St Anthony's Nsg & Rehab Ctr

Based on observation, interview and record review the facility failed to prevent one of five residents (R46) from sustaining a smoking/vape-related burn and failed to complete quarterly Smoking Assessment Evaluations for four of 18 Residents (R33, R46, R51 and R79) reviewed for smoking in the sample of 33. Findings include: Facility Resident and Employee Smoking Policy dated 10/14/24 documents: It is the policy of the facility to provide a safe environment for Residents, staff and visitors by providing guidelines for the use of smoking materials; and the Smoking Evaluation tool will be done upon admission, quarterly and with change of condition; and the information will be available to staff members and will be updated with any changes in the Resident's capabilities and needs. Procedure for Residents: Smoking is only permitted under the supervision of a staff member in the facilities designated smoking areas based upon a smoking evaluation. the Smoking Evaluation tool will be done upon admission, quarterly and with change of condition; and the information will be available to staff…

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 a resident was free from sexual abuse by a staff member for 1 of 3 residents (R33) reviewed for abuse in a sample of 33. Findings include: A policy titled Abuse and Neglect Prevention last revised 10/14/24 defines abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. It includes abuse, sexual abuse, physical abuse, and mental abuse including facilitated or enabled through the use of technology. The policy continues, 3. Willful, as defined at 483.4 and as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm and 6. Mistreatment means inappropriate treatment r exploitation of a resident. This abuse policy documents, No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. A facility reported incident report dated (undated) documents R33 has a Brief Interview for Mental Status/…

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

Based on observation, interview and record review the facility failed to provide an appropriate indication for use of an antipsychotic medication and failed to provide supporting behaviors for the use of an antipsychotic medication for one resident (R21) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 33. Findings include: Facility Policy/Psychotropic Medications dated 10/14/24 documents: The facility must ensure that residents who: Have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Antipsychotics will be used only for Behavioral Symptoms that are: A danger to the resident or to others OR cause the resident inconsolable or persistent distress, a significant decline in function, and/or substantial difficulty receiving needed care, AND Not due to a medical condition or problem AND Persistent or likely to reoccur without continued treatment AND Not sufficiently relieved by non-pharmacological interventions AND…

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

Based on observation, interview and record review the facility failed to prevent a significant medication error for one resident (R21) who receives an antipsychotic medication of five residents reviewed for unnecessary medications in the sample of 33. Findings include: Facility Policy/Medication Administration dated 10/14/24 documents: The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all medications, to meet the needs of each resident. On 2/25/25 and 2/26/25 at random times throughout both days R21 was observed in his room, frequently calling out for help. On 2/27/25 at 3:15pm V2, DON (Director of Nursing) stated R21's behavior is mostly a constant yelling out. Hospice Physician Order dated 1/22/25 indicates to Start Seroquel (antipsychotic) 50mg (milligrams) by mouth three times per day. Nurse Note dated 1/27/25 at 11:22am indicates Hospice nurse in facility for routine visit and received new orders for R21 to increase the following medications from twice daily to three times…

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 staff follow infection control practices during wound care, in that, V4/Licensed Practical Nurse failed to change gloves during pressure ulcer wound care for R25. This failure has the potential to effect one resident [R25] of two residents reviewed for Pressure ulcer wound care, in a total sample of 33. Findings include: The [NAME], A., [NAME], P., [NAME], W., & [NAME], N. (2024). Clinical Nursing Skills & Techniques (11th ed., pp. 1115-1116). Elsevier Health Sciences, document: 11. Apply clean gloves and remove soiled dressings; remove gauze one layer at a time; 12. Examine dressings for quality of drainage (color, consistency), presence or absence of odor, and quantity of drainage (note if dressings were saturated, slightly moist, or had no drainage). Discard dressings in waterproof biohazard bag. Remove and discard gloves; 13. Perform hand hygiene and apply clean gloves; 17. Apply dressings per order. Place time, date, 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 record review and interview the facility failed to change an indwelling catheter as ordered and failed to monitor urinary output for one resident (R6) of three residents reviewed for indwelling catheter in a total sample of seven. Findings Include: R6's Physician Order Sheet dated October 2024 documents 16 fr (french) (indwelling) catheter for neurogenic bladder. Change every month and PRN (As needed). On 1/31/25 at 10:00 AM V2 (Registered Nurse/Director of Nursing) stated that all residents with catheters should have I & O (Intakes and Outputs) done every shift. V2 stated that she was not aware of any issues with R6's catheter. R6's Electronic Medical Record did not contain any documentation of R6's urinary output from the time of his admission [DATE]) until transfer to the hospital (1/23/25). V1 (Administrator) provided hand written day sheet notes that did have urinary outputs documented on 10/27/24,10/31/24,11/25/24,11/26/24,11/29/24,11/30/24,12/1/24,12/5/24,12/9/24 and 12/11/24. V1 had multiple…

