Amberwood Care Centre

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident did not attempt to exit the facility out a fire exit door, and failed to transfer a resident with a gait belt which applies to 2 of 25 residents (R39, R104) reviewed for safety in a sample of 25. The findings include: 1. R39's Facility assessment dated [DATE] showed R39 to be a [AGE] year old male male with moderate cognitive deficits. This Assessment showed R39 was admitted to the facility with diagnoses which include: cognitive communication deficit, hemiplegia an hemiparesis following a cerebral infarction, and history of traumatic brain injury. On 9/9/24 at 12:10 PM, R39 was attempting to go out the South East fire exit door in his wheelchair at the end of the hallway. The exit door is adjacent to R39's room. R39 pushed the release bar to open the door. The door alarm was not going off when the door was opened. There was no staff in the hallway at the time R39 opened the door. R39 was in his wheelchair having…

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 maintain resident catheters below the level of the bladder and keep the drainage bag off the floor. This applies to 3 of 8 (R66, R90, R39) residents reviewed for catheters in the sample of 25. The findings include: 1. On 9/9/2024 at 11:09AM, R66's urinary catheter drainage bag was observed hanging on the resident's walker level with the resident's bladder. Urine was observed sitting in the catheter tubing with sediment present in the tubing. On 9/10/2024 at 11:53AM, V2 Director of Nursing (DON) said catheter bags should be kept below the level of the resident's bladder to prevent infections. R66's Order Summary Report dated 9/9/2024 shows an order for Foley Catheter, change monthly and PRN (as needed). 2. On 9/9/24 at 11:00 AM, R90 was sitting in his reclined wheelchair in his room. R90's urinary catheter drainage bag was tucked to R90's right side hip level above the level of the bladder. At 12: 15 pm- R90 was still in his room watching TV, catheter bag remained in the same position, tucked on his right side…

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 wash hands and change gloves and failed to implement Enhance Barrier Precaution (EBP) for 2 of 25 residents ( R104, R39) reviewed for infection control in the sample of 25. The findings include: 1. On 9/9/24 at 9:10 AM, V11 (Certified Nursing Assistant-CNA) was providing incontinence care to R104. R104 had a bowel movement. After providing incontinence care and without changing her soiled gloves, V11 turned R104 side to side and applied new incontinent brief, applied R104's blanket, pulled the privacy curtain, opened R104's closet looking for clothings then said she needs to go out and get something. V11 then removed her soiled gloves and left R104's room without washing her hands. On 9/11/24 at 8:10 AM, V3 (Assistant Director of Nursing -ADON) said staff should change their gloves and wash their hands when completing dirty task to clean task, when the gloves is visibly soiled and when a tasks was completed wash hands to prevent the spread of infection. The Facility Policy entitled Personal Protective Equipment…

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 the residents received the correct portion size of fried potatoes, mixed vegetable, and pureed Italian sausage during the lunch meal for all residents receiving meals in the facility. The findings include: The facility data sheet dated 6/15/24 shows 126 residents reside in the facility. On 6/15/24 at 12:06PM, V5 (Dietary Aide) was plating the lunch meal. There were three large pans on the steam table: one with Italian sausage, one with mixed vegetable, one with shredded potatoes. There were four smaller pans, one with chopped/ground Italian sausage, pureed Italian sausage and bun, mashed potatoes, and pureed vegetables. The large pan of mixed vegetables had a spoodle with a white handle resting in it. V5 verified this spoodle was a 3 ounce serving size (not the recommended 4 ounce). V5 used the spoodle to scoop up a level serving size of the mixed vegetables and put it on the plates. V5 used his gloved hand to measure a handful of shredded potatoes and put the handful of potatoes on the plate. V5 filled…

