Quincy Healthcare & Sr Living

Based on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNA) were provided and completed a minimum of 12 hours of training that includes Dementia and Abuse over a 12 month period. This failure has the potential to affect all 71 residents residing in the facility.Findings include:The facility's Facility Assessment, dated 7/5/24, documents the facility cares for residents with Cognitive loss/ Dementia. This assessment also documents CNA's (Certified Nursing Assistants) receive yearly competency and on hire. This assessment documents required yearly trainings for CNAs will include Dementia and Abuse/Neglect training.On 07/9/25 at 9:40 AM, V1 (Administrator) confirmed she does not have proof that CNAs working in the facility have had 12 hours of training, including Abuse and Dementia training, in the past year. V1 stated I am not able to locate any training for the CNA's. In January 2025 the training system changed over, and it is now on the computer. I am unable to locate any training for the past 12 months.The facility's Long-Term Care…

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

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing and humidification supplies were dated, changed weekly, and maintained in a sanitary condition for 6 of 6 residents (R7, R15, R43, R46, R53, and R61) reviewed for oxygen therapy in the sample of 34.Findings Include:The facility's Oxygen Administration policy dated 2001 documents, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol. Nasal cannula, nasal catheter, mask (as ordered). After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record, the date and time that the procedure was performed for oxygen administration.1. On 7/7/2025 at 10 AM, R7 was sitting in her room, in her recliner chair with oxygen flowing 2 liters per nasal cannula. R7's oxygen tubing was not dated, and the humidification bottle was not labeled. R7's Physician Order Sheet, dated 7/9/2025, documents oxygen therapy at 2 liters per minute per nasal cannula.2. On 7/7/25 at 1:30 PM, R15 was in her…

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 answered timely to provide toileting assistance for one of 18 residents (R29) reviewed for call lights in the sample of 34.Findings include:The facility's Dignity policy, dated 2/2021, documents Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: promptly responding to a resident's request for toileting assistance.The facility's Resident's Call System policy, dated 9/2022, documents Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Calls for…

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

Based on interview and record review, the facility failed to ensure a Level II PASARR (Preadmission Screening and Resident Review) evaluation was completed for a resident who required further review after the Level I screen. The facility also failed to ensure staff responsible for PASARR coordination had adequate knowledge of PASARR requirements for one (R32) of three residents reviewed for PASARR's out of a sample list of 34.Findings include:The facility's admission Criteria policy revised 3/2019 documents the facility admits only residents who's medical and nursing care needs can be met. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level I PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. If the level 1 screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred…

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

Based on observation, interview and record review, the facility failed to ensure that direct resident care staffing hours are adequate to meet the needs of residents in the facility. This failure has the potential to affect all 75 residents residing in the facility. Findings include: The facility's Facility Assessment, dated 4/15/25, documents the facility has an average daily census of 77. This assessment documents Assuming our normal average level of acuity our staffing levels are set per the table (for daily staffing). Any new admit with higher level medical and care needs will result in a review and assessments of the current staffing ratios to ensure appropriate coverage to ensure resident comfort and ability to meet needs timely. The staffing will be adjusted as needed based on changes to the resident population. Resident PDPM (Patient Driven Payment Model) categories will assist with determining staffing needs based on acuity. Direct care staff, residents, resident representatives, and others' feedback is considered when allocating direct care staff hours. This same…

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 services of a full time Director of Nursing. This failure has the potential to affect all 75 residents residing in the facility. Findings include: The facility's Facility Assessment, dated 4/15/25, documents the facility has an average census of 77 residents. This assessment also documents the facility will provide nursing services that include one full-time Director of Nursing. The facility's Director of Nursing job description, dated 1/2011, documents The Director of Nursing (DON) will plan, organize, develop and direct the facility's nursing services in accordance with all current federal, state and corporate standards, regulations, and guidelines to assure the highest degree of quality care. The Director of Nursing is responsible for the nursing services provided within the facility twenty-four (24) hours a day, seven days a week, including ensuring proper staffing & supervision at all times. This encompasses the development & implementation of patient care programs, nursing policies & procedures, 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 provide services of a Infection Control Preventionist. This failure has the potential to affect all 75 residents residing in the facility. Findings include: The facility's Facility Assessment, dated 4/15/25, documents the facility has an average census of 77 residents. This assessment also documents the facility will provide nursing services that include a Infection Preventionist. The facility's Quality/Infection Control job description, dated 1/1/25, documents As directed and counseled by the DON (Director of nursing), will supervise and direct the care provided to the residents, with a focus on attaining clinical outcomes established by the physician and in the care plan. Communicates with physicians and families any time there is a significant change in the resident's condition. Further duties include: monitoring patient care by reviewing start of care and resumption of care documentation, assessing patient clinical outcomes, analyzing the processes and procedures used in patient care, and ensuring all patients receive…