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 misappropriation of jewelry to the state agency or local law enforcement for one of three residents (R1) reviewed for misappropriation in the sample of four. Findings include: The facility's Abuse policy (undated), documents It is the policy of (the facility) to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation resident property from abuse, neglect, misappropriation of resident property, and exploitation. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the nursing home Administrator/Designee. The nursing home Administrator/Designee will report abuse/neglect and/or allegations thereof to (the state agency) per state requirements. This same policy documents The facility…

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

Based on interview and record review the facility failed to follow their abuse policy and complete a background check on a contracted employee with a known criminal history. This failure has the potential to affect all 89 residents currently residing in the facility. Findings include: The Facility's Healthcare Worker Background Check policy, revised 10/14/24, documents, The purpose of this policy is to establish and maintain a safe environment for residents, staff, and visitors. Before employment, all prospective healthcare employees must undergo a criminal history background check. This screening process ensures compliance with the (State) Healthcare Worker Background Check Act. The background check will include verification through the (State Agency) Health Care Worker Registry to identify any disqualifying offenses. A check against the U.S. Department of Health and Human Services (HHS) Office of Inspector General's List of Excluded Individuals and Entities, ensuring the candidate is eligible for employment in federally funded healthcare programs. Healthcare employees 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.

Based on interview and record review the Facility failed to promote an environment to provide respect and dignity for four (R2, R3, R4 and R5) of five Residents reviewed for Resident Rights in a sample of five. Findings include: Facility Resident Rights Policy, revised 11/18, was reviewed and documents that the Facility must treat you with dignity and respect, must care for you in a manner that promotes your quality of life and provide services to keep your physical and mental health at their highest practical levels. Facility Grievance Policy and Procedure, undated, documents: the Administration at this Facility will make every effort to promptly and satisfactorily resolve complaints, concerns or grievances brought to the attention of the Facility. This includes grievances filed concerning allegations of improper Resident treatment; and will make prompt efforts to resolve grievances the Resident may have. Facility Resident Council Minutes, dated 7/1/24 through 10/16/24, were reviewed. Resident Council Minutes, dated 9/25/24, document concerns that R2 reported concerns with V7…

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 an effective pest management program. This failure has the potential to affect all 80 residents residing in the facility. Findings include: On 07/29/24 at 10:15 AM, R4 stated, In the other room I was in, there were roaches and that is probably what was biting me. Last time I went to the eye doctor, I was waiting in the room and saw a cock roach coming out of my bag. I hurried and killed it and threw it away before the doctor saw it. I have not seen anyone spraying. On 07/29/24 at 10:30 AM, R7 stated, The roaches are big and have wings. They are very prominent in the big and little shower room and soiled linen room. There are roaches in the hall. They like to come out more at night. On 07/29/24 at 11:00 AM, R8 stated, We have roaches and flies down on the third floor. They are big. On 7/29/24 at 2:10 PM, V8 (Housekeeping Supervisor) We have water roaches mostly in the basement, but they are up on the floors too. They come through the pipes. On 7/29/24 at 1:45 PM, V12 (Certified Nursing Assistant)…

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 residents cares were implemented for four of six residents (R1, R2, R4, R6) reviewed for improper nursing care in a sample of six. Findings include: The Wound Care Policy, no date, documents If the residents Braden score equals out to high risk, they will continue to have appropriate interventions in place deemed necessary by wound care nurse/Director of Nursing. Any high-risk resident or a resident with a wound will receive the appropriate pressure relieving devices deemed appropriate by the wound care nurse/Director of Nursing. The Scabies Policy, reviewed 01/01/24, documents 5. Identification Regular skin assessments should be conducted for all residents to identify signs and symptoms of scabies. 6. Diagnosis Skin scrapings should be obtained to confirm the presence of mites.9. Monitoring and Follow-up Reassess residents forty-eight hours after treatment to ensure the effectiveness of the treatment and absence of new symptoms. 1. R1's 3/11/24 Wound Care Notes documents R1's Left Distal Thigh wound type is…