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 have a narcotic pain patch available for a resident as ordered. This failure applies to one of three residents (R1) reviewed for pain medications in the sample of ten. The findings include: The facility face sheet for R1 shows he was admitted to the facility on [DATE] with diagnoses to include spinal stenosis, bipolar disorder, emphysema, and encephalopathy. The facility assessment dated [DATE] shows R1 to be cognitively intact and is dependent on staff for his care. The December 2023 Physician orders shows an order for a narcotic pain patch to be applied and replaced every 72 hours. The medication administration record for December 2023 shows no pain patch was applied on 12/24/23 or 12/25/23. On 1/10/24 at 1:00PM, R1 said he went without his pain patches for two days and was told the pharmacy had run out of them. On 1/10/24 at 9:30 AM, V9 Licensed Practical Nurse (LPN) said she had placed a pain patch on R1 on 12/26/23, the day the patches…

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 privacy to a resident while providing personal care. This applies to one of three residents (R1) reviewed for privacy in the sample of 16. Findings include: The facility face sheet for R1 shows diagnosis to include spinal stenosis, benign prostatic hyperplasia with lower urinary tract symptoms and schizoaffective disorder. The facility assessment dated [DATE] for R1 shows him to have severe cognitive impairment and requires maximum assistance with all care. On 11/15/23 at 11:00 AM, R1 was being provided perineal care by V8 and V9 both Certified Nursing Assistants (CNA). R1 was completely naked and being turned side to side. The privacy curtain between the two beds was not pulled. R1's room mate and V3 Hospice Registered Nurse (RN) were both in the room and had a clear view of the care being provided to R1. On 11/15/23 at 11:10 AM, V3 Hospice RN said she wished the staff had closed the privacy curtain while providing care to R1. V3…

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 continue an ordered antibiotic when a resident returned from the hospital. This applies to one of three residents (R1) reviewed for medications on the sample list of 16. Findings inlcude: The facility face sheet for R1 shows diagnosis to include spinal stenosis, benign prostatic hyperplasia with lower urinary tract symptoms and schizoaffective disorder. The facility assessment dated [DATE] for R1 shows him to have severe cognitive impairment and requires maximum assistance with all cares. The hospital records for R1 show he was in the hospital from [DATE] to 10/27/23 with a diagnosis of pyelonephritis (Kidney infection). The final discharge medication list from R1's 10/27/23 hospital discharge shows an order for cefdiner (antibiotic) to be given twice a day for the next 5 days starting on 10/27/23. The October Medication Administration Record (MAR) shows the medication was not started until 10/31/23. (4 days after the ordered start date) The Physician…

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 the safety of a resident while sitting unsupervised outside on a patio for 1 of 3 residents (R1) reviewed for safety on the sample list of 6. The findings include: R1's admission Record printed 9/16/23 shows she was admitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis (partial paralysis on one side of the body) affecting Right side, Aphasia (inability to understand or express speech) following Cerebral Infarction, and Dysphagia (difficulty swallowing food or liquid). R1's facility assessment dated [DATE] shows R1 had severe cognitive impairment. This assessment shows she required extensive assistance of 2 staff with bed mobility, transfers, dressing, and toileting. R1 was not steady with moving from a seated to standing position, walking, turning around, moving on and off the toilet, and with surface-to-surface transfers. R1's cognition care plan initiated 8/5/23 shows she has 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.

