26/2023, 10/29/23, 11/4/2023, 11/7/23, 11/8/23, 11/11/23, 11/20/23, and 12/14/2023. On 12/26/2023 at 10:00 AM V1, Administrator, stated V2 and V14, Registered Nurses, are managers and the managers do not clock in. V2 stated there is not a way to tell what actual days V2 and V14 worked. On 12/29/2023 at 9:05 AM, V1 stated she is currently using agency to assist with staffing. V1 stated V2 does not work the floor. V2 stated she is actively seeking and hiring her own staff. The Long Term Care Facility Application For Medicare and Medicaid (CMS-671), dated 12/18/23, documents 58 residents reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide food at palatable temperature for 3 of 3 residents (R7, R22, and R49) reviewed for meal service in the sample of 44. This failure has the potential to affect all residents in the facility. Findings include: 1. On 12/21/23 at 11:17 AM, with a calibrated metal stemmed thermometer, the steam table temperatures were taken. The [NAME] beans were 169.0 degrees Fahrenheit (F), gravy 154.2 degrees F, Hamburgers 133.7 degrees F, diced Turkey 142.3 degrees F, Sweet potatoes 150.6 degrees F, pureed green beans 135.6 degrees F. The service was started at 11:35 AM. On 12/21/23 at 12:16 PM, the hall trays left the kitchen. On 12/21/23 at 12:30 PM, the last meal tray (test tray) was served. The following temperatures were taken using the same calibrated metal stemmed thermometer. The ground chicken was at 110.8 degrees F. It tasted oily and cold. The pureed chicken was at 112.0 degrees F. It tasted cold, was very salty, and did not taste like…

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 maintain the kitchen in a clean an sanitary manner, have hand hygiene products available, throw away expired food, and cover, label, and date left over food to prevent foodborne illness. These failures have the potential to affect all 58 residents residing in the facility. Findings include: On 12/18/23 at 10:00 AM during initial tour of the kitchen the following were noted. 1. On 12/18/23 at 10:00 AM, the kitchen was entered. V17, Dietary Aide, was operating the dish machine. V17 was questioned where the hand sink was located in the kitchen , V17 stated, Over there and pointed to a sink that was 2 feet away. The hand sink was filled with soiled cleaning towels. V17 was questioned if there was another hand sink in the kitchen, V17 stated, Around the corner. This surveyor went to that hand sink and washed her hands. While washing hands, V16, Dietary Manager, came and introduced herself. This surveyor, in the presence of V16, tried to obtain paper towels to dry hands. The dispenser did not have any towels in it.…

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 QA&A (Quality Assurance Committee) failed to recognize an infection control problem, and the QAPI (Quality Assurance Performance Improvement) committee failed to perform a Performance Improvement Plan (PIP) regarding an infection control problem. This failure has the potential to affect all 58 residents residing in the facility. Finding include: On 12/27/23 at 10:20 AM, V1 (Administrator) was questioned if the committee had recognized the infection control issue of isolation, identifying an outbreak, and tracking and trending of infections. V1 stated, We really never have discussed infection control because we haven't had issues until the last month. We had COVID in October, then in December, and then this GI (Gastrointestinal) issue. On 12/27/23 at 10:25 AM, V1 stated the facility does not have a PIP (Performance Improvement Plan) in writing, but they do them verbally. The Quality Assurance Committee policy, dated 8/20, documents, Quality Assurance Committee is utilized to: Identify areas of concerns. Detect trends or patterns that signal…