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

Based on record review, observation and interview, the facility failed to implement isolation precautions as ordered for suspected scabies for one of two residents (R4) reviewed for infection control practices in a sample of nine. Findings include: The Scabies Policy, reviewed 01/01/24, documents PPE (Peresonal Protective Equipment) Usage: Staff should use gloves and gowns when providing direct care to residents suspected or confirmed to have scabies. Contact Precautions: Implement Contact Precautions for residents with confirmed or suspected scabies, including the use of gloves, gowns, and dedicated equipment. R4's Progress Notes, 7/10/24 at 5:44 PM, documents R4 was seen by the physician regarding scabs scattered around arms and legs. The physician believes them to be scabies. R4 placed on conact isloation. R4's Physician's Order, dated 7/10/24, documents R1 is to be on strict contact precaution isolation related to scabies. On 7/29/24 at 10:15 AM, R4's room lacked a Contact Precaution signage and personal protective equipment. On 7/29/24 at 10:15 AM, R4 stated I'm in isolation.…

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 implement its abuse policy of protecting a resident from further potential abuse during an abuse investigation, for one of three residents (R1) reviewed for abuse in the sample of 3. Findings include: The facility policy, Resident Abuse and Neglect Prevention Policy, dated 6/3/2000 directs staff, An Owner, Licensee, Administrator, Licensed Nurse, Employee or Volunteer of a nursing home shall not physically, mentally,or emotionally abuse, mistreat or neglect a resident. Protection: It is the policy of this facility that the resident will be protected from the alleged offenders. Procedures must be in place to provide the resident with a safe, protected environment during the investigation. The alleged perpetrator will immediately be removed and resident protected. Employees accused of alleged abuse will be immediately removed from the facility and will remained removed pending the results of a thorough investigation. The facility Investigation, dated 7/9/24 documents, (R1) reported during third shift to V5/Certified 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined the facility failed to ensure physician orders for life sustaining treatment where accurate and complete for 5 of 5 (R6, R24, R35, R38 and R58) residents in a sample of 32 residents. Findings include: The policy (not titled/dated) documented The facility will place the POLST (Physician's Order for Life Sustaining Treatment) form in the Medical Record (scan to the electronic health record) along with the residents advance directives if he/she has one. Social Services/Nursing will complete the POLST form with the individual or the legally recognized health care decision maker, after discussing options for care. POLST forms will be reviewed at the time of careplans and at the time of any significant change in the resident's condition, and at the residents' request. At any time, an individual with decision making capability can revoke the POLST form or change his/her mind about treatment preferences by executing a written advanced directive or, 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 provide Range of Motion programing to residents with limitations in Range of Motion for three of three residents (R22, R45, R58) reviewed for limited range of motion in the sample of 32. Findings include: The facility's (undated) Restorative Rehabilitation Services policy documents The facility will provide Rehabilitation Services, consisting of Physical Therapy, Occupational Therapy, Speech Therapy, Restorative Nursing and Occupation and Physical Rehabilitation programs. Restorative Nursing. Restorative nurse care techniques are used consistently for residents to: Gain and maintain function. Prevent further disability. Restore function to resident's greatest potential. Restorative programs will be performed by Certified Nursing Assistants seven days per week on all three shifts. This same policy also documents Passive range of motion (PROM) will be performed to prevent contractures and prevent further loss of range of motion. Certified…