Based on observation, interview, and record review, the facility failed to ensure holes in a resident's room were repaired and exposed wires were concealed for 1 of 5 residents (R4) reviewed for homelike environment in the sample of 9. The findings include: On 8/30/23 at 9:58 AM, R4's room had a wall above the TV with two cords/wires dangling from an outlet box opening and a cable going to the TV. There was another round hole in the wall above the TV as well. R4 said it, It looks like a piece of junk and it sure doesn't look like a professional job; it could be done right to look nice. On 8/30/23 at 10:12 AM, V3, Maintenance Director, went to R4's room and said he can put a plate cover over the outlet hole. V3 said the other hole is from a previous TV mount and he could mud it and cover the hole. V3 said he does not think the exposed wires/cords are a safety issue, but he could cover the hole to make it appear nicer. The Residents' Rights for People in Long-Term Care Facilities handbook (rev November 2018) shows, Your facility must be safe, clean, comfortable, and homelike.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the designated smoking area was kept clean and safe for smoking. The facility failed to ensure residents were supervised when smoking, fall interventions were implemented, and extension cords were not being used for 4 of residents (R82, R21, R77, & R12) reviewed for safety and supervision in the sample of 25 and 1 resident (R3) outside of the sample. The findings include: 1. On 6/27/23 at 9:42 AM, R82 was sitting on the side of her bed and stated she wanted to talk about the smoking [NAME] at the facility. R82 stated, We used to have a metal can for an ashtray in the smoking [NAME]. It was like a metal soup can. The maintenance guy took it away and said it was a fire hazard. We all sit inside the [NAME] and smoke 2-3 cigarettes in 15 minutes and we don't have anywhere to put them so we have to throw them on the floor. At least having the can was safer because it kept the cigarettes and ashes contained. Staff go out there with drinks…

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 protect a resident's dignity by knocking prior to entering a resident's room and failed to change soiled linens. This applies to 1 of 2 residents (R14) reviewed for dignity in the sample of 25. The findings include: R14's admission Record (Face Sheet) showed an original admission date of 12/26/2020 with diagnoses to include: anxiety, altered mental status, and muscle weakness. R14's 4/10/23 Minimum Data Set (MDS) showed he had moderate cognitive impairment with a brief interview for mental status score of 12 out 15. The MDS showed he was totally dependent on two staff for bed mobility and transfers. On 6/27/23 at 9:38 V12 Certified Nursing Assistant (CNA) entered R14's room without knocking or announcing who she was. V12 made several paces into the room, observed the State surveyor in the room, said whoops, sorry and exited the room. V12 then knocked on the door, said patient care and entered the room. V12 opened the resident's closet without permission, grabbed an unknown item, then left. On 6/27/23 at 9:38…