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 a fall for one resident (R2) of 3 residents reviewed for transfers in the sample of 3. Finding include: The Lifting Machine, Using a Mechanical Lift policy dated 7/2017 documents Purpose: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lift device. It is not a substitute for manufacturers training or instructions. General Guidelines: 1. At least 2 (two) nursing assistants are needed to safely move a resident with a mechanical lift. R2's Face Sheet documents R2 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease, Chronic Kidney Disease Stage 4, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Cerebral Infarction, Transient Cerebral Ischemic Attack, Varicose Veins of Left Lower Extremity with Ulcer of Unspecified Site, Chronic Diastolic Heart Failure, Essential (Primary) Hypertension, Type 2 Diabetes Mellitus with Diabetic…

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 call lights were answered in a reasonable amount of time for three of three residents (R1, R2, and R3) reviewed for call lights in the sample of three. Findings include: The facility's Resident Call System policy, dated 9/2022, document's Policy Interpretation and Implementation: 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 6. Calls for assistance are answered as soon as possible, but no later than five minutes. Urgent requests for assistance are addressed immediately. 1. R1's MDS (Minimum Data Set) Assessment, dated 9/16/24, documents R1 is cognitively intact. On 9/27/24 at 9:05 AM R1 stated, Sometimes the call lights have taken longer to be answered, around 30 minutes to an hour. I have had to wait a long time, several times, for someone to answer my call light and I don't like that. Especially when I need help. The facility's Alarm Response Report dated 9/20/24 through 9/27/24, documents R1 waited 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 interview and record review, the facility failed to answer the residents' call light system in a reasonable amount of time for six of six residents (R7, R32, R40, R42, R55, R69) reviewed in a sample of 38 residents. Findings include: The document, Resident Call Light, dated 9/2022, states, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Calls for assistance are answered as soon as possible, but no later than five minutes. Urgent requests for assistance are addressed immediately. Call light response times are reviewed as part of the Quality Assurance Performance Improvement. The Alarm Response Report, for the week of 8/18/24 through 8/24/24, documents that two call lights took over two hours before answered: one 2 hours 25 minutes and one 2 hours 36 minutes; seven call lights took one hour or more before answered: 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 and record review the facility failed to notify the facility Ombudsman, of Facility Discharges/Transfers, monthly and failed to provide the resident and resident representative with a written notice of transfer for five residents (R18, R33, R46, R66, and R75) of five residents reviewed for transfer/discharges in the sample of 38. Findings include: Transfer or Discharge Documentation policy dated December 2016, documents Policy Statement When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. Policy Interpretation and Implementation 4. When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: b. That an appropriate notice was provided to the resident and/or legal representative. 1. R18's Nursing Note dated 5/21/24 at 1:55 AM documents R18 admitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide a bed hold notification to the resident or resident representative for five of five residents (R18, R33, R46, R66, and R75) reviewed for hospital transfers in the sample of 38. Findings include: The Bed-Holds and Returns policy dated March 2022, documents Policy Statement Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. Policy Interpretation and Implementation 1. All residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice: a. well in advance of any transfer (e.g.(example), in the admission packet); and b. at the time of transfer (or, if the transfer was an emergency, within (twenty-four) 24 hours). Transfer or Discharge Documentation…