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 complete a scheduled suprapubic urinary catheter change per the physician's order for one of three resident (R22) reviewed for catheters in the sample of 32. Findings include: The facility's (undated) Urinary Catheter Insertion policy documents There must be a physician's order for catheter insertion specifying the size and type of urinary catheter and why the catheter is clinically necessary. Document the procedure in the resident's chart. R22's Physician Order Sheet, dated 3/20/24, documents Suprapubic Catheter 16 French with ten milliliter balloon, change catheter and urinary bag every 45 days and (as needed) if blockage or leakage occurs notify physician. One time a day every 45 day(s) for catheter care. This order has a start date of 10/9/2023. R22's Treatment Administration Record, dated 1/1/24-1/31/24, documents R22's catheter was changed on 1/7/24 and no other days that month document a catheter change was completed. R22's Treatment Administration Record, dated 2/1/24-2/29/24, does not document R22's catheter 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 Record Review and Interview, the facility failed to complete Physician order weekly weights for a resident with a severe protein calorie malnutrition for one of one resident (R22) reviewed for nutrition in the sample of 32. Findings include: The facility's (undated) Weight Policy documents Weights will be done at least monthly to identify any changes in weight. Additional weights shall be taken at the discretion of the physician, nursing staff, dietician, and food service director as ordered. R22's Physician Order Sheet dated 3/20/24, documents R22 has a diagnosis of Severe Protein- Calorie Malnutrition and an order for Weekly weight to be done one time a day every Tuesday. This orders start date is 9/26/23. R22's Care Plan, dated 10/5/23 documents R22 has a diagnosis of malnutrition (R22 is) Malnourished as evidenced by Nutritional Screening Tool. Monitor weight closely for gain/loss. R22's Weights and Vitals Summary, dated 3/20/24, does not document a weekly weight was completed for R22 from September 26th 2024 through March 20th 2024. On 3/21/24 at 10:20 AM, V2 (Interim…

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 obtain the physician ordered daily weights prior to dialysis treatments and failed to provide ongoing communication with the dialysis center for two of two residents (R27 and R38), reviewed for dialysis, in a sample of 32. FINDINGS INCLUDE: The facility policy, Dialysis, dated (reviewed) 10/20/21 directs staff, It is the policy of this facility to provide coordination of care with the resident's dialysis provider. The facility will co-coordinate care with the dialysis provider in developing an appropriate plan of care to include: Weights as ordered by the physician. A communication tool is utilized to report on the resident. 1. R38's current Physician Order Sheet, dated March 2023 documents that R38 was admitted to the facility on [DATE] with the following diagnoses: End Stage Renal Disease, Obstructive and Reflux Uropathy and Dependence on Renal Dialysis. Dialysis three times a week on Tuesday, Thursday and Saturday. R38's Weight form for January 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify Post Traumatic Stress Disorder (PTSD) triggers and identify specific interventions to address the behaviors for one of one resident (R40), reviewed for PTSD, in a sample of 32. FINDINGS INCLUDE: The (undated) facility policy, PTSD (Post Traumatic Stress Disorder) directs staff, It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and addresses the needs of trauma survivors by minimizing triggers and/or re-traumatization. The facility will identify triggers which may re-traumatize residents with a history if trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the care plan. R40's current Physician Order Sheet,…

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 medications were stored at the proper temperature for three of three residents (R59, R192 and R197) reviewed for medication storage, in a sample of 32. FINDINGS INCLUDE: The (undated) facility policy, Storage of Medications, directs staff, Ensure that medications are stored in a safe, secure and orderly manner. Medications requiring refrigeration must be stored in the refrigerator located in the drug room at the nurse's station. Medications must be stored separately from food and must be labeled. On March 19, 2024 at 8:30 A.M., an observation of the facility Second Floor medication storage refrigerator, with V10/Licensed Practical Nurse present, revealed a Refrigerator Temperature Log, dated March 2024 hanging on the outside of the door. The refrigerator contained (3) 150 ML (Milliliter) Normal Saline balls with Acyclovir (Antiviral) 750 MG (Milligrams) for intravenous use, for R192; (6) 100 ML Normal Saline balls with Meropenem (Carbopenem Antibiotic) 1 Gram for intravenous use, for R197; and (4)…

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 document review and interview, it was determined the facility failed to ensure infection prevention precautions were implemented for 1 of 2 (R58) residents in a sample of 32 residents. Findings include: The Procedure for Isolation: Initiation of Isolation Precautions policy reviewed 6/12/18 documented use Contact Precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such as handling environmental surfaces or resident-care items. Organisms such as Methicillin-resistant Staphylococcus aureus (MRSA). R58 was admitted on [DATE] with diagnoses of Cerebral Vascular Accident with Hemiplegia and Diabetes Mellitus Type 2. R58's urine culture collected on 2/26/24 by the facility's staff documented Methicillin resistant Staphylococcus aureus (MRSA) growth which was reported on 2/29/24. R58's urine culture collected on 3/8/24 during a hospital visit documented MRSA growth which was reported on 3/10/24. On 3/2/24, 3/9/24 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.