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 required abuse training was complete for 6 of 6 employee records reviewed for abuse. This failure has the potential to affect all 58 residents residing in the facility. Findings include: 1. A Review of V30's, Certified Nurse Aide, (CNA), employee required education records began on 12/21/23 at 1:21 PM. V30's Individual Employee Training Record documents V30's hire date was 11/22/22. V30's Individual Employee Training Record did not indicate completion of Abuse training for 11/22/2022 through 12/21/23. 2. A Review of V44's, CNA, employee required education records began on 12/21/23 at 1:21 PM. V44's Individual Employee Training Record documents V44's hire date was 11/29/21. V44's Individual Employee Training Record did not indicate completion of Abuse training for 11/29/2022 through 12/21/23. 3. Review of V60's, CNA, employee required education records began on 12/21/23 at 1:21 PM. V60's Individual Employee Training Record documents V60's hire date was 10/2/18. V60's Individual Employee Training 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely and complete incontinence and for 6 of 6 residents (R6, R8, R9, R10, R25, R29) reviewed for incontinent care in a sample of 44. 1. R6's Face Sheet, undated, documents R6 was admitted to the facility on [DATE], with the diagnoses of Dementia, Major depressive disorder, Type 2 Diabetes Mellitus (DM), and Left femur fracture. R6's Care Plan, dated 3/2/23, documents R6's Bowel and Bladder: Incontinent of bladder and bowel at times Continent/Incontinent Toileting: Every two hours to the toilet, assist of one Incontinence Products- Large pull-up. R6's Minimum Data Set (MDS), dated [DATE], documents R6 has a severe cognitive impairment and requires extensive assistance from one to two staff members for all Activities of Daily Living (ADLs). R6 is occasionally incontinent of urine and always continence of bowel. On 12/18/23 at 12:38 PM, R6 was taken to her room in her wheelchair by V5, Certified Nursing Assistant (CNA), who…

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 establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use for 5 of 5 residents (R9, R23, R36, R50, R210) reviewed for antibiotic stewardship in the sample of 44. 1. The Facility's Monthly Infection Log for the month of October 2023 does not document an organism causing R9's infection. The log documents No for culture and organism is blank. The log also documents R9 was treated with the antibiotic Keflex. R9's Physician Order Sheet (POS), not dated, documents cephalexin capsule; 500 mg; amt: 1 tab (tablet); oral Special Instructions: give 500 mg (milligrams) by mouth twice a day x 7 days starting at 8:00am on 10/07/2023. R9's Medication Administration Record (MAR) for the month of October 2023 documents that R9 received 5 of 14 doses of Cephalexin 500mg. It also documents that R9 received 14 of the 14 doses of Macrobid 100MG. 2. The Facility's Monthly Infection Log for the month…

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 label medications including insulin pens and Tubersol vials when opened per standards of practice and failed to ensure only medications are kept in medication refrigerators. This has the potential to affect all 48 residents living in the facility. Finding include: 1. On 11/21/22 at 10:44 AM, the main nursing station medication room was observed with V24 Registered Nurse (RN). The medication refrigerator had 2 bottles of breast milk and a Tubersol (Tuberculin Purified Protein Derivative) vial that was almost empty. The vial failed to have a date on it. On 11/21/22 at 10:44 AM, V24, stated that the breast milk was hers. On 11/21/22 at 11:30 AM, V1, Administrator, stated that breast milk should not be kept in the medication refrigerator. The Tubersol insert, undated, documents, A vial of Tubersol which has been entered and in use for 30 days should be discarded. 2. On 11/14/22 at 11:30 AM, V10, Licensed Practical Nurse (LPN) went to give R37…

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 store food in storage container to prevent contamination, maintain a clean kitchen, label outside food with a name and a date, wash hands upon entering the kitchen and maintain an air gap for an ice machine to prevent the contamination and prevent food borne illness. This has the potential to affect all the 48 residents living in the facility. Findings include: 1.On 11/15/22 at 11:57 AM, V6, Cook, entered the kitchen. V6 went to the steam table and began to serve the noon meal. V6 failed to wash his hands before serving the meal. The Hand Washing Procedure, dated 8/19, documents, When to wash hands: Every time you enter the kitchen or satellite pantry. 2. On 11/15/22 at 11:45 AM the kitchen was observed. There was a metal knife block that holds 7 knives. The top of the block where the knives are inserted was layered in food crumbs. There is a plastic container of dry milk observed with a plastic cup in the dry mix. 3. On 11/15/22 at 12:37 PM, the nourishment room was observed. There is a half drank McDonald's…