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 place an oxygen sign for one resident (R18), failed to ensure a nebulizer mask and nebulizer tubing was changed every seven days and stored in a bag between uses for one resident (R27), and failed to date oxygen tubing/humidifier bottles per facility policy for three residents (R18, R69, and R330) of four residents reviewed for respiratory care, in the sample of 38. Findings Include: The Respiratory Therapy Prevention of Infection policy dated November 2011, documents The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. General Guidelines 1. Distilled water used in respiratory therapy must be dated in an initialed when opened and discarded after twenty-four (24) hours. Infection Control Considerations Related to Oxygen Administration 3. [NAME] bottle with date and initials upon opening and discard after twenty-four (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 obtain physician ordered scheduled medications from the pharmacy for four of four residents (R15, R53, R63, and R76) reviewed for pharmacy services in the sample of 38. Findings include: The facility's Pharmacy Services Overview policy dated April 2019 documents, Policy Statement: The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. 1. Pharmaceutical services consist of processes of receiving and interpreting prescriber's orders, acquiring, receiving, storing, controlling, reconciling, compounding (e.g. (example), intravenous antibiotics), dispensing, packaging, labeling, distributing, administering, monitoring responses to, using and/or disposing of all medications, biologicals, chemicals. 2. The facility shall contract with a licensed consultant pharmacist to help get, obtain, and maintain timely and appropriate pharmacy services that support…

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 offer snacks to residents; failed to ensure resident preferences were met while eating in rooms (due to COVID in the building); failed to ensure that resident meals were complete including beverages when served; failed to deliver ice water to the residents during each shift for six of six residents (R7, R32, R40, R42, R55, R60) reviewed for snacks and meals in a sample of 38. Findings include: The document, Frequency of Meals, dated 7/2024, states, Each resident will receive three meals daily, in accordance with resident needs, preferences, requests and plan of care. Alternative meals will be offered to residents. Residents will also be offered nourishing snacks. Nourishing snacks will be available for residents who need or desire additional food between meals. Evening snacks will be offered routinely to all residents. The facility will choose the snacks that are served at bedtime. However, the dietician and food services manager will solicit input from the residents and/or the resident council. The document, Snacks…

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

Based on interview and record review the facility failed to provide the Beneficiary Notice to two (R232, R329) of three residents reviewed out of a sample of 38 residents. Findings: The document, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, dated 9/2022, states, Residents are informed in advance when changes will occur to their bills. The facility issues the Skilled Nursing Facility Advance Beneficiary Notice Central Management System) CMS form 10055 for the following triggering events: A. Initiation - In the situation in which the director of admissions or benefits coordinator believes Medicare will not pay for extended care items or services that a physician has ordered, Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) is issued to the beneficiary before those non-covered extended care items or services are furnished to the beneficiary. B. Reduction - In the situation in which the facility proposes to reduce a beneficiary's extended care items or services because it expects that Medicare will not pay for a subset of extended 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 record review and interview the facility failed to obtain a level II PASRR (Pre-admission Screening and Resident Review) screening for two of three residents (R32, R34) reviewed for Level II PASRR screening with the diagnosis of Mental Illness in the sample of 38. Findings include: The facility's admission Criteria policy dated March 2019 documents, Policy Statement: Our facility admits only residents who's medical and nursing care needs can be met. Policy Interpretation and Implementation 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for MD, ID, or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state…