Based on record review and interview, the facility failed to ensure pneumococcal immunizations were offered/administered to four residents (R22, R27, R35, and R57) of five residents (R6, R22, R27, R35, and R57) reviewed for pneumococcal immunization administration/status in a total sample of 32 residents. FINDINGS INCLUDE: Facility policy, entitled Pneumonia Vaccine-Pneumococcal Immunization-PPV, not dated, document, 1. PPV should be administered to all residents in the facility unless it is contraindicated or refused. R22, R27, R35, and R57's Electronic Medical Records (EMR) were reviewed for immunizations. R22, R27, R35, and R57's EMR does not document pneumococcal immunizations were ordered, offered, nor provided. 03/20/24 02:21 PM V4/Infection Prevention Nurse confirmed R22, R27, R35, and R57 should have, but did not, receive the pneumonia vaccine and to V4's knowledge, R22, R27, R35, and R57 do not have any contraindications, nor refusals, on file, for the pneumococcal vaccine.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent misappropriation of property for 8 residents (R3, R4, R5, R8, R9, R10, R11 and R12) of 12 reviewed for misappropriation of property in a sample of 13. Findings Include: 1.) R12's Incident Report dated 10/23/2023, documents the following, An investigation is currently underway in our facility regarding some narcotics allegedly identified as missing on Saturday, October 21st, 2023, at approximately 2:20PM. The narcotic is recorded as received from the Pharmacy on 2nd shift Friday, October 20, 2023. A full investigation was initiated upon suspicion on Saturday and continues at this time. R12's Packing Slip from the pharmacy, dated 10/20/2023, documents that 120 tablets/4 cards of 30 Hydrocodone/Acetaminophen tablet 7.5-325MG (narcotic pain medicine) were delivered to the facility on [DATE]. R12's Controlled Drug Receipt/Use of Disposition Form, dated 10/20/2023, documents that the facility received 120 tablets of hydrocodone/4 cards of #30. 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 prevent abuse for two residents (R1 and R7) of four residents reviewed for abuse in the sample of thirteen. Findings Include: R1's Initial Incident Investigation Report, with no date, documents the following: Type of Incident: Allegation of Verbal Abuse. R1's Diagnosis and Mental Status, including, but not limited to acute kidney failure, major depressive disorder, congestive heart failure, morbid obesity, muscle weakness. R1 has a BIMS (Brief Interview for Mental Status) score of 15 which indicates R1 to be cognitively intact. Incident Summary: During cares, R1 became upset with V9/CNA (Certified Nursing Assistant) because R1 stated his light had been on for a lengthy period. R1 alleges that V9 complained of having to provide cares to him and made inappropriate comments in response to R1. R1 does state that the cares were provided as needed. No injuries were sustained. V9/CNA was suspended pending investigation. Investigation immediately initiated. R1's Final Incident Investigation Report, with no date, sent 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 record review and interview the facility failed to ensure staff were qualified and competent related to tracheostomy care for 1 of 1 (R3) resident with a tracheostomy. Findings include: The following residents were admitted with tracheostomies: a) R3 was admitted on [DATE] through 10/24/23 and on 12/11/23 to present. b) R6 was admitted on [DATE] through 9/22/23. c) R7 was admitted on [DATE] through 12/8/20 and on 2/23/21 through 5/29/23. During record review of R3 6 of 7 (V3, V23, V25, V32, V33, V34) nurses who conducted tracheostomy care on R3 between 12/11/23 and 12/18/23 lacked documentation of tracheostomy training. During record review of R6 4 of 4 (V5, V12, V13, V35) nurses who conducted tracheostomy care on R6 between 9/20/23 and 9/22/23 lacked documentation of tracheostomy training. The Inservice Attendance Record for Nurses Meeting dated 10/3/23 noted 8 of 32 (V5, V8, V11, V13, V19, V20, V36, V37) nurses received education on tracheostomy care. On 1/9/24 at 3:31 PM, V3 (Licensed Practical…

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 a physician's order for a hand mitt restraint, failed to re-evaluate the need for a mitt restraint and failed to document release of a mitt restraint for one resident (R1) of one resident reviewed for restraints. Findings include: Facility Policy/Restraint Free Environment dated 2023 documents: Physical Restraint: refers to any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include but are not limited to: Applying leg or arm restraints, hand mitts, soft ties, or vests that the resident cannot remove. A physician's order alone is not sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the determination to use a restraint. The need for any said restraint shall be assessed and…