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 incontinent care prior to the resident developing inflamed skin; failed to provide oral care; and failed to provide handwashing. This applies to 4 of 4 (R2, R14, R72, & R16) residents reviewed for activities of daily living in the sample of 25. The findings include: 1. R2's admission Record (Face Sheet) showed an original admission date of 11/22/2017 with diagnoses to include: stroke, epilepsy, diabetes, and quadriplegia. R2's 5/4/23 Minimum Data Set (MDS) showed she had severe cognitive impairment with a brief interview for mental status score of 6 out of 15. R2's MDS showed she was totally dependent on two staff for bed mobility and transfers. R2's Cognition Care Plan from (revision 9/26/2021) showed she has impaired cognitive function, has poor self and environmental awareness .has difficulty being able to respond to such communications appropriately . R2's Care Plan also showed she is at risk for impaired skin integrity. 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 monitor resident weights per physician request and failed to ensure a knee immobilizer was applied per physician order for 3 of 5 residents (R13, R38, and R27) reviewed for quality of care in the sample of 25. The findings include: 1. R13's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes, obesity, chronic gout, chronic ischemic heart disease, hypertension, and hemiplegia and hemiparesis following cerebral infarction. R13's June 2023 physician order sheet showed no orders for routine weight monitoring. R13's 3/24/23 Cardiology NP (Nurse Practitioner) note showed, . Chief Complaint: Routine Cardiology follow-up CHF (Congestive Heart Failure) . Plan: 1. Chronic diastolic heart failure: Fluid status appears stable . Will continue current doses of hydrochlorothiazide, lisinopril, and Carvedilol as ordered. Please notify cardiology of any 3 pound weight gain overnight or 5 pounds in 1 week .…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a catheter bag was maintained in a way to prevent cross contamination and failed to ensure catheter orders and maintenance interventions were in place for 2 of 4 residents (R46) reviewed for catheters in the sample of 25. The findings include: 1. R46's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include unspecified wound of left buttock, neuromuscular dysfunction of bladder, retention of urine, spinal stenosis, major depressive disorder, and presence of urogenital implants. R46's facility assessment dated [DATE] showed he has moderate cognitive deficits, has an indwelling catheter in place, and requires extensive assistance for all cares. On 6/28/23 at 11:08 AM, R46 was in his bed, positioned in the mechanical lift sling, and had his catheter drainage bag sitting in between his legs in his lap and above the level of his bladder. Urine with sediment was visible in the catheter tubing. R46's care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident with a continuous tube feeding was in the proper position for 1 of 3 residents (R72) reviewed for tube feeding in the sample of 25. The findings include: On 06/27/23 at 11:03 AM , R72 was lying in bed. The R72's head of the bed (HOB) was at 20-30 degrees. R72 had slid down in the bed and his neck was resting at the bed in the bed. R72's head was bent forward and almost flat on the bed. R72 stated, My neck is hurting. I always slid down and when I get like this for too long, it hurts my neck. R72 had tube feeding infusing via a feeding pump at 70 ml/hr (milliliters/hour). On 6/29/23 at 8:19 AM, R72 was in the same position. The HOB was elevated at 20-30 degrees, but R72 had slid down in the bed and his head was bent forward and to the left at the bend in the bed. R72's feet were against the foot of the bed and his knees were bent up in the air. R72 stated, I think I need a new position. I always slid down like this. R72's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the filter on a resident's oxygen concentrator was clean, a nasal canula was not left laying on the floor, and oxygen was administered as needed for a resident (R21) reviewed for oxygen in the sample of 25. The findings include: On 6/28/23 at 7:53 AM, R21 was not in his room. His oxygen concentrator was turned on and running; his nasal cannula was on the floor on the far side of his bed and out of his reach. The oxygen tubing was not marked as to when it was last changed. The bubbler on R21's oxygen concentrator was a disposable kind, that was a quarter full and not dated. The filter on the back of the oxygen concentrator was buckled and filled with thick layers of gray dust. On 6/28/23 at 8:51 AM, R21 was sitting in his wheelchair in his room and appeared a little short of breath. R21's nasal canula was on the floor, on the far side of his bed, and out of reach. R21 stated he had come back from breakfast a little while ago and did…

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 ensure medications were available for 1 of 1 resident (R13) reviewed for medications in the sample of 25. The findings include: R13's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes, obesity, chronic gout, chronic ischemic heart disease, hypertension, and hemiplegia and hemiparesis following cerebral infarction. R13's care plan initiated 5/16/22 showed, The resident has hypertension related to inappropriate diet, lifestyle choices, and stroke . Interventions: . Give anti-hypertensive medications as ordered . R13's record included another care plan initiated 5/16/22 that showed, The resident has coronary artery disease related to hypercholesterolemia, hypertension . Interventions: . Give all cardiac medications as ordered by the physician. Monitor and document for side effects. Report adverse reactions to MD (physician) PRN (as needed) . Give medications for hypertension . R13's June 2023 eMAR…