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 therapy or restorative services to prevent a functional decline for one of one resident (R46) reviewed for Activities of Daily Living decline in the sample of 38. Findings include: Facilities' policy Activities of daily Living (ADLs), Supporting dated 3/2018, documents Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition demonstrate that diminishing ADLs are unavoidable. Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. R46's current Care Plan documents that R46 became a non-weight bearing mechanical lift on 1/12/24. Prior to R46's care plan dated 1/12/24, R46's Care Plan documented R46's transfer status was sit-to-stand lift with two staff assistance. R46's Minimum Data Set (MDS) assessment dated [DATE], 4/14/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to perform weekly skin checks, obtain a treatment once a pressure ulcer was identified, and develop and implement pressure relieving interventions to prevent the development of pressure ulcers for one of seven residents (R41) reviewed for pressure ulcers in the sample of 38. Findings include: The facility's Prevention of Pressure Injuries policy dated April 2020, documents Purpose The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Skin Assessment 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs (Activities of Daily Living). e. Reposition resident as indicated on the care plan. Mobility/Repositioning 1. Reposition all residents 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 observation, interview, and record review the facility failed to develop and implement services to maintain and/or improve range of motion limitations for one of one resident (R49) reviewed for limitations in range of motion in the sample of 38. Findings include: The facility's Restorative Nursing Services policy dated 07/2017 documents, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. Restorative goals may include but are not limited to supporting and assisting the resident in adjusting or adapting to changing abilities, developing, maintaining, or strengthening his/her phycological and psychological resources, maintaining his/her dignity, independence, and self-esteem, and participating in the development and implementation of his/her plan of care. R49's Physician's Orders dated 8-27-24 document R49 has the diagnoses 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, observation and record review, the facility failed to provide ongoing communication with the dialysis center, monitor a dialysis access site, document observations post-dialysis, and ensure a care plan was implemented regarding monitoring, care, and emergency management of a dialysis access site for one of two residents (R25) reviewed for dialysis in the sample of 38. Findings Include: The facility's Hemodialysis Catheters-Access and Care Of policy, dated 2/2023, documents Care of AVFs (arteriovenous fistula) and AVG (arteriovenous graft): 3. Care involves the primary goals of preventing infection and maintaining patency of the catheter (preventing clots). 4. To prevent infection and/or clotting: a. Keep the access site clean at all times. d. Check for signs of infection (warmth, redness, tenderness, or edema) at the access site when performing care at regular intervals. h. check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access. Care Immediately…

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 document targeted behaviors and diagnoses to justify the use of antipsychotic medications, perform antipsychotic evaluations and assessments, and perform gradual dose reductions of scheduled antipsychotic medications for two of two residents (R27 and R41) reviewed for the use of antipsychotic medications with the diagnosis of Dementia in the sample of 38. Findings include: The facility's Psychotropic Medication Use policy dated July 2022, documents Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation 1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 3. Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes a. indications for use; b. dose (including duplicate therapy); c. duration; d. adequate…

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 enhanced barrier precautions to protect vulnerable residents for 16 residents (R1, R2, R3, R4, R5, R8, R9, R10, R11, R12, R14, R15, R16, R18, R19, R20) reviewed for infection control. Findings include: Enhanced Barrier Precautions policy dated August 2022 documents, 1. Enhanced barrier precautions (EBP's) are utilized to prevent the spread of multi-drug resistant organisms (MDRO's) to residents. 2. EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. 3 Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use and h. wound care (any opening requiring a dressing). 4. EBS's are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with the following: a. Pan-resistant…

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 provide pressure ulcer treatments as ordered for one resident (R3) reviewed for pressure areas in the sample of three. Findings include: An October 2010 policy titled Wound Care documents the steps in the procedure of changing a wound dressing include: 4. Put on exam gloves. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. R3's Physician Order Sheet (POS) documents a treatment of heel protectors on at all times. The order documents, Schedule: Every day at 6:00 AM - 6:00 PM; 6:00 PM - 6:00 AM. Protocol: As tolerated, (R3) does not like the heel protectors and often prefers pillow instead for offloading. R3's POS documents an order dated 05/09/24 for a 0.25% sodium hypochlorite solution to be applied to R3's right heel with moist gauze only over eschar area (cut to fit), apply barrier around the wound, cover with an abdominal pad and gauze wrap, change daily. On 06/04/24 at 3:55 PM a progress note written by V3, Nurse…

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 safely dispense medications to three of four Residents (R2, R3 and R4) reviewed for medication administration in a sample of four. Findings include: Facility Administering Oral Medications Policy, undated, documents: the purpose of this procedure is to provide guidelines for the safe administration of oral medications; and remain with the Resident until all medications have been taken. 1. R2's Physician Order Sheet, dated 4/27/24, document R2's diagnoses including: Parkinsonism, Congestive Heart Failure, Muscle Weakness, Hypertension, Cerebrovascular Disease, Tremor, Dementia, Chronic Obstructive Pulmonary Disease, Centilobular Emphysema, Chronic Kidney Disease Stage Three, Peripheral Vascular Disease, Major Depressive Disorder an Anxiety. R2's Medication Administration Record, dated 4/27/24 at 8:00 am, documents that R2 was administered scheduled 8:00 am medication (Atenolol 50 milligram/mg tablet, Torsemide 10 mg tablet, Senna Lax 8.6 mg tablet, Aspirin 81 mg chewable tablet, Carbidopa 10 mg/Levadopa 100 mg…