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

Based on observation, interview and record review the facility failed to reschedule a Urology appointment, failed to provide justification for an indwelling urinary catheter and failed to provide the physician ordered size catheter for two residents (R6, R8) of three residents reviewed for urinary catheters. Findings include: Facility Policy/(Indwelling) Catheter Management dated 7/17/20 documents: There will be medical necessity/justification for the use of a urinary catheter which is identified in the physician order. The resident's care plan will reflect the use of a catheter, including size and balloon size, the type indicated for use, the bag utilized, and any facility protocols for the need to change catheter bag and/or tubing. Physician's Order Report Summary indicates R6 has orders initiated on 11/12/23 for an indwelling urinary catheter size 18Fr (French) with a 10cc (cubic centimeter) balloon. Orders do not indicate necessity/justification for catheter. Current Care Plan indicates R6 has an indwelling urinary catheter for neurogenic bladder, date initiated/revised 9/8/22.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow physician orders, dietary and dialysis recommendations for liquid nutrition and hydration for one resident (R1) of three resident reviewed for hydration. Findings include: Facility Policy/Hydration (undated) documents: All residents shall be served sufficient fluids with meals, medication passes and in between meals. Fluid restrictions, intakes/outputs will be monitored and recorded. The facility shall assure that residents are provided with adequate fluid intake to maintain proper hydration and health. Current Physician Order Summary Report indicates R1 was admitted to the facility on [DATE] with diagnoses that include End Stage Renal Disease/Dialysis Dependent, Seizure Disorder, Hemiplegia/Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Unspecified Protein Calorie Malnutrition, Dementia, Gastrostomy. Order Summary indicates R1 has orders as follows: --Liquid nutrition every 24 hours as needed may give 2…

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 services of a registered nurse, as required. This failure has the potential to affect all 89 residents currently in the facility. FINDINGS INCLUDE: Facility Nursing Schedule staffing sheets dated 10/29/2023 and 10/30/2023 document no registered nurse in the facility for 8 hours out of 24 hours, on each day. On 10/31/2023 at 10:15 A.M., V1/Administrator stated, We don't have many RN's (registered nurses) on staff. I don't have any nurse management RNs, except my DON (Director of Nurses). (V2/Director of Nurses) left here in an ambulance about a week and a half ago (10/18/2023) due to a back injury and hasn't been back. (V2/DON) has given her (resignation) notice and her last day is today (10/31/2023). I will have to hire an interim DON (Director of Nurses), until I can hire a full time one. We need an Assistant Director of Nurses, too. At that time, V1/Administrator confirmed no registered nurses were present in the facility on 10/29/2023 and 10/30/2023. The facility Room Roster dated 10/30/2023 confirms 89…

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 update a plan of care to include pressure wound prevention interventions for one resident (R1) of three residents reviewed for pressure wounds, in sample of 3. FINDINGS INCLUDE: The (reviewed 08/20/2021) facility policy, Pressure Ulcers/Skin Integrity/Wound Management, directs staff, A system is in place for the prevention, identification, treatment and documentation of pressure and non-pressure wounds. Upon admission: A Braden skin assessment be completed upon admission. Those residents who represent a high risk will have further preventative interventions put in place. Weekly: A weekly skin check will be conducted and documented for at-risk residents. This is a hands-on, direct visual assessment. Assessment information should identify specific factors that might increase the risk of pressure ulcer development such as: Decreased mobility, Cognitive impairment, Significant weight loss in a resident who also has mobility/positioning concerns, impaired…

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 obtain the required weekly weights for three of three residents (R1, R2 and R3) reviewed for feeding tubes, in a sample of 3. FINDINGS INCLUDE: The facility policy, Enteral Feedings documents, Enteral tube feeding provides nourishment and/or medication (s) when the resident is unable to take food and/or fluids by mouth for an extended period of time. Weigh resident weekly to monitor for weight loss. 1.) R1's Physician Order Sheet, dated October 2023 documents that R1 was admitted to the facility on [DATE] and includes the following diagnoses: Dysphasia following cerebral infarction, Quadriplegia, Severe Protein- Calorie Malnutrition, Gtube. R1's Mini Nutritional Assessment, completed 9/21/2023 documents, At risk of malnutrition. R1's Care Plan, dated 10/10/2023 includes the following interventions for potential for malnutrition, Monitor weight closely for gain/loss. R1's electronic medical record, Weights and Vitals Summary documents, 9/21/2023 Weight…