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

Based on interview and record review the facility failed to conduct Quality Assessment and Assurance meetings at least quarterly and failed to have an infection preventionist on the committee. This failure has the potential to affect all the 48 residents living in this facility. Findings include: On 11/16/22 at 1:00 PM, V1, Administrator, stated the facility has not conducted a quarterly Quality Assurance meeting in the last year. V1 stated I have no sign in sheets of who attended because we did not meet. V1 stated that they do not have an agenda for Quality Assurance meetings because they haven't had a meeting in over a year. On 11/16/2022 at 2:30 PM V2, Director of Nursing, confirmed the facility has not had a Quality Assurance Quarterly meeting. On 11/14/22 at 9:30 AM V1 stated they do not have an infection preventionist. On 11/16/22 at 2:00 PM V2 stated that the facility does not have an infection preventionist. V2 stated the facility is trying to hire one but currently do not have one. Facility policy titled Quality Assurance Performance Improvement, revised 6/1/22, documents A…

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

Based on interview and record review, the facility failed to employ a Certified Infection Preventionist. This failure has the ability to affect all 48 residents living in the facility. Findings include: On 11/14/22 at 9:30 AM V1, Administrator stated the facility does not have an infection preventionist. On 11/17/22 at 1:43 PM, V2, Director of Nursing, DON, stated that the facility does not have an Infection Preventionist. V2 stated We are trying to fill the position. The policy Infection Control, dated 12/17/19, documents, Infection Control Committee Members. 1. Administrator 2. Director of Nurses 3. Infection Preventionist - designated coordinator of the Infection Prevention Control Program. The Resident Census and Conditions of Residents, CMS 672, dated 11/14/22, documents that facility has 48 residents living in the facility.

Based on observation, record review and interview, the facility failed to administer medications as ordered. There were 28 opportunities with 2 errors resulting in a 7.14% medication error rate. The errors involved one resident (R3) in the sample of 17 residents observed during medication administration. Findings include: 1. On 11/16/2022 at11:25 AM, V14, Licensed Practical Nurse (LPN) was administering medications for R3. V14 removed a plastic neb vial out of drawer on med cart. Surveyor requested box with order on it, V14 stated not one just laying in drawer by his stuff. V14 then entered medication storage room and attempted to access convenience box medication. V14 was unable to access the convenience box. V14 stated I will get it later. V14 then popped clonazepam, 0.5 milligrams (mg), Gabapentin 300 mg, and Hydrocodone 5/325 mg out of medication card and placed in medication cup. V14 handed medication cup to R3. R3 dropped the Gabapentin 300 mg from medication cup into the front of his shorts. V14 removed medication from R3's shorts and wasted medication. V14 did not administer…

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.

A. Based on observation, interview and record review, the facility failed to disinfect a multi-use blood glucose machine in between residents' and perform hand hygiene and glove changes to prevent the spread of potential infection for 7 of 10 residents (R3, R4, R20, R21, R30, R36) reviewed for infection control in the sample of 33. B. Based on interview and record review, the facility failed to implement a water policy and procedure to prevent water borne illness including Legionella Disease. This has the potential to affect all 48 residents living in the facility. A. Findings include: 1. On 10/14/22 at 10:43 AM, V10, Licensed Practical Nurse (LPN) entered R20's room and obtained a blood glucose level of 252. When finished she returned to the medication cart and obtained a Micro-Kill Germicidal Alcohol cleansing wipe and placed it down on the cart, V10 then placed the blood glucose machine on top of the wipe and then placed a new cloth over it. V10 failed to cleanse the machine. V10 removed her gloves and failed to sanitize her hands. At 10:45 AM, V10 obtained a blood glucose…

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.