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 handle soiled linens and change gloves after providing incontinence care to prevent cross-contamination. This applies to 2 of 2 residents (R2 &R32) reviewed for infection control in the sample of 25. The findings include: 1. R2's admission Record (Face Sheet) showed an original admission date of 11/22/2017 with diagnoses to include: stroke, epilepsy, diabetes, and quadriplegia. R2's 5/4/23 Minimum Data Set (MDS) showed she had severe cognitive impairment with a brief interview for mental status score of 6 out of 15. R2's MDS showed she was totally dependent on two staff for bed mobility and transfers. R2's Cognition Care Plan from (revision 9/26/2021) showed she has impaired cognitive function, has poor self and environmental awareness .has difficulty being able to respond to such communications appropriately . R2's Care Plan also showed she is at risk for impaired skin integrity. On 6/27/23 at 8:54 AM, R2 was in bed and asleep on 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 treat residents in a dignified manner. This applies to 2 of 25 residents (R26 and R18) reviewed for dignity in the sample of 25. The findings include: 1. On April 4, 2022, at 12:08PM, R26 was being fed lunch by V11 Certified Nursing Assistant (CNA). V11 stated we have two feeders here today. R26 was in the same room as R18. 2. On April 4, 2022, at 12:08PM, R18 was being fed lunch by V12 CNA. V11 stated we have two feeders here today. R18 was in the same room as R26. On April 5, 2022, at 12:16PM, V2 (Director of Nursing) said residents should be called by their preferred name and it is not acceptable to call residents names such as feeders. The facility's Quality of Life - Dignity policy last revised on 2009 shows staff shall speak respectfully to residents at all times. and not labeling or referring to residents by his or her. care needs.

Based on observation, interview, and record review, the facility failed to provide privacy for a resident during personal cares for one of 25 residents (R2) reviewed for privacy in the sample of 25. The findings include: On 4/4/22 at 10:45 AM, V6 CNA (Certified Nursing Assistant) was providing personal peri care to R2. V6 did not pull R2's privacy curtain closed. R2's roommate was sitting in the room in his wheel chair facing R2 on R2's left side. R2 was laying in his bed, V6 was standing on R2's right side. V6 removed R2's incontinence brief and exposed R2's genital area. R2's genital area was visible to R2's roommate. On 4/5/22 at 10:23 AM, R2 said he would like the privacy curtain to be closed during personal cares. R2 said one time the CNA had to ask R2's roommate to quit looking at R2 during personal care. On 4/5/22 at 10:46 AM, V9 CNA said that the resident's curtain should be closed during incontinence care to provide the resident with privacy. On 4/05/22 at 12:18 PM, V2 DON (Director of Nursing) said staff should pull the resident's privacy curtain closed during incontinence…

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 a policy for the recording of grievances for 1 of 25 residents (R6) reviewed for grievances in the sample of 25. The findings include: 1. On April 4, 2022, at 2:45PM, V1 Administrator said there was a complaint on January 15, 2022, from R6's family member regarding staff speaking disrespectfully to her in front of R6. V1 said there was no grievance form completed after the grievance was received from R6's family member. V1 said she wasn't aware a grievance form needed to be completed for this incident. The facility's Grievance Policy does not ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, intervention, and record review the facility failed to change gloves and perform hand hygiene to prevent cross contamination for three of 25 residents (R79, R2, R4) reviewed for infection control in the sample of 25. The findings include: 1. R79's Order Summary Report dated 4/5/22 shows R79 was admitted to the facility on [DATE] with diagnoses including weakness, personal history of covid-19, major depressive disorder, dysphonia, pressure ulcer of sacral region stage 4, multiple sclerosis, convulsions, infection and inflammatory reaction due to other urinary catheter, and spinal stenosis. On 4/4/22 at 10:59 AM, V6 CNA (Certified Nursing Assistant) wiped R79's front peri area and buttock area. There was a small amount of stool to R79's buttock. V6 touched R79's sink knobs, R79 urinary catheter bag, touched R79's body to reposition her, touch R79's head and arms all without changing her gloves or performing hand hygiene. 2. On 4/4/22 at 10:45 AM, V6 CNA performed incontinence care for R2. V6…