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 and interview the facility failed to assist 11 residents (R4-R14) out of bed and provide feeding set up and assistance out of 22 reviewed for assistance with activities of daily living. Findings Include: On 10/18/23 at 8:10 AM V6 (Licensed Practical Nurse) stated We had one call in and one no call no show today, it has been only myself and (V11/Certified Nurse Aide) here since 6:00 AM when third shift left. I have had to give medicine and call a doctor and a family member, so I have not had time to help (V11) get anyone up yet. On 10/18/23 at 8:30 AM V11 (Certified Nurse Aide) stated I am waiting on (V6/LPN) to help me get the two person assist people up. But when breakfast gets up here, we will have to stop and pass trays then wait for them to get done eating and then change everyone again and get them up, hopefully before lunch. On 10/18/23 8:35 AM V12 (Restorative CNA) entered the 200 hallway and stated, I am here to help to get people up. On 10/18/23 breakfast was posted to be served at 8:30 am. On 10/18/23 at 8:35 AM V4 was lying in bed with a hospital gown…

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 store food in a manner that ensures food safety, in that refrigerated items were opened and undated. This failure has the potential to affect 74 residents of 75 residents, residing in the facility. Findings include: Central Management Services Form 672, entitled Resident Census and Conditions of Residents, 12/13/22, document 75 residents, reside in the facility, with one resident receiving nutrition through a feeding tube. Facility Policy, entitled Storage of Refrigerated Foods, dated Copyright 2018, document, Policy: Refrigerated food is stored in a manner which ensures food safety and preservation of nutritive value and quality. Procedure: Foods stored in the refrigerator is covered, labeled and dated with the use by date. On 12/13/22, at 9:30 a.m., during the initial kitchen tour, with V12 /Dietary Manager, the walk-in refrigerator had the following open and undated packages of food: bag of Cheese, Roast beef slices, ham slices, frozen cooked eggs, hot dogs, bacon, 2 pounds hamburger, and salad. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to determine the clinical appropriateness for one resident (R47) to self-administer medications of 18 residents reviewed for medications in the sample of 18. Findings include: Facility Policy/Self-Administration of Medications dated 2016 documents: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of the evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. 9. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration. Current Physician's Order Report indicates R47 was 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 observation, interview and record review the facility failed to revise the individualized care plan for two residents (R47, R57) of 18 residents reviewed for care plans in the sample of 18. Findings include: 1) Current Physician's Order Report indicates R47 was admitted to the facility on [DATE] with diagnoses that include Chronic Obstructive Pulmonary Disease (COPD) and Acute and Chronic Respiratory Failure with Hypoxia. Report indicates R47 has orders for oxygen at 2 - 4 liters per nasal cannula as needed for Shortness of Breath. Progress Note dated 9/16/22 indicates R47 was admitted to the facility under Hospice Care. Hospice Visit Notes dated 11/28/22 through 12/13/22 indicate R47 receives continuous oxygen at 2 Liters. Note also indicates R47 is alert and fully oriented. On 12/13/22 at 11:10am R47 stated that he uses oxygen 24/7 and has for the last 3 years. On 12/13/22, 12/14/22 and 12/15/22 R47 had oxygen via nasal cannula on at all times. Current Care Plan initiated on 9/16/22 and revised 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide oxygen humidification and failed to monitor oxygen saturation levels for one resident (R47) of three residents reviewed for oxygen administration in the sample of 18. Findings include: Facility Policy/Oxygen Administration dated/revised 2010 documents: Check the mask, tank, humidifying jar, etc to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. Periodically re-check water level in humidifying jar. Before administering oxygen and while the resident is still receiving oxygen therapy, assess for the following: Arterial blood gases and oxygen saturation, if applicable Current Physician's Order Report indicates R47 was admitted to the facility on [DATE] with diagnoses that include Chronic Obstructive Pulmonary Disease (COPD) and Acute and Chronic Respiratory Failure with Hypoxia. Report…

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

Based on observation, interview and record review the facility failed to provide an appropriate indication for use of an antipsychotic medication and failed to identify specific target behaviors for one resident (R34) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 18. Findings include: Facility Policy/Antipsychotic Medication Use dated/revised 2016 documents: Antipsychotic medications may be considered for residents with Dementia but only after medical, physical, functional, psychological, emotional, psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 3. The attending Physician and other staff will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. Current Physician's Order Report indicates R34 was admitted to the facility 3/3/21…

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.