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 timely administer medications as ordered by the Physician for one (R3) of four Residents reviewed for Medication Administration in a sample of four. Findings include: Facility Administering Oral Medications (Version 1.2), undated, documents: purpose is to provide guidelines for the safe administration of oral medications; verify that there is physician's medication order for this procedure; follow the medication guidelines in the policy; use Medication Administration Record; check the label on the medication and confirm name and dose with the Medication Administration Record; make sure all documentation is completed in a timely manner; responsible for administering all medications following the policies and standards of practice; monitor and assist in developing safety measures to provide a safe environment at all times; and promote safe practices at all times. R3's Physician Order Sheet/POS, dated 4/27/24, document R2's diagnoses including: Sepsis, Cellulitis of Lower Limb, Pressure Ulcer Left Heel,…

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 at least one shower per week and per resident's preference for one of three residents (R1) reviewed for showers in the sample of three. Findings include: The facility policy, provided by V1 (Administrator) on 1/14/24, states B) Each resident shall have at least one complete bath and hair wash weekly and as many additional baths and hair washes as necessary for satisfactory personal hygiene. R1's Minimum Data Set assessment dated [DATE], documents R1 is cognitively intact with a Brief Interview for Mental Status of fourteen out of fifteen and R1 requires assistance with all activities of daily living. R1's Skin Assessment sheets that are completed with a shower, document R1 had showers on the following days: 1/15/24, 1/18/24, 1/25/24, 1/29/24, 2/8/24 (9 days without a shower), and 2/14/24. R1's medical record does not document that R1 has refused showers or requested only bed baths. On 2/15/24 at 2:30 p.m., V1 stated all residents are scheduled…

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 opened multi-dose diabetic insulin pens were labeled with the date opened for three of 33 residents (R32, R47, R431) reviewed for storage and labeling of medications in a sample of 33. Findings include: The facility's Administering Medications policy dated 04/2019 documents, 12. Ensure when opening a multi-dose container, the date opened is recorded on the container. On 10/31/23 at 12:03 PM V3 (Registered Nurse/RN) was standing at the medication cart passing medications on her hallway. V3 opened the top medication drawer where residents' vials of opened insulin injector-pens were stored. In this drawer R32's Basaglar insulin 100 units/1(ml) milliliter vial injector-pen was opened without a label indicating the date opened and R47's Novolog 100 units/ml vial injector-pen was opened without a label indicating the date opened. On 10/31/23 at 12:05 PM V3 verified R32's and R47's insulin pens were opened and had not been labeled with the date the insulin pens were opened. On 11/1/23 at 11:15 AM V4 (RN) 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.

Based on observation, interview and record review, the facility failed to document a medical diagnosis and behaviors to warrant the use of an antipsychotic medication, attempt a gradual dose reduction, document justification for the use of dual antipsychotics and assess for underlying conditions prior to increasing both antipsychotic medications for two of four residents (R9, R70) reviewed for Antipsychotics in the sample of 33. Findings include: The facility's Antipsychotic Medication Use policy dated 07/2022 documents, Residents will not receive medications that are not clinically indicated to treat a specific condition. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. A clinician in conjunction with the interdisciplinary team must evaluate and documented the situation (exacerbation of symptoms) within seven days, to identify…

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 a fall for one resident (R4) of 4 residents reviewed for transfers in the sample of 6. Findings include: R4's Face Sheet documents that R4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, wedge compression fracture of second lumbar vertebrae, subsequent encounter for fracture with routine healing, calculus of kidney, hypertension, anxiety, and muscle weakness. R4's MDS (Minimum Data Set) assessment dated [DATE] documents R4 has a BIMS (Brief Interview of Mental Status) of 13 (cognitively intact) with lower extremity impairment on one side. R4 requires extensive assist of two staff for transfers, extensive assist of two staff for bathing, and is not steady, only able to stabilize with staff assistance. R4's Care Plan dated 8/25/23 at 2:55 PM, documents effective 3/7/19, R4 requires assistance with her Activities of Daily Living. 3/8/19, R4 needs help from two staff transferring in/out 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.