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 pressure injury prevention interventions were in place and failed to identify a deep tissue injury (DTI) for two of four residents (R79, R2) reviewed for pressure injuries in the sample of 25. The findings include: 1. R79's Order Summary Report dated 4/5/22 shows R79 was admitted to the facility on [DATE] with diagnoses including weakness, personal history of covid-19, major depressive disorder, dysphonia, pressure ulcer of sacral region stage 4, multiple sclerosis, convulsions, and spinal stenosis. On 4/4/22 at 10:02 AM, V7 Wound Care Nurse said that R79 has a stage four pressure injury located to her sacrum. V7 did not state that R79 had a pressure injury to her right foot. On 4/4/22 at 10:59 AM V6 CNA (Certified Nursing Assistant) was performing incontinence care for R79. R79 had a large dressing located to her sacral area. The bottom of R79's dressing towards her rectum was not intact. There was gauze packing that was falling…

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 1 of 8 residents (R104) reviewed for foot care received toenail care in the sample in 25. The findings include: On 4/4/22 at 11:05 AM R104 was lying in bed without socks. R104 said he needs his toenails trimmed. R104 said the guy that comes to trim toenails doesn't take his insurance. R104's toenails were long and thick with debris under & around them. R104's Face Sheet dated 4/6/22 shows R104's diagnoses include, but are not limited to, Type 2 Diabetes. R104's Minimum Data Set (MDS) dated [DATE] shows he is cognitively intact. R104's Current Care Plan (Review last completed 2/11/22) shows R104 has an ADL (Activities of Daily Living) Self Care performance deficit and requires limited assistance by one staff member participation with personal hygiene. R104's Current Care plan also shows he has Diabetes and should be referred to the podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. R104's Physician…

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 fall prevention interventions were in place for three of 25 residents (R2, R72, R39) reviewed for safety in the sample of 25. The findings include: 1. R2's Order Summary Report dated 4/5/22 shows R2 was admitted to the facility on [DATE] with diagnoses including: Acquired absence of leg below knee, neuralgia and neuritis, macular degeneration, heart disease, polyneuropathy, chronic obstructive pulmonary disease, chronic respiratory failure, and sepsis. R2's Fall Risk assessment dated [DATE] shows R2 has a high risk for falling. R2's Care Plan initiated 7/1/16 shows, [R2] is high risk for falls related to BLE (bilateral lower extremity) amputation. [R2] needs a safe environment with even floors free from spills and or clutter, adequate, glare free light, a working and reachable call light, the bed in low position at night, handrails on walls, and personal items within reach. [R2] uses chair/bed electronic alarm. Ensure the device 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to keep a urinary drainage bag below the level of the bladder for one of three residents (R79) reviewed for catheters in the sample of 25. The findings include: R79's Order Summary Report dated 4/5/22 shows R79 was admitted to the facility on [DATE] with diagnoses including: Weakness, neuropathic bladder, convulsions, neuromuscular dysfunction of bladder, multiple sclerosis, and infection and inflammatory reaction due to other urinary catheter. An order for ertapenem sodium solution daily for ESBL in urine. R79's Care Plan initiated 9/21/21 shows she has been on antibiotics a multiple different times due to urinary tract infections. On 4/4/22 at 10:59 AM, V6 CNA (Certified Nursing Assistant) lifted R79's urinary drainage bag above the level of her bladder multiple times to reposition the urinary drainage bag. The urinary drainage bag and tubing had urine in it. On 4/5/22 at 10:30 AM, V8 LPN (Licensed Practical Nurse) said urinary drainage…

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 maintain a residenta midline intravenous access (IV) site based upon professional standard of practice by not changing the dressing for one of one resident (R79) reviewed for IV access in the sample of 25. The findings include: On 4/4/22 at 10:28 AM, R79 had a midline IV access site to her left upper arm. The date on the dressing was 3/28/22. R79 stated she did not know when the dressing was last changed. The edges of the dressing were peeling up. On 4/5/22 at 1:39 PM, the same dressing was present to R79's left upper arm. The dressing was still peeling up at the edges. The dressing was dated 3/28/22. R79 said she was not sure how often they change the dressing. (Same dressing on for eight days). R79's Order Summary Report dated 4/5/22 shows she was admitted to the facility on [DATE] with diagnoses including: weakness, personal history of covid-19, convulsions, sciatica, pressure injury of sacral region stage four, multiple sclerosis,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a CPAP (continuous positive airway pressure) machine was obtained for one resident (R104) with obstructive sleep apnea out of 5 reviewed for respiratory care in the sample of 25. The findings include: On 04/04/22 at 10:42 AM, R104 said he has not had his CPAP machine since being admitted to the facility. No CPAP machine was seen in R104's room. On 04/05/22 at 01:03 PM, V2, Director of Nursing (DON), said she believes R104's CPAP has broken parts which have been on backorder. V2 said they wouldn't take a patient if they could not meet their needs. On 04/05/22 at 01:19 PM, V1, Administrator, said she knows R104's CPAP machine which he brought from home was infested with bedbugs and has been bagged up since he arrived in August [2021]. V1 said she believes V3, Assistant DON (ADON) might be working on getting a new CPAP machine for R104. On 04/05/22 at 01:28 PM, V3 said R104 brought an infested CPAP machine with him when he was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement pain management interventions for one of 25 residents (R79) reviewed for pain in the sample of 25. The findings include: R79's Order Summary Report dated 4/5/22 shows R79 was admitted to the facility on [DATE] with diagnoses including weakness, personal history of covid-19, major depressive disorder, dysphonia, pressure ulcer of sacral region stage 4, multiple sclerosis, convulsions, and spinal stenosis. On 4/4/22 at 10:28 AM, R79 complained of pain to her right shoulder and asked V4 LPN (Licensed Practical Nurse) for an ice pack. V4 told R79 she would get an ice pack. On 4/4/22 at 10:59 AM, during incontinence care and repositioning, R79 complained of pain and discomfort to her right shoulder. R79 told V6 CNA (Certified Nursing Assistant) that she had asked V4 for an ice pack. On 4/4/22 at 2:15 PM, R79 did not have an ice pack to her right shoulder. V4 came into R79's room to help with repositioning and R79 asked V4 again if she…

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 administer medications as ordered. There were 27 opportunities with 9 errors resulting in a 33.33% error rate. This applies to 2 of 3 residents (R79, R104) observed in the medication pass. 1. R79's Order Summary Report dated 4/5/22 shows an order for Arginaid packet two times daily for wound healing, Ascorbic Acid 500 mg (milligram) two times daily, cholecalciferol 1000 units two times per day, enulose solution (lactulose) give 15 ml (milliliters) one time a day for constipation, keppra tablet 1000 mg two times a day for seizures, morphine sulfate ER (extended release) 15 mg every 12 hours for pain, senna S 8.6 mg-50 mg two tablets two times a day for bowel management, and sodium chloride table 1 gram two tablets by mouth three times per day for low sodium. It shows R79 was admitted to the facility on [DATE] with diagnoses including weakness, personal history of covid-19, major depressive disorder, dysphonia, pressure ulcer of sacral…

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 food processing equipment was properly sanitized before using for 3 of 3 residents (R18, R21 and R26) reviewed for sanitization in the sample of 25. The findings include: The facility provided list shows that R18, R21 and R26 are on a pureed diet. On 4/4/22 at 10:44 AM, V13 (Dietary Supervisor) pureed hot dogs. V13 brought the mixing bowl, blade, lid and spatula to the 3 compartment sink to clean. V13 dipped the equipment into the sanitization sink and then removed. V13 then immediately used it to make pureed bean. At 10:52 AM, V13 brought the same equipment to the 3 compartment sink after pureeing beans. V13 submerged the equipment for 30 seconds and then immediately used to make pureed broccoli. On 4/4/22 at 10:57 AM, V14 (Dietary Manager) said that equipment should be fully submerged in the sanitizer for 1 minute and then air dried before using it. The facility's Manual-Sanitizing in Three-Compartment Sink Policy revised on 5/20/14 shows,After washing and rinsing utensils or equipment are sanitized in…